CoQ10 for Ultra-Endurance Athletes: 150mg of Ubiquinone Reduce Stress & Inflammation and Stabilize Cell Membranes in 52.4 Mile Torture from 640m to 3,393m!

Image 1: Susan Kokesh, blogger and the Crazy Running Mum at the Sierra Nevada ultra-endurance run a 52.4 miles "double marathon"
  in September 2010; I probably would not even have survived this torture - respect!

As a health conscious physcial culturist, you are probably aware that the vitaminesque nutrient CoQ10, which, due to its ubiquitous presence in all living beings, is also known as ubiqinone, plays a fundamental role in cellular bioenergetics. It is a necessary cofactor in the mitochondrial electron transport chain (i.e. your cell's way of "breathing", its respiratory chain) and is therefore essential for the production of ATP, the fundamental energy unit your cells are operating on. In that, CoQ10 works as a mobile redox agent that shuttles electrons and, interestingly, also protons (those little blue and red balls from Bohr's atom model ;-) in the electron transport chain. Within the health and fitness community, it is however better known for its antioxidant value, as in its reduced form, ubiquinol, it is a potent lipophilic (which means that it does not combine with fats) antioxidant, which is able to recycle and regenerate other antioxidants, such as vitamin E and vitamin C (Ernster. 1995). Moreover, CoQ10 participates in cell signaling and gene expression and has been used as a dietary supplement (among others) for the treatment of neurodegenerative diseases and statin-induced myopathies.

In view of its pluripotent influence on mammalian metabolism (on a side note: the "-10" in CoQ10 indicates the length of the isoprenoid sidechain that is attached to the common benzoquinone ring structure; the latter is unique and can be found in humans and a few other mammals only), it should thus not surprise you that Chavier Díaz-Castro and his collegues from the University of Granada report that the intake of 150mg of the natural version of CoQ10 (2,3-dimethoxy-5-methyl-6-decaprenyl-1,4-benzoquinone; natural = has trans configuration), profoundly modulated "the undesirable effects of the evoked oxidative stress and inflammation signaling during high-intensity" (Díaz-Castro. 2011).

Illustration 1: Supplementational protocol used in the study; CoQ10 was administered as 2,3-dimethoxy-5-methyl-6-decaprenyl-1,4-benzoquinone in powder form in 30mg capsules.

As you can see in illustration 1, the 20 highly trained male amateur athletes (all had run The Sierra Nevada ultra-endurance race in the previous 2 years), who participated in the study were not given the whole dose of 150mg of CoQ10 at once, but followed what I would like to call a "loading protocol" in the two days before the event. The placebo group received an identically looking product containing beer yeast, cellulose,
acacia, silica stearic acid, magnesium stearate, cellulose gum, and maltodextrin.

The total distance of The Sierra Nevada run is >50km. It is considered one of the hardest trials worldwide, mainly because the run, in the course of which the participants "climb" from 640m to a final altitude of  3,393m is almost on a continuous incline! A 5.5 hour torture, for which the CoQ10 supplemented athletes needed on average ~25min less than the subjects in the placebo group. In this study, the exercise performance was yet of negligible importance. What the scientists were really interested were the markers of oxidative damage and inflammation and as the following data shows, those were markedly influenced by the ingestion of this rather "mediocre" (compared to what you see some "health-gurus" advocate) amount of CoQ10.

Figure 1: Effects of CoQ10 supplementation of total bilirubin, triglycerides and urinary creatinine in 20 ultra-endurance runners (data calculated based on Díaz-Castro. 2011)

As you can see in figure 1, CoQ10 induced a significant reduction in urinary creatinine even before the race started (figure 1, left column). Moreover, there were significant differences in the bilirubin (indicates heme catabolism), triglycerides and (again) creatinine (indicates net protein catabolism):

Intense physical exercise resulted in an increase in net protein catabolism and an increase in
creatinine excretion in the PG after the physical test (p < 0.001); however, the urinary levels of creatinine were lower (p < 0.05 before and p < 0.001 after the physical test) in the CoQ10 treated group. Other interesting result was that although there was an increase in urinary creatinine in the CG, it was lower than in PG (38.77 ± 10.20 vs. 88.23 ± 11.21, p < 0.05). We also observed a decrease in the bilirubin concentrations in the CG after the run (p < 0.001) with lower values compared to PG group.

