The International Society of Sports Nutrition recently published a new position stand on the safety and efficacy of creatine supplementation and I thought it would be useful to summarise the main points specifically in relation to athletic performance. 

Creatine, particularly the most bioavailable form creatine monohydrate, is one of the most popular supplements used by athletes, predominantly power- and strength-based athletes. It’s one of the few supplements that I usually recommend to my powerlifting and CrossFit clients, looking to become more serious within their sport. Research has consistently shown that it increases capacity for high-intensity exercise, improves sprint performance, increases muscle mass and strength adaptations, and enhances post-exercise recovery by promoting greater glycogen replenishment and less inflammation. In addition, there is some evidence to suggest that athletes supplementing with creatine monohydrate experience less injuries, while those exercising in hot and humid environments may increase their tolerance to those conditions because of creatine’s osmotic properties that help retain a small amount of water. The position stand also shows that creatine monohydrate supplementation could be an effective nutritional strategy to lessen muscle atrophy caused by immobilisation from injury, promote recovery during rehabilitation, and even limit damage from concussion, traumatic brain injury and spinal cord injury, that can occur in more high-risk sports such as rugby, downhill skiing, etc.

The main role of creatine monohydrate supplementation is to increase phosphocreatine (PCr) stores by combining with a phosphoryl (Pi) group. PCr helps to shuttle a Pi group to resynthesise adenosine diphosphate (ADP) into adenosine triphosphate (ATP), which had been initially degraded into ADP + Pi to provide free energy in order to power a muscle contraction. In other words, the increased PCr stores help maintain the ATP availability needed for high-intensity exercise, particularly anaerobic sprint-type exercise. Creatine monohydrate supplementation also facilitates intracellular energy transport via the creatine kinase (CK)/PCr energy shuttle, that tightly connects sites of ATP production via glycolysis and oxidative metabolism, with ATPases that utilise ATP in order to fuel metabolism. Creatine also acts as a mild direct free radical scavenger and as an indirect antioxidant in the mitochondria due to the reduced production of reactive oxygen species as a result of the tight coupling of ATP production and ATP export.

The position stand provides some nice examples of different sports that could benefit from creatine monohydrate supplementation, which are outlined in Table 1 according to the respective physiological mechanism. 

Table 1 – Sports that may benefit from creatine monohydrate supplementation. Adapted from Kreider, et al (2017).

*I would add CrossFit to each column since it incorporates elements from several sports.

The daily turnover of creatine is normally between 1-3g depending on an individual’s muscle mass. Around half of the daily requirement is obtained from dietary intake. An omnivorous diet (including 450g of uncooked beef or salmon, for example) provides 1-2g/day of creatine, which equates to 60-80 per cent saturation in muscle cells. Accordingly, supplementation increases muscle creatine and PCr stores by 20-40 per cent. What isn’t present in the diet is made endogenously by the liver and kidneys from the amino acids glycine, arginine and methionine.

Because vegetarian/vegan athletes have lower intramuscular creatine levels, since creatine is predominantly present in meat, fish and seafood, they may benefit even more from creatine monohydrate supplementation than their omnivorous counterparts.

According to the position stand, the most effective supplementation protocol is a loading phase with roughly 0.3g/kg body weight (or 5g) four times daily for 5-7 days, followed by a maintenance phase of 0.03g/kg body weight (or 3-5g up to 10g for larger athletes) for 4-6 weeks. An alternative protocol is to consume 3g/day of creatine monohydrate for 28 days. This is a more gradual and conservative approach with lower initial performance effects than the first protocol. Once creatine stores are saturated, it normally takes 4-6 weeks for creatine stores to return to baseline levels. Taking creatine monohydrate in conjunction with just carbohydrate, or carbohydrate and protein, seems to promote greater creatine retention.

The authors further state that creatine monohydrate is a safe and effective approach for children and adolescent athletes as long as they are supervised during competitive training, consume a nutritious diet that supports their performance and are aware of the appropriate use of creatine monohydrate supplementation.

Creatine monohydrate is one of the few nutritional supplements that research has consistently shown to have ergogenic benefits. It is also considered a safe and even effective preventative nutritional approach for athletes who engage in sports with an increased risk of head or spinal cord injury. Of course, not all individuals will respond in a similar way to creatine monohydrate supplementation. If an athlete is not responding, it is likely that they already have naturally high creatine stores. Nevertheless, creatine is probably one of the best ergogenic and preventative supplements out there for power- and strength-based athletes, as long as they have their foundation in place – a high-quality, nutritious and consistent diet.