Acne Vulgaris .
`
`A Disease of Wes tern Civilization
`
`Loren Cordain, PhD; Staff an Lindeberg, MD, PhD; Magdalena Hurtado, PhD;
`Kim Hill, PhD; S. Boyd Eaton, MD; Jennie Brand-Miller, PhD
`
`Background: In westernized societies, acne vulgaris is
`a nearly universal skin disease afflicting 79% to 95% of
`the adolescent population. In men and women older than
`25 years, 40% to 54% have some degree of facial acne,
`and clinical facial acne persists into middle age in 12%
`of women and 3% of men. Epidemiological evidence sug(cid:173)
`gests that acne incidence rates are considerably lower in
`nonwesternized societies. Herein we report the preva(cid:173)
`lence of acne in 2 nonwesternized populations: the Kita(cid:173)
`van Islanders of Papua New Guinea and the Ache hunter(cid:173)
`gatherers of Paraguay. Additionally, we analyze how
`elements in nonwesternized environments may influ(cid:173)
`ence the development of acne.
`
`with multiple comedones or grades 2-4) was observed.
`Of 115 Ache subjects examined (including 15 aged 15-25
`years) over 843 days, no case of active acne (grades 1-4)
`was observed.
`
`Concluslons: The astonishing difference in acne inci(cid:173)
`dence rates between nonwesternized and fully modern(cid:173)
`ized societies cannot be solely attributed to genetic dif(cid:173)
`ferences among populations but likely results from
`differing environmental factors. Identification of these fac(cid:173)
`tors may be useful in the treatment of acne in Western
`populations.
`
`Observations: Of 1200 Kitavan subjects examined (in(cid:173)
`cluding 300 aged 15-25 years), no case of acne (grade 1
`
`Arch Dermatol. 2002;138:1584-1590
`
`A CNE AFFECTS between 40
`
`million and 50 million in(cid:173)
`dividuals in the United
`States. 1 Although acne
`mainly affects adoles(cid:173)
`cents, it is also present in children and
`adults. One study found some degree of
`facial acne in 54% of women and 40% of
`men older than 25 years. 2 In this same
`group, clinical facial acne affected 12% of
`the women and 3% of the men and per(cid:173)
`sisted into middle age. Cunliffe and Gould3
`reported similar results 20 years earlier. In
`pediatric populations, the prevalence of
`acne increases with age. In 10- to 12-year(cid:173)
`old children, 28% to 61 % of the popula(cid:173)
`tion has clinically diagnosed acne, whereas
`79% to 95% of 16- to 18-year-old adoles(cid:173)
`cents are affected.+6 Even a significant per(cid:173)
`centage of children (aged 4-7 years) are di(cid:173)
`agnosed with acne. 5 Thus in the Western
`world, acne is a ubiquitous skin disease af(cid:173)
`fecting primarily adolescents but also a sig(cid:173)
`nificant portion of adults older than 25
`years.
`Few studies have evaluated the preva(cid:173)
`lence of acne in nonwesternized soci(cid:173)
`eties. However, there is suggestive evi(cid:173)
`dence in nonindustrialized societies that
`
`the incidence of acne is lower than in west(cid:173)
`ernized populations. Schaefer,7 a general
`practitioner who spent almost 30 years
`treating Inuit (Eskimo) people as they
`made the transition to modern life, re(cid:173)
`ported that acne was absent in the Inuit
`population when they were living and eat(cid:173)
`ing in their traditional manner, but upon
`acculturation, acne prevalence became
`similar to that in Western societies.
