The Antisocial Doctors Podcast

Episode 17: Should We All Be Taking Creatine?

• Sonia Singh • Episode 17

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0:00 | 51:48

In this episode, we talk about why creatine is suddenly everywhere on social media and why patients are asking about it for everything from brain fog and mood to menopause and dementia prevention. We tease what the evidence actually says (and doesn’t say), why context matters, and how to think about “for whom” and “for what” before adding any supplement. We also touch on common misconceptions, practical considerations that come up in real clinic visits and lab work, and why nuanced, shame-free conversations beat hot takes and miracle-claim marketing. If you’re curious about whether creatine belongs in your routine—or just tired of confusing wellness messaging—come listen.

00:00 Podcast Intro
01:24 Why Creatine Now
03:48 Viral Claims Breakdown
05:46 Why It Went Viral
09:07 Creatine Basics Explained
10:43 How To Take Creatine
12:34 Muscle Benefits Evidence
15:33 Menopause And Bone Health
18:13 Cognition And Dementia Data
21:33 Sleep Deprivation Studies
25:56 Creatine for Depression
28:30 Why Evidence Stays Weak
31:04 Side Effects and Labs
34:15 Supplement Quality Risks
35:09 Hype and Hidden Harms
38:10 Personal Takeaways
41:01 Clinical Bottom Line
43:40 Talking to Patients
45:52 Practice Changes and Trust
49:26 Wrap Up and Disclaimer

📖 Read the full episode summary, sources, and resources on our Substack:
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Sonia Singh MD

You're listening to The Anti-Social Doctors Podcast hosted by me, Sonia Singh, a board-certified internal medicine physician with a master's in nutrition and a special interest in health anxiety.

Rebecca Berens MD

And me, Rebecca Behrens, a board-certified family medicine physician with a special interest in disordered eating.

Sonia Singh MD

We're also millennial women, anxious moms, and curious humans navigating social media. We've seen firsthand how these platforms can be powerful tools for education and connection, but can also make us unwell.

Rebecca Berens MD

This podcast is meant to be the antidote to your doom scrolling, a solve for the anxiety, stress, guilt, shame, and confusion that comes from social media's messaging around health. In each episode, we discuss a health-related topic trending on social media with curiosity, nuance, evidence, humility, and compassion.

Sonia Singh MD

This is not your average debunking podcast. We wanna explore not just what is trending on social media, but why. Why are so many people drawn to this? What is the nugget of truth here? What are the facts? What can we learn from this as patients and doctors? No shame, no blame, no snark.

Rebecca Berens MD

We're so glad you're here

Sonia Singh MD

Hi, Rebecca

Rebecca Berens MD

Hi, Sonya

Sonia Singh MD

How's it going today?

Rebecca Berens MD

It's, it's going.

Sonia Singh MD

The usual, huh?

Rebecca Berens MD

Always.

Sonia Singh MD

So today we're talking about honestly an oldie but a goodie, a topic that's been a topic for actually many years, but I think has taken on new momentum recently.. The topic today is creatine, and I've been asked about creatine by patients for basically my entire career. But usually it was in people who are very athletic or very into fitness that were asking me. And a couple months ago, I had a patient who is a sweet sedentary librarian message me and say, "Should I be taking creatine for my brain fog and depression?" And I was like, "What?" And immediately was like, "Oh, I think, sh- you know..." I was like, "Tell me more. Tell me more about where you got this idea." And she was like, "Oh, I've been seeing all over social media that creatine helps with cognition and focus and mood, and I decided that maybe I should give it a shot." So that's what prompted me to do initially a deeper dive on this and explore what the latest is on creatine. I'm curious if you've been getting similar questions in your practice.

Rebecca Berens MD

Yeah, I definitely recently. I feel like it's come along with all the perimenopause stuff- that's on social media. It's like the next thing. First people were asking about hormones, and then it was like, "Okay, so what other supplements do I need? Should I be taking creatine? Should I be taking, magnesium threonate?" All the different supplements that come along with perimenopause recommendations a lot. Yeah. But yeah, see, it's interesting 'cause I've, I don't think I ever had patients ask me about it before. It just sort of- Oh, really? Yeah. It just came up, like for the really athletic patients, we would be talking about some unrelated thing and... Or maybe their creatinine level was high or something. Yes, yeah. And they're like, "Oh yeah, but I take creatine." I'm like, "Oh, okay. We didn't, you didn't break thing, bring that up at all when I asked you if you take any medicines or supplements." It's just like a assumed thing like, "Oh, of course I'm taking that," but yeah, it's, it was never something that I talked about a lot with patients other than- people mentioning it until very recently.

Sonia Singh MD

No, actually you're right about that. Most of them were not coming to me and being like, "What do you think about this?" Yeah. They would just be, "I'm taking this. Are you okay with it?" So or yes, it would be after the fact where I would be like, "Oh, your creatine came back a little high." And they say, "Oh yeah, I'm taking creatine." So you're, yeah, you're totally right about that. Usually they weren't coming to me for- permission or advice. They were informing me that they were doing it. Okay, so what are the new claims around creatine? So I think m- many people have heard that creatine is good for trying to build muscle, but now it's also being pitched as something that boosts your brain, helps with your mood, concentration, brain fog, bone health. The message that I'm seeing through social media is anyone who is tired, sleep deprived, foggy, depressed, menopausal, perimenopausal should be taking this supplement. I did listen to a couple of biohacking podcasts on the topic of creatine as I tried

Rebecca Berens MD

to-

Sonia Singh MD

Bless you. get a fuller context for these episodes. And there was one which honestly I could have rage texted you, but I was driving. But the- describing it as an alternative to SSRIs. He was just "Why take those terrible pharmaceuticals, when you could just be taking creatine?" He also described it as essential for people who are stressed or chronically sleep deprived. He was like, "Oh, my wife with young kids she's always up in the night. And so I told her, 'You gotta take the creatine.'" And then I've also- Not,

Rebecca Berens MD

not, "I'll get up with the kids at night. Just take some creatine." That's true.

