The negative stigma of creatine in the media continues

Earlier this week, I caught an article in the New York Times covering a rare occurrence: 24 members of a high school football team in Oregon developed rhabdomyolysis (muscle breakdown) from an intense workout with limited water in very hot temperatures.  Rhabdomyolysis is characterized by an increase in the enzyme creatine kinase, which is maybe one reason why reports erroneously seem to jump on the following dogma:

Officials were waiting for the results of tests to determine whether the athletes were using any supplements, like creatine, which can aggravate the condition.

With a quick search, other absurdities included:

Football Players Wary of Creatine After McMinnville Incident

As well as:

One substance tied to the syndrome is Creatine found in supplements.

The Journal of Athletic Training at the National Institutes of Health concluded: “… because of the intracellular fluid retention in the muscle cell … serious medical concerns may exist for individuals supplementing with CrM. (Creatine).”

Which is scientifically naive because research shows that if anything creatine may be protective against heat stress because of this fluid retention.

Winkler said blood test results expected Tuesday could show whether the athletes ingested creatine, which is found in legal high-powered protein supplements. He added officials are not testing for steroids because it would be unlikely for that many students to have access, and “creatine makes way more sense.”

Right, no matter the dozens of oral steroids readily available on the internet that actually aren’t destroyed by the liver because of 17 alpha alkylation and because the Anabolic Steroid Control Act is rarely enforced.

There are many more, as well as a long history of people and media blaming creatine for dehydration, muscle or kidney damage, cramps, and other maladies.  Never-mind the established risks in many of these cases of muscle trauma, dehydration, and heat stress- fingers are still pointed at creatine.

I don’t know how they are testing for this as suggested from the NYTimes article, as creatine is found in meats such as steak or fish.  Testing plasma creatine would not necessarily mean athletes are supplementing, though meat consumption would need to be high and consistent to reach plasma saturation.  Acute creatine supplementation of 1-10 grams reaches a maximal plasma concentration in less than 2 hours, when it is distributed to various tissues.  Notably for athletic performance, intramuscular forms of creatine are increased with large acute doses or consistent small doses.  As these stores saturate, baseline plasma creatine increases to a maximal concentration, which theoretically could be tested to indicate supplementation.  Creatine is eliminated from the body at a rate of about 2% of the total pool per day, which would have to be considered as well.  The considerations for testing would be numerous.  The International Society of Sports Nutrition (who have their own journal) stated in their 2007 position paper on creatine (1) that there is no valid test for creatine supplementation.

In this paper (which is open access here), they note a number of studies showing a neutral or protective effect of creatine on muscle injury or heat stress:

If anything, it could be argued that banning the use of creatine would be unethical as it has been reported to decrease the incidence of musculoskeletal injuries [2,66,75,94], heat stress [2,95,96]

A separate paper published in 2008 by Dalbo et al. (2) covers the issue in more detail, highlighting studies by Vogel et al. (2000), Kern et al. (2001), Kilduff et al. (2004), Mendel et al. (2005), Volek et al. (2001), Watson et al. (2006), Weiss et al. (2006), Branch et al. (2007), Easton et al. (2007), and Wright et al. (2007) that collectively suggest that creatine has either a neutral or beneficial effect on dehydration risk by increasing water retention, lowering body temperature, and reducing exercising heart rate and sweat rate.  This BJSM paper is available to read if you sign up for free through the BMJ.

There just isn’t a plausible explanation why there are no reports in the (large body of) literature of creatine increasing risk of muscle damage, so rational thinking would preclude creatine as a causal factor in these 24 cases in a single team, while millions of people have taken in before without developing rhabdomyolysis.  It simply isn’t logical that so many concentrated cases would suddenly appear.

Not surprisingly, the ISSN pushed out a press release by email yesterday about the issue, which I think is important to republish here for more visibility (the little I can help):

FOR IMMEDIATE RELEASE:

Creatine Does Not Promote Dehydration or Rhabdomyolysis in Athletes

WOODLAND PARK, CO, AUGUST 25, 2010 – Recent media reports have suggested that ingestion of the dietary supplement creatine monohydrate may have contributed to the hospitalization of several athletes from McMinnville High School in Oregon for rhabdomyolysis (i.e., a rapid breakdown of skeletal muscle due to injury that typically presents with marked elevations in the enzyme creatine kinase [CK] in the blood) and/or anterior compartment syndrome (ACS). It is well known that excessive exercise in hot and humid environments can promote dehydration, muscle breakdown, and result in marked elevations in muscle CK levels. In severe instances, this may lead to exertional rhabdomyolysis particularly in athletes who have been engaged in intense exercise in hot and humid environments for several days and who become chronically dehydrated. Additionally, excessive exercise in individuals unaccustomed to heavy training bouts can promote anterior compartment swelling, pain, and pressure. It is well known that dehydration and/or heat illness can exacerbate this clinical course.

According to press reports, the athletes in this case were engaged in a several day “immersion” camp.  The athletes began to complain about swelling in their arms after performing a series of push-up and chair dip exercises in a 30-second alternating bouts of repetitions for over 20 minutes until exhaustion in a hot and humid wrestling room.  Temperatures in the room were reported as high as 115-120°F.  Moreover, the athletes were reported to have to start a repetition scheme over again if all of the athletes did not complete their repetition goals.  Further, the athletes were not allowed to drink water during the training session.  None of the athletes indicated they took creatine (or any other supplement or drug).   Nevertheless, media reports indicated officials are investigating whether creatine may have been linked to this incident.

