Evidence for a Role of Diet?
10.4 Clinical Evidence of a Therapeutic Effect of Low Glycemic Load Diets in Acne Vulgaris
A recent randomized controlled trial found that a low glycemic load (GL) diet that mimics the diets of acne-free populations may alleviate acne symptoms and hor- monal markers of acne. In a 12-week study, 43 young male subjects (age 15–25 years) with mild to moderate acne consumed either a conventional high-GL diet or a low- GL diet and had their acne assessed every 4 weeks (Smith et al. 2007a, b). The experimental low-GL diet was achieved through a reduction in carbohydrate intake and through selection of low-GI foods. After 12 weeks, study participants on the lowGL diet demonstrated a 20% greater reduction in acne lesion counts than the participants on the high-GL diet. The lessening of acne severity can be explained by improvements in metabolic-endocrine parameters. When compared to controls, participants on the low-GL diet demonstrated significant improvements in insulin sensitivity and hormonal markers of acne (increases in SHBG and IGFBP-1, sug- gesting decreased bioavailability of testosterone and IGF-I) (Smith et al. 2007b).
These changes may also relate to the modest weight loss (2.5 kg) that occurred with the reduction in dietary glycemic load. Post hoc analyses revealed that the effect of the low-GL diet on acne and certain endocrine parameters was lost after statistically adjusting for weight loss. This suggests that weight loss mediated the reduction in insulin resistance and its associated hyperinsulinemia, which may be important in the clinical regression of acne.
At present, it remains uncertain whether diet can alleviate acne without weight loss. In theory, hyperinsulinemia can be reduced through improvements in the meta- bolic state of insulin resistance and/or reducing postprandial hyperglycemia.
Interestingly, another study found no difference in the global assessment of acne in weight-maintained individuals following the consumption of diets that had a high and a low glycemic index (Reynolds et al. 2010, personal communication). Although this suggests that weight loss may be responsible for the clinical regression in the earlier study, it should be noted that differences in the nature of the dietary interven- tions (reduced dietary glycemic index versus reduced dietary glycemic load) and the assessment of acne (acne lesion counts versus global assessment of acne) may also account for the different study outcomes.
154 R. Smith and N. Mann
Few studies have reported an association of body weight and the incidence of acne. The U.S. National Health Survey of 1966–1970 found that dietary excess (as reported by the parent) was significantly associated with a greater degree of acne prevalence, particularly in young boys (US Department of Health Education and Welfare 1976). A survey of 2,720 soldiers demonstrated that adult men with acne were significantly heavier (5.6 kg) than adult men without acne. However, this asso- ciation was found to be dependent on age, as weight was not associated with age in adolescents aged 15–19 years. Interestingly, a similar age-dependent association between acne and obesity was found in the low-GL study. This study found that acne lesion counts correlated with body mass index (BMI) in men ³18 years of age, but this association was not true for boys <18 years of age (Fig. 10.2). The reason for the age-dependent association is unknown, but it is possible that acne during adolescence may relate more to physiological changes in insulin sensitivity (via a weight-independent mechanism), whereas adult acne may be more pathological in origin (obesity-related insulin resistance).
These clinical observations may provide a foundation for future dietary recom- mendations in the management of acne. There is already scope for diet as a treat- ment option, as acne patients often treat themselves with over-the-counter therapies.
Diet therapy may be used alone or in conjunction with conventional acne therapies in cases of mild to moderate acne. However, as severe nodulocystic acne can be painful, disfiguring, and leave permanent scars, it is recommended that patients seek optimal treatment from a specialist physician. When considering diets for adolescents,
Fig. 10.2 Age-dependent association of acne severity and body mass index (BMI). Bivariate analysis was performed with a two-tailed Pearson’s correlation (n = 43)
10 Glycemic Load and Acne 155
there are two eating behaviors that also require special consideration: eating that leads to obesity and the disturbed psychiatric conditions of anorexia and bulimia.
Like acne, obesity can have significant negative psychological consequences, including low self-esteem, social inhibition, depression, and anxiety. Low-GL diets may present a useful strategy for individuals seeking to lose weight and at the same time prevent or lessen the severity of acne. However, diet should not be considered as a strategy for psychologically vulnerable individuals with a preexisting eating disorder, as it may increase the food-associated anxiety and the preoccu- pation with food.
There is now also compelling evidence from clinical and epidemiological studies to suggest a potential role of diet in acne development. In 1969, the authors of the chocolate study stated that “it would be remarkable if skin functions were easily influenced by the vagaries of the diverse diets which have evolved in human popu- lations.” During the four-decade scientific vacuum since the chocolate study, much has been learned from the diets of non-Westernized societies. Dietary intervention trials suggest that low-GL diets can alleviate acne symptoms, possibly through improving insulin metabolism and decreasing the bioavailability of testosterone and IGF-I. These endocrine changes may influence the desquamation of follicular kera- tinocytes and sebum production, two primary factors involved in the development of an acne lesion. It remains to be objectively determined whether weight loss is the principal factor in the clinical alleviation of acne.
Take Home Messages
A recent randomized controlled trial found that a low-glycemic-load diet that
•
mimics the diets of acne-free populations improves acne symptoms when com- pared to a high glycemic load diet.
Low-glycemic-load diets may alleviate acne by decreasing insulin demand and
•
influencing mediators such as sex-hormone binding globulin, insulin-like growth factor-I, and insulin-like growth factor-binding proteins. Together, these may affect several aspects of the disease process, including sebum production and desquamation of follicular keratinocytes.
It remains to be objectively determined whether weight loss associated with
•
low-glycemic-load diets is the principal factor for the alleviation of acne.
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159 A. Pappas (ed.), Nutrition and Skin: Lessons for Anti-Aging, Beauty and Healthy Skin,
DOI 10.1007/978-1-4419-7967-4_11, © Springer Science+Business Media, LLC 2011
Core Messages
Atopic dermatitis is a chronic inflammatory skin condition.
•
It is associated with many problems concerning the structure and function of the
•
stratum corneum, especially the skin barrier function.
Deficiencies of downstream metabolites of linoleic acid are associated with the
•
condition.
Intervention studies suggest that omega-6 fatty acids, especially
• g-linolenic acid,
may be useful for mild atopic conditions.
Orally ingested and topically applied oils containing
• g-linoleic acid improve skin
barrier functioning.