Sonia Singh MD

That was not part of the conversation. Apparently only she was sleep deprived. He was busy hacking and optimizing. But anyway it's- Yeah I've also seen it floated as a strategy to reduce risk of dementia or Alzheimer's and cognitive decline generally. Does that kind of summarize the claims, or are there other ones that you have heard that you wanna throw on there?

Rebecca Berens MD

Yeah. That, I definitely, I feel like the most that I've heard about it is around menopause, perimenopause, helping people maintain their muscle mass for metabolic health and that sort of thing. But then it does bleed into oh, and also brain fog, and I'm like, okay, but that's a jump. But I'm very curious to see what the evidence shows, 'cause I honestly- Yeah have not dug very deeply into this. I've just, hasn't been something that I have spent a lot of time reading about.

Sonia Singh MD

Yeah. I've been I've unfortunately clicked on a lot of clickbait in the last few months that's "The supplement that's hiding in plain sight that could change your life," and that's the vibe that creatine has. So anyway why is this viral? So- I'm excited to cover this topic because I actually think it's different from a lot of the co- topics we've covered previously in several important ways. And one is this, is I think this growing interest in creatine is actually in part a reflection of growing and evolving evidence for creatine's benefits. I do think the interest is partially because of a real change in the amount of information and data we have on this, not just oh, we found this thing and we got hyped about it like fiber maxing, for example. Very initial research on creatine was mostly focused on muscle, athletes, men. And in the early 2000s, there started to be more interest in whether there were neurocognitive bene- benefits as well. And so that has been growing for the past 20-something years. And then in the late 2010s and then early 2020s, there was a lot more n- research looking at women and then mood and energy levels and more on cognition. So really there has been growing research around this and it's not just, purely out of nowhere. Other reasons it's viral are things we've talked about with a lot of different topics. So fitness culture becoming mainstream, this has definitely been taken and talked about in gyms for many decades, so it's not new in that in that context. Growing interest in metabolic health, which has weirdly become like a like a- in the zeitgeists in the past, probably just five years or so. And then fear of losing muscle mass in the context of GLP-1 weight loss or just perimenopause and menopause. We talked about this also in the protein episode and interesting protein. I think a lot of people right now who are losing weight with GLP-1s are concerned about maintaining their muscle mass. And now also with all of the hype and awareness around menopause and what happens to your body composition during that time, I think a lot of people are thinking about what can I do to maintain that and not have that, muscle loss happen?

Rebecca Berens MD

Yeah.

Sonia Singh MD

I also just think millions of people are tired and depressed- and there's numerous reasons for that. But all of those people would love a quick and easy and cheap solution. And when something gets presented as that, it's very interesting and attractive. And then lastly, you touched on this, but I feel like as wellness in general has grown, and the supplement space has become really crowded, a lot of people are getting frustrated with feeling like, oh my gosh the world is telling me to take so many things. What are the essential things? What is the most basic stack, quote unquote? What are... If I only am gonna have the bandwidth to take one or two things what should those be? And I've seen that creatine seems to come up a lot in that kind of, when people pose that kind of question. Any other thoughts from your end on, why people are so into creatine at the moment?

Rebecca Berens MD

Yeah, I think it's like you said, it's come alongside these other trends, like the metabolic health trend, the menopause trend. Not that they're trends they're serious concerns, right? But those have become trendy topics on social media. And and yeah, I think, like you said, this is a little different than a lot of the other things we've covered, and I'm really interested to hear the new research 'cause I think this is something that is much more reasonable than some of the other things- Yes we have talked about. So yeah let's talk about it. Let's

