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MUSINGS, OPINIONS, TIPS AND EXPERIENCES
Year : 2013  |  Volume : 4  |  Issue : 4  |  Page : 358-364  

Synopsis of Diet in Dermatology: A one day CME conducted by the Department of Dermatology, Kasturba Medical College, Manipal, March 3, 2013


Department of Dermatology and Venereology, Kasturba Medical College, Manipal University, Manipal, Karnataka, India

Date of Web Publication28-Oct-2013

Correspondence Address:
Shrutakirthi Damodar Shenoi
Department of Dermatology, Kasturba Medical College and Hospital, Manipal - 576 104, Karnataka
India
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Source of Support: None, Conflict of Interest: None


PMID: 24350027

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   Abstract 

Food is intricately related to mind and body and is one of the elements sustaining life, in disease as well as in health. There are many myths and misgivings regarding partake of food and its medicinal properties. The Department of Dermatology, Kasturba Medical College (KMC), Manipal organized a continuing medical education (CME) on Diet in Dermatology on 3rd March 2013 focusing on pertinent issues regarding diet and medicinal use of food.

Keywords: Continuing medical education, dermatology, diet


How to cite this article:
Prabhu SS, Nayak SU, Shenoi SD, Pai SB. Synopsis of Diet in Dermatology: A one day CME conducted by the Department of Dermatology, Kasturba Medical College, Manipal, March 3, 2013. Indian Dermatol Online J 2013;4:358-64

How to cite this URL:
Prabhu SS, Nayak SU, Shenoi SD, Pai SB. Synopsis of Diet in Dermatology: A one day CME conducted by the Department of Dermatology, Kasturba Medical College, Manipal, March 3, 2013. Indian Dermatol Online J [serial online] 2013 [cited 2019 May 22];4:358-64. Available from: http://www.idoj.in/text.asp?2013/4/4/358/120688


   Introduction Top


Food is intricately related to mind and body. Rich and poor alike are obsessed with food and eating, and most patients are overly concerned about the diet to follow to cure their illness. "Diet" originates from the word 'diaeta' which translates to 'a prescribed way of life'. The Department of Dermatology, Kasturba Medical College (KMC), Manipal organized a continuing medical education (CME) on Diet in Dermatology on 3 rd March 2013 focusing on the following issues: Nutritional assessment of dermatology patients, though important in conditions like atopic dermatitis, psoriasis, acute skin failure, is usually neglected. Is diet important in dermatology? Metabolic syndrome is associated with psoriasis, acanthosis nigricans, etc. and hinders early healing. How to diagnose and manage it? What is the proper diet for obese diabetics with skin problems? How to maintain adequate protein and energy intake in a child with food allergy? There is a tendency to prescribe potpourri of fanciful combinations of antioxidants, green tea extract, polyphenols omega fatty acids, etc., Are these really indicated? What is the role for triglycerides, essential fatty acids (EFA) and antioxidants?


   Diet in Dermatology: An Overview Top


Dr. Smitha Prabhu, Associate Professor, Department of Dermatology started off the CME with an overview of the topic. She discussed the various dermatological conditions in which diet plays an important role. Dermatitis herpetiformis is a disorder where diet has a definitive role in worsening the disease. In other conditions like psoriasis, atopic dermatitis, acne, urticaria, pruritus, and some forms of contact dermatitis, diet has a probable role. Food allergy to peanuts, milk, seafood, eggs, and wheat is common in atopic children as well as in urticaria; whereas evening primrose oil and polyunsaturated fatty acids (PUFA) are beneficial in atopy. Though the role of food is controversial in atopic dermatitis, in suspected cases, diagnostic tests like prick test, skin application food test, oral challenge test, etc., may be used judiciously. According to recent Cochrane review 'there appears to be no benefit for elimination diet in unselected cases, which may result in malnutrition and growth retardation'. A low glycemic diet is found to be beneficial in acne patients. Avoidance of proinflammatory fatty acids and high glycemic load helps in many skin disorders like psoriasis and acne, and in maintaining a healthy body mass. Gluten, which is a wheat protein implicated in dermatitis herpetiformis is also found to worsen psoriasis. Low protein diet and supplementation of PUFA help in uremic and cholestatic pruritus. Role of food in protein contact dermatitis, flushing, and specific metabolic conditions [Table 1], [Table 2] and [Table 3] was discussed. Skin signs of obesity and malnutrition are well known, but the subtle skin signs as pointers towards eating disorders like Russel's sign (callosity on metacarpal head of index finger due to repeated induced vomiting) and dry skin with lanugo hair of anorexia nervosa may be missed. The skin manifestations of nutritional deficiencies [Table 4] were also mentioned. Though the beneficial role of dietary supplements like omega fatty acids and antioxidants in pharmacological amounts has not been conclusively validated, it seems that doctors and nurses believe that dietary supplements may improve their health as 72% doctors and 89% nurses use dietary supplements, at least occasionally.
Table 1: Contact dermatitis and food

