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ABSTRACT

OBJECTIVE: To study the effects of nutrition and other lifestyle factors on hair and skin, which reflect the body's aging process, and on numerous aspects of mental, physical, and energy functioning. METHODS: The six-month program included protocols for nutrition, physical activity, supplementation, stress management, behavior modification, and personal environment factors. MEASURES: The study obtained ratings on the degree of change in 20 measures of hair, skin, and nail conditions and in 22 measures of mental, physical, and energy functioning. RESULTS: The percentage of participants who saw improvements in each of the 20 measures of hair or skin status ranged from 37.4% to 86.7%. Incidentally, we found that anywhere from 36.3% to 91.5% saw positive change in each measure of mental, physical, or energy functioning. CONCLUSION: The findings suggest that a comprehensive lifestyle intervention is an effective way to improve the condition of hair and skin and achieve changes in day-to-day functioning that can improve one's quality of life. The study also demonstrates the value of a "wellness model" in the medical paradigm, one that uses natural, nontoxic interventions to enhance the functioning of patients.

INTRODUCTION
The six-month "Hair and Skin Study" was a part of a larger, ongoing intervention study that evaluated the effect of multiple lifestyle factors – nutrition, supplementation, exercise, stress management, behavior modification, and personal environment – on objective measures of bodily functioning and overall wellness. The biological health measures of the prior study have included body weight, blood pressure, and cholesterol and triglyceride lipid levels. In this phase of the intervention, we focused on the effect of lifestyle changes on the condition of hair and skin, which are observable indicators of the aging process, and on various aspects of physical, mental, and energy functioning. Participants who entered the study had problems with hair, skin, or both.

The goal of the study was to improve the condition of participants' hair and skin. For hair, specific goals were to induce new hair growth in bald areas, slow thinning of hair, and reverse graying. These problems are caused by the aging process and/or genetic predispositions. The attempt to overcome genetic limitations was a new challenge for the intervention program. For skin, the goal was to reverse or improve the effects of sun damage and premature aging of the skin.

We designed the nutritional portion of the intervention to combat processes that cause aging and to help build the body's capacity to repair damage. The causes of aging, among others, include damage to DNA from oxidative stress, whereby free radicals attack cells and compromise their ability to function, and glycation, which creates a cross-linking of proteins and sugars that has a negative effect on cells and damages skin over time. We also had to address the process of inflammation in the body, which leads to deterioration and aging.

Therefore, we emphasized a high intake of phytonutrients in the program's largely vegetarian diet.^1-6We hypothesized that the body must be saturated with phytonutrients to have the capacity to exceed basic functions – such as repairing damage to cells, detoxifying, and preventing illness – and begin to prevent damage to DNA and actually repair it, leading to improvements in hair and skin. The question was whether people could reach the level the input needed to compensate for negative factors and allow the body to repair itself. This level of compensation, if achieved, would help to reduce system damage, reverse DNA damage, and exceed genetic limitations that had caused loss of hair or graying. We also could observe the effects of this approach on various aspects of skin health.

In addition to the focus on phytonutrients, we included all of the same protocols that were used in our prior lifestyle intervention studies. Participants had to eat the healthy foods included in our diet, exercise regularly, take recommended supplements, avoid harmful foods and environmental chemicals and toxins, manage stress, and work toward self-empowerment through behavior modification. (See discussion of the specific protocols below.)

Applying these interventions, our prior lifestyle studies have documented positive changes in a number of biological measures, including weight, impedance for body fat, blood pressure, and lipids status (total cholesterol, LDL cholesterol, and the ratio of total cholesterol to HDL cholesterol). Incidentally, prior participants also saw improvements in seven subjective measures of physical and mental functioning, including energy, immune function, mental function, sugar and carbohydrate problems, skin health, joint function, and digestion. The results suggested that people can improve their quality of life and overall wellness by optimizing such aspects of day-to-day functioning.

METHODS
The "Hair and Skin Study" included 368 people at the outset; 140 of those participants completed all aspects of the study. The participation criterion for age and hair loss was as follows: people 22 to 80 years of age had to have experienced balding, thinning, or graying of hair for at least seven years. The purpose of this parameter was to exclude people who had experienced singular life events, such as chemotherapy, infection, or stress, that may have precipitated a temporary hair loss. Many participants also entered the study with significant skin problems, such as poor skin texture and skin tone, wrinkles, acne, and blemishes.

As part of the intervention, we held a group meeting for participants every other week that included a lecture and information about diet, exercise, stress management, meditation, and supplementation. Individual questions and concerns were addressed. Participants also were required to maintain a weekly journal in which they wrote about life issues and challenges. The journal writing helped them to identify their life goals, methods of achieving those goals, and any obstacles they might encounter along the way.

To measure the results of the six-month study, we created a comprehensive, preformatted questionnaire that asked participants to rate the level of change (or lack thereof) in 20 specific measures of hair, skin, and nail condition and in 22 aspects of mental, physical, and energy functioning. The rating scale provided for five outcomes in each measure listed: worse, unchanged, improved, slightly improved, or much improved. At the end of the six-month program, we also filmed participants as they discussed any changes that had occurred with their hair, skin, and day-to-day functioning.

