Norman Swan (2:31)

So we should start by talking about what creatine is.

Sana Qadar (2:34)

Well, we have touched on this very briefly before. We did do an episode of what's that rash? A while ago called Is it safe to dose yourself with pre workout? And so we talked about it because it's often an ingredient in a pre workout blend. But there's just that much hype around creatine specifically at the moment that we are coming back in with it today. I am going to say it's amino acid adjacent, but it's not an amino acid.

Norman Swan (3:04)

This one's made from amino acids. So it's a combination of amino acids.

Sana Qadar (3:08)

I mean if you're not a dietitian or a chemist, that probably doesn't really mean that much to you anyway.

Norman Swan (3:13)

But the body makes its own creatine and probably makes about 50% of what we need. The other 50% comes from our diet, meat, fish and other foodstuffs. And it's got a really fascinating role in the body. It's a bit like one of those, you know, hydro schemes where you pumped hydro, where you have the lake at the top of the hill and when you need the energy, the lake empties and it goes down through the turbine and generates energy and then when there's off peak electricity it pushes the water back upstream. Malcolm Turnbull was trying to get this going. I think in the. Well actually might still be going in the snowy mountains. I'm not snowy.

Sana Qadar (3:51)

Hydro's a thing.

Norman Swan (3:52)

Snowy 2.0. Well the hydro is, but with a pumped hydro. But anyway, we're now stringing into non. Watch that rash territory.

Sana Qadar (3:59)

The gaps in my knowledge are gaping.

Norman Swan (4:01)

I know that Malcolm's a listener, so I'll get hammered for it. But anyway. And effectively that's what creatine does.

Sana Qadar (4:07)

What I've got an amino acid lake and it flows down into my muscles when I need it, kind of.

Norman Swan (4:13)

And the secret enzyme is called creatine kinase, of which there are various forms in the body. There's creatine kinase for the brain and various other parts of the. But what creatine kinase does is the core energy compound in the body is called ATP.

Sana Qadar (4:30)

Yes.

Norman Swan (4:31)

And when you don't need the ATP, creatine kinase will take the phosphorus from the ATP. That's what the P part is of the ATP. Take the phosphorous and attach it to creatine so it becomes phosphocreatine and then that turns the ATP into adp, which is like the storage tank, the storage lake at the top of the hill. And then when you need energy, the phosphate is taken off the creatine, put back into the ATP and it becomes ATP ready for energy. So essentially it's what they call an energy buffer. So phosphocreatine absorbs the energy store and makes it available when it's Needed for either bursts of energy or whatever. And that happens in muscle and it happens in other tissues as well.

Sana Qadar (5:23)

Most of the body's creatine pool is in the muscle, though. And that makes sense because they're big organs that require a lot of energy. And a lot of our discussion about creatine in the past on what's that rash and also just kind of in general has focused on muscles. So supplementing it, if you're like a bodybuilder or some kind of athlete. We did touch on that a little bit in the pre workout episode. I didn't want to spend too much time on that today, but just to kind of acknowledge that that's how it's been viewed in the past, as like maybe why you'd want to supplement with. But it feels like in the last couple of years, year or two, maybe less, that it's gotten a real reputation as perhaps having other superpowers beyond muscles, which relate to the questions that we've gotten around, brain function and perimenopause and all of those sorts of things as well.

Norman Swan (6:09)

Yeah. So as I said, there is a form of this enzyme, creatine kinase, which exists in the brain and creatine can exist in the brain too, and it's involved in energy production in the brain as well and in other tissues. There are some tissues in the body where there's not a lot of creatine kinase, but there is in the heart, there's in sperm. Where they need sperm, they've got to.

Sana Qadar (6:31)

Wiggle their little tails.

Norman Swan (6:32)

Yeah. You know, when they got to get into action, they've got to get into action. And you just need that creatine kinase to get there, to do it. So it's been implicated to be able to help depression, cognitive function and so on. So it's not a mad idea because it is involved in energy production in the brain. The problem with all this stuff is that whilst there are thousands of studies into creatine, they are mostly actually in energy production in muscles. The quality of the research into foggy brain, menopausal symptoms, perimenopausal symptoms, depression, are small studies full of flaws that you really just can't hang your hat on.

