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Dietary nutrient intakes and skin-aging appearance among middleaged American women

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Nutritional factors play a key role in normal dermatologic functioning. However, little is known about the effects of diet on skin-aging appearance. We evaluated the associations between nutrient intakes and skin-aging appearance. Using data from the first National Health and Nutrition Examination Survey, we examined associations between nutrient intakes and skin aging in 4025 women (40-74 y). Nutrients were estimated from a 24-h recall. Clinical examinations of the skin were conducted by dermatologists. Skin-aging appearance was defined as having a wrinkled appearance, senile dryness, and skin atrophy. Higher vitamin C intakes were associated with a lower likelihood of a wrinkled appearance [odds ratio (OR) 0.89; 95% CI: 0.82, 0.96] and senile dryness (OR: 0.93; 95% CI: 0.87, 0.99). Higher linoleic acid intakes were associated with a lower likelihood of senile dryness (OR: 0.75; 95% CI: 0.64, 0.88) and skin atrophy (OR: 0.78; 95% CI 0.65, 0.95). A 17-g increase in fat and a 50-g increase in carbohydrate intakes increased the likelihood of a wrinkled appearance (OR: 1.28 and 1.36, respectively) and skin atrophy (OR: 1.37 and 1.33, respectively). These associations were independent of age, race, education, sunlight exposure, income, menopausal status, body mass index, supplement use, physical activity, and energy intake. Higher intakes of vitamin C and linoleic acid and lower intakes of fats and carbohydrates are associated with better skin-aging appearance. Promoting healthy dietary behaviors may have additional benefit for skin appearance in addition to other health outcomes in the population.
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Dietary nutrient intakes and skin-aging appearance among middle-
aged American women
14
Maeve C Cosgrove, Oscar H Franco, Stewart P Granger, Peter G Murray, and Andrew E Mayes
ABSTRACT
Background: Nutritional factors play a key role in normal derma-
tologic functioning. However, little is known about the effects of diet
on skin-aging appearance.
Objective: We evaluated the associations between nutrient intakes
and skin-aging appearance.
Design: Using data from the first National Health and Nutrition
Examination Survey, we examined associations between nutrient
intakes and skin aging in 4025 women (40 –74 y). Nutrients were
estimated from a 24-h recall. Clinical examinations of the skin were
conducted by dermatologists. Skin-aging appearance was defined as
having a wrinkled appearance, senile dryness, and skin atrophy.
Results: Higher vitamin C intakes were associated with a lower
likelihood of a wrinkled appearance [odds ratio (OR) 0.89; 95% CI:
0.82, 0.96] and seniledryness (OR: 0.93; 95% CI: 0.87, 0.99). Higher
linoleic acid intakes were associated with a lower likelihood of senile
dryness (OR: 0.75; 95% CI: 0.64, 0.88) and skin atrophy (OR: 0.78;
95% CI 0.65, 0.95). A 17-g increase in fat and a 50-g increase in
carbohydrate intakes increased the likelihood of a wrinkled appear-
ance (OR: 1.28 and 1.36, respectively) and skin atrophy (OR: 1.37
and 1.33, respectively). These associations were independent of age,
race, education, sunlight exposure, income, menopausal status, body
mass index, supplement use, physical activity, and energy intake.
Conclusions: Higher intakes of vitamin C and linoleic acid and
lower intakes of fats and carbohydrates are associated with better
skin-aging appearance. Promoting healthy dietary behaviors may
have additional benefit for skin appearance in addition to other
health outcomes in the population. Am J Clin Nutr 2007;86:
1225–31.
KEY WORDS National Health and Nutrition Examination
Surveys, NHANES, vitamin C, wrinkles, skin aging, linoleic acid,
nutritional epidemiology
INTRODUCTION
Skin aging is a continuous process that is heavily determined
by the combined influences arising from intrinsic aging, the
environment (eg, sun exposure), and lifestyle factors [eg, ciga-
rette smoking, low body mass index (BMI; in kg/m
2
), and meno-
pausal status] (1–5). Among these factors, the harmful effects of
chronic sun exposure (photoaging) and smoking on premature
skin aging are widely supported (6 –9). During the course of skin
aging, both skin function and appearance are affected. Changes
in appearance are the most visible signs of aging and include
wrinkles, irregular pigmentation, sagging, atrophy, elastosis, and
telangiectasia (1, 6). Such changes in appearance have substan-
tial negative affects on self-esteem and social well-being (10).
Furthermore, appearance was shown to be an indicator of overall
health status, and it has been shown that “looking old for one’s
age” is associated with increased risk of mortality (11, 12).
