Acne diet controversy

In the field of dermatology, prevailing knowledge is that there is no connection between diet and acne. However, as research continues and new studies are done, some believe that there is a valid causal relationship between diet and development of acne.

Contents 1 History of the controversy 2 Research, clinical trials, and studies 2.1 Insulin, IGF-1, and SBGH studies 2.1.1 Linking diet to IGF-1 2.1.2 Linking IGF-1 to acne 2.2 Androgen studies 2.2.1 Linking diet to androgen production 2.2.2 Linking androgen production to acne 2.3 Immune studies 2.3.1 Linking hypersensitivity to acne 2.3.2 Linking insulin to hypersensitivity 2.4 Overarching diet and acne studies 3 Books 4 News and analysis 4.1 Vegan and low GI diets 4.2 Omega-3 fatty acids 4.3 Dairy 4.4 Insulin and inflamation 5 Controversial influencing factors 6 Calorie reduction (fasting) and acne 7 Foods to eat and avoid to prevent acne 8 Other acne diet articles 9 References

[edit] History of the controversy

The evidence that is cited most often that deemed no connection between diet and acne seems to be a study done about 40 years ago on chocolate bars and acne. The methods and conclusion of this study has been under debate recently, and on-going research seems to be disproving the prevailing interpretation of that study.

Fulton JE Jr, Plewig G, Kligman AM. "Effect of chocolate on acne vulgaris." The Journal of the American Medical Association. 1969 Dec 15;210(11):2071-4. Cited in PubMed; PMID 4243053.

http://jama.ama-assn.org/content/210/11/2071.short

The American Academy of Dermatology runs "AcneNet" which has on it's page Acne Myths:

Myth #2: Acne is caused by diet. Extensive scientific studies have not found a connection between diet and acne. In other words, food does not cause acne. Not chocolate. Not french fries. Not pizza. Nonetheless, some people insist that certain foods affect their acne. In that case, avoid those foods. Besides, eating a balanced diet always makes sense. However, according to the scientific evidence, if acne is being treated properly, there's no need to worry about food affecting the acne.

This is the prevailing opinion in today's professional dermatology.

[edit] Research, clinical trials, and studies

[edit] Insulin, IGF-1, and SBGH studies

Insulin is a hormone (chemical protein) produced and stored in the human body. It helps regulate carbohydrates and fats, stores energy, and ultimately helps the body function properly. When the control of insulin fails, diabetes is a result; so proper levels of insulin is important for health. Insulin-like growth factor 1 (IGF-1) is a hormone similar to insulin produced by the liver. It plays an important role in child development, as well as adult growth. Sex hormone-binding globulin (SBGH) is a protein that binds to the androgen testosterone.

The following studies may imply that by eating more vegetables and less meat and dairy, IGF-1 levels can be reduced, which then lowers the risk or severity of acne.

[edit] Linking diet to IGF-1

• In 1998, Maes M et al says "a postreceptor defect in GH action contributes to the GH resistance in protein-calorie malnutrition".^[1]
• In 2000, Allen NE et al says "serum insulin-like growth factor-I was 9% lower in 233 vegan men than in 226 meat-eaters and 237 vegetarians".^[2]
• In 2006 Norat T et al says, "circulating IGF-I is modestly related with the intake of protein and minerals, and with milk and cheese".^[3]
• In 2005 Larsson SC et al says, "of healthy well-nourished men, greater dietary intakes of protein, zinc, red meat, and fish and seafood were associated with higher IGF-I concentrations".^[4]

[edit] Linking IGF-1 to acne

• In 2003, Cordain L et al says "Insulin is a well-established growth-promoting hormone, and recent evidence indicates that hyperinsulinemia causes a shift in a number of endocrine pathways that may favor unregulated tissue growth leading to additional illnesses." and "These endocrine shifts alter cellular proliferation and growth in a variety of tissues, the clinical course of which may promote acne".^[5]
• In 2004 Borgia F et al says "Hirsutism and acne severity correlated negatively with serum sex hormone-binding globulin (SHBG) levels (p<0.05). No correlation between acne severity and hirsutism was found. In post-pubertal women, severity of acne seems to depend on peripheral hyperandrogenism, with a negative relationship between the acne severity and serum SHBG levels."^[6] The Wikipedia entry on SHBG says that "SHBG levels appear to be controlled by a delicate balance of enhancing and inhibiting factors. Its level is decreased by high levels of insulin and insulin-like growth factor 1 (IGF-1) (see:milk)."^[7]

[edit] Androgen studies

Androgens are a class of hormones which include testosterone and dihydrotestosterone and a precursor to estrogen.