There were also significant differences in the inflammatory response, with (statistically significant, p<0.05) lower values of interleukin 6 (IL-6; -32%) and TNF-alpha (-23%) before the start of the race, and -22% lower TNF-alpha values after the "torture". Moreover, the basal hydroper-oxide content in the erythrocyte membranes, the scientists measured as an indicator of the degree of oxidative stress were lower before and after the exercise test, as the scientists call it.

Taken together, these results suggest that the addition of a small dose of CoQ10 to your supplemental regimen could induce unexpectedly profound cell-stabilizing benefits, of which it would yet be interesting to see how those translate into performance benefits, health and longevity, in the long run.

Ask Dr. Andro: The Pharmacokinetics of Creatine (Part I/II) - How Is Creatine Absorbed into the Bloodstream?

Illustration 1: There is a bunch of things that could potentially go wrong with creatine uptake: The creatine from dietary sources could be mal-absorbed (1) in the small intestine, (2) not make it into the cell, or (3) be excreted too readily either before or immediately after it was transported into the muscle.

Question from Lerner (via comments): Do Creatine Transporters behave the same as glucose transporters? (I.e., serum insulin binds to cellular insulin receptors, which causes Transporters to migrate from inside the cell to the plasma membrane - and the Transporters then pull in the external glucose.)

Answer Dr. Andro: As you may have noticed, I took the freedom to set Learner's question into a broader context. A context I broached in my dissertations on Athletic Edge Nutrition's new creatine product Creatine RT on Tuesday, Aug 16, 2011. Thus, the questions I will be trying to answer (unfortunately, I have to rely on existing studies and do not have my own lab, here ;-) are the following ones:

1. How does creatine get into the blood?
2. How does creatine get into the muscle? (cf. Part II)
3. What can influence these processes?
   

In view of the fact that this is quite an extensive topic, I decided to tackle it in a two part series, where in part 1 (today) I will focus on the issue of creatine absorption into the bloodstream, a putative problem the clever researchers from the supplement industry pretend to have solved, already. Creatine ethyl-ester, Creatine malate, Creatine citrate, Creatine HCL, Creatine whatever, and Krealkalyn(TM)... are the names of the "solutions" to the purported inferiority of creatine monohydrate, the shelves of your local supplement story have to offer.

How does Creatine Get into Your Blood?

In essence all these esters, acids, chlorides and other "creatine + X"-combinations have been designed to mug you... ah, I mean to increase the amount of creatine that makes it into your bloodstream, or in other words, to increase bioavailability. Now, as Wesley Mc Call and Adam Persky state in chapter 13 of Creatine and Creatine Kinase in Health and Disease, there are four potential reasons why creatine bioavailability could be less than 100%, in the first place:

1. Degradation (to creatinine) in the stomach
2. Insufficient dissolution, i.e. passing the intestines "unsolved"
3. Problems with creatine uptake by the epithelial cells
4. Degradation by gut bacteria

1. Creatine could degrade when it reaches your stomach:

We know for certain that creatine degradation is maximal at pH 3 (Cannon. 1927, cf. figure 1). Now, a healthy stomach should have a pH of 1 and for about 84 years everybody (supplement producers included) would have been able to take a look at the data of the 1927 study by Cannon and Shore, who found that after 25 h in a solution with a pH of 1 only ~2% of the creatine would have "degraded" into its dehydration product creatinine and that the often cited "breakdown" of creatine monohydrate in the acidic milieu of your stomach is not really an issue, after all.

Figure 1: Percent creatinine in solution of previously pure creatine after 25, 50, 125 and 1903h at a certain pH (data adapted from Cannon. 1927).

Moreover, the data in figure 1 clearly shows that you would have to have the creatine sit in your stomach for more than 2h before it would make a statistically significant difference (25h: pH1=2%, pH6=2%; 125h ph1=9%, pH6=3%) whether your stomach had a pH 1 or a pH that is greater 6. Now, that certainly sounds ridiculously long, still in conjunction with food (Mc Call. 2008) and outside of the petri dish these effects are, as we are about to see further down, still physiological relevant.