`For editorial comment
`see page 1591
`Prior to World War II, Okinawa was
`an isolated island outpost in the South
`China Sea, and its native inhabitants lived
`a rural life with few or none of the trap(cid:173)
`pings of industrialized societies. Exten(cid:173)
`sive medical questionnaires by US physi(cid:173)
`cians administered to local physicians who
`had practiced from 8 to 41 years revealed
`that, "These people had no acne vul(cid:173)
`garis."8 Dermatological examination of
`9955 schoolchildren (aged 6-16 years)
`conducted in a rural region in Brazil found
`that only 2. 7% of this pediatric popula(cid:173)
`tion had acne. 9 Dermatological examina(cid:173)
`tion of 2214 Peruvian adolescents by pe-
`
`From the Department of Health
`and Exercise Science, Colorado
`State University, Fort Collins
`(Dr Cordain); Department of
`Community Medicine,
`University of Lund, Lund,
`Sweden (Dr Lindeberg);
`Department of Anthropology,
`University of New Mexico,
`Albuquerque (Drs Hurtado and
`Hill), Department of Radiology
`and Anthropology, Emory
`University , Atlanta, Ga
`(Dr Eaton); and Department of
`Biochemistry, Human Nutrition
`Unit, University of Sydney,
`Sydney, Australia
`(Dr Brand-Miller).
`
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`diatricians demonstrated that acne prevalence (grades 1-4)
`was lower (28%) in Peruvian Indians than in mestizos
`(43%) or whites (45%). 10
`In South Africa, dermatologists found lower rates
`of acne among the Bantu 11 than among whites12 residing
`in Pretoria. Bantu adolescents (aged 15-19 years; n=510)
`maintained a 16% incidence rate of acne, 11 whereas among
`the white adolescents (n= 1822), the incidence was 45%. 12
`For the entire sample of Bantus of all ages (n=39O5) , the
`overall occurrence of acne was 2%, 11 whereas in the total
`white sample across all ages (n= 16676), the incidence
`of acne was 10%. 12 Among the Zulu it was suggested that
`acne became a problem only when these people moved
`from rural African villages to cities. 13 All of these stud(cid:173)
`ies suggest that the prevalence of acne is lower among
`rural, nonwesternized people than in fully modernized
`Western societies.
`Herein we report the absence of acne in 2 nonwest(cid:173)
`ernized populations: the Kitavan people living on the Tro(cid:173)
`briand Islands near Papua New Guinea and the Ache
`hunter-gatherers of Paraguay. Additionally, we evaluate
`how elements in nonwesternized environments may in(cid:173)
`fluence the development of acne.
`
`RI ',l ll I',
`
`THE KITA YAN ISLANDERS
`
`Population Parameters
`
`Kitava is an island belonging to a group of coral atolls known
`as the Trobriand Islands located in Milne Bay Province,
`Papua New Guinea. Kitava has a surface area of 25 krn2 and
`is home to 2250 native inhabitants who live as subsis(cid:173)
`tence horticulturalists and fishermen. Electricity, tele(cid:173)
`phones, and motor vehicles were absent in 1990. Most Kita(cid:173)
`vans live in villages of 20 to 400 people. Some Western goods
`are received from the New Guinea mainland, but the in(cid:173)
`fluence of the Western lifestyle has been minimal.
`
`General Health
`
`Cardiac death and stroke are extremely rare among Kita(cid:173)
`vans.14 Overweight, hypertension, and malnutrition are
`also absent. 14·15 Kitavans have low levels of serum insu(cid:173)
`lin, 16 plasma plasminogen activator inhibitor 1 activ(cid:173)
`ity, 17 and leptin, 18 which suggests high insulin sensitiv(cid:173)
`ity throughout life. A moderately high level of physical
`activity, roughly 1.7 multiples of basal metabolic rate in
`male subjects, is another characteristic feature.16 Three
`of 4 Kitavan men and women are daily smokers. Infec(cid:173)
`tions, accidents, cqmplications of pregnancy, and senes(cid:173)
`cence are the most common causes of death. Life expec(cid:173)
`tancy is estimated at 45 years for newborns and 75 years
`or more at age 50. Mean age at menarche is 16 years. 19
`
`of dairy products, alcohol, coffee, and tea was close to
`nil, and that of oils, margarine, cereals, sugar, and salt
`was negligible. Estimated carbohydrate intake was high,
`almost 70% of daily energy, while total fat intake was low
`(20% of daily energy). Virtually all of the dietary carbo(cid:173)
`hydrate intake was in the form of low-glycemic load tu(cid:173)
`bers, fruits, and vegetables.