Sonia Singh MD

dive into it. Okay. So what are the facts with a little more context and nuance than social media's gonna give us? So we gotta start this conversation by just talking about what is creatine? I think in pop culture, like when I was researching this it seems like there's a lot of memes around creatine where your mom thinks they're steroids or, People think it's just protein. There's a lot of confusion, I think- Yeah around what it actually is. So creatine is actually an amino acid derivative, so it's not a steroid, it's not a peptide, it's not a protein. It's produced endogenously by your liver and kidneys, and then it's also consumed via the diet. And it's found in animal products mainly, and it does get degraded by cooking, so it's really more in raw animal products, which we're not eating a ton of in general. But the function that creatine has in the body is that it donates a phosphate group to con- DP back to ATP, which is the main energy currency in your body. So if you remember from high school bio- good old ATP is important for a ton of different processes, and so you can imagine why this would seem like a very attractive mechanism to try to optimize. Supplementation has been shown to increase muscle stores. So most of your creatine is stored in the muscle, and the supplementation can increase your stores by 20 to 40%. And so once the muscle is saturated, then the rest of the creatine can be rapidly available in the muscle and elsewhere to regenerate that ATP and inc- or reps your velocity, your power when you're doing high intensity activities. So that is a very high level overview of biologically what creatine is. I'm briefly gonna talk about like how it's usually taken and dosed just 'cause I wasn't sure where exactly to put that, and that's a common question that people ask. So the most common form is creatine monohydrate. That's the, by far the most well-studied and it's the most cost-effective. It's cheap and widely available. There are other forms out there, so like creatine hydrochloride is probably the next most popular, and it's marketed as being more bioavailable and possibly having less side effects or GI side effects as the creatine monohydrate. But monohydrate is already very well-tolerated and very bioavailable, so most people, I think, agree that it's not necessary to try to find one of these fancier ones, especially when creatine monohydrate is what we have the most data on. It's available as powder, gummies, capsules. The timing of taking it does not matter. What I learned recently was that I guess if you do the powder form and you're mixing it with a food or drink or something else, it can degrade when mixed with a food or a liquid over time. So a lot of the packages will say you have to consume within 30 minutes or 60 minutes or something like that. There's some idea that taking a loading dose is the most rapid way to start seeing benefits from creatine. So loading would be 20 grams per day divided into four doses. So each time you're taking five grams, and you're doing it four times a day for five to seven days. And the theory of this is that you're saturating your muscle stores, and then you're moving to a maintenance dose that kind of keeps you going from there. Most experts, I think, say that, that loading is not really necessary for most people. Usually building muscle is not an urgent need that people have. So unless you're an athlete that needs to perform at a high level in a short period of time, it's probably not a huge deal to not do the loading. So most people do maintenance dosing, which is three to five grams per day. So now let's move on to what is the data and evidence around creatine and its benefits. So the thing I'm gonna spend the least time talking about is the thing that is the most well-studied and the least controversial, which is the musculoskeletal benefits. So there is very robust evidence. We're talking numerous large randomized controlled trials over 40 years showing that creatine supplementation significantly improves muscle strength and lean body mass when combined with high-intensity training or exercise. So the important-- the most important piece here I don't think anybody out there debates that this is true, that creatine supplementation does seem to help you build muscle mass without building fat mass, basically. So it's not burning fat, but it's helping you build muscle more efficiently, essentially, but only when combined with high-intensity exercise or resistance training of some sort. So in the absence of exercise, like for a sedentary person, taking creatine is not going to change their body composition, and there's multiple studies that have shown that. So my sweet librarian, who unfortunately is sedentary for a variety of reasons, would not have any change in her body composition from taking creatine. That is the uncontroversial, well-established fact about creatine.

Rebecca Berens MD

So I'm curious, when in these studies-

Sonia Singh MD

Yes

Rebecca Berens MD

was this comparing creatine plus training to-

Sonia Singh MD

Training alone

Rebecca Berens MD

people training alone? Okay, so same amount of training. Or training with a

Sonia Singh MD

placebo.

Rebecca Berens MD

Okay. Yes. So training, same amount of training- Yes adding creatine. Okay. So right, but then-

Sonia Singh MD

So basically you get more bang for your buck from the exercise you are already doing. But what I, what is going to be a theme in every single indication that I talk about is the base intervention, which in this case is exercise, is doing the heavy lifting. Yes. And this is augmenting- That's what

Rebecca Berens MD

I'm getting at here. I'm like, if you just exercise without the creatine.

Sonia Singh MD

So this is augmenting whatever benefits. And and if you think about it, it c- it makes sense. Yeah. And in when I listen to a lot of these ones, a lot of these experts talking about this a question, a common question was like what are you gonna see? What are you actually gonna notice if you're doing this?" And the i- what most of them said was once your stores are saturated and you're supplementing consistently, you should be able to see that you can do a couple more reps than you could, that maybe you shave off a couple of seconds from a sprint. It's not gonna be some dramatic, this is not a s- this is not an anabolic steroid. It's not gonna be a dramatic effect. But if you're doing those things, then over time you are more effectively hypertrophying the muscle and you are building more muscle. And so it's burning fat or just magically changing your body composition. It's just making your exercise slightly more efficient and allowing you to do slightly more, and that in turn leads to more muscle mass and more muscle growth. So that is the part that I feel very confident in knowing that creatine can do. So now let's talk about some of the other categories that have been talked about. So- You mentioned that you've heard it most in the context of perimenopause and menopause. So I do think one of the biggest arguments for that claim is around muscle mass loss. We know that during perimenopause and menopause, there's this shift in body composition with slightly more muscle mass, slightly more fat mass and less muscle mass. And so when people are saying what can I do to prevent that?" Exercise is number one. Yeah. But number two could be, in making sure you have adequate protein, which we talked about in the protein episode. But another one, another option you have is to add creatine to your, r- exercise regimen to basically again, get more bang for your buck, to more efficiently shift your body composition towards more muscle mass. So I, th- there ha- there have not been a lot of great studies specifically in the menopause population. There are studies where there are both men and women were, over 65 or over 55, so likely in the menopausal range. But this benefit seems to be true regardless of who you are. So you know, I, the data around menopause specifically is not, super strong. The other reason a lot of people talk about it with respect to menopause is supposed benefit for bone density. So here's a brief summary on the best data we have on this. So there was one one year randomized control trial with 47 patients, so not huge- which found that creatine taken at .1 gram per kilogram per day plus resistance training reduced femoral neck bone density loss, increased femoral sha- shaft subperiosteal width, and resulted in greater gains in strength. However, when they repeated a very similar protocol with 237 patients and followed them for two years, they found that it preserved the bone geometric properties, whatever that means, but had no effect on the bone mineral density. So there was one very promising study that said, "Oh, look, there's actually some benefit for the bone," and then there was another one in which they didn't really replicate that, but they did seem to see more preservation of the bone strength compared to people who were And this was all exercise plus creatine or exercise plus placebo. Okay. And they were randomized and controlled and blinded they did not know what they were taking, so anyway. Those were the two, those were the two big landmarks. They did also do studies on creatine alone without the exercise component, and that pretty clearly has shown no benefit for bone density. So if you are not somebody who is exercising and you're just post-menopausal and you're like, "I'm worried about my bones," taking creatine every day is unlikely to give you any benefit. Again, exercise is doing the heavy lifting here. Okay. So now let's move on to cognition. So this is a really hot topic. I'm seeing so much stuff around demen- reducing dementia risk and sharpening cognition and all of that. There's probably, 20 to 50 studies on this topic that are fairly recent. I'm not gonna go and summarize all of them. I'm trying to strike this balance between editorializing without... I don't wanna editorialize this. I wanna share what the data is and you can draw your conclusion about how strong you think it is. But if you want a, a overarching conclusion from what's out there, the European Food Safety Authority reviewed 20 human studies in 2024, so fairly recently, and concluded that clear evidence of benefit for cognition had not been established. So some big body looked at everything that was available and did not feel comfortable saying that we have evidence that creatine supplementation improves cognition. One of the big landmark studies that people point to often to say that it does was a study actually back in 2003, and that was in 45 patients, and they were actually all vegetarians, which is an important caveat because as we talked about, creatine also comes from food sources. And so vegetarians may just have baseline lower creatine stores because they're consuming less meat. So that was the study, I think, that got people interested in oh, there's cognitive benefits to creatine. But then when they tried to replicate the same study in a larger population in 2023 they could not produce the same results. The strongest data we have that creatine helps with cognition is from a study of 32 older adults, so these were adults with a mean age of 76, who took a high dose creatine supplementation. So that's 20 grams per day. So that's the loading dose that typically people would only do for five to seven days, if at all. And they did that for two whole weeks, and then they did cognitive testing, cognitive tasks before and after, and then there was also a control group. And those people did have benefit. So interestingly, I don't think in this study they forced them to exercise. So these were A group of, quote, "elderly people with an average age of 76," who were given the creatine over the course of two weeks or given placebo over the course of two weeks, and then did a series of cognitive tests, including random number gener- generation, forward and backward number and spatial recall, and long-term memory tasks. So anyway, interesting data for sure. Very small sample size. Short period, average age of 76. That's what I would take home from that point. Of note, I could really not find any great evidence that long-term creatine supplementation reduces dementia risks. That's something to consider. So-

