Creatine - Frequently Asked Questions and Misconceptions: What Does the Scientific Evidence Really Show?

There are currently over 1,000 scientific publications on creatine supplementation. Even so, questions regarding not only the effectiveness, but also the safety of creatine still remain. So let's take a look at the ten most frequently asked questions about creatine together and find answers based on scientific evidence.

Based on the enormous popularity of creatine supplementation, the International Society for Sports Nutrition (ISSN) published an article in 2017 on the safety and efficacy of creatine supplementation in sports and medicine [ 1 ]. This comprehensive document provides an evidence-based review of the literature examining the effects of creatine supplementation on performance, recovery, injury prevention, exercise tolerance and rehabilitation, neuroprotection, aging, clinical and disease populations, and pregnancy. Reviewing the safety profile of creatine is also an important aspect.

However, despite this comprehensive document, there are still questions and misconceptions about creatine supplementation. Therefore, an internationally recognized team of research experts was assembled in 2021 to conduct an evidence-based scientific review of the literature on creatine supplementation.

What did they find?

1. Does creatine cause water retention?

The supposed myth of creatine supplementation increasing body water (TBW) is likely due to early research showing that creatine supplementation at 20 g/day for six days was associated with water retention for the first few days [ 2 ] . For example, studies have shown that three days of creatine supplementation increased TBW, extracellular body water (ECW), and intracellular water (ICW). Based on these short-term studies, the widely accepted claim that creatine increases water retention in the long term [ 3 ].

A number of exercise studies (5-10 weeks) involving creatine supplementation have shown no increase in total body water . For example, resistance-trained men receiving creatine at approximately 20 g/day followed by 4 weeks at approximately 5 g/day experienced no significant change in ICW, ECW, or TBW [ 4 ]. Other studies have shown similar results [ 5 ] [ 6 ] [ 7 ]. Powers et al. demonstrated that creatine supplementation was effective in increasing muscle creatine content, which was associated with increases in body mass and TBW, but did not alter ICW or ECW volumes.

In summary - while there is some evidence that creatine supplementation increases water retention in the short term, we find several other studies that suggest it does not change total body water (intracellular or extracellular) in the long term. As a result, creatine supplementation may not lead to water retention.

Does creatine cause hair loss and baldness?

Speculation about the relationship between creatine supplementation and hair loss and baldness often stems from a single study by van der Merwe et al. [ 8 ] who followed college-aged rugby players who supplemented with creatine (25 g/day for 7 days, followed by 5 g/day for another 14 days) and noted an increase in serum dihydrotestosterone (DHT) concentrations over time.

DHT is a metabolite of testosterone that is created by an enzymatic reaction converting free testosterone to DHT.

In men, DHT can bind to androgen receptors in sensitive hair follicles and cause them to shrink, ultimately leading to hair loss [ 9 ].

It is important to note that the results of van der Merwe et al. have not been replicated and that intense resistance exercise itself may also cause an increase in these androgenic hormones.

Studies show that changes in these hormones, especially DHT, are associated with some cases of hair loss and baldness [ 10 ]. However, the theory that creatine supplementation leads to hair loss and baldness is still considered a myth as there is not enough evidence to support this relationship.
And what do other sources say? To date, 12 other studies have examined the effects of creatine supplementation on testosterone. Two studies reported small, physiologically insignificant increases in total testosterone after six and seven days of supplementation [ 11 ] [ 12 ], while the remaining ten studies reported no change in testosterone concentrations. Free testosterone, which the body uses to produce DHT, was also measured in several of these studies [ 13 , 14 , 15 , 16 ] and no increases were found.

Overall, current evidence does not suggest that creatine supplementation increases total testosterone, free testosterone, DHT, or causes hair loss/baldness.

Is creatine only effective for men?

The rate and course of action of creatine may differ in healthy men and women [ 17 ].

Hormonally driven changes in the female body may affect the bioavailability of creatine at different stages of reproduction, suggesting potential positive effects of creatine supplementation in women [ 18 ]. Creatine supplementation may be especially important during menstruation, pregnancy, postpartum, perimenopause, and postmenopause.

In women, we can observe lower levels of creatine in the brain in the frontal lobe. Increasing the concentration of creatine in the brain by supplementation can, especially in women, reduce the symptoms of depression [ 19 , 20 ]. The risk of depression is about twice as high in women during their reproductive years and accelerates during the hormonal changes of puberty.

There is a small number of studies that have examined the effects of creatine supplementation in younger female athletes. Various studies have shown that creatine supplementation can significantly increase muscle creatine concentrations, muscle mass and strength, sprint and agility performance, and other physical parameters [ 21 , 22 , 23 , 24 ].

