Everything about creatine – the most comprehensive, unbiased, science-based guide!

1. What is creatine and how does it work?

What is creatine?

Key facts you should know about creatine:

• Creatine is a derivative of the amino acids glycine, arginine and methionine
• Creatine is synthesised primarily in the liver and kidneys (and in smaller amounts in the pancreas)
• Creatine is stored primarily as free creatine or bound to a phosphate molecule in skeletal muscle
• Skeletal muscle contains 95% of all creatine in the body
• The heart, brain and testes contain the remaining 5%

References:

Terrilion K. Int J Sports Nutr 7:138, 1997 ; Volek JS & W.J. Kraemer. J Strength Cond Res 10:200, 1997

What are the effects of creatine?

Strength coach David Sandler summarised all the benefits of creatine supplementation as follows: Creatine allows you to train longer and handle a greater training volume. It helps you perform more reps and, through its use, it is possible to increase phosphocreatine stores in the body by 10% to 40%.

References:

Increased PCr stores improves the ability of your muscles to resynthesize ATP from ADP following high-intensity, shortduration exercise. Kreider RB et al. JEP online 1.1, 1998

Effects of creatine confirmed by research and studies:

• Increased muscle mass
• Increased maximal strength (measured as 1RM bench press)
• Improved muscular endurance
• Increased anaerobic power and performance (demonstrated across many activities including repeated jumps, jump squats, kicking and repeated sprints in football players)
• Supports hydration in extreme outdoor conditions

References:

• Creatine supplementation (6 g/d for 12 weeks) during resistance training resulted in increased fat-free mass, thighvolume, muscle strength, myofibrillar protein content, and Type I, IIa, and IIx MHC mRNA expression compared to tocontrols. Willoughby et al. MSSE: 33: 1674-81, 2001
• Increase in total-body mass and lean mass with no gain in fat. Balsom P et al. Acta Phhysiol Scand 1995;154:303;Grindstaff Pl et al. Int J Sport Nutr. 1997; 330-346; Vandenberghe K et al. JAP 1997;83:2055
• Increased Type I and II muscle fiber hypertrophy Sim L et al. CJAP 23(5): 507, 1998; Volek et al. 1999
• Effect of creatine supplementation on aerobic performance and anaerobic capacity in elite rowers in the course of endurance training. Chwalbinska-Moneta J. Int J Sport Nutr Exerc Metab. 2003 Jun; 13(2): 173-83
• The effects of creatine supplementation on cardiovascular, metabolic, and thermoregulatory responses during exercise in the heat in endurance-trained humans. Kilduff LP et al. Int J Sport Nutr Exerc Metab . 2004 Aug; 14(4): 443-60
  
• Bosco C et al. Int J Sports Med 1997; 18:369
• Greenhaff PL et al. Clin Sci 1993; 84:565
• Harris RC et al. J Physiol 1993; 467:74P
• Balsom PD et al. Scan J Med Sci Sports 1993; 3:143
• Balsom PD et al. Acata Physiol Scand 1995; 154:303
• Birch R et al. Eur J Appl Physiol 1994; 69:268
• Earnest CP et al. Acta Physiol Scand 1995; 153:207
• Mujika I et al. Med Sci Sports Exerc 2000; 32:518-25
• Chwalbinska-Moneta J. Int J Sport Nutr Exerc Metab. 2003 Jun; 13(2): 173-83

Does creatine help with weight loss?

When one of my clients needs to shed body fat, the first and most effective technique is generally to extend sets and shorten rest periods in order to perform more work within a given time. As a result, clients burn more calories both during and after training, thanks to a phenomenon known as EPOC (excess post-exercise oxygen consumption). The harder you train, the more pronounced this effect becomes. From the studies mentioned above, we know that creatine helps you perform one to two additional reps per set and also leads to strength gains, which in turn allows the use of heavier weights in training. You train more and harder — two highly effective methods for burning fat.