`
`Methodology
`
`During 7 weeks in 1990, one of us (S.L.) visited all 494
`houses in Kitava and performed a general health exami(cid:173)
`nation in 1200 subjects 10 years or older, including 300
`subjects between 15 and 25 years. Dr Lindeberg is a gen(cid:173)
`eral practitioner whose formal training included detec(cid:173)
`tion of acne comedonica, acne papulopustulosa, and acne
`conglobata. As a practicing physician in Sweden, he regu(cid:173)
`larly examines European patients with acne ranging from
`grade 1 through grade 4.
`All subjects were examined specifically for skin dis(cid:173)
`orders, including acne. However, the examinations were
`also designed to detect a number of other common West(cid:173)
`ern diseases. Subjects were examined in daylight at a close
`enough distance to detect acne or scarring. In male sub(cid:173)
`jects, the face, chest, and back were examined, whereas in
`female subjects, only the face and neck were examined. For
`the classification of acne the following system was used:
`grade 1, comedones present ( open or closed), few pa pules
`present; grade 2, comedones and papules present, few pus(cid:173)
`tules present; grade 3, comedones, papules, and pustules
`present, few nodules present; and grade 4, comedones, pap(cid:173)
`ules, pustules, nodules, and cysts present.
`
`Dermatological Results
`
`Not a single papule, pustule, or open comedone was ob(cid:173)
`served in the entire population examined (N = 1200). Al(cid:173)
`though no closed comedones were reported, it is pos(cid:173)
`sible that they were present but undetected. Single bruises,
`scars, pa pules, or pustules of infectious origin were fairly
`common, including tropical ulcers, which rapidly healed
`following treatment with penicillin V. A number of in(cid:173)
`tramuscular abscesses were also encountered.
`
`THE ACHE HUNTER-GATHERERS
`
`Population Parameters
`
`The Ache of eastern Paraguay were full-time hunter(cid:173)
`gatherers occupying a 2OOOO-km2 area between the Para(cid:173)
`guay and Parana rivers until contact with Western civi(cid:173)
`lization in the mid-l 97Os. Following contact, the Ache
`people settled in small communities near their tradi(cid:173)
`tional foraging range and now follow a mixed hunting(cid:173)
`gathering and farming economy. Many aspects of Ache
`socioecology have been studied over the past 20 years. 20-23
`
`Diet
`
`General Health
`
`Tubers, fruit, fish, and coconut represent the dietary main(cid:173)
`stays in Kitava. Dietary habits are virtually uninflu(cid:173)
`enced by Western foods in most households. The intake
`
`Since the late 197Os, multiple lines of evidence have dem(cid:173)
`onstrated that contact with Western civilization was not
`necessarily beneficial from an overall health perspec-
`
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`

`tive. 22 Over the contact period, the Ache population has
`decreased by 30% as a result of deaths, primarily of res(cid:173)
`piratory tract infections. However, chronic diseases preva(cid:173)
`lent in urban communities (eg, diabetes, asthma, hyper(cid:173)
`tension, and other cardiovascular disease) are still absent
`or rare. 22·24
`
`Diet
`
`The Ache diet contains wild, foraged foods, locally cul(cid:173)
`tivated foods, and Western foods obtained from exter(cid:173)
`nal sources. By energy, their diet consists of 69% culti(cid:173)
`gens, 17% wild game, 8% Western foods, 3% domestic
`meat, and 3% collected forest products.25·26 The culti(cid:173)
`gens consist mainly of sweet manioc, followed by pea(cid:173)
`nuts, maize, and rice, whereas the Western goods are
`mainly pasta, flour, sugar, yerba tea, and bread.23
`
`Methodology
`
`The population was examined repeatedly over an 843-
`day period (September 1997 to June 2001), specifically
`for acne and for other skin and health disorders. I.