In summary, there is mounting evidence that creatine supplementation has the potential to be a multifactorial therapeutic intervention across the lifespan in women with little or no side effects.

Does creatine increase fat mass?

The theory that creatine supplementation increases fat mass is of concern to the exercising individual. However, randomized controlled trials (which lasted from one week to two years) do not support this claim . [ 26 ][ 27 ] [ 28 ] [ 29 ] Acute creatine supplementation (7 days) had no effect on fat mass in young and older adults; however, there was an increase in lean mass [ 30 , 31 ].

In summary, creatine supplementation does not increase fat mass across the population.

Is creatine harmful to children and adolescents?

Concerns about the safety of creatine supplementation in children and adolescents (<19 years) are still widespread. Most of the available evidence in the adult population suggests that short- and long-term creatine supplementation is safe and generally well tolerated [ 1 ]. However, the issue of safety in children and adolescents remains open.

Recently, in a comprehensive review examining the safety of creatine supplementation in adolescents, Jagim et al. reviewed several studies that examined the effectiveness of creatine supplementation among different populations of adolescent athletes and found no evidence of adverse effects .

It is important to mention that the creatine supplementation protocols were well tolerated and did not produce adverse changes in laboratory parameters of renal function, liver function, inflammatory markers, oxidative stress, and bone health. [ 42 , 43 , 44 ].

In addition, Sakellaris et al. [ 44 ] reported significant improvements in outcomes related to traumatic brain injury in children and adolescents receiving oral creatine supplementation (0.4 g/kg/day) for 6 months. These neurological benefits may have potential use for young athletes participating in contact sports with a risk of concussion.

These findings support the hypothesis that creatine supplementation is likely safe for children and adolescents. Current scientific evidence regarding the safety of creatine is sufficient and has been recognized by experts as safe for its intended use.

In conclusion, based on limited evidence, creatine supplementation appears safe and potentially beneficial in children and adolescents.

Is creatine only useful for strength activities?

Although creatine supplementation is thought to primarily benefit athletes who engage in high-intensity intermittent strength-type activities, there is increasing evidence to suggest that creatine supplementation may have beneficial effects for other activities as well.

For example, the combination of creatine supplementation with carbohydrates or carbohydrates and protein promotes higher muscle glycogen storage than carbohydrate supplementation alone [ 32 ]. Glycogen replenishment is important to promote recovery and prevent overtraining during intense training periods.

There is evidence that subjects who supplemented their diet with creatine experienced less muscle damage, inflammation, and muscle soreness after completing a 30 km running race [ 33 ] as well as during 4 weeks of more intense training [ 16 ]. Because of this, creatine supplementation can help athletes recover from intense exercise and better tolerate periods of intense training .

There is also evidence that athletes who supplement with creatine during training experience fewer muscle injuries and a shorter recovery time from injury. [ 34 ] Last but not least, creatine supplementation (with or without glycerol) has been reported to help athletes hyperhydrate, thereby increasing exercise tolerance in the heat [ 35 , 36 ].

In addition, there is evidence from animal models that creatine supplementation is neuroprotective [ 37 , 38 ] and can reduce the severity of spinal cord injury, cerebral ischemia, concussion and traumatic brain injury [ 39 , 40 , 41 ].

This evidence was so compelling that the International Society of Sports Nutrition recommended that athletes participating in sports with the potential for concussion and/or spinal cord injury take creatine for its neuroprotective effects [ 1 ].

In conclusion, there are a number of sports activities, not just resistance/strength, that can benefit from creatine supplementation.

Is creatine an anabolic steroid?

Anabolic steroids are a synthetic version of testosterone, an androgenic hormone that occurs naturally in both men and women. These steroids are often used in conjunction with strength training to increase muscle mass and strength through increased muscle protein synthesis[ 45 ].

Creatine is converted to creatine phosphate, regulated by the enzyme creatine kinase in the muscle, and used to produce intracellular energy (ATP) [ 46 ]. Creatine supplementation may increase the ATP capacity and energy produced during heavy anaerobic exercise, thereby potentially increasing muscle strength, repetitions, and exercise volume, which may subsequently contribute to muscle performance and muscle growth during the training period.

Although the physiological and performance results of anabolic steroids and creatine may be similar, their mechanisms of action and legal classification are different.

In short, since creatine has a completely different chemical structure, it is not an anabolic steroid.

Does creatine cause kidney damage/renal dysfunction?

Questions and concerns about creatine supplementation and its effect on kidney damage or renal dysfunction are common. When it comes to the pervasive misinformation in sports nutrition, the notion that creatine supplementation leads to kidney damage/dysfunction is perhaps second only to the myth that protein supplementation and high habitual protein intakes cause kidney damage.

