Intro

Dr. Cameron Chesnut 0:00

Welcome to the Five Codes Podcast, where we discuss evidence-based methods to elevate yourself to the next level through optimizing the way you look, move, perform, feel, and connect. Welcome to today's deep focus episode of the Five Codes Podcast, all about creatine. Creatine is something very near and dear to my heart, quite literally. I've used it since I was a young athlete, personally, and as I've seen a great evolution with it, I use it very regularly with my patients pre- and post-operatively to improve their entire recovery. It's quite remarkable, and I have seen lots of changes in the field since I've been using it so regularly. So it's really interesting to talk about. I think it's one of the most misunderstood molecules in medicine, but also one of our greatest assets when we really get into how it works and what it does and how universal it can

Creatine's Branding Problem

Dr. Cameron Chesnut 0:51

be. So creatine maybe has one of the biggest branding problems in medicine because people think of it as a muscle supplement. But I could, if I could put my, I guess, central thesis around this whole thing. This is my idea. This is what I want you to take away. This is the key point. So creatine is not a muscle-based supplement. It creates a reservoir of energy for any tissue in our body when it needs to create more energy, when we need to make more ATP, whether that is our brain, our muscle, or when we are healing from surgery. That's the key here. And that's an interesting way to think about it because that's not how most people are looking at creatine use. And the reason I say that creatine has a branding problem is because when people hear creatine, they think of muscles, like building muscle. And this is it's been this way for a long time, 30 plus years. I mean, the creatine actually study, the molecule discovery goes back hundreds of years. But when we think about what it's used for mostly now, it's traditionally been to build muscle. Creatine is not an anabolic steroid, much I think a lot of people lump it in as like, oh, you you take creatine and your muscles get big. If you take creatine and don't do anything, your muscles actually don't change. Creatine allows your muscles to do more work. That's the whole point. It's that energy reservoir system that when the muscles are working, they need more energy. Creatine allows that to happen. We need creatine from food. We get creatine from meat, basically. And that could be red meat, could be fish, poultry, uh, salmon, and sardines. These are really high sources, herring, really high sources of creatine, so as beef. Our brain places a very high energy demand on our overall system. It occupies 20% of our metabolic energy demand right there in that one thing. So it makes sense that it has its own ability to create this reservoir for when it needs it. Uh, but it's more than just muscle. It's been thought of as muscle, it makes things big, it's an anabolic. There's a lot of misconceptions surrounding it, but in reality, our muscles do use creatine and energy. Our brain uses

The ATP Energy System Explained

Dr. Cameron Chesnut 2:44

it, our heart uses it, our immune system uses it. And so when we really think about all those high energy systems, when more demand is placed on them, that's where creatine comes in. And if we really get to the nerdy science of how it works, we've heard of the energy currency of our entire body, how our cells use energy is something called ATP, adenosine triphosphate, three phosphates on there. We have a whole system to make ATP. Uh, the Krebs cycle makes ATP and it makes it of carbohydrate and fat. And but when we make that AT, those ATP molecules, depending on whether we're burning carbohydrate or fat, or whether it's an oxidative or anaerobic environment, it's different on how many we make, but we have this currency, this ATP. And when we need energy, we take a phosphate off, we release energy, and now we have a DP and a phosphate molecule. So you have adenosine diphosphate instead of triphosphate, and this is where the creatine comes in. It's a phosphate donor to the ADP, and boom, all of a sudden we have ATP again instead of a complex system to recreate it. It's a it's a phosphate donor, and we immediately have a new ATP molecule. So when things are in high demand and we can't create it as fast as we need it, that's where creatine comes into the whole thing. And it becomes really important when you think about, yeah, exercise. Also becomes really important when you think about illness, healing from surgery, or significant cognitive demands, or stress on our central nervous

Surgery as a Metabolic Stress

Dr. Cameron Chesnut 4:07

system. So this is where we really get into surgery because creatine's creation of this energy reservoir is exactly what we need in a pre- and post-surgical situation. People think of surgery as this mechanical situation, which it is to some degree. Uh, but when you really go to higher levels of thinking with it, I think of surgery as a metabolic demand, as a metabolic stress, especially in preparation and recovery. There's inflammation, there's oxidative stress, there's hypoxia during the anesthesia to our brain, there's building new proteins, there's recreating structures that were damaged. There's so much signaling happening on a metabolic level. This is exactly where something like ATP helps this process get through its high energy demand. Even our sleep changes posto-peratively, something that I think very few people talk about. And this is where something like creatine shines. It helps our brain, our immune system, and our surgical recovery get through all of the healing that it needs to do. It protects us from the anesthesia or the aspects of anesthesia that we wouldn't want. I talk a lot about BDNF, brain-derived neurotrophic factor, which is like the growth neuroplasticity part of our brain. And creatine even helps increase BDNF levels. So taking it before surgery gets you ready for surgery, and then we have all this energy reserve for afterwards. So creatine fits so nicely into my pre and postoperative surgical protocol.