`Hurtado, MD, a general practitioner from the Instituto
`Venezolano de Investigaciones Cientifics, Caracas, Ven(cid:173)
`ezuela, initially examined all 115 subjects. Dr Hurtado's
`formal training included the detection and diagnosis of
`acne using the International Consensus Conference on
`Acne Classification system27 with the following catego(cid:173)
`ries: mild, few to several comedones, papules, and pus(cid:173)
`tules, no nodules; moderate, several to many comedo(cid:173)
`nes, papules, and pustules, few to several nodules; and
`severe, numerous comedones, papules, and pustules, many
`nodules. The face, chest, neck, and back of all subjects
`were examined at a close distance under bright lighting.
`Every 6 months following the initial assessment,
`identical follow-up examinations were conducted by 1
`of 6 family practitioner physicians who were also for(cid:173)
`mally trained in the detection and recognition of acne
`using either the International Consensus Conference on
`Acne Classification system27 or the ·4-grade classifica(cid:173)
`tion scheme used in the Kitavan sample. All subjects were
`regularly screened for any health problems by a health
`care worker, and all ailments were recorded in a log, in(cid:173)
`cluding rashes, skin infections, and other dermatologi(cid:173)
`cal disorders. One of us (M.H.) compiled all of the health
`care data during the observation period, including the
`dermatological data used in the present study. Over the
`observation period, the sample included an average of
`115 subjects (59 men and women 16 years or older and
`58 boys and girls younger than 16 years), including 15
`subjects aged 15 to 25 years.
`
`Dermatological Results
`
`Not a single case of active acne vulgaris (mild, moderate,
`or severe27 or grades 1 to 4) was observed in all 115 sub(cid:173)
`jects over the 843-day study period by any of the 7 exam(cid:173)
`ining physicians. One 18-year-old man appeared to have
`acne scars. Not a single papule, pustule, or open comedo
`was observed in the entire population. Although no closed
`comedones were reported, it is possible that they could have
`
`been present and gone undetected. As in the Kitava sample,
`skin infections and intramuscular abscesses were com(cid:173)
`mon and responded well to treatment with antibiotics such
`as erythromycin and tetracycline.
`
`C 01\11\11 '\/ I
`
`GENETIC AND ENVIRONMENTAL
`CONSIDERATIONS
`
`Of the 300 Kitavans at greatest risk for acne (aged 15-25
`years), not a single case of acne was observed. In a simi(cid:173)
`lar Wes tern population, some degree of facial acne would
`be found in at least 120 subjects.2·4-6 In Western popu(cid:173)
`lations the development of acne has hereditary and en(cid:173)
`vironmental components. Familial studies have demon(cid:173)
`strated that hereditary factors are important in determining
`susceptibility to acne,28 whereas twin studies have sug(cid:173)
`gested that although sebum secretion is under genetic con(cid:173)
`trol, the development of clinical lesions is modified by
`environmental factors. 29
`Clearly, genetic susceptibility to acne cannot be ruled
`out in the interpretation of our observations. However, it
`is unlikely that the effective absence of acne in the Kita(cid:173)
`van and Ache people resulted entirely from genetic resis(cid:173)
`tance to acne, since other South American Indians10 and
`Pacific Islanders30 whose ethnic backgrounds are similar
`to the Ache and Kitavans but who live in more western(cid:173)
`ized settings maintain considerably higher acne inci(cid:173)
`dence rates than those we report. Consequently, our ob(cid:173)
`servations are suggestive that elements common to the Ache
`and Kitavan environments but not present in Western
`settings may operate together with genetic factors to
`prevent acne.
`
`THE PROXIMATE ETIOLOGY
`OF ACNE VULGARIS
`
`Acne is well understood to result from the interplay of 3
`factors: (1) hyperkeratinization and obstruction of
`sebaceous follicles caused by abnormal desquamation
`of the follicular epithelium; (2) androgen-stimulated in(cid:173)
`creases in sebum production; and (3) colonization of the
`follicle by Propionibacterium acnes, which generates in(cid:173)
`flammation.31·32 The ultimate mechanism responsible for
`factors 1 and 2 is not well understood.32·33 It is likely that
`any environmental element underlying the develop(cid:173)
`ment of acne must operate via modulation of the known
`proximate or ultimate (genetic) causes.