Furthermore, we know that creatine helps build and maintain metabolically active muscle tissue (which burns more energy). Simply put, the more muscle you have, the harder you can train and, consequently, the more calories you burn — both during and after your workout.

Creatine also helps boost metabolism directly through the cellular hydration it promotes. A well-hydrated cell tends to be more metabolically active.

Does creatine help improve endurance?

Unlike the consistent effects of creatine on strength and power sports, when testing its impact on endurance improvement, the scientific literature presents both positive and negative results. says Alan Aragon.

Does this mean that creatine supplementation is pointless for improving endurance? Not entirely. Many of these sports involve a mix of different intensities. Any type of training that combines short, explosive, high-intensity activity with longer steady-state efforts may benefit from the effects of creatine, provided that any additional lean muscle mass gained does not negatively impact performance.

For endurance athletes, the best approach is to try creatine supplementation personally and determine whether its effects are beneficial.

2. How to use creatine?

Which type of creatine is best?

There are currently several forms of creatine available on the market:

• Creatine monohydrate
• Creatine ethyl ester
• Creatine phosphate
• Creatine citrate
• etc.

I personally recommend creatine monohydrate to all my clients and athletes. More specifically, micronised creatine monohydrate.
Creatine monohydrate is definitively the best choice. Not only is it the most cost-effective option, but it has also been shown to have superior bioavailability compared to other forms — meaning monohydrate has a higher biological value. says Alan Aragon.

Other forms of creatine marketed as superior to monohydrate have been shown to degrade to creatinine more rapidly, whereas classic creatine monohydrate retains its active form and therefore its effectiveness.

Alan Aragon also adds that the highest quality creatine monohydrate carries the Creapure trademark, which is a guarantee of the finest quality creatine available on the market.

References:

• Kre-alkalyn® supplementation has no beneficial effect on creatine-to-creatinine conversion rates. Tallon MJ, Child R.
• Creatine ethyl ester rapidly degrades to creatinine in stomach acid. Child R, Tallon MJ.Presented at the 4th International Society of Sports Nutrition (ISSN) annual meeting.
  Both studies were presented at the 4th Annual International Society of Sports Nutrition (ISSN) Conference.

How many grams of creatine should I take?

Scientific studies have shown that 3 to 6 grams of creatine per day is a sufficient dose. A higher dose is not more effective, and once the muscles are saturated, any excess creatine is excreted by the body.

Is a loading phase necessary?

Yes and no. It depends on how quickly you want to see results. If you are looking for a fairly rapid improvement in anaerobic performance and lean muscle mass gains, then it makes sense to carry out a loading phase, says Jose Antonio.

If time is not a concern, a daily maintenance dose is recommended, which will ensure full muscle saturation in approximately one month. If you do decide to go ahead with a loading phase, the recommended dose is 20 g per day for 7 to 14 days.

Is it necessary to take creatine with carbohydrates?

Fifteen years ago, the answer was: "Yes." Everyone was told to mix their creatine with juice or another carbohydrate-based drink. Today, we look at this from the perspective of your training goal.

"Using high-glycaemic carbohydrates to enhance creatine uptake has a solid scientific basis and is supported by studies," says Jose Antonio. However, large amounts of carbohydrate drinks are not the best choice for body composition. This means that if your training goal is fat loss, or if you compete in a weight-category sport, taking creatine with carbohydrates is not the ideal option. Even without carbohydrates, a significant increase in total intramuscular creatine concentration will still occur — it will simply take a little longer.

Alan Aragon also notes that there is no need for anyone to take creatine with carbohydrates once the loading phase is complete, or after taking a maintenance dose for longer than one month. At this stage, the muscles are fully saturated with creatine, and any additional carbohydrates consumed are simply extra calories.

Is creatine cycling necessary, or should it be taken continuously?

For most people, there is no need to worry about cycling creatine — that is, how long to take it and how long to take a break from it. Continuous use delivers consistent performance improvements. Athletes whose competition weight is restricted by weight categories should take a break from creatine from time to time, as creatine promotes intracellular water retention, which is beneficial for performance but also increases body weight. It is therefore recommended to discontinue creatine use 6 weeks before a competition weigh-in.