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Table 2: Flushing and food

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Table 3: Genetic and metabolic conditions and food

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Table 4: Skin manifestations of common nutritional deficiencies

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   Cholesterol and Triglyceride Metabolism Simplified Top


Dr. Manjula Shantaram, Professor of Department of Biochemistry, Yenepoya Medical College, Mangalore, gave a lucid lecture on the various aspects of cholesterol metabolism. Cholesterol is essential for our good health by maintaining the intact organization and functioning of the lipid bilayer of most membranes, it is a precursor for bile acids (which help in digestion of dietary fat), steroid hormones which regulate gene expression, and vitamin D. Half of the body cholesterol is synthesized by the liver and the rest obtained from food. Fifty percent of liver synthesis of cholesterol is blocked when statins are administered. Triglycerides are simple fats and are entirely different from cholesterol. These are usually present in adipose tissue and not needed for lipid bilayer. Lipoproteins are complexes of lipids and protein and are needed in lipid transport. Based on their density they are divided into chylomicrons, very low density lipoproteins (VLDL), low density lipoproteins (LDL), and high density lipoprotein (HDL). Chylomicrons transport dietary triacylglycerol (TAG) from intestine to peripheral tissues, VLDL transport endogenous TAG from liver to peripheral tissue, LDL transport cholesterol from liver to peripheral tissue, and HDL transport cholesterol from peripheral tissue to liver for degradation and excretion. Dietary excess fat is packaged into VLDL which is taken up by fat cells and converted to fatty acids. Some VLDL is converted to LDL which is rich in cholesterol. The normal values for each of these are standardized. In certain conditions of excess cholesterol and TG, these are deposited as yellowish nodules or plaques in subcutis giving rise to various xanthomas. Eruptive xanthomas contain triglycerides, tuberous xanthomas contain triglycerides and cholesterol, and xanthelasmas mainly contain cholesterol and deposition of lipids in cornea gives rise to arcuslipoides. For a healthy heart and body, diet should contain required amounts of fat and cholesterol.


   Metabolic Syndrome: Diagnosis and Management Top


Dr. M. Mukhyaprana Prabhu, Professor, Department of General Medicine, KMC, Manipal spoke on the metabolic syndrome, which is very relevant to modern life. The term was coined in 2001 for defining a proinflammatory and prothromobotic state that includes hyperglycemia, obesity, elevated blood pressure, and dyslipidemia. Obesity pandemic is spreading worldwide and its current overall prevalence is 39.1% with urban citizens being more affected. Indians along with Chinese and middle Eastern population have a higher inherent risk. International Diabetes Federation (IDF) criteria for metabolic syndrome is given in [Table 5].
Table 5: International Diabetes Federation criteria for diagnosis of metabolic syndrome

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Complications of metabolic syndrome are wide and varied, like risk for development of coronary artery disease, increased risk for stroke, nonalcoholic steatohepatitis (NASH), obstructive sleep apnea, polycystic ovarian syndrome, various malignancies, hypogonadism, and accelerated ageing. Biomarkers for metabolic syndrome include C-reactive protein (CRP), interleukin (IL)-6, tumor necrosis factor (TNF) alpha, fibrinogen, plasminogen activator inhibitor, and adiponectin. Increased carotid intimal thickness as measured by color Doppler and epicardial fat measured by echo correlate with metabolic syndrome.

In dermatology, psoriasis is closely linked to metabolic syndrome. The relationship between psoriasis and metabolic syndrome was first detected in 1973 when the New England Journal of Medicine reported an increased prevalence of occlusive vascular disease in psoriatic patients. Many other studies followed, which confirmed that psoriasis and metabolic syndrome are closely associated and psoriatics have higher risks of myocardial infarction, angina, atherosclerosis, peripheral vascular diseases, and stroke. Increased cardiovascular risk in psoriasis may also be due to use of corticosteroids, acitretin, and cyclosporine; the increased prevalence of obesity and other associated risk factors; and uncontrolled inflammation leading to endothelial dysfunction and dyslipidemia. Management of metabolic syndrome: Primary intervention by promotion of healthy lifestyle, increase in exercise and physical activities, decreased consumption of calories and fat, and change in dietary composition is stressed upon. Secondary intervention includes lipid lowering agents, hypoglycemic, and antihypertensives tailored to the patient's suitability.


