Does Chocolate Cause Acne?

Does Chocolate Cause Acne?
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What are the effects of dairy products, sugar, and chocolate on the formation of pimples?

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Below is an approximation of this video’s audio content. To see any graphs, charts, graphics, images, and quotes to which Dr. Greger may be referring, watch the above video.

Acne affects nearly one in ten people in the world, “making it [perhaps] the eighth most prevalent disease worldwide.” What’s the role of nutrition? Well, go back a century, and dermatology textbooks were recommending various dietary restrictions. For example, recommending those with acne avoid foods like “pork, sausage, cheese, pickles, pastries,…sweets, cocoa, and chocolate.”

Yeah, but old-timey medicine was full of crackpot theories. Dr. Kellogg, for example, blamed acne on masturbation. Nothing a few corn flakes couldn’t fix, though!

Population studies have found associations between acne and the consumption of foods like dairy, sweets, and chocolate. But, you don’t know if it’s cause and effect until you put it to the test. There have been high quality reports, like the Harvard Nurses study, that looked at nearly 50,000 women, and found a link between adolescent milk-drinking and acne—particularly skim milk, something that’s been found for teenage boys as well.

They thought it might be the hormones in milk that were responsible. But, it could also be the milk protein, whey—of which they add extra to skim milk to make it less watery—which may play a direct role in acne formation or as hormonal carriers. That would explain cases like this, where whey-protein powders were implicated in precipitating acne flares in teens who had acne that just didn’t seem to want to go away, until they stopped the whey. It doesn’t appear to just be a protein effect, since soy-protein supplements, for example, did not seem to cause the same problem.

But, for dairy, in terms of interventional studies, all we have are these kinds of case series. If you do a systematic review of acne and nutrition, you get results like this for dairy: out of the 20 or so papers on acne and dairy out there, about three-quarters suggest adverse effects, and the remainder report no effect, with no studies suggesting a beneficial effect of dairy on acne. So, you could look at this and conclude a dairy-free diet is worth a try. But, this is based on low-grade evidence, level C and D evidence, where C is like the population studies, and D is like those series of case reports. What we want, ideally, are randomized interventional studies—level A and B evidence, which we don’t have for dairy, but we do have for chocolate.

When it comes to acne, no food is “more universally condemned than chocolate.” So, if you’re the “Chocolate Manufacturers Association,” how are you going to design a study to make your product not look so bad? Well, you can always use the old drug company trick of pitting your product against something even worse. And so, they fed people chocolate bars, versus fake chocolate bars made out of partially hydrogenated vegetable oil: trans fats. So, make it have more sugar, throw in some milk protein, and make it 28% pure trans-fat laden, Crisco-like vegetable shortening. And, surprise, surprise, there were just as many pimples on the fake chocolate bars— allowing them to conclude that eating high amounts of chocolate is A-OK when it comes to acne.

And, the medical community fell for it. “Have we been guilty of taking candy away from babies?” “Too many patients harbor the delusion that their health can somehow be mysteriously harmed by something in their diet.” That original study “finding that chocolate consumption supposedly does not exacerbate acne has continued to remain virtually unchallenged for decades and continues to be cited even in…recent review[s].” For example, this pediatrics journal. Years ago, it was “demonstrated that chocolate consumption had no effect on acne.”

“…[T]his serves as a cautionary example of how ‘research-based evidence’ should be vigorously scrutinized prior to being incorporated into clinical practice.” Just because something is published in the Journal of the American Medical Association doesn’t necessarily mean it’s a good study— especially when industry interests are involved.

Maybe we should be telling acne patients to try cutting down on not only the sweets and the dairy, but also the trans fats found in partially hydrogenated vegetable oils. But, we can’t “be unequivocal in [our] advice to acne sufferers” on foods to include or exclude until they’re put to the test in “well-designed randomized controlled clinical trial[s].” But, there simply weren’t any such trials on acne, until, now—which we’ll cover, next.

Please consider volunteering to help out on the site.

Image credit: congerdesign via Pixabay. Image has been modified.

Motion graphics by Avocado Video.

