Neuromuscular and Multi-Omics Synergy of Combined Creatine × HMB Supplementation Plus Exercise to Improve Muscle Function in Sarcopenic Frailty (MULTI-FRAIL)

Effects of Creatine Monohydrate and β-Hydroxy-β-Methylbutyrate Supplementation Combined With Multicomponent Exercise on Physical Performance, Cognition and Quality of Life in Institutionalized Older Adults: A Randomized Double-Blind Parallel-Group Trial

Sarcopenia and physical frailty are highly prevalent among institutionalized older adults and are major contributors to functional decline, reduced mobility, and loss of independence. Combined exercise and targeted nutritional strategies have emerged as promising approaches to mitigate these age-related impairments.

This randomized, double-blind, placebo-controlled, parallel-group clinical trial aims to evaluate the independent and combined effects of creatine monohydrate (CRE) and β-hydroxy-β-methylbutyrate (HMB), administered alongside a supervised multicomponent exercise program, on physical function, body composition, cognitive performance, and quality of life in institutionalized older adults with physical frailty and sarcopenia.

A total of 50 adults aged ≥65 years were enrolled and randomized to one of four intervention groups for 12 weeks: placebo plus exercise, creatine plus exercise, HMB plus exercise, or creatine plus HMB plus exercise. A supplement-free follow-up period will be conducted to evaluate the sustainability of intervention effects.

In addition to clinical and functional outcomes, the study incorporates molecular and biological assessments to explore mechanistic pathways underlying functional adaptation and interindividual variability in response to the interventions.

Study Overview

• Status: Active, not recruiting
• Conditions: Frailty; Sarcopenia; Aging; Malnutrition Elderly
• Intervention / Treatment: Dietary supplement: Creatine Monohydrate; Behavioral: Multicomponent Exercise Program; Dietary supplement: β-Hydroxy-β-Methylbutyrate (HMB); Dietary supplement: Placebo (Cellulose)

Detailed Description

This randomized, double-blind, placebo-controlled, parallel-group clinical trial is designed to evaluate the independent and combined effects of creatine monohydrate (CRE) and β-hydroxy-β-methylbutyrate (HMB) supplementation when administered alongside a structured multicomponent exercise program in institutionalized older adults with physical frailty and sarcopenia. Sarcopenia and frailty are highly prevalent in this population and are associated with functional disability, increased health care utilization, and reduced quality of life. Nutritional strategies targeting muscle metabolism, when combined with systematic exercise, may attenuate functional decline and improve health outcomes in this vulnerable group.

Study Population and Design

A total of 50 institutionalized adults aged ≥65 years were enrolled from nursing homes in the province of Burgos (Spain). Participants were stratified by sex and randomized to one of four parallel intervention groups for a 12-week intervention period: placebo plus exercise, creatine plus exercise, HMB plus exercise, or creatine plus HMB plus exercise. All intervention groups will be followed by a supplement-free follow-up period to assess the persistence of intervention effects.

Intervention

Dietary supplementation will be administered once daily using identical sachets to ensure blinding and equivalent supplement volume across groups. Participants will receive a total of 6 g/day of powder, consisting of cellulose (placebo), creatine monohydrate, HMB, or their combinations, depending on group allocation. Supplement administration will be supervised by nursing staff and mixed with food or beverages according to standard procedures.

All participants will complete a supervised multicomponent exercise program conducted four times per week (~60 minutes per session). Exercise sessions will include resistance, balance, coordination, and flexibility training, with intensity individually adapted according to functional capacity using the Borg Rating of Perceived Exertion Scale.

Outcomes and Assessments

Clinical, functional, cognitive, and quality-of-life assessments will be conducted at baseline, post-intervention (Week 12), and during follow-up. Primary and secondary outcome measures focus on physical performance, muscle strength, body composition, cognitive function, activities of daily living, nutritional status, and quality of life.

