CEimpact Podcast

Creatine - Separating Facts from Fiction

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Creatine is often associated with athletic performance, but growing evidence points to its broader benefits for brain health, aging, and overall muscle preservation. This episode breaks down what pharmacists need to know about creatine’s evidence-based uses, safety considerations, and counseling opportunities. Tune in to strengthen your knowledge and help ensure patients receive accurate, evidence-based information about this widely used supplement. 

HOST
Joshua Davis Kinsey, PharmD
VP, Education
CEimpact

GUEST
Mark Smith, PharmD, CDCES, AFAA-CGFI
Pharmacist
UAB Medicine

Ian Haywood,  PharmD, BCPS, CDCES
Clinical Pharmacist
Baptist Memorial Hospital

 
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CPE INFORMATION
Learning Objectives
Upon successful completion of this knowledge-based activity, participants should be able to:
1. Describe the evidence-based uses of creatine beyond athletic performance, including its potential benefits for brain health and aging.
2. Identify key counseling points for pharmacists when discussing creatine supplementation with patients.

0.05 CEU/0.5 Hr
UAN: 0107-0000-25-200-H01-P
Initial release date: 6/9/2025
Expiration date: 6/9/2026
Additional CPE details can be found here.

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Speaker 1:

Hey, CE Impact subscribers, Welcome to the Game Changers Clinical Conversations podcast. I'm your host, Josh Kinsay, and as always, I'm excited about our conversation today. Creatine is often thought of as just a sports supplement, but emerging research shows it may have far-reaching benefits for brain health, aging and overall muscle preservation. In today's episode, we'll discuss what pharmacists need to know about creatine's evidence-based uses, safety considerations and how to guide patients with accurate, meaningful information. And because this is a topic of interest that I know nothing about, I have got two expert witnesses today, two experts to kind of share some details with us today. So super excited to have both of you with us, Mark Smith and Ian Haywood. And, if you guys don't mind, go ahead and take a couple minutes to introduce yourselves to our learners and tell us a little bit about your practice site and your passion for the profession. And again, we're just we're grateful to have both of you joining us today.

Speaker 2:

So 1000%, josh again. Thank you again so much for having us. First and foremost, it's truly an honor to be back here a second time on such a great platform, so thank you for the invite as well. Absolutely, my name is Mark Smith. I'm a pharmacist currently at UAB Hospital in Birmingham, alabama, where I practice on the inpatient setting and see patients in our orthopedics surgery department. As well to being a pharmacist and in the hospital setting, I'm also a group fitness instructor have been for over three years now and so fitness and pharmacy sort of have this positive relationship in my life right now, in addition to being a certified diabetes care and education specialist, which I have been for about five years. So diabetes education, fitness and pharmacy has been a crucial part of my career thus far.

Speaker 1:

Awesome, awesome. Thanks, mark. All right, ian.

Speaker 3:

Hey there. Thanks again, josh, for having me again. I really appreciate it. We had a great time last time I was on here and I'm pretty sure we're going to have another great time this episode as well. My name is Ian Haywood. I'm actually the quality coordinator at Baptist Memorial Hospital for the Diabetes Self-Management Education and Support Program here. This program actually is also an elective rotation for the PGY1 residents that come to Baptist Memorial Hospital here in Memphis, tennessee. So I guess you could say I'm a big educator and that's what I really enjoy. Also, in my free time I do a lot of physical activity, exercise, working out, running. So that's always been a part of my life, so that, along with my passion for diabetes care, that's kind of they all kind of align and work together to kind of promote fitness and promote, you know, better health for our diabetes patients. So that's a little bit about what I do and I'm looking forward to talking to you guys about creatine.

Speaker 1:

Yeah, awesome. Thank you so much. Thanks again for taking time out of your busy schedules I know it takes a lot and remind me the episode you all it was when Jen was still hosting. So remind me what episode that was Was it on diabetes? Was it the?

Speaker 2:

topic yeah, it was on diabetes. It was the high intensity interval training with CGM.

Speaker 1:

Oh great, yeah, yeah, awesome, yeah, awesome, awesome. And then you both also participated in one of our courses, in the um cgm course.

Speaker 3:

Uh, right, that's right, that's right, yeah, yeah great, yeah, so we've.

