Association Between Adult Acne and Dietary Behaviors: Findings From the NutriNet-Santé Prospective Cohort Study | Acne | JAMA Dermatology | JAMA Network
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    2 Comments for this article
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    Request for Comment on Potential Confounders
    Nicolette Gonzales, MD and MPH Candidate | George Washington University: Milken Institute of Public Health
    Confirmation of the association between diet and acne is sought out by many, and with conflicting studies, it becomes murky. Several confounding factors have been controlled for and it appears the participants go through somewhat extensive questionnaires, with the number of uncompensated steps required in participation in this study, what is the impact, if any, of self-selection bias on the study. Also, what, if any, controls have been put in place to mitigate the effect of self-selected participants?
    Mentioned within the study limitations portion of this study is the possibility for incorrect self-diagnosis of acne, would this same phenomenon possibly
    impact any of the 11-question medical history survey questions? It does not appear the administered surveys are available for viewing.
    Next, it seems age at menarche, pregnancy, and menopause are taken into account to assess any hormone-related factors. However, it is not mentioned if whether the participant utilizes an oral or topical hormone-based therapy such as contraceptives. If this was assessed, does use of exogenous hormones also prove to have little influence over acne? Some oral contraceptives, such as Yaz (drospirenone/ethinyl estradiol), have been FDA approved to treat acne. Spirinolactone, a common diretic, can also impact endogenous hormones (Al-Natour, 2017) If any of the female participants were taking such a therapy, was this taken into account as a confounder of acne?
    Along the same vein, and possibly noted within the medical history questionnaire, was there any consideration for any affect oral anti-inflammatories could have on acne, such as any tetracyclines like doxycycline or minocycline (Rosso, 2015). While not always prescribed for acne, it could reduce breakouts if prescribed for other reasons such as infection. Would prescriptions like this be required to be reported for the study?
    Also, would use of any past drugs be reported in the study such as isotretinoin which reportedly “cures” acne in around half of those who take it (Azoulay, Oraichi, Berard, 2007)? A participant who may report positive for past acne but negative for acne currently, could be adhering to a high glycemic diet and not experience breakouts to the degree of their peers due to past adherence to an isotretinoin treatment. There are also topical treatments for acne which did not appear to be reported or described. It is not clear whether participants are to adhere to similar cleansing habits and whether this would have an effect.
    Lastly, in regard to hygiene, was there any consideration for lifestyle differences such as differences in sleep hygiene, picking of lesions, or number of times the participant touches their face. Spreading of Propionibacterium acnes through poor hygiene could contribute to prolonged breakouts and may mask an effectiveness (or ineffectiveness) of the participants diet (Dreno, 2018).

    Al-Natour, S. H. (2017). Acne Vulgaris: Perceptions and Beliefs of Saudi Adolescent Males. Journal of Family & Community Medicine, 24(1), 34.
    Azoulay, L., Oraichi, D., & Bérard, A. (2007). Isotretinoin Therapy and the Incidence of Acne Relapse: A Nested Case–Control Study. British Journal of Dermatology, 157(6), 1240-1248.
    Del Rosso, J. Q. (2015). Oral Doxycycline in The Management of Acne Vulgaris: Current Perspectives on Clinical Use and Recent Findings with a New Double-Scored Small Tablet Formulation. The Journal of Clinical and Aesthetic Dermatology, 8(5), 19.
    Dreno, B., Bagatin, E., Blume‐Peytavi, U., Rocha, M., & Gollnick, H. (2018). Female Type of Adult Acne: Physiological
    CONFLICT OF INTEREST: None Reported
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    Dietary intake and risk of acne in adults
    Tomoyuki Kawada, MD | Nippon Medical School
    Penso et al. conducted a cross-sectional study to evaluate the association between dietary behaviors and acne in adults [1]. Adjusted odds ratios (ORs) (95% confidence intervals [CIs]) of the consumption of fatty and sugary products, sugary beverages, and milk for current acne were 1.54 (1.09-2.16), 1.18 (1.01-1.38), 1.12 (1.00-1.25), respectively. In addition, adjusted OR (95% CI) of an energy-dense dietary pattern for current acne was 1.13 (1.05-1.18). I want to discuss the association with special reference to dairy products and health.

    Samuels et al. conducted a meta-analysis to verify the association of acne vulgaris with depression and anxiety [2].
    Although there are moderating influences by factors such as age, study setting, and geographic region, they found a weak but significant association between them. Regarding the risk of depression, Sun et al. evaluated the associations between different types of milk products and depressive symptoms [3]. Adjusted ORs (95% CIs) of the second and the third higher intakes of skim milk and the third higher intake of milk desserts against the lowest group for depressive symptoms were 0.46 (0.29-0.75), 0.48 (0.27-0.85), and 0.70 (0.55-0.88), respectively. In contrast, adjusted ORs (95% CIs) of the highest, the second higher and the third higher intakes of whole milk against the lowest group for depressive symptoms were 1.55 (1.11-2.16), 1.70 (1.15-2.50), and 1.61 (1.05-2.46), respectively. I think that the content of dairy products should be classified for the risk assessment of acne.

    On this point, Dai et al. conducted a meta-analysis to investigate the association between milk consumption and acne [4]. Although there was a positive association between milk consumption and acne risk, different types of milk products and the amount of consumption presented a different risk of acne.