`
`DIET AND HYPERINSUUNEMIA
`
`Although diet is infrequently considered as an etiologic
`agent in the development of acne,34 it represents a well(cid:173)
`recognized factor in acute35and chronic36·37 hyperinsu(cid:173)
`linemia. Recent evidence has demonstrated that the hor(cid:173)
`monal cascade triggered by diet-induced hyperinsulinemia
`elicits an endocrine response that simultaneously pro(cid:173)
`motes unregulated tissue growth and enhanced andro(cid:173)
`gen synthesis. Hence, hyperinsulinemic diets may rep(cid:173)
`resent a previously unrecognized environmental factor
`in the development of acne via their influence on fol-
`
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`licular epithelial growth and keratinization and on an(cid:173)
`drogen-mediated sebum secretion.
`
`HYPERINSULINEMIA AND FREE
`IGF-1 AND IGFBP-3
`
`Chronic and acute hyperinsulinemia initiate a hor(cid:173)
`monal cascade that favors unregulated tissue growth by
`simultaneously elevating levels of free insulinlike growth
`factor 1 (IGF-1) and reducing levels of insulinlike growth
`factor bindingprotein3 (IGFBP-3).38-41 Because free IGF-1
`is a potent mitogen for virtually all body tissues,42 el(cid:173)
`evated concentrations of free IGF-1 have a high poten(cid:173)
`tial for stimulating growth in all tissues, including the
`follicle.
`In support of the notion that insulin-triggered el(cid:173)
`evations in free IGF-1 levels may promote acne via hy(cid:173)
`perkeratinization are data showing that IGF-1 is re(cid:173)
`quired for keratinocyte proliferation in humans43 and that
`in transgenic mice, overexpression ofIGF-1 results in hy(cid:173)
`perkeratosis and epidermal hyperplasia. 44 Furthermore,
`women with postadolescent acne maintain elevated
`serum concentrations of IGF-145 and are mildly insulin
`resistant.46
`The reductions in IGFBP-3 levels stimulated by el(cid:173)
`evated serum insulin levels38·39 or by acute ingestion of
`high-glycemic load carbohydrates47 also may contrib(cid:173)
`ute to unregulated cell proliferation in the follicle. In mu(cid:173)
`rine knockout cells lacking the IGF receptor, IGFBP-3
`acts as a growth inhibitory factor.48 Accordingly, IGFBP-3
`is inhibitory to growth by preventing IGF-1 from bind(cid:173)
`ing to its receptor. Hyperinsulinemia indirectly in(cid:173)
`creases the number of epidermal growth factor recep(cid:173)
`tors by elevating levels of plasma nonesterified fatty acids,49
`and it also induces production of transforming growth
`factor 131. 50 Increased concentrations of these cytokines
`depress localized keratinocyte synthesis of IGFBP-3,
`thereby increasing the availability of free IGF-1 to its ke(cid:173)
`ratinocyte receptors,51 which in turn promotes keratino(cid:173)
`cyte proliferation. Consequently, hyperkeratinization of
`sebaceous follicles may result synergistically from eleva(cid:173)
`tions in free IGF-1 levels and/or reductions in concen(cid:173)
`trations of IGFBP-3.
`
`IGFBP-3 AND RETINOID RECEPTORS
`
`Insulin-mediated reductions in IGFBP-3 levels may fur(cid:173)
`ther promote unregulated follicular growth by affecting
`the nuclear retinoid signaling pathway. Retinoids are
`natural and synthetic analogues of vitamin A that
`inhibit cell proliferation and promote apoptosis. 52 The
`body's natural retinoids (trans retinoic acid and 9-cis(cid:173)
`retinoic acid) act by binding 2 families of nuclear recep(cid:173)
`tors: retinoic acid receptors (RARs) and retinoid X
`receptors (RXRs). Retinoid receptors, in turn, activate
`gene transcription by binding as RAR-RXR het(cid:173)
`erodimers or RXR-RXR homodimers to retinoic acid
`response elements located in the promoter regions of
`target genes whose function is to limit growth in many
`cell types. 53
`Insulinlike growth factor binding protein 3 is a li(cid:173)
`gand for the RXRa nuclear receptor and enhances RXR-
`
`RXR homodimer-mediated signaling.54 Studies in knock(cid:173)
`out rodents show that the RXRa. gene is required for
`actions of the 2 endogenous retinoic acid ligands (trans
`retinoic acid and 9-cis-retinoic acid) ,55·56 and RXRa ago(cid:173)
`nists and IGFBP-3 are growth inhibitory in many cell
`lines.57 Additionally, RXRa is the major RXR receptor in
`skin.58 Consequently, low plasma levels of IGFBP-3 in(cid:173)
`duced by hyperinsulinemia may reduce the effective(cid:173)
`ness of the body's natural retinoids to activate genes that
`normally would limit follicular cell proliferation.