Sana Qadar (7:14)

Well, let's look at them kind of one by one because I'd like to unpack this. I think depending on who you are and what phase of life you, you're in at the moment. We live in a world where we are either seeing nothing about something, always it feels like it's all we're seeing. And so when I was prepping for this episode, Norman, over the last couple of days, look at me. So I mentioned to a mate that we were gonna do creatine. And this is someone who's in their 40s, very athletic, and they were like, oh my gosh, creatine. Like it's all that all of my fellow female athletes are talking about. You gotta watch this woman's YouTube channel. There's like all these other YouTubers and stuff. It has a real cult following in. And I think especially. And it's telling to me that the six different question askers that I rattled off before are all women's names. I don't know if they're all women, but like, they certainly read as such. And it's very much this sort of perimenopausal space that it seems to be at a fever pitch at the moment. I'm interested to kind of unpack perhaps where these concepts maybe started and just sort of drill down into what the pros and cons are that we've able to surmise from the research so far. Where did this idea of creatine being more than just a muscle supplement start?

Norman Swan (8:28)

It's hard to know exactly where it started. So athletes taking the drug say they, is it a drug more energetic? Well, it is a drug and when you're taking it as a supplement, that's my point actually about supplements, is that you're taking them in natural doses and you're actually taking them as a drug. You're not taking them as a natural supplement. You know, a natural way to take it is actually to have a healthy meal based on the.

Norman Swan (8:53)

And or diets like it, which are chock full of creatine. It's unnatural to take it as a supplement. So you're taking it as a drug and people taking it as a drug. So athletes, teenage boys, thinking that it's going to improve their muscle strength when they're playing rugby, say they feel more energized on it. Well, hard to measure that sense of energy. I'm not decrying it, but it comes from. There's solid science here behind this, which is that creatine, creatine kinase is involved in energy generation in the brain. Energy generation between nerve cells is a different story from actually feeling more energy. You can't necessarily translate those things together. But I mean, for example, a randomized control trial, 36 healthy perimenopausal and menopausal women, aged on average around 50, random allocation into four groups. So as soon as you've allocated into four groups of 36 people. There's nine people per group. You would not register a drug. It would be 10, 15 times that number of people in a much larger trial. Better designed.

Sana Qadar (10:02)

I mean this is the one that I think you're talking about is one of the ones that looks kind of the most credible at first blush. It's certainly one that's gotten a lot of media coverage. One thing that's important to call out is that the lead author is actually seems to have some pretty important conflicts of interest. They're the member of the scientific advisory board on creatine in health and medicine and they co own a patent supplements based on liquid creatine, the European Patent Office and another patent as well and is a co founder of a company which develops food products enriched with creatine. So I mean no shade on the results itself, but definitely someone with a vested interest in finding that creatine's useful.

Norman Swan (10:43)

So and then there's another study on creatine supplementation on menopausal women's body composition, their thinking, estrogen strength and sleep. 15 women, 14 weeks study, you know.

Sana Qadar (10:54)

Very short and as far as very small.

Norman Swan (10:57)

You just natural variation. I mean just two seconds on clinical trial design that watch that rash listeners need to know about is you might say, well, it's a study and it shows a difference. The thing about a reliable clinical trial is that the sample has got to be large enough that you can eliminate natural variation. So if you take women or men or anybody with common symptoms such as sleep disturbance, muscle strength, things that are hard to measure, muscle strength, cognitive ability, that's not that hard to say. But there's natural variation on this. With 15 women in the study, natural variation will swamp the effects of the drug. You've got to have hundreds of women. I know it's inconvenient, but you've got to have hundreds if not thousands of women to get beyond the noise of daily life. And this study would not have done that.

Sana Qadar (11:52)

Those studies are expensive as well and they take a long time.

Norman Swan (11:55)

That's the common criticism. It's only the pharmaceutical industry that has the money to do this, which means that government funding agencies need to fund it. But then the government funding agencies have priorities and they say, well, is the signal strong enough with creatine that we should do it? So do you want me to give you the reason why I wouldn't go near creatine supplements?

Sana Qadar (12:17)

Yeah, like I guess it's the thing with supplementation where you sort of go, well okay, but like what's the downside? But there is a downside.

Norman Swan (12:25)

There sure is. And it's cancer.

Sana Qadar (12:28)

Ah, okay.

Norman Swan (12:29)

And it's conflicting information, but it's enough to say, well, if I want to get my creatine, I'm going to get it from food. And so people have said in the creatine space that creatine prevents the spread of cancer. It's actually not creatine. It's a form of creatine called cyclocreatine. Creatine itself is associated with. With breast cancer spread and possibly spread of glioblastoma, malignant brain cancer. So it's not causative, but it seems to facilitate the spread.

Sana Qadar (13:04)

How is it. Because it's an energy, like it's energizing.

