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Huang et al. Sports Medicine - Open (2024) 10:115
https://doi.org/10.1186/s40798-024-00784-8 Sports Medicine - Open
*Correspondence:
Daniel Hung-Kay Chow
danielchow@eduhk.hk
Full list of author information is available at the end of the article
Abstract
Background Although recent studies have increasingly focused on examining the potential benets of creatine
supplementation to improve performance in swimming events, the impact of creatine supplementation on
swimming performance remains a topic of debate and controversy. A comprehensive meta-analytical review was
undertaken to evaluate the eects of creatine supplementation on the performance, physiological response, and
body composition among swimmers.
Methods The research methodology adhered strictly to the guidelines outlined by the Preferred Reporting Items
for Systematic Reviews and Meta-Analyses (PRISMA). A comprehensive search was conducted across six databases
(Cochrane Library, Web of Science, Scopus, Embase, PubMed, and SPORTDiscus) until March 23, 2024. Eligible studies
that investigated the impact of creatine supplementation on swimming time, physiological parameters, and body
composition in swimmers were included. For the meta-analysis, a random-eects model was employed to determine
the collective eect and assess variations across distinct subgroups dened by swimming time, physiological metrics,
and body composition. Meta-regression analysis was conducted on datasets comprising ten or more studies.
Standardized mean dierences (SMD) along with their corresponding 95% condence intervals (CI) were calculated.
To evaluate the methodological rigor of the included studies, the Physiotherapy Evidence Database (PEDro) scale was
utilized.
Results The systematic review included seventeen studies with a total of 361 subjects. No signicant dierences
were observed in the overall eect during single sprint swimming (SMD: -0.05, 95% CI: -0.26, 0.15; p = 0.61), repeated
interval swimming (SMD: -0.11; 95% CI: -0.46, 0.25; p = 0.56), physiological response (SMD: 0.04, 95% CI: -0.16, 0.23;
p = 0.71), and body composition (SMD: 0.18; 95% CI: -0.05, 0.41; p = 0.12) between creatine and placebo groups.
Eects of Creatine Supplementation
on the Performance, Physiological Response,
and Body Composition Among Swimmers:
A Systematic Review and Meta-Analysis
of Randomized Controlled Trials
DongxiangHuang1,2, XiaobingWang1, TomohiroGonjo3, HidekiTakagi4, BoHuang5, WenruiHuang6, QiShan2 and
Daniel Hung-KayChow2*
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Huang et al. Sports Medicine - Open (2024) 10:115
Background
Creatine (Cr) is pivotal in the modulation of energy
metabolism and has been widely used by athletes to
enhance muscle mass, strength, and overall sports per-
formance [1, 2]. It has been extensively demonstrated
that increasing the dietary intake of Cr leads to elevated
levels of Cr and phosphocreatine in skeletal muscles [3].
High-dose short-term (approximately 20g per day for 5
days) or low-dose long-term (approximately 3g per day
for 28 days) Cr supplementation can result in a roughly
25% increase in muscle Cr and phosphocreatine levels
[4, 5]. e dietary incorporation of Cr has the potential
to augment muscle Cr and phosphocreatine levels by an
estimated range of 20–40% [6].
Swimming is recognized as a sport that requires both
aerobic and anaerobic energy systems [7]. e ATP-
phosphocreatine energy system plays a crucial role in
energy production, contributing 80% during a 50m swim
and 25% during a 100m swim [8]. e rapid depletion
of phosphocreatine in muscles during swimming leads
to a substantial increase in energy demand [9, 10]. Con-
sequently, the growing interest in exploring the potential
benets of Cr supplementation for enhancing swimming
performance is reected in the rising number of scientic
studies focusing on this area.
Despite numerous studies investigating the impact
of Cr supplementation on single sprint swimming [7,
10–17], repeated interval swimming [18–22], or a com-
bination of both [23–25], there is no consensus on its
advantages for swimming performance. Most studies
suggested that Cr supplementation could not aect sin-
gle sprint swimming performance [7, 10, 13, 16, 23, 25].
while some studies indicated performance enhancement
[12, 14, 15, 17]. Similarly, the impact of Cr on repeated
interval swimming performance is a subject of debate
while most studies proposed improvement [18, 20, 22–
24], Silva et al. (2007) reported no enhancement [21].
Critically evaluating and synthesizing available stud-
ies would be useful in understanding the reason behind
the inconsistent study outcomes and in generating more
concrete evidence on the eect of Cr on swimming per-
formance. Even though Hopwood et al. (2006) conducted
a narrative review on this topic [9], their conclusions
were based on studies conducted before 2005 and did not
address the eects of Cr on physiological indicators and
body composition. Since 2005, ve studies have explored
Cr supplementation’s eects on swimming performance
[14–16, 21, 22]. warranting an updated systematic review.
Furthermore, given the potential limitations of individual
studies, a meta-analysis is crucial for a comprehensive
understanding of the conicting ndings.
e objective of this study is to conduct a comprehen-
sive synthesis and meta-analysis of the existing literature
regarding the impact of Cr supplementation on the per-
formance, physiological response, and body composition
among swimmers.
Methods
is study evaluated the eects of Cr supplementation on
swimming performance, physiological response and body
composition, following the protocols outlined in the Pre-
ferred Reporting Items for Systematic Reviews and Meta-
Analyses (PRISMA) statement [26], as detailed in the
electronic supplementary material 1. e study protocol
was registered in the Prospective Register of System-
atic Reviews (PROSPERO) with the registration num-
ber CRD42024536195 prior to conducting the search
methodology.