Rebecca Berens MD

Yeah, it's just being, like, extrapolated from this two-week-

Sonia Singh MD

Yes.

Rebecca Berens MD

Yeah supplementation.

Sonia Singh MD

Right.

Rebecca Berens MD

Yeah. I'm just like, this is such a fascinating study. Why?

Sonia Singh MD

Yes. Wait till you hear about the sleep deprivation studies. You're gonna like it. But going back to my sweet librarian patient who was not exercising and was asking about this, in this study they did not exercise, but the mean age of the patients was 76. She's 35 years old. And we know that, body composition, brain function, so many things are changing over the course of time. I don't know that this... The data is not strong to begin with, and I certainly don't know that it's generalizable to a lot of the people that it's being generalized to on social media. Okay, so moving on now to sleep deprivation. So one of the things the guy said in the podcast was like, "My wife's not getting enough sleep, so I told her, 'You gotta be taking creatine.'" There's a theory that emerged during the cognitive research that perhaps the more stressed your brain is, the more likely we're gonna see benefits from the creatine supplementation. So they designed these studies which sound real, What's... Is it... I was gonna say sadism and masochism. It sound real- they sound really sadistic. Okay? Basically, this guy named McMorris did a randomized controlled trial where he gave subjects 20 grams per day of creatine, so again, high dose supplementation, for a week. Then he deprived them of sleep for 24 or 36 hours and made them do mild to moderate intensity exercise.

Rebecca Berens MD

It

Sonia Singh MD

sounds

Rebecca Berens MD

like residency. Oh, yeah. They should have just

Sonia Singh MD

studied residents. Apparently they all need to be taking creatine. So the creatine- it was creatine or placebo. So the creatine group had a slightly positive effect on mood at 24 hours, and had better performance on central executive tasks at 36 hours. Another researcher designed a similar study where he deprived people of sleep for 21 hours, and then gave th- them .35 grams per kilogram of creatine, so that comes out to 25 to 30 it was an even higher dose, as a single dose, which is a lot and not really how most people are taking it. And those who had the creatine did have improved processing speed on cognitive tasks compared to placebo. Both of these were very small. They have yet to be, replicated in a larger population. But the thought I kept having when I was reading this is- Like, how would they have performed if he'd just let them nap for 20 minutes? What if they just slept a little bit?

Rebecca Berens MD

Yeah.

Sonia Singh MD

Isn't that the root cause solution, and I can hear my stressed out, sleep-deprived patients saying "It's not that easy. I can't," like- "I just can't get more sleep right now." So that's understandable. And I do think there's something. There's something going on here, and it's very interesting. And clearly they've created extreme circumstances in this case to try to elucidate some benefit. But, if you look at the changes in performance, they're very subtle, and, I don't remember all the details at this point, but for instance, when they say they had better performance on central executive tasks, they had them do a battery of other types of tasks, and it was only certain types of things that they were able to perform slightly better on. So we're not talking here about a dramatic change in performance. Yeah. This is not the equivalent of probably caffeine. It's probably not the equivalent of Adderall or something like that. But- but it's something, and this is in again, like a pretty extremely stressed brain that has been sleep-deprived for 21 hours. So-

Rebecca Berens MD

Yeah

Sonia Singh MD

not really the same as your typical, working professional who doesn't quite get enough sleep, night after night. But-

Rebecca Berens MD

Yeah

Sonia Singh MD

interesting.

Rebecca Berens MD

Yeah. I still- I'm just like... first of all, I'm like, residents are prime, primarily available for you to study. So I feel like that study could easily be done- That's true In a large group of people very quickly, and they're just right there in the med schools already.

Sonia Singh MD

Already sleep-deprived.

Rebecca Berens MD

They're already sleep-deprived and running up and down stairwells- in the hospital. So I feel like this study could be done. And yeah I also would love them to do it- and compare them to just people who are sleeping. 'Cause like my central problem with this guy's argument is my wife's sleep deprived with the kids, and she should take... I'm like, you should just help her-

Sonia Singh MD

Yeah.