Although research over more than 20 years has shown no adverse effects of recommended doses of creatine supplements on kidney health, this concern unfortunately still persists.

The hypothesized relationship between creatine supplementation and kidney damage/renal dysfunction can be traced to two factors: a misunderstanding of creatine and creatinine metabolism and a case study published in 1998. [ 47 ]

In skeletal muscle, both creatine and creatine phosphate are non-enzymatically degraded to creatinine, which is exported into the blood and excreted in the urine. Healthy kidneys filter creatinine that would otherwise rise in the blood. Therefore, blood creatinine levels can be used as a marker of kidney function. There appears to be an unsubstantiated perspective that if the kidneys are "forced" to excrete higher than normal levels of creatine or creatinine, there will be some "overload" on the kidneys, causing kidney damage and/or renal dysfunction. In fact, transient increases in blood or urine creatine or creatinine caused by creatine supplementation are unlikely to reflect a decrease in renal function.

Since the publication of this case study in 1998, the number of experimental and controlled research studies examining the effects of creatine supplementation on kidney/renal function has increased substantially. Overall, consumption of recommended doses of creatine supplements appears to have no adverse effects on kidney function in healthy individuals [ 48 , 49 , 50 , 51 ].

Overall, it can be said that experimental and controlled research shows that creatine supplementation at recommended doses does not cause kidney damage and/or renal dysfunction in healthy individuals.

Is creatine beneficial for older adults?

More and more studies show that creatine supplementation plays a therapeutic role in various clinical conditions in the elderly population.
One of the most promising areas that could benefit from creatine supplementation is age-related sarcopenia.

Sarcopenia is defined as a skeletal muscle condition characterized by a decrease in muscle mass, strength and function. This condition is associated with a higher risk of adverse outcomes, including falls, fractures, physical disability, and mortality [ 52 ].

Creatine supplementation may increase strength, muscle mass, activity of daily living, and delay fatigue in older adults. However, it should be noted that creatine alone (without exercise) is unlikely to lead to substantial increases in muscle strength or functional performance [ 53 , 54 , 55 ], although it does improve some muscle parameters.

The fact that creatine is more effective in conjunction with a training stimulus suggests that the main mechanism of action of creatine is its ability to increase the volume and intensity of training, which can affect various physiological parameters [ 56 , 57 , 58 ], and ultimately lead to greater skeletal muscle adaptations .

From a clinical and health perspective, it is recommended that creatine supplementation be combined with resistance training to achieve the best possible adaptations in older adults.

In summary, there is increasing evidence that creatine supplementation, particularly when combined with exercise, provides health and performance benefits in older adults.

Is a creatine "loading phase" necessary?

A creatine "loading phase" is defined as creatine supplementation for 5-7 days at 20-25g/day, often divided into smaller doses throughout the day (eg four to five 5g servings).

The "saturation" phase of creatine supplementation is followed by a daily "maintenance" phase, often in the range of 3-5g per day.

Lower daily creatine dosing strategies (ie, 3–5 g/day) are well known to increase creatine stores and lead to greater improvements in muscle mass, performance, and recovery compared to placebo [ 1 ]. These dosing strategies are effective but delay peak muscle storage of creatine.
In a comparative study between "loading" and "maintenance" phases, creatine accumulation in muscle was shown to be similar (~20% increase) even when taking 3 g/day for 28 days or 20 g/day for 6 days.[ 2 ].

The choice between a creatine supplementation strategy depends on the individual's goals. For example, if an athlete is hoping to maximize the potential of creatine supplementation in a very short period of time (< 30 days), they may be advised to use a creatine "loading" strategy or we recommend our Creaflow product.

Thanks to current scientific knowledge, muscles can be quickly saturated with creatine without the need for a "saturation" phase. The mechanism of insulin allows acceleration of creatine saturation. That's why we developed the product Creaflow, which combines creatine with other substances to quickly saturate muscle cells with creatine.

However, if an athlete or training individual is planning long-term creatine supplementation (>30 days) or is trying to minimize any potential weight gain associated with the "loading" phase, a creatine "maintenance" strategy is a good choice .

In short, accumulating evidence suggests that you don't need to use a "loading" phase of creatine. Lower daily doses of creatine supplementation (ie 3-5 g/day) are effective for increasing muscle creatine stores, muscle performance, muscle growth and recovery.

 

Conclusion

Creatine supplementation is still accompanied by misconceptions that discourage potential users from using it. Creatine is an interesting substance that is definitely worth learning more about and trying. We hope that with this document we have provided you with compelling evidence to help you decide whether to try creatine. If you still have any questions, contact us on the social networks flownutrition_cz and flownutritioncz .