Chapter 2: The Real Root Causes of Acne
Acne vulgaris, or acne for short, is a disease that affects the skin, typically on the face, but also on the back, chest, neck, or arms. At its core, acne is a bacterial infection followed by an inflammatory response from the body. The process of acne forming is relatively straightforward:
- The body produces excess skin cells and/or sebum oil
- Dead skin cells and/or sebum oil clog the pore
- Acne bacteria swarm the clogged pore and infect it
- The body triggers an inflammatory response – creating a big, protruding, red pimple
For now, this simple process is all you need to understand about acne – pores get clogged, infection occurs, and inflammation takes over. What’s important isn’t the scientific lingo around how acne forms, but rather why this process occurs in the first place:
- Why does our body produce too many skin cells or too much sebum oil?
- Why do pores get clogged in the first place?
- Why do big, red, protruding inflammatory comedones (also known as pimples) form?
And, most importantly, why do acne products not prevent these things from happening in the long run? The answers to these questions are the root causes of acne.
Overview: The 3 Main Root Causes of Acne
While there are hundreds, possibly of thousands of biological mechanisms that can contribute to acne (far too many to list here), our current clinical research points to three main root causes playing a role in just about every type of acne: insulin (hormones), inflammation, and indigestion.
Root Cause #1: Insulin and Other Acne-Causing Hormones
When we think of “hormonal acne,” we usually think that sex hormones like testosterone and estrogen are the culprit. While this is partially true, it paints an incomplete picture of hormonal acne, and it makes us believe that acne is something that just comes up during puberty when levels of sex hormones increase, and that the acne will leave after these hormones are done.
DHT and estrogen, sex hormones found in both men and women that rise during puberty, can cause the skin to produce excess oil, which can lead to clogged pores and acne, but this isn’t necessarily the case. More than half the individuals with acne during puberty continue to have acne after puberty, and many people don’t even start developing acne until adulthood1. Even after sex hormone levels have died down, we still find ourselves with acne. Furthermore, despite rates of acne being higher than ever before, testosterone levels are actually lower than they were in previous decades[i].
Plus, remember the Aché tribe with a zero percent rate of acne that I mentioned earlier? Their adolescents undoubtably go through the hormonal transitions of puberty, yet none of them had acne. Sex hormones can contribute, or worsen, acne, but you won’t necessarily have acne if you have high levels of sex hormones.
The reason for this is simple – sex hormones aren’t the only hormones that cause acne, and in fact, there is a hormone that has an even larger effect on acne than DHT and estrogen – insulin.
Insulin is a hormone secreted by the pancreas that helps break down the carbohydrates found in food into usable energy for the body. Basically, after you eat something, a form of sugar called glucose enters the bloodstream (blood sugar). Glucose in the bloodstream isn’t really an ideal energy source for the body – it can’t be used by muscles or tissues, which need something called glycogen to function.
You can think of the body like a car. Glucose is like raw oil before it’s processed into gasoline. Cars need gasoline, and our body needs glycogen, so glucose won’t do the trick, but we can turn glucose into usable energy with a little bit of help – that help comes from insulin.
To aid in storing and using this energy, the pancreas releases insulin, a hormone that travels through the body and helps cells convert and absorb the glucose found in the blood. Some of the glucose is used by the cells, and some of it is stored as glycogen (fuel) for later.
For some of us, this process works just fine – the body releases enough insulin to fulfill its needs, but not too much or too little. Insulin by itself isn’t evil – it’s only when we have too much insulin that we begin to get into problems related to acne. This is a condition called insulin resistance, and it affects upwards of half the American population[ii]. Furthermore, it’s a huge factor in hormonal acne. Insulin resistance might seem complicated, but it’s a pretty simple process.
