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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.

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Exercise Physiology, Strength, Mobility, Exercises

Why we need to look beyond just traditional strength training exercises for older adults

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Exercise professionals involved with older adults pay a great deal of attention to the lower limb prime movers¹ and exercises² which will enhance the strength and power of these important muscles, and so we should. There are all sorts of ingenious ways to increase the strength, function and aesthetics of these muscles, just take a quick look at Instagram and you’ll see what I mean. The hip abductors are now recognised also, in both research and practice, as playing a pivotal role in hip and knee function influencing gait and postural stability, particularly in the medio-lateral plane. But what about the hip adductors? Are they a forgotten piece of the puzzle? Rarely do we see much attention paid to exercising these muscles of older adults in any sort of meaningful way³. This is interesting in and of itself and a curiosity, but the inference is that the adductor muscle group is not viewed as important enough to dedicate any time to specifically develop its neuromuscular capacity irrespective of some recent research that certainly suggests otherwise. There is now enough evidence to support the adductors being treated as a distinct target for improved muscle strength and power production. In fact, FGS would contend that this muscle group deserves the same degree of focus as the quads, GMax, hamstrings and hip abductors in any resistance training program for older adults given the following:

  • Age-related hip adductor strength loss appears to be more pronounced compared to the knee extensors (Daun & Kibele, 2019).

  • Postural instability with ageing is especially problematic in the medio-lateral plane (Mille et al 2013).
  • Neuromuscular rate of activation of adductors (AM) is significantly lower in older versus younger adults for both forceful static muscular contractions (IMVC) and dynamic recovery following lateral balance perturbations (Inacio et al 2019).

  • Power-based resistance training of the hip adductors (and hip abductors) has been shown to elicit improvements in maximal neuromuscular performance and enhanced medio-lateral balance recovery. Traditional (slower tempo) performed resistance training did not result in significant improvements in isolated or balance-related neuromuscular or biomechanical performance (Inacio et al 2018).

Based on the abovementioned research, FitGreyStrong’s recommendation is to ensure that weight-bearing exercises that load and challenge the adductor muscle group (frontal plane) be included in resistance training programs of older adults. Moreover, it should be acknowledged that open kinetic chain seated machines may not provide the appropriate neuromuscular challenge to bring about improvements in medio-lateral balance and function (Daun & Kibele, 2019; Inacio et al 2018) however, further research is required4.
Footnotes:
1 Quads, GMax and hamstrings
2 Squats, deadlifts, glute bridges, hip thrusts, leg curls, sit-to-stands, step-ups etc
3 The same could be said for the hip flexors where age-related muscle mass and strength losses occur disproportionately compared to other major muscle groups and this obviously impairs physical function and gait potentially increasing the risk for falls.
4 Thanks to Rhys Manchester for pointing out some inconsistencies with these concluding remarks.

For local Townsville residents interested in FitGreyStrong’s specialised Exercise Physiology services or exercise programs for older adults or for Master’s competitors wanting 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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Tidbits, Exercise Physiology, Strength, Nutrition

Can Vitamin D supplementation augment strength gains in older adults doing resistance training?

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In a recent meta-analysis (see here), vitamin D was found to provide an additive benefit for older adults partaking in resistance training (RT). In other words, when compared to older adults taking a placebo, significantly greater gains in muscle strength were achieved in those supplemented with vitamin D. However, upon closer analysis several issues become obvious that are difficult to reconcile. The following discusses some of these issues inherent in the findings of this paper (see below).

The group 1 analysis of 3 trials finds vit D supplementation augments muscle strength of the lower limbs, SMD=0.98; see fig 2 below. (Please click on any image to open and make larger for viewing).

…but what is with the scale used for the x-axis; it seems all wrong…..all the green squares sit nicely on zero……. and where is my forest plot with 95% CI bars and my black triangle to show overall SMD?

As a crude comparison & to put this in context, Chilibeck et al (2017) found SMD=0.25 for the effect of creatine supplementation on lower body strength during RT in older adults. Perhaps the most effective supplement available? Could vit D really be that much better? 

The authors acknowledge serious inconsistency with substantial heterogeneity (see table 5) for this outcome measure and even suggest that maybe: “….these studies were unsuitable for comparison”, but conclude nonetheless that there is: “tentative support for the additive effects of RT and vit D supplementation for the improvement of muscle strength in older adults”, including those replete in Vit D.