Molecular and Biological Assessments

In addition to clinical outcomes, the study incorporates biological and molecular assessments to explore mechanistic pathways underlying functional adaptation and interindividual variability in response to supplementation and exercise. Venous blood samples will be collected for the analysis of inflammatory markers, oxidative stress and antioxidant status, hormonal profiles, and circulating and exosomal molecular signatures related to muscle metabolism and neuromuscular function. Body composition parameters will be assessed using dual-energy X-ray absorptiometry (DXA).

Statistical Analysis

Statistical analyses will be conducted using mixed-effects models appropriate for parallel-group randomized designs, with treatment group, time, and their interaction as fixed effects, and sex and age included as covariates where appropriate. Post-hoc pairwise comparisons will be adjusted for multiple testing. Statistical significance will be set at p < 0.05.

Ethics and Data Protection

The study was approved by the Ethics Committee of the University of Burgos (IR 24/2023). Written informed consent was obtained from all participants or their legal representatives. All data will be pseudonymized and managed in accordance with the General Data Protection Regulation (GDPR) and Spanish data protection laws.

• Study Type: Interventional
• Enrollment (Actual): 50
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Spain
  • Castille and León
    • Burgos, Castille and León, Spain, 09002
      • Residencia de Mayores Fuentes Blancas (Diputación Provincial de Burgos)

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Institutionalized older adults (≥65 years) residing in the Fuentes Blancas Nursing Home (Diputación de Burgos).
• Clinical diagnosis of frailty or sarcopenia according to validated criteria (e.g., Fried phenotype, SPPB ≤ 9, or low ALMI by DEXA).
• Ability to participate in an exercise program as assessed by the medical staff.
• Written informed consent provided by the participant or, if cognitively impaired, by a legally authorized representative.

Exclusion Criteria:

• Severe renal insufficiency (eGFR < 30 mL/min/1.73m²) or liver failure.
• Advanced heart failure (NYHA class III-IV) or unstable cardiovascular disease.
• Active cancer or other severe medical conditions that contraindicate participation.
• Severe cognitive impairment (MMSE < 10) precluding adherence to the program without caregiver support.
• Known allergy or intolerance to creatine, HMB, or inulin.
• Participation in another clinical trial within the past 3 months.
• Any condition that, in the opinion of the medical team, may compromise safety or adherence to the intervention.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Quadruple

