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Strength, Exercise Physiology, Nutrition

Is creatine as good as it’s cracked up to be? Older adults and resistance training

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What is creatine? 

The use of creatine (Cr) can be traced back to the early 1990s when several elite sprint athletes reported performance-enhancing benefits following gold medal winning performances at the 1992 Barcelona Olympic Games (Anderson, 1993). This sparked the birth of a new era with creatine gaining widespread popularity as a legitimate ergogenic aid (Bird, 2003). Creatine is a nitrogenous organic acid abundant in metabolically active muscle, heart and brain tissue. It is synthesised endogenously in the liver and kidneys from the amino acids arginine, glycine and methionine, and absorbed from the diet primarily from red and white meat (Chilibeck et al., 2017; Phillips, 2015). Most creatine is stored intramuscularly as phosphocreatine (PCr) (Candow et al., 2014). PCr functions principally as a temporal energy buffer by donating a high-energy phosphate to ADP through the enzymatic reaction of creatine kinase, which re-synthesises and replenishes ATP stores and thus helps maintain skeletal muscle energy availability during very short, intense anaerobic exercise (Kreider et al.,, 2017; Candow et al., 2014; Candow & Chillibeck, 2010). PCr also acts as a spatial energy buffer shuttling intracellular energy between mitochondria and sites of cellular ATP utilization (Kreider et al., 2017; Gualano et al., 2016). 

To show that older women can get a lot of benefits from getting fitter and stronger and need to lift weights
Older people embrace powerlifting in Castlemaine (Australia) to avoid aged care home (courtesy ABC news)

Creatine supplementation increases the Cr/PCr reservoir by 20-40% (Kreider et al., 2017) and it is posited that this enhances PCr-mediated ATP resynthesis during and after high-intensity exercise bouts (Deane et al., 2017; Close et al., 2016), thereby allowing greater amounts of work to be accomplished (Phillips, 2015). This is particularly relevant for resistance training (RT) given that a dose-response relationship has been shown to exist between training volume and gains in skeletal muscle mass (Schoenfeld et al., 2017a; Schoenfeld et al., 2017b), and muscle strength (Figueiredo et al., 2017; Ralston et al., 2017). Other possible mechanisms to account for creatine ergogenicity are reduced exercise-induced muscle damage, reduced oxidative stress, increased GLUT4 in muscle fibre membranes, increased cell swelling that activates protein synthesis within muscle fibres, and decreased reliance on anaerobic glycolysis/reduced lactate production (Chilibeck et al., 2017; Kreider et al., 2017; Devries and Phillips, 2014). Although the exact mechanisms of action are still to be determined (Phillips, 2015), creatine supplemented RT has been extensively researched, especially in younger populations (Buford et al., 2007; Kreider et al., 2017). Consuming 5 grams of creatine (or 0.3 grams per kilogram body weight) four times daily for 5-7 days is generally viewed as the most effective way to increase muscle creatine stores and can be adequately maintained by consuming 3-5 grams/day following this loading phase (Kreider et al., 2017).

To show the differences in creatine uptake in muscle following supplementation in vegetarian, normal, creatine loading and creatine loading with cho or cho/pro
Muscle total creatine stores (figure courtesy of Kreider et al. 2017, J Int Soc Sports Nutr.)

Is creatine effective in older adults?

Three meta-analyses of randomised, placebo-controlled trials (Chilibeck et al., 2017; Candow et al., 2014; Devries and Phillips, 2014) have been published on the effects of creatine supplementation during RT on lean tissue mass and muscle strength in middle-aged and older adults (45-80 years old). No meta-analysis has yet assessed the effectiveness of creatine on RT outcomes in adults specifically 60 years or older. Most recently, Chilibeck et al. (2017, pg219) found significantly greater increases in lean tissue mass (1.4 kg; SMD=1.35), upper (i.e. chest press; SMD=0.37) and lower (i.e. leg press; SMD=0.25) body muscle strength when middle-aged to older adults (50-80 years old) were supplemented with creatine during RT. However, whilst the results of this study are often promoted as evidence that creatine has ergogenic value for this cohort, the standardised mean differences reported for muscle strength were trivial based on the effect sizes proposed by Rhea (2004) to delineate what is, and what is not meaningful following RT. If we apply more traditional effect sizes (Sullivan and Feinn, 2012), these strength improvements still remain small. One of the longest trials to investigate the impact of creatine supplementation and RT in middle-aged and older male adults (49-69 years old) found no additional benefits on measures of bone, muscle or strength after 12 months (Candow et al., 2020). Moreover, Beaudart et al., (2018) concluded that the research findings were equivocal for creatine after conducting a systematic review into the effects of various nutrients on muscle mass, muscle strength and physical performance in older adults (≥60 years old).

Scale for determining the magnitude of effects sizes in strength training research
Taken from Rhea (2004)