   Essential Fatty Acids and Anti-Oxidants: Truth Versus Hype Top


PUFA and antioxidants have come up in the radar of health faddists, nutritionists, and the general public alike; thanks to the awareness created by various health magazines and the media. But are these claims really true? Mrs. Meenakshi Garg, Head of the Department of Dietetics and Applied Nutrition, Manipal University, gave an interesting overview of this subject. EFA are those which cannot be produced by the human body and include linoleic (18 carbon ω 6) and linolenic (18 carbon ω 3) fatty acids. The protective role of ω 6 FA in the body includes proper functioning of nervous system, immune system, skin and eye, prevention of cardiovascular diseases, alleviation of arthritis, and menstrual and muscle pains. ω 3 FA are anti-inflammatory and help by lowering triglyceride and cholesterol levels, aid in cancer prevention, increased insulin sensitivity, have a protective function in the nervous system and eyes, and inhibit platelet adhesion. EFA are structural components of cell membranes and help in their stability and fluidity and are precursors for eicosanoids. Skin is the first target for EFA deficiency which leads to altered barrier function, disruption in epidermal homeostasis leading to increase in transepidermal water loss (TEWL) causing xerosis, scaling, erythema, and dermatitis. EFA deficiency can be prevented by consuming adequate amount of food rich in omega fatty acids like leafy vegetables, seeds, nuts, grains, sunflower, safflower, corn, soya or cottonseed oil, walnuts, wheat germ, milk, and oily fish. The recommended daily allowance for ω 6 and ω 3 FA in an adult is approximately 5-10% and 0.6-1.2% of total daily calories, respectively. Though EFA are supposedly helpful in improving skin conditions like psoriasis, atopic dermatitis, and other eczemas as evidenced by some studies, the current consensus is that supplementation much above the recommended dietary allowance (RDA) levels does not have much benefit and may even lead to adverse effects like increased bleeding tendency, decreased blood pressure, fishy aftertaste, and bloating. Some nutritionists claim that ω 6 to ω 3 ratio in the diet should be maintained at 5:1 to 10:1, though emerging studies state that the increased intake of ω 3 will be more helpful than maintaining the ratio.

Antioxidants are substances that prevent or delay cell damage by neutralizing harmful free radicles which contain unpaired electrons by donating their electrons and include vitamin C and E, selenium, carotenoids, lycopene, lutein, zeaxanthin, flavonoids, polyphenols, phytoestrogens, etc., These are abundant in fresh fruits and vegetables. Research has not shown artificial antioxidant supplementation to be beneficial in prevention of diseases. Moreover, extremely high doses of antioxidants may lead to health problems like diarrhea, bleeding, and toxic reactions. Megadoses of vitamins can lead to toxicities like hemorrhage (vitamin E), diarrhea, malignancies, atherosclerosis, renal stones (vitamin C), alopecia, skin rash, fatigue, and central nervous system (CNS) anomalies (selenium). Phytochemicals are found in a variety of plant sources [Table 6] and have antioxidant activities.
Table 6: Natural sources of phytochemicals

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She concluded by saying a systematized Cochrane review published in 2012 states that 'the current evidence does not support the use of antioxidant supplements in patients with various diseases.' Why don't antioxidant supplements work? This may be due to the fact that in the natural state various antioxidants are combined with various other constituents which may help in their efficacy, and difference in the chemical composition in food vs commercial antioxidants influence their effects. For example, vitamin E supplements contain only alpha tocopherol whereas in food, eight chemical forms are present. Moreover, antioxidants may be specific for each disease, that is, eyes contain lutein in more amounts, and capsules containing lutein may be more beneficial for conditions like macular degeneration rather than for skin conditions.


   Assessment of Nutritional Status in Dermatology Top


Mrs. Suvarna Hebbar Chief Dietician, KMC Hospital, Manipal, focused on the assessment of nutritional status of a dermatological patient. General examination of the patient with focus on specific manifestations of vitamin and mineral deficiency is a must. Anthropometric measurements (weight, height, skin fold thickness, and body mass index (BMI)) measure the current status and do not differentiate between acute and chronic states. The international standard for assessing body size in adults is the BMI. Waist circumference predicts mortality better than any other anthropometric measurement and is useful in calculation of the waist-hip ratio. Laboratory investigations should look for general and specific deficiency. Nutritional intake of humans is assessed by five different methods. These are: 24 h dietary recall, food frequency questionnaire, dietary history since early life, food dairy technique, and observed food consumption. The dietary data should be evaluated both for qualitative and quantitative value. The talk was concluded by a case study which involved the nutritional assessment of an erythrodermic patient and preparation of a sample menu.