Imagine that you’re packing a suitcase. You finish putting all your clothes in, and now it’s time to put your shoes in. There’s still a bit of room left, so it’s not a huge deal – you’ll just jam in the shoes and close the suitcase. Oops! You forgot that you also need to pack a suit. You manage to squeeze everything in and now you are barely able to even zip the suitcase shut. Shoot! You forgot you need to pack a beach towel, too! At this point, unless you take something out of the suitcase, it seems unlikely you’re going to be able to even close it without throwing out your back.
I know it sounds like a silly analogy, but your body is a bit like this suitcase, and glucose in the bloodstream is like the extra shoes or towel that you’re trying to fit in. When you eat food, the glucose is converted to glycogen and stored in the body for future use. But when you consistently eat more carbs (or foods that spike blood sugar levels, like dairy) than you need, it becomes harder and harder to “pack” more energy into the body, because all your cells are already full of usable glycogen. To force the blood sugar into the cells, you release more and more insulin to get the same job done. Unless you use some of the energy (by exercising, walking, etc.), it’s going to be really hard for the body to pack all that glucose into the body. Repeat this cycle over and over again, and you have insulin resistance – a condition where the body releases way too much insulin anytime you eat certain foods.
Insulin and Acne
Insulin resistance is problematic for several different reasons – it’s associated with a higher risk of certain diseases, can lead to chronic fatigue, and if you’re not careful, will lead to diabetes (insulin resistance is oftentimes called prediabetes for this reason). But what we’re worried about for now is how insulin causes acne.
The most important thing to remember is that insulin doesn’t act alone – when your body produces insulin, it also produces a series of other hormones and molecules throughout the body. Many of these insulin-triggered hormones and molecules are behind the root causes of acne. There are three that we’re going to focus on here – Insulin-like Growth Factor 1 (IGF-1), Interleukin 1 Alpha (IL-1 Alpha), and Insulin-Like Growth Factor Binding Protein 3 (IGFBP-3).
I know these names probably sound complicated, but there’s no need to worry about the specifics of each. We’ll quickly go over how each contributes to acne, but the important thing to remember is that insulin is the single largest trigger for these three other acne-causing hormones and compounds.
Acne-Causing Hormone #1: IGF-1
IGF-1 is one of the single most important hormones to look at when it comes to acne. One of IGF-1’s primary roles is letting your body know how many new cells to create. It’s a growth hormone – it regulates the rate at which the body creates new cells and replaces old ones. IGF-1 is great if you’re looking to bulk up, gain muscle mass, or recover faster from workouts, but for your skin, high levels of IGF-1 is generally a bad thing.
Because IGF-1 is a growth hormone, it triggers your body to produce a ton of new skin cells. These skin cells are created far beneath the surface of the skin and slowly rise up over a period of roughly 30 days. When this big batch of skin cells reach the surface of the skin, they compete for space and resources and end up actually blocking the pore. This blocked pore is the perfect breeding ground for infection and inflammation to take hold and for acne to form.
On top of that, IGF-1 also triggers other hormones that tell our skin to produce more sebum oil. Sebum oil can easily become oxidized (damaged) and clog pores. Worse yet, IGF-1 actually decreases our ability to handle oxidative stress. When oil on the skin becomes damaged or infected, we need antioxidants to prevent further oxidation and damage from occurring, and IGF-1 decreases our body’s ability to fight this oxidation. So not only does IGF-1 trigger more skin oil to be produced, but it also hinders our ability to prevent this oil from becoming oxidized, blocking pores and causing acne. It’s no surprise that researchers have found a strong link between IGF-1 and acne[iii].
Just like insulin, the key to IGF-1 is balance. You need some IGF-1 to properly function, grow, and repair, but not too much so you’re producing tons of unnecessary skin cells. The problem in today’s world is that consuming tons of carbs and dairy is the norm, so we’re constantly producing way too much IGF-1 for our own good.
Acne-Causing Hormone #2: IGFBP-3
IGFBP-3 controls how quickly your skin cells die off and get replaced. High levels of IGFBP-3 causes skin cells to stick to each other and form rough scales on the surface of the skin. These scales then end up blocking the pore from the outside air, making it prone to infection and inflammation.