Rebecca Berens MD

so that she can get more sleep. Right Instead of eking out the last little shred of cognitive processing that she can muster- with some creatine. I'm so confused why we are doing

Sonia Singh MD

this. Remember it's ATP though. The- she just needs a little bit more ATP. So anyway-

Rebecca Berens MD

Oh my God i'm so glad that you listened to that 'cause I would've been, so enraged listening to that pod-

Sonia Singh MD

I don't do it because it's fun. I do it because I just think in order to give people a full picture of this, I need to know what they're hearing and like- Absolutely what claims are being made. And it's very... 'Cause, when I sit and I do my research on Open Evidence and PubMed and only scientific sources, I come out with one conclusion. And then when I listen to that stuff, it's so funny 'cause it feels like there's a very big gap between what

Rebecca Berens MD

I- Alternative facts.

Sonia Singh MD

Yeah.

Rebecca Berens MD

Alternative facts.

Sonia Singh MD

Okay, so the last category that I was gonna talk about was benefits for depression and mood. So the best meta-analysis, again, I'm not gonna go through each study 'cause it would be a little tedious, but the best meta-analysis I could find on this topic, it was by Eckert et al., found that there may be a small to moderate benefit for individuals with depression, but the average effects were not clinically important, and the true effect may be trivial or null. So there are some studies showing benefit of creatine supplementation as an adjunct. So this is the most important part of this. Most of the data that shows benefit used Lexapro plus creatine, CBT plus creatine versus those interventions alone. So there's really very little or weak data to say that as a monotherapy, like just creatine supplementation by itself would have benefit for mood or would be a treatment for depression. That, that is not really justifiable based on the data that we have so far. So

Rebecca Berens MD

the- Were they also exercising when they took the creatine? 'Cause exercise also is beneficial in depression. If the people who are taking creatine are exercising more than the people who are not taking creatine-

Sonia Singh MD

Yes.

Rebecca Berens MD

Then it's not a control situ- I guess I'm just curious if that was controlled for.

Sonia Singh MD

I did not look into the details of those. But I would hope that they either told both of them to exercise or the people were blinded and didn't know if they were taking creatine and, or not taking creatine and so that, but but I honestly did not dig further into it, mainly because the data is not that strong to begin with. So if anything, it would just make me think it's even weaker, so I

Rebecca Berens MD

should not, we should not be de-prescribing our SSRIs for creatine.

Sonia Singh MD

Oh, yes, that's- that's essentially, yes. So anyway the, again, this kind of, I think in some forums, gets presented as if it could be an alternative to taking an SSRI, but it really is not. That is not what the data is telling us. In fact, it's telling us it, that it could be more of an adjunct. And, I just think all these things, so many of these things are interrelated, so even if the benefit is still on body composition, perhaps there is something about having more muscle mass and having more lean mass that puts you in a state that results in better, better mood and less depression. Easily it, there could still be some mediation going on there. But the effect, whatever it is very small and is really just an adjunct to other therapies that are first line. So one important caveat. So I've gone through now a lot of the overview of the research on creatine. One caveat to note here is creatine is cheap and it is widely available. It is not patentable. And a common criticism with a lot of different supplements or natural, quote-unquote, substances is that there isn't gonna be stronger data because, no one wants to study this. This is not something that the pharma industry is gonna sponsor. There's not a lot of other places. And it's true that big clinical trials on humans cost millions of dollars, and so it is challenging to produce some of this data. So it's not shocking that it's taken 40 years for us to even accumulate this amount of data. So I... when you look at these studies and you think, "Ah, it's only 250 people. It's only 50 people. It's only..." Yeah, I want people-- I wanna be transparent about the fact that for a lot of things in this category we might not see the type of data we see on statins and GLP-1s and, so many other things that are lucrative to, to study and to prove efficacy in. So anyway, that's... It's just something to keep in mind. I don't want it to seem like we just poo-poo everything, you know- Yeah on here that doesn't have a big, robust clinical trial. And I, I think what's unique about creatine is that we do have 40 years of data. And even though the data for some of these newer indications that people are talking about, like mood and bone density and cognition, all this, and even that- even though that data is weak and evolving the safety data is great. We have plenty of years of evidence of this being a very safe intervention, which is unique and unlike some of the other things we have talked about on this podcast.

Rebecca Berens MD

Yeah, definitely. And I think... i'm joking a little bit, but I'm also not. This is one of those things where if there are government initiatives for us to- de-prescribe things, then we- Yeah should maybe fund some studies for alternatives, right? I think that's part of the problem is if we feel like we're too dependent on pharma, then we- Yeah need to use our tax dollars to fund non-pharma- options-

Sonia Singh MD

Yeah, I

Rebecca Berens MD

mean, I would- To research them. That's- I would love- That's just the only way that we can handle that problem.