Literature Search Strategy
e search for relevant studies was conducted indepen-
dently by two authors (DX and XB), with any discrepan-
cies resolved through third-party adjudication (DC). An
exhaustive literature retrieval was conducted across six
electronic databases, namely the Cochrane Library, Web
of Science, Scopus, Embase, PubMed, and SPORTDis-
cus, covering the period from their inception to March
23, 2024. Search records were obtained by employing
the subsequent Boolean strategy: (Creatine OR “cre-
atine monohydrate” OR “creatine loading” OR “creatine
supplementation” OR “oral creatine”) AND (swimming
OR swimmers OR swim). e specics of the search
methodology are delineated in Supplementary Table S1,
as presented in the electronic supplementary material 2.
e search was augmented by manual methods, encom-
passing an analysis of the reference lists from the selected
studies and an assessment of the literature that cited the
included research articles (i.e., forward citation tracking).
Conclusions Creatine supplementation exhibited ineectiveness in enhancing the performance, physiological
response, and body composition among swimmers.
Key Points
No signicant evidence to support that creatine supplementation can improve swimming performance was found.
Creatine supplementation showed no signicant impact on physiological response.
No signicant eects of creatine supplementation on body composition were found.
Keywords Creatine, Swimming performance, Body composition
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Huang et al. Sports Medicine - Open (2024) 10:115
Inclusion and Exclusion Criteria
Studies that conformed to the subsequent inclusion cri-
teria were selected for this review: (i) inclusion of swim-
mers as participants, regardless of their training level,
age, or gender; (ii) examination of the isolated eects of
Cr ingestion in any form; (iii) provision of detailed infor-
mation on the protocol of Cr supplementation, including
dosage and duration; (iv) the outcomes are swimming
time (e.g., 50m time and 100m time), physiological indi-
cators (e.g., blood lactate, heart rate, blood ammonia, and
blood pH), and body composition (e.g., body mass, lean
body mass, and skinfolds); (v) original, peer-reviewed
studies written in English; and (vi) utilization of a ran-
domized placebo-controlled design.
Studies were excluded if they: (i) combined Cr with
other supplements and could not isolate the eects of
Cr; (ii) consisted of comments, editorials, or reviews;
(iii) lacked a placebo group for comparison of results; (iv)
were conducted on subjects who have a history of a med-
ical ailment, disease, or trauma.; or (v) focused on artistic
swimming, water polo, and n swimming.
Text Screening
e procedure was carried out independently by two
authors (DX and XB), with any dierences between the
reviewers being reconciled through consensus in consul-
tation with a third author (DC). e initial stage of the
process entailed the assessment of titles and abstracts
to eciently narrow down the pool of research studies
required to fulll the inclusion and exclusion criteria.
Subsequently, the complete texts were examined by the
researchers to identify the experimental trials that were
relevant for inclusion.
Data Extraction
Data extraction from each study that met the inclusion
and exclusion criteria encompassed the following: (i)
study design details, (ii) characteristics of the study sam-
ple, (iii) information on the Cr supplementation protocol
(dosage and duration), (iv) specics of the swimming test
protocol, (v) data on swimming performance, physiologi-
cal response and body composition, and (vi) main nd-
ings. Among the included studies, ve employed dierent
protocols to assess the same performance outcome [10,
20, 23–25]. In these cases, each protocol was considered
an independent dataset for conducting the meta-analy-
sis. Consequently, all protocols were separately included
in the relevant analysis of the performance outcome. In
instances where essential data were unavailable in the
original publication, contact was made with the research-
ers of the included studies. Information from one article
was acquired through direct communication with the
authors [13]. Additionally, standard error values provided
in certain studies were converted to standard deviation.
Methodological Quality and Publication Bias
e process was conducted by two separate researchers,
DX and XB, with any discrepancies between the review-
ers resolved by DC. e methodological rigor of the
studies included in the analysis was assessed using the
Physiotherapy Evidence Database (PEDro) scale [27]. e
PEDro scale is commonly utilized in systematic review
studies examining the eectiveness of supplements and
nutritional ergogenic resources [28–30]. It provides a
reliable and objective means of evaluating the internal
validity of randomized controlled trials [31]. e scale
consists of 11 items, with ratings assigned to items 2
through 11. A positive response receives a score of 1
point, while a negative response receives 0 points. us,
the maximum achievable score on the scale is 10 points.
A high and low PEDro score indicates a minimal and high
risk of bias, respectively. e quality of the PEDro scale
was assessed using a scoring system, where scores of 9
or 10 points were considered excellent, scores between
6 and 8 points were considered good, scores between 4
and 5 points were considered fair, and scores of 3 points
or lower were considered poor [32]. Potential publication
bias across studies was investigated by visually assessing
the asymmetry of the funnel plots for the combined data.
is method aided in evaluating the presence of bias in
the dissemination of research included in the review.
Statistical Analysis
Standardized mean dierences (SMD) and their corre-
sponding 95% condence intervals (95% CI) were utilized
to quantify the eect sizes for the eects of Cr supple-
ments on the performance, physiological response, and
body composition in swimmers. e SMD were calcu-
lated using pooled mean and standard deviation in the
change in the dependent variables from pre- to post-
condition for each group, and its values were categorized
as trivial (< 0.2), small (0.2–0.3), moderate (0.4–0.8),
or large (> 0.8) [33]. Heterogeneity among studies was
assessed using the I2 statistic, with low (< 25%), moder-
ate (25–75%), or substantial (> 75%) risk of heterogeneity
[34]. To address signicant heterogeneity (I2 > 50%), sen-
sitivity analyses were conducted by systematically exclud-
ing studies to identify potential outliers or studies with
extreme results. is helped assess the robustness of the
ndings and explore the impact of specic study char-
acteristics, such as swimming distance, on the observed
heterogeneity.