Combine IGFBP-3 and IGF-1 and you get a pretty nasty combination: too many skin cells are being produced, they stick to each other on the surface of the skin, and they’re not being shed fast enough. The end result is that you have a ton of dead, rough, scaly skin cells that can easily clog pores.
Acne-Causing Compound #3: IL-1 Alpha
IL-1 alpha is what’s called cytokine, which basically means that it’s a small compound that acts as a “signal”. IL-1 alpha signals an inflammatory response to the body, so that when the pore does become blocked and infected from IGF-1 and IGFBP-3, IL-1 helps turn it into an inflamed, red, angry pimple. In many cases, this increased inflammation is the only thing that makes an underlying acne infection visible on the surface of the skin.
Summary: Insulin-Driven Acne
Remember the process we outlined earlier on how acne forms?
- A pore becomes blocked or clogged by excess skin cells or sebum oil
- An infection takes place
- An inflammatory response is triggered
Well, these insulin-like hormones are all directly related to the physiological process of acne forming on the surface of the skin:
- IGF-1 and IGFBP-3 blocks pores
- IGF-1 increases oil production
- IL-1 and IGF-1 promotes inflammation
As you can see, insulin, and the hormones that accompany insulin, contribute to all three of the root causes of acne, which is why there is no surprise that one study found that fasting insulin levels (a good marker of insulin resistance) were over 50% higher in patients with severe acne when compared to individuals without acne[iv]. Combined with the fact that more than half of all Americans are considered “prediabetic” (in other words, they have insulin resistance), you can easily see why this is a problem for acne.
Still, like I said, insulin isn’t evil – the key is making sure you have a healthy insulin response, and if necessary, decreasing your intake of foods that produce this hormone. In the next section, we’re going to go over, in detail, the foods that trigger the most insulin and tactics that you can use to prevent insulin resistance from occurring, but for now let’s move on to the next root cause of acne – inflammation.
Root Cause #2: Inflammation
Inflammation, just like insulin, isn’t inherently bad. Basically, inflammation is our body’s basic mechanism to help heal and protect the body. It’s our natural response to foreign invaders, like toxins, bacteria, viruses, and physical damage. In moderation, inflammation is a good thing. When you get a cut or bruise, inflammation is your body’s way of making sure it doesn’t get infected. You wouldn’t survive if it wasn’t for inflammation. Inflammation only becomes problematic when it becomes chronic, or, in other words, when we have an overactive immune system that triggers inflammatory events too often.
Unfortunately, just like insulin, inflammation and chronic inflammation are more common than ever before. They can be triggered by extremely common ingredients found in everyday foods – even “healthy” foods, like yogurt, protein bars, and salad dressings. It’s no surprise that rates of both chronic inflammation and acne are at all-time highs[v].
With chronic inflammation, your immune system (which responds to threats like viruses, bacteria, and other foreign invaders) is overly active. It treats everything like a major threat, even if it really isn’t dangerous. Stress, naturally occurring infections, and even certain foods become sources of inflammation. These are routine bodily functions, but because of an overactive immune system, your body responds to them like serious threats – one of these “routine bodily functions” is, you guessed it, acne infections.
An acne infection isn’t all that dangerous or threatening to the body. It doesn’t take a large inflammatory response to make sure no damage is done, but when you suffer from chronic inflammation, your body thinks any infection is a huge threat. Even small acne infections caused by a blocked pore put your immune system on high alert. Tons of pro-inflammatory cells called cytokines are sent to the pore to clean up the mess. In order to stop this harmless acne infection, your body responds as if it were a serious cut or injury – by producing a red, protruding, inflamed comedo, or pimple.
In summary, acne is an inflammatory response – pimples are the byproduct of inflammation in response to a bacterial infection. This is yet another reason why using harsh chemicals or cleansers won’t get rid of most acne – chronic inflammation is an immune response which occurs inside the body, not on the surface of the skin. While some anti-inflammatory topicals can help with the appearance of acne, they’re only treating the surface level issue of inflammation.