At the time of writing only a handful of studies have assessed the monotherapy supplementation of creatine in older adults (≥60 years) undergoing RT (Smolarek et al., 2020; Gualano et al., 2014; Deacon et al., 2008; Pinto et al 2016; Aguiar et al., 2013; Alves et al., 2013; Brose et al 2003; Chrusch et al., 2001; Bermon et al., 1998). Of those that measured changes in lean tissue mass, participants supplemented with creatine consistently achieved greater benefits compared to placebo (Gualano et al., 2014; Pinto et al 2016; Aguiar et al., 2013; Brose et al 2003; Chrusch et al., 2001). In contrast, the effects of creatine on muscle strength were less consistent with the vast majority of studies showing no additional benefit versus placebo for core RT lower limb exercises i.e. leg press (Deacon et al., 2008; Pinto et al., 2016; Alves et al., 2013; Brose et al 2003; Bermon et al., 1998). Three of the four studies that explored the impact of creatine on physical function found no evidence of performance enhancement compared to placebo for a number of standard tests (Aguiar et al., 2013; Brose et al 2003; Gualano et al. 2014; Deacon et al., 2008); these included the 30-second chair stand test, 30 metre walk time, time to climb 14 stairs, the timed-up-and-go test, and the shuttle walk distance test. No RCTs have yet tested whether creatine supplementation in older adults (≥60 years) positively impacts balance or quality of life. Encouragingly though, Neves et al., (2011) demonstrated improved quality of life and physical function in postmenopausal women (mean age=58 years old) with knee osteoarthritis that took creatine during RT. The only study to have assessed the effect of creatine on dynamic balance found that improvement of balance performance was actually inhibited in older middle-aged adults (Johannsmeyer et al., 2016); those that were randomly allocated to the placebo group during drop-set RT experienced significantly greater improvement in dynamic balance (30.8%) compared to the creatine group (19.4%), with a reduction in balance errors detected for the placebo group only.  In sum, creatine supplementation in older adults during RT appears to support increased lean tissue mass, but this has not necessarily translated into appreciable gains in muscle strength, physical function and/or improved balance versus placebo.

Is creatine well tolerated and safe?

Creatine when used in healthy, older adults appears to be well tolerated and safe. There have been no reports or evidence of any adverse effects that are serious in nature (Chilibeck et al., 2017; Goudarzian et al., 2017; Pinto et al., 2016; Gualano et al., 2014; Alves et al., 2013; Brose et al 2003; Chrusch et al., 2001; Bermon et al., 1998) and self-reported issues associated with the use of creatine have been uncommon (Pinto et al 2016; Gualano et al., 2014; Alves et al., 2013; Brose et al., 2003). No adverse events related to, nor changes in either kidney or liver function have been reported from RCTs (Gualano et al., 2014; Tarnopolsky et al., 2007; Brose et al., 2003) and other studies that included both middle-aged and older adults are devoid of any such side-effects (Johannsmeyer et al., 2016; Chilibeck et al., 2015; Lobo et al., 2015; Cornelissen et al., 2010; Eijnde et al., 2003). Some studies have reported that gastrointestinal (GI) distress and muscle cramping and/or muscle strain may be more common in those receiving creatine (Chilibeck et al., 2015; Chrusch et al., 2001). In healthy, older men (mean age=70 years old) loose stools were reported by Chrusch et al., (2001) as a side-effect during the 1-week loading phase and increased muscle cramping/strain occurred between weeks 3 and 5. Middle-aged to older postmenopausal women (mean age=57 years old) taking creatine experienced a higher number of these adverse events when GI complaints and muscle cramping were grouped for assessment (Chilibeck et al., 2015). None of these side-effects led to study discontinuation and appear to be transient in nature with no impairment of exercise training response noted. 

What questions do we need further clarification on? 

Many questions remain unresolved. Despite the evidence supporting increased lean tissue mass following creatine supplementation, it seems too early to claim definitively that such a strategy substantially and consistently improves muscle strength or physical function in all older adults undergoing RT. Training adaptations, in theory, should be augmented by creatine. It is well acknowledged that ageing causes skeletal muscle atrophy with disproportionately greater reduction in cross-sectional area (CSA) of PCr-rich type-II muscle fibres (Nilwik et al., 2013; Kushmerick et al., 1992), and this results in much lower levels of intramuscular creatine in the quadriceps vastus lateralis (thigh) muscle of older versus younger adults (Chilibeck et al., 2017). Lifestyle changes with ageing – particularly reduced dietary meat intakes, decreased physical activity levels (Chilibeck et al., 2017) and increased sedentary time (Diaz et al., 2017; Dunlop et al., 2015) – may further impact muscle PCr levels and modify any potential benefits of creatine supplementation. Further research is therefore required to establish whether the magnitude and heterogeneity of RT adaptations is modulated by significant inter-individual differences in creatine uptake kinetics, given that training responsiveness is correlated to the change in intramuscular creatine stores. Research by Syrotuik and Bell (2004) provide support for this possibility where it was demonstrated that young, healthy men had 3 different levels of response to a 5-day creatine load as measured by post-supplementation intramuscular creatine levels. Responders to creatine loading possessed a biological profile of the lowest initial muscle Cr/PCr levels, greatest percentage of type-II muscle fibres, largest muscle fibre CSA and lean tissue mass, plus were the only subjects to achieve improvement in 1RM leg press when compared to quasi- and non-responders. It is plausible that this may partially account for the lack of consistency in the research as such inter-individual variation could significantly water down any generalised group benefits. These responder profiles outlined above also raise another potential limitation in those older adults that are most in need of an ergogenic effect (i.e. those with sarcopenia and muscle weakness), as they may be the least likely, by extension, to reap the meaningful benefits of creatine supplementation. Furthermore, it is well accepted that intramuscular post-supplementation creatine levels (at day 28) are comparable for “slow” (3 grams/day for 1 month) and “rapid” load (4×5 grams/day for 5-7 days and 3-5 grams/day thereafter) protocols (Hultman et al., 1996). Thus, it would be prudent to compare whether the slow load approach is better tolerated than the rapid load approach (i.e. reduction of GI-related side-effects and muscle cramping/pulls) based on the evidence where some older adults appear to be more sensitive to large initiation doses of creatine.

