Achieve Beautiful Skin: Hormones & Diet

Mark Tager, MD

That is a long story, and it goes way back to being one of the OGs in wellness. I did. I went to Duke Medical School, where I helped start the first nutrition class for medical students and the first elective course on nutrition for medical students. I went into family practice, and I was in Oregon, and I set up the Institute of Preventive Medicine in Portland, Oregon, in the 1970s. I would see patients for an hour at a time and teach classes. I got to teach a Monday night yoga class and then went on to Kaiser Permanente, where I did direct health promotion for the northwest region. But I have always had this incredible interest in wellness. Then it got married to aesthetics, and about 20 years ago, I created the FRAX laser with some colleagues. I have always looked at ways that we have to support and engage patients and consumers in taking better care of themselves. 

Today is great because we have so many tools that we can provide to people. That is the exciting part of things. I have always had this love for nutrition and wellness and the workings of the autonomic nervous system. I would like to say that I am a recovering family doctor who has seen the light. Fortunately, there are many clinicians these days who are doing integrative, functional, anti-aging, and holistic work. I do not feel so alone anymore, as I felt that way way back in the seventies.

Felice Gersh, MD

Well, I am in your camp, as  I was just, yeah, so excited to learn about all the different areas that you have been involved with and this new area where you have talked about and written about nutrition and the role of food, hormones, and skin. Maybe you could just walk us through from the beginning. Well, first of all, acne, which is devastating to women with PCOS, is often recalcitrant cystic acne. But what exactly is acne, and what is its relationship to hormones? Then we will talk about how to try to improve it.

Mark Tager, MD

Absolutely. Let us look at this entire category. 90% of women with PCOS will have one or more skin conditions. There is certainly a very prevalent acne. But rosacea causes hair loss, hair thinning, excessive hair growth, and facial. They may get a condition called acanthus nigricans, which is associated with high insulin levels, rashes, eczema, and dry skin. What we see is this incredible melding of forces to cause acne. We will see the hormonal changes. We will see insulin resistance and elevated glucose levels. We will see these hormonal changes that drive sebum production that drive these changes in the skin. Acne becomes a large concern. 

Now, what is interesting is that we are beginning to learn more about the genetics of acne. There is a test company called Fagron, F-A-G-O-R-N, and they make an acne genetic test to see which women will be more prone to developing scarring or pigment and also which medications will work the best based on people’s pharmacogenetics. We each have our genes, and these genes help determine what works for us and what does not work for us. For example, for one person, minoxidil or minocycline might work well, for someone else it would not. We are beginning to see acne, certainly with greater sophistication in treatment. But with so much of this, the skin changes. The skin improvement that we want mirrors everything we are doing in the whole body as well. All of the recommendations that you make to your patients about weight and diet lifestyle supplements transfer over to the skin.

Felice Gersh, MD

Well, the skin is certainly a huge organ. It is a complex organ. Maybe you could walk us through a little bit more about the skin. In terms of there being oil, there is sebum, there is. Now we know there is a whole microbiome in the skin. There is a different layer. There the different moisturizers, and there is collagen. Maybe you could tell us a little bit about what exactly skin is, what keeps it healthy, and then what is going wrong with it. From all of these factors coming together, the perfect storm in women with PCOS created all these skin problems.

Mark Tager, MD

For sure. Well, let us start with the anatomy. You have essentially three layers: the epidermis, the dermis, and then the hypodermis. The epidermis, if you think about it, is interesting. If you could pull out one hair from your head, I cannot do it. But the width of your epidermis—that is the width of your epidermis. A cross-section of the width of a hair The epidermis is essentially critical for keeping moisture in the skin. It is the first line of barrier protection. It is the beginning of immunity, as we have these cells that participate in immune health. But the dermis is where the real action is. There are two layers of the dermis. We see that that is where the blood vessels are. That is where the nerves are. That is where the immune cells are. That is where the stem cells are. We have something called the DE junction, which is the junction between the epidermis and the dermis. This is an undulating layer, and that is where stem cells reside. Stem cells also reside in the hair follicles. We have this incredible system of protection and barrier protection in the epidermis and the action where we have the nerve fibers, and the blood vessels. It is interesting because the skin keeps things out. That is its job. It is a lot of things that moisturize patients, certainly, but the skin is a pretty tight barrier. If we think about it, between five and about 8% of the blood flow goes to the skin. This is where we are bringing the nutrients, the essential nutrients, into the skin from the blood vessels, as opposed to trying to shove these nutrients into the skin. In topicals, it is both. 