That’s why it’s crucial to tackle acne at the source: by fixing the dietary imbalances and triggers that lead to chronic inflammation.
How Our Consumption of Unhealthy Fats Cause Chronic Inflammation
Just like the other root causes of acne, chronic inflammation is largely a side-effect of our modern diet and lifestyle. The main culprit: our increased consumption of unhealthy, industrialized fats.
Note: Digestive issues and food intolerances are also a major cause of both inflammation and insulin, which is why I consider them to be their own root cause – for this reason, they will be covered in the next section. All the root causes connect with each other and influence one another.
Before we even get into this topic, I need to start out by saying that fat is not evil. In fact, many fats are extremely healthy for you and your skin. I actually recommend that most individuals struggling with insulin and inflammation-related acne start out by decreasing carb consumption and increasing healthy fat consumption (again, we’ll cover this in the next section).
The problem isn’t fat in general, but a specific type of fats that are inflammatory, known as polyunsaturated omega-6 fatty acids. For years the USDA told us that in order to be healthy, we needed to avoid healthy, saturated fats and instead eat plenty of whole grains and refined carbohydrates. The end result is that both consumers and food producers alike have replaced these healthy fats (like coconut oil, extra-virgin olive oil, and ghee butter) with unhealthy, acne-causing industrial fats (like vegetable oils and margarine).
The reason for this is pretty straightforward – these seemingly healthy fats look a lot better on a nutrition label. If you believe that “saturated fat is evil,” then these processed, low-saturated-fat vegetable oils, like canola, corn, or sunflower oil, seem like they’re a lot better for you than saturated fats like coconut or olive oil. In reality, the exact opposite is true. It’s not saturated fat we need to worry about, but polyunsaturated fat.
Polyunsaturated Fats, Omega-3, Omega-6, and Inflammatory Acne
In the world of fats, none are more important for how our body handles inflammatory responses than polyunsaturated fats, and more specifically, two types of polyunsaturated fats – Omega-3 and Omega-6:
- Omega-3 Fats: Anti-inflammatory. More Omega-3s means less inflammation, which means less acne
- Omega-6 Fats: Pro-inflammatory. More Omega-6s means more inflammation, which means more acne
Your body needs both fats to thrive. Omega-6 isn’t completely evil – it’s necessary for brain development, hair growth, and a well-functioning immune system, it’s just that too much omega-6 can lead to chronic inflammation. Basically, you need to balance the amount of omega-6 fatty acids you eat with omega-3 fatty acids, otherwise you’re likely to trigger large inflammatory responses.
Before humans started consuming vegetable and seed oils, it’s estimated that our omega ratio, or the amount of omega-6 fats we consumed versus the amount of omega-3 fats, was somewhere around 1:1, meaning we ate equal amounts of omega-3s and omega-6s. Some estimates say it was closer to 2:1, meaning we ate 2x as many omega-6s. For clear skin, an omega ratio of somewhere between 2:1 and 4:1 is ideal, meaning you want to consume no more than 2-4x as much omega-6 as you do omega-3.
Now, given that information, where would you guess your omega ratio is at?
If you’re like most Americans, you probably eat a shocking 10 times more omega-6 fatty acids than omega-3 fatty acids[vi], which can lead to an increased risk of cardiovascular disease, cancer, and autoimmune disorders[vii] (which is particularly important for acne). When your omegas are out of balance your immune system is constantly on high alert, and the likelihood that your body will produce an inflammatory response to an acne infection is greatly increased.
In the next chapter, we’ll go over exactly which foods are highest in omega-6 fatty acids (and which foods are highest in omega-3 fatty acids, which are great for your skin), but for now, it’s important to realize that, just like with insulin, most of us have diets which contain foods loaded with omega-6 fatty acids, even if you’re eating “healthy” foods. Unless you have already gone out of your way to eliminate all vegetable oils from your diet, you’re probably pumping your body full of inflammation-causing fats without even knowing it.