Individual values for muscle creatine monohydrate
Taken from Syrotuik & Bell (2004)

Final comments

It is worth mentioning that besides any possible beneficial effect of creatine on lean tissue mass, skeletal muscle strength or function, there are several other therapeutic reasons that may potentially justify such use in older adults. An increasing amount of data from both human and rodent experiments support multiple other benefits for creatine, including lowering cholesterol and triglyceride levels, reducing liver fat accumulation, decreasing homocysteine levels, having antioxidant properties, improving glycaemic control, slowing tumor growth in some types of cancers, mitigating bone loss, positively affecting cognitive function and in some cases, serving as an antidepressant (Kreider et al., 2017). Consequently, the position stand on the safety and efficacy of creatine supplementation in exercise, sport, and medicine published by the International Society of Sports Nutrition concluded that (2017:11): 

Available short and long-term studies in healthy and diseased populations, from infants to the elderly, at dosages ranging from 0.3 to 0.8 g/kg/day for up to 5 years have consistently shown that creatine supplementation poses no adverse health risks and may provide a number of health and performance benefits.

References

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Anderson O. (1993) Creatine propels British athletes to Olympic gold medals: Is creatine the one true ergogenic aid? Running Research News 9, 1-5

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Candow et al. Effect of 12 months of creatine supplementation and whole-body resistance training on measures of bone, muscle and strength in older males. Nutr Health. 2020, Nov 24 (online ahead of print)

Candow DG, Chilibeck PD, Forbes SC. Creatine supplementation and aging musculoskeletal health. Endocrine. 2014 Apr 1;45(3):354-61.

Candow DG, Chilibeck PD. Potential of creatine supplementation for improving aging bone health. The journal of nutrition, health & aging. 2010 Feb 1;14(2):149-53.

Candow DG, Zello GA, Ling B, Farthing JP, Chilibeck PD, McLeod K, Harris J, Johnson S. Comparison of creatine supplementation before versus after supervised resistance training in healthy older adults. Research in Sports Medicine. 2014 Jan 2;22(1):61-74.

Chilibeck PD, Candow DG, Landeryou T, Kaviani M, Paus-Jenssen L. Effects of creatine and resistance training on bone health in postmenopausal women. Medicine & Science in Sports & Exercise. 2015 Aug 1;47(8):1587-95.

Chilibeck PD, Kaviani M, Candow D, Zello, G. Effect of creatine supplementation during resistance training on lean tissue mass and muscular strength in older adults: a meta-analysis. Open Access Journal of Sports Medicine 2017 Nov 2; 8: 213-226.

Chrusch MJ, Chilibeck PD, Chad KE, Davison KS, Burke DG. Creatine supplementation combined with resistance training in older men. Medicine & Science in Sports & Exercise. 2001 Dec 1;33(12):2111-7.

Close GL, Hamilton DL, Philp A, Burke LM, Morton JP. New strategies in sport nutrition to increase exercise performance. Free Radical Biology and Medicine. 2016 Sep 30;98:144-58.

Cornelissen VA, Defoor JG, Stevens A, Schepers D, Hespel P, Decramer M, Mortelmans L, Dobbels F, Vanhaecke J, Fagard RH, Vanhees L. Effect of creatine supplementation as a potential adjuvant therapy to exercise training in cardiac patients: a randomized controlled trial. Clinical rehabilitation. 2010 Nov;24(11):988-99.

Deane CS, Wilkinson DJ, Phillips BE, Smith K, Etheridge T, Atherton PJ. “Nutraceuticals” in relation to human skeletal muscle and exercise. American Journal of Physiology-Endocrinology and Metabolism. 2017 Apr 1;312(4):E282-99.

Devries MC, Phillips SM. Creatine supplementation during resistance training in older adults-a meta-analysis. Med Sci Sports Exerc. 2014;46(6):1194–203

Diaz KM, Howard VJ, Hutto B, Colabianchi N, Vena JE, Safford MM, Blair SN, Hooker SP. Patterns of sedentary behavior and mortality in US Middle-aged and older adults: a national cohort study. Annals of internal medicine. 2017 Oct 3;167(7):465-75.

Dunlop DD, Song J, Arnston EK, Semanik PA, Lee J, Chang RW, Hootman JM. Sedentary time in US older adults associated with disability in activities of daily living independent of physical activity. Journal of physical activity & health. 2015 Jan;12(1):93.

Eijnde BO, Van Leemputte M, Goris M, Labarque V, Taes Y, Verbessem P, Vanhees L, Ramaekers M, Eynde BV, Van Schuylenbergh R, Dom R. Effects of creatine supplementation and exercise training on fitness in men 55–75 yr old. Journal of Applied Physiology. 2003 Aug 1;95(2):818-28.

Figueiredo VC, de Salles BF, Trajano GS. Volume for Muscle Hypertrophy and Health Outcomes: The Most Effective Variable in Resistance Training. Sports Medicine. 2017 Oct 11:1-7.

Goudarzian M, Rahimi M, Karimi N, Samadi A, Ajudani R, Sahaf R, Ghavi S. Mobility, Balance, and Muscle Strength Adaptations to Short-Term Whole Body Vibration Training Plus Oral Creatine Supplementation in Elderly Women. Asian Journal of Sports Medicine. 2017 Mar 1;8(1).

Gualano B, Macedo AR, Alves CR, Roschel H, Benatti FB, Takayama L, de Sá Pinto AL, Lima FR, Pereira RM. Creatine supplementation and resistance training in vulnerable older women: a randomized double-blind placebo-controlled clinical trial. Experimental gerontology. 2014 May 31;53:7-15. 

Gualano B, Rawson ES, Candow DG, Chilibeck PD. Creatine supplementation in the aging population: effects on skeletal muscle, bone and brain. Amino acids. 2016 Aug 1;48(8):1793-805.

Hultman E, Soderlund K, Timmons JA, Cederblad G, Greenhaff PL. Muscle creatine loading in men. Journal of applied physiology. 1996 Jul 1;81(1):232-7

Johannsmeyer S, Candow DG, Brahms CM, Michel D, Zello GA. Effect of creatine supplementation and drop-set resistance training in untrained aging adults. Experimental gerontology. 2016 Oct 31;83:112-9.