Sonia Singh MD

Yeah, I would love to see big studies on what is the ideal dietary pattern for somebody who's struggling with depression. What is the ideal exercise regimen for people who are trying to reduce their dementia risk? And for some of those, we have general ideas, but if we're going to rely on those, more exclusively or strongly in favor of those prior to doing medicines, then yeah, we need to invest more money and support in doing that. So I totally agree. So what are the risks? Let's talk a little bit about the downsides of creatine supplementation. So the primary side effects people might experience with these are GI side effects. So usually it's gonna be, like, GI cramping. You can also get some edema or fluid retention. When people say they're taking creatine to get swole it literally does cause some swelling of the muscle- 'cause it's pulling water. When you increase your creatine stores in the muscle, water comes with it, so it's pulling water into the muscle. So you can m- you know, experience a little bit of that water weight gain or fluid retention. And then I think you might have mentioned this, but, so creatine gets broken down and forms creatinine, which is one of the things we use to measure kidney function on basic labs. And so creatine supplementation can raise your creatinine by 0.07 to 0.13 milligrams per deciliter. So it's a pretty small elevation. And it is not a reflection of the change in the actual filtration rate of the kidneys or kidney function. So it's not actually hurting your kidneys. It's just affecting the lab level that we use to estimate your kidney function. So it's an important thing to tell your doctor about if you're taking this- because if they see a bump in your creatinine level or if you're already on the border and this pushed you into the abnormal range, they may flag that and say, "Oh, we gotta repeat this, got this." But if they know you're taking creatine, that may give them enough reassurance to say, "Oh, no. That's expected. We're gonna leave this alone." Now, if you're a clinician, and you're trying to distinguish between true kidney disease and a bump from creatine use, you can check a value called the cystatin C, which is independent of creatine supplementation, and so it should give you a a better estimation of the actual filtration rate and kidney function.

Rebecca Berens MD

Yeah, this is super important 'cause I definitely... for patients who are on GLP-1s whenever we're doing labs, I frequently see people with bumps in creatinine, and it's always difficult to know are you not drinking enough fluids? Yeah. Because I'd seen that be an issue before, where people are getting dehydrated easily. And I actually wonder, If maybe I'm missing some people that are taking creatine- That maybe in the interval of when we first talked about it and now they've started something, and we just didn't have a conscious conversation about it, yeah. And I'm seeing it, I'm like, "Oh gosh." But yeah, this is a really important thing to, to understand. So yeah, you do need to tell the doctor. And if your- And, and- If your labs change in that way it... Your doctor may not be thinking about that. Especially if they are seeing 1,000 people a day. You may wanna just flag that as "Oh, could this be because I take creatine?"

Sonia Singh MD

And I think because a lot of people are taking it as a powder that they're, throwing into a shake or a drink, a lot of times they just don't even think of it as a medication- Yes supplement. And so it doesn't even occur- Yes to them to put it on their list when they're, reporting stuff to the doctor. But yeah, this is a supplement that definitely should be on your medication list and reported to your doctor.

Rebecca Berens MD

Yeah. I ha- see that all the time with pre-workout and stuff. Yeah, yep. People don't... even if I ask specifically about supplements, pre-workout doesn't come up. Right and it's later. I'm like, "What's going on with your heart rate?" And I'm like, "Oh, I just took pre-workout an hour ago." Okay. So yeah. Yeah. Important to tell about the doctor about everything that you take.

Sonia Singh MD

So those are the main sort of side effects. When we think about risks, I think we also need to zoom out and just think about the risks of any type of supplement generally. So there's the cost, whatever you're spending on it. As we've discussed previously on this podcast, supplements have pretty limited regulation in the US. All the safety data is essentially post-market. There's risks of impurity, contamination, depending on the source. So what I usually tell patients is if they're in the market for a supplement and they're looking for something, always look for some sign of third-party testing. NSF and USP are, the two big organizations that do third-party testing, but there are some others. And then I always encourage people to look for single ingredient. If they're looking for some particular thing they wanna supplement, like creatine, I would just look for something that's just creatine monohydrate without about, without a bunch of other things added. When it's proprietary blend, you literally have no idea what you're getting, and so it's always safest to go with something that's single ingredient. So anyway, those are all things that we should consider as part of the risks. The other risks that I was thinking about after listening to that podcast were just that I think, overstating some of these benefits could lead to people delaying or declining other things that are first-line evidence-based treatments. So somebody who's fatigued or sleeping poorly might say, "Oh, I'm just gonna try some creatine," and maybe they delay going and asking their doctor and getting a sleep study that they really need. Or somebody who's really anxious or depressed and just really resistant to going and talking to somebody or taking a medication will say it's easier for me to try this. Let me try this for a few months." And, I think a lot of people would say, "Oh what's the harm? It's you've already said it's pretty safe, that's true, but delaying treatment or declining treatment because you believe this is gonna be effective for you I do think is a harm we should consider. And then lastly, this is just me getting a little bit on my soapbox, and I'm gonna admit there's some personal bias in here, but- the messaging around this of every woman who's tired, every woman who's menopausal every woman who has not been able to find her wor- Like, literally in one podcast she was just like, anyone. If you're carrying groceries you're doing resistance training. And if you ever walked into a room and forgot why you were there this could benefit you." I just was like- I don't know. I... That messaging of everyone should be doing this- I think there's also an insidious harm in that, that kind of makes these women, especially often women who are already overwhelmed and stretched thin and feel like their plate is full and there are so many other things they should be doing, it just adds another thing to that list. And I personally am really bad at doing new stuff. I just It's hard for me to incorporate a new thing into my life, 'cause my life feels very full. And so for somebody like me, this is more likely to be, a you should be doing this and you're not, so now you're just walking around feeling guilty all the time about it rather than something that really brings me tangible benefit. I just think overstating, how essential and beneficial it is has that other sort of, deeper level of harm.

Rebecca Berens MD

And I think also to your point about delaying other intervention if you do say "Oh, I'm gonna start trying this," and then you're not consistent with it and it's not helping, you're like, "Oh, it's just 'cause I'm not consistent enough," that could go on for years. Perfect. Of "I just never was consistent enough, and that's why..." And then it's yeah, y- years ago you could have been diagnosed with your sleep apnea and treated, right? So I th- I think that's an important point to make, because it's not, it's not just a case of it's adding work to your day, it's also contributing further to the delay of an actually appropriate intervention. And I think it, to, to your point too I think, going back to my rage at this man, like, why is that the solution to another problem? If we're tired because we're sleep deprived, why is the solution to take a supplement? Why is the solution not, "Hey, sleep is a vital biological need. How can we get you more of it?"