Balanced nutrition is essential not only to prevent chronic
disease such as cardiovascular disease, certain cancers, and di-
abetes (13) but also to maintain health and ensure normal func-
tioning. Certain nutrients were identified to play a critical role in
the normal functioning of the skin, particularly when nutrient
deficiencies are apparent, eg, vitamin C in collagen synthesis (14,
15). Several studies have observed improved protection of the
skin against sun damage (photoprotection) by dietary supple-
mentation with vitamins E and C, carotenoids (
-carotene and
lycopene), and polyunsaturated fatty acids (PUFAs) (16, 17).
However, those studies are limited by the use of supplements,
some with several active ingredients, making it difficult to de-
termine which nutrient is having an effect. One study observed a
photoprotective effect of a diet higher in vegetables, fruit, and
olive oil on the skin (18). Whether habitual dietary intakes have
a significant effect on skin-aging appearance has not been shown.
This is critical to adequately design potential interventions tar-
geted to improve or delay the skin-aging process. Therefore, in
the present cross-sectional analysis, using the first National
Health and Nutrition Examination Survey (NHANES I) (19), we
examined the relation between nutrient intakes and the preva-
lence of the appearance of wrinkles, senile dryness (dryness as a
result of aging), and skin atrophy (thinning) in middle-aged
women. This examination allowed us to examine the relation
between nutrient intakes, rather than supplements, and skin-
aging appearance, rather than photoprotection, for the first time
to our knowledge.
SUBJECTS AND METHODS
Data source
The NHANES I was conducted in the United States by the
National Center for Health Statistics between 1971 and 1974
1
From Corporate Research (MCC, OHF, and AEM) and Statistics Group
(PGM), Unilever Colworth Park, Bedford, United Kingdom, and Unilever
R&D Port Sunlight, Wirral, United Kingdom (SPG).
2
Presented in part in poster form at the 4th International Conference on the
Health Benefits of Fruit and Vegetables within a Mediterranean style diet
(EGEA IV), Brussels, Belgium, 17-19 April 2007.
3
Supported by Unilever Corporate Research United Kingdom.
4
Reprints not available. Address correspondence to MC Cosgrove, Uni-
lever Corporate Research, Colworth Park, Sharnbrook, Bedford, MK44 1LQ.
United Kingdom. E-mail: maeve.cosgrove@unilever.com.
Received March 7, 2007.
Accepted for publication June 12, 2007.
1225Am J Clin Nutr 2007;86:1225–31. Printed in USA. © 2007 American Society for Nutrition
by guest on May 15, 2011www.ajcn.orgDownloaded from
(19). Briefly, NHANES I was conducted on a nationwide sample
of 32 000 noninstitutionalized persons aged 1–74 y. Details of
methods, including the development, plan, and operation of the
survey and data collection forms have been published and are
available elsewhere (20 –22).
Study sample
All women aged 40 y were eligible for inclusion. From the
original available sample of 23 808 subjects, 10 152 men, 8477
women aged 40 y, 1062 women who did not have a dermato-
logic examination, and 92 women with unsatisfactory 24-h di-
etary recalls were excluded. The final sample consisted of 4025
women aged 40 –74 y.
Assessment of skin aging
A complete clinical dermatologic examination of the skin was
undertaken to evaluate variations in texture and color, certain
manifestations of aging, and all pathologic changes. The derma-
tologic examinations were performed by 101 dermatologists that
followed a studywide protocol after uniform training and stan-
dardized definitions (23). To ensure consistency with the exam-
ination protocol, a random sample of the 20 637 examinations
was checked by a senior dermatologist (24). The dermatologist
classified the subjects into 1 of 3 categories of cumulative life-
time sunlight exposure: 1) low (unimpressive), 2) moderate, and
3) high (considerable), based on the subjects’ occupation and
amount of leisure time spent outdoors. Skin aging was defined by
3 independent determinants of the process: wrinkled appearance,
senile dryness (dryness as a result of aging), and skin atrophy
(thinning).
Dietary assessment
A 24-h dietary recall was administered to each respondent by
a trained dietary interviewer, with 3-dimensional food models,
including household measures, to estimate food portions (23).
The interviewer probed for clarity of foods and beverages con-
sumed and for commonly forgotten items (eg, sugar in tea, bev-
erages with meals). Estimates of nutrient intake for each food and
beverage reported were obtained from the US Department of
Agriculture food composition data (25).
Assessment of other variables
Height and weight were measured using standard methods
(26), and BMI was calculated. The physical activity question
about nonrecreational activity was: “In your usual day, aside
from recreation, how active are you?” The possible responses
were 1) very active, 2) moderately active, or 3) quite inactive.
Additional covariate information about age, smoking habits,
menopausal status, race, education, and family income was ob-
tained with the use of questionnaires.
