Back when I was a Ph.D. student, I had this roommate who was a great athlete; he even went on to play professional sports. He was also a great student, graduating with honors. And on top of that he was a great looking guy, a big hit with the ladies.
But despite all the great things he had going for him, he had one fatal shortcoming: his skin. Whenever he was stressed out about sport, school, or women, he'd suffer severe breakouts. Quickly, almost overnight, his face would swell and get overtaken by bumps, lumps, whiteheads, and blackheads.
And it was then that he'd disappear from existence. He wouldn't leave the house. Heck, he'd barely leave his room. He'd suffer severe depression. In essence, he was a different guy entirely.
It always pained me to see him go through these phases of his life. It sucks watching your best friend on such a roller coaster with no way to help out. I'm sure acne sufferers and their loved ones know exactly what I'm talking about.
So when Dr. Alan Logan shared his latest research with me, I knew I wanted to help spread the word.
Alan is a naturopath and lecturer in Harvard's mind-body medicine courses. He studies how nutrition and lifestyle can impact everything from body composition to brain health to skin health. In his latest book, The Clear Skin Diet, Alan provides an in-depth discussion of how nutrition and lifestyle can either worsen acne or eliminate it.
Dr. John Berardi: To start off, Alan, your name should already be familiar to the T-Nation audience. The interview you did for us, Nutrition, Your Brain, and Your Body, got tons of great feedback. For those who missed the interview, let's give everyone a quick glimpse of who you are and what you do.
Dr. Alan Logan: I'm a naturopathic physician, trained in Toronto, with a focus on nutritional medicine. As we discussed last time, I'm not into healing crystals, putting pyramids over people's heads and all that other wacky stuff. Instead, my primary business is research of the nutritional sciences and translating it into clinical considerations.
Dr. Berardi: Although some naturopaths are pretty out there, you're as well-referenced as they come. And I'm always impressed with your ability to see the connections between different fields of study.
Dr. Logan: It pretty much comes with the territory since I walk the line between research and clinical practice. As an invited faculty member in Harvard's Continuing Medical Education courses, I lecture on dietary supplements, the placebo response, as well as the relationship between food, learning, and behavior. And I'm big on both the research and on clinical applications of this research.
Dr. Berardi: Okay, let's talk nutrition then. Around here at Testosterone, most folks think of nutrition mostly as a means to improve body composition and improve performance. However, I know you're always looking at nutrition in new ways. For example, in your book, The Brain Diet, you discussed how nutrients can impact brain health, mood, and behavior. What other novel nutrition related endpoints are you currently looking at?
Dr. Logan: My more recent investigation, spanning the last two years, has been focused on the relationship between dietary choices, specific nutrients, and skin health. More specifically, it was an investigation of the relationship between diet and acne.
As a result of this research, I collaborated with Boston dermatologist Dr. Valori Treloar and we turned over every nutritional and lifestyle stone imaginable in our exploration of acne. The end result is our new book, The Clear Skin Diet.
Dr. Berardi: I read an advance copy of The Clear Skin Diet and noted that you've pretty much
called out mainstream dermatology with your controversial theories,
especially with respect to nutrition.
Why is there so much in-fighting in the field. I mean, doesn't everyone who's nutritionally aware already know that certain foods trigger acne symptoms?
Dr. Logan: You're right, John. International studies show that the majority of those with acne believe that diet is a significant factor. Doesn't matter where you conduct the research — Asian nations, Europe, the Middle East, United Kingdom, North and South America — participants always cite diet as a factor.
The controversy surrounds the fact that these people have been told by dermatologists for the last thirty years that they're wrong! And I can't blame the dermatologists because that has been their only training. It's been etched into the textbooks since the early 1970s through today, and they clearly state that there's no relationship between diet and acne.
The justification for dermatology relegating diet and acne to "myth" status is a complete house of cards, held up by the shakiest of foundations — two horribly designed studies from 1969 and 1970. These studies wouldn't even see the light of day if we tried to publish them today. I'd get laryngitis if we had a detailed conversation on the design flaws. In short, they were far too small, far too short, and one didn't even have a control group.
Dr. Berardi: These were chocolate studies, right?
Dr. Logan: You've got it. They were designed to determine whether chocolate ingestion was related to acne. And like I said, they're not worth the paper they're printed on.
