Creatine: Benefits vs Side Effects (The Science)

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If you spend enough time in the gym, you’ll almost certainly hear about Creatine supplements. You might have even heard about it from your favourite fitness influencer on YouTube.

But what is Creatine? How does it work? And what are the possible side effects?

So it’s time to drop those dumbbells and pick up a pen to look at the science behind this fascinating supplement.

Our bodies are built to move. Our bones provide a solid internal structure to hold ourselves up and our muscles attach to these bones to give us the ability to move. But to move, our muscles need energy, and the fuel that powers our muscles is called ATP.

Think of our muscles like the engine of a petrol thirsty car. Our muscles have a small store of ATP that can fuel the engine for about 3 seconds. Our muscles need a way to continuously refuel and make new ATP [1].
Our muscles have three energy systems that it can use to regenerate ATP: The phosphocreatine system, the glycogen-lactic acid system and the aerobic system. Of these three systems, the phosphocreatine is the fastest and most responsive, which makes it useful for short duration, high intensity exercise. It can rapidly regenerate ATP but we only have enough stored Creatine to power about 10 seconds of intense muscle activity.

Our bodies can make its own creatine from 3 amino acids: methionine, glycine, and arginine. [2] The first step of creatine production starts in our kidneys with the final step occurring in our liver. [3] Our bodies make about 1g per day. [4] But we can also absorb Creatine from our digestive system, and our bodies can soak up this additional Creatine in our muscles, up to a certain limit [5]

This is where Creatine Supplements come into play.

They increase the amount of Creatine stored in our muscles. As a result, our muscles can sustain powerful activity for longer. What this means in practical terms is the ability to push out more reps in the gym and improve performance in high intensity exercise.

Over time, this increased exercise capacity can lead to improvements in muscle mass and strength. [6]
So how much benefit are we actually talking about? Well this depends on multiple factors including genetics, diet, the type of training and the type of outcome being measured, but an approximate overall performance increase of about 5-15% is what the research tells us. [6]

Studies show a spectrum of benefit – some people will get more benefit from creatine supplementation, and some people will experience less. For example, one review article showed that although the average increase in muscle strength from creatine supplementation was 8%, the improvement in bench press 1 rep max ranged from 3% to 45%. [7] This wide range reflects the variable response to Creatine supplements.
Some studies suggest that people who choose a vegetarian diet may have more to gain from creatine supplementation since the main source of dietary creatine are meat products. A recent study found that while vegetarians do benefit from creatine, they don’t appear to have a consistent additional benefit in performance compared to non-vegetarians who also take creatine. [8]

So far we’ve looked at exercise related benefits of creatine. But what about benefits to other aspects of our health? In particular, there has been interest in improvements in brain health. Although 95% of stored creatine is in muscles, the brain also uses the phosphocreatine system for energy.

While muscles rely on creatine produced from our kidney and liver, our brains are different in that they can produce their own creatine. [9] Also our brains seem to be less sensitive to dietary creatine than our muscles. Studies have found that vegetarians and non-vegetarians have similar levels of brain phosphocreatine, and that in response to creatine supplements, brain creatine levels rise less that the increase in muscle creatine. [9]

Research into creatine and brain health has led to mixed results.

In otherwise healthy people, some studies show an improvement in short term memory and reasoning, but others do not. The benefit seems to be greater for people who have experienced some kind of brain stress such as sleep deprivation, mental fatigue or a mild traumatic brain injury. The authors of one systematic review state that “it is possible that creatine administration improves cognition of diseased, aged or stressed individuals whereas for younger, unstressed individuals there is no such a benefit”. [10]

The primary benefit of creatine is on athletic performance. There may be some secondary benefit on brain health, but the research is mixed. So don’t swap your textbooks for a creatine supplements just yet!
Alright now we need to talk about side effects of Creatine. Creatine has been around as a supplement since the early 1990s so we have almost 30 years of anecdotal use to go by. We should keep in mind creatine is a dietary supplement, not a medication or hormone.

When used within the recommended dose of 3 to 5 grams per day, research shows no serious harm with up to 4 years of creatine use in adults. [4,11,12,13] There is no consistent evidence that creatine causes hair loss, kidney damage or liver damage. [14]

Some people may experience gut related side effects like bloating or nausea after taking creatine. Others may experience a 1 to 2 kilo increase in body weight as creatine can increase the fluid content of muscle cells.

But we should remember that creatine has not been adequately tested for safety in children or teenagers. Potential long term consequences, for example with 10 to 20 years of use, are unknown at this stage. And one other consideration is that many of the researchers and studies looking into creatine have received either direct or indirect support from Creatine manufacturers. This doesn’t mean we should completely disregard these articles, but it does mean we should approach these articles with a certain amount of healthy skepticism.

The International Olympic Committee considers Creatine to be a supplement with good to strong evidence of benefit when used in specific scenarios, and the Australian Institute of Sport places Creatine in Group A of sports supplements, which means that they consider it to have strong scientific evidence for use. Creatine is not prohibited by the World Anti Doping Agency. Based on surveys, about 15 to 40 percent of athletes and military personnel use creatine [15]

The people who stand to benefit most from Creatine supplements are those who already have solid training foundations and are looking for an additional edge. This means that they already have a well thought out nutrition program with the appropriate number of calories and protein content, a consistent training schedule with good technique and are willing to experiment with creatine to see if it benefits them.

There is research interest in the effects of creatine for older people and those who are undergoing rehabilitation from injury. [17,18]. But that is a topic for another day.

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References

[1] Guyton and Hall Textbook of Medical Physiology 12th ed
[2] https://www.uptodate.com/contents/nutritional-and-non-medication-supplements-permitted-for-performance-enhancement
[3] https://journals.lww.com/acsm-csmr/Fulltext/2013/07000/Creatine_Supplementation.10.aspx
[4] https://www.ais.gov.au/__data/assets/pdf_file/0007/1000501/Sport-supplement-fact-sheets-Creatine-v4.pdf
[5] https://pubmed.ncbi.nlm.nih.gov/28615996-international-society-of-sports-nutrition-position-stand-safety-and-efficacy-of-creatine-supplementation-in-exercise-sport-and-medicine/
[6] https://pubmed.ncbi.nlm.nih.gov/34199588/
[7] https://pubmed.ncbi.nlm.nih.gov/14636102/
[8] https://pubmed.ncbi.nlm.nih.gov/32349356/
[9] https://pubmed.ncbi.nlm.nih.gov/33578876/
[10] https://pubmed.ncbi.nlm.nih.gov/29704637/
[11] https://www.sciencedirect.com/science/article/abs/pii/S1051227619302286
[12] https://pubmed.ncbi.nlm.nih.gov/29059531/
[13] https://bjsm.bmj.com/content/bjsports/52/7/439.full.pdf
[14] https://pubmed.ncbi.nlm.nih.gov/33557850/
[15] https://www.wada-ama.org/en/prohibited-list
[16] https://www.ncbi.nlm.nih.gov/labs/pmc/articles/PMC5469049/
[17] https://pubmed.ncbi.nlm.nih.gov/30762623/
[18] https://pubmed.ncbi.nlm.nih.gov/34071875/