Number of Arms

4

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Creatine + HMB + Exercise; Participants receive a total of 6 g/day of powder consisting of 3 g/day of creatine monohydrate and 3 g/day of β-hydroxy-β-methylbutyrate (HMB), administered once daily, combined with a supervised multicomponent exercise program for 12 weeks.	Dietary supplement: Creatine Monohydrate; Sachets containing creatine monohydrate used as an active dietary supplement. Administered once daily during the intervention period.; Behavioral: Multicomponent Exercise Program; Supervised exercise sessions, 4 times per week (~60 minutes each), including resistance, endurance, balance, coordination, and flexibility training. Intensity adapted to participants' functional status (Borg scale 6-9). Conducted throughout the 12-week intervention period.; Dietary supplement: β-Hydroxy-β-Methylbutyrate (HMB); Sachets containing calcium β-hydroxy-β-methylbutyrate used as an active dietary supplement. Administered once daily during the intervention period.
Placebo Comparator: Placebo + Exercise; Participants receive a total of 6 g/day of cellulose (placebo), administered once daily, combined with a supervised multicomponent exercise program for 12 weeks.	Behavioral: Multicomponent Exercise Program; Supervised exercise sessions, 4 times per week (~60 minutes each), including resistance, endurance, balance, coordination, and flexibility training. Intensity adapted to participants' functional status (Borg scale 6-9). Conducted throughout the 12-week intervention period.; Dietary supplement: Placebo (Cellulose); Sachets containing cellulose used as placebo filler to match supplement volume, appearance, and taste. Administered once daily, mixed with yogurt or juice, during the intervention period.
Active Comparator: Creatine + Exercise; Participants receive a total of 6 g/day of powder consisting of 3 g/day of creatine monohydrate and 3 g/day of cellulose (placebo filler), administered once daily, combined with a supervised multicomponent exercise program for 12 weeks.	Dietary supplement: Creatine Monohydrate; Sachets containing creatine monohydrate used as an active dietary supplement. Administered once daily during the intervention period.; Behavioral: Multicomponent Exercise Program; Supervised exercise sessions, 4 times per week (~60 minutes each), including resistance, endurance, balance, coordination, and flexibility training. Intensity adapted to participants' functional status (Borg scale 6-9). Conducted throughout the 12-week intervention period.; Dietary supplement: Placebo (Cellulose); Sachets containing cellulose used as placebo filler to match supplement volume, appearance, and taste. Administered once daily, mixed with yogurt or juice, during the intervention period.
Active Comparator: HMB + Exercise; Participants receive a total of 6 g/day of powder consisting of 3 g/day of β-hydroxy-β-methylbutyrate (HMB) and 3 g/day of cellulose (placebo filler), administered once daily, combined with a supervised multicomponent exercise program for 12 weeks.	Behavioral: Multicomponent Exercise Program; Supervised exercise sessions, 4 times per week (~60 minutes each), including resistance, endurance, balance, coordination, and flexibility training. Intensity adapted to participants' functional status (Borg scale 6-9). Conducted throughout the 12-week intervention period.; Dietary supplement: β-Hydroxy-β-Methylbutyrate (HMB); Sachets containing calcium β-hydroxy-β-methylbutyrate used as an active dietary supplement. Administered once daily during the intervention period.; Dietary supplement: Placebo (Cellulose); Sachets containing cellulose used as placebo filler to match supplement volume, appearance, and taste. Administered once daily, mixed with yogurt or juice, during the intervention period.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Short Physical Performance Battery (SPPB)	The SPPB assesses lower-extremity physical function through balance, gait speed, and chair stand components, generating a total score ranging from 0 to 12 (higher scores indicate better physical performance). Only the total score will be analyzed as the primary outcome.	Baseline, Week 12 (end of intervention), and 3-month follow-up
Timed Up and Go (TUG)	Time in seconds to rise from a chair, walk 3 meters, turn around, return, and sit down. Lower times indicate better mobility and balance.	Baseline, Week 12 (end of intervention), and 3-month follow-up
Appendicular Lean Mass (ALM, kg) by DEXA	Appendicular lean mass (sum of arms and legs lean tissue) measured in kilograms using DEXA. Higher values indicate greater muscle mass in limbs.	Baseline, Week 12 (end of intervention), and 3-month follow-up