    Finally, Juhl et al. conducted a meta-analysis to evaluate the association in individuals aged 7⁻30 years, and dairy products, such as milk, yogurt, and cheese, were significantly associated with an increased OR for acne, although there were heterogeneity and publication bias [5]. As aging is closely associated with acne [6], risk assessment of dietary intake for acne should be conducted by considering the potential factors that might affect the risk of acne presentation or severe acne.

    References
    1. Penso L, Touvier M, Deschasaux M, Szabo de Edelenyi F, Hercberg S, Ezzedine K, Sbidian E. Association between adult acne and dietary behaviors: Findings from the NutriNet-Santé Prospective Cohort Study. JAMA Dermatol 2020;156(8):854-862.
    2. Samuels DV, Rosenthal R, Lin R, Chaudhari S, Natsuaki MN. Acne vulgaris and risk of depression and anxiety: A meta-analytic review. J Am Acad Dermatol 2020;83(2):532-541.
    3. Sun J, Wang W, Zhang D. Associations of different types of dairy intakes with depressive symptoms in adults. J Affect Disord 2020;274:326-333.
    4. Dai R, Hua W, Chen W, Xiong L, Li L. The effect of milk consumption on acne: a meta-analysis of observational studies. J Eur Acad Dermatol Venereol 2018;32(12):2244-2253.
    5. Juhl CR, Bergholdt HKM, Miller IM, Jemec GBE, Kanters JK, Ellervik C. Dairy Intake and acne vulgaris: A systematic review and meta-analysis of 78,529 children, adolescents, and young adults. Nutrients 2018;10(8):1049.6.
    6. Heng AHS, Chew FT. Systematic review of the epidemiology of acne vulgaris. Sci Rep 2020;10(1):5754.
    CONFLICT OF INTEREST: None Reported
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    Original Investigation
    June 10, 2020

    Association Between Adult Acne and Dietary Behaviors: Findings From the NutriNet-Santé Prospective Cohort Study

    Author Affiliations
    • 1Paris 13 University, Institut National de la Santé et de la Recherche Médicale, Institut National de la Recherche Agronomique, Conservatoire National Des Arts et Métiers, Nutritional Epidemiology Research Team, Epidemiology and Statistics Research Centre, University of Paris, F-93022 Bobigny, France
    • 2Epidemiology in Dermatology and Evaluation of Therapeutics, EA7379, Paris-Est University, Paris Est Créteil University, Département Infectieux/Immuno/Vaccin, F-94000 Créteil, France
    • 3Department of Dermatology, Mondor Hospital (Assistance Publique, Hôpitaux de Paris), Paris Est Créteil University, F-94000 Créteil, France
    • 4Clinical Investigation Center 1430, Institut National de la Santé et de la Recherche Médicale, F-94000 Créteil, France
    JAMA Dermatol. 2020;156(8):854-862. doi:10.1001/jamadermatol.2020.1602
    Key Points

    Question  Is dietary behavior associated with acne in adults?

    Findings  In this cross-sectional study of 24 452 participants in the French NutriNet-Santé study, the consumption of fatty and sugary products, sugary beverages, and milk was associated with current acne in adults. This association was noted after adjustment for sociodemographic variables and confounding factors, including daily energy intake, the number of dietary records completed, and depressive symptoms.

    Meaning  These findings suggest that a Western diet (ie, rich in animal products and fatty and sugary foods) is associated with the presence of acne in adults.

    Abstract

    Importance  Acne is a chronic, multifactorial inflammatory disease. The association between consumption of dairy products and fatty and sugary foods and occurrence and progression of acne remains unclear.

    Objective  To assess the association between dietary behavior and current acne in adults.

    Design, Setting, and Participants  A cross-sectional study was performed as part of the NutriNet-Santé study, which is an ongoing observational, web-based cohort study that was launched in France in May 2009. The present study was conducted from November 14, 2018, to July 8, 2019. A total of 24 452 participants completed an online self-questionnaire to categorize their acne status: never acne, past acne, or current acne. Associations between dietary behavior (food intake, nutrient intake, and the dietary pattern derived from a principal component analysis) and current or past acne were studied in multinomial logistic regression models adjusted for potential confounding variables (age, sex, physical activity, smoking status, educational level, daily energy intake, number of dietary records completed, and depressive symptoms).

    Results  The 24 452 participants (mean [SD] age, 57 [14] years; 18 327 women [75%]) completed at least 3 dietary records. Of these, 11 324 individuals (46%) reported past or current acne. After adjustment, there was a significant association between current acne and the consumption of fatty and sugary products (adjusted odds ratio [aOR], 1.54; 95% CI, 1.09-2.16), sugary beverages (aOR, 1.18; 95% CI, 1.01-1.38), and milk (aOR, 1.12; 95% CI, 1.00-1.25). An energy-dense dietary pattern (high consumption of fatty and sugary products) was associated with current acne (aOR, 1.13; 95% CI, 1.05-1.18).

    Conclusions and Relevance  In this study, consumption of milk, sugary beverages, and fatty and sugary products appeared to be associated with current acne in adults. Further large-scale studies are warranted to investigate more closely the associations between diet and adult acne.

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