Norman Swan (13:06)

I don't know why, but that's probably why is that it fuels the tumor. Now, emburied in that is actually something that's therapeutic, because if you can block that effect, you can possibly treat the cancer or make it less likely to spread, which is where this version of creatine called cyclocreatine comes in, because it actually gets in the way of the natural energy cycle and blocks that, and it may be associated with preventing cancer spread as an addition to cancer therapy. It's an incredibly complicated story, but just for me, taking creatine to get a little bit of extra energy, whether that's real or imagined, we know the muscle stories. The muscle story might be real that you're getting. I mean, the muscle bulk probably comes from the absorption of water into the muscles rather than true muscle bulk. But there is some evidence that you get a bit more energy out of your muscles by taking creatine. If it was really strong, the Olympic committee would have banned it. But it's hard to measure as well. So that's the other thing with creatine. The issue here is, why would you take it if there's this risk here?

Sana Qadar (14:15)

That is a really interesting thing that we'll have to look at in years to come. And I suppose is also worth calling out some of the other, you know, less worrying, but still serious side effects of creatine in certain people. Supplementation, if you've got, say, kidney damage or kidney disease, it can be dangerous for you. And I mean, some people report muscle cramps and gastro upset, which could be the creatine. I think with gastro stuff, maybe it could be the other things that are in your powder, but just worth keeping in mind. The thing with the creatine, I think, Norman, is that. That people who have Taken it and love it might be listening to this and being like, well, A, excuse me and B, am I going to get cancer now?

Norman Swan (14:56)

Well look, I'm talking about me, not you and what I would do if you're finding you're getting benefit from it. I mean the big studies in athletes and we're using it for muscles, those are where there are big studies don't show much risk. So the theoretical idea that it might actually nurture cancer or its cancer spread are still in the lab and in the test tube. For me it's enough to put me off. But you're fine with it, Be fine with it.

Sana Qadar (15:21)

You do you boo.

Norman Swan (15:22)

Yeah.

Sana Qadar (15:23)

And I mean one of the questions we got was specifically about Alzheimer's. That's a very particular kind of question about brain function. What do we know?

Norman Swan (15:31)

Well, we've got one study that was an eight week study of creatine monohydrate, which is the commonest by the way. The cyclocreatine that I mentioned earlier is not in a supplement and you definitely not want to take cyclocreatine, a diet.

Sana Qadar (15:48)

Why is that?

Norman Swan (15:48)

Well, because it blocks the creatine pathway and you need your creatine pathway. So you might take it as part of cancer therapy in a trial, but not in this situation. So creatine monohydrate is one of the commonest supplements. So they did an eight week trial in people with Alzheimer's disease. Again, a small trial, 20 grams a day, eight weeks. But it wasn't a double blind controlled.

Sana Qadar (16:11)

Study and that's a very short trial for something that's such a long term disease. Yeah.

Norman Swan (16:16)

So they noticed improvements. Well, I would say that's nice, but need something a bit bigger than that. That's double blind.

Sana Qadar (16:23)

It's a bit demoralizing. I think when you hear stories like this and it sounds like it's. I know the whole, like if it sounds too good to be true, it probably is. Like I get that. But I think if you're looking around for something for your parent with Alzheimer's or you're feeling brain foggy because you're in perimenopause, like it's very tempting to go for something like this. It feels low risk, high reward.

Norman Swan (16:43)

Well, if you understand the risks and you listen to watch that rash, nobody has quantified by the way the risks attached to breast cancer or glioblastoma or other forms of cancer. So it's theoretical, it's in animal studies, it's in laboratory studies, but nonetheless that's there and if you're dealing with something like Alzheimer's disease and you want to try it out, that's probably the main downside. And if you've got Alzheimer's disease, getting cancer in 20 years time is probably the least of your worries.

Sana Qadar (17:14)

Goodness, what a dull night to end on, Norman.

Norman Swan (17:16)

Well, you know, try it out again, not recommending it, but the risk in somebody with Alzheimer's of that side effect is low because you're already towards the end of life and cancer takes a while to develop.

Sana Qadar (17:29)

Okay, so let's say we don't want to supplement with creatine. You've really poured a whole lot of cold water on that, Norman. But you say it is important for the way our body functions. It is possible to get it from our diet. How do we prioritise that, get it from our diet?

Norman Swan (17:43)

Well, a well rounded diet with high quality protein is how you get it because it's made from amino acids. And so you want a diet that has a wide range of amino acids and that will include the amino acids that are involved in creatine production. And that's what you want. So it's not a very difficult thing.

Sana Qadar (18:04)

Maybe a bit more difficult if you're vegetarian or vegan. I know that people who have those diets have lower creatine levels than people who have an omnivorous diet.

Norman Swan (18:13)

And they might be the people who've got a bigger safety margin with the creatine if they take some creatine supplementations, which is. We're not recommending that. Something you need to talk over with your GP or dietitian.