`
`HYPERINSULINEMIA, IGF-1, ANDROGENESIS,
`AND SEBUM PRODUCTION
`
`Sebum production, essential to the development of acne,32
`is stimulated by androgens.31·32 Consequently, hyperinsu(cid:173)
`linemia may promote acne by its well-established andro(cid:173)
`genic effect. Insulin and IGF-1 stimulate the synthesis of
`androgens in ovarian59·60 and testicular61·62 tissues. Fur(cid:173)
`thermore, insulin and IGF-1 inhibit the hepatic synthesis
`of sex hormone binding globulin (SHBG),63·64 thereby in(cid:173)
`creasing the bioavailability of circulating androgens to tis(cid:173)
`sues. Cross-sectional studies demonstrate inverse relation(cid:173)
`ships between serum SHBG and insulin65 and IGF-1.66-68
`Additionally, sebum production is stimulated not only
`by androgens,31·32 but also by insulin69 and IGF-1.70 Di(cid:173)
`rect injections of recombinant IGF-1 in humans elicit an(cid:173)
`drogenesis and acne. 71 Higher serum androgen, 72 insu(cid:173)
`lin,45 and IGF-1 46 concentrations are associated with the
`presence of acne in women. Taken together, these data sug(cid:173)
`gest that the endocrine cascade induced by hyperinsu(cid:173)
`linemia enhances sebum synthesis and the development
`of acne.
`
`POL YCYSTIC OVARY SYNDROME
`
`Acne is a characteristic feature in patients with polycys(cid:173)
`tic ov~ry syndrome, who are also frequently hyperinsu(cid:173)
`linemic, insulin resistant, and hyperandrogenic. 73 These
`patients typically maintain elevated serum concentra(cid:173)
`tions of androgens and IGF-1 and lower concentrations
`of SHBG.73·75 Androgen levels can be lowered and dis(cid:173)
`ease symptoms alleviated by improving insulin sensitiv(cid:173)
`ity through weight loss76 or by use of pharmaceuticals
`such as metformin77 that improve insulin metabolism. Nu(cid:173)
`merous studies78-80 have reported that tolbutamide, an an(cid:173)
`tihyperglycemic drug similar to metformin, is therapeu(cid:173)
`tically effective in treating acne.