Statistical analyses
We first conducted univariate analyses to describe the distri-
bution of nutrient intakes and demographic and lifestyle at-
tributes by having a wrinkled appearance, senile dryness, and
skin atrophy. Significant differences were assessed using Pear-
son’s chi-square and independent t tests for categorical and
continuous variables, respectively. Differences in mean nutrient
intakes were assessed with the use of analysis of variance,
adjusting for age (continuous), race (white, black, other),
energy intake (continuous), education [12 y, high school
graduation (12 y), 12 y], sunlight exposure (unimpressive,
moderate, considerable), total family income ($5000, $5000
9999; $10 000), menopausal status (responded yes to the ques-
tion “Have your menstrual periods stopped entirely?” compared
with no), BMI (continuous), supplement use (responded yes to
the question “Are you taking vitamins or minerals?” compared
with no), and self-reported daily physical activity (very active,
moderately active, quite inactive). Intakes of linoleic acid, total
dietary cholesterol, calcium, and vitamins A and C were log
transformed, because they were not normally distributed.
To determine the associations of nutrient intakes with skin-
aging appearance, nutrients that substantially changed the effect
on the outcomes (P 0.2) were examined with the use of binary
logistic regression analysis (27). We used logistic regression
models in 3808 women with complete data, controlling for age,
race, energy intake, education, sunlight exposure, family in-
come, menopausal status, BMI, supplement use, and physical
activity to determine the associations of fat, carbohydrate, thia-
mine, and vitamin C with a wrinkled appearance; of saturated
fatty acids, oleic acid, linoleic acid, and vitamin C with senile
dryness; and of fat, carbohydrate, and linoleic acid with skin
atrophy. Variables that substantially changed the effect on the
outcomes examined (P 0.2) (27) or were associated with skin
aging in prior studies (3–5, 22) were considered as potential
confounders. Family income may be related to skin-aging ap-
pearance thorough pathways other than its influence on diet;
therefore, it was included in all models. The odds ratio (OR)
represents the odds for a 1-unit increment (eg, 1 g protein). To
illustrate nutritionally relevant estimates, new ORs were calcu-
lated on the basis of 33% of the median intake for each nutrient
(except for log-transformed nutrients and thiamine, whose me-
dian intake was 1 mg) (28).
Subgroup analysis
Cigarette smoking is a well-established independent risk fac-
tor for facial wrinkling and skin aging (6–9). In this analysis,
smoking data were only collected for 1401 women (n ҃ 539
current and previous smokers; n ҃ 862 never smoked). There-
fore, stratified analysis was conducted to examine skin-aging
appearance without ignoring the smoking data or losing large
sample numbers because of the missing data.
We used a P value 0.05 for significance, and all tests were
2-sided. All analyses were performed with SPSS, version 14
(SPSS Inc, Chicago, IL).
RESULTS
Characteristics of the study sample
A wrinkled appearance was present in 899 (22.3%), senile
dryness in 1159 (28.8%), and skin atrophy in 515 (12.8%)
women. The distribution of the skin-aging appearance in the
4025 women is shown by the presence or absence of wrinkles,
senile dryness, and skin atrophy in Figure 1. Of the 3 signs of
skin-aging appearance, wrinkles were significantly correlated
with senile dryness (r ҃ 0.36) and skin atrophy (r ҃ 0.52). Senile
dryness was significantly correlated with skin atrophy (r ҃ 0.30).
Characteristics of all women and of each outcome separately are
shown in Table 1. Skin-aging outcomes were found significantly
1226 COSGROVE ET AL
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in older women; women with a wrinkled appearance, senile dry-
ness, and skin atrophy were 10 y, 10 y, and 9 y older, respec-
tively. Women with the appearance of wrinkles, with senile dry-
ness, and with skin atrophy were more likely to be white, have
12 y education, have a low family income, be postmenopausal,
and have higher sunlight exposure. Women with skin atrophy
were significantly associated with a lower BMI, and women with
a wrinkled appearance and with senile dryness were less likely to
be physically active. No significant differences in supplement
users and skin-aging outcomes were observed.
Distribution of nutrient intakes by skin-aging appearance
Multivariate-adjusted means for nutrient intakes (adjusted for
age, race, energy intake, education, sunlight exposure, family
income, menopausal status, BMI, supplement use, and physical
activity) are shown by outcomes of skin-aging appearance in
Table 2. Women with a wrinkled appearance had significantly
lower intakes of protein, total dietary cholesterol, phosphorus,
potassium, vitamin A, and vitamin C than did women without a
wrinkled appearance. Women with senile dry skin had signifi-
cantly lower intakes of linoleic acid and vitamin C than did
women without senile dry skin. Women with skin atrophy had a
No find in gs of sk in agi
n = 24 45
Wrinkles
= 270
n = 26 0
n = 13 4
5
n = 57 0
2
Senile
Dr y
Skin
Atroph y
in ng
Wrinkles
n = 270
0
n = 59
5
0
n = 5
Senile
Dr y
Skin
Atroph y
Wrinkles
n = 23
5
Senile
Dr y
Skin
Atroph y
FIGURE 1. Distribution of 4025 women by the presence of a wrinkled
appearance, senile dryness, and skin atrophy.