The important thing to remember for now is this: acne is an inflammatory disease – even if an acne infection occurs on the skin, which it often does, inflammation is what makes that simple little infection a visible, bright, red, pimple or blackhead.
Root Cause #3: Intolerances and Other Digestive Issues
High consumptions of omega-6 or insulin aren’t the only culprits for inflammation-driven acne – food intolerances, reactions to certain antinutrients found in many foods, and other digestive issues also play major roles in acne – in fact, this specific type of inflammation is so important that we’re going to treat it as its own root cause under the label of “Intolerances and Digestive Issues”.
It has different triggers than other types of inflammation, and understanding this type of inflammation is absolutely crucial for beating acne from within – in fact, I would actually argue that it’s the most important, simply because each and every person will have different intolerances and digestive issues that they bring to the table. If we can understand why and where our digestive system is triggering acne-causing inflammation, we can start to beat it from within.
Digestive Issue #1: Intestinal Permeability
The first major type of digestive issue that affects people with acne is oftentimes called “leaky gut syndrome.”
Note: There is major speculation within the scientific community about both the root causes and the diagnosis of “leaky gut syndrome,” but for the time being, research seems to indicate that gut permeability, or “leaky gut,” is legitimate and associated with acne and other inflammatory or autoimmune conditions.
Leaky gut syndrome occurs when the lining of your intestine becomes damaged and allows certain chemicals and nutrients from the food you eat to “leak” into your bloodstream. These chemicals, although relatively harmless, are not supposed to be in the bloodstream. So, your body does what it would do for any threat – it triggers an inflammatory response.
It’s easy to see why this is a problem – if an inflammatory response is being triggered every time you eat, it’s nearly impossible to avoid chronic inflammation and the acne that comes with it.
But what causes leaky gut syndrome in the first place?
Usually, the intestinal lining that protects your body from these leaks becomes damaged over years due to the repeated consumption of potent antinutrients called lectins.
Most of the foods we eat have lectins in them, and in moderate doses they pose no real threat. Plants use lectins to protect themselves from being eaten in the wild – it’s their best attempt to make themselves indigestible in order to fight off any predators. If a berry has potent enough lectins to make a squirrel trying to eat it sick, then the berry survives and “reproduces”, so to speak.
Just about every plant or seed has lectins in it. Some of these, humans can digest extremely well, like the lectins found in most fruits and vegetables. Some of them we really can’t handle, and they enter our intestine totally undigested. These undigested lectins can actually permeate, or penetrate, our intestinal wall, and enter our bloodstream. In other words, they “punch holes” in our gut, which allows chemicals to leak through into the bloodstream and trigger an acne-causing inflammatory response.
When this intestinal wall continues to become weaker and weaker, more and more foods can pass through and trigger an inflammatory response. That’s why people with leaky gut syndrome may become intolerant to foods they’d otherwise be fine with – eggs, meats, certain vegetables, etc.
Thus, avoiding lectins and other antinutrients that can contribute to leaky gut syndrome is crucial for clear skin – in the diet section we’ll go over all the foods to avoid if you’re sensitive to lectins, or if you commonly break out after eating certain foods.
Digestive Issue #2: An Unhealthy Gut Microbiome
You’ve probably heard of the gut microbiome, which is the colony of microorganisms (bacteria, fungi, yeast, etc.) living in our body that aid with digestion. We need the gut microbiome to help break down food, absorb nutrients, and protect the body. In fact, the connection between the gut microbiome and just about every other part of our body has been explored greatly in the last several years, and it’s been shown that our gut microbiome doesn’t just influence how well we digest food, but also how we feel and think throughout the day.
Now, just like leaky gut, our microbiome has a huge impact on how well our body can digest certain foods – research shows that there is a very special, intimate relationship between the gut microbiome and the health of our intestines, which means that if we’re not careful, an unhealthy gut microbiome can actually increase the permeability of our intestine and lead to inflammatory acne[viii].