Image 2: You probably expected that it ain't advisable to take your creatine with a Big Mac, but would you have guessed that juices are counter-indicated, as well?

Did you know that the ingestion of a meal will increase the PH of your stomach drastically? Dressman, et al. report an increase to pH ~6 after consuming a hamburger and a glass of milk (Dressman. 1990). After no more than 30 minutes, however, gastric secretion had reduced the pH to 4-3 and after roughly 90 minutes, the stomach of the subjects was the same "acid pit" (pH 1.3) as it was before the ingestion of the meal. This goes to tell you that taking creatine with a meal or even worse right after a meal could be counter-indicated.

Tip: You better wait at least 90 minutes after your last meal, before you flush down your creatine with water, as even the presence of carbohydrates from juices has been shown to "delay the time to peak concentration", which usually is less than 2h and to decrease the maximal concentration at peak concentration (Mc Call. 2008).

What you certainly want to avoid, though, is a pH somewhere between 3-4. However, even in this "worst" case scenario less than 10% of the creatine would undergo the (at higher pH partly reversible!) reaction from creatine to creatinine. So, as Mc Call and Persky point out, the "relatively short time the creatine actually spends in the stomach means that very little of the oral dose of creatine should be lost" (Mc Call. 2008) - at least, if you take it on an empty (and healthy, i.e. highly acidic) stomach.

2. Creatine (Monohydrate) could not dissolve and thus be not absorbed

Illustration 2: Creatine is taken up by enterocytes in the jejunum and the illeum.

The issue of undissolved creatine monohydrate crystals, has been discussed on bulletin-boards and in the ads of several supplement companies ever since the first "advanced" creatine products hit the market. Yet, while it is beyond debate that the enterocytes of your small intestines (in rats creatine has been found to be absorbed in the ileum (Peral. 2005) and the jejenum (Tosco. 2004), cf. image 2) cannot absorb bulky creatine crystals, the solubility of creatine monohydrate in water at 20°C is 14 g/L at a neutral pH of 7. Now, with lower pHs and higher temperatures (as mentioned before your stomach should have a pH of about 1-2 and your body temperature obviously is ~37°C) it is absolutely unlikely that the creatine would not dissolve. Using creatine citrate, which, due to its lower pH (solution has pH 3.5), has a 1.5x higher solubility, or other highly soluble forms of creatine is thus not necessary, if your stomach is the warm acid pit it is supposed to be.

Interestingly, a study by Harris et al. suggests that the creatine from meat such as the paddies of the burger in image 2 (I am assuming here that there is still some meat in McDonalds burgers / here in Germany they have recently begun advertising their meat quality ;-) is more readily absorbed (this refers to absolute amounts, not to the time-course) than either creatine suspended (=more creatine in water than can be solved) in water or creatine tablets / lozenges (Harris. 2002). A probable explanation for this phenomenon could be that the creatine is safely contained in the meat, until the latter is broken down by enzymes that are activated as  the pH of the stomach is decreasing. Thus only very limited amounts of free creatine will be exposed to pH levels in the detrimental3-4 range.

3. Creatine could simply not be taken up by the enterocytes in the small intestine

Obviously, any general digestive problem related to nutrient transport across the epithelial barrier in the intestines could compromise creatine uptake, as well. As mentioned earlier the presence of large (180g) amounts of carbohydrates have been shown to slow gastric emptying and consequently creatine absorption, considerably (Vist. 1995). In addition several other meal-constituents could also increase the pH temporarily and thus initially decrease solubility (when pH is still very high) and consequently increase creatine to creatinine breakdown (when the pH passes the critical 3-4 range, see above).