I have a book called Feed Your Skin. I answer four questions. What should I eat, what supplements should I take, what procedures should I have, and what topicals should I apply? The recommendations we make for skin health and beauty are even more important. Because you are the perfect storm, we have hormones; we have the sad diet, which is, if you look at acne, the studies show that, wait, go back and tell a funny story. You and I had dinner one night a couple of months ago, and we reflected upon our medical training, in which we were dinosaurs, then. When you were to ask a dermatologist, Hey, does diet have anything to do with acne? They say, No, it has nothing to do with acne. Now there are still some dermatologists who say that, but we know that dairy, sugar, and fatty foods all contribute to acne. Throw in hormones, a little zinc deficiency, and other mineral deficiencies. That is what you mentioned—the perfect storm.

Felice Gersh, MD

Well, in looking at the skin or many different areas of the skin impacted, when you have PCOS, you mentioned all these different layers. Is it a layer-wide issue? The barrier function is impaired and are the moisturizing capabilities and the blood flow to the skin? All of these things are part and parcel of the development of acne in women with PCOS.

Mark Tager, MD

Yes, what we have is the coming together of several factors. We have inflammation, which is systemic inflammation. We have the changes that take place in the gut and the gut microbiome as a result of these hormonal changes, as well as dietary changes as a result of those changes. What we are learning now is that there is a gut-brain-skin axis, and that is the triangle. What you eat and your hormonal state affect the bacteria in your gut. Now, I often ask people to tell me how much they think their brain weighs, and it shocks people, they go anywhere from half a pound to 10 pounds, and it is about 3 to 4 pounds. Well, the bacteria in your gut weigh about the same amount. We have to think of our gut bacteria as an organ. 

Now, what they do is produce neurotransmitters and short-chain fatty acids. Now, for the short-chain, let us take the short-chain fatty acids first. What they do is produce butyrate. It is essential for the lining of the gut, but it also produces propionate and acetate. Acetate goes throughout the body, and we will see that in the skin. People with acne often have very low levels of acetate, which is a short-chain fatty acid that is critical. What do we do when we start trying to change the microbiome with fiber, primarily with fiber, with some probiotics, and with dietary changes? We are trying to feed the bacteria, particularly one bacteria. It is known as Akkermansia. It is one of the commensal good bacteria, and Akkermansia is what is producing the acetate. There are some companies,  that have, for example, probiotics that stimulate Akkermansia to produce more lactate, and that lactate is helpful for the skin.

The other thing is that these bacteria interface with the nervous system. This is where a lot of the antioxidants work. They tickle, and they produce substances that tickle the vagus nerve, the afferent fibers of the vagus nerve that go to the brain, that send signals down to decrease inflammation in the spleen and the macrophages. There are these wonderful connections and these cycles that come together. This is why we say that so many of these conditions begin in the gut. If you look at and there have been studies on this, if you look at the diet of women with PCOS, you just analyze those diets. They do not consume a good diet. They are deficient in fiber. They are deficient in omega-3s, calcium, magnesium, zinc, and vitamins in particular. There is niacin, for example, which is deficient. We see this constellation that mirrors the standard American diet, but it is often worse because we see it, and the effects are worse because they are magnified because of the hormonal and insulin resistance kinds of activities going on.

Felice Gersh, MD

Well, so it certainly would seem that the limited approach that many doctors and patients are taking, which is just putting on topicals, is missing the boat. What is going on in the gut needs to be addressed. Otherwise, you are just fooling yourself, that you are solving the problem. Would that be a good way of thinking about it?

Mark Tager, MD

We both subscribe to the overarching philosophy of root-cause medicine. This is what distinguishes the kinds of care that functional integrative practitioners practice. What we have done is siloed health care into various efficient little silos of 12 or 15 minutes. You get one problem, and you get one chief complaint. If it is a GI or GI doctor, you go to an endocrinologist; if it is cardiology, you go to a cardiologist. What we need to do is look across these multiple symptoms, and we will always come back to lifestyle, exercise, diet, and stress management. Now, what is the problem with that? The problem is that you look at the traditional allopathic system, which is great for acute care and great for surgical interventions. It is not set up to spend time and energy on a root cause medicine. This is where the analysis of exercise and diet comes in. 