Furthermore, research also shows that a lack of diversity in the gut microbiome (oftentimes due to antibiotics) can be to blame for food intolerances that trigger inflammation-causing allergic reactions[ix]. It’s important to note that these allergic reactions oftentimes aren’t full-blown life-or-death ordeals– they can express themselves in various ways, including inflammation and acne.
Lastly, an unhealthy and unbalanced gut microbiome is associated with considerably higher rates of stress, depression and anxiety, all of which can also contribute to acne[x].
It makes sense that because our gut microbiome touches just about every aspect of our health, that it is also connected to acne, but it’s important to realize that research on the microbiome is an extremely new field of research. That’s why, contrary to what you might think, I actually don’t recommend taking a ton of probiotics or natural anti-fungal or anti-bacterial remedies to heal the gut microbiome – oftentimes this strategy can do more harm than good. We’ll cover natural probiotic-rich foods in the Diet section, and later go over the select probiotics I do recommend in the Supplements chapter.
Digestive Issue #3: Intolerances
In addition to the two clear-cut issues above, many people have other food intolerances that might not strictly fall into one of those two categories. Maybe, for whatever reason, there are foods that you just cannot digest properly, and when you eat them your body triggers an inflammatory response. You may have a perfectly good gut microbiome and a healthy intestinal wall, but still elicit an inflammatory response – tree nut allergies in healthy individuals is a good example of this.
Because of this, I have outlined a simple protocol that we will use in the Diet section of the book to find out which foods you may be intolerant to without having to take super expensive tests.
Side Note: SIBO, Candida, and Other Fungal/Yeast/Bacterial Issues
In addition to basic gut microbiome issues, there are also more serious and severe bacterial, fungal, and yeast-related disorders that can contribute to acne. Some of these include small intestine bacterial overgrowth (SIBO), small intestinal fungal overgrowth (SIFO), and candida, amongst many others.
These are really in their own category, because they influence all three aspects of the digestive issues that can lead to acne – they can alter the gut microbiome, can increase or alter intestinal permeability, and can even lead to intolerances.
As I briefly mentioned above, treating any one of these disorders is extremely problematic if you don’t know what you’re doing – most doctors will recommend taking a round of antibiotics, which can essentially destroy colonies of beneficial bacteria, dramatically weaken the immune system[xi], and of course, in the long run, lead to more acne. On the other hand, even trying to treat these issues with natural antifungals or antibacterials (oregano oil, berberine, capric acid, etc.) can also lead to challenges. While these won’t do as much damage as a prescription antibiotic, these “natural” alternatives nevertheless have the potential to wipe out good bacteria and decrease overall gut health.
Many books or bloggers take a relatively haphazard approach when it comes to diagnosing and treating these extremely serious conditions. Time and time again, I’ve seen this process leading to forums full of individuals following certain “SIBO” protocols without even knowing if they have SIBO. They’re pumping themselves full of natural antifungals and doing far more harm than good, reporting lethargy, brain fog, and difficulties digesting foods they used to be fine with, only to be met with comments about how they’re going through a “detoxing” process that can’t be found in any scientific literature.
That’s why our approach to these ailments will be a diet-first approach, followed by proper testing and, if applicable, a natural anti-fungal, anti-viral, and anti-bacterial regime. But for now, don’t worry about this – as I said, in any case, diet comes first, even if you wish to treat these ailments with some added medicines. We’ll cover diet in great detail in the next section and have a specific Bacterial/Yeast Overgrowth Protocol you can follow in the Protocols section.
Digestive Issues Summary
In a nutshell, intolerances and digestive issues are mainly why it’s so tricky to treat acne – while most people will respond relatively similarly to different insulin-spiking or inflammatory foods, many people have problems with safe foods that are low in carbs, high in nutrients, and low in inflammation-causing omega-6 fatty acids.