Subgroup analyses were carried out to compare the
eects of Cr supplementation on dierent swimming
times, specically 50 m versus 100 m times, to exam-
ine variations based on swimming distance. Subgroup
analyses were also conducted on various physiological
outcomes to dierentiate the specic eects of Cr supple-
mentation on dierent aspects of swimming physiology.
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Huang et al. Sports Medicine - Open (2024) 10:115
In addition, subgroup analyses were also performed on
dierent body composition outcomes, such as body mass
and lean body mass, to ascertain if the supplementation
has diering eects on various body composition param-
eters. For all meta-analyses, the random-eects model
was applied [35]. Meta-regression analyses assessed
potential moderators inuencing the impact of Cr sup-
plementation on single sprint swimming during 50 m
time trials and blood lactate levels, requiring a minimum
of 10 studies for each analysis [36]. Identied moderators
comprised performance level (competitive swimmers vs.
non-competitive swimmers), duration of supplementa-
tion (less than 20 days vs. more than 20 days), and sup-
plementation protocol (acute loading vs. maintenance).
Statistical evaluations were conducted using the alpha
level set at p < 0.05. Meta analysis was done using Review
Manager (5.4.1, USA) software [37], and Meta-regression
analyses was conducted using the ‘metan’ command from
the Stata (version 15) ‘meta’ package.
Results
Search Results
e systematic search conducted across six databases
yielded 2,705 search results. Among these results, 65
full-text papers were carefully examined. After thorough
review, 17 studies were deemed eligible and included in
the nal analysis. Figure1 presents the ow chart illus-
trating the search strategy employed.
Study Characteristics
e meta-analysis included a total of 361 partici-
pants across the seventeen studies (Table1). All stud-
ies employed a randomized placebo-controlled design.
Among them, twelve studies utilized a double-blind, pla-
cebo-controlled, randomized design [11–13, 15, 17–23,
25], while two studies employed a randomized single-
blind design [10, 14]. ree studies did not specify the
blinding method [7, 16, 24]. e majority of the stud-
ies included both male and female participants [10–13,
18–20, 24, 25], although ve studies exclusively focused
on male swimmers [14, 16, 17, 22, 23] and three targeted
female swimmers [7, 15, 21]. e sample size in each
study ranged from 10 [7] to 38 [17] participants. Within
the studies adhering to the acute loading supplementa-
tion regimen, the ingested dosages varied, starting from
a low of 0.3g/kg/bm [13] to a peak of 25g daily [24]. For
the maintenance supplementation regimen, daily dosage
consumption uctuated between 2g [7] and 20g [21].
e duration of supplementation protocols ranged from
5 [11, 12, 23] to 63 days [16]. Among the 17 studies, nine
investigated the eects of acute loading of Cr supplemen-
tation [11, 12, 14, 15, 17, 18, 22, 23, 25], ve examined
the eects of maintenance loading after an initial acute
loading phase [10, 13, 19, 20, 24], and three specically
explored the eects of maintenance loading [7, 16, 21].
e evaluation of swimming performance now clearly
delineates swimming time, which consists of single sprint
swimming time and repeated interval swimming time,
involving distances of 50 m and 100 m. Physiological
response includes parameters such as blood lactate lev-
els, heart rate, blood ammonia, and blood pH. Addition-
ally, body composition is evaluated through body mass,
lean body mass, and skinfolds.
Methodological Quality and Publication Bias
e average PEDro scale score for the studies included
was 8.41, indicating a high level of methodological qual-
ity. Out of the seventeen studies, twelve [11–13, 15,
17–23, 25] were classied as excellent quality, while ve
investigations [7, 10, 14, 16, 24] were categorized as good
quality. e detailed scores on the PEDro scale can be
found in Table2. Figure S1 in Supplementary Material 2
displays the publication biases across various outcomes,
encompassing single sprint swimming time, repeated
interval swimming time, physiological variables, and
body composition metrics. e scatter of data points
forms an approximate inverted funnel pattern around the
overall eect size, suggesting no publication bias.
Meta-analysis Results
Single Sprint Swimming Time
A total of eleven studies reported the eect of Cr on sin-
gle sprint swimming time [7, 10–17, 23, 25]. As depicted
in Fig. 2, the results of our meta-analysis indicate that
there was no overall eect favoring the Cr condition
(SMD: -0.05, 95% CI: -0.26, 0.15; p = 0.61), with low but
non-signicant heterogeneity observed (p = 0.99; I2 = 0%).
Subgroup analysis further revealed that there was a trivial
and non-signicant reduction observed in the 50m time
(SMD: -0.06; 95% CI: -0.32, 0.20; p = 0.64), with low but
not signicant heterogeneity detected (p = 0.95; I2 = 0%).
Additionally, a trivial but insignicant improvement
was found in the 100m time (SMD: -0.04; 95% CI: -0.38,
0.30; p = 0.82), with no signicant heterogeneity observed
(p = 0.90; I2 = 0%).