The following studies may imply that dietary weight loss and other methods of lowering insulin can reduce androgen, which in turn decreases the prevalence of acne.

[edit] Linking diet to androgen production

• In 2000, Renato P et al says, "Androgen suppression is linked to diet. Dietary-induced weight loss and administration of insulin-lowering drugs improves hyperandrogenism."^[8]

[edit] Linking androgen production to acne

• In 1965, Pochi PE et al studied the relationship between hormones and acne vulgaris.^[9]
• In 1970, Sterba R et al says "those with androgen excess developed hirsutism, acne, anabolism".^[10]
• In 1977, Phillips GB says "significant correlations were observed" between serum sex hormones and glucose, insulin and lipid abnormalities.^[11]
• In 1978, Zaun H et al says "the hormonal disturbances finds its expression mainly or exclusively in disorders of the skin or hair growth".^[12]
• In 1986, Amiel SA et al says "data suggest that insulin resistance occurs during puberty in both normal children and children with diabetes."^[13]
• In 1993, Caprio S et al says "in patients with thalassaemia and Turner's syndrome, insulin resistance and increased insulin secretion are very early metabolic defects that appear before the development of diabetes".^[14]
• In 2000, Pugeat M et al says "An increased production or metabolism of testosterone, the main active androgen, shows up clinically in dermatological symptoms such as hirsutism, hyperseborrheic acne and alopecia".^[15]
• In 2001, Slayden SM et al says, "data [from the study] suggest that androgen suppression may be useful in treating acne in many of these patients."^[16]
• In 2004, Azziz R et al says that acne improved in 81% of assessed patients who were treated with antiandrogen therapy.^[17]
• In 2004, Bottner A et al says "there is a strong association of adiponectin serum concentrations with obesity, pubertal development, and metabolic parameters in children".^[18]
• In 2005 Galobardes B et al says "Higher androgen levels or higher androgen activity could plausibly explain the observed lower coronary heart disease and higher prostate cancer mortality among men with a history of acne."^[19]

[edit] Immune studies

Delayed Type Hypersensitivity is an undesirable reaction produced by a normal immune system. Examples include arthritis, asthma, and other allergic or immune diseases.

The following studies (along with the insulin studies previous) may imply that a low glycemic diet, reduction of meat and dairy may reduce insulin, thereby reducing inflammation (or hypersensitivity), and thereby reducing the prevalence of acne.

[edit] Linking hypersensitivity to acne

• In 1995, Webster GF reviewed "findings [that] suggest that an overly vigorous immune response to Propionibacterium acnes may be the fundamental problem in patients with inflammatory acne".^[20]
• In 2004 Branisteanu D et al says that the study findings "highly supports the hypothesis that the mechanisms underlying the development of acne vulgaris belong to the Delayed Type Hypersensitivity".^[21]

[edit] Linking insulin to hypersensitivity

• In 2006 Shoelson S et al says, "obesity, [type 2 diabetes], and CVD share a metabolic milieu characterized by insulin resistance and chronic subacute inflammation."^[22]

