#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
Peter Attia, MD, introduces a practical framework for evaluating supplements, then applies it to popular ones like creatine, fish oil, and vitamin D. The episode aims to empower listeners to critically assess supplements for their individual health needs.
Deep Dive Analysis
8 Topic Outline
Introduction to AMA and Supplement Complexity
A Framework for Evaluating Supplements
Distinction Between Supplements and Pharmaceuticals
Applying the Framework: Creatine Overview
Creatine: Purpose, Dosing, and Mechanism of Action
Creatine: Proven Benefits and Cognitive Potential
Creatine: Risk vs. Reward and Quality Considerations
Introduction to Fish Oil Evaluation
2 Key Concepts
Supplement Regulation
Supplements are not rigorously regulated by the FDA, which has tacitly referred to them as 'generally regarded as safe.' This process is less rigorous compared to pharmaceutical products, which undergo more extensive regulation and oversight.
Phosphocreatine System
This is an energy system that rapidly generates adenosine triphosphate (ATP) for short, all-out bursts of activity (e.g., a 40-yard dash). It relies on phosphocreatine as a phosphate donor to quickly replenish ATP stores, which are the body's primary energy currency.
6 Questions Answered
One should use a structured framework that asks specific questions about the supplement's purpose (correcting deficiency vs. supranormal levels), impact on lifespan/healthspan, trackable biomarkers, mechanism of action, and risk-reward balance, including quality.
The primary difference lies in regulation; pharmaceutical products undergo more rigorous regulation and oversight by the FDA, whereas supplements are not as strictly regulated and are generally regarded as safe without the same level of scrutiny.
Key questions include: Is it correcting a deficiency or aiming for supranormal levels? Is it for lifespan or healthspan (and which specific apparatus)? Is there a trackable biomarker? Do you understand its mechanism of action? What is the balance of risk to reward, including potential side effects, magnitude of effect, data confidence, and supplement quality?
Creatine primarily helps improve various parameters of muscle performance, such as power and hypertrophy, especially in high-intensity and anaerobic activities, and there is emerging evidence suggesting potential cognitive benefits like improved memory.
Creatine generally has robust safety data and is considered low risk, but individuals with imperfect kidney function should consult their doctor and temporarily stop taking it before blood tests for creatinine, as high doses can impact serum creatinine levels.
Women may benefit disproportionately more than men due to lower natural stores and potentially less dietary consumption, and there is some evidence it may be helpful during periods of rapid hormonal change like pregnancy, perimenopause, and menopause.
15 Actionable Insights
1. Adopt Supplement Evaluation Framework
Systematically evaluate any supplement by asking seven key questions: purpose (deficiency vs. supranormal), target (lifespan/healthspan), specific healthspan apparatus (physical, cognitive, emotional), trackable biomarker, mechanism of action, and risk-to-reward balance, including quality.
2. Scrutinize Supplement Quality
Be highly skeptical and intensely scrutinize the quality of any supplement you consider, as regulation is minimal and nefarious behavior is significantly more prevalent than in pharmaceuticals.
3. Review Existing Supplements Systematically
Mentally ‘dump out’ all current supplements and medications, then systematically re-evaluate what should be added back in, ensuring you understand the purpose and data for each.
4. Avoid Ideological Supplement Bias
Do not get ideologically attached to ’natural supplements’ versus ‘pharmaceutical agents’; instead, analyze any molecule ingested using a consistent, evidence-based framework.
5. Know Your Supplement’s Purpose
Understand precisely why you are taking each supplement, rather than continuing use based on past recommendations or social media trends without current justification.
6. Creatine for Performance & Mass
Take creatine to achieve supraphysiologic levels, which can improve athletic performance, particularly in resistance training, and potentially increase lean muscle mass.
7. Optimal Creatine Daily Dose
Consume 3-5 grams of creatine per day to maximize muscle stores, as higher doses beyond this amount do not provide additional benefits.
8. Creatine for High-Intensity Bursts
Use creatine to enhance performance in activities requiring short, intense bursts of energy, such as sprinting or anaerobic exercises.
9. Creatine for Cognitive Function
Consider taking creatine for potential benefits in warding off cognitive impairment and improving memory, based on emerging research.
10. Creatine Benefits for Women
Women may experience disproportionately greater benefits from creatine supplementation, potentially aiding in reducing depression and supporting health during periods of rapid hormonal change (menstrual cycle, perimenopause, menopause).
11. Women’s Creatine Dosing
Women should aim for the same 3-5 grams per day creatine dosage as men, as their typically smaller size means they may derive more significant benefits from this amount.
12. Avoid Creatine During Pregnancy
Avoid creatine supplementation during pregnancy unless absolutely necessary, as there is insufficient human data to confirm its safety.
13. Creatine & Kidney Function
If you have imperfect kidney function, consult your doctor before starting creatine supplementation due to its impact on kidney function markers.
14. Inform Doctor About Creatine
Always inform your doctor if you are taking creatine before any blood tests, and consider stopping it for a couple of weeks prior, as it can affect serum creatinine levels used to assess kidney function.
15. Choose Pure Creatine Monohydrate
Opt for creatine monohydrate, ensuring the product is pure with no fillers or extra ingredients, as it is inexpensive and effective.
4 Key Quotes
if I were to just dive into this podcast and give you my point of view on a random collection of supplements, it would be akin to giving you a bunch of fish when in reality, what I want to do is make sure you, of course, know how to fish.
Peter Attia
Our view is generally to approach this the way the kidney approaches the filtration of glucose, sodium, and potassium, which is you dump everything out and then ask the question, what should be added back in?
Peter Attia
Supplements are not regulated. By definition, the FDA has tacitly referred to them as generally regarded as safe. But the process by which that's determined is not entirely that rigorous.
Peter Attia
I would put this [creatine] in the low risk, modest reward category.
Peter Attia
1 Protocols
Creatine Blood Test Preparation for Kidney Function Assessment
Peter Attia- If you have anything but perfect kidney function and are taking creatine, inform your doctor.
- Stop taking creatine for a couple of weeks before any blood test that measures your creatinine levels.
- This ensures that the creatine supplementation does not artificially impact serum creatinine measurements, which are used to determine kidney function.