Repeated Interval Swimming Time
e impact of Cr on repeated interval swimming time
was examined in a cumulative four studies [18, 20, 23,
24]. Compared to placebo, supplementation with Cr led
to a trivial and not signicant reduction in the overall
eect (SMD: -0.11; 95% CI: -0.46, 0.25; p = 0.56), with
low but not signicant heterogeneity observed (p = 0.94;
I2 = 0%). Subgroup analysis further indicated a trivial and
not signicant decrease in repeated interval swimming
time during the 50m test (SMD: -0.09; 95% CI: -0.49,
0.31; p = 0.65), with low and not signicant heterogeneity
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Huang et al. Sports Medicine - Open (2024) 10:115
detected (p = 0.72; I2 = 0%). Similarly, a trivial and non-sig-
nicant eect was found for the 100m test (SMD: -0.14;
95% CI: -0.86, 0.57; p = 0.69), with no signicant hetero-
geneity observed (p = 0.95; I2 = 0%) (Fig.3).
Physiological Response
Six studies examined the impact of Cr on physiological
factors [10, 12, 20, 22, 23, 25]. In the meta-analysis, no
signicant dierence was found for the total eect when
comparing the Cr group to the placebo group (SMD:
0.04, 95% CI: -0.16, 0.23; p = 0.71), with no signicant het-
erogeneity observed (p = 0.70; I2 = 0%). Cr supplementa-
tion showed a trivial and non-signicant eect on blood
lactate levels (SMD: 0.03; 95% CI: -0.29, 0.35; p = 0.87),
with no signicant heterogeneity detected (p = 0.28;
I2 = 18%). Furthermore, no signicant eect was observed
Fig. 1 Search strategy owchart
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Sample Supplementation protocol
Reference Study
design
Sex Status N Acute
loading
Maintenance Duration
(days)
Swimming test
protocol
Outcomes Main ndings
Azizi. 2011 [15] RDBPC F Competitive
swimmers
20 20g/day -- 6 1 × 60m 50m time Cr alongside an eective conditioning
regimen can enhance the athletic perfor-
mance of female competitive swimmers.
Burke et al. (1996)
[11]
RDBPC M + F Elite swimmers 32 20g/day -- 5 1 × 25m
1 × 50m
1 × 100m
(swimmers’ pre-
ferred strokes)
50m time
100m time
Cr supplementation cannot enhance
single-eort sprint ability of elite
swimmers.
Dawson et al.
(2002) [10]
RSBPC M + F Competi-
tive junior
swimmers
20 20g/day (5
days)
5g/day (22 days) 27 1 × 50m
1 × 100m
(FC swimming)
50m time
100m time
Blood lactate
Body mass
Skinfolds
Competitive junior swimmers’ single
sprint performance did not improve after
4 weeks of Cr supplementation.
Grindsta et al.
(1997) [18]
RDBPC M + F Competi-
tive junior
swimmers
18 21g/day -- 9 3 × 100m
(FC swimming)
50m time
100m time
Body mass
Lean body mass
Competitive junior swimmers may ben-
et from 9 days of Cr supplementation
during sprint swimming.
Leenders et al.
(1999) [19]
RDBPC M + F Competitive
university
swimmers
32 20g/day (6
days)
10g/day (8 days) 14 6 × 50m
10 × 25m (swim-
mers’ preferred
strokes)
Body mass
Lean body mass
The impact of repeated intervals during
training on performance in a single com-
petitive event remains uncertain.
Mendes et al.
(2004) [25]
RDBPC M + F Competitive
swimmers
18 20g/day -- 8 1 × 100m
1 × 50m
3 × 3 × 50m
(swimmers’ pre-
ferred strokes)
50m time
100m time
Blood lactate
Supplementing with Cr does not
boost performance or muscle mass in
swimmers.
Mujika et al.
(1996) [12]
RDBPC M + F Competitive
swimmers
20 20g/day -- 5 1 × 25m
1 × 50m
1 × 100m
50m time
100m time
Blood lactate
Body mass
Blood ammonia
Highly trained swimmers cannot benet
from Cr supplementation for sprint
performance.
Peyrebrune et al.
(1998) [23]
RDBPC M Competitive
swimmers
14 9g/day -- 5 1 × 50 yards
8 × 50 yards
50 yards time
Heart rate
Blood lactate
Blood ammonia
Blood pH
Daily intake of 9g Cr for 5 days improves
swimming performance in elite athletes
during repeated sprints, but not in a
single 50-yard sprint.
Peyrebrune et al.
(2005) [20]
RDBPC M + F Competitive
swimmers
20 20g/day (10
days)
3g/day (42 days) 52 2 × (5 x 200m)
3 × (8 x 50m)
50m time
heart rate
Blood lactate
Blood ammonia
Body mass
Skinfolds
Oral Cr supplementation increases re-
peated sprint swimming performance.
Table 1 Summary of the included studies
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Huang et al. Sports Medicine - Open (2024) 10:115
Sample Supplementation protocol
Reference Study
design
Sex Status N Acute
loading
Maintenance Duration
(days)
Swimming test
protocol
Outcomes Main ndings
Roshan et al.
(2013) [22]
RDBPC M Non-elite
swimmers
16 20g/day -- 6 6 × 50m
(FC swimming)
Blood lactate
Heart rate
Swimming performance, blood lactate
levels, anaerobic performance, and heart
rate uctuations may improve with Cr
supplementation.
Scorcine et al.
2013
[16]
RPC M trained
swimmers
30 -- 5g /day 63 1 × 500m
1 × 50m
50m time Cr supplementation had no impact on
endurance in swimming
Selsby et al.