Now just let us take PCOS. One of the things we know is that intensity of exercise and resistance training are more important than duration. We want to be able to have patients with PCOS do more intensity in their workouts. It does not imply that it has to be as long. Then also getting that resistance training now. The other thing is that we have to first begin with diet because you and I both know that you cannot supplement a poor diet. You can make all the supplement recommendations in the world. But if someone is going home and eating all of this refined sugar, 125 pounds a year, if they are eating this high-fat, high-carb diet, nothing, we can recommend supplements, but they fail in comparison to the importance of making dietary changes. Now I subscribe to something that Dr. Jeffrey Bland said not terribly long ago, and that is that we have to think of supplements as conditionally essential nutrients.

In this case, that condition is PCOS. Some essential nutrients can be helpful. I think that if you want to be able to ramp up AMPK, so much of diseases are tied to mitochondria. Mitochondria, the little energy factories, are organelles that produce the energy in the body, and AMPK is an enzyme that turns this up and turns up the burning of energy. It is a little thing. We can turn up AMPK, in several ways. One of the best ways is with berberine. There has been a big movement for Berberine. It is one of those energy sinks. It goes ahead and turns up the AMPK. It does this fairly naturally. It is fairly safe. You do not want to take it when you are pregnant or breastfeeding. It is also contraindicated if you are taking metformin because you get additional GI symptoms, but it has good effects on the glucose issues faced by women with PCOS and can also help reduce cholesterol. 

One of the problems is that it is not very well absorbed, and there is one of the brands, Enzymedica, that has a version that is coated with phytosomes. It is a berberine phytosomes, and that enables better absorption because, left to its own devices, berberine is not well absorbed. I think that is an important thing. Vitamin D is critical. It increases insulin synthesis, and its release is also important for the barrier protection of the skin, along with omega-3. If we think about it, we have all heard about leaky guts, but there is leaky skin as well. The gut lining and the skin are pretty similar in terms of what they do. But we want to keep this skin barrier intact, and vitamin D plays a role in that particularly, the very important omegas. Fish oils and flaxseed oil are excellent for this as well. Then, there is all of the antioxidant support we want to get from green tea, and xanthan, but all of the vitamin C is important. All of these things combined, but they are conditionally essential nutrients based upon getting people to first change their diets. They have got to move towards a Mediterranean diet. The keto diet has also been shown to be effective for women with PCOS.

Felice Gersh, MD

In terms of letting us go backward, by the way, I am also a big fan of Berberine, and letting us go backward to start you talked about with your book, with the diet, you said the three things. Let us start with diet. A lot of people know you should not eat a lot of processed foods, but maybe just give an overview of what are some of the key foods that every woman with PCOS should try to include in her diet on a daily or weekly basis. Maybe just walk through the diet a little bit more.

Mark Tager, MD

Yes. Where you want to go is, first of all, where you want to rely heavily on plants. If you think about it, I go out to my garden and I see all these colorful plants, and I know that when I am eating the rainbow, I am getting all of the phytonutrients that are important for my health. I am also getting fiber, and fiber if you think about it, is the food for the good bacteria in the gut; that is where fiber comes from. You feed the gut bacteria fiber; they make those short-chain fatty acids; they make the neurotransmitters. But it is hard because so many of their recommendations are to eat less of this or avoid it. We have got to get away from fried foods, chips, French fries, corn chips, saturated fats, butter, and margarine, cut back on red meat, and keep away from processed snacks. If it is manmade, either it is a manmade snack that is what you want to keep away from, or you can decrease your packet and get into the habit of reading labels. Look for added sugars. There are some things that, quote-unquote, are protein bars, and you see massive amounts of added sugars kept away from the prepared cereal, high in sugar, in snow meals, and sugary beverages. Moderate: be moderate in your alcohol use. Cut down on refined flour, white bread rolls, pizza, and crusty pasta. 