3. The impact of creatine on health

During my work as a coach with athletes, I have noticed their growing interest in health. Ten to fifteen years ago, it was very rare to hear athletes discussing the long-term impact of their training and diet on their health. This is partly because young people tend to feel a certain sense of invincibility. This shift also has a great deal to do with the way society perceives health through appearance. In other words, if you look good and are in great shape, you must surely be healthy too.

Nowadays, this notion is more widespread than ever. Yet someone who looks physically outstanding may feel far from well — whether due to chronic injuries, overtraining, or poor nutritional habits. We have all heard of athletes who died at a young age. Sometimes this premature death is caused by undiagnosed genetic conditions, but in other cases it could have been prevented.

Athletes themselves are acutely aware of this fact. They ask more questions about proper nutrition than they used to, particularly regarding supplements and their impact on health. What is the point of being stronger, leaner and better-looking than everyone else if you do not live long enough to enjoy it?

A few surprising health benefits of creatine:

1. Reduces inflammatory processes caused by intense training
2. Improves cognitive performance
3. Improves both long-term and short-term memory in vegetarians
4. Accelerates recovery in patients with chronic pulmonary disease
5. Helps alleviate symptoms of neuromuscular disorders
6. Protects cellular DNA from age-related mutations

Alan Aragon notes: "The clinical and therapeutic applications of creatine represent a very exciting and emerging area of research." For example, recent studies have demonstrated the effectiveness of creatine in improving glycaemic control in type II diabetes. A beneficial effect of creatine on knee osteoarthritis has also been demonstrated.

References:

• Creatine in Type 2 Diabetes: A Randomized, Double-Blind, Placebo-Controlled Trial. Gualano B et al. Med Sci Sports Exerc. 2011 May; 43(5):770-8
• Beneficial effect of creatine supplementation in knee osteoarthritis. Neves M Jr. et al. Med Sci Sports Exerc . 2011 Feb 8.[Epub ahead of print]
• Creatine supplementation reduces plasma levels of pro-inflammatory cytokines and PGE2 after a half-ironman competition. Bassit RA et al. Amino Acids 2008 Aug; 35(2):425-31
• Oral creatine monohydrate supplementation improves brain performance: a double-blind, placebo-controlled, cross-overtrial. Rae C et al. Proc Biol Sci. 2003 Oct 22; 270(1529):2147-50
• The influence of creatine supplementation on the cognitive functioning of vegetarians and omnivores. David
• Benton andRachel Donohoe. British Journal of Nutrition 2011; 105: 1100-1105
• Creatine improves health and survival of mice. Bender A et al. Neurobiol Aging 2008 Sep; 29(9):1404-11
• Clinical use of creatine in neuromuscular and neurometabolic disorders. Tarnopolsky MA. Subcell Biochem . 2007;46:183-204
• Creatine supplementation during pulmonary rehabilitation in chronic obstructive pulmonary disease. Fuld JP et al. Thorax2005 Jul; 60(7):531-7
• Creatine supplementation normalizes mutagenesis of mitochondrial DNA as well as functional consequences. Berneburgtí M et al. J Invest Dermatol. 2005 Aug; 125(2):213-20

4. Side effects of creatine

You have probably heard alarming stories about creatine — kidney damage, muscle tears, muscle cramps. The irony is that no study has demonstrated any side effect of creatine other than weight gain. For most athletes who use creatine, gaining weight is a benefit rather than a drawback.

The following research demonstrates the inaccuracy of these myths and claims.

Does creatine cause cramps and muscle injuries?

Based on research conducted at Baylor University: The incidence of cramping and injuries in Division IA football players was significantly lower or comparable in creatine users compared to football players who did not use creatine.

References:

• Greenwood M et al. J Athl Train. 2003 Sep; 38(3):216-219.
  