(2003) [13]
RDBPC M + F Competitive
university
swimmers
15 0.3g/ kg /bm
(5 days)
2.25g/day (9 days) 14 1 × 50 yards
1 × 100 yards
50 yards time
100 yards time
Body mass
Cr supplementation for swimming works
for 50- and 100-yard sprints.
Sompol Sanguan-
rungsirikul. 2004
[17]
RDBPC M trained
swimmers
38 10g/day -- 7 1 × 400m 50m time Cr supplementation in young amateur
swimmers enhanced anaerobic capacity,
power, and performance in the nal 50-
meter sprint of the 400-meter competi-
tive event.
Silva et al. (2007)
[21]
RDBPC F Competitive
swimmers
16 -- 20g/day 21 2 × 25m Body mass
Lean body mass
Cr supplementation did not aect
weight, composition, or performance.
Thompson et al.
1996 [7]
RPC F university
swimmers
10 -- 2g/day 42 1 × 100m
1 × 400m
50m time Oral Cr supplementation does not aect
muscle Cr concentration, oxygen supply,
or aerobic/anaerobic metabolism.
Theodorou et al.
(1999) [24]
RPC M + F Elite swimmers 22 25g /day (4
days)
5g /day (56 days) 60 A = 10 × 50m
B = 8 × 100m
C = 15 × 100m
(swimmers’ pre-
ferred distances)
50m time
100m time
Body mass
Swimming performance improves dra-
matically after 4 days of acute Cr loading.
Vatani et al. (2011)
[14]
RSBPC M Amateur
swimmers
20 20g /day -- 6 1 × 50m
1 × 100m
(breaststroke)
50m time
100m time
Short-term Cr supplementation in-
creased amateur swimmer 50m sprint
performance.
F: female. FC: front crawl. M: male. RDBPC: randomized double-blind placebo control. RSBPC: randomized single-blind placebo control. RPC: randomized placebo control
Table 1 (continued)
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Huang et al. Sports Medicine - Open (2024) 10:115
Table 2 Ratings of the included studies based on the Physiotherapy evidence database (PEDro) scale
Study 1 2 3 4 5 6 7 8 9 10 11 Total
Azizi. 2011 [15]Yes 1 0 1 1 1 1 1 1 1 1 9
Burke et al. (1996) [11]Yes 0 1 1 1 1 1 1 1 1 1 9
Dawson et al. (2002) [10]Yes 1 1 1 1 0 0 1 1 1 1 8
Grindsta et al. (1997) [18]Yes 0 1 1 1 1 1 1 1 1 1 9
Leenders et al. (1999) [19]Yes 1 1 1 1 1 1 0 1 1 1 9
Mendes et al. (2004) [25]Yes 1 0 1 1 1 1 1 1 1 1 9
Mujika et al. (1996) [12]Yes 1 0 1 1 1 1 1 1 1 1 9
Peyrebrune et al. (1998) [23]Yes 1 0 1 1 1 1 1 1 1 1 9
Peyrebrune et al. (2005) [20]Yes 1 0 1 1 1 1 1 1 1 1 9
Roshan et al. (2013) [22]Yes 1 0 1 1 1 1 1 1 1 1 9
Scorcine et al. 2013 [16]Yes 1 0 0 0 0 1 1 1 1 1 6
Selsby et al. (2003) [13]Yes 1 1 1 1 1 1 1 1 1 1 10
Sompol Sanguanrungsirikul. 2004 [17]Yes 1 0 1 1 1 1 1 1 1 1 9
Silva et al. (2007) [21]Yes 1 1 1 1 1 1 1 1 1 1 10
Thompson et al. 1996 [7]Yes 1 0 0 0 0 1 1 1 1 1 6
Theodorou et al. (1999) [24]Yes 1 0 1 0 0 0 1 1 1 1 6
Vatani et al. (2011) [14]Yes 1 0 1 1 0 0 1 1 1 1 7
1, clear eligibili ty criteria were established; 2, volunteers wer e randomly assigned to th eir respective groups; 3, allocatio n was concealed; 4, baselin e characteristics
of the groups were similar in terms of important prognostic indicators; 5, blinding was implemented for all participants; 6, therapists administering the therapy
were also blinded; 7, assessors measuring key outcomes were blinded; 8, outcome measures were obtained from 85% of the initially allocated participants; 9, all
partici pants with available out come measures received th e allocated treatment o r control condition, or an in tention-to-treat a nalysis was conducte d; 10, Sta tistical
analyses comparing groups were presented for a minimum of one primary outcome; 11, The research furnished point estimates as well as variability indices for at
least one primary outcome
Fig. 2 Pooled analysis of the eect of Cr on single sprint swimming time. Subgroup eects are delineated according to the categorization variables as-
sociated with time across varying distances (50m time vs. 100m time)
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Huang et al. Sports Medicine - Open (2024) 10:115
on heart rate (SMD: 0; 11; 95% CI: -0.30, 0.51; p = 0.61),
and no signicant heterogeneity was found (p = 0.39;
I2 = 2%). Additionally, no signicant negative eect was
found on blood ammonia levels (SMD: -0.15, 95% CI:
-0.62, 0.32; p = 0.53), with no signicant heterogeneity
observed (p = 0.82; I2 = 0%). Moreover, trivial and non-sig-
nicant improvement were observed in blood pH (SMD:
0.16, 95% CI: -0.40, 0.71; p = 0.58), with no signicant het-
erogeneity detected (p = 0.88; I2 = 0%) (Fig.4).