Time after time, I’ve heard from clients that cutting out a particular food was the key factor they needed to beat acne, but you’d be amazed at which foods it is – seemingly safe foods, like spinach, broccoli, blackberries, avocados, or even beef can cause certain people issues. Yes, of course, all of these people had already cut out the biggest offenders of insulin and inflammation-driven acne, including most grains, processed foods, and sugar, but still, the food that makes all the difference is often just something that you’re intolerant to.
Putting It All Together: The Real Root Causes of Acne
While there are hundreds, possibly even thousands of triggers for acne, when we look at the underlying physiological mechanisms for why acne forms, it almost always comes through one or more of these pathways.
As an example, poor sleep is correlated with higher rates of acne[xii]. Why is this? Well, sleep loss or deprivation leads to increased biomarkers of inflammation[xiii], insulin resistance[xiv], and potentially even decreased diversity of the gut microbiome[xv]. Poor sleep, in itself, is a cause of acne only as it increases insulin resistance and inflammation, and damages our digestive system.
To really just nail the point home, let’s take a look at how all three causes actually impact the biological process of acne infection and inflammation that lead to pimples:
Insulin and insulin-driven hormones cause an increase in skin cell and sebum production, which makes it more likely for pores on the skin to become clogged with oil or dead skin cells and become infected by acne bacteria. Once the bacterial infection takes place, inflammation causes the infection to become bright, red, and protruding – a pimple forms.
There are many factors that can cause inflammation, but chief among them are dietary intolerances and digestive problems, along with other inflammation-causing compounds triggered by insulin.
It’s important to remember that all of the root causes act together – insulin triggers and increases biomarkers for inflammation while our gut microbiome can actually influence the amount of acne-causing insulin we release, and so on. For this reason, tackling just one of the root causes isn’t going to be sufficient to get rid of acne. We need to get to the source and tackle all three issues with our diet and lifestyle.
Thanks for Reading!
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[ii] New CDC report: More than 100 million Americans have diabetes or prediabetes | CDC Online Newsroom | CDC. (2017, July 18). Retrieved February 2, 2021, from CDC Newsroom website: https://www.cdc.gov/media/releases/2017/p0718-diabetes-report.html
[iii] Cappel, M., Mauger, D., & Thiboutot, D. (2005). Correlation between serum levels of insulin-like growth factor 1, dehydroepiandrosterone sulfate, and dihydrotestosterone and acne lesion counts in adult women. Archives of Dermatology, 141(3), 333–338. https://doi.org/10.1001/archderm.141.3.333
[iv] Emiroğlu, N., Cengiz, F. P., & Kemeriz, F. (2015). Insulin resistance in severe acne vulgaris. Advances in Dermatology and Allergology, 4(4), 281–285. https://doi.org/10.5114/pdia.2015.53047/
[v] Bosma-Den Boer, M. M., Van Wetten, M. L., & Pruimboom, L. (2012). Chronic inflammatory diseases are stimulated by current lifestyle: How diet, stress levels and medication prevent our body from recovering. Nutrition and Metabolism, Vol. 9, p. 32. https://doi.org/10.1186/1743-7075-9-32
[vi]Kris-Etherton, P. M., Taylor, D. S., Yu-Poth, S., Huth, P., Moriarty, K., Fishell, V., … Etherton, T. D. (2000). Polyunsaturated fatty acids in the food chain in the United States. American Journal of Clinical Nutrition, 71(1 SUPPL.), 179S-188S. https://doi.org/10.1093/ajcn/71.1.179s
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[ix] Plunkett, C. H., & Nagler, C. R. (2017). The Influence of the Microbiome on Allergic Sensitization to Food. The Journal of Immunology, 198(2), 581–589. https://doi.org/10.4049/jimmunol.1601266
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[xiii] Mullington, J. M., Simpson, N. S., Meier-Ewert, H. K., & Haack, M. (2010, October). Sleep loss and inflammation. Best Practice and Research: Clinical Endocrinology and Metabolism, Vol. 24, pp. 775–784. https://doi.org/10.1016/j.beem.2010.08.014
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