[edit] Overarching diet and acne studies

• In 2006 Adebamowo CA et al says with adolescent girls "We found a positive association between intake of milk and acne". ^[23]
• Smith R et al says the results of a study in 2007 "suggests nutrition-related lifestyle factors play a role in acne pathogenesis."^[24]
• Smith R et al also says "improvement in acne and insulin sensitivity after a low-glycemic-load diet suggests that nutrition-related lifestyle factors may play a role in the pathogenesis of acne."^[25]
• In the American Journal of Clinical Nutrition, Smith R et al says "A low-glycemic-load diet improves symptoms in acne vulgaris patients".^[26]
• In 2008, Smith R et al says, "results suggest that increases in dietary glycemic load may augment the biological activity of sex hormones and IGF-I, suggesting that these diets may aggravate potential factors involved in acne development."^[27]
• In 2008 Adebawomo CA et al says with teenaged boys "We found a positive association between intake of skim milk and acne".^[28]
• A 2008 study by Rubin MG et al says after adding omega-3 fish oil to diets "not one subject had a worsening of inflammatory acne lesions during the two months, and all had at least some reduction in inflammatory papules".^[29]
• In 2009 Liepa GA et al recommends "anti-inflammatory compounds (fiber, omega-3 fatty acids, vitamin E, and red wine)" to reduce androgen production that "affects up to 10% of all American women and can lead to the development of acne".^[30]
• A 2009 study by Rouhani P says that more than 80% of those studied who were on a South Beach Diet saw improvement in their skin complexion within three months.^[31]
• In 2010 Bowe WP et al says, "Compelling evidence exists that high glycemic load diets may exacerbate acne. Dairy ingestion appears to be weakly associated with acne, and the roles of omega-3 fatty acids, antioxidants, zinc, vitamin A, and dietary fiber remain to be elucidated."^[32]

[edit] Books

Author and naturopathic physician Alan C. Logan writes in his book (along with dermatologist Dr. Valori Treloar) The Clear Skin Diet: A Nutritional Plan That Works that North American dietary habits have a strong causal relationship to acne. He says that fats such as omega-3 fatty acids protect against acne whereas saturated or trans fats promote it. He suggests fruits, vegetables, green tea, soy, fish, berries, and fiber-rich foods to lessen androgens while lessening meat, milk, sugar, fats, sugars, and low-fiber carbs.

Author and doctor Loren Cordain writes The Dietary Cure for Acne which suggests a dietary plan that can eliminate acne.

[edit] News and analysis

[edit] Vegan and low GI diets

• A 2002 article from the American Medical Association authored by Cordain L et al titled "Acne Vulgaris: A Disease of Western Civilization" (PDF) discusses several dietary habits and the effect on acne (or the lack of acne in the Kitavan people of New Guinea).^[33]
• A 2003 article titled "Acne has Everything to do with Diet" by Dr. John McDougall M.D. says that acne is prevalent in countries that have adopted the Western diet. He says that the incidence of acne in underdeveloped countries is often 0%. "Acne is completely absent – not a single sufferer – in these two populations living primarily on unprocessed, low-fat plant-foods." in reference to Kitavan Islanders of Papua New Guinea and the Ache of Eastern Paraguay who have a diet of 70% carbs from plant foods.^[34]
• A 2006 article titled "Low GI diet clears up acne in boys" mentions Dr. Neil Mann saying, "The acne of the boys on the higher protein-low GI diet improved dramatically, by more than half".^[35]
• A 2007 article titled "Low Glycemic Load Diet May Improve Acne" by an unnamed author says "The low-glycemic diet was associated with a significant [reduction] in total acne compared with the normal diet."^[36]
• A 2008 article titled "Acne diet breakthrough earns a PhD" by an unnamed author talks about Dr Robyn Smith and "her pioneering nutritional science research, which helped formulate a ground-breaking anti-acne diet."^[37]
• A 2008 article titled "Diet and Acne" by Keri J et al says that "An increasing amount of recent evidence suggests a dietary contribution to the pathogenesis of acne but further investigation, especially nutritional research, is necessary to clearly delineate its role. Large, randomized, controlled trials of acne patients versus control subjects with selective glycemic load diets should be performed to help elucidate the link between diet and acne."^[38]

[edit] Omega-3 fatty acids

• A 2004 article titled "Omega 3 Fatty Acids and Acne" by an unnamed author says that "Omega-3 fatty acids along with a low-glycemic diet may have a synergistic effect for reducing the risk of acne."^[39]