Speaker 1:

We've um, partnered with you all several times and super excited to have you again today. So, um, again, it sounds like, with your background, you're very poised to give us great information on this topic today. So I'm really excited to hear what you guys have to say. So let's jump into the content. So let's just kind of set the foundation, remind us exactly what creatine is. How does it work in the body? It's generally associated with athletic performance, those that are heavily involved in the gym. So just kind of give us a foundation review of that, if you don't mind.

Speaker 2:

Yeah, sure, you're 1000% right about that with the fitness aspect of it. So creatine, another from. Verbiage like creatine versus creatinine can often be confusing at times. So making sure that we say creatine for the sake of our discussion today, and I'll try my best to keep it on the straight and narrow as well. But creatine essentially is a naturally occurring substance that is synthesized in the liver, pancreas and kidneys from specific amino acids and it's one of the precursors that lead to the production of ATP essentially, and so it's predominantly stored in our skeletal muscle about 95% and then the other remaining percentages is restored in some body tissues as well as the brain as well.

Speaker 2:

But the biggest thing with creatine is how it's phosphorylated and how it's activated under high, intense energy demands. So that's the popularity when it comes to fitness, in that not only do people that take creatine on a regular basis experience an increase in lean muscle mass, they also experience increases in energy and short bursts due to the production of creatine during those moments. So this is a this is a substance that has been around for a long time. It's been extensively studied and it's exciting to see its its sort of reemergence in in topics that are in addition to fitness in topics that are in addition to fitness, such as major depressive disorders, some neurodegenerative disorders, and as well as some of the benefits in our aging patient population, as well as a precursor to energy metabolism, taking that ADP and converting it to ATP, which, as we know from one of our basic science classes, the ATP, is the energy powerhouse of the cell and responsible for many, many functions from an energy standpoint in our body, great, great.

Speaker 1:

That's a great foundational review. I feel like I just had a good little cliff notes.

Speaker 2:

That's awesome.

Speaker 1:

Some of that, you know, it's been many, many years since I was in school, so some of that is just, you know, gone. But thanks again, that's really helpful. I have to admit I forgot that it was a naturally occurring substance in our body. So you know, I think that that's just again just a great reminder and making sure that everybody's on the same page as we talk about it here.

Speaker 1:

So, you mentioned some of those expanded roles beyond the athletic performance perspective. So let's go ahead and dig just a little bit into those. We can continue to talk about them as we go through. But I heard you mention something about neurological disorders, aging what else? Have we kind of seen an uptick with creatine use in recent years?

Speaker 2:

Absolutely so. In addition to the skeletal, muscle and fitness aspect that we all know about, there's four key components. I'll discuss too, and Ian will nicely do, the other two as well, the first one being cognitive health. And by cognitive health, what studies have shown over the years is that there have been improvements in memory in patients that take creatine products. There's been improvements in attention time as well as processing speed. So basically, an improvement in cognition in patients that are, in individuals that utilize creatine within their regimen and from a mental health standpoint.

Speaker 2:

So we've talked about cognition. From a mental health standpoint, we're getting into conditions such as major depressive disorder. Studies, which is one of the primary studies that led to our conversation, was the use of creatine in patients that have major depressive disorder, and so studies have shown that there has been a improvement in patients with major depressive disorder that have creatine. One of the biggest studies that we saw was cognitive behavioral therapy, or CBT, combined with creatine therapy was successful in reducing major depressive disorder in those patients, versus CBT and the placebo by itself. So we're starting to see, in addition to the muscle component, we're also seeing cognition and mental health, and there are several others as well, right, ian?

Speaker 3:

Yeah, there's also a lot of research and evidence going into showing that creatine has like a neuroprotective properties and improvements in cognitive performance, especially during stress or sleep deprivation, especially with the older population. A couple research articles actually come to mind. A couple research articles actually come to mind One by Ray Etel in about 2003. He found improved working memory and intelligent task performance in weeks two with five grams of creatine in patients that were vegetarians. That was super interesting, actually. And again there was another article from Avgarinos Etal in 2018. He did like a meta analysis that showed that significant cognitive benefits, particularly in short term memory and reasoning, was found in the creatine group as well. So it's just been really interesting to see we're so used to seeing creatine just having to deal with athletes being this wave of research going in a different direction, other than what we're most commonly see.

Speaker 1:

When we're talking about supplementing for these patients in some of those studies, because what I envision or what I've seen creatine used before, it's usually a powder and it's mixed into it like a drink, right, like a supplemental drink or whatever. Is that the same format in which these patients were receiving it or is it a different modality that they're getting it?