The problem is, when you go down that list, you feel, How many times have I preached this? What has to happen is a fundamental shift in mindset. This is hard to get people to do, so people make that shift and say, I am going to adopt a wellness lifestyle. I am going to move my body, I am going to manage my stress, and I am going to nourish my body in a way that gives me the energy I need to live my life, keeps me at an ideal weight, helps me manage and deal with this PCOS, and that means you turn more plants. You eat less, you are more thankful, and you eat slowly. I think those are the keys. There has to be, at some point, a fundamental shift up here to make the dietary changes. Many people do know what to do these days. They know when they are eating well and when they are not eating well. The other thing is that it is the 90% rule. 90% of the time you eat well,  and 10%, somebody’s birthday, and you are going to have a small piece of that cake. That is the 10%, but it is the 90% that we have to work on. It is when you sit with people and say, What is the key? What is the key that I can use to unlock this problem and get them motivated to make that change? That is what we all do, and that is what takes time, energy, and caring for people.

Felice Gersh, MD

Would you say that you mentioned eating the colors of the rainbow—just a diversity of different plant foods, fruits, and vegetables? Or are there foods that become certain fad foods? Are there superfoods? Do not even worry about that.

Mark Tager, MD

I am not a fan of this. Five foods to eat for PCOS and seven foods to eat for hypertension The reality is that we have got to just be more plant-based. We’ve got to stay away from the stuff that was made and made in a laboratory, in a factory. I want to minimize the additives and preservatives in food. I think that is all gimmicky. I get asked that a lot. Some journalists to tell you what the five foods are that I should always eat. Now, having said that there are some foods that you can lean on. You lean on things; you lean on your avocados, your walnuts, and your flax seed. You lean on those things. You try to get them into your diet. You lean on the sour, the fermented foods, the sauerkraut, and the kimchi. You lean on that. You lean on those fresh fruits. You lean heavily on those. You lean on seafood. Perhaps lean chicken, for example, is something that many people can lean on. You can lean on eggs. 

Now, I have to go to one of my rants, if you will let me. It has to do with the myth that we were told for so long about fats. Fats are bad. Fats are bad, for generations, our generation, and others. Yes, maybe 20 years, we threw out the egg yellows thinking, There are 300 milligrams. It is cholesterol. How bad is that? Well, your liver makes many more times that every day. It is made from saturated fat. But when you throw out the egg yellows, you are throwing out all the B vitamins, including choline, which is essential for brain function. More than 90% of people are not meeting the estimated average requirement for choline. That is one of my rants. The eggs vilified and eggs yellow have been vilified periodically. We either elevate or vilify foods. Yet it is a balance that is most important. trying to eat food that looks like it came from the ground or came from a pasture. I think that those are the important things. Then, of course, you are going to layer on top of personal beliefs. Are you vegetarian? Are you a vegan? Are you a pescatarian? You can layer those beliefs and what seems to be working for you on top of all that, as well.

Felice Gersh, MD

Now I have to ask you a little bit more about dairy, and then there is a question about fermented dairy, whether yogurt is full-fat or non-fat, or what is bad about dairy and acne. Maybe you could just tell us a little bit more about the whole issue of dairy in women with PCOS and acne.

Mark Tager, MD

Yes. Again, there was a large study that was done compiling all the research on diet, and they did find that dairy was a major contributor to acne. Now if you look at the spectrum of dairy, you have, first of all, lactose and lactose intolerance, which, by the way, is genetic. I happen to have the genes for lactose intolerance. I am very careful there. Then you have got full fat versus the skim approaches of dairy as well. People can have allergies, by the way, to proteins. They can have sensitivities to the sugars that are in dairy. What you have there is this spectrum of relationships. 

Now, some data says that when we took out the fat in milk, they replaced it with more whey, and that can cause more GI upset than full-fat milk. Fermented milk certainly got the bacteria easier. It is a natural source of bacteria, and I think that is why I recommend it. Again, this is all individual; some people do well on dairy, while others do not. You can go ahead and get an information panel on people, by the way, which is also very helpful. Or you can do dietary eliminations with folks, and I recommend that people take dairy out of their diet along with the other foods that cause very prominent allergies. Go cold turkey for 4 to 6 weeks, and then reintroduce dairy and see what happens. 

We have a genetic overlay on this, so we cannot make the blanket statement that everyone needs to avoid dairy. In some people, it provokes acne. In others, it does not. I think you want to find out where you stand on acne, each one of us, because of your genes, because of any sensitivities you have had, and because of the IgG component, the immunoglobulins. all of those combined so that we can make this general recommendation. But I think what we want to do is have more specific recommendations. IgG food testing and elimination diets to help people find out more about their relationship to dairy.