[edit] Dairy

• A 2007 article titled "A Clear Connection" by Graber C of The Boston Globe discusses the material covered in the book The Clear Skin Diet. It includes the story of twins who grew up separated, one sister consumed significant amounts of dairy and having severe acne while the other sister consumed minimal dairy and did not have acne.^[40] It also mentions dermatologist Dr. Jeffrey Dover saying that suggesting patients to avoid dairy has had some patients show "impressive improvement of their acne".
• A 2008 article titled "Diet and acne" by Dandy F, M.D. says that despite common belief, there is no convincing evidence that separates diet and acne. He sees that evidence is "slowly but surely accumulating" and that the "association between acne and dairy is solid". It continues to explain that acne is caused by the action of dihydrotestosterone and concludes with dietary change suggestions.^[41]
• http://www.notmilk.com/z.html

[edit] Insulin and inflamation

• A 2007 article titled "Type 2 Diabetes: Inflammation, Not Obesity, Cause Of Insulin Resistance" by an unnamed author says that "UCSD scientists proved that, by disabling the macrophage inflammatory pathway, insulin resistance and the resultant Type 2 diabetes can be prevented".^[42]

[edit] Controversial influencing factors

Some believe that the pharmaceutical companies have no financial incentive to fund studies that cannot produce a patentable medicine/product. Therefore, it is not in their best interest to research any connection between diet and acne. Directory of dermatologic surgery and oncology of Tufts University School of Medicine Dr. Gary Rogers says that the nutritional aspect of health is overlooked and studies don't have much financial backing if the pharmaceutical industry can't profit from the results.^[40]

[edit] Calorie reduction (fasting) and acne

• Forum discussion http://www.acne.org/messageboard/index.php/topic/221108-fasting-cured-my-acne/page__st__80
• Health effects of fasting http://en.wikipedia.org/wiki/Fasting#Health_effects

[edit] Foods to eat and avoid to prevent acne

If the causal relationship between diet and acne as linked in the studies is true, here is a list of foods to eat and avoid to prevent acne breakouts or reduce the severity of acne. The level of change or improvement is unknown, and there are several other factors believed to affect acne such as stress and humidity.

Preferred

• Fiber-rich foods
• Omega-3 fatty acids
• Fish
• Clams
• Vitamin B5 (pantothenic acid)
• Vitamin E
• Vitamin C
• Vitamin D
• Zinc
• Selenium
• Green tea
• Red wine
• Berries
• Coconut
• Broccoli
• Cauliflower
• Brussels sprouts
• Cabbage
• Kohlrabi
• Fruits (* Overly sweet fruits may not be beneficial to the skin)
• Vegetables
• Cinnamon
• Ginger
• Turmeric
• Basil
• Oregano
• Garlic
• Egg plants
• Mulberries
• Reservatrol (See Reservatrol controversy)
• Tubers (taro, yam)
• Fermented Non-wheat grains (Millet, barley, maize, corn, rice)

Reduce or avoid

• Low-fiber carbs
• Meat
• Nuts
• Processed foods
• Processed wheat
• Processed flour
• Processed oils
• Alcohol
• Wheat
• Gluten
• Sugar
• Fats
• Milk, cheese, and other dairy

Unsure

• Yogurt (Plain)
• Soy (See Soy estrogen controversy)
• Almonds
• Eggs (See Egg cholesterol controversy)
• Tomatoes

[edit] Other acne diet articles

• A 2011 article by nutritionist Andrews R titled All about acne nutrition discusses the connection and offers food suggestions. The site www.precisionnutrition.com was founded by Dr. John Berardi.