The first study failed to include a control group, among other design flaws. And the second study that did use a "placebo" control group had a major, fatal flaw. You see, the "chocolate group" received a standard chocolate bar with its high saturated fat and sugar content. But the placebo group got a look-a-like bar where the saturated fat was substituted with — wait for it — hydrogenated vegetable oil, the latest food invention that was all the rage in 1969.
Why's that such a problem? Well, today we know that hydrogenated vegetable oils are beyond unhealthy and well capable of promoting inflammation in the body. And inflammation is a major cause of acne.
Beyond the fat usage, the most colossal blunder of the two studies was that neither one took into account the background diets. In other words, in addition to the chocolate, we have no idea what anyone was eating or drinking during the "study." Who was consuming milk, soft drinks, fried foods, processed foods? We have no clue about consumption! It's absurd!
Yet, here they were, these studies, inked into the annals of dermatological "sciences" and teaching. And unfortunately, for whatever reason, the door of investigation was slammed shut on diet and acne, leaving patients completely invalidated.
As one dermatologist actually wrote in the American Family Physician journal in 1971, "Too many patients harbor the delusion that their health can somehow be mysteriously harmed by something in their diet."
Dr. Berardi: Wow, what unbelievable arrogance we see in that quote right there! So as a tribute to that dermatologist, let's discuss chapter two of your book. In this chapter you've included one of the greatest expository pieces I've read to date on how limited the average medical student's nutrition training can be. What's up with this and why does it piss you off so much?
Dr. Logan: The average person would be shocked at the sad state of affairs that is nutritional training in our medical schools. It does upset me because people with chronic illnesses look to physicians for guidance on nutritional matters, assuming that they are well versed.
In truth, only 30% of medical schools require an actual nutrition course, and even this is almost exclusively related to intravenous nutrition and biochemistry of the cells. It's not the clinical stuff.
According to a study last year in the American Journal of Clinical Nutrition, 78% of graduating medical students didn't feel that they were extensively educated enough to provide appropriate nutritional counseling. In their patient contact hours, only 17% had frequently counseled patients in nutrition.
The real problem is lack of accountability. For my license to practice I had to take separate board exams in biochemical and clinical nutrition. For MDs, it's a different story. Only 3% of medical board exam questions are even remotely connected to nutrition. Why study it, why learn it, why make the effort if you're not going to be tested on it?
And so it goes. For students in the world of pharmaceutical drugs and surgical techniques, nutrition becomes the stuff of home economics class.
Dr. Berardi: You know, I was particularly surprised by the studies published in Nutrition Journal showing the following:
1. Nearly 25% of medical students didn't know that fat contains, gram-for-gram, more calories than an equivalent serving of protein or carbohydrates.
2. Nearly 50% of the students were unaware that olive oil is rich in monounsaturated fat.
3. Nearly 50% of the students thought that folic acid (B9) supplementation can make up for a B12 deficiency.
Dr. Logan: It's a bit shocking, but once again, it's reflective of a broken system. It's pretty easy to fix this. A little less influence by Big Pharma on setting the curriculum and even just a little more on nutrition and lifestyle, even just the basics, would be a good start.
Dr. Berardi: Plus it'd be nice if the medical students themselves actually knew something about good nutrition personally.
Dr. Logan: Absolutely! At present, medical students are hardly the poster children for healthy eating. Only 11% of them meet even the minimum five servings of fruits and vegetables!
Dr. Berardi: Okay, let's quit picking on the field of medicine. After all, despite these flaws, there are some great things happening in medicine every hour of every day. Getting back to the subject of skin health, in your book you present the case that our current diets may be to blame for the increase in both adolescent and adult acne over the last 50 years. What do you think the biggest nutritional culprits are?
Dr. Logan: It's the same old chestnuts: processed foods, too much inflammation-promoting vegetable oil, saturated and trans fats, too much sugar, soft drinks and, in particular, too much milk and dairy.