Fifteen Years of Clinical Use

Dr. Cameron Chesnut 5:28

The interesting part about this is that I've been using creatine for my patients my whole career, basically. So if we look back well over a decade, we're talking like 15 years of very significant creatine use in patients going into surgery and coming out of surgery. There's been some very unique aspects of that with dosage changes and just who's taking it. In my female patients, for example, if I go back even 10 years ago, not even to the beginning, but let's say 10 years ago, a very small percentage. It was rare that I had a patient coming into surgery who was on creatine. It was like, well, that's for guys. Doesn't that hurt your kidneys? Both of those are very false things that are not true. Uh isn't it going to make my muscles bigger, make me retain water? These are all not necessarily true things, right? So it was, it was a bit of a, there's a little friction to get my female patients on creatine leading into surgery. Now, flip 10 years down the road, and it's rare that I have a patient come to me who's not on creatine. And this makes sense. Creatine is sort of like people say supplement of the year. I'm going to say supplement of the century, right? How it's really come into its own and been better understood, although the creatine research has been very steady for a long, long time. We know that it's incredibly safe, right? Um we have we have studies in happening in pregnant women, in babies, in preteens, in adults, and men and women in elderly populations, in neurodegenerative, like Alzheimer's type populations, in frail populations. It's creatine is very, very safe and very, very effective in lots of different situations. And so now it's rare that I don't have people on it. And this is why I think every surgeon, every athlete, and every high performer should understand it at least very well. And that encompasses basically my entire audience. If you're watching this, you are one of those things. I almost guarantee it. Um it's important to go

Dosing and Tissue Saturation

Dr. Cameron Chesnut 7:20

that direction. Uh, it's important to understand what it does. But then we get into, okay, well, what does it mechanistically look like to use creatine pre and post-operatively around surgery? What does that look like? Well, there's been evolutions in this for me as well. And if we want to get into the logistics of using creatine pre and post-operatively, that's another area that has changed quite a bit over time. And we can talk about dosing, timing, schedules, how long before and how long after we want to do it. If we look at the basic interesting parts of creatine, at different doses, different tissues respond and get saturated, if you will. So in our diet, we tend to get one to three grams. Does take quite a bit of meat to get to that three gram mark, but we're getting some in our diet. If we're a vegetarian, that's a bit of a different conversation, and maybe even a uh reason why creatine is a even better option for somebody who's a vegan. When we start start talking about supplementing, the most basic dose is five grams. That's one scoop. If you are using creatine, your scoop is five grams usually. And that has traditionally been the dose for muscle use. There's this idea of preloading it or saturating it beforehand with 10 up to even 20 grams a day to preload or get your muscle saturated. That's fine to do. You want to, some people have some GI upset with higher doses. I don't personally, um, but that's something to think about. You can spread your creatine throughout the day. You can microdose it throughout the day, you could do five grams multiple times, whatever you want to do. But even if you just start with five grams once a day, within about a month your muscle levels are saturated. So you get to the same endpoint as to how you do it. And that one month is a key time frame. Uh even when we start talking about loading before surgery, like a loading phase. Um, five grams leading into surgery is gonna get us saturated where we want. Interestingly, the muscle's pretty like greedy for creatine. It will take that five grams up. If we start looking at seven to eight grams of dosing, now we start talking about benefits beyond muscle, even into bone health. We know that bone density decreases less in frail and elderly populations or even in younger populations who are building bone density when we start getting to seven and eight grams of creatine, which is interesting and important and gets into some of the metabolic effect of these cells called osteoblasts that build bone. They are a high energy demand cell, as you would imagine when you're making bone. And so creatine helps them. Fantastic.