Kreider RB, Kalman DS, Antonio J, Ziegenfuss TN, Wildman R, Collins R, Candow DG, Kleiner SM, Almada AL, Lopez HL. International Society of Sports Nutrition position stand: safety and efficacy of creatine supplementation in exercise, sport, and medicine. Journal of the International Society of Sports Nutrition. 2017 Jun 13;14(1):18.

Kuriansky J, Gurland B. The performance test of activities of daily living. The International Journal of Aging & Human Development.1976; 7:343-352.

Kushmerick MJ, Moerland TS, Wiseman RW. Mammalian skeletal muscle fibers distinguished by contents of phosphocreatine, ATP, and Pi. Proceedings of the National Academy of Sciences. 1992 Aug 15;89(16):7521-5

Lobo DM, Tritto AC, da Silva LR, de Oliveira PB, Benatti FB, Roschel H, Nieß B, Gualano B, Pereira RM. Effects of long-term low-dose dietary creatine supplementation in older women. Experimental gerontology. 2015 Oct 31;70:97-104.

Neves Jr M, Gualano B, Roschel H, Fuller R, Benatti FB, Pinto AL, Lima FR, Pereira RM, Lancha Jr AH, Bonfa E. Beneficial effect of creatine supplementation in knee osteoarthritis. Medicine and science in sports and exercise. 2011 Aug;43(8):1538-43.

Nilwik R, Snijders T, Leenders M, Groen BB, van Kranenburg J, Verdijk LB, van Loon LJ. The decline in skeletal muscle mass with aging is mainly attributed to a reduction in type II muscle fiber size. Experimental gerontology. 2013 May 31;48(5):492-8.

Phillips SM. Nutritional supplements in support of resistance exercise to counter age-related sarcopenia. Advances in Nutrition: An International Review Journal. 2015 Jul 1;6(4):452-60.

Pinto CL, Botelho PB, Carneiro JA, Mota JF. Impact of creatine supplementation in combination with resistance training on lean mass in the elderly. Journal of cachexia, sarcopenia and muscle. 2016 Sep 1;7(4):413-21.

Ralston GW, Kilgore L, Wyatt FB, Baker JS. The Effect of Weekly Set Volume on Strength Gain: A Meta-Analysis. Sports Medicine. 2017 Jul 28:1-7.

Rhea MR. Determining the magnitude of treatment effects in strength training research through the use of the effect size. Journal of strength and conditioning research. 2004 Nov 1;18:918-20.

Schoenfeld BJ, Ogborn D, Krieger JW. Dose-response relationship between weekly resistance training volume and increases in muscle mass: A systematic review and meta-analysis. Journal of sports sciences. 2017a Jun 3;35(11):1073-82.

Schoenfeld BJ, Ogborn D, Krieger JW. The dose–response relationship between resistance training volume and muscle hypertrophy: are there really still any doubts?. Journal of sports sciences. 2017b Oct 18;35(20):1985-7.

Sullivan, Gail M., and Richard Feinn. “Using effect size—or why the P value is not enough.” Journal of graduate medical education 4, no. 3 2012: 279-282.

Syrotuik DG, Bell GJ. Acute creatine monohydrate supplementation: A descriptive physiological profile of responders vs. nonresponders. The Journal of Strength & Conditioning Research. 2004 Aug 1;18(3):610-7.

Tarnopolsky M, Zimmer A, Paikin J, et al., Creatine monohydrate and conjugated linoleic acid improve strength and body composition following resistance exercise in older adults. PLoS One. 2007;2(10):e991.

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Mobility, Exercise Physiology, Strength, Weight/Fat loss

Strength Training Alters The Trajectory Of Ageing

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On a global scale, the number of people over 60 yr is expected to more than double from 841 million in 2012 to more than 2 billion by 2050. This change in demographics will have profound implications for many aspects of life. Furthermore, Government bodies worldwide will be faced with considerable challenges related to aging policy and how best to deal with this new reality.

Of the many things that occur during the ageing process one of the most obvious signs is the loss of skeletal muscle mass (sarcopenia) and strength (dynapenia) with decrements in physical function and potential predisposition to disability. The process whereby there is a gradual loss of muscle mass and concomintant reduction in strength and physical function with ageing – is primarily caused by a loss in number of muscle fibres and preferential loss and atrophy of fast-twitch type-IIx fibres. The loss in fibre number and atrophy and loss of type-IIx fibres may be related to a loss of innervation of muscle fibres and a progressive loss of alpha-motorneurons (see here).

I want to try and explain, therefore, why I think it is so important for anyone over 40 to spend some time in their week lifting weights – or what is more technically known as resistance training (for the short version click here). There has been a significant amount of research conducted to show that one of the very best ways to slow down this process is to perform regular and challenging resistive-based exercise or weight training. Recently, more data has emerged suggesting that an even greater benefit may be achieved with high-velocity power training (see here & here). Such training is slightly different to traditional strength training in that exercises are performed with light-to-moderate loads or weight, but movement speed is performed at fast to very fast speeds. Evidence demonstrates that such activity can even reverse some of the changes seen due to the combination of ageing and sedentariness, by specifically stimulating and increasing the strength and size of these fast twitch type-II muscle fibres (see here).

Over 25 years ago a seminal and ground-breaking research study was conducted which completely questioned our scientific understanding of what was possible when very old frail people were exposed to resistance training. In many ways the findings of this study are at the core of why most, if not all people over 40, should be doing some resistance training – colloquially speaking – “pumping iron”. Whilst weight, strength or resistance training may not be everyone’s cup of tea if there is one form of exercise that can substantially and dramatically improve functional physical capacity it is this form of exercise that promises so much.