[Editor's note: We asked John Berardi to clarify the note about the adverse effects of milk. Here's how he responded:
"Some think it's the hormones in the milk (either growth hormones,reproductive hormones, or other growth factors). Some think it's because milk may stimulate androgen production (with milk containing 4 precursors to DHEA - which is considered "the acne hormone"). And some think it's due to the insulin release associated with milk (high insulin is linked with acne).So it'd be safe to clarify Dr Logan's caution about dairy and direct it at milk specifically, and not milk-based protein powders."]
The flipside of a diet top heavy in these foods and beverages is the absence of acne-protective factors: fiber to stabilize blood sugar, antioxidants from colorful fruits and vegetables, not enough omega-3 fatty acids, and low intake of specific anti-acne nutrients like zinc, selenium, and chromium.
Dr. Berardi: So, dietary displacement — making room for more junk foods by removing healthy foods — is really to blame.
Dr. Logan: In no small part, yes. And the background to our position in The Clear Skin Diet is the documented increase in acne in peoples who've adopted a Western diet.
The Inuit of Alberta, Canada, and the Japanese are examples of where changes in acne rates coincide with processed foods, unhealthy fats and the like. A study in the Archives of Dermatology in 2002 blew the doors wide open on the acne-diet connection.
It was Dr. Loren Cordain of Colorado State that deserves full credit as it was he who led this study. T-Nation readers may know him by his best-selling book, The Paleo Diet.
What they found was that in isolated hunter-gatherer type communities in the Pacific Rim and in Paraguay, there were virtually zero signs of acne, hardly a blackhead to be found. These populations were separated by some 10,000 miles, yet the common threads were diets with almost no processed foods, no dairy, lots of vegetables, fiber-rich roots, high omega-3 intake, and very importantly, an overall diet that had a low glycemic load. In other words, the totalities of the diets were such that they would not spike blood sugar and insulin levels.
Following this there were two separate Harvard studies that showed clear associations between milk consumption and the development of acne. Other forms of dairy were also implicated, including ice cream, sherbet, and cheeses.
Interestingly, yogurt wasn't a culprit, perhaps because the bacteria alter the structure. These bacteria may also play a direct role. We found two international studies and had them translated, one from Russia and the other from Italy. Both showed that oral administration of the so-called friendly bacteria, or probiotics, improves acne.
Moving forward you have to conduct clinical trials, intervention studies in a controlled fashion. It's tough to do in acne, but researchers from Australia pulled it off.
In August 2007, two separate studies were published, one in the Journal of the American Academy of Dermatology, and the other in the American Journal of Clinical Nutrition. The end results in both was that a diet high in lean meat, fiber, healthy fats, and lower in saturated fats, simple sugars, and processed foods significantly improved acne over three months vs. controls. In fact, there were about 22 less acne lesions in the healthy diet group. That ain't bad at all.
Overall the diet was similar to the hunter-gatherer approach, one with the same anti-acne low glycemic load that Dr. Cordain had discovered in 2002. By the way, the participants were completely unaware that this was an acne study per se; they thought the investigation was to see if changes to protein/carbohydrate ratios might influence some blood markers.
Dr. Berardi: Beyond Dr. Cordain's studies, you present an interesting comparison between the Japanese and North Americans with respect to diet and acne prevalence. What's the link?
Dr. Logan: Well, in 1964 there was a large comparative study in acne rates between Japanese teens living in Tokyo and Yokohama vs. American teens in urban centers. The rates of acne were 50% less in Japan. At the time it was written off to genetics.
Problem with that is today the rates of acne in Japan and North America are the same! We're fortunate that international record keeping from the World Health Organization allows us to go back in time and compare the diet in Japan in 1964 vs. today. As you might imagine — massive increases in saturated fat, milk intake, vegetable oils, sugar, and processed foods. This combined with a more sedentary lifestyle.
Dr. Berardi: But what about genetics? Obviously nutrition isn't the only factor involved in acne. What other lifestyle factors, genetic factors, etc. can promote a worsening of acne symptoms and breakouts?
Dr. Logan: You're right; diet isn't everything in acne. Really, we may have wanted to call the book The Clear Skin Lifestyle.
Research has shown that stress can lead to flare-ups of acne. For example, exam stress and relationship breakups have been associated with a worsening of acne. I'd speculate that work stress in our modern world is also a contributor. Cortisol, the stress hormone, promotes sebum production which can increase the risk of blocking up the pore.