Sonia Singh MD

Or I guess- the, applying that to my situation of just saying "I'm already doing too many things. I don't wanna do more things," maybe the solution is for me to do less things- Yeah, do less things and to take some things off of my plate.

Rebecca Berens MD

Yeah.

Sonia Singh MD

Okay. But you know what? I am going to... This is this is quite exciting. Because of all of the things we have talked about on this episode, I usually go in skeptical and come out more skeptical. But for this, I actually was like, I think there is enough data here that this kinda makes sense." And I looked at, how much five grams is, and I was like, "I can put that in my water bottle," so anyway, I ordered myself some creatine today.

Rebecca Berens MD

Nice.

Sonia Singh MD

Yes. And the caveat is I am now exercising for the first time in the last decade of my life, and I have done it for six months. If I was earlier in this exercise routine, I would not have done it because I would not have trusted myself to keep doing it. But at this point I'm like, "No, this is part of my life now. I am exercising. I'm turning 40 in a few weeks. I am probably going to start losing some muscle mass over the next 10 years." And so I'm kinda like this thing is safe, and it's easily available, and I think I can just put a scoop of it in my bottle that I take to the gym." And I'm going into it, I think, with realistic expectations. I'm not suddenly going to be, like, really muscular. But- I guess it would make me feel like I'm making the exercise that I am doing do more for me. So anyway, this is a big, this is a mark the calendar. This is the day that we actually talked about something that I'm like, "Yeah, maybe I'll do that actually- Yeah now that I've looked at all of the data."

Rebecca Berens MD

Yeah, no, I was actually googling creatine gummies when you said it came in gummy form because I will eat a gummy. I will not- Yeah take a supplement 'cause I hate taking pills, but I will eat

Sonia Singh MD

a gummy. So here's the problem with the gummies. The gummies- Oh,

Rebecca Berens MD

no

Sonia Singh MD

are usually... I'm sorry. Oh. This is bursting your buzz. The gummies are... it depends. The gummies are usually 1 to 1.5 gram, What is it? What did I say? Grams. So it's just you have to eat five of them.

Rebecca Berens MD

Oh, I can eat five gummies for sure. Oh, okay. That's not a problem. Okay. I'm like, look, I we have a gummy vitamin D supplement, which I... Okay, I know the gummies are not as good as the other forms of supplements. The gummy- Like, I'm aware of that

Sonia Singh MD

is one that you will take if you-

Rebecca Berens MD

Exactly, and that's the thing. Yeah. I will eat the gummy. I will not swallow the pill, so I'm like, even with my prenatals, I was like, "I'm not gonna swallow that disgusting"- enormous horse pill, but I will take the gummies. So yeah, I think that's something I would reasonably also do. And similarly, I'm I actually just herniated a disc a couple weeks ago 'cause I'm, Oh, no old now, and I got an MRI, and I have the back of a 60-year-old apparently. I, I used to exercise regularly before I had children, and then yeah, now I don't do any resistance exercise or much less than I did, so I'm gonna have to get back into that to save my ability to walk. So I will probably also get myself some creatine to take for my new exercise program once I can finally bend forward again.

Sonia Singh MD

Wow, this is exciting. Let's move on to what can we learn from this as doctors and humans? So I would say the bottom line here on creatine is that for patients who are engaging in high intensity exercise or resistance training consistently, good evidence that creatine is going to augment the effects of that exercise on their body composition. So essentially it's giving you more bang for your buck of the exercise you are doing. There is not a ton of data to support its use in patients who are not exercising. The data on cognition is very limited and is strongest in older patients, so probably not generalizable to the broader population. And in most of those other categories, like mood and sleep deprivation s- exercise, sleep, CBT- SSRIs the, the basic fundamentals are still what's going to be, the first line solution and what's doing the heavy lifting. And I think we just need to keep an eye on the data as it evolves around some of these other, potential benefits. But for doctors, I would say when patients bring this up to you, it's a great opportunity to just emphasize some of the importance of those basic things. "Look, this is not gonna do you a ton of good if you're not doing the exercise piece already, so let's first talk about how we can help you do that." Or "Okay, you're sleep deprived and you're worried about how it's affecting your concentration, so you wanna take this. Let's talk about why you're sleep deprived and how we can help you with that." And it's a great example of just, how nuance is lost on some of these platforms. I am constantly amazed by how often not just patients, sometimes even fellow doctors will say, "Is X supplement or whatever good?" And I'm like, that is not d- my, my non-medical mother can ask that question and patients can definitely ask that question, but especially as medical professionals the question should really be for what and in whom? And so- Yeah it's not you're y- at the end of this episode we just conclude "Creatine's great. Everyone should take it." It's no. You have to think about who that person is what their lifestyle looks like, what they would be taking it for, whether it's likely to help them achieve those goals. This is a nuanced conversation that requires some discussion. It's not just a very easy "Oh, yes, everyone take it." And Yeah I also hear doctors on the flip side who are just anti-all supplements. Yeah. And I think for us this is a good reminder that there are supplements out there that, have good data for efficacy and safety, and that, we should be informed about and we should be able to have, informed nuanced conversations about with our patients. So hopefully this overview helps more of our colleagues be able to do that. 'Cause it's hard to stay, up to date on all of this data as it's evolving, literally year to year. Yeah. I think that's, I think that's all I had. What do you... Do you have anything to add to that in terms of what we can learn?