4. Creatine could be degraded by bacteria in the gut

Image 2: Biridobacterium tongum is a probiotic and a natural enemy of putrefective bacteria, who "suffocate" from the lactic acid, acetic acid and bacteriocins (image from dophilus.com)

Even if the creatine survives passage through the stomach, is dissolved and the enerocytes are ready to absorb it, it could still be taken up by putrefective bacteria (bacteria that break down organic material) of which William C. Rose in a paper in the Annual Review of Biochem. writes that they transform creatine  into methylhydantoin, which previously had been shown to yield sarcosine under the influence of micro-organisms" (Rose. 1933) Unless you want Patrick Arnolds sarcosine as an adjunct to d-aspartic acid (as in TestForce 2), I would say this is another good reason to keep your gut clean and tidy ;-)

Conclusion: Absorption should not be an issue

If your gut is healthy, acidic and free of pathogenic amounts of putrefective bacteria there is absolutely no reason you could have problems absorbing creatine - especially if you stick to my recommendations and

• do not escalate single dosages beyond 5g, 
• take your creatine on an empty stomach (or at least 90 min after your last meal)*
  (taking creatine with carbs + protein will increase breakdown to creatinine, and decrease the maximal serum levels, but, on the other hand, it will increase muscular creatine retention, cf. Part II)
• do not take creatine with a meal or protein or large amounts of carbohydrates**
  (read more on the carb issue in the 2nd part of this installment of "Ask Dr. Andro", tomorrow)

A tweak to this general guideline resolves around the "mysterious" issue of alkaline creatine. The results from the Cannon study show that you have the choice:

• increase your stomach pH beyond 6, or 
• decrease your stomach pH below 2 

 if you want to avoid the breakdown of creatine to creatinine.

Figure 2: Relative increase in creatine in dry muscle mass of horses, after supplementation with creatine monohydrate, kre-alkalyn or Gastner's patented creatine + sodium carbonate +sodium hydrogen carbonate formula (Gastner. 2010)

Timing creatine away from meals would be option #2, option #1, on the other hand, would entail supplementing with some strong alkalizing agent such as sodium or potassium bicarbonate, and in fact, this is exactly what KreAlkalyn, the purported "super-creatine" is - a ph-buffered creatine-monohydrate product. Thomas Gastner holds the patent to a formula of which had a higher stability than KreAlkalyn and consists of nothing else but 2.98g creatine monohydrate + 150mg sodium carbonate + 118mg sodium hydrogen carbonate. According to self-conducted animal experiments (horses= the increased stability entailed a statistically significant improvement in muscular creatine retention after 4 weeks on creatine enriched feed pellets (+7% over creatine monohydrate and +10% over KreAlkalyn).

Image 3: Kre-Alkalyn - expensive, but probably
useless - at least when taken with food.

The results of Gastner's experiment should obviously be taken with some skepticism. Nevertheless, the picture we are seeing here is conclusive, because either you rely on the acidity of your stomach (using plain creatine monohydrate) or you put enough alkaline buffers into your product so that the acidity of the stomach remains greater than pH 6 for a long enough amount of time. With Kre-Alkalyn (and horse stomachs) it appears that Jeffrey Gollini who holds the patent for KreAlkalyn managed to hit exactly that most unfavorable pH range, where the overall pH of the food + KreAlkalyn solution in the (horse-)stomach falls back into the 3-4 range very quickly and the creatine uptake is reduced due to the increased breakdown of  creatine to creatinine.

In summary, this is a clear points win for creatine monohydrate taken on an empty stomach (or, alternatively with a significant amount of buffers + food). Fidgeting with citrates, malates, and esters which will eventually be cleaved (if you are unlucky at the very same moment your gastric pH has returned to the "danger zone" of 3-4), may be promotional, but either is not likely to be superior (citrate, malate & co) or has been shown (creatine ethyl ester, cf. Spillane. 2009) to be inferior to the undefeated 'top dog' creatine monohydrate.

Click here to read Part II: How Does Creatine Get into the Muscle

Your Meat Consumption is Probably Not the Reason You're a Creatine Non-Responder: 5% Faster 50m-Sprint Time in 6 Days W/ 20g/day of Creatine for Vegetarians & Omnivores

It's hard to be a non-responder andno way to change it.