To show that middle-aged or older adults derive huge benefits from lifting weights and strength training
Lifting weights helps keep older people young

A pivotal moment in my life occurred whilst doing PhD studies in the early 1990s. My project was to review the literature in a chosen area and my area of interest that I had developed for a while by then was resistance training. I had been introduced to this type of exercise as a means to improve athletic performance as an aspiring junior Track & Field athlete. The dramatic improvement in my performance once I had added this to my training program was extraordinary. Since that point in time I have lifted weights regularly and done countless squats, deadlifts, power cleans, tossed tractor tyres, pulled on pulley’s, performed push-ups, stood on Swiss Balls, jumped over hurdles……………………………………

I chose to focus on and study the morphological (structural) and functional changes that occur in human skeletal muscle as we age and what can be done to attenuate or slow these changes down. The simple answer to that question is to perform regular but challenging resistance training.

It was during this literature review that a very important piece of research came to my attention.

The question that had remained largely unanswered was how much of the biological “age-related” decline in muscle size, strength and function is attributable to ageing per se or to the extremely sedentary lifestyles adopted by many people as they grow older?

It is quite clear that both the ageing process and disuse syndromes (meaning no physical activity) contribute to a preferential loss of muscle fibres, specifically type-IIx fibres, and it is these muscle fibres that are involved in movements that require high amounts of force, power and speed. The critical question is, then, to what degree could intervening with a progressive resistance training program alter the trajectory of this decline in muscle strength and function and is it indeed possible to even reverse some portion of the assumed “age-related” decline seen in older people.

The study that everyone should read

The study that was published in JAMA (The Journal of the American Medical Association) June 13, 1990 by Maria Fiatarone and colleagues (see here) undertook to determine the feasibility and the physiological consequences of high-resistance strength training in the frail elderly. You are probably wondering just how frail. Well, not wanting to mince my words these participants were very frail and were probably coming to the final years or even months of their lives.

Their average age was just over 90, there were 6 women and 4 men, 60% had level 2 pattern of care (meaning they were not independent and required moderate assistance), 8 had a history of falls, 7 habitually used ambulatory assistive devices, there was over 4 chronic diseases per person and daily medications taken per person equated to more than 4. The most common medical diagnoses were osteoarthritis (7 subjects), coronary artery disease (6 subjects), osteoporotic fracture (6 subjects) and hypertension (4 subjects). Four of 10 subjects had anthropometric evidence of undernutrition and a substantial proportion did not obtain the recommended daily allowance for important micronutrients. (Click on graphs for clearer view of results)

To show the difference in cross-sectional area of skeletal muscle in older adults that are independent compared to those that require assistance
Muscle mass versus functional mobility

Muscle accounted for only 31% of the total cross-sectional area of the thigh as determined by CT scans, which meant that there was more fat and bone than muscle and it would be stating the obvious to you that this is not conducive to good balance, strength or functional mobility. Baseline muscle function was terrible with a 6 metre walk taking an average time of 22 seconds to complete with one subject taking almost 1 minute. Many struggled to raise themselves out of a chair without the assistance of their arms. Strength at the beginning of the study was positively correlated with fat-free mass (total muscle) and midthigh muscle area, whereas it was related inversely to time taken to stand from a chair and time to walk 6 metres.

What this means is that those that had more muscle tissue and greater strength at the start of the study (baseline) were able to perform better on the walk test and chair stand by executing these tasks more quickly.

Reduced physical strength and mobility with ageing affects health and wellbeing
The ageing process can be modified with exercise

Now to the interesting part of the study.

The results

Notwithstanding that there were only 10 elderly people involved, the findings were incredible and well beyond what was expected. What was even more surprising was only one simple exercise was employed: unilateral leg extension (i.e. single-leg) using a standard weight-and-pulley system. The 8-week training program used principles of progressive resistance training (in other words, as they got stronger the relative loads were increased), employed concentric and eccentric muscle contractions (whereby the muscle shortens and lengthens whilst under tension), trained 3 times/week completing 3 sets of 8 repetitions of each leg in 6-9 seconds/rep, with 1- to 2- minute rest periods between sets.

In light of their age, their general health status and the fact that they were only doing one simple exercise that primarily focused on the quadricep muscle (thigh) it would be within reason to think that the outcomes of the program would be quite negligible. However, that did not happen and this basically demonstrates that no matter how old, how injured, how dysfunctional you may be, your body and the skeletal muscle you stimulate – by performing challenging physical movement – will not only respond but it will respond quite robustly.

Exercise slows the ageing process and how weight training can increase muscle strength even the those that are 60, 70, 80 years old
Muscle strength improvement follows resistance training

Tolerance of the resistance training program was excellent with 90% completion rate (9 out of 10 finished), and no cardiovascular complications were seen. There was occasional hip and knee discomfort and that would be expected but no analgesics were required and no training sessions were missed. Gains in muscle strength were impressive and after just 8 weeks of training average strength had increased by over 170% and responsiveness to training was not different in men vs women. Some subjects made quite extraordinary gains of almost 400%. Muscle size increased in 5 of the 7 of the subjects that were CT scanned for total midthigh muscle area. Of those with stable body weight, the mean muscle area increases were significant with total midthigh muscle area going up 11.7%, the quadriceps up by 14.5% and the hamstrings/adductors by 10.6%.

Functional mobility accompanied the improvements in strength and muscle hypertrophy (growth). The time taken to complete the walking test improved substantially from 44 seconds to 29 seconds representing a 48% improvement. Two subjects no longer needed canes to walk at the end of the study and one of three subjects who could not initially rise from a chair without the use of their arms became able to do so. Importantly, no subjects experienced falls during the study. The physiological and functional improvements  were truly incredible. The effects of detraining were assessed too (stopped the program) and what this showed was that the gains made were very quickly lost with a significant 32% decrease in maximum strength after only 4 weeks of ceasing the training.