TABLE 1
Demographic, lifestyle, and dietary characteristics of women aged 40 –74 y in the first National Health and Nutrition Examination Survey (NHANES I) by
the appearance of skin aging
Variables
All women
(n ҃ 4025)
Wrinkled appearance Senile dryness Skin atrophy
Absence
(n ҃ 3126)
Presence
(n ҃ 899) P
1
Absence
(n ҃ 2866)
Presence
(n ҃ 1159) P
1
Absence
(n ҃ 3510)
Presence
(n ҃ 515) P
1
Age (y) 58.1 11.2
2
55.9 11.1 65.6 7.5 0.001 55.3 11.1 65.0 7.9 0.001 56.9 1.2 66.1 7.5 0.001
BMI (kg/m
2
)
26.4 5.6 26.5 5.7 26.2 5.5 NS 26.4 5.7 26.4 5.4 NS 26.5 5.7 25.9 5.3 0.020
Energy (kcal) 1376 559 1397 571 1305 508 0.001 1403 568 1310 529 0.001 1389 567 1289 487 0.001
Race (%) 0.001 0.003 0.001
White 82.2 79.3 92.0 80.9 85.2 80.7 92.4
Black 17.1 19.8 7.8 18.2 14.4 18.6 7.2
Other 0.7 0.8 0.2 0.8 0.3 0.7 0.4
Education (%)
3
0.001 0.001 0.001
12 y 54.8 52.0 64.5 51.0 64.3 53.1 66.3
12 y 29.4 31.7 21.1 32.5 21.5 30.8 19.7
12 y 15.9 16.3 14.4 16.5 14.2 16.1 14.0
Family income (%)
4
0.001 0.001 0.001
$5000 41.7 38.4 52.9 36.3 54.9 39.7 55.0
$5000–9999 29.5 29.7 28.9 30.7 26.6 29.9 27.0
$10 000 28.8 31.8 18.2 32.9 18.5 30.4 17.9
Physical activity (%) 0.009 0.001 NS
Quite inactive 11.9 12.3 10.5 10.5 15.1 11.9 11.5
Moderately active 49.8 48.5 54.3 48.5 53.1 49.2 54.2
Very active 38.3 39.2 35.3 41.0 31.8 38.9 34.4
Postmenopausal (%)
5
75.5 69.9 95.0 0.001 67.8 94.5 0.001 72.7 94.8 0.001
Sunlight exposure (%)
6
0.001 0.001 0.001
Low 45.9 47.0 42.1 47.7 41.4 47.1 37.4
Medium 39.0 39.0 38.8 38.9 39.1 38.2 43.8
High 15.2 14.0 19.1 13.4 19.5 14.6 18.8
Supplement use (%) 37.0 36.9 37.6 NS 37.8 35.0 NS 37.2 35.7 NS
1
Independent t test was used for continuous variables, and chi-square test was used for categorical variables.
2
x SD (all such values).
3
n ҃ 3993.
4
n ҃ 3852.
5
n ҃ 3036.
6
n ҃ 4004.
NUTRIENT INTAKES AND SKIN AGING IN AMERICAN WOMEN 1227
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significantly lower linoleic acid intake than did women without
skin atrophy.
Logistic regression analysis of nutrient intake and skin-
aging appearance
Multivariate-adjusted logistic regression ORs for skin-aging
appearance outcomes with selected nutrient intakes are shown in
Table 3. A 1-unit increase on the log scale in intakes of vitamin
C were associated with an 11% reduction in the odds of a wrin-
kled appearance and a 7% reduction in the odds of senile dryness.
Similarly, a 1-unit increase on the log scale in intakes of linoleic
acid were associated with 25% and 22% reductions in the odds of
senile dryness and skin atrophy, respectively. A 17-g increase in
fat and a 50-g increase in carbohydrate intakes increased the ORs
of a wrinkled appearance and skin atrophy. The multivariate-
adjusted logistic regression models yielded an R
2
of 0.17, 0.16,
and 0.15 for a wrinkled appearance, senile dryness, and skin
atrophy, respectively. Variables that substantially affected the
regression coefficients in the models were age, race, and sunlight
exposure for all outcomes, plus menopausal status for wrinkles
and senile dryness and BMI for skin atrophy. Supplement use
was not significantly associated with any of the 3 signs of skin-
aging appearance; no interactions were observed between mean
nutrient intakes and supplement use (data not shown).