Body Composition
e inuence of Cr on body composition was investi-
gated in seven studies [10, 12, 13, 18–20, 24]. In compari-
son to the placebo, there was a trivial and not statistically
signicant dierence observed for the overall eect
(SMD: 0.18; 95% CI: -0.05, 0.41; p = 0.12), with a low and
non-signicant level of heterogeneity detected (p = 0.55;
I2 = 0%). A trivial and not statistically signicant increase
was observed in body mass (SMD: 0.11; 95% CI: -0.19,
0.41; p = 0.49), with a low and non-signicant level of
heterogeneity detected (p = 0.94; I2 = 0%). Similarly, Cr
demonstrated trivial and not signicant eect in body
composition as measured by skinfolds (SMD: 0.17; 95%
CI: -0.34, 0.68; p = 0.52), with a low and non-signicant
level of heterogeneity detected (p = 0.87; I2 = 0%). On
the other hand, moderate but not statistically signi-
cant increases were observed in lean body mass (SMD:
0.66; 95% CI: -0.45, 1.77; p = 0.24), with a substantial but
non-signicant level of heterogeneity detected (p = 0.01;
I2 = 76%) (Fig.5). e study conducted by Grindsta et al.
(1997) resulted in high risk of heterogeneity on lean body
mass [18]. Subsequent to the exclusion of this particular
study, a meta-analysis was performed on the remaining
data, as shown in Fig. S2 (supplementary material 2),
which led to a considerable decrease in heterogeneity
(from 76 to 0%). However, the variation between groups
did not reveal a statistically signicant disparity when
comparing the Cr group with the placebo group.
Meta-Regression Results
Table3 presents the results of a meta-regression analy-
sis assessing the impact of Cr on single sprint swimming
time during 50m event (single 50m time) and blood lac-
tate levels. e analysis considered moderators such as
performance level (competitive swimmers vs. non-com-
petitive swimmers), duration of supplementation (less
than 20 days vs. more than 20 days), and supplementa-
tion protocol (acute loading vs. maintenance). Findings
indicated that these moderators did not signicantly
aect the single 50m time and blood lactate.
Discussion
Summary of Main Findings
is study presents the rst systematic review and meta-
analysis investigating the eects of Cr supplementation
on the performance (measured as 50 m time, 100 m
time), physiological response (measured as heart rate,
blood lactate, blood ammonia, and blood pH) and body
composition (measured as body mass, lean body mass,
and skinfolds) in swimmers. e main nding was that
there was no statistically signicant impact of Cr supple-
mentation on the performance, physiological response
and body composition among swimmers. Collectively,
the ndings of this meta-analysis indicate that incorpo-
rating Cr supplementation might not be a viable consid-
eration for swimmers seeking to enhance their swimming
Fig. 3 Pooled analysis of the eect of Cr on repeated interval swimming time. Subgroup eects are delineated according to the categorization variables
associated with time across varying distances (50m time vs. 100m time)
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Huang et al. Sports Medicine - Open (2024) 10:115
performance. ese results inform and direct future
research eorts to further explore the ergogenic eects of
Cr in this specic athletic context.
Single Sprint Swimming
Our meta-analysis demonstrated that Cr supplementa-
tion did not signicantly impact 50m and 100m times in
single sprint swimming (Fig.2). is nding aligns with
previous studies [10–12, 23, 25], likely due to the rela-
tively lower depletion of phosphocreatine stores during
single-sprint swimming. erefore, Cr supplementation
shows limited eectiveness in this context.
However, contrasting results were reported by two
studies [13, 14], where signicant improvements in 50m
sprint times were observed following Cr supplementa-
tion. ese discrepancies were attributed to variations in
participant athletic abilities, study designs, and exercise
protocols [13]. To address these inconsistencies, we con-
ducted a meta-regression analysis examining factors such
as the swimmers’ performance level, the duration of Cr
supplementation, and the supplementation protocol. Our
analysis revealed that none of these factors signicantly
inuenced the eectiveness of Cr supplementation on
50m sprint swimming performance (Table3).
Similarly, no signicant eect on 100m swimming per-
formance was observed (Fig. 2), consistent with previ-
ous studies [10–12, 14, 25]. Interestingly, improvements
in performance in the single 100m freestyle sprint were
demonstrated by Selsby et al. (2003) [13]. e authors
attributed these improvements to the performance level
of the participants, who had lower swimming abilities and
levels. ey suggested that lower-level swimmers may be
more likely to increase intramuscular Cr stores than elite
athletes. However, this viewpoint was not supported by
Vatani et al. (2011) [14], which also included participants
with lower-level swimming abilities. Sensitivity analy-
sis identied Selsby et al. (2003) [13] as a source of het-
erogeneity, likely due to participant ability and sample
Fig. 4 Pooled analysis of the eect of Cr on physiological variables. Subgroup eects are delineated according to the categorization variables associated
with dierent outcomes (blood lactate vs. heart rate vs. blood ammonia vs. blood pH)
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Huang et al. Sports Medicine - Open (2024) 10:115
size. Excluding this study reduced heterogeneity signi-
cantly, conrming that Cr supplementation is unlikely to
enhance single-sprint swimming performance.
In conclusion, the comprehensive ndings from our
meta-analysis, including the additional insights gained
from our meta-regression and sensitivity analyses, indi-
cate that Cr supplementation does not consistently or sig-
nicantly enhance single-sprint swimming performance
across various levels of swimmers. While isolated reports
suggest some improvements in specic subgroups, these
were not suciently consistent to conrm a general
benet across a diverse range of swimmers. Our study
underscores the need to consider individual variability
and study design when assessing the ecacy of nutri-
tional supplements in enhancing sports performance.