What are the major implications of these findings?

exercise physiology, exercise physiologist, Townsville Queensland Australia
Strength is fundamental to life

The results clearly demonstrated that progressive resistance training at sufficient loads (greater than 80% 1RM; i.e. lifting 80% of the maximum weight you can lift once) can induce dramatic and substantial increases in muscle strength, size and function in frail men and women up to 96 years of age. Achieving such favourable responses to strength training in these subjects is remarkable when one considers their very advanced age, extremely sedentary lifestyles, multiple chronic diseases and functional disabilities, and nutritional inadequacies. What is clear is that the preservation of fat-free mass (muscle) as one ages is a critical factor and directly affects muscle strength in the older person.

Exercise and resistance training specifically, is able to provide the neuromuscular system the appropriate physiological stimulus to reverse and modify a portion of the muscle weakness and functional loss often and simply put down to old age. Re-read that sentence because that is huge!

The final thing I would like to say on this study which deserves comment is that the results are all the more impressive because the subjects performed only one simple exercise (leg extension done unilaterally). Obviously if one employs resistance training exercises that are more complex, multi-jointed and aim to stimulate all the muscles of the upper and lower extremities (using different exercises) the structural and functional improvements would potentially be even greater.

For local Townsville residents interested in FitGreyStrong’s Exercise Physiology services or exercise programs designed to improve muscular strength, physical function (how you move around during the day) and quality of life or programs to enhance athletic performance, contact FitGreyStrong@outlook.com or phone 0499 846 955 for a confidential discussion.

For other Australian residents or oversees readers interested in our services, please see here.

Disclaimer: All contents of the FitGreyStrong website/blog are provided for information and education purposes only. Those interested in making changes to their exercise, lifestyle, dietary, supplement or medication regimens should consult a relevantly qualified and competent health care professional. Those who decide to apply or implement any of the information, advice, and/or recommendations on this website do so knowingly and at their own risk. The owner and any contributors to this site accept no responsibility or liability whatsoever for any harm caused, real or imagined, from the use or distribution of information found at FitGreyStrong. Please leave this site immediately if you, the reader, find any of these conditions not acceptable.

© FitGreyStrong

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Weight/Fat loss, Exercise Physiology, Nutrition

Regular Exercise Doesn’t Promote Weight Loss: Fact or Fiction?

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Several years ago researchers and authors Malhotra, Noakes & Phinney published an article in the British Journal of Sports Medicine titled:

“It is time to bust the myth of physical inactivity and obesity: you cannot outrun a bad diet” (see here)

This created quite a storm in several fields of scientific research including many fitness and nutrition blogs. It was lambasted by some though as inaccurate and misleading – just Google the title of the article and you’ll understand what I mean. Essentially, their article claimed that regular physical activity does not promote weight loss and that excessive consumption of carbohydrates, in particular, sugar, is the primary cause of the obesity epidemic. Whilst excessive sugar consumption has played an important role in exacerbating the obesity crisis, it would be naive and short-sighted to suggest that this is the be-all and end-all in explaining society’s current predicament.

More recently Julia Belluz and Javier Zarracina published (April 2016) an article at Vox titled:

“Why you shouldn’t exercise to lose weight, explained with 60+ studies” (see here)

This article posits that exercise is unhelpful for weight loss and makes very similar claims to the Malhotra et al. paper. Of course, the real question is, are these claims valid? Could it really be true that weight loss is not facilitated by increasing daily energy expenditure and exercise? I think the answer to these questions are not black or white. My main concern with the articles mentioned above is that they are rather myopic, polarising and do not provide a fair and balanced assessment of the current evidence.

Instead, the evidence published to date demonstrates that ‘our’ increasing waistlines are closely related – but not confined to – the interaction of the following 3 factors. Firstly, the sum total of all physical movement performed whilst awake has substantially decreased over the last 50 years. Secondly, activities of a sedentary nature have dramatically increased. What are you doing right now? Thirdly, total energy intake over the last 50 years has continued to increase over and above total daily energy expenditure requirements. If movement levels are low and energy intake high – irrespective of where the excess is derived from – body weight, body fat and BMI will naturally increase. But does increasing physical activity levels via a formalised exercise program and/or non-exercise based physical activities (e.g. leisure time movement, domestic chores/activities) facilitate weight loss by increasing total daily energy expenditure? The answer to this is yes and no.

Today I want to focus on the evidence that was accessible following a  brief Google Scholar search that supports exercise as well as other non-exercise increases in daily physical movement as being promoters of weight loss. For anybody not familiar with Google Scholar (https://scholar.google.com.au), it is a search engine by Google that searches for only published, peer-reviewed journal-based research and consequently provides information that is evidence-based rather than ‘opinion-based’ which is largely what would be accessed via Google, Yahoo or any other search engine. So, what did I find?

One of the more interesting pieces of research that directly contradicts the article by Malhotra and co. is that written by Church et al. (2011). They concluded that over the last 50 years in the U.S., daily occupation-related energy expenditure was estimated to have decreased by more than 100 calories per day, and this reduction in energy expenditure could account for a significant portion of the increase in mean U.S. body weights for women and men. What this would suggest is that rather than increased obesity rates being caused exclusively by too many carbs or too much sugar, as argued by the “you can’t outrun a bad diet” article, the current problem has been driven by large reductions in energy expenditure due to changes to occupation-related physical movement. In other words, we have transitioned from jobs that are active and require a lot of physical movement to jobs now that have most of us sitting on our backsides for hours on end.

Work places changes to physical activity
Doing this all day can’t be helpful

Previous reports based on estimated caloric consumption from food production and food disappearance (food waste) estimates have concluded that increased caloric consumption could account for most, if not all, of the weight gained at a population level in the U.S. Nonetheless, a recently validated differential equation model was used to identify a conservative lower bound for the amount of food waste in the U.S. (Hall et al. 2009). This analysis determined that prior estimates of national food waste were grossly underestimated; indicating that the national average caloric intake was much lower than previously estimated. As such, these results and those of Church imply that increased caloric intake or for that matter, increased sugar consumption, cannot solely account for the observed trends in national weight gain in the US.