In some people the ingestion of creatine appears to be ineffective. Aside from minor diarrhea, when they increase the dosage to the 20g+ range per day in a desperate effort to reap the benefits of one of the, if not the only tried and proven natural ergogenic with significant (real world!) effects, these creatine non-responders don't get any results from either creatine monohydrate or any of the fancier, but mostly inferior "advanced creatines" you can buy at you local, national and international supplement vendor.

One of the commonest and eventually most reasonable explanation for "non-responding", I've heard is the hypothesis that non-responders have a high enough creatine intake from meat that would reduce any additional benefit from supplemental creatine to unmeasurable levels.

You can learn more about creatine at the SuppVersity

Creatine Doubles 'Ur GainZ!

Creatine, DHT & Broscience

Creatine Better After Workout

ALA + Creatine = Max Uptake?

Creatine Blunts Fat Loss?

Build 'Ur Own Buffered Creatine

And in fact, with beef and co being your best dietary creatine sources, it seems legit that meat-eaters would benefit less from supplemental creatine than vegetarians whose plant-based diets are more or less devoid of creatine.

By now you should yet be used to the fact that there are billions of things in the realm of nutrition, health and fitness that make perfect sense and still don't exist... and yes, the aforementioned hypothesis that omnivores won't benefit from creatine is one of them.

Figure 1: Higher increase in the previously low creatinine levels, but identical increase in 50m spring performance in vegetarians ans omnivores in response to 6 days on 20g of creatine (Seyedjalali. 2014)

If you take a look at the data in Figure 1, data from a recent study from the Chandrashekar Agashe  College  of  Physical Education in India, you will see that the omnivores had higher blood creatine (=used creatine) levels, but an identical increases in 50m sprinting performance.

The study at hand does therefore the findings of this study support the usefulness of short-term creatine supplementation at 20 grams  per  day  for  6  days, but it does not support the hypothesis that the corresponding increases in 4x 50 m dash run performance would be more pronounced in the vegetarian subjects, whose baseline creatine intake borders zero.

Are you like one of three subjects in Greenhaff's 1994 study?

Bottom line: If you belong to the small group of creatine non-responders you will obviously have to wait until someone identifies another hopefully non-genetic determinant of your non-existing response to the provision of creatine monohydrate or any other form of creatine. Until then, a highly efficient creatine recycling / endogenous production and / or the inability to use exogenous creatine remain the most likely and eventually the only realistic explanation for a phenomenon of which only the second one, i.e. the inability to use supplemental creatine as a means to increase muscular the creatine stores has scientific backup from one of the early studies on creatine (Greenhaff. 1994)

Reference:

• Greenhaff, P. L., et al. "Effect of oral creatine supplementation on skeletal muscle phosphocreatine resynthesis." American Journal of Physiology-Endocrinology and Metabolism 29.5 (1994): E725.
• Nimkar, Nayana, and Ph D. Physical Education. "Comparative Effect of Creatine Supplementation Blood Lactate and Intermittent Running Performance on Vegetarian and Non-Vegetarian Active Males." Heg©< e Òeew {veeieefjkeÀeb® ³ee jkeÌleoeye Je ceOegcesneJej efveJe [keÀ ÒeeCee³eece Je Deemeveeb® ee nesCeeN³ee HeefjCeeceeb® es DeO³e³eve-mebefoHejepe Me. Deewlee [s: 30.

Victorious Veteran: Creatine Monohydrate Still First Class! Usefulness & Safety of “Innovative” Creatine Formulas Questionable.

If we discount a high protein intake as a regular constituent of a healthy diet, creatine is unquestionable the King of Natural Ergogenics. Its impact on athletics way beyond the Gold’s Gyms of the bodybuilding world is evident from its being cited as “effective and safe” in almost each and every “position stand” published in one of the journals of the various sports & nutritional societies all over the world in regular intervals. Thus, with the (nephro-)toxity myth being finally dispelled, creatine has become a stable in the supplement regimen of both recreational, as well as professional athletes.