Subgroup analysis
In NHANES I, smoking data were collected for a subsample of
adults. In this study smoking information was available for only
1401 women, of which 539 (38%) were smokers (current and
previous) and 862 (62%) had never smoked. The mean age of
smokers was 54.5 y; the mean age of nonsmokers was 58.5 y
(P 0.001). In this subgroup the majority of the associations
observed between nutrients and skin-aging appearance in the
total population remained after the stratification for smoking.
Furthermore, additional associations were observed among
smokers. Smokers with a wrinkled appearance had significantly
lower intakes of protein and niacin than did smokers without
wrinkled appearance (P 0.05), and smokers with skin atrophy
had higher calcium intakes than did smokers without skin
atrophy (P 0.05) (data not shown).
TABLE 2
Nutrient intakes in women by the appearance of skin aging
1
Nutrients
Wrinkled appearance Senile dryness Skin atrophy
Absence
(n ҃ 2925)
Presence
(n ҃ 856) P
2
Absence
(n ҃ 2705)
Presence
(n ҃ 1103) P
2
Absence
(n ҃ 3322)
Presence
(n ҃ 486) P
2
Protein (g/d) 57.2 0.34
3
54.8 0.66 0.002 57.0 0.36 55.9 0.59 0.124 56.8 0.32 55.4 0.86 0.115
Fat (g/d) 55.5 0.27 55.9 0.52 0.486 55.5 0.28 55.7 0.46 0.798 55.5 0.25 55.8 0.67 0.691
Carbohydrate (g/d) 158 0.78 160 1.51 0.153 158 0.82 159 1.34 0.677 158 0.72 160 1.96 0.253
Saturated fatty acid (mg/d) 19.9 0.13 19.9 0.26 0.853 19.9 0.14 19.9 0.23 0.807 19.9 0.12 19.9 0.34 0.936
Oleic acid (mg/d) 21.4 0.13 21.5 0.25 0.765 21.4 0.13 21.7 0.22 0.205 21.5 0.12 21.3 0.32 0.543
Linoleic acid (g/d)
4
1.73 0.01 1.72 0.02 0.655 1.74 0.01 1.68 0.02 0.008 1.73 0.01 1.68 0.03 0.049
Dietary cholesterol (mg/d)
4
5.41 0.01 5.33 0.03 0.014 5.40 0.01 5.38 0.02 0.641 5.40 0.01 5.37 0.04 0.484
Calcium (mg/d)
4
6.12 0.01 6.10 0.02 0.536 6.13 0.01 6.09 0.02 0.108 6.11 0.01 6.15 0.03 0.220
Phosphorus (mg/d) 880 5.02 858 9.75 0.046 879 5.29 867 8.61 0.244 875 4.67 877 12.66 0.862
Iron (mg/d) 9.40 0.06 9.22 0.12 0.186 9.35 0.07 9.38 0.11 0.853 9.38 0.06 9.22 0.16 0.356
Sodium (mg/d) 1615 14.9 1633 29.0 0.590 1628 15.7 1597 25.6 0.329 1610 13.9 1681 37.6 0.081
Potassium (mg/d) 1826 11.8 1771 23.0 0.036 1827 12.5 1782 20.3 0.067 1813 11.0 1817 29.9 0.901
Vitamin A (IU/d)
4
7.98 0.02 7.88 0.04 0.021 7.98 0.02 7.90 0.03 0.061 7.96 0.02 7.96 0.05 0.995
Thiamine (mg/d) 0.81 0.01 0.83 0.01 0.162 0.81 0.01 0.81 0.01 0.825 0.81 0.01 0.83 0.02 0.343
Riboflavin (mg/d) 1.23 0.01 1.21 0.02 0.448 1.23 0.01 1.21 0.02 0.501 1.22 0.01 1.24 0.03 0.654
Niacin (mg/d) 13.1 0.11 12.8 0.22 0.128 13.1 0.12 13.0 0.19 0.546 13.1 0.10 12.8 0.28 0.278
Vitamin C (mg/d)
4
3.94 0.02 3.82 0.04 0.015 3.95 0.02 3.83 0.04 0.009 3.92 0.02 3.86 0.05 0.282
1
Adjusted for age, race, energy intake, education, sunlight exposure, family income, menopausal status, BMI, supplement use, and physical activity.
2
Derived from ANOVA.
3
x SE (all such values).
4
Log transformed.