Future research should continue to explore the nuanced
eects of Cr under more dened and controlled condi-
tions to ascertain any specic advantages it might oer to
particular populations.
Repeated Interval Swimming
While anaerobic energy signicantly contributes to a
single 50m sprint, accounting for up to 80% of energy
expenditure [38], its role diminishes as repetitions
increase during repeated interval swimming, with aero-
bic metabolism becoming more prominent [7], espe-
cially as phosphocreatine stores are depleted, even with
supplementation. Although phosphocreatine resynthesis
remains crucial for short bursts of eort, maintaining
performance across multiple sprints increasingly relies
Table 3 Meta-regression analysis for dierent moderators to predict the eects of cr supplementation on single 50m time and blood
lactate
Coecient Standard error Z P value 95% CI
Single 50m time
Performance level 0.06 0.31 0.19 0.85 -0.55, 0.67
Duration of supplementation 0.41 0.62 0.66 0.51 -0.81, 1.63
Supplementation protocol -0.33 0.55 -0.59 0.55 -1.41, 0.75
Blood lactate
Performance level 0.71 0.42 1.69 0.09 -0.11, 1.53
Duration of supplementation -0.56 0.33 -1.69 0.09 -1.21, 0.09
Supplementation protocol -0.56 0.33 -1.69 0.09 -1.21, 0.09
Fig. 5 Pooled analysis of the eect of Cr on body composition. Subgroup eects are delineated according to the categorization variables associated with
dierent outcomes (body mass vs. skinfolds vs. lean body mass)
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Huang et al. Sports Medicine - Open (2024) 10:115
on aerobic pathways [39]. e potential benets of Cr
supplementation for anaerobic exercise performance
have been established [40], particularly in enhancing
phosphocreatine resynthesis after sprints [41–43]. How-
ever, in repeated sprint swimming, its impact may be
limited by the growing reliance on aerobic metabolism
as phosphocreatine stores are depleted. Numerous stud-
ies have suggested that Cr can enhance performance in
repeated interval swimming during both 50m time [18,
20, 23, 44] and 100m time [23]. However, the physiologi-
cal mechanisms underlying these improvements remain
unclear, with many researchers still uncertain about the
reasons behind this eect.
Our meta-analysis revealed a novel nding that Cr
supplementation did not signicantly aect 50m time,
100m time, or overall time in repeated interval swim-
ming(Fig.3). is result aligns with Fernández-Landa et
al. (2023) meta-analyses, which indicated that Cr supple-
mentation had no signicant impact on endurance per-
formance [45]. is might be due to Cr’s action at the
peripheral muscle level. While Cr is known to enhance
muscle hypertrophy and increase the recruitment of
fast-twitch muscle bers [46], these alterations in skel-
etal muscle could potentially negatively aect endur-
ance performance. Furthermore, Leenders et al. (1999)
investigated the eects of Cr supplementation on average
velocity during a 10 × 25 yard repeated interval swim set
and found no signicant change. e authors suggested
that this lack of eect is likely due to the short recovery
period between sprints, which may have been insucient
for adequate replenishment of phosphocreatine stores
[19].
Although our analysis revealed no statistically signi-
cant enhancements in 50m and 100m repeated interval
swimming times following Cr supplementation, these
results should be interpreted with caution due to the
small sample sizes and varying quality of the included
studies. In particular, our conclusions may be inuenced
by biases related to not accounting for dierences in
training setups and rest intervals. Future research should
rigorously control experimental variables, such as the
number of repetitions and the duration of rest inter-
vals, to ensure more reliable results. It is also critical to
increase the sample size and improve the overall quality
of studies to address these limitations eectively.
Physiological Response
A distinctive aspect of this review is the use of meta-
analysis to investigate the impact of Cr on physiologi-
cal markers in swimmers. Our ndings indicate that Cr
supplementation does not signicantly alter post-exer-
cise blood lactate levels, heart rate, blood ammonia, or
pH values, as illustrated in Fig. 4. ese outcomes are
consistent with those reported by Peyrebrune et al. (1998,
2005) [20, 23].
A study reported a similar lactate concentrations before
and after supplementation [25]. However, other studies
presented contrasting views, suggesting that Cr supple-
mentation could improve lactate levels [10, 22]. While
the underlying mechanisms were not clearly elucidated in
these studies, a research suggested that Cr may delay lac-
tate accumulation associated with sprint swimming [13].
Additional ndings from Roshan et al. demonstrated an
improvement in heart rate with Cr supplementation [22].
Regarding blood ammonia levels, two studies pro-
posed views that contradict our ndings, suggesting that
Cr supplementation signicantly reduced post-exercise
blood ammonia levels [12, 47]. ey attributed this phe-
nomenon to an enhanced rate of ADP to ATP formation
after Cr supplementation, leading to a decreased degra-
dation of purine nucleotides. Although research on the
eects of Cr supplementation on physiological indicators
yields inconsistent results, with some studies indicating
no signicant changes and others suggesting improve-
ments, our meta-analysis concludes that Cr supplemen-
tation has no impact on these indicators. Nevertheless,
given the limited scope of studies incorporated, our
results ought to be approached with prudence. Future
research should further investigate Cr’s potential eects
on swimmers’ physiological indicators, emphasizing the
inclusion of more diverse sample sizes and supplementa-
tion regimes to enhance the robustness of the evidence
base.