Speaker 2:

There's several studies that we saw. We've seen the use of the powder form. We've also seen the use of creatine capsules as well. Those have been the predominant forms and it's interesting that you mentioned that and that kind of, in case anyone asks. You would rarely see creatine in a liquid form that you can buy from the store.

Speaker 2:

That's because if it's left in the water for an extended period of time, it gets converted to creatinine which is so that interaction or that reaction takes place, and so that's why, like it comes in that powder or capsule form, so that when it is formulated it has to be ingested, almost you know pretty quickly, okay, okay, interesting.

Speaker 1:

And I'm interested in the fact that there are capsules because I'm a texture person and I hate the grittiness of I hate all of the powder. I just I can't do it. Everybody's always like just slam it and it just oh, can't, can't do it.

Speaker 3:

There are different formulations, though there's some gummies.

Speaker 1:

Okay interesting. Capsules powder. Yeah, okay, so it doesn't have to be the chalky aftertaste.

Speaker 2:

No, you definitely don't have to go to the extent of. We were listening to this podcast on some medical providers talking about creatine and they had like a round table question. It's like, how do you take your creatine? And one of the providers said he just dry powders it, which means that he just takes no absolutely by itself.

Speaker 1:

So phone mouth exactly yeah, I imagine like those. You remember those pixie sticks when you were kids and you tear yeah, I sticker, I bet. Yet I just I can't imagine that takes good potential marketing idea actually.

Speaker 1:

Yeah, maybe, yeah, rip off the creatine stick. So yeah, okay, interesting, and it's really interesting that we're seeing kind of a go in a different direction as far as what it can be used for. Obviously, our podcast here is for pharmacists, so what's the pharmacist's role in this? What should we be doing? Should we be ready to answer questions about it? Is there certain education we should be providing? Should we be pointing to certain versions of the supplement as opposed to others? Just what are some of the things that pharmacists can do in this space that can really make sure that, I guess, the awareness is there and also proper education and use?

Speaker 2:

Sure, I think one of the most important things is that pharmacists, as you mentioned, being on the front lines for the majority of the time.

Speaker 2:

It's important that we bridge the gap that exists between the research and the real-world implementation. So being that connector is going to be extremely crucial, and that's partly done by educating the patient on these type of products and so getting the most recent evidence, and one of the things that stands out the most is identifying the appropriate candidates, and so that's pharmacists can play a huge role in that. Some examples just include the older population that are at risk of fall and have a lot of that dietary creatine that you would otherwise miss as a vegetarian when missing out on those types of products, and then also individuals with cognitive impairment. We've mentioned that creatine has been studied in cognitive impairment, but there just hasn't been much funding behind studies that can say, hey, creatine really, really works. And the reason that it hasn't been much funding is because it's been around for so long that, you know, no one is like really rushing to like fund a study that that can lead or draw those conclusions.

Speaker 2:

Not a new or novel product. Not a new or novel product, exactly. So to kind of say that I think that we can play a huge role as pharmacists in sort of identifying patients that might be a potential candidate for creatine therapy.

Speaker 1:

Yeah, and Mark, I really love the connection you made there and you alluded to it earlier and I didn't make the full connection until you reiterated it but with the reason for its use in vegetarian, because you mentioned that that was part of the study and so now that makes sense because you're right. Either they're missing out on some of those building blocks of the protein components and so potentially less muscle mass and whatnot. So that's interesting to me for sure. But as far as like dosing goes, do we see each of those things? Are they the same similar usual supplemental dose? Or is it in order to get cognitive behavioral changes you have to be like five times what the bottle recommends? Or whatever Like are we? Does that make?

Speaker 3:

sense. So, to be honest, the doses that were researched and that's what we kind of need more of. We need the more research with the higher doses. Right now, the doses that have been commonly researched are the three to five grams, or potentially even up to 10 grams, or they may have even given the loading dose of, you know, 20 grams for the first five to seven days and then dropping it down to the maintenance dose, which is about five grams for the duration of the trial. So technically, there has been studies where if the dose is increased, it has shown to actually have more creatinine that's actually crossed the blood-brain barrier and that is actually shown to have an effect on the results of a study in terms of depression.