TABLE 3
Multivariate-adjusted odds ratios (ORs) relating nutrient intake to skin
aging appearance
1
Increment
2
OR (95% CI) P
Wrinkled appearance
Fat (g/d) 16.73 1.28 (1.08, 1.53) 0.005
Carbohydrate (g/d) 49.15 1.36 (1.14, 1.63) 0.001
Thiamine (mg/d) 1.00 1.31 (1.05, 1.63) 0.019
Vitamin C (mg/d)
3
1.00 0.89 (0.82, 0.96) 0.003
Senile dryness
Saturated fatty acid (mg/d) 5.80 0.90 (0.81, 0.99) 0.030
Oleic acid (mg/d) 6.41 1.18 (1.05, 1.33) 0.006
Linoleic acid (g/d)
3
1.00 0.75 (064, 0.88) 0.001
Vitamin C (mg/d)
3
1.00 0.93 (0.87, 0.99) 0.034
Skin atrophy
Fat (g/d) 16.73 1.37 (1.09, 1.71) 0.006
Carbohydrate (g/d) 49.15 1.33 (1.06, 1.66) 0.012
Linoleic acid (g/d)
3
1.00 0.78 (0.65, 0.95) 0.012
1
Model adjusted for age, energy intake, race, menopausal status, sun
-
light exposure, BMI, family income, education, supplement use, and physical
activity. For each outcome the nutrient intakes in the model were adjusted for
each other.
2
Based on a 1-unit increment for log-adjusted nutrients and thiamine
and based on an increase in 33% of the median intake for all other nutrients.
3
Log transformed.
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DISCUSSION
We found that higher intakes of vitamin C and linoleic acid and
lower intakes of fats and carbohydrates were associated with
better skin-aging appearance (lower prevalence of wrinkled
appearance, senile dryness, and skin atrophy) independent of
factors known to affect skin aging.
Lower intakes of vitamin C were significantly associated with
the prevalence of a wrinkled appearance and senile dryness,
independent of age, sun exposure, race, menopausal status, en-
ergy intake, education, family income, BMI, supplement use,
and physical activity. To our knowledge, this is the first study to
directly relate dietary intakes of vitamin C with skin aging. In
skin, vitamin C exerts different biologic roles, including partic-
ipation in collagen synthesis, the regeneration process, and
wound repair (29). Vitamin C is an important antioxidant found
in the skin and may lower the prevalence of wrinkles and senile
dryness by its actions as an antioxidant (29). Moreover, several
studies have shown that vitamin C has photoprotective properties
through oral or topical applications (17). Topical application of
vitamin C shows photoprotective properties and suggests im-
provements of wrinkles (30, 31). Reviewing dietary supplemen-
tation, Boelsma et al (16) identified 4 studies that showed a
photoprotective effect of vitamin C on skin. Those studies were
short-term supplementation trials with high doses of vitamin C
and in combination with vitamin E, whereas our findings are
from habitual intakes of vitamin C from food sources.
Our results also suggest that a higher dietary intake of linoleic
acid has a beneficial role in reducing the chances of developing
senile dryness and skin atrophy in middle-aged women. Linoleic
acid (nҀ6 PUFA) is an essential fatty acid that cannot be pro-
duced endogenously and is converted after ingestion to other
PUFAs such as eicosapentaenoic acid (EPA) and docosahexae-
noic acid (DHA). The association between linoleic acid intake
and skin aging has not been investigated; however, several stud-
ies have examined the photoprotective effects of EPA and DHA
intakes from fish-oil supplements (16, 17). Topical application of
EPA has also showed photoprotective properties (32). Linoleic
acid may therefore lower the prevalence of senile dryness and
skin atrophy by acting as a source of EPA and DHA. Further-
more, low intake of linoleic acid can lead to dermatitis with
marked abnormalities (16, 33), and this could also be important
in its role in skin-aging appearance.
Our results also suggest that a higher dietary intake of fats and
carbohydrates has a negative role in skin-aging appearance. To
our knowledge this is the first study to show an association
between dietary intakes of fats and carbohydrates with features of
skin aging. Furthermore, higher thiamine intakes were associ-
ated with an increased likelihood of a wrinkled appearance.
Thiamine is an essential B vitamin found in enriched cereals and
whole grains. More research is needed to understand these
associations.
Our findings add evidence to a predominately supplement and
topical application-based hypothesis that what we eat affects our
skin-aging appearance. One other study by Purba et al (18) has
reported a significant effect of vegetables, fruit, and olive oil on
wrinkles; however, they examined the effect on skin surface
microstructure photodamage, whereas in our study we looked at
the effect of nutrient intakes on visual features of skin aging that
were determined by trained dermatologists. Because most exist-
ing evidence comes from supplemental trials or topical applica-
tion of nutrients (16–18, 30 –32, 34), our study adds to the ex-
isting evidence in this field, because it examined nutrient intakes
from foods rather than from nutritional supplements.