Effects on the Brain and Sleep

Dr. Cameron Chesnut 9:51

When we start looking at central nervous system effects, this is probably my other most interesting area. When I think about the metabolic physiology of what it's doing for muscles, immune cells, bone, those are rebuilding, right? But then there's this whole other aspect, you know, that I'm obsessed with what happens with our brains pre and postoperatively with protecting our brains around anesthesia and even our sleep, because our sleep plays into our overall recovery in addition to how our brain responds after anesthesia. So our brain makes its own creatine, as I mentioned earlier, which I think is a really interesting point to its importance that that's preserved there for a reason. But creatine doesn't cross the blood-brain barrier too readily. It doesn't sound like you take creatine and go straight to your brain. At higher doses of creatine, now we're talking studies looking at like 10 grams, 20 grams, even beyond 30 grams of creatine, then we start seeing higher levels in our central nervous system in our brain, and we start seeing functional changes with that as well. This is really, really important. Those tend to be most noticeable when we are in difficult or cognitively demanding or depleted states in our central nervous system. This could be a really challenging task, recording a podcast. This could be taking a test. It could be when you are sleep deprived. And there's that's a really uh easy thing to study. And so there's really good studies looking at sleep deprivation. I notice it when I'm jet lagged traveling. Uh, creatine helps me in those states. When I'm getting ready for surgery, this is certainly a lever that I pull differently than when I'm not getting ready for surgery. So anything that has this placing a lot of stress and energy demand, back to our energy reservoir idea on our central nervous system, is where creatine really shines. Surgery definitely, even with my neuroprotective anesthesia protocol, creates some stress on our central nervous system. There's hypoxia, oxygen, you know, low oxygen tension states in the brain, basically. There's all of the metabolic demand from the surgery itself that can affect the brain. So we want the energy reserves in the brain to be high in these situations. So this is a perfect example. This doesn't really get talked about much, but having that creatine energy reservoir available before you go into surgery is going to help the recovery afterwards. We know that you also don't sleep as well postoperatively. Now, again, my anesthesia protocol is trying to restore sleep architecture as quickly as we possibly can, but we're going to have some sleep disturbance. And this is interestingly in studies one of the areas where creatine shines the most. And what I mean by that is if you take, let's say, healthy volunteers, most of the studies are healthy volunteers, and you sleep deprive them and you give them cognitively demanding tests, they don't do as well. If you have pretest andor pre-no sleep and post-no sleep, they don't do as well without sleep. Interestingly, if you supplement that with creatine, the same person does their test before, then they get their no sleep, sleep deprivation, 20 plus hours of sleep deprivation, then you they get creatine and they take those same cognitive tests, it seems to relieve the delta, the burden between how they did when they were well rested and how they do when they're not well rested, even to the point of actually having a little bit higher performance when they're sleep deprived on creatine. So again, this is just a perfect situation to illustrate that when you are under cognitive demand, when you are under metabolic stress in your brain, high energy demand in your brain, sleep deprivation, whatever it may be, this could be Iron Man or Iron Man triathlon, or it could be a big event, it could be a challenging emotional time in your life. Creatine is going to help your brain function better. And I say emotional time because there's evidence showing that creatine can help mental health states. There's evidence showing that can help neurodegenerative conditions, and we talk about uh Alzheimer's, and it's not because it stops the progression of those, but it's because those types of neurodegenerative states tend to place the brain in a constantly upregulated energy demand situation. And that's where creatine can help that process. In frail and elderly individuals, people you know who are, you know, maybe functional in life, but kind of deteriorating elderly, creatine can help them just with their sit to stand, you know, getting into back to their activities of daily

Safe Across Every Population

Dr. Cameron Chesnut 14:24

living. So it's got a broad application, even in kids. Um, you know, there's studies of young athletes, we're talking like teens and preteens, um, and creatine helping their muscular recovery, improving their agility in athletic sport and things like soccer. Um, there's studies going on in pregnant women and infancies, a lot of those are happening in Australia. There's not enough to really make any definitive recommendations about that, but it appears to be safe in those populations as well. So from a safety standpoint, from an efficacy standpoint, and from a broad applicability standpoint, creatine is a very, very great option. I mean, I give this to my kids, honestly, um, because they are young athletes and they are growing and they are working on all of these things. They're doing cognitive demanded tests, they have stressful situations in their life. Um, and so it's gonna help them. They do eat meat and they do all those things, but uh, from what I've seen really digging into this evidence, it was an absolute like, yes, that's one of the very few things I do give them because I know that it's going to give them those energy reservoirs that they're gonna be able to tap into. And the safety profile behind it is so good that I didn't have any reservation about that at all. So it makes for my patients out there know that this is something that I give, I take personally and I give to my kids. That's how confident I am in its ability to be of a benefit and how safe it is for you leading into and after surgery.

