Chapter 134
Creatine
In my video see.nf/hmb, I talk about the shortcomings of HMB (β-hydroxy-β-methylbutyrate), magnesium, omega-3 fatty acids, and vitamin D as aids against age-related muscle loss, but there is one supplement that does something, namely creatine.
Creatine is a natural compound in the human body that has mainly to do with energy production in muscles and the brain. It is also produced in the bodies of many animals, including those we eat. So when we consume their muscles, we get additional creatine through our diet. (Its name comes from kreas, the Greek word for “flesh,” in which it was first isolated.) We need about 2 grams per day, so if we eat meat, we take in around one gram through food, and the body produces the rest itself. Very rarely, people are born without the ability to make creatine; they must obtain it from food. In everyone else, the body can make as much as it needs for a normal concentration in the muscles.
When people avoid meat, less creatine is circulating in their bloodstream, but the amount in the brain remains the same because the brain simply produces as much creatine as it needs. Creatine levels in the muscles of vegetarians are lower, but that does not seem to impair their performance, because both vegetarians and meat eaters respond to creatine supplementation with a similar increase in muscle performance. If creatine in vegetarians’ muscles were insufficient, the increase would presumably have been greater. So if you eat meat, the body has to produce less creatine itself.
If the creatine content of muscles were to decline with age, that could explain age-related muscle loss. But that does not seem to be the case. Biopsies of muscle from younger and older adults show no difference in creatine content. If it improves performance, however, perhaps more of it would be helpful. According to the International Society of Sports Nutrition, creatine monohydrate is the most effective ergogenic supplement athletes have to increase exercise capacity and fat-free body mass during training. No wonder that surveys suggest more than 70 percent of athletes take creatine supplements. What can creatine do for older people?
Without exercise? Nothing. Most studies of creatine supplementation alone show no benefits for muscle mass, strength, or performance. Which makes sense. Creatine supplementation delays muscle fatigue and enables longer and more intense training. And that length and intensity are what make the difference. So creatine alone does not help, and creatine taken as part of a supervised and deliberately moderate training program does not either. If older people are allowed to train as much as they can, however, most studies on the prevention and treatment of sarcopenia with creatine supplementation show that lean mass increases, just as it does in younger adults.
Taking 3 to 5 grams of creatine daily and doing strength training two to three days per week for an average duration of about four months led to a gain of three pounds of fat-free mass. Some of that fat-free mass, however, could be water, not muscle. Creatine causes water retention, which then counts as fat-free mass, but combined with resistance training, creatine also increases muscle strength more than a placebo. As long as training continues, the additional gain in mass and strength in older adults continues for at least twelve weeks after stopping creatine.
One reason I never advocated creatine supplementation for muscle maintenance in older adults was that, up until 2017, systematic reviews concluded that creatine during training increases muscle mass and strength, but apparently does not improve functional capacity. In 2019, however, an updated meta-analysis reported a significant improvement compared with placebo on the sit-to-stand test, which is a good indicator of a lower risk of falling. Again: This was only the case when people also trained. No benefit has still been demonstrated for creatine supplementation alone. Creatine should therefore always be prescribed in conjunction with progressive strength training.
The Society on Sarcopenia, Cachexia and Wasting Disease formed an expert group that, despite a lack of long-term studies, proposes creatine for the treatment of sarcopenia. The recommended dose to achieve muscle saturation is 3 grams a day. In one month, this slow and steady rate yields the same muscle levels as taking 120 grams in a week. Not to forget that in older adults, at least twelve weeks of resistance training together with creatine supplements are necessary to achieve a significant additive effect. More recent findings suggest that creatine should preferably be taken after training rather than before, but this still needs to be confirmed.
Are there side effects? Well, if we can go by mice, longevity might be one of the side effects. The average health span of the creatine mice was 9 percent longer than that of the control animals, and those on creatine performed better on behavioral tests; above all, they had better memory. But is taking creatine safe? I explore that question in detail at see.nf/creatinerisk.
In short, the only serious side effects in humans seem to occur in people with kidney problems, or in those who take more than a gigantic 20 grams a day for more than four weeks—although in fact, half of creatine preparations exceed the maximum level permitted by food authorities for at least one contaminant. An independent testing laboratory that checked dietary supplements for contamination recommended the brand BulkSupplements, which happened to be the least expensive as well, at about ten cents per 3-gram daily serving, that is, about a level teaspoon.
Essential tremor
In How Not to Die, I deal extensively with Parkinson’s as one of the most common causes of death. The most common movement disorder, however, is so-called essential tremor, which affects one in 25 adults over 40 and up to one fifth of those over 90. In addition to disabling hand tremor, it can also make itself felt neurologically in other ways, namely through cognitive impairment, depression, and sleep disorders. As I explain at see.nf/tremor, attention is focused on a class of tremor-triggering chemicals, the beta-carboline alkaloids, which belong to the heterocyclic amines. This is a class of carcinogens that form at high temperature in a chemical reaction between components of muscle tissue.
For those who do not want to reduce their meat consumption, various marinades have been tested to reduce the formation of these substances. Hibiscus extracts did not change the levels; red wine made everything almost ten times worse. A Caribbean marinade and various berry extracts, by contrast, helped. For example, if camel meat is marinated in strawberry juice for 24 hours before frying, that can reduce the formation of a beta-carboline alkaloid by up to 40 percent.
Can diet change anything further if you already have the disease? Vanillin—the predominant aroma compound in vanilla extract—was able to help against chemically induced tremor in rats, but there are not yet any clinical studies.
Preserving sex life
The cliché that older adults are asexual is ageist and incorrect. Sex is an important part of our entire adult lives, as shown by the fact that the overwhelming majority (85 percent) of surveyed nursing homes report that their residents are sexually active. Sexual activity, however, tends to decline with age. Although some 90-year-olds from regions where people live especially long continue to “vouch” for their active sex lives, a nationwide survey in the United States of thousands of older adults found a gradual decline in sexual activity with increasing age, from 73 percent of those ages 57 to 64 to only 26 percent of those ages 75 to 85. Of these 26 percent, most (54 percent) had intercourse two to three times per month, but 23 percent at least once per week. The decline in sexual activity may have less to do with age than with declining health.