Now, the financial revenue you can make from a non-patentable amino acid that is commonly found in fish and meat products is obviously limited. Thus, the steadily increasing number of players on the supplement market is continuously trying to “reinvent the wheel”, by putting forward a new, better-absorbed, more effect, side-effect free or whatever else the marketing guys had on their minds forms of N-(aminoiminomethyl)-N-methyl glycine (=chemical formula of creatine). These “superior” forms of creatine are then put forward as the must have for every seriously training athlete and/or creatine non-responders (these are people, where – due to various not fully understood mechanisms – creatine has no measurable effect on performance, (intracellular) water retention and body weight) and usually disappear from the market just about at the same time, the first batch has been sold and disappointed customers begin to vent their anger on the blogs and bulletin boards of the fitness world.

With reference to the purported superiority of novel forms of creatine R. Jäger, one of the leading researchers in the field writes in a recently published paper (Jaeger. 2011), the results of which have previously been presented at the 2010 Creatine in Health and Sports conference:

[…] the efficacy, safety, and regulatory status of most of the newer forms of creatine found in dietary supplements have not been well established. Additionally, there is little to no evidence supporting marketing claims that these newer forms of creatine are more stable, digested faster, and more effective in increasing muscle creatine levels and/or associated with fewer side effects than CM.

In their extensive review of the literature Jäger et al. dissect many of the commonly held views on the purported “instability” and “low absorbtion rate” of creatine monohydrate, evaluate the different creatine contents of various supplemental forms and their individual solubility, stability and bioavailability. And while some other forms are in fact more soluble…

Creatine monohydrate dissolves at 14 g/L at 20°C resulting in a neutral pH of 7. A saturated solution of tricreatine citrate in water has a pH of 3.2; whereas a saturated solution of creatine pyruvate even has a pH of 2.6 (pyruvic acid is a stronger acid than citric acid). The decrease in pH results in an increase in solubility: 29 g/L creatine citrate at 20°C, and 54 g/L creatine pyruvate at 20°C. Normalized by the relative amount of creatine per molecule (monohydrate 87.9%, citrate 66%, pyruvate 60%), creatine citrate (19.14 g/L) shows a 1.55-fold and creatine pyruvate (32.4 g/L) a 2.63-fold better solubility when compared with the monohydrate (12.3 g/L).

The acidity of your stomach is high enough, anyway, so that even if you just swallow the powder it will eventually dissolve, when it comes in contact with your gastric acid - for monohydrate [CM] Jaeger reports the absorption to be as high as 99%.

Furthermore, pre-solving of creatine in water is counter-indicated, because, as Jaeger et al. write, …

[…] solution precludes the manufacture of shelf-stable standard ingredient. If creatine is not consumed immediately after it has been dissolved in water, it should be stored at a low temperature to retard the degradation.

So you better throw away your liquid creatine - chances are its 99% degraded even before you bought it from your retailer.

The instability is even more of concern in the case of Creatine Ethyl Ester (CEE) which has been found to be “actually less stable than CM.” (Child & Tallon. 2007).

CEE is mostly converted into creatinine under physiological conditions encountered during transit through the various tissues, suggesting no ergogenic effect is to be expected from supplementation of CEE.

The latter, i.e. creatine ethyl esther, is also less bioavailable, 

Figure 1:Changes in total muscle creatine content in response to placebo (PLA), creatine monohydrate (CRT), and creatine ethyl ester(CEE) supplementation (Spillane et al. 2009, cf, fig. 1).

and studies (Spillane. 2009) suggest that its higher rate of degradation to creatinine may pose a possible health risk.

Also, while Jaeger et al. report some evidence for the beneficial effects of co-supplementation with glucose, protein or (low dose) D-pinitol, I personally doubt that either of them is necessary to take advantage of the repeatedly proven ergogenic effects you can get from the cheapest, most researches, safest and easiest to obtain form of creatine – creatine monohydrate.

On a side note: My friends @ironmagazine.com have found an interesting study on the effect of creatine + nitrate, which is currently hyped as “the next big thing”. Although, I suppose that the amount of the carcinogen N-nitrososarcosine, which is a byproduct of their reaction, is hardly high enough to trigger cancerous growth, the lack of direct scientific evidence that creatine nitrate has any beneficial effect over the individual use of nitrates (for pump) and creatine (for performance) at least makes me wonder if you could not eat a buckload of beet roots (high in nitrate) with your creatine monohydrate to achieve the same effect ;-)