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Grip Strength	Maximal isometric handgrip strength measured in kilograms using a validated hydraulic dynamometer (e.g., Jamar Plus+). Each test performed with the dominant hand in seated position, elbow at 90°. Best of three attempts recorded.	Baseline, Week 12 (end of intervention), and 3-month follow-up
Leg and Back Isometric Strength	Maximal isometric strength of leg and back extensors assessed in kilograms using a back/leg dynamometer (e.g., Baseline Evaluation Dynamometer). Participants stand on the platform and pull a fixed bar upwards. Best of two attempts recorded.	Baseline, Week 12 (end of intervention), and 3-month follow-up
Seated Arm Curl Test	Dynamic strength/endurance of upper limbs measured as the number of full arm curl repetitions in 30 seconds using a 2 kg dumbbell for women and a 4 kg dumbbell for men. Participants are seated upright without armrests.	Baseline, Week 12 (end of intervention), and 3-month follow-up
Barthel Index	Measure of independence in activities of daily living (feeding, bathing, mobility, toileting, etc.). Score ranges from 0 (total dependence) to 100 (independent).	Baseline, Week 12 (end of intervention), and 3-month follow-up
Mini Nutritional Assessment (MNA)	Validated tool to screen and assess nutritional status in older adults. Score ranges from 0-30 (higher = better nutritional status).	Baseline, Week 12 (end of intervention), and 3-month follow-up
Cognitive Function - Mini-Mental State Examination (MMSE)	Cognitive function assessed using the Mini-Mental State Examination (MMSE). Scores range from 0 to 30, with higher scores indicating better cognition.	Baseline, Week 12 (end of intervention), and 3-month follow-up
Quality of Life - World Health Organization Quality of Life-Brief (WHOQOL-BREF)	26-item validated questionnaire covering physical, psychological, social and environmental domains. Scores range from 26 to 130; higher scores indicate better perceived quality of life.	Baseline, Week 12 (end of intervention), and 3-month follow-up
Total Lean Mass (kg) by DEXA	Whole-body lean soft tissue mass measured in kilograms using DEXA (Hologic Discovery or GE Lunar system) with manufacturer's software and standardized positioning. Higher values indicate greater muscle mass.	Baseline, Week 12 (end of intervention), and 3-month follow-up
Total Fat Mass (percent body weight) by DEXA	Whole-body fat mass measured with DEXA and expressed as a percentage of total body weight. Higher values indicate greater adiposity.	Baseline, Week 12 (end of intervention), and 3-month follow-up
Visceral Adipose Tissue (VAT, cm³) by DEXA	Visceral adipose tissue (VAT) volume estimated by DEXA in the android region of interest, expressed in cubic centimeters (cm³). Higher values indicate greater central adiposity.	Baseline, Week 12 (end of intervention), and 3-month follow-up
Whole-Body Bone Mineral Density (BMD, g/cm²) by DEXA	Whole-body BMD measured by DEXA, expressed as grams per square centimeter (g/cm²). Higher values indicate greater bone mineral density.	Baseline, Week 12 (end of intervention), and 3-month follow-up
Cognitive Function - MEC (Spanish Adaptation of MMSE)	Cognitive function assessed using the MEC (Spanish version of the MMSE). Scores range from 0 to 35, with higher scores indicating better cognition.	Baseline, Week 12 (end of intervention), and 3-month follow-up
Number of Falls	Incidence of falls recorded by nursing staff during the study period. Unit: number of events per participant. Lower numbers indicate better outcomes.	Baseline to 3-month follow-up
Number of Hospitalizations	Incidence of hospital admissions for any cause. Unit: number of events per participant. Lower numbers indicate better outcomes.	Baseline to 3-month follow-up
Incidence of Respiratory and Urinary Infections	Number of documented respiratory and/or urinary tract infections. Unit: number of events per participant. Lower numbers indicate better outcomes.	Baseline to 3-month follow-up
Incidence of Pressure Ulcers	Number of new pressure ulcers recorded by nursing staff. Lower numbers indicate better outcomes.	Baseline to 3-month follow-up
Incidence of Urinary or Fecal Incontinence	Occurrence of urinary and/or fecal incontinence episodes recorded in clinical charts. Lower numbers indicate better outcomes.	Baseline to 3-month follow-up
Serum C-reactive protein (CRP, mg/L)	CRP will be measured in serum samples using a high-sensitivity ELISA. Results expressed in mg/L. Higher values indicate greater systemic inflammation.	Baseline, Week 12 (end of intervention)
Interleukin-6 (IL-6, pg/mL)	Serum IL-6 concentration will be measured by ELISA and expressed in pg/mL. Higher values indicate greater systemic inflammation.	Baseline, Week 12 (end of intervention)
Tumor Necrosis Factor-alpha (TNF-α, pg/mL)	Serum TNF-α concentration will be determined by ELISA and expressed in pg/mL. Higher values indicate greater systemic inflammation.	Baseline, Week 12 (end of intervention)
Reduced Glutathione (GSH, µmol/L)	Plasma reduced glutathione measured by colorimetric assay and expressed in µmol/L. Higher values indicate better antioxidant status.	Baseline, Week 12 (end of intervention)
Oxidized Glutathione (GSSG, µmol/L)	Plasma oxidized glutathione measured by colorimetric assay and expressed in µmol/L. Higher values indicate greater oxidative stress.	Baseline, Week 12 (end of intervention)
Thiobarbituric Acid Reactive Substances (TBARS, nmol MDA equivalents/mL plasma)	Lipid peroxidation index measured as TBARS and expressed in nmol MDA equivalents/mL of plasma. Higher values indicate greater oxidative stress.	Baseline, Week 12 (end of intervention)
Malondialdehyde (MDA, µmol/L)	Plasma MDA determined spectrophotometrically and expressed in µmol/L. Higher values indicate greater oxidative stress.	Baseline, Week 12 (end of intervention)
Total Antioxidant Capacity (TAC, mmol Trolox equivalents/L)	Plasma TAC measured using colorimetric assay and expressed as mmol Trolox equivalents/L. Higher values indicate better antioxidant defense.	Baseline, Week 12 (end of intervention)
Relative expression levels of selected circulating microRNAs	Changes in the relative expression levels of selected circulating microRNAs associated with muscle metabolism, neuromuscular function, inflammation, oxidative stress, and anabolic signaling pathways. MicroRNAs will be quantified from peripheral blood samples using molecular profiling techniques.	Baseline, Week 12 (end of intervention), and 3-month follow-up
Relative expression levels of selected exosome-derived microRNAs	Changes in the relative expression levels of selected exosome-derived microRNAs related to muscle function, inflammation, and metabolic regulation, analyzed from circulating extracellular vesicles isolated from plasma samples.	Baseline and Week 12
Frequency of selected genetic variants related to creatine and HMB responsiveness	Analysis of the frequency of selected genetic variants related to muscle metabolism, anabolic signaling, and exercise responsiveness to explore interindividual variability in functional and molecular responses to creatine and HMB supplementation.	Baseline
Relative abundance of selected circulating proteins involved in muscle and inflammatory responses	Changes in the relative abundance of selected circulating proteins involved in muscle metabolism, inflammation, oxidative stress, and functional adaptation in response to creatine and HMB supplementation combined with exercise. Protein abundance will be assessed using targeted proteomic approaches.	Baseline and Week 12