The following is a summary of some of the research that has been published investigating whether obesity is related to physical inactivity and what effect increased physical activity has on obesity risk and management.

1. Banks et al. (2010) reported that: “Obesity increases with increasing screen-time, independent of purposeful physical activity.”

2. Goodpaster et al. (2010) found that: “Among patients with severe obesity, a lifestyle intervention involving diet combined with initial or delayed initiation of physical activity resulted in clinically significant weight loss and favourable changes in cardiometabolic risk factors.” In the group where physical activity was delayed, the addition of such physical activity promoted greater reductions in waist circumference and hepatic fat content.

3. Banks et al. (2011) showed that: “Domestic activities and sedentary behaviours are important in relation to obesity in Thailand, independent of exercise-related physical activity. In this setting, programs to prevent and treat obesity through increasing general physical activity need to consider overall energy expenditure and address a wide range of low-intensity high-volume activities in order to be effective.”

4. Villareal et al. (2011) demonstrated that: “…in obese older adults a combination of weight loss and exercise provides greater improvement in physical function than either intervention alone.”

5. McGuire & Ross (2012) reported that: “…light physical activity, incidental physical activity and sedentary behaviour were not associated with abdominal obesity amongst inactive men and women whereas moderate-to-vigourous physical activity predicted lower visceral adipose tissue.”

6. The study by Fan et al. (2013) was: “…to test if moderate-to-vigorous physical activity (MVPA) in less than the recommended ≥10-minute bouts related to weight outcomes.” Both higher-intensity short bouts and long bouts of physical activity related to lower BMI and risk of overweight/obesity whereas neither lower-intensity short bouts nor long bouts related to BMI or risk of overweight/obesity. They concluded that: “The current ≥10-minute MVPA bouts guideline was based on health benefits other than weight outcomes. Our findings showed that for weight gain prevention, accumulated higher-intensity PA bouts of <10 minutes are highly beneficial, supporting the public health promotion message that ‘every minute counts’.”

7. Cleland et al. (2014) found that: “High sitting and low activity increased obesity odds among adults. Irrespective of sitting, men with low step counts had increased odds of obesity. The findings highlight the importance of engaging in physical activity and limiting sitting.”

8. Jakicic et al. (2014) concluded that moderate-to-vigorous physical activity (MVPA > 10) of 200-300 min per week, coupled with increased amounts of low-intensity physical activity (LPA), are associated with improved long-term weight loss. Interventions should promote engagement in these amounts and types of physical activity.

9. Murabito et al. (2015) discovered that moderate-to-vigorous physical activity (MVPA) as measured by accelerometry was associated with less visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT) and better fat quality as assessed by multi-detector computed tomography. With increasing MVPA, there was a concomitant decrease in VAT. Higher levels of MVPA were associated with higher SAT fat quality, even after adjustment for SAT volume. They concluded that:

“MVPA was associated with less VAT and SAT and better fat quality.”

10. Mekary et al (2015) reported that: “….over 12 years long-term weight training is associated with less waist circumference increase, whilst moderate-to-vigorous aerobic activity was associated with less body weight gain in healthy men.”

11. Hume et al. (2016) concluded that: “….counter to the energy surfeit model of obesity, results suggest that increasing energy expenditure may be more effective for reducing body fat than caloric restriction, which is currently the treatment of choice for obesity.”

12. Myers et al. (2016) suggests that there exists clear associations among objective measures of physical activity, sedentary behaviour, energy expenditure, adiposity and appetite control. They produced data that indicates strong links between physical inactivity and obesity with this relationship likely to be bidirectional.

13. Wu et al. (2017) tested 12-weeks of low- and high-intensity exercise training in Mexican-American and Korean premenopausal overweight/obese women. Results showed that such exercise reduced body mass index, body fat percentage, fat mass and visceral adipose tissue with concurrent increases in lean mass.

14. Quist et al. (2018) examined the effects of 6-months of active commuting and leisure-time exercise on fat loss in women and men who were overweight or obese. Clinically meaningful fat loss of over 4 kilograms was elicited. Vigorous intensity exercise was shown to be more effective in reducing body fat versus moderate intensity exercise.

15. Stoner et al. (2019) concluded that the findings of their meta-regression “lend support to the use of exercise prescription for promoting weight loss and improving health outcomes in adolescents with overweight/obesity.”

16. Zhang et al. (2020) found that 12-weeks of intense exercise (without concurrent nutritional intervention, i.e. ‘put on a diet’) significantly improved cardiometabolic parameters (i.e. fasting blood glucose) and decreased weight, total percent body fat, whole-body fat mass, android, gynoid, and trunk fat mass, abdominal subcutaneous fat and abdominal visceral fat. Reductions of over 15 cm² of abdominal visceral fat were achieved in just 3 months!

17. Berge et al. (2021) produced clinically significant weight loss in people with severe obesity despite the study having no specific focus on body weight reduction. The group that performed moderate‐intensity continuous training combined with high‐intensity interval training lost an average of 5 kilograms in 24-weeks.

Weight training, older adults and quality of life
Staying strong as we age is critical to health

What does this research tell us?

Quite a lot I would say. Of particular note is that this only represents a very small sample of the evidence that directly counters the claim that widespread societal levels of physical inactivity have little to do with burgeoning obesity rates. What is more, it crystallizes just how contentious Malhotra, Noakes & Phinney’s editorial was. Exclusively assigning blame for the obesity epidemic to the excessive intake of sugar is not supported, I believe, by the current evidence. The dramatic reductions in the sum total of all physical activity accumulated during the day appears to account for a substantial amount of the increased weight seen in recent decades.