How to Choose and Dose Creatine

Dr. Cameron Chesnut 15:44

I will say if we get into the nuts and bolts of looking at how to choose your creatine or how to dose it and things like that. I usually start my patients about a month before. Now, this is this is broad and variable, it can be a little bit different than this. I start them about a month before and I continue afterwards. There's studies showing that creatine levels can stay up for months after supplementation. So consistency is key, but if you are traveling or if you miss a day or something like that, it's not as though you're starting from, you know, square one again. Uh you are, you know, you're able to keep those levels up, especially if it's something that you're very consistent with and if you're getting it in your diet as well. So I like the supplementation to start well pre-operatively and to continue into the postoperative period, generally for months afterwards. When you're choosing your creatine, make sure that it's third-party tested to contain creatine. Most of the time it's a white powder, relatively flavorless. You can get gummies and things like that. And there's been reports of gummies that were tested that didn't actually have any creatine in them. So just make sure that you're getting a high quality product. For my patients, I'm giving this to you directly. Um, so make sure that it's third-party tested. There's different types of creatine. There's creatine monohydrate. It's got one water molecule attached to it. That's definitely the most studied across many, many, many studies, many, many, many decades. Super safe and very, very effective. There's other types. There's creatine hydrochloride, which may dissolve a little bit better. All the regular creatine, creatine monohydrate also dissolves pretty well. There's no evidence to show that it's better. There's a lot of marketing and hype around those now, but nothing to really show that it works better over something that is so solid like creatine monohydrate. Uh there's betaine, which is often you'll see with creatine, and it has to do with the methylation part of creatine metabolism. So if you are somebody with elevated homocysteine levels, this is something you can check, talk to your provider or your doctor about. That can help and be mixed in with creatine. It's not a replacement for, but in addition to, something to maybe think about and look at. But in general, it's a powder form. You want to make sure you're getting a high quality one. Creatine monohydrate is a great option. You can take it uh at five grams at a time, one gram at a time. You can take it all at once. If that doesn't upset your stomach, it doesn't for me personally. Um you can also take it throughout the day. You don't have you don't have to take it right before, during, or after training. It's really, like I said, consistency and a saturation event more than it is a reservoir for immediate action. You want to keep your reservoir topped off. It doesn't matter when you do it. You'll tap into your reservoir of energy demand when you need it, if it's exercise, if it's surgery, whatever it may be, and then it comes back up. Um, and and you can be really simple about what works best for you. Some people put it in their coffee, and there's some conversation about caffeine levels with that and things, but in general, in your coffee, in your sports drink, in the morning, I literally put it in my mouth as a powder and take water from the sink and rinse it down. And I'll do 10, sometimes even 20 grams that way. Um so you've got to make sure you have enough water to get it down. Stay hydrated, drink normally. There's a lot of false ideas about creatine causing water retention or causing cramps and things like that. Uh if you're staying adequately hydrated, the water is inside of your cells, which is good, it's where we want it. And so uh those aren't, those are not concerns. Uh, those are not things that we would stop you from doing creatine. So uh very safe, very simple. Uh you don't have to be too regimented with it. Take it however you can get it down. I like that four weeks before. I like to continue it for months afterwards. And interestingly, with a lot of my patients, you know, if if they are perimenopausal, that's one group that has been highly studied actually with creatine. Uh, there's benefits too. I talked about bone density and muscle mass. There's benefits all throughout the different age spectrums from kids up, but this is one of those. I I love this idea in my practice that when people come in for their procedure, we're able to pull the levers and kind of re-recreate their the way that they feel and when they look in the mirror. We're able to recreate and match those things up. But oftentimes my patients leave afterwards on a long-term health trajectory that is positive, um, that is better than it was when they came into me. And it's not just the things that I did. That's things that they learn and it's things that they adopt and pick up that have to do with how they prepared and how they recover. And creatine is definitely one of those. It can have great long-term trajectory benefits with consistency. And for some of my patients, especially and leading into these years, this is the first time they'd ever taken it. So a really great example of one of my sub-values and sub-goals is to increase, um, increase the long-term benefit of your health from having your procedure with me. I also love creatine and