• Long-term creatine supplementation does not significantly affect clinical markers of health in athletes. Kreider R et al. Mol Cell Biochem. 2003 Feb; 244(1-2):95-104.

Does creatine supplementation have an adverse effect on the kidneys?

Numerous studies have found no negative impact:

1. Testing doses ranging from 3 to 30 grams per day over periods of 10 months to 5 years. None of the studies — whether short-term, medium-term or long-term — demonstrated any harmful effect on the kidneys or overall health.
2. Subjects administered a daily dose of 10 grams of creatine or a placebo for 3 months showed no renal impairment in healthy men engaged in aerobic training. Furthermore, the same study recommends aerobic exercise as a means of potentially improving kidney function.

References:

• Long-term oral creatine supplementation does not impair renal function in healthy athletes. Poortmans JR and FrancauxM. Med Sci Sports Exerc 1999 Aug; 31(8):1108-10
  
• Effects of creatine supplementation on renal function: a randomized, double blind, placebo-controlled clinical trial.Gualano B et al. Eur J Appl Physiol. 2008 May; 103(1):33-40. Epub 2008 Jan 11
  
• Borsheim E et al. Int J Sport Nutr Exerc Metab 2004 June; 14:255-71
  
• Williams MB et al. J Strength Cond Res 2003 Feb; 17:12-9

Does creatine cause dehydration, muscle stiffness, muscle strains or other injuries?

Jose Antonio, in one of his articles on his website, states: During one season of NCAA Division IA football training and competition, it was found that creatine users experienced significantly fewer cramps, less heat stress and dehydration, less muscle stiffness, fewer muscle strains and overall fewer injuries than non-users of creatine. Even for well-trained athletes, it is clear that regular creatine use causes no harm — in fact, it may actually protect against certain exercise-related complaints.

References:

• Blomstrand E et al. Eur J Appl Physiol Occup Physiol 1991; 63:83-8
• Greenwood M et al. J Athl Train. 2003 Sep; 38(3):216-219
• Kreider R et al. Mol Cell Biochem. 2003 Feb; 244(1-2):95-104

Brad Schoenfeld, responding to a report claiming that creatine leads to a specific type of injury, states: A recent article published in the New York Daily News linked creatine use to the current high incidence of oblique muscle injuries. According to Lewis Maharam, a sports physiotherapist and former president of the New York chapter of the American College of Sports Medicine, creatine adds water molecules to muscle fibres, pushing them apart. As a result, muscles tear more easily and take longer to heal. These are very strong claims, and with all due respect to Dr Maharam, I have found no peer-reviewed studies that even suggest such an effect. Yes, creatine increases intracellular hydration, but this cannot be regarded as a negative influence on muscles. On the contrary, studies have shown that increased intracellular water content has a positive effect on protein synthesis and reduces protein breakdown, which definitively strengthens cellular structure (1). If Dr Maharam or anyone else has evidence to support the contrary, I would be very happy to see it.

Brad Schoenfeld cites a study: Changes in cellular hydration not only contribute to the regulation of metabolism, but also critically determine the cellular response to various forms of stress. Cell swelling triggers anabolic processes and protects the cell against heat and oxidative stress, while cellular dehydration contributes to insulin resistance and catabolism and increases cellular sensitivity to stress-induced damage.

References:

• The Cellular Hydration State: A Critical Determinant for Cell Death and Survival. Schliess F and Häussinger D. Biological Chemistry 2002 March-April; 383(3-4): 577–583

5. Creatine and young people under the age of 18

Is creatine safe for children?

Administering creatine to children and even infants has a long history. A very small number of children are born with a congenital creatine metabolism disorder. This is an extremely rare condition, but if left untreated, it can lead to serious health problems such as intellectual disability and autism. Some of these children have been treated with creatine monohydrate, receiving doses of 4 to 8 grams per day for up to 25 months — the equivalent of 80 to 160 grams per day for an adult. These patients showed significant improvements in brain function, and overall creatine levels in the body returned to normal. David Sandler adds: "Some of the earliest research on creatine was conducted on very frail infants. So yes, creatine is safe."