Collaborators and Investigators

• Sponsor: Universidad de Burgos
• Investigators: Study Chair: Juan Mielgo-Ayuso, PhD, Universidad de Burgos

Publications and helpful links

General Publications

• Cadore EL, Rodriguez-Manas L, Sinclair A, Izquierdo M. Effects of different exercise interventions on risk of falls, gait ability, and balance in physically frail older adults: a systematic review. Rejuvenation Res. 2013 Apr;16(2):105-14. doi: 10.1089/rej.2012.1397.
• Beaudart C, Zaaria M, Pasleau F, Reginster JY, Bruyere O. Health Outcomes of Sarcopenia: A Systematic Review and Meta-Analysis. PLoS One. 2017 Jan 17;12(1):e0169548. doi: 10.1371/journal.pone.0169548. eCollection 2017.
• Cruz-Jentoft AJ, Bahat G, Bauer J, Boirie Y, Bruyere O, Cederholm T, Cooper C, Landi F, Rolland Y, Sayer AA, Schneider SM, Sieber CC, Topinkova E, Vandewoude M, Visser M, Zamboni M; Writing Group for the European Working Group on Sarcopenia in Older People 2 (EWGSOP2), and the Extended Group for EWGSOP2. Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing. 2019 Jan 1;48(1):16-31. doi: 10.1093/ageing/afy169.
• Rezola-Pardo C, Rodriguez-Larrad A, Gomez-Diaz J, Lozano-Real G, Mugica-Errazquin I, Patino MJ, Bidaurrazaga-Letona I, Irazusta J, Gil SM. Comparison Between Multicomponent Exercise and Walking Interventions in Long-Term Nursing Homes: A Randomized Controlled Trial. Gerontologist. 2020 Sep 15;60(7):1364-1373. doi: 10.1093/geront/gnz177.
• Fernandez-Landa J, Calleja-Gonzalez J, Leon-Guereno P, Caballero-Garcia A, Cordova A, Mielgo-Ayuso J. Effect of the Combination of Creatine Monohydrate Plus HMB Supplementation on Sports Performance, Body Composition, Markers of Muscle Damage and Hormone Status: A Systematic Review. Nutrients. 2019 Oct 20;11(10):2528. doi: 10.3390/nu11102528.
• Fernandez-Landa J, Fernandez-Lazaro D, Calleja-Gonzalez J, Caballero-Garcia A, Cordova A, Leon-Guereno P, Mielgo-Ayuso J. Long-Term Effect of Combination of Creatine Monohydrate Plus beta-Hydroxy beta-Methylbutyrate (HMB) on Exercise-Induced Muscle Damage and Anabolic/Catabolic Hormones in Elite Male Endurance Athletes. Biomolecules. 2020 Jan 15;10(1):140. doi: 10.3390/biom10010140.
• Fernandez-Landa J, Fernandez-Lazaro D, Calleja-Gonzalez J, Caballero-Garcia A, Cordova Martinez A, Leon-Guereno P, Mielgo-Ayuso J. Effect of Ten Weeks of Creatine Monohydrate Plus HMB Supplementation on Athletic Performance Tests in Elite Male Endurance Athletes. Nutrients. 2020 Jan 10;12(1):193. doi: 10.3390/nu12010193.
• Holecek M. Beta-hydroxy-beta-methylbutyrate supplementation and skeletal muscle in healthy and muscle-wasting conditions. J Cachexia Sarcopenia Muscle. 2017 Aug;8(4):529-541. doi: 10.1002/jcsm.12208. Epub 2017 May 10.
• Devries MC, Phillips SM. Creatine supplementation during resistance training in older adults-a meta-analysis. Med Sci Sports Exerc. 2014 Jun;46(6):1194-203. doi: 10.1249/MSS.0000000000000220.