Below is an approximation of this video’s audio content. To see any graphs, charts, graphics, images, and quotes to which Dr. Greger may be referring, watch the above video.

Acne affects nearly one in ten people in the world, “making it [perhaps] the eighth most prevalent disease worldwide.” What’s the role of nutrition? Well, go back a century, and dermatology textbooks were recommending various dietary restrictions. For example, recommending those with acne avoid foods like “pork, sausage, cheese, pickles, pastries,…sweets, cocoa, and chocolate.”

Yeah, but old-timey medicine was full of crackpot theories. Dr. Kellogg, for example, blamed acne on masturbation. Nothing a few corn flakes couldn’t fix, though!

Population studies have found associations between acne and the consumption of foods like dairy, sweets, and chocolate. But, you don’t know if it’s cause and effect until you put it to the test. There have been high quality reports, like the Harvard Nurses study, that looked at nearly 50,000 women, and found a link between adolescent milk-drinking and acne—particularly skim milk, something that’s been found for teenage boys as well.

They thought it might be the hormones in milk that were responsible. But, it could also be the milk protein, whey—of which they add extra to skim milk to make it less watery—which may play a direct role in acne formation or as hormonal carriers. That would explain cases like this, where whey-protein powders were implicated in precipitating acne flares in teens who had acne that just didn’t seem to want to go away, until they stopped the whey. It doesn’t appear to just be a protein effect, since soy-protein supplements, for example, did not seem to cause the same problem.

But, for dairy, in terms of interventional studies, all we have are these kinds of case series. If you do a systematic review of acne and nutrition, you get results like this for dairy: out of the 20 or so papers on acne and dairy out there, about three-quarters suggest adverse effects, and the remainder report no effect, with no studies suggesting a beneficial effect of dairy on acne. So, you could look at this and conclude a dairy-free diet is worth a try. But, this is based on low-grade evidence, level C and D evidence, where C is like the population studies, and D is like those series of case reports. What we want, ideally, are randomized interventional studies—level A and B evidence, which we don’t have for dairy, but we do have for chocolate.

When it comes to acne, no food is “more universally condemned than chocolate.” So, if you’re the “Chocolate Manufacturers Association,” how are you going to design a study to make your product not look so bad? Well, you can always use the old drug company trick of pitting your product against something even worse. And so, they fed people chocolate bars, versus fake chocolate bars made out of partially hydrogenated vegetable oil: trans fats. So, make it have more sugar, throw in some milk protein, and make it 28% pure trans-fat laden, Crisco-like vegetable shortening. And, surprise, surprise, there were just as many pimples on the fake chocolate bars— allowing them to conclude that eating high amounts of chocolate is A-OK when it comes to acne.

And, the medical community fell for it. “Have we been guilty of taking candy away from babies?” “Too many patients harbor the delusion that their health can somehow be mysteriously harmed by something in their diet.” That original study “finding that chocolate consumption supposedly does not exacerbate acne has continued to remain virtually unchallenged for decades and continues to be cited even in…recent review[s].” For example, this pediatrics journal. Years ago, it was “demonstrated that chocolate consumption had no effect on acne.”

“…[T]his serves as a cautionary example of how ‘research-based evidence’ should be vigorously scrutinized prior to being incorporated into clinical practice.” Just because something is published in the Journal of the American Medical Association doesn’t necessarily mean it’s a good study— especially when industry interests are involved.

Maybe we should be telling acne patients to try cutting down on not only the sweets and the dairy, but also the trans fats found in partially hydrogenated vegetable oils. But, we can’t “be unequivocal in [our] advice to acne sufferers” on foods to include or exclude until they’re put to the test in “well-designed randomized controlled clinical trial[s].” But, there simply weren’t any such trials on acne, until, now—which we’ll cover, next.

Please consider volunteering to help out on the site.

Image credit: congerdesign via Pixabay. Image has been modified.

Motion graphics by Avocado Video.

Doctor's Note

Even if chocolate contributed to pimple formation, is it the sugar or the milk in chocolate? What about dark chocolate? Cocoa? I discuss that in my next video, Does Cocoa Powder Cause Acne?.

For more on acne, check out:

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