Body Composition
Although Cr supplementation has been shown to
increase body mass in various sports [48–58], our meta-
analysis of the eects of Cr on body composition in
swimmers found no signicant changes in body mass and
lean body mass with Cr supplementation (Fig.5). ese
ndings are consistent with previous research [18, 19].
some studies also reported no signicant eect of Cr on
body mass [10, 13, 24]. Mujika et al. (1996) [12], however,
reported a signicant increase in body mass following Cr
supplementation. Mujika et al. (1996) and Grindsta et
al. (1997) measured body mass immediately after acute
loading [12, 18], while other studies measured body mass
after an acute loading followed by a maintenance phase
[10, 13, 19, 20, 24]. It is worth noting that Grindsta et
al. (1997) [18] had a more extended Cr supplementation
period of 9 days compared to the 5-day supplementation
period in Mujika et al. (1996) [12]. ese dierences in
the measurement timing or supplementation duration
may explain the inconsistent conclusions between Mujika
et al. (1996) [12] and other studies [10, 13, 18–20, 24].
Subgroup analysis exhibited no signicant eects of Cr
on skinfolds (Fig.5). is is consistent with Dawson et al.
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Huang et al. Sports Medicine - Open (2024) 10:115
(2002) [10] and Grindsta et al. (1997) [18], who found
no impact of Cr on skinfolds. However, it is pertinent to
acknowledge that this analysis was based on only three
studies. Further research is necessary to determine the
impact of Cr supplementation on body composition in
swimmers.
Limitations and Methodological Quality
e primary limitation of this systematic review and
meta-analysis is the limited number of studies, totaling
17, examining creatine supplementation in swimmers.
is small sample necessitated the inclusion of studies
with combined male and female data, potentially obscur-
ing sex-specic eects. Our meta-regression analysis
was also conned to a few covariates: performance level,
duration of supplementation, and protocol, which only
aected the 50 m time in single sprint swimming and
blood lactate levels. Additionally, these results may be
biased due to variations in training setups and rest inter-
vals across studies. To enhance the reliability of future
research, it is crucial to increase the sample size and
improve the methodological quality of studies. Moreover,
future studies should separate male and female data to
better understand sex-specic responses and apply strin-
gent controls on experimental variables, including repeti-
tion counts and rest periods, to mitigate these limitations
eectively.
From a methodological perspective, the included stud-
ies exhibited good to excellent quality according to the
PEDro scale. is indicates that included studies with
suboptimal research methodology did not compromise
the current meta-analysis results. As a result, the validity
of our conclusions is strengthened, as studies of inade-
quate methodological quality do not inuence the nd-
ings presented in this study.
Conclusions
e impact of Cr on swimming is minimal and lacks sta-
tistical signicance, suggesting that it is unlikely to be an
eective enhancer of swimming performance. Consider-
ing the prevalence of this supplement as one of the most
commonly utilized ergogenic aids in swimming, it is cru-
cial for athletes, coaches, nutritionists, dietitians, and
sports scientists to carefully consider the ndings of the
current meta-analysis, especially when seeking to opti-
mize swimming performance.
Future research should focus on exploring the benets
of Cr supplementation in specic populations, such as
international, national, regional, recreational, and lower-
level swimmers, and understanding its potential side
eects. Investigating which subgroups are more likely
to benet from Cr supplementation and examining side
eects such as tremors, insomnia, increased heart rate,
headaches, abdominal/gastrointestinal discomfort, and
muscle soreness will be crucial. Conducting these studies
will contribute to a more comprehensive understanding
of the potential role of Cr in swimming performance.
Abbreviations
Cr Creatine
CI Condence interval
PRISMA The preferred reporting items for systematic reviews and
meta-analysis
SD Standard deviation
F Female
FC Front crawl
M Male
RDBPC Randomized double-blind placebo control
RSBPC Randomized singles-blind placebo control
RPC Randomized placebo control
Supplementary Information
The online version contains supplementary material available at https://doi.
org/10.1186/s40798-024-00784-8.
Supplementary Material 1
Supplementary Material 2(Please replace 'Supplementary Material 2’
by the newly uploaded le 'Supplementary Material_2.pdf’ as there are
changes in the reference numbers)
Acknowledgements
We acknowledge the valuable contributions of the studies included in
this meta-analysis, and are grateful for the public data that facilitated a
comprehensive synthesis.
Author Contributions
DX, XB, and DC conceived and designed research; DX, XB and WR performed
review and meta-analysis; DX and Q analyzed data; DX, TG and DC interpreted
the results; DX drafted manuscript; DX, TG, HT, B and DC edited and revised the
manuscript. All authors approved the nal version of the manuscript.
Funding
No funding was received for the preparation of this article.
Data Availability
The datasets used/analysed during the current study are available from the
corresponding author on reasonable request.
Declarations
Ethics Approval and Consent to Participate
Not applicable.
Consent for Publication
Not applicable.
Competing Interests
The authors declare that they have no competing interests with the content
of this article.
Author details
1School of Physical Education, Shaoguan University, Shaoguan, P.R. China
2Department of Health and Physical Education, The Education University
of Hong Kong, Hong Kong, P.R. China
3Institute for Life and Earth Sciences, School of Energy, Geoscience,
Infrastructure and Society, Heriot-Watt University, Edinburgh, UK
4Faculty of Health and Sport Sciences, University of Tsukuba, Tsukuba,
Japan
5School of Physical Education and Sports Science, South China Normal
University, Guangzhou, P.R. China
6Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, P.R. China
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 14 of 15
Huang et al. Sports Medicine - Open (2024) 10:115
Received: 17 June 2024 / Accepted: 14 October 2024
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