Original article written by Scott Forbes, Dean Cordingley, Stephen Cornish, Bruno Gualano, Hamilton Roschel, Sergej Ostojic, Eric Rawson, Brian Roy, Konstantinos Prokopidis, Panagiotis Giannos, Darren Candow
Background
Mental health has gained a lot of attention in the sporting world over the last few years. Similarly, mild traumatic brain injury (mTBI), commonly referred to as concussion, has become a focal point in American football, ice hockey, rugby and football (soccer) over the last decade due to its adverse effects on brain and mental health.
How might nutrition play a role in supporting mental health and brain health? Creatine supplementation has a sport nutrition staple for decades, and since its discovery in the early 1990s, countless studies have examined its effects on sports performance, strength, resistance to fatigue, etc. Yet, only recently have researchers begun to explore its effects on the brain and mental health.
What the authors did
Dr. Darren Candow, PhD, at the University of Regina and colleagues recently summarized the current body of knowledge in a narrative review on the effects of creatine supplementation on brain function and health[1]. In the review, they explore areas such as mental health (i.e. depression and anxiety), cognitive function during sleep deprivation, and potential neuroprotective effects following traumatic brain injury or concussion.
What the authors found
Can supplemental creatine increase brain levels?
The brain is an energetically costly organ, consuming approximately 20% of total energy demands despite accounting for only 2% of total body mass. The brains approximately 100 billion neurons require a constant supply of adenosine triphosphate (ATP) energy for key functions – such as ion gradients, neurotransmitters, synaptic activities, etc. and can produce its own supply of creatine.
However, this ability makes the brain more reluctant to take up supplemental creatine[2]. How much can supplemental creatine currently augment brain levels? The 12 studies included in Candow’s review reported brain creatine uptake to be between a 3% to 10% increase.
But, experts are still trying to answer two key questions; how to increase creatine uptake in the brain and the optimal dose of creatine required to trigger the greatest brain uptake? At the moment, more works needs to be done.
Can creatine precursors improve brain uptake?
In an attempt to augment brain creatine uptake, researchers are looking at precursors of creatine. Specifically, a direct precursor of creatine called glycocyamine (GAA) has been studied extensively in animals and more recently in humans.
For example, a recent randomized controlled trial in healthy men supplementing with 3 g of creatine per day, over four weeks, found significant elevation (up to 16.2%) in brain creatine levels as measure by magnetic resonance (MR) spectroscopy[3].
Studies in women with chronic fatigue syndrome, and older men, have also found beneficial changes in brain performance[4,5]. This early data is encouraging, but the caveat is safety trials are still needed to avoid possible neurotoxicity of supplemental amino acids.#
Creatine and concussions
Strategies to help mitigate the deleterious effects of repeated head trauma are greatly needed. After head trauma, the brain undergoes a state of hyper-metabolism, soon thereafter followed by a state of hypometabolism, where the energy supply to the brain is inadequate and creatine levels fall significantly. Creatine supplementation during this period, note the review authors, may play a key role in blunting the adverse effects of mTBI.
Research in children and teens up to 18 years old, following severe TBI, found a creatine dose of 0.4g/kg/day was associated with reduction in post-traumatic amnesia, improvements in neurophsyical, cognitive and behavioural symptoms and reduced hospital stay[6,7]. Follow up research found creatine supplementation yielded improvements in headaches and dizziness post-concussion as well[8].
Creatine & mental health
The two most common mental health disorders are depression and generalized anxiety disorder Approximately 26-30% of the American population will be affected by a mental health disorder, while about 10% of the population over the age of 15 are struggling with a persistent mental health condition[9,10]. Currently, medications provide only limited benefit and there is a growing need to provide more integrative support options.
Recently, the National Health and Nutrition Examination Survey (NHANES) established a connection between risk of depression and low dietary intake of creatine[11]. Interventional studies have also found lower creatine levels in the prefrontal cortex of the brain were associated with lower mood and increased risk of depression[12].
But, does creatine supplementation actually improve symptoms of low mood, or, are they merely associated?
To date, only case studies and small-scale trials have been conducted making it difficult to tease out the impact of creatine supplementation. In fact, most trials have used creatine in combination with medications to assess its ability to augment the pharmaceuticals effects on depression. Thus, more research is needed.
With respect to generalized anxiety disorder (GAD), the second most common mental health disorder, the review paper noted research is very sparse at this time.
Creatine, sleep deprivation & cognitive function
Sleep deprivation is well known to adversely impact brain bioenergetics. Emerging evidence suggests creatine supplementation, during periods of sleep deprivation, may enhance cognitive function.
For example, following 24 hours of sleep deprivation, creatine supplementation resulted in less change in performance from baseline in random movement generation, choice reaction time, balance and mood state[13]. Creatine supplementation has also been shown to buffer drops in complex executive function after sleep loss.
Limitations
The evidence for use of creatine supplementation for depression and concussion is still quite limited. The optimal dosing strategy to support mental health, as well as both prior to and following TBI requires further study, as well as strategies to augment brain uptake of supplemental creatine.
What does this mean for the practitioner
- In youth sport, the prophylactic use of creatine to protect the brain in contact sports like American football, rugby, ice hockey and football (soccer) should be considered by teams and organizations.
- In athletes post-concussion, consideration should be given to using creatine loading doses to ensure brain energy demands are being supported. More research in this area is needed to identify the optimal dose and uptake.
- During periods of sleep deprivation, such as during long-haul travel or congested competitive schedules, supplemental creatine may support cognition in athletes and performance staff.
- In retired athletes with chronic exposure to head trauma, creatine supplementation could be considered to support cognition and memory in ageing.
- The excellent safety profile of creatine supplementation in humans shows the risk is low for adverse events, making it an attractive therapeutic option.
Recommended resources
- Podcast – Creatine myths and common questions – Scott Forbes
- Article – International Society of Sports Nutrition position stand: creatine supplementation and exercise – Thomas Buford and colleagues