[edit] References

1. ↑ Maes M et al 1998 http://www.eje-online.org/content/117/3/320.abstract "Decreased serum insulin-like growth factor I response to growth hormone in hypophysectomized rats fed a low protein diet: evidence for a postreceptor defect".
2. ↑ Allen NE et al 2000 http://www.nature.com/bjc/journal/v83/n1/full/6691152a.html "Hormones and diet: low insulin-like growth factor-I but normal bioavailable androgens in vegan men" British Journal of Cancer
3. ↑ Norat T et al 2006 http://www.nature.com/ejcn/journal/v61/n1/abs/1602494a.html "Diet, serum insulin-like growth factor-I and IGF-binding protein-3 in European women" International Agency for Research on Cancer, Lyon, France
4. ↑ Larsson SC et al 2005 http://www.ajcn.org/content/81/5/1163.abstract "Association of diet with serum insulin-like growth factor I in middle-aged and elderly men" Karolinska Institutet, Stockholm, Sweden
5. ↑ Cordain L et al 2003 http://www.ncbi.nlm.nih.gov/pubmed/14527633 "Hyperinsulinemic diseases of civilization: more than just Syndrome X" Colorado State University, United States
6. ↑ Borgia F et al 2004 http://www.ncbi.nlm.nih.gov/pubmed/15202836 "Correlation between endocrinological parameters and acne severity in adult women" University of Messina, Italy
7. ↑ http://en.wikipedia.org/wiki/SHBG retrieved Sept 30, 2011
8. ↑ Renato P et al, 2000 http://jcem.endojournals.org/content/85/8/2767.short "Effect of Long-Term Treatment with Metformin Added to Hypocaloric Diet on Body Composition, Fat Distribution, and Androgen and Insulin Levels in Abdominally Obese Women with and without the Polycystic Ovary Syndrome" University of Bologna, Italy
9. ↑ Pochi PE et al 1965 http://www.ncbi.nlm.nih.gov/pubmed/4221206?dopt=Abstract "Plasma testosterone and estrogen levels, urine testosterone excretion, and sebum production in males with acne vulgaris"
10. ↑ Sterba R et al 1970 http://www.ncbi.nlm.nih.gov/pubmed/4252699?dopt=Abstract "Effect of various ovulation inhibitors in different female constitutional types"
11. ↑ Phillips GB 1977 http://www.ncbi.nlm.nih.gov/pubmed/193114?dopt=Abstract "Relationship between serum sex hormones and glucose, insulin and lipid abnormalities in men with myocardial infarction"
12. ↑ Zaun H et al 1978 http://www.ncbi.nlm.nih.gov/pubmed/82309?dopt=Abstract "Dermatologic indications for anti-androgenic treatment".
13. ↑ Amiel SA et al 1986 http://www.ncbi.nlm.nih.gov/pubmed/3523245?dopt=Abstract "Impaired insulin action in puberty. A contributing factor to poor glycemic control in adolescents with diabetes"
14. ↑ Caprio S et al 1993 http://www.ncbi.nlm.nih.gov/pubmed/8262487?dopt=Abstract "Insulin-resistant syndromes in children" Yale University, United States
15. ↑ Pugeat M et al 2000 http://www.ncbi.nlm.nih.gov/pubmed/11595827?dopt=Abstract "Association of insulin resistance with hyperandrogenia in women"
16. ↑ Slayden SM et al http://www.ncbi.nlm.nih.gov/pubmed/11334899 "Hyperandrogenemia in patients presenting with acne" University of Alabama at Birmingham, United States
17. ↑ Azziz R et al 2004 http://www.ncbi.nlm.nih.gov/pubmed/14764747?dopt=Abstract "Androgen excess in women: experience with over 1000 consecutive patients" University of Birmingham at Alabama, United States
18. ↑ Bottner A et al 2004 http://www.ncbi.nlm.nih.gov/pubmed/15292348?dopt=Abstract "Gender differences of adiponectin levels develop during the progression of puberty and are related to serum androgen levels" University of Leipzig, Germany
19. ↑ Galobardes B et al 2005 http://aje.oxfordjournals.org/content/161/12/1094.full "Acne in Adolescence and Cause-specific Mortality: Lower Coronary Heart Disease but Higher Prostate Cancer Mortality" University of Bristol, United Kingdom
20. ↑ Webster GF 1995 http://www.ncbi.nlm.nih.gov/sites/entrez?term=7622652&cmd=search&db=pubmed "Inflammation in acne vulgaris"
21. ↑ Branisteanu D et al 2004 http://www.ncbi.nlm.nih.gov/pubmed/15688807 "Immunohistochemical evidence of chronic inflammation in acne vulgaris" Universitatea de Medicină şi Farmacie Gr.T. Popa Iaşi, Facultatea de Medicină, Clinica Dermatologică.