Felice Gersh, MD

Another big area that people talk about is gluten. Is there any relationship between gluten and acne? Is that an actual issue when it comes to the acne aspect of PCOS?

Mark Tager, MD

Here we have Frank’s Celiac disease which affects 1% of the population, and then we have other folks who are sensitive to gluten who have non-celiac gluten sensitivity, and that could be anywhere from 6 to 8% of people. Again, we have this relationship with food. Now there is a relationship when we have the genes that are around the HLA genes for celiac. This is a very significant problem for people. But what about the five, or six times more people who have some form of gluten sensitivity now that will again, have the gut, brain, and skin, we have left out the brain in this. We have just talked about skin and gut, but we have this triangle. What we will see are people with gluten sensitivity and some who will manifest with skin issues. Why? Because what is happening is in the gut, it is manifested in the skin. 

Again, what is your relationship with gluten? If you think about it, it is very complicated. Human beings have 20,000 genes; wheat has 70,000. Wheat is a much more complex organism. Many people, when they get wheat from Europe and Italy, do not have GI symptoms. But if you are having GI symptoms, very often this will manifest one way or another on the skin, and it manifests through the production of short-chain fatty acids. It manifests through the neurotransmitters that are sending signals to the brain and to the skin. If you want to begin to get great skin, you need to address the gut. That is why so many functional practitioners begin their work with the gut. Its gut work is fairly standard. You cannot remove the harmful agents from the gut. Very often you will see people with a leaky gut. What we will do is see. 

In 1975, we thought that everything in the gut was glued together—the one-cell lining was glued together. Then Japanese researchers found out what could pass between these cells into the gut. This is where the whole theory of leaky guts began. We have Zonulin, which is a protein that opens up those gates discovered by Alessio Fasano. Now we are letting all of these proteins in digested fragments enter the body. 

What happens is that they get a mimetic effect. We have these receptors, and a little protein comes along, and it looks like the protein that should be binding, but it binds in fact, and causes inflammation. We will see this in the joints, and we will see this in the skin. This is where the connection between the leaky gut and the connection to gut microbiome plays a big role in eczema and psoriasis. It is also connected to the brain as well. We do need PCOS patients to return to a serious deep dive of the gut and make sure we can fix that, get that working well, and attend to the lifestyle and diet. It is not just one thing. It is not just, take your metformin. It is a holistic approach to treatment.

Felice Gersh, MD

Well, I 100% agree. We know that even when you eat a great diet, sometimes vital nutrients can be insufficient. You already touched on some of the great supplements that can help women with PCOS deal with their acne and other aspects of PCOS. Maybe you could tell us a few more. You mentioned berberine and B, the Omega 3s, and vitamin D; are there others? It is very difficult for anyone to take 70 pills a day. I guess we have to prioritize them or take them in groups together. How do you tackle this supplement issue, and what are the key ones you would recall?

Mark Tager, MD

I handle this in the Feed Your Skin book. The answer, in many ways, depends. It depends on you, your genes, and the medications you are taking. I think that is critically important. It depends on hormonal status. It depends on the quality of the diet. It depends on the diseases that people have. There is no one answer. Now, having said that everybody wants, okay, stop, stop it. Tell me what I should take. I will tell you and give you some ways to approach it. I think that given the fact that more than 90% of people in this country have vitamin D deficiency and do not even meet the estimated average requirements of vitamin D3 K supplementation is important, and that is one of the fatty fat-soluble vitamins. You take that with the meal. vitamin D. Now the other thing is to make sure to get good, high-quality fish oil, and that is important to get your omega-3s up. I think of those as skin barrier protection. Okay. Now, 72% of people in the country say they are taking multiple daily vitamins and minerals. I am not impressed very often, but the quality of some of those supplements, and if you look at some of the most popular ones, they have all sorts of food dyes in them. They have got all sorts of magnesium stuff to bulk things up. They have got things that should not be there. I do think that a quality multiple vitamin A mineral is fine, which is a good thing. 