Genetics are, of course, a major factor. But they too aren't everything. And we now know that diet and lifestyle can influence genetic expression. That is, whether or not you get an illness, or the degree to which one experiences an illness can be mediated by environmental factors despite shared genetics.
As with most chronic illnesses, in acne you have this bell curve thing. At one end are those who could eat fast food daily, have poor sleep and tons of stress, yet have superb skin. At the other end there are those with severe acne who might do everything right, eat a stellar diet, keep stress in check, and yet see only marginal differences with these efforts. The bulk of those who experience acne are in the middle.
John, our genetics haven't changed in the last 40 years, so they can't be used as an excuse for the documented, significant increases in acne rates among university students, professional women, and other adults. Can't write it off with the genetics card, and it's not because the diagnostic criteria have changed either. We simply have to look to the environment — diet and stressors top the list.
Dr. Berardi: Well, all of these lifestyle and nutritional considerations certainly help explain the story I shared with you earlier. My roommate suffered from severe acne breakouts whenever he was having any substantial stress — whether it was sport, school, or relationship stress.
Dr. Logan: Hormones — cortisol!
Dr. Berardi: Right, and due to this stress, he'd eat lots of sugar and inflammatory junk foods.
Dr. Logan: And there's the dietary link.
Dr. Berardi: In the end, what could he have done to prevent these breakouts?
Dr. Logan: Well, he could have managed them by keeping stress in check and exercising. Also, practicing meditation, mindfulness, and other stress management techniques are important.
Finally, quality sleep is critical. Most acne patients report a worsening of acne when they don't sleep well on a regular basis. Of course poor sleep elevates the stress hormone cortisol and changes our dietary habits to one of unhealthy comfort foods.
Dr. Berardi: Speaking of food, what about on that front?
Dr. Logan: It's pretty simple. To manage acne the diet should be rich in lean protein sources, fish, poultry, eggs, game meats, or very lean beef.
Also, saturated fats should be controlled while trans fats avoided, and so should processed carbs and sugars. To this end, make sure to check labels. For example on cereal, choose the one with the lowest grams of sugar and highest grams of fiber.
Tomato may also be a specific anti-acne food since the lycopene in there can lower an acne-promoting hormone. Green tea is the beverage of choice since it limits the formation of dihydrotestosterone (DHT) via Testosterone, and DHT is a much more potent acne promoter than Testosterone.
Also, to manage acne, you should maximize your omega-3 fatty acid intake, choose canola or olive as the cooking oils of choice, and don't forget to color the diet as much as possible with fruits and vegetables, berries in particular. And very importantly, avoid milk!
Dr. Berardi: Basically what many Testosterone readers already do.
Dr. Logan: For sure. I know the T-Nation nutritional IQ is very high. After my last interview and the banter we had back and forth on that thread, I have no doubt that T-Nation readers would ace the 3% of nutrition questions on medical board exams.
Of course, T-Nation knows that Dr. Treloar and myself haven't discovered plutonium by accident here. It's not like we were the first to split the atom. Overall, this is the same healthy diet that's been recommended for cardiovascular disease and diabetes. However, there are subtleties with this anti-acne diet that are a bit different.
Dr. Berardi: For example?
Dr. Logan: The nutritional demand for zinc is high in acne; zinc levels have been shown to be low and oral supplements are helpful.
Chromium is also important. An older study showed benefit with oral supplementation, probably because it helps regulate blood sugar and insulin levels.
Selenium is another one. There may be an additional burden in acne because a particular antioxidant enzyme, glutathione peroxidase, is hard at work in the skin of acne patients and it won't work without selenium. The selenium levels have been shown to be low and oral supplementation has been shown to be helpful.
This antioxidant story in acne is surprisingly significant and underappreciated. Those with acne have lower levels of antioxidant nutrients in the blood, and the more severe the acne, the lower the antioxidants.
The omega-3 connection to acne is such an emerging story because we now know that these fats, and the EPA from fish oil in particular, can put the brakes on the formation of an inflammatory chemical that's otherwise a major sebum producer.
So supplementation with EPA, zinc, selenium, and chromium may be helpful. In fact, Genuine Health Inc. of Toronto, Canada, has put these ingredients together in capsule form, along with green tea in a commercially available supplement called Perfect Skin.