References:

• Creatine replacement therapy in guanidinoacetate methyltransferase deficiency, a novel inborn error of metabolism. Stockler S et al. Lancet 1996 Sep 21; 348(9030): 789-90

Are there conditions in which creatine supplementation is beneficial for children?

Yes, creatine has been successfully used in children with muscular dystrophy. In one study, children taking creatine monohydrate for 4 months gained both strength and muscle mass, experienced fewer fractures, and all of this occurred without any side effects. Creatine has also been used in paediatric oncology patients undergoing chemotherapy. Corticosteroids, which are used to manage the side effects of chemotherapy, are well known for causing rapid fat gain. In patients taking creatine, these gains were attenuated.

References:

• Creatine monohydrate enhances strength and body composition in Duchenne muscular dystrophy. Tarnopolsky MA et al. Neurology 2004 May 25; 62(10): 1771-7
  
• Creatine monohydrate attenuates body fat accumulation in children with acute lymphoblastic leukemia during maintenance chemotherapy. Bourgeois JM et al. Pediatric Blood Cancer 2008 August; 51(2): 183-7

Does creatine improve performance in young athletes?

A study was conducted on 16 elite junior swimmers, half of whom took creatine (5 grams four times daily for 5 days) and the other half received a placebo. The creatine group showed improvements in both strength and performance, despite the fact that these young athletes were already in peak competitive condition under intensive training.

References:

• Creatine supplementation improves the anaerobic performance of elite junior fin swimmers. Juhász I et al. Acta Physiol Hung. 2009 Sep; 96(3): 325-36

6. Conclusion

Simply put:

• Creatine is safe
• Creatine is effective

Proven benefits:

• Increased muscle mass
• Increased muscle fibre cross-sectional area (muscle density)
• Fat loss
• Improved hydration
• Increased strength, power, speed and endurance
• Improved functional capacity in patients with various neuromuscular disorders
• Enhanced focus and cognitive capacity
• Reduces brain injury following acute trauma
• Improvement of sensory and motor functions in infants with congenital creatine synthesis deficiency
• Better outcomes in patients with COPD (Chronic Obstructive Pulmonary Disease)

In addition, creatine acts as a moderate antioxidant in vitro and has a positive effect on mood and task performance following 24 hours of sleep deprivation.

Creatine does not cause:

• Muscle cramps or heat stress
• Oblique muscle strains
• Impaired kidney function

For best results:

• Take 3–6 grams of creatine monohydrate daily to maintain elevated creatine saturation
• If you choose to carry out a loading phase for faster results, take 10–20 grams per day for 7 to 14 days.
• Athletes competing in weight-category sports should discontinue creatine at least 6 weeks before their weigh-in.

In closing, I would once again like to thank my friends for sharing their expertise and research with me. Their websites can be found at the following addresses:

Jose Antonio: www.joseantoniophd.com
Brad Schoenfeld: http://workout911.com/
Alan Aragon: http://alanaragon.com/

7. Special acknowledgements

I consider myself to be among the leading expert coaches in the field of strength and conditioning. I know what the top researchers and practitioners are currently working on. I am familiar with the latest techniques. I can discuss current controversial topics with anyone.

But when the conversation turns to nutrition, I am not quite the expert. I am a student.
The information contained in this publication comes from three of my friends and colleagues:

• Jose Antonio, Ph.D., CEO of the ISSN
• David Sandler, Director of Education for the NSCA
• Alan Aragon, nutritional consultant who works with a wide range of clients and is regularly cited in publications such as Men's Health.

This article presents their knowledge and research findings.

Author: Nick Tumminello
Copyright © 2012 by Nick Tumminello. All rights reserved.

No part of this publication may be modified or reproduced in any form, whether mechanical or electronic, without the written permission of Nick Tumminello.