   Diet Plan for an Obese Patient with Skin Disease, Diabetes, and Hypertension Top


Mrs. Garg elaborated upon a model diet plan for patients with metabolic syndrome and skin disease like psoriasis. She stressed upon lifelong commitment towards lifestyle changes like low calorie diet to achieve a healthy BMI of less than 25 kg/m 2 facilitated by healthy eating habits with low intake of saturated and trans-fats and cholesterol, at least 30 min of moderate to intense physical activity on most days of the week, stopping smoking, and alcohol consumption. A healthy weight reduction is 0.5-1 kg per week; more than this being due to water loss rather than to fat loss. Regular mean times, avoidance of high calorie snacks and fad diets, and reducing portion sizes were stressed upon [Figure 1]. Components of therapeutic lifestyle changes (TLC) were discussed, which include heart healthy diet, weight reduction, and regular physical activity. Principles of diet included restriction of calories, moderate carbohydrate content, high fiber, adequate protein, vitamins, and minerals with restricted fat.
Figure 1: Strategies for healthy weight reduction

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The various steps in planning a diet were discussed [Table 7].
Table 7: Steps in planning a diet

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The energy requirement of an individual is based on three factors: Basal metabolic rate (BMR), thermic effect of food, and physical activity and is calculated in many ways, a simple chart is given below [Table 8].
Table 8: Calorie requirement based on weight

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The general breakup of calories from macronutrients is as follows: Protein-20-25% of total calories, fat-20-30%, carbohydrates-60-65%. [Table 9] depicts a model for healthy food servings and [Table 10] denotes a sample diet plan for Indians.
Table 9: Food servings and their equivalents

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Table 10: Example of healthy diet plans for a normal person

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Mrs. Garg next discussed about glycemic index and glycemic load; lower the values, lesser the intake of simple sugar. Basically, proteins and fats have low glycemic index, whereas simple sugars have higher values. The beneficial effects of dietary fibers and their sources were also discussed. Fibers have a protective effect on heart, gastrointestinal tract (GIT), and pancreas by lowering blood cholesterol, slowing the absorption of glucose, causing slow transit of food through GIT, softening and bulking up stools, and by causing a feeling of satiety.

In patients with hypertension and renal disease, we often advice sodium restriction, which is classified as mild (2-3 g), moderate (1 g), strict (0.5 g), or severe (0.25 g) restriction. Mg of salt × 0.4 gives the value of sodium intake in mg. Severe restriction is nutritionally inadequate and is usually not advised. The beneficial effects of Mediterranean diet which uses more of olive oil and red wine in moderation, and the intensity levels of various physical activities were also discussed. Moderate physical activity includes brisk walking, swimming, bicycling, playing basketball and volley ball, homecare, and social dancing.

Finally, the benefits of weight loss were touched upon, that is, boost up in energy, decrease in blood pressure, total cholesterol and blood sugar levels, increase in HDL cholesterol, reduction of depression, insomnia, stress, and prevention of osteoporosis, certain cancers, heart disease and stroke.


   Dietary Advice in Milk Allergy Top


Mrs. Suvarna Hebbar discussed in detail the approach to an infant with milk allergy. This talk was of significance as cow's milk allergy is seen in nearly 7% of all infants and cows' milk is the most common antigen to which they are exposed and almost all infant milk formulae are made of cow's milk protein. A family history of allergy is often encountered. Milk allergy is more common in obese and those with a higher degree of hygiene practice. Parental education, reading of labels of packaged food stuffs before consumption, monitoring of annual growth rate, and monitoring of dietary intake are recommended. Prevention of cow's milk allergy can be achieved by giving babies extensively hydrolyzed formula combined with breast milk and no solid food until 6 months of age and replacing milk with other food alternatives which will give same nutrition to the child. Alternatives for milk allergy include extensively hydrolyzed formula, partially hydrolyzed formula, oat milk, almond milk, soya milk, and coconut milk. Vitamin A and D and calcium supplementation is advised. Even though milk allergy is often 'out grown' by 5 years, subsequent reintroduction is to be done only under medical advice. Proper dietary advice to parents is important as unnecessary deletion of multiple food stuffs are common which can lead to failure to thrive. Diagnosis of milk allergy is not straight forward and sometimes requires various tests and detailed diet history, trial elimination diet, and maintenance of a food diary.

This one day intense CME concluded with a questions and answers session, wherein there was intense discussion touching upon many aspects of diet in dermatology which hitherto were not much focused upon.

We have referred the following articles in preparation of the text matter.

  1. Kaimal S, Thappa DM. Diet in dermatology revisited. Indian J Dermatol Venereol Leprol 2010;76:103-15
  2. Basavaraj KH, Seemanthini C, Rashmi R. Diet in dermatology: present perspectives. Indian J Dermatol Venereol Leprol 2010;55:205-10


Various relevant journal and text book articles have been referred by various speakers in preparing their topics.


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10]



 

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