Speaker 3:

But again, this is all still new to us and there still hasn't been a lot of enough studies for these dosings to kind of be Fleshed out completely. Yeah, completely that's a good question you ask and that's kind of what we've noticed with the research. There's just kind of been a little bit of variation, but they stay. Nobody's really pushed out to the extreme of when beyond like 20 grams of no, and majority of them have just been about five or five and so okay, um, just because I think maybe even the safety too there's.

Speaker 1:

You know, still like you know, that's what I was gonna ask, yeah, like around the safety, because you think about, you know, like some of your vitamins that are wasted in in the urine and it's like you can't really overdose on some of those. But then you have the fat-soluble ones. You know A, d, e and K that you can. So, like, where does creatine fall in that? Like, is it one of those things where you can get too much, or is it one of those things where it's like, eh, it'll just waste away if you don't use it, it's fine.

Speaker 2:

So one thing that we know for and we might end up addressing this again later on in the podcast, but one thing we know for sure is that in healthy individuals by healthy I mean patients that do not have established CKD or chronic kidney disease creatine is relatively safe. Creatine is very, very safe and so, in terms of just elimination, there's no potential risk for an otherwise healthy individual to go up to that, like Ian mentioned, 20 gram amount without being worried about oh my God, something's bad going to happen to me.

Speaker 1:

Right, my kidneys are going to shut down. I can't filter it, right.

Speaker 2:

Outside of that increased serum creatinine that will likely reflect on your labs or something like that, but it won't be clinically significant in an otherwise healthy patient because if they stop taking it it's going to go back down to that baseline level. The example that it was like 0.9 starting out and then you go on creatine therapy for a couple of months or so and then you go get labs drawn again and it's like 1.1. You can dc that creatine and you'll notice that it'll go back down. So it's not that. So that increase doesn't relate or correlate to being clinically significant in terms of a person needing to be worried about CKD.

Speaker 2:

Or it's not damaging the kidneys to where you're leading. It's not damaging, or anything like that. Now, on the other hand, there's the other side of that, in that individuals that do have established CKD. Everything that we've come across so far is talk to your nephrologist. Sure, sure, find out what. Find out what your nephrologist says, because there hasn't been there hasn't been much push in advocating for the use of creatine in patients that do have established CKD no-transcript makes sense, okay.

Speaker 3:

And then, josh, the dehydration aspect too. Right, because what you know creatinine really does, it's actually pushing all your fluid into your cells. So as it's pushing all your fluid into your cells, your body's actually can become dehydrated, so that with somebody having CKD and already you're having an imbalance and them having to balance fluids and waste and everything, and then becoming super dehydrated, it could lead to possible issues. So that's kind of where I would just be kind of cautious for patients that have any AKI or CKD issues or anything like that.

Speaker 1:

Okay, yeah, that's great to know when we're talking about using it in the neurological for patients that have any AKI or CKD issues or anything like that. Okay, yeah, that's great to know. When we're talking about using it in the neurological sense or for athletic performance and then also aging and whatnot. Are there any other contraindications considerations? Does it interact with prescription medications that patients might be on? Is there something that pharmacists? Obviously that's one of the key things that we do as pharmacists, so is that something we should be looking out for as well?

Speaker 2:

Yeah, the biggest thing that we came across with regards to medication in conjunction with creatine are NSAIDs, and so the thing that we've come across is that you know so. Ibuprofen the thing that we've come across is that you know so. Ibuprofen, naproxen, aleve anything that's considered an NSAID. Didn't really see about like topical NSAIDs so that I can't make a statement on that, but at least we know for sure oral NSAIDs is going to be like one of those things that you want to watch out for in terms of drug therapy in combined with creatine, because of the way that the NSAIDs are metabolized. They're.

Speaker 1:

Yeah, that makes sense, and so I'm assuming it would be constant use, everyday use of NSAIDs as opposed to. I have a headache and I'm taking two ibuprofen kind of thing.

Speaker 3:

And other like net for toxic agents, sure, sure.

Speaker 1:

Right, right, which that just makes logical sense if you think about it. So yeah, okay, that's yeah. So we've talked a little bit about the broader use of it, the benefits of it beyond just sports performance. I guess one thing I want to touch on, and maybe we haven't touched on it enough, but I, when we say it's for our aging patients, are we talking about that just in general of the neurological benefits, or are there other benefits that it's doing? Actually, you did mention that it's increasing muscle mass, because a lot of those patients we see that dwindle or maybe they're not as active and so therefore that's kind of going down. So is there any other benefits for the aging population that we can kind of highlight?