Firstly, there is a substantial amount of research which demonstrates that sedentary behaviours, sitting time and low physical activity levels manifestly increase one’s risk of becoming overweight or obese. Secondly, moderate-to-vigourous physical activity compared to light physical activity has been shown to be associated with less visceral and subcutaneous adipose tissue, impacts positive effects on fat quality, is related to lower BMI, lowers risk of overweight/obesity, prevents weight gain following weight loss, promotes greater reductions in waist circumference and produces favourable changes in cardio-metabolic risk factors.

So to conclude, my Google Scholar search unveiled that there is a large body of evidence that demonstrates that there may be no myth to bust regarding obesity and physical inactivity or foundation to suggesting that physical activity plays no role toward promoting weight loss. Others have been critical of this line of thinking too, in particular Dr Steven Blair, so I would suggest that if you wanted to read further on this here would be a good place to start.

My next article will explore the evidence that exercise does not assist weight loss in all exercisers due to various compensatory mechanisms (see here). Until then, stay active, keep moving and don’t forget to include some resistance exercise in your week.

For local Townsville residents interested in FitGreyStrong’s Exercise Physiology services or exercise programs designed to improve health, physical function and quality of life or to enhance athletic performance, contact FitGreyStrong@outlook.com or phone 0499 846 955 for a confidential discussion.

For other Australian residents or oversees readers interested in our services, please see here.

Disclaimer: All contents of the FitGreyStrong website/blog are provided for information and education purposes only. Those interested in making changes to their exercise, lifestyle, dietary, supplement or medication regimens should consult a relevantly qualified and competent health care professional. Those who decide to apply or implement any of the information, advice, and/or recommendations on this website do so knowingly and at their own risk. The owner and any contributors to this site accept no responsibility or liability whatsoever for any harm caused, real or imagined, from the use or distribution of information found at FitGreyStrong. Please leave this site immediately if you, the reader, find any of these conditions not acceptable.
© FitGreyStrong
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Exercise Physiology, Strength, Exercises

A brief analysis of the differences between the Sumo and conventional Deadlift

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The Sumo deadlift (sagittal-frontal planes) is a popular resistance training exercise for strength athletes, powerlifters and experienced gym enthusiasts, but it is not an exercise that you see utilised all that much by older adults or in rehab programs. Interestingly, there is very little research that has explored the benefits of the Sumo deadlift or compared it to the conventional deadlift (sagittal plane) which is now more commonly used across different athletic, rehab and clinical settings.

The Sumo Deadlift

However, based on the limited research that has been published, the Sumo deadlift appears to be an excellent exercise to simultaneously improve muscle strength in many major muscle groups. When Escamilla et al (2002) compared the Sumo and conventional deadlifts, results showed that electromyographic (EMG) activity (when expressed as a percentage of maximum voluntary isometric contraction) was not significantly different for rectus femoris, lateral hamstring (biceps femoris), medial hamstrings (semitendinosus/semimembranosus), lateral gastrocnemius, hip adductors (adductor longus, adductor magnus, and gracilis), gluteus maximus, L3 paraspinals, T12 paraspinals, middle trapezius, upper trapezius, rectus abdominis and external obliques. Modest but significantly higher muscle activity was reported for the Sumo versus conventional DL for vastus lateralis (48 vs 40), vastus medialis (44 vs 36) and tibialis anterior (18 vs 13). This is interesting as it suggests that when these exercises are performed at moderate submaximal loads, posterior chain muscle activity is no different for both exercises, but there is relatively greater quadriceps muscle activity generated for the Sumo. That being said, load may alter this with Campitelli et al 2018 showing that as load increases for the Sumo DL, greater ankle and knee angles and a more inclined/flexed trunk angle manifested but once load increases such that maximum intensity (100% 1RM) and effort is required, significantly greater joint moment and L4–L5 shear forces were observed for the conventional DL versus Sumo DL (Cholewicki et al 1991).

Whilst I don’t think that this is going to mean too much for athletes [i.e., Sumo or conventional will do the trick], it does provide some choice, with the decision to pick one exercise over the other perhaps more based on preference and comfort than any major differences in training outcomes. In contrast, for rehab purposes, as paraspinal muscle activity was found to be no different for both lifts at submaximal loads, even though there is less hip flexion [i.e., less inclined/flexed trunk angle for the Sumo], the Sumo may provide people that experience CLBP (back pain) and clinicians alike an opportunity to utilise an exercise (at least initially) that may help circumvent the moderate-to-severe fear and anxiety that some have when contemplating or actually bending over or forward (hip and vertebral flexion). This potentially helps or allows 3 key things to be accomplished in a rehab setting: (1) strength improvements in important, large muscle groups; (2) physical conditioning that will facilitate bridging across to other movements that involve greater hip and vertebral flexion, and perhaps most importantly; (3) room to work on and concomitantly address multiple other psychosocial and attitudinal influences that impact a person’s lived experience of back pain.

Anterio-lateral view of Sumo Deadlift

For local Townsville residents interested in FitGreyStrong’s Exercise Physiology services or exercise programs designed to improve health, physical function and quality of life or to enhance athletic performance, contact FitGreyStrong@outlook.com or phone 0499 846 955 for a confidential discussion.

For other Australian residents or oversees readers interested in our services, please see here.

Disclaimer: All contents of the FitGreyStrong website/blog are provided for information and education purposes only. Those interested in making changes to their exercise, lifestyle, dietary, supplement or medication regimens should consult a relevantly qualified and competent health care professional. Those who decide to apply or implement any of the information, advice, and/or recommendations on this website do so knowingly and at their own risk. The owner and any contributors to this site accept no responsibility or liability whatsoever for any harm caused, real or imagined, from the use or distribution of information found at FitGreyStrong. Please leave this site immediately if you, the reader, find any of these conditions not acceptable.
© FitGreyStrong
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