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From a cost/benefit perspective, one of the most useful supplements is creatine, often consumed as the form of creatine monohydrate. This assumes you are getting enough protein, of course; if you consume insufficient protein, a branch chain amino acid-rich supplement will probably have more bang for your buck. Athletes have used creatine for decades to increase muscle mass and improve physical performance. This creates the added benefit of making creatine one of the most extensively studied supplements for physical performance, which is why I feel completely comfortable saying everyone should be supplementing it.

(*However, just to be safe, never take these blog posts as medical advice- we are all unique individuals, and you should consult a medical professional who knows you personally before trying any supplements, medications, biohacks, saunas, ground up grasshopper powder, or whatever else is making headlines today.)

Without supplementation, we come by creatine naturally from the meat products in our diets, and it is also produced in significant quantities by the liver and kidneys. Creatine is a source of energy, primarily in muscle cells, by acting as a “phosphate donor”. By breaking off that phosphate, other enzymes in the cells can perform their jobs like facilitating muscle contraction or electrolyte transport. It is also used in other metabolically active tissue like the central nervous system.

1. Wait, isn’t that dangerous?

Creatine has been mythologized for years, both the good and the bad. One common concern about creatine is that it contributes to water retention. This could be clinically meaningful to people with kidney and heart disease that makes them sensitive to changes in water balance. But that rumor isn’t necessarily true… or doesn’t tell the entire story. In reality, studies show that fluid volume in the body increases when a person starts taking creatine. This is more common if the regimen is “loaded” with several days of extremely high doses to spur faster uptake by muscles. However, over time, the fluid redistributes from the “periphery” into muscles. This means there is little concern for risks like peripheral or pulmonary edema.

Another concern comes from the persistent myth that creatine and protein supplementation can cause or contribute to the progression of kidney disease. Protein’s role in this area isn’t straightforward and will be discussed another day, but when it comes to creatine this rumor is completely untrue. This misconception is likely the result of the way we professionals usually study kidney function. Creatinine is a product that comes from the breakdown of creatine in the body. All else being equal, healthcare professionals interpret a rise in creatinine as worsened kidney function. However, this doesn’t take into account people who use creatine supplements.

As creatine levels increase from outside sources, so does the metabolism of creatine into creatinine. This has nothing to do with decreased kidney function, and everything to do with higher levels of creatine, which becomes correlated with an increase in skeletal muscle. Overall, a 2023 narrative review addressing the specific concept of “creatine supplementation-induced kidney failure,” reiterated that available randomized controlled trials cumulatively show creatine does not induce kidney failure; though, concerned healthcare providers may find it prudent to monitor kidney function in older patients or those at risk of worsening kidney function due to the incomplete body of evidence in these special populations(1).  In the available literature, “creatine supplementation appears safe and well tolerated in virtually all medical patient populations (2).”

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2. Creatine’s Place in a Prehabilitation Toolbox

Resistance training and muscle growth are important parts of prehab—as touched on in the exercise pillar—and creatine is helpful to both ends. Research has shown that when training in hot environments, creatine supplement users had significantly less heat illnesses, dehydration, muscle tightness, and cramping compared to non-users. Overall, athletes supplementing creatine had fewer sports related injuries, particularly when training in heat. This could be due to creatine’s hydrating effect as water follows it into skeletal muscle. Patients with kidney disease and frequent muscle cramps who started supplementing creatine also reported significant improvement (3,4).

Sports medicine researchers consider creatine safe and potentially beneficial for people of all ages.

Creatine supplementation in a patient undergoing prehabilitation has multiple benefits. When combined with resistance training, creatine allows for greater strength increases and muscle gain, along with decreased pain from exercise. Creatine alone has minimal effect on muscle growth without exercise, but it may lessen loss of muscle mass (atrophy) due to short-term inactivity. This is very important for recovery after a surgery or treatment because exercise usually isn’t feasible during this phase. Losing as little muscle mass as possible is hugely beneficial, especially for those who have the greatest difficulty building muscle in the first place.

Creatine may also benefit individuals with metabolic disease. Metabolic-associated fatty liver disease (MAFLD, previously called “non-alcoholic fatty liver disease”) is becoming much more common in people with central obesity and metabolic disease. The good news is that studies have shown improvements in MAFLD with creatine supplementation. Through similar mechanisms in the brain, creatine has also been shown to potentially have antidepressant effects in certain individuals.

It’s important to note that individuals starting to take creatine are also typically increasing their fitness participation. Exercise has well-documented psychiatric and metabolic benefits that could be affecting depression and fatty liver disease just as much as the creatine, itself.

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3. Can I Just Get It From My Diet? How much can I really need?

Meat products are a main dietary source of creatine. There is no recommended daily amount for creatine consumption, so technically, we also can’t say if someone has a deficiency. However, most people can potentially derive one of the many benefits from supplementing creatine, which would imply the average diet does not max out the capacity for creatine intake. Since creatine is most found in animal products, vegetarians and vegans could likely most benefit from a daily creatine supplement.

These days the prevailing wisdom is that consumers can overcome any marginal benefit a fancy formulation of creatine (esters, etc.) provides over garden variety creatine monohydrate by simply increasing their dose of monohydrate. In other words, even if creatine ethyl ester, for example, is better absorbed, a higher dose of creatine monohydrate likely provides the same net creatine uptake at a lower total cost. Before any representatives from “Big Creatine” hunt me down, I have not conducted an exhaustive search of every head-to-head comparison of creatine monohydrate and its creatine cousins. At this point, if an existing creatine formulation is “statistically significantly” better at something, it probably isn’t a clinically meaningful improvement. In other words, with a large enough sample size, we can find statistical significance in smaller and smaller differences in clinical effect. However, if creatine monohydrate increases muscle mass by 5% and creatine-fancy-expensive-ketoglutarate increases muscle by 5.2%, does it actually matter?

Considering its demonstrable benefits, creatine supplementation may play a role in certain patients undergoing prehabilitation. When combined with resistance training, creatine allows for potentially greater strength increases and hypertrophy with decreased pain from exercise.  Without an exercise stimulus, creatine alone has minimal effect on muscle growth. Studies conflict on whether it can mitigate the normal loss of muscle mass from short-term inactivity such as when recovering from injury, illness, or surgery(5).  However, as many patients undergoing prehab are also struggling with psychiatric illness, frailty, and other systemic issues, creatine may represent a minimal risk, low cost supplement that may be worth exploring.  

If you enjoyed the above and are not a member of “Big Creatine” looking to give us a hard time, please click here to get a bundle of these insights and other new exciting headlines emailed to you once per month. It’s free, and we promise not to spam you. Spam would be counterproductive- as a food source, it is not in our prehab toolbox. As an outreach strategy, it makes readers understandably inclined to tell “Big Creatine” where we’ve been hiding.

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