Although vitamin A has long been noted to have antiwrinkle
properties, and retinol (vitamin A) is commonly used in the
cosmetics industry as a topical antiwrinkle agent (34, 35), clinical
trials have failed to show this effect when taken orally as sup-
plements. Our findings that women with a wrinkled appearance
had lower vitamin A intakes support the evidence that vitamin A
benefits skin-aging appearance. We also found that women with
a wrinkled appearance had lower protein intakes. Lower protein
intakes in older adults were shown to increase skin fragility (36).
Vitamin A and protein however did not affect the prevalence of
a wrinkled appearance in the multivariate-adjusted logistic re-
gression models.
The favorable association of vitamin C and linoleic acid in-
takes with skin aging may be attributed to the dietary sources of
these nutrients. At the time of this survey, the main sources of
vitamin C in the US diet were orange juice (more than a quarter
of total vitamin C intake), citrus fruit, fruit juices, and tomatoes
(37). Linoleic acid is found in oils such as rapeseed and soybean
oils and in foods such as green leafy vegetables and nuts (38).
Furthermore, as mentioned earlier, the body can convert linoleic
acid into EPA and DHA (nҀ3 PUFAs). These nutrients were not
measured in NHANES I, but their main dietary sources are fish
and fish oils (39). Current dietary recommendations promote
higher intakes of fruit and vegetables and fish and PUFAs (13, 40,
41). Despite several campaigns to promote the consumption of
fruit and vegetables and the evidence that diets poor in fruit and
vegetables are associated with poor health outcomes, most adults
are still not eating enough fruit and vegetables (42, 43). There-
fore, a benefit for skin-aging appearance from eating aspects of
a healthy diet, such as fruit, vegetables, nuts, and fish, and re-
ducing fat intake may motivate people and improve current pro-
motions for healthy eating.
Our findings need to be interpreted while considering some
limitations. This study is a cross-sectional analysis, and no con-
clusions about the direction of associations between nutrient
intakes and skin-aging appearance can be determined. NHANES
I data were collected in 1971–1975 and a cohort effect cannot be
ruled out. Furthermore, changes in nutrient intakes have occurred
in the past 30 y (44); hence, extrapolation to current populations
might be affected. Although we used NHANES I data, which has
a well-characterized population with good measures of a number
of variables such as age, sun exposure, race, BMI, and meno-
pausal status, allowing potential confounding to be controlled
for, residual confounding cannot be discarded. One factor that
was not measured was the use of facial cosmetics. Nevertheless,
on the basis of current knowledge we cannot determine whether
use of such products is modified by nutrient intake. The derma-
tologic component of this survey was not designed to specifically
detect associations between nutrients and skin appearance; there-
fore, post hoc analyses have to be interpreted with caution. How-
ever, few studies exist in which comprehensive measures of both
dietary intake data and skin-aging appearance are present and
thus can be used to test the hypothesis of this study. The dietary
data were collected using a 24-h dietary recall. Estimates from a
single day of intake may not represent usual, long-term intakes,
because of day-to-day variation in the subjects’ food intakes.
NUTRIENT INTAKES AND SKIN AGING IN AMERICAN WOMEN 1229
by guest on May 15, 2011www.ajcn.orgDownloaded from
However, this study used trained interviewers to improve data
collection.
This is the first study to examine the effect of nutrient intakes
rather than supplements on skin-aging appearance. Our findings
suggest that higher intakes of vitamin C and linoleic acid are
associated with a lower prevalence of a wrinkled appearance,
senile dryness, and skin atrophy, whereas higher intakes of fats
and carbohydrates are associated with a higher likelihood of
features of skin aging. The favorable associations may be attrib-
utable to the dietary sources of these nutrients (fruit, vegetables,
and nuts) and are independent of factors known to affect skin
aging. Perhaps appealing benefits such as reducing skin-aging
appearance may motivate healthy eating, and new campaigns to
promote healthy dietary behaviors could consider this issue. Our
findings support current recommendations that promote aspects
of a healthy diet such as higher intakes of fruit, vegetables, and
nuts and indicate a new direction for nutrition research in relation
to public health.
We thank the National Center for Health Statistics for access to the original
data sets of the First National Health and Nutrition Examination Survey.
Available online at http://www.cdc.gov/nchs/nhanes.htm (last accessed 20
June 2006). We also thank Kirsten L Rennie for her valuable comments in the
process of writing this manuscript.