22. ↑ Shoelson S et al 2006 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1483173/ "Inflammation and insulin resistance" Harvard Medical School, Boston, Massachusetts, USA.
23. ↑ Adebamowo CA et al 2006 http://www.ncbi.nlm.nih.gov/pubmed/17083856?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=3&log$=relatedarticles&logdbfrom=pubmed "Milk consumption and acne in adolescent girls" Harvard School of Public Health, Boston, USA
24. ↑ Smith R et al http://www.ncbi.nlm.nih.gov/pubmed/17448569 "The effect of a high-protein, low glycemic-load diet versus a conventional, high glycemic-load diet on biochemical parameters associated with acne vulgaris: a randomized, investigator-masked, controlled trial" RMIT University, Australia
25. ↑ Smith R et al 2007 http://www.ncbi.nlm.nih.gov/pubmed/17616769 "A low-glycemic-load diet improves symptoms in acne vulgaris patients: a randomized controlled trial" RMIT University, Australia
26. ↑ Smith R et al 2007 http://www.ajcn.org/content/86/1/107.abstract "A low-glycemic-load diet improves symptoms in acne vulgaris patients: a randomized controlled trial" RMIT University, Australia
27. ↑ Smith R et al 2008 http://www.ncbi.nlm.nih.gov/pubmed/18496812 "A pilot study to determine the short-term effects of a low glycemic load diet on hormonal markers of acne: a nonrandomized, parallel, controlled feeding trial" RMIT University, Australia
28. ↑ Adebawomo CA et al 2008 http://www.ncbi.nlm.nih.gov/pubmed/18194824?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=1&log$=relatedarticles&logdbfrom=pubmed "Milk consumption and acne in teenaged boys" Harvard School of Public Health, Boston, Massachusetts, USA
29. ↑ 2008 Rubin MG et al http://www.lipidworld.com/content/7/1/36 "Acne vulgaris, mental health and omega-3 fatty acids: a report of cases"
30. ↑ Liepa GA 2009 http://www.ncbi.nlm.nih.gov/pubmed/18203965?ordinalpos=5&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum "Polycystic ovary syndrome (PCOS) and other androgen excess-related conditions: can changes in dietary intake make a difference?" Eastern Michigan University, USA
31. ↑ 2009 Rouhani P http://www.eblue.org/article/S0190-9622(08)01520-X/abstract "Acne improves with a popular, low glycemic diet from South Beach"
32. ↑ 2010 Bowe WP et al http://www.ncbi.nlm.nih.gov/pubmed/20338665 "Diet and acne"
33. ↑ Cordain L et al 2002 http://archderm.ama-assn.org/cgi/reprint/138/12/1584.pdf "Acne Vulgaris: A Disease of Western Civilization" archderm.ama-assn.org
34. ↑ McDougall J 2003 http://www.nealhendrickson.com/mcdougall/031100acnePF.htm "Acne has Everything to do with Diet" www.nealhendrickson.com
35. ↑ Unknown author 2006 http://www.theage.com.au/news/National/Low-GI-diet-clears-up-acne-in-boys/2006/10/05/1159641420053.html "Low GI diet clears up acne in boys" www.theage.com.au
36. ↑ Unknown author 2007 http://www.medicalnewstoday.com/releases/77676.php "Low Glycemic Load Diet May Improve Acne" www.medicalnewstoday.com
37. ↑ Unknown author 2008 http://www.rmit.edu.au/browse;ID=c1evno1se3m6 "Acne diet breakthrough earns a PhD" www.rmit.edu.au
38. ↑ Keri J et al 2008 http://www.medscape.com/viewarticle/579326 "Diet and Acne" University of Miami, United States
39. ↑ Unknown author 2004 http://www.worldhealth.net/news/omega-3_fatty_acids_and_acne/ "Omega 3 Fatty Acids and Acne" www.worldhealth.net
40. ↑ ^{40.0 40.1} Graber C 2007 http://www.boston.com/bostonglobe/magazine/articles/2007/12/16/a_clear_connection/ "A Clear Connection" The Boston Globe
41. ↑ Dandy F 2008 http://www.ncbi.nlm.nih.gov/pubmed/18280909 "Diet and acne" Dartmouth Medical School, Hanover, New Hampshire, USA
42. ↑ Unknown author 2007 http://www.sciencedaily.com/releases/2007/11/071106133106.htm "Type 2 Diabetes: Inflammation, Not Obesity, Cause Of Insulin Resistance" www.sciencedaily.com

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