Answers to all of your questions about creatine

After high school I remember training with my brother. And the goal wasn't to improve performance in a sport. And it wasn't to sprint faster. Or to rehab an injury.

It was purely for bodybuilding. We trained to get as big and strong as possible with more emphasis on the former.

And while we didn't invest a dime into programming or coaching we always found it in the budget to have a tub of protein, some bars and creatine.

So while creatine has been available commercially to the average gym goer for over 30 years there are still a number of myths regarding this supplement. Some of the top supplement researchers and editors of the Journal of the International Society of Sports Medicine collaborated to put out a review of the more common questions that exist about creatine. The following is a brief summary of this review with the citation to follow.

Does creatine lead to water retention?

Researchers will distinguish between total body water (TBW), intracellular water (ICW) and extracellular water (ECW). Most studies do not show an increase in TBW. When loading creatine this is usually done at higher doses than during the maintenance phase and early research showed some water retention but didn't distinguish between ICW and ECW.

The general understanding is that there is some evidence of water retention, primarily ICW, over the short term. Several studies show creatine doesn't alter TBW (ICW or ECW) relative to muscle mass.

Does creatine damage the liver or kidneys?

After more than 20 years of research there are no adverse effects from taking the recommended dosage of creatine. Creatine and phosphocreatine are degraded to creatinine. The amount of creatinine in the blood is proportional to body mass and creatine intake.

There was a case study from the late 1990s when an individual did experience elevated levels of creatinine and usage was discontinued for this reason. Apparently this individual had previous renal/hepatic issues and was loading at 15 g per day. The case study makes no mention of the diet of the individual which can contribute to elevated levels of creatinine.

For healthy individuals, ingesting normal dosages, there are no known adverse effects for the kidneys or liver.

Does creatine cause dehydration or cramping?

During the loading phase of 20 g/ day for 5-7 days there may be an increase in body mass of 1-3 kg, which is mostly body water retention. The studies that do show dehydration/cramping don't control for other supplements and beverages.

As well, a study looked at how many creatine users use the recommended daily dose and found 91% exceeded these amounts.

Another study had subjects put into two groups. 38 of them took creatine and another 34 took a placebo. Those that took creatine had less cramping, heat illness, dehydration, tightness, muscle strains and injuries.

And a study involving haemodialysis patients (n=10) that reported frequent cramping were given 12 grams of creatine before haemodialysis and saw a decreased frequency of cramping by 60%.

The take home message is the creatine does not appear in the research or anecdotally to result in cramping or dehydration.

Does creatine increase fat mass?

Whenever a substance is known to increase body mass, as creatine does, there may be concern for an increase in fat mass. This concern may be justified in that rarely do we add 100% muscle mass and zero fat mass when we increase our mass.

The literature is pretty clear and consistent on this however. There are numerous studies showing an increase in body mass, an increase in fat free mass yet no increase in fat mass. One study with swimmers showed no change in body composition.

A common criticism of the studies showing no increase in fat mass is that they are less than 8 weeks in duration and thus not long enough in duration to demonstrate a physiological change. There are more than enough studies greater than 8 weeks which show no significant change in fat mass.

Of interest was a study involving children with lymphoblastic leukemia. For 16 weeks some of the children received creatine and the others a placebo. Those taking creatine saw their fat mass decrease while those that didn't take it saw an increase in their fat mass.

Supplementing with creatine may increase body mass without increasing fat mass.

Is a loading phase required?

If you're familiar with using creatine as a supplement you'll know there's something called a 'loading' and a 'maintenance' phase. The loading phase involves taking creatine at 20-25 grams per day for 5 to 7 days to saturate the muscle. Once the loading phase is complete then the maintenance phase follows at doses of 3-5 grams per day.

A study compared loading versus simply going to the maintenance phase and determined that both resulted in an increase of muscle creatine concentrations by 20%. Loading speeds up the process but doesn't add any additional benefits. Going straight to a loading phase delays but doesn't limit the benefits of using creatine when used for at least four weeks.

When an athlete is looking to benefit from creatine in a short period of time i.e. less than 3 weeks, than a loading protocol would be preferred. If creatine will be used for a longer duration i.e. at least four weeks, than it would be fine to go straight to a maintenance phase, especially if avoiding or minimizing the increase in body mass is desirable.

Is creatine just for power or resistance athletes?

We know that creatine is a phosphagen and helps supply and replenish cellular energy for short burst, high intensity activities. So typically it has been sought out by athletes that need to display high levels of force in a short period of time. This would include sprinting, jumping, throwing and kicking among other actions.

But does creatine help other athletes and functions?

There is growing evidnce to suggest that it is. For example, when creatine is taken with carbohydrate or carbohydrate with protein there is greater glycogen storage compared to carbohydrate alone. Glycogen is the form of carbohydrate that we store in the muscle and liver and is important for training and recovery.

Those that supplement with creatine show less muscle damage and in a four week study with runners training up to 30 km those taking creatine experienced less muscular damage, inflammation and soreness.

Lastly, creatine appears to offer protective benefits to the brain and spinal cord and may be a good idea for those in collision sports and at risk for concussion.

Creatine offers many benefits and need not be limited to only those in power or resistance sports.

Below is a summary of each of the sections of the review. For more details and to read the sections not covered above see the citation below. The section below in italics is copied directly from the review.

Based on our evidence-based scientific evaluation of the literature, we conclude that:

1. Creatine supplementation does not always lead to water retention.
2. Creatine is not an anabolic steroid.
3. Creatine supplementation, when ingested at recommended dosages, does not result in kidney damage and/or renal dysfunction in healthy individuals.
4. The majority of available evidence does not support a link between creatine supplementation and hair loss / baldness.
5. Creatine supplementation does not cause dehydration or muscle cramping.
6. Creatine supplementation appears to be generally safe and potentially beneficial for children and adolescents.
7. Creatine supplementation does not increase fat mass.
8. Smaller, daily dosages of creatine supplementation (3-5 g or 0.1 g/kg of body mass) are effective. Therefore, a creatine ‘loading’ phase is not required.
9. Creatine supplementation and resistance training produces the vast majority of musculoskeletal and performance benefits in older adults. Creatine supplementation alone can provide some muscle and performance benefits for older adults.
10. Creatine supplementation can be beneficial for a variety of athletic and sporting activities.
11. Creatine supplementation provides a variety of benefits for females across their lifespan.
12. Other forms of creatine are not superior to creatine monohydrate.

Antonio J., Candow D.G., Forbes S.C., Gualano B., Ragim A.R., Kreider R.N., Rawson E.S., Smith-Ryan A.E., VanDusseldorp T.A., Willoughby D.S. & Ziegenfuss T.N. (2021). Common questions and misconceptions about creatine supplementation: what does the scientific evidence really show? Journal of the International Society of Sports Nutrition, 18(13).