Speaker 3:

Well, there's been some growing interest in a lot of the research in terms of the potential for creatine to have some anti-inflammatory and osteoprotective effects. So they think there was a trial with creatine, with or without resistance training, and that kind of led to an increase in lean mass, an increase in muscle strength and also reduce the risk of falls in older adults. And so this kind of is important because if you're hopefully I won't have this issue, but I'm pretty sure, like a lot of grandparents and grandmothers, it's very difficult for them to just come out, just to get off the toilet, sure, just to get up out of the chair. So there's actually been like a trial. There was a trial back in 2017 by Chilibe Etal. He did like a meta-analysis showing that creatine and resistance training improved lean body mass and significantly increased leg muscle strength in older adults. And this is huge because this actually can help directly correlate to fall risk mitigation, and so there's huge benefits just on taking creatine as you get older, especially if somebody is going to continue to do some resistance training, which kind of leads me me being a diabetes educator.

Speaker 3:

I'm always promoting that for my patient. It's not just you doing cardio If I have a 65-year-old, 67-year-old patient in here. I'm always telling them to do some resistance training with resistance bands or using their own body weight and stuff like that. And so me now like, after kind of doing a little bit more research about creatine, this is something that kind of makes me want to. You know, you know, tell them to potentially.

Speaker 1:

Yeah, that's great, I've got just a few minutes left. So one of the things I wanted to be sure I touched on and I'll admit to our listeners that I had shared some of the public misconceptions and our little talk before we actually got on to record because I feel like I have for some reason thought that it was one of those banned substances. You know, like you can't take it at the Olympics or it's, it's. You know it's a faux pas if you see someone using creatine in the gym or whatever. So clearly that's not the case. But you all had some interesting information to share with me in the beginning. Um, so if you want to just kind of talk to that a little bit too, let's clear up the misconceptions that creatine as a supplement is a bad thing, or it's only used by gym nerds and it can be overused and whatever. So if you want to kind of just talk to that misconception really quick, yeah, I can mention a couple of things.

Speaker 2:

I think it kind of ties back into the going back to the kidneys again if I could. I think it kind of ties back into the going back to the kidneys again if I could. The misconception one of the biggest misconceptions is that a person starts taking creatine.

Speaker 2:

It's going to potentially ruin my kidneys and in an otherwise healthy individual that is not the case.

Speaker 2:

It is not going to cause any damage to your kidneys.

Speaker 2:

Again, however, a person that has established CKD, that type of dialogue, that type of interaction, conversation needs to be had with the nephrologist.

Speaker 2:

Another thing too is and this kind of talks about the underutilization of creatine in practice. So we have studies that have shown, as Ian mentioned, about the benefits of creatine in the elderly population that do have the lean muscle mass, and the evidence is solid, like the evidence is solid with the aging population with lean muscle mass. It's solid in the area of TBI or traumatic brain injury and concussion, and it's becoming more and more solid with major depressive disorder. But what hasn't happened as a result of that is the increased use of that by providers, and we can go back and forth as to why that is, but one of the. I think we kind of hit the head on one of them being like since it's not funded, it's it doesn't get a lot of spotlight, so it doesn't get a lot of attention, and so we don't see that, we don't see the research that that shows benefits, great benefits and a great product that's been around for a long time and it's relatively inexpensive.

Speaker 2:

We don't see that equality of use in those patients as a result of that. So I mean, those are two big misconceptions that stood out to me with regards to that.

Speaker 1:

Yeah, and then Ian, you had touched on earlier because I'd said, you know, is it one of those banned substances or is it, you know, the performance enhancer, like it's not in the same category steroid? But you had mentioned how sometimes where the confusion comes in is that creatine is possibly found in some of those banned products, faux products, and so that maybe is where some of the misconception lies, is that while it's an ingredient in there, it is not the culprit, like it's correct, and the product is banned.

Speaker 3:

so yeah, and you can just get it by yourself, right? You can just get actually creatine just all culprit, like it's not the reason the product is banned. So yeah, and you can just get it by yourself, right, you can just get actually creating just all by itself in its pure form, right?

Speaker 1:

and that is completely acceptable. There's no, you know, no one's gonna look at you odd in the gym if you have that or if you're using that for something in your house or anything. It's so cool. And also I mentioned earlier I used the term gym nerds and I mean that with full love and support. I don't mean that as a negative thing.

Speaker 3:

We're going to fly you down here for a quick gym action one day, absolutely.