Rebecca Berens MD

I think also, like you said, just in the In, in the p- the piece about not just poo-pooing all supplements, it's a really good opportunity to provide education about yes, some supplements have benefit. This is the evidence for this supplement. There's, X, Y, Z. And as an opportunity to reflect on some supplements are combos of things. Like we talked about earlier- not these proprietary blends, trying to get single ingredient, looking for third-party testing, 'cause this is a great opportunity to have that conversation in a very positive way. Yeah. 'Cause I feel like a lot of times when we're having that conversation, it's because this patient's "Oh, I just started taking this liver thyroid detox," and you're like- "Don't take that," right? Yeah, that's right. Whereas this is yes, this could be beneficial for you because of this data- Yeah in your situation. And make sure you're looking for these criteria when you're buying a supplement. Because it... I think it just comes off so much more positively- when we're educating them about s- something that they're... It's a, in a positive way rather than in a "That's such a bad idea. Don't take that. It's-" everything's terrible," it just- it just comes across better, I think, in that s- in that scenario.

Sonia Singh MD

And it breaks up this idea that we are all in the pocket of big pharma and we wanna push drugs on people. Because, I genuinely... I try to tell people all the time that if there is an evidence-based lifestyle intervention that is going to work for your situation I wanna tell you about it. I want you to try it, if there's a supplement that's going to help you in your situation, I also want you to try it. But for a lot of the things that are out there, there is not good evidence for them, and this is one thing where it's there is actually evidence for this. And so I think it, it goes a long way in rebuilding trust, as you're saying. Yeah. To just use an example where you're like, "Look I am not universally against supplements. And to be able to talk to them about, "I know you may have heard this is possibly a treatment for depression, or you can use this instead of a medication or instead of therapy," but the studies on that, the stu- that's not really what the studies show. And so whoever is telling you that is either not looking at that or is overstating, is exaggerating what they're reading. Yeah, I think this is... i'm glad we covered this topic. I was like I went into it, I went into it actually quite skeptical and was impressed, when I got to the end of it. So okay, the last thing is, like, how we would talk about with this with our patients, which we're covering already. Honestly, given how popular it is, I I almost think I should add it to... I have a section in my intake forms, it's for medications, and then I have a section for supplements. I might just put a little thing that's like including powders and, you know-

Rebecca Berens MD

Yeah

Sonia Singh MD

shakes or something like that that encourages people to at least tell me about it so that I know. And yeah, like you said, I think just being a little bit more positive, but then also honest about where w- where there's gaps in the research I think would really prove to people okay, this person is not just making blanket recommendations. They're not just dismissing me completely. They're informed on this, and they're actually giving me some valuable and practical guidance.

Rebecca Berens MD

Yeah. And I think also like you mentioned, having it on the intake and, reminding people to tell you about it, but also when I'm interpreting lab results. Like I said, I see a lot of patients on GLP-1s whose creatinines bump, and I haven't been specifically asking this every single time, and I definitely will be now. Because, I ask at the beginning. I ask about supplements. But people add things, and maybe it just doesn't come up again, and they don't think to tell me. And if I don't ask them again, it's not gonna prompt them to remember. So I need to be more consciously asking that because I bet that's probably a lot of the reason for a lot of these creatinine bumps that I was just not thinking about. So yeah. And particularly, like you said, if it is in a powder that people are not maybe thinking of as a medication or a supplement, but they're thinking of it as this "Oh, it's like my gym drink," or whatever. Yes, it's just not, So I think that's definitely gonna change my practice in that way. And I think it's also, that's another good opportunity to introduce to patients that, hey, supplements also affect you medically. Because I think the other fallacy that people think is supplements aren't like medications. They don't do the harmful things that medications do. I actually had a patient recently who's taking a blood thinner- for atrial fibrillation, and we were talking, And they just in passing mess- mentioned a supplement they were taking. Oh. And it was one of those proprietary blend things. And I was like, oh, let me double check that you can take that with your blood thinner because they might interact. And actually several of the things within that blend did interact with her blood thinner, and it sh- it had not occurred to her that was a possibility. And I, and again, I just, I think that patients don't necessarily realize that, and so it's just another good opportunity, again, for education to say there's reasons that we need to know this. And it actually does have an implication for your labs or for your health otherwise, or interactions with your other medications.

Sonia Singh MD

I'm just realizing, how many things we have added to our intake forms doing this podcast. I added eating disorder screening questions. Yay. I added a digital hygiene question. What else have we added? I feel like I've con- been making tweaks as we've had conversations on a lot of these topics, which is which is so wonderful. The doing this exercise of doing these deep dives is s- informing my practice on a regular basis,

Rebecca Berens MD

yeah, no, absolutely. And I think that patients I always, when they come in, I always tell them, "Thank you for filling out the marathon paperwork- Yes that I sent you." Yes.

Sonia Singh MD

It is pretty long. But,

Rebecca Berens MD

but, it's so funny 'cause a lot of places that you go, you fill out the paperwork, and no one ever asks you about it- right or says anything about it. Or they just ask you all the questions again, as if you didn't already fill out the paperwork. So I think people are always worried about that when there's, Yes marathon paperwork, but I think that it probably helps the rapport that we're like, "You filled out all this paperwork. Let's go through all of it and talk about it." Yes. But yeah, I think that's practice-changing information, and just goes to show you we're always learning.

Sonia Singh MD

Yep. All right. So if you wanna learn more, you can head to our Substack. So we're at www.theantisocialdoctors.com, and that's our Substack. It is free to subscribe. We have write-ups of basically what we discuss in the episode, followed by what we call the antidote, which is affirmations for patients around the topic, scripting to talk about these topics with their patients, and then an, a long list of our references. And for this one, these are pretty relevant and you may wanna do a little deeper dive to see how you feel about some of this data, so those will all be included there. That brings us to the end of the show. Thanks, Rebecca.

Rebecca Berens MD

Thanks, Sonia.

Sonia Singh MD

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