The International Society of Sports Nutrition (ISSN) is the leading professional organization in the field of sports nutrition. In 2007, the Research Committee of the ISSN formed a team of sport nutrition researchers, dietitians, and physicians to extensively review the available scientific literature on creatine supplementation and exercise and to develop a Position Stand for the Society which was published in the Journal of the International Society of Sport Nutrition (see:www.jissn.com/content/4/1/6).   After extensive review of the literature, the ISSN adopted the following positions relative to this issue:

1. Creatine monohydrate is the most effective ergogenic nutritional supplement currently available to athletes in terms of increasing high-intensity exercise capacity and lean body mass during training.

2. Creatine monohydrate supplementation is not only safe, but possibly beneficial in regard to preventing injury and/or management of select medical conditions when taken within recommended guidelines.

3. There is no scientific evidence that the short- or long-term use of creatine monohydrate has any detrimental effects on otherwise healthy individuals.

4. If proper precautions and supervision are provided, supplementation in young athletes is acceptable and may provide a nutritional alternative to potentially dangerous anabolic drugs.

5. At present, creatine monohydrate is the most extensively studied and clinically effective form of creatine for use in nutritional supplements in terms of muscle uptake and ability to increase high-intensity exercise capacity.

6. Creatine monohydrate has been reported to have a number of potentially beneficial uses in several clinical populations, and further research is warranted in these areas.

Specific to the alleged association of creatine to development of rhabdomyolysis and ACS; a number of studies have evaluated the effects of creatine supplementation on dehydration, cramping, fluid retention, muscle injury, CK levels, and health status in athletes engaged in intense exercise (including football players engaged in intense training in hot and humid environments). These studies have consistently indicated that creatine supplementation does not promote cramping, muscle injury, elevations in CK, and/or heat related injuries. Conversely, studies report that creatine may improve the athlete’s ability to tolerate intense exercise in hot and humid environments and lessen the incidence of injury. Athletes have been using creatine on a widespread basis as a dietary supplement since the early 1990’s. No clinically significant side effects have been reported and a number of potentially beneficial medical uses are being studied. It is the opinion of the ISSN that suggestions that creatine caused this incident is inconsistent with the scientific literature and implausible.

According to noted sports nutrition scientist Richard Kreider, Ph.D., FACSM, FISSN of Texas A & M University, “Many studies have been done (since the early 1990’s) that show creatine does not cause dehydration, muscle damage, or increase susceptibility to heat-related illness in athletes involved in intense training in hot and humid environments.  If anything, research shows that creatine promotes hyperhydration (i.e., whole body fluid retention) leading to less thermogregulatory stress during intense exercise in the heat.  It is unfortunate that individuals unfamiliar with the creatine literature are speculating that creatine caused this problem when the athletes indicated they did not take creatine and they ignore the obvious precursors: excessive and inappropriate training in a hot and humid environment.”

About the ISSN: The International Society of Sports Nutrition is the only non-profit academic society dedicated to promoting the science and application of evidence-based sports nutrition and supplementation. www.theissn.org

CONTACT: Jose Antonio, Ph.D. – CEO
International Society of Sport Nutrition

ISSN@sportsnutritionsociety.org561 239 1754

So,

The fact is that over 200 studies have been published on creatine and athletic performance, and so far safety does not seem to be an issue in healthy athletes.  It is by far the most studied ergogenic aid, and one of the only effective supplements available.  Media reporters and many physicians need to wake up to the evidence.

References

1. Buford TW, Kreider RB, Stout JR, Greenwood M, Campbell B, Spano M, Ziegenfuss T, Lopez H, Landis J, & Antonio J (2007). International Society of Sports Nutrition position stand: creatine supplementation and exercise. Journal of the International Society of Sports Nutrition, 4 PMID: 17908288

2. Dalbo VJ, Roberts MD, Stout JR, & Kerksick CM (2008). Putting to rest the myth of creatine supplementation leading to muscle cramps and dehydration. British journal of sports medicine, 42 (7), 567-73 PMID: 18184753

  • http://carbsanity.blogspot.com CarbSane

    Stories like this bug me because there was a “Fox News Alert!” (well maybe it wasn’t an FNA) blitz about this “curious” story, but, as is typical, I had not heard or seen anything in follow-up. Took a few searches to find this: McMinnville football: Workout, heat, dehydration cited by health division

    Bottom line on creatine?
    Blood tests for creatine levels were inconclusive, the report indicated, because the tests do not distinguish creatine supplementation from naturally occurring creatine levels.

    No story there …..

  • http://carbsanity.blogspot.com CarbSane

    Stories like this bug me because there was a “Fox News Alert!” (well maybe it wasn’t an FNA) blitz about this “curious” story, but, as is typical, I had not heard or seen anything in follow-up. Took a few searches to find this: McMinnville football: Workout, heat, dehydration cited by health division

    Bottom line on creatine?
    Blood tests for creatine levels were inconclusive, the report indicated, because the tests do not distinguish creatine supplementation from naturally occurring creatine levels.

    No story there …..