Speaker 1:

Well, we are out of time. So I think we've had a great discussion on just the fact that this should be, and is, somewhat being brought back into the forefront and making sure that we're aware, as pharmacists, that we may have patients asking about it and maybe it's something that we think about for those individuals that are vegetarians or low muscle mass or aging population that do have difficulties with quick movement and whatnot because of low muscle mass or because of osteoporosis or whatnot. So we see where we can be making some recommendations to our patients, and that's great. One thing I always like to kind of summarize at the end is what do you think are the game changers here? So what exactly? What's our take-home point for our listeners from today's episode?

Speaker 3:

point for our listeners. From today's episode, One of the take home points is basically that well, one thing I want to kind of sneak in here really quick is that I think right now in our society there's a big push on GLPs, and one of the big things with GLPs is that you can lose up to about 30 to 40% of your lean muscle, and so having a natural substance that we already have in our body that creatine itself shown studies that can actually increase lean muscle mass, increase your muscle strength when you're taking these GLPs, that can be something that people maybe we should kind of look into a little bit more and maybe get some more research with that combination. I think it just makes sense, but that's just kind of like another podcast for another day, kind of.

Speaker 1:

Yeah, no, I'm glad you threw that in because I mean're right.

Speaker 1:

We have so many patients um are on glps and we've had so many sessions and podcasts and discussions and and ces on it and you know, it just is, I don't see it going away anytime soon, and so I feel like that that's something that we're going to continue to be faced with as pharmacists is making sure that those patients are supported properly, and I I love this idea. Maybe there's somebody out there who is is gonna fund the research for you, ian, and can get that off the ground, so yeah.

Speaker 3:

But a clinical pearl for me would be just, if you guys do decide to get on creatine, to make sure you hydrate yourself, stay hydrated. Creatine, remember it's taking a lot of your fluid and pushing it into your muscle cells so by that sense you can become very dehydrated. So make sure you're hydrated. And if you have any GI discomfort with the creatine, try the micronized version of creatine monohydrate it's called micronized and that should help alleviate some of the GI symptoms. If you do have some with Lortec and creatine Awesome.

Speaker 1:

Another great tip for pharmacists as they're talking with patients. Mark, what's your summary?

Speaker 2:

Yeah, my biggest call to action, in addition to everything that we've talked about today and the information that we've kind of shared and exchanged, is for our pharmacists.

Speaker 2:

That are, whether you're in retail and the retail community setting, or if you're an inpatient, see if you can identify a patient or two, you know, every once in a while it doesn't have to be like a proactive type thing, like you don't have to go and say, hey, I'm going to go and put on my pharmacist cape and I'm going to put everybody on creatine and see if they meet the criteria.

Speaker 2:

This is one of these things that can kind of happen organically and I feel like, because it's been established for so long and it's been around for so long, the safety net that you have as a practitioner can lead to more confidence.

Speaker 2:

Because who's to say that? An elderly patient that's in his or her 60s or 70s, that otherwise hasn't been familiar with creatine, and you just so happen to see that they don't have CKD and that you've noticed that they've lost some muscle mass recently, like it's just like little small things like that, and you say, hey, mr and Mrs, so-and-so, I think that maybe you could look into this over-the-counter product that you don't have to have a prescription for, that is relatively inexpensive. Maybe you might want to try looking into this right here or at least see what your primary care provider says about this. And if they want to have a conversation, I'll be more than willing to have that conversation with them. That's how we get that, that's how we bridge the gap. That's how we bridge the gap, and so that will be my call to action for the pharmacists that are either in the community setting or in the hospital setting, or whichever setting you're in.

Speaker 1:

Yeah, I love that.

Speaker 1:

I love the fact of you know it's not a mission to put everybody on creatine, or to find every single patient that's eligible or whatever, but but yeah, I think you know, just being more aware that this is an option, that this is not a faux pas, it's not a negative thing, it is relatively safe and effective and as long as you're utilizing it appropriately, then I think it can really benefit patients. So, yeah, this has been super great. Thank you so much, mark and Ian Really appreciate you giving of your time again and sharing your expertise and, being gym nerds, we appreciate that.

Speaker 3:

As always. Thank you, josh, I appreciate you.

Speaker 1:

Thanks, josh, thanks. So if you're a CE plan subscriber, be sure to claim your CE credit for this episode of Game Changers by logging in at CEimpactcom. You.