Now let us talk about K. That is your skin. You need antioxidant protection. Okay? Antioxidant protection means adding additional vitamin C if you need it. But I am a big fan of astaxanthin, which is a carotenoid that gives the salmon their red color. It is a great antioxidant. I recommend that again; I take that with a meal. CoQ10 is another excellent one. Then, once you start thinking about that, you are thinking about your mitochondrial health because, remember, PCOS is a mitochondrial issue. CoQ10 is particularly important because 26 million Americans take statins. Statins notoriously deplete CoQ10, and that is, in fact, maybe why we get these muscle aches and these muscle problems because we are depleting CoQ10. CoQ10 is very important as well. It gets us the mitochondria along with the most part magnesium. 

Magnesium is another key ingredient that comes in many forms, and in general, the glycine form is good, but I lean on the taurine and this little taurine that crosses the blood-brain barrier and then crosses the blood-brain barrier. Those are forms of magnesium that also cross the brain. That is a good thing. That is a nice little addition. Glycine 8 and taurine are all good magnesium sources. Magnesium is important. Getting enough calcium is good. The other thing is blood vessels’ health. We know so much more now about: you have 60,000 miles of blood vessels going throughout your body, and inflammation begins at the linings of the organs, and these cells that line the organs secrete specific angiocrines, which are little different cytokines in each organ. It is very specific. You want to try to keep the health of the linings, just like the gut. You have to protect the 60,000 miles. I am a big fan of things that protect glycocalyx. It is a little hairy lining that lines vessels in a product called Aturacil; it is remnants of the seaweed that are very protective. I am also a big fan of nitric oxide. Nitric oxide in addition to mitochondrial activity, does help with blood vessels. 

As you have taught me, if you look at these pathways, the pathway whereby we take arginine and make nitric oxide, and we also get it from nitrates that are converted over. When you manufacture nitric oxide in the body, you are taking the amino acids arginine and oxygen and an enzyme called NOS, Nitric oxide synthase, and you make nitric oxide. But what happens is, first of all, that some people have defects in the NOS3 Gene, but also that genetic enzymatic activity is dependent upon your favorite hormone that is Estradiol. You taught me this. We are looking at estradiol, and as we get decreases in estradiol, we get, and then genetically, some people have just a variance in their NOS3 Gene, so these folks are not making the nitric oxide that they need to, so we fix the hormones, but we also have to supplement nitric oxide. 

Most of that is going to be a supplement that comes from beets and arugula. Some nice little Berkeley Life makes a product. HumanN makes a product. I like the little chewable tabs, and what is fun about that is that they have these little salivary tests that you can test your nitric oxide before and afterward. The oral bacteria are critical in converting the nitrates into nitric oxide. One of the reasons that some people say we should not be using mouthwash is because what mouthwash is doing is killing off all those good oral bacteria that we need to convert the nitrates eventually into nitric oxide.

Felice Gersh, MD

Well, so glad you brought the nitrates and a little plug there for beets and other green leaf peas. I love the veggies. Nitrates occur almost every single day. This was incredibly fascinating. The whole new area of linking the gut, the brain, to the skin, which, as you said, was not that long ago, is in my memory banks when dermatologists would say, quote, It does not matter.

Mark Tager, MD

It does not matter.

Felice Gersh, MD

Or it has nothing to do with your skin, nothing to do with acne. Now, of course, we know it has everything to do with acne. This is transformational for women with PCOS. This is a little bit of information out there, guys. This is truly transformational information. I know everyone out there because the majority are dealing with these skin issues. I would love to learn more about what you are doing. Your books? I know you have many books. Of course, this is the latest one. But learn more about and from you. How can they possibly do that?

Mark Tager, MD

Well, the first thing, you want to grab: Feed Your Skin Right, it is on Amazon. They can follow me at DRMTager on Instagram. They can also hit me up on LinkedIn. I encourage you to have a bit of a LinkedIn dialog because that is just a great place to sit where we can exchange information. They could hit me up at [email protected], and then they can follow you or follow me at some of the conferences we speak at. We have an online training course, by the way, for professionals called Inside Skin Beauty, and I hope I can help you. I am pretty approachable. Questions. I am more than glad to handle some of those. If you get in touch with me in any of those ways,

Felice Gersh, MD

I cannot thank you enough, and I cannot wait to see you at some upcoming conferences. I am sure we are going to cross paths, as we always do. Thank you again so much for joining and for sharing all this vital information.

Mark Tager, MD

Thank you.