Study record dates

Study Major Dates

• Study Start (Actual): March 10, 2026
• Primary Completion (Estimated): December 30, 2026
• Study Completion (Estimated): May 30, 2027

Study Registration Dates

• First Submitted: September 29, 2025
• First Submitted That Met QC Criteria: December 8, 2025
• First Posted (Actual): December 10, 2025

Study Record Updates

• Last Update Posted (Actual): May 4, 2026
• Last Update Submitted That Met QC Criteria: April 28, 2026
• Last Verified: April 1, 2026

More Information

Terms related to this study

• Keywords: quality of life; nursing home; microRNA; physical performance; inflammation; supplementation; oxidative stress; proteomics; HMB; geriatric assessment; creatine; multi-omics; concurrent training; multicomponent exercise; institutionalized older adults
• Additional Relevant MeSH Terms: Neurologic Manifestations; Nervous System Diseases; Neuromuscular Manifestations; Pathologic Processes; Pathological Conditions, Anatomical; Muscular Atrophy; Atrophy; Pathological Conditions, Signs and Symptoms; Signs and Symptoms; Frailty; Inflammation; Sarcopenia; Amino Acids, Peptides, and Proteins; Organic Chemicals; Carbohydrates; Amino Acids; Polymers; Macromolecular Substances; Biomedical and Dental Materials; Manufactured Materials; Technology, Industry, and Agriculture; Polysaccharides; Glucans; Guanidines; Amidines; Biopolymers; Cellulose; Creatine
• Other Study ID Numbers: UBU-FB-CREHMB-CRXO-2025; IR 24/2023 (Other Identifier: Ethics Committee Approval Number)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: De-identified individual participant data (IPD) underlying the published results of this trial (including baseline characteristics and outcome measures) will be made available to qualified researchers upon reasonable request. Data will be shared only after publication of the main results and following approval of a research proposal and data access agreement.
• IPD Sharing Time Frame: Beginning 6 months after publication of the main results, for at least 5 years.
• IPD Sharing Access Criteria: Researchers may request access by contacting the Principal Investigator (Prof. Juan Mielgo-Ayuso, Universidad de Burgos). Requests will be reviewed by the study steering committee. Access will be granted to qualified researchers whose proposals are scientifically and ethically sound, and who agree to sign a data access agreement.
• IPD Sharing Supporting Information Type: STUDY_PROTOCOL; SAP; ICF; ANALYTIC_CODE

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No