Sana Qadar (18:23)

So bottom line here for Felicity, Deb, Jasmine, Jo, Gemma and Peter is basically prioritise protein in a healthy diet. Talk to your GP or your dietitian.

Norman Swan (18:33)

Particularly if you are perimenopausal or menopausal, where because of your age, you are at increasing risk of something like breast cancer. And do you want to take something that may, even if it's from lab research, increase that risk? No.

Sana Qadar (18:48)

Well, thank you all so much for sending through your questions. I hope this hasn't been too much of a downer for you.

Norman Swan (18:55)

The money you and I would make if we just.

Sana Qadar (18:58)

Well, the money we're saving people. I think Norman is a good way of thinking of it. Feel free.

Norman Swan (19:02)

But you know what I'm saying, if we had no morality, we could just tout sort of crappy solutions for complicated problems.

Sana Qadar (19:08)

That's the dream. Maybe one day. But for now we're here being ethical and moral and all that boring stuff. We love answering your questions. Thatrashbc.net au is our email address. It's also where you can send your feedback and notes to us.

Norman Swan (19:22)

And Siobhan's written in who was our question asker for the dreams episode?

Sana Qadar (19:26)

Yes, Siobhan says. So excited to be mentioned and so fascinating. By the way, I am a very creative person, having spent many years in the arts industry. So Norman's mention of that was very interesting. My husband says recently he's remembered his dreams more frequently. She says. Must be an age thing. I think it sounds more like you're paying attention and listen like. And kind of like remembering them on purpose because we've been talking about it. What do you reckon?

Norman Swan (19:54)

I don't know. I've always been able to remember my dream. I had this really weird dream last night.

Sana Qadar (19:58)

Okay, go on.

Norman Swan (20:00)

So all sorts of people came into it, including somebody I know who's a journalist and then suddenly graduated in medicine and was giving free advice on the radio. Maybe that's just my role. And then suddenly I was in a rugby game and Mark Butler was playing on the wing.

Norman Swan (20:17)

And he got clobbered on the way through and then I woke up. So I had no idea what happened to Mark Butler.

Sana Qadar (20:23)

Did you text Mark Butler this morning and say you were in my dream last night, babe?

Norman Swan (20:26)

I don't know. Maybe Susan Lee was on the sidelines cheering. I have no idea. But anyway, that was last night's Dr. But thanks very much, Siobhan, for giving us that feedback. I'm on your husband's side.

Sana Qadar (20:36)

So the other thing I have to mention here, this is like a very important point of housekeeping, is that you mentioned in our dreams episode about the night terror that you had when you were a wee boy that you discovered as an adult, where the impetus for that came from. And I stopped you from finishing your story and told people if they remembered you telling me about what that was from back in the day to email us with the answer and that we would get our fridge magnet and. Oh, what's that? Rash branded fridge magnet out to you. Well, thank you so much. We have had quite a few people correctly remember your prizes in the mail. But Norman, if you could please reveal your knight terror origin story.

Norman Swan (21:16)

It was from watching Alice in Wonderland as a child. And it's the late scenes in Alice in Wonderland where she's being chased.

Sana Qadar (21:23)

And you realized when your kids were watching Alice in Wonderland that was where the picture had come from.

Norman Swan (21:28)

It was like a train hitting me. It was amazing.

Sana Qadar (21:30)

We also had some more correspondence about our dreams episode, Brett says, I've gotten into the habit of taking a nap in the afternoon on my lawn. However, because I feed the local magpies, they'll often wake me up and demand food, which they do by pecking my feet or pulling my hair. Often this seems to drag me out of a REM sleep cycle as I awake, conscious of having been dreaming, though the dream soon evaporates. I'm so impressed with Brett's bravery. Sleeping on the lawn, being attacked by birds to wake him up.

Norman Swan (22:03)

God, that's right.

Sana Qadar (22:05)

I would be afraid of ant bites.

Norman Swan (22:06)

Well, maybe he's having nightmares about alfredishcock. I mean, I would be.

Sana Qadar (22:12)

And then one more message from Kim, who says, my curiosity today comes from my love of yore. As in our closing titles. Music. I find myself doing a little dance in my seat when I listen to it, and I love, love, love the little tune you have at the end shows. Does anyone else write in to tell you that they vibe and do a little dance to your closing tune?

Norman Swan (22:33)

Yes, is the answer.

Sana Qadar (22:34)

Kim, I love that you love it. I also dance along a little bit too. Thank you so much for joining us.

Norman Swan (22:39)

As always, I'm jiggling in my seat till I see you next week.

Sana Qadar (22:43)

See you then.