The author’s responsibilities were as follows—MCC: was responsible for
the design and concept, analysis of the study, data interpretation, and prep-
aration of the manuscript; OHF: commented on this work and helped prepare
the manuscript; SPG: was responsible for study conception and design;
PGM: was responsible for acquisition of the data and participated in the data
analysis and data interpretation; AEM (study supervisor): was responsible for
skin content and helped revise the manuscript. None of the authors had a
conflict of interest in relation to this study.
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Reply to E Baggott and SL Morgan
Dear Sir:
We agree with Baggott and Morgan that folic acid or its de-
rivatives are valuable in reducing the toxic side effects of meth-
otrexate in patients with rheumatoid arthritis (RA) and, indeed,
we (1) pointed this out (page 523). However, we do not think we
made a conceptual error in our “thought experiment”: what we
wrote was that studies need to be done to determine whether the
incidence or severity of RA and psoriasis have changed in coun-
tries that have introduced folic acid fortification. We also asked
whether treatment choice or drug efficacy has changed in these
countries. The report by Arabelovic et al (2) that appeared after
our Commentary was submitted shows that the average dose of
methotrexate used has increased in the United States since 1996;
the explanation offered by Baggott and Morgan is just as specu-
lative as the suggestion that this change is a consequence of
fortification. A key question is whether Baggott and Morgan
consider it ethical to give additional folic acid to untreated RA
patients to see whether it changes their symptoms, even if such a
trial were to take place in a country without fortification. We think
not. Finally, to say that there is no evidence that fortification has
increased the incidence of RA simply reflects the fact that no such
study has been conducted. We believe that such studies should be
conducted, in the same way as they have been to determine the
incidence of cancer (3). What we need is more evidence.
No conflicts of interest were declared.
A David Smith
Helga Refsum
OPTIMA
Department of Physiology
Anatomy & Genetics
University of Oxford
Oxford
United Kingdom
david.smith@pharm.ox.ac.uk
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Erratum
Cosgrove MC, Franco OH, Granger SP, Murray PG, Mayes AE. Dietary nutrient intakes and skin-aging
appearance among middle-aged American women. Am J Clin Nutr 2007;86:1225–31.
In the third paragraph in the left-hand column on page 1229, the following sentence should have been deleted:
“Linoleic acid ѧ is converted after ingestion to other PUFAs such as eicosapentaenoic acid (EPA) and docosa-
hexaenoic acid (DHA).” In the same paragraph, the following sentence also should have been deleted: “Linoleic
acid may therefore lower the prevalence of senile dryness and skin atrophy by acting as a source of EPA and
DHA.” Finally, in the second full paragraph of the right-hand column on page 1229, the following sentence
should have been deleted as well: “Furthermore, as mentioned earlier, the body can convert linoleic acid into EPA
and DHA (n–3 PUFAs).”
480 LETTERS TO THE EDITOR
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Background: Tobacco smoking, similar to ultraviolet (UV) A radiation exposure, has previously been identified as an important factor contributing to premature aging of human skin. To investigate the relationship between these two environmental factors, we have conducted a cross-sectional study of 83 subjects (48 males, 35 females, age range 23–95), in which sun exposure, pack-years of smoking history and potential confounding variables were assessed by questionnaire. Facial wrinkles were quantified using the Daniell score. In order to study the molecular mechanism by which smoking caused wrinkle formation, in vitro studies were conducted to assess the alteration of matrix metalloproteinase-1 (MMP-1) mRNA expression in human fibroblasts stimulated with tobacco smoke extract or/and UVA. Results: Logistic statistic analysis of the data revealed that age [odds ratio (OR)=7.5, 95% confidence interval (CI)=1.87–30.16], pack-years (OR=5.8, 95% CI=1.72–19.87), and sun exposure (OR=2.65, 95% CI=1.0–7.0) independently contributed to facial wrinkle formation. When excessive sun exposure (>2 h/day) and heavy smoking (35 pack-years) occurred together, the risk for developing wrinkles was 11.4 times higher than that of non-smokers and those with less sun exposure (<2 h/day) at the same age. The in vitro studies revealed that MMP-1 expression was significantly increased in fibroblasts after the stimulation with either tobacco smoke extract or UVA. Maximum induction was observed when cells were treated with tobacco smoke extract plus UVA, indicating that the two factors act in an additive manner. MMP-1 induction was significantly higher in the low glutathione (GSH) content fibroblast compared to that in the high GSH fibroblast, indicating that the differences in glutathione content define the susceptibility of fibroblasts towards UV- or tobacco smoking-induced MMP-1 expression. Conclusion: Tobacco smoke and UVA cause wrinkle formation independently of each other. We propose that both factors cause aging of human skin through additive induction of MMP-1 expression.