Preparing and Recovering Like an Athlete

Dr. Cameron Chesnut 20:25

one of the tie-ins when I think of the athlete's mindset. Um, I talk about this for myself all the time, preparing, executing, and recovering like an athlete and doing the same thing for you in your surgical preparation, your execution of your procedure, and in your recovery. I treat you like an athlete as well. And it doesn't, rubber doesn't meet the road any more than it does with something like creatine, which is thought of as a supplement for athletes, basically, for bodybuilders or iron man. It's interesting that, you know, like us, think of thinking of surgery as a metabolic stress in a metabolic, you know, event, um, something like an Ironman triathlon, which I have done several myself, looking at how those athletes train and recover, creatine doesn't just help their performance in the event, which it does ultimately. So even if you look at their inflammatory markers after they've been training and competing and executing one of those really high demand events, it's lowering their inflammation.

Creatine and Inflammation

Dr. Cameron Chesnut 21:21

People have heard like, oh, creatine helps is anti-inflammatory. Well, not in the way that we would think of as like a non-steroidal anti-inflammatory, like ibuprofen or aspirin or something like that. It's not just blocking and stopping all inflammation. This really tracks with my surgical philosophy as well. I don't use steroids after surgery for this exact reason. I want the inflammatory healing process to happen, but I want it to be supported and I want it to be efficient. And this is where creatine fits in so beautifully. Because you can see this in athletes, connecting my patient mindset with my athlete's mindset when they're doing these really high endurance-based events like Iron Man, their inflammatory profile improves after taking creatine. They still got to do the work, they still got to recover from it, they still get stronger from it, but it's more efficient. Uh, it happens faster, and the ultimate result of it is better when you have something like creatine on board. So it really just fits in with my overall philosophy from an athlete's mindset and from making your health better afterwards. And creatine may be one of the few supplements that has such broad benefits, helping athletic recovery, athletic performance, surgical recovery, sleep, cognitive performance, cognitive decline, bone density, all of these metabolic demand types of events. It's so unique to have a supplement that benefits all these, especially with the safety profile that goes behind this and the applicability to broad populations. It's been studied in so many, I'm not going to say every population, but in so many populations, men and women, across different ages, across different health spectrums, it's a very, very safe option. It's one of my go-tos. I'm glad to see that it's increased in popularity so much. And if you are already taking it, when we link up and we're going through your protocol, I will probably slightly alter the way that you're taking it, when you're taking it, how you're taking it, leading into your procedure. Because again, at that point, we're really focused on that as our end of goal and objective. But again, many people are familiar with it now and it's all good, and it's only going to help your transition into your surgical preparation, into your surgical recovery afterwards. And again, if you're not taking it, odds are you may, it may be one of the things that you're taking afterwards long-term that you sort of stick with and keep on board for a long-term option after your surgery.

Closing Thoughts

Dr. Cameron Chesnut 23:39

I'm going to close with this final thought. Creatine just fits in so well with my overall philosophy of being in your prime, optimization, surgical recovery, things like that, because it's creating a reserve. Everything on our body has a reserve. We have our lungs have a reserve, our pulmonary reserve, our heart has a reserve called our cardiac reserve. And reserves are not something that you notice, right? You, and this is one of the things that people say about creatine is I take it and I don't feel any different. It's not like caffeine. It's not a stimulant, right? Well, you don't notice your reserves until the stress or the high energetic demand arrives. Something like an Iron Man or newborn baby or surgery or a demanding cognitive, you know, task in front of you, sleep deprivation, whatever it may be. So when we think of it that way, it fits so well into my overall philosophy and my long-term thinking for your health and the way that I want you to approach your surgery, recover from your surgery. It's definitely a key element in there, and I encourage you to be open-minded about its use. If you have any questions or topics you would like me to explore further, please leave them in the comments. I read them all and they often help shape the future conversations here. I also want to be clear that the views shared on this podcast are my own and are not associated with or representative of my clinical teaching affiliation with the University of Washington School of Medicine, nor should this be taken as individual medical advice. Thank you for spending your time with me. I appreciate you being here, and I will see you on the next episode.