The Uusi-Rasi et al (2015) trial was weighted heavily (75%) and rightly so being the most well designed, largest & longest RCT to date. In fact SMD of this trial in the group 1 analysis = 1.16. This is very impressive and clinically relevant if accurate and valid. Uusi-Rasi et al (2015) in contrast states: “Irrespective of vit D, exercise increased muscle strength. The predicted mean increase in lower limb extension strength was almost 15% in both exercised groups and differed significantly from the placebo without exercise group.”

“Another unexpected finding was that exercisers treated with vit D supplementation showed consistently smaller benefits than exercisers receiving placebo……our results indicate that vit D may not improve neuromuscular function, at least when vit D intake is sufficient.” The largest and longest RCT to date found no additional – and perhaps even attenuated – benefit of vit D supplementation in replete resistance-training older adults, which is at complete odds to the meta-analysis.

The Agergaard et al (2015) trial showed no additional benefit of vit D on muscle strength in older adults (vit D replete). Sample size for older adults was very small also and weighted acccordingly in the meta.

….and Bunout et al (2006) found that combined calcium/vit D supplementation was no more effective than calcium-only supplementation in older adults undergoing RT but – and this is a critical point of difference to the other 2 studies.

– all participants were arguably vit D insufficient; to be included participants had to be 16 ng/ml (40 nmol/L) or less for serum 25(OH)D. An important point that was missed by the authors of the meta-analysis (see further below).

These 3 studies included in the group 1 analysis of muscle strength of the lower limbs were identified as “all participants took part in RT and the intervention arm was supplemented with vit D (describing the additive effect of vit D supplementation when combined with RT)”

However, Bunout et al (2006) did not include a RT group that received a ‘true’ placebo. Both exercising groups in this trial received supplementation of some sort.

….one group was supplemented with vit D & calcium (intervention), the other exercising group were supplemented with calcium-only (control). “……vit D was given along with calcium in this trial, since a low calcium intake can limit the effects of the vitamin.

To isolate the effect of the vitamin, controls for supplementation received calcium also.” However results showed there were no statistically significant differences between these groups in baseline to final percentage change for right and left quadriceps strength, and right and left hand grip strength. In fact, the RT plus calcium-only group achieved better mean numerical responses in strength (non-significant) when compared to the RT plus vit D/calcium group (see table 2)……..so is it somewhat unusual that such a large SMD was found in the meta favouring the group that received vit D?

The authors state in the meta discussion that: “Interestingly, although the studies included within group 1 did not specify serum 25(OH)D levels as inclusion/exclusion critieria, baseline and postintervention serum 25(OH)D were within the ‘sufficient’ range (>30 nmol/L).”

Now there are 2 issues with this statement. Firstly, it is false that all studies included in group 1 did not specify serum 25(OH)D levels as inclusion/exclusion criteria. Bunout et al (2006) in fact did just that and specified a cut-off point for inclusion.

Subjects were screened and included only if their serum 25(OH)D levels were 16 ng/ml (40 nmol/L) or less. Secondly, mean baseline serum 25(OH)D of the vit D supplemented group in Bunout et al (2006) was 12.4 ng/ml (30 nmol/L) and many experts would propose that serum 25(OH)D of around 30 nmol/L in older adults is insufficient. It is also worth noting that Vit D status for participants of each of the 3 studies varied considerable and could possibly confound the meta.

After reviewing the 3 trials very carefully (used in the group 1 analysis of Antonia and Greig 2017), the finding that vit D supplementation significantly augments muscular strength of older adults doing RT, including those replete for vit D (SMD=0.98), is perplexing.

It is plausible and there is some evidence that vit D supplementation may augment strength of exercising older adults that have insuffient or deficient levels of vit D [serum 25(OH)D <50 nmol/L & <25 nmol/L] but such data is as yet not forthcoming in older adults performing RT

After reviewing Antoniak & Greig (2017) in which vit D supplementation significantly enhances strength in older adults doing RT, I cannot but view the findings as an artefact possibly generated by the unresolvable and substantial heterogeneity that was detected in the analysis.

The conclusion of tentative support for the ergogenity of vit D in older RT adults, irrespective of serum 25(OH)D status, is therefore premature and unsubstantiated.

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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