Dr. Berardi: But what about commercial, topical products — you know, the ones that seem to be making all the folks happy on the infomercials? Why focus on nutrition when these are available?
Dr. Logan: There do seem to be an unusual amount of acne-curing miracles on TV these days. Over-hyped commercial products as promoted by celebrities are nothing more than well packaged and marketed ingredients that have been available over-the-counter for years: benzoyl peroxide and glycolic acid.
Clinical studies, which apparently didn't include these miracle-cure participants, show moderate results for benzoyl peroxide. It's far from a cure. As for glycolic acid, almost nothing is known about its effectiveness at the low levels used in products as hawked by celebrities. At doses used by dermatologists — far, far higher than that in the hyped products — preliminary research suggests it may provide some benefit.
However, why place a band-aid on the problem with these "cures." Why not fix the problem from the inside out while boosting nutritional status and overall healthfulness of the diet at the same time?
Dr. Berardi: And while we're on the topic of other remedies, what about the stuff that seems to make everyone really sad — Accutane?
Dr. Logan: As for Accutane, it's a very, very effective drug for acne. However, there are significant risks of birth defects in the offspring of female users should they become pregnant while on the drug.
Also, the medication is mired in controversy and it does have a virtual laundry list of adverse events that have been reported in the medical literature. Most notable are the depressive symptoms and association with suicide.
It's interesting, because the very nutrients that may be low in acne — omega-3 fatty acids, zinc, selenium, and chromium — may be influencing the high rates of depression in cases of acne. Of course, the appearance of the skin is the driving force, but the nutrient connection with acne depression has been overlooked.
Dr. Berardi: Wow, another link to my buddy's story. He'd suffer severe depression when he'd get his breakouts. What's up with that?
Dr. Logan: The omega-3 and depression story is becoming more established by the month, to the point where in December 2006 an American Psychiatric Association committee recommended the use of fish oil supplements as an add-on to standard care in depression.
At least five studies have shown that low selenium levels are associated with lowered mood states. Zinc in low levels has been associated with depression many times and new research with oral zinc supplements shows improvement in depressive symptoms.
Two recent studies show that chromium supplements help with various aspects of depressive symptoms. The point is that nutrients may be playing a bigger role in the emotional fallout of acne than previously recognized.
Dr. Berardi: The same deficiencies may be causing acne and depression! I wish I would've known this stuff a few years ago!
Well, Alan, this interview has been really interesting and has helped explain a lot of my own experiences with acne. I'd like to wrap up the interview with the following question:
the typical T-Nation reader prioritizes muscle mass and strength, prioritizes high Testosterone levels, trains with high volume and intensity, sweats hard and often, and eats a high protein diet. What's the prognosis, doc?
Dr. Logan: The good news for T-Nation readers is that the new acne studies were based on a high protein diet, lots of lean protein. Lean beef, poultry, and fish were recommended.
Since this type of diet is usually the staple of those who are all about building and maintaining lean mass, I think most T-Nation readers are likely doing well from a baseline diet perspective.
I should also point out that the acne preventive test diets were also significantly higher in fiber and lower in saturated fat. That is a natural fall-out from a diet where the carbs are fiber rich and fruits and vegetables are encouraged.
In the end, this typically leads to a small reduction in insulin-like growth hormone (IGF-1) and Testosterone. Now, it's not nutritional castration, but it's significant enough to make a difference in hormonally driven diseases, like acne and prostate cancer.
For example, a Harvard study that followed men over time discovered that men who go on to develop prostate cancer have an 8% higher IGF-1 level vs. men who don't subsequently develop prostate cancer. These are small but significant differences.
Dr. Berardi: Uh-oh!
Dr. Logan: For most, there will be little to no conflict with these healthy changes and the maintenance of lots of lean body mass. For those who wouldn't dream of giving up even one half of one percent of Testosterone levels through diet, at the very least eliminate dairy as a first step toward improving acne. Then maximize fish oil intake, maximize your antioxidant intake, drink green tea, and consider supplementing with the nutrients discussed — zinc, chromium, and selenium.
Dr. Berardi: Awesome, Alan. Great stuff! Thanks for the interview and keep us up to date on your latest research.
Dr. Logan: Will do!