`
`DIETARY CHARACTERISTICS AND INSULIN
`RESISTANCE IN NONWESTERNIZED SOCIETIES
`
`Both the Ache and Kitavan diets are composed of mini(cid:173)
`mally processed plant and animal foods and are virtu(cid:173)
`ally devoid of typical Western carbohydrates that yield
`high glycemic loads that may acutely35 or chroni(cid:173)
`cally36·37 elevate insulin levels (Table). Recently accul(cid:173)
`turated hunter-gatherer populations who have adopted
`Western diets frequently are hyperinsulinemic and in(cid:173)
`sulin resistant and have high rates of type 2 diabetes,81·82
`whereas hunter-gatherer and less westernized popula(cid:173)
`tions living in their native environments rarely exhibit
`
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`Glycemlc Loads of Western Refined and Unrefined Traditional Foods*
`
`Western Refined Foods
`
`Unrefined Traditional Foods
`
`Food
`Crisped rice cereal (Rice Krispies)
`Jelly beans
`Toasted corn cereal (Cornflakes)
`Hard candy (Life Savers)
`Rice cakes
`Table sugar (sucrose)
`Shredded wheat cereal
`Graham crackers
`Wheat and barley cereal (Grape-Nuts)
`Toasted oat cereal (Cheerios)
`Rye crispbread
`Vanilla wafers
`Corn chips
`Candy bar (Mars)
`Stoned wheat thins
`Shortbread cookies
`Granola bar
`Angel food cake
`Bagel
`Doughnuts
`White bread
`Waffles
`Bran cereal (All-Bran)
`Whole wheat bread
`Croissant
`
`Glycemlc Index
`88
`80
`84
`70
`82
`65
`69
`74
`67
`74
`65
`77
`73
`68
`67
`64
`61
`67
`72
`76
`70
`76
`42
`69
`67
`
`Glycemlc Load
`77.3
`74.5
`72.7
`67.9
`66.9
`64.9
`57.0
`56.8
`54.3
`54.2
`53.4
`49.7
`46.3
`42.2
`41.9
`41.9
`39.3
`38.7
`38.4
`37.8
`34.7
`34.2
`32.5
`31.8
`31.2
`
`Food
`Parsnips
`Baked potato
`Boiled millet
`Boiled broad beans
`Boiled couscous
`Boiled sweet potato
`Boiled brown rice
`Banana
`Boiled yam
`Boiled garbanzo beans
`Pineapple
`Grapes
`Kiwi fruit
`Carrots
`Boiled peas
`Boiled beets
`Boiled kidney beans
`Apple
`Boiled lentils
`Pear
`Watermelon
`Orange
`Cherries
`Peach
`Peanuts
`
`Glycemlc Index
`97
`85
`71
`79
`65
`54
`55
`53
`51
`33
`66
`43
`52
`71
`48
`64
`27
`39
`29
`36
`72
`43
`22
`28
`14
`
`Glycemlc Load
`19.5
`18.4
`16.8
`15.5
`15.1
`13.1
`12.6
`12.1
`11.5
`9.0
`8.2
`7.7
`7.4
`7.2
`6.8
`6.3
`6.2
`6.0
`5.8
`5.4
`5.2
`5.1
`3.7
`3.1
`2.6
`
`*Glycemic load = glycemic index x carbohydrate content in 100-g portions. The glycemic reference is glucose with a glycemic index of 100.
`
`these symptoms,83-85 including other unacculturated South
`American Indian tribes.86 Neither the Kitavan islanders
`nor the Ache hunter-gatherers manifest the classic symp(cid:173)
`toms of insulin resistance. The Kitavans are not over(cid:173)
`weight or hypertensive, 14·15 and they maintain low se(cid:173)
`rum concentrations of insulin, 16 plasminogen activator
`inhibitor 1, 17 and leptin, 18 which are indicators of high
`insulin sensitivity.
`Dietary interventions using low-glycemic load car(cid:173)
`bohydrates may have therapeutic potential in the treat(cid:173)
`ment of acne because of the beneficial endocrine effects
`of these diets. Low-glycemic load diets are associated with
`a reduced risk for type 2 diabetes,87 and dietary inter(cid:173)
`ventions using low-glycemic load carbohydrates im(cid:173)
`prove insulin sensitivity.88 Furthermore, a large-scale in(cid:173)
`tervention89 has demonstrated that diets rich in low(cid:173)
`glycemic load foods reduced serum testosterone and
`fasting glucose levels while improving insulin metabo(cid:173)
`lism and increasing concentrations of SHBG. 89 These en(cid:173)
`docrine changes are consistent with those known to pro(cid:173)
`mote normal follicular cell proliferation and to reduce
`sebum production. It is possible that low-glycemic load
`diets may have therapeutic potential in reducing symp(cid:173)
`toms of acne, a disease virtually unknown to the Ache
`and Kitavans.
`
`Accepted for publication March 16, 2002.
`Corresponding author: Loren Cordain, PhD, Depart(cid:173)
`ment of Health and Exercise Science, Colorado State
`University, Fort Collins, CO 80523 (e-mail : cordain
`@cahs.colostate.edu).
`
`-------Hllliii§NC•e-------
`
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