THE VALUE OF LIFESTYLE INTERVENTIONS
The medical literature contains a growing body of information about the importance of the lifestyle choices we make. For those people who would argue there is no scientific support for the elements of this protocol, the literature offers more than abundant evidence to the contrary. Indeed, it is the volume of studies published in scientific journals on the individual components of the intervention that proves the value of each component.

We have conducted an extensive review of the literature to identify articles on the lifestyle components included in the "Hair and Skin Study." (A listing of "Literature Citations on the Components of the Intervention" is included with this article.) These citations provide background information on the many benefits of each lifestyle change and thereby can support health care professionals in implementing such interventions with patients. One useful approach is to share some of the reference materials with patients so that they can learn about the benefits involved in each of the lifestyle changes. The references cover the following topics:

1. Nutrition
      Vegetarian diet (42 references)
      Fruits, vegetables, antioxidants, and phytochemicals (27 references)
      Meat consumption (9 references)
      Nutrition and DNA damage and repair (8 references)
2. Supplementation (14 references)
3. Exercise (46 references)
4. Stress management and relaxation
      Tai chi (9 references)
      Qi gong (14 references)
      Meditation (18 references)
      Stress management (3 references)
      Prayer (11 references)
      Yoga (7 references)
      Journal writing (6 references)
5. Self-actualization (14 references)
6. Environmental hygiene (2 references)

Among studies of lifestyle interventions, many have evaluated the effect of one lifestyle factor alone, such as diet or exercise, on participants' health.^7-9Others are multifactorial interventions that have studied the effects of two or more lifestyle factors combined, such as nutrition, physical activity, stress management, smoking cessation, and group or social support.^10-13For example, Ornish et al. studied the effect of diet, smoking cessation, stress management, and moderate exercise on patients with atherosclerosis.¹⁴ Esposito et al. investigated the effect of weight loss, diet, and physical activity on premenopausal obese women without diabetes, hypertension, or hyperlipidemia.¹⁵ Toobert et al. studied the effect of diet, stress management, exercise, group support, and smoking cessation on postmenopausal women with type 2 diabetes.¹⁶

Our study is the first we are aware of that combined the six lifestyle factors noted—nutrition, exercise, supplementation, stress management, behavioral change, and personal environmental hygiene—into one comprehensive program. We asked participants to make the changes concurrently, as do people in everyday life. This approach allowed us to study the combined effects on hair and skin and on numerous aspects of daily functioning that help determine one's well-being.

THE PROGRAM PROTOCOLS
Participants integrated the following six components of the intervention into their lifestyle:

Nutrition
The diet required by the program was largely vegetarian.^17-19(See the "Literature Citations" included with this article for nearly 40 more references on vegetarian eating.) The nutritional protocols focused on a high intake of complex carbohydrates and allowed healthy fats as well. Participants could elect to eat fish if they wished, because the omega-3 fatty acids found in various types of fish protect against heart disease and stroke and provide other health benefits.^20-22However, types of fish containing high levels of mercury or polychlorinated biphenyls were to be avoided.²³

One important aspect of the diet was to supply with body with antioxidants. These compounds neutralize free radicals, which can damage cells and DNA, and counter the process of oxidation in the body. Free radicals and oxidative stress may contribute to degenerative diseases and the aging process.²⁴ An antioxidant defense is important at all times, but it takes on added significance when people are exercising regularly and/or losing weight, as was the case with our participants. Exercise and weight loss offer significant benefits, but they also produce more free radicals that must be stabilized. In the case of weight loss, free radicals are produced as the fat mass decreases, and fat cells release toxins in the body.

Research shows that the types of foods emphasized in our dietary protocols are good sources of antioxidants. A 2004 study used the oxygen radical absorbance capacity (ORAC) assay to analyze the antioxidant capacities of more than 100 foods. The top ten foods in total antioxidant capacity per serving were small red bean (dried), wild blueberry, red kidney bean (dried), pinto bean, blueberry (cultivated), cranberry, artichoke (cooked), blackberry, dried prune, and raspberry. Among all of the foods and spices studied, the top fruits were blueberries, cranberries, and blackberries; the top vegetables were beans, artichokes, and Russet potatoes; the top nuts were pecans, walnuts, and hazelnuts; and the top spices were ground cloves, cinnamon, and oregano.^25,26 Other studies confirm the antioxidant activity of commonly eaten fruits and vegetables.^27,28

Specifically, the program's diet featured the following three-pronged approach:

Elimination of Unhealthy Foods
The diet excluded foods and beverages that contribute to glycation and inflammation and have documented negative health effects. The banned foods included all animal protein (beef and poultry) and shellfish; dairy products; wheat; alcohol and caffeine; simple sugars and artificial sweeteners; soft drinks and carbonated beverages; fried, barbecued, and processed foods; food additives, canned and salted foods, dried fruits, preservatives, coloring agents, flavorings, MSG, and yeast.

Inclusion of Healthy Foods
Participants were asked to eat organic foods as much as possible. We suggested that they eat a light breakfast (such as a protein smoothie containing berries, protein powder, vitamin C, flaxseed oil, walnuts, and rice or soy milk), a main meal between 1 PM and 3 PM, and a light dinner (such as grains, a salad, sea vegetable, and/or soup).

In particular, the diet included the following foods and beverages:

• Good-quality protein from vegetarian sources (such as beans, legumes, nuts,
  and seeds) and from fish (optional)
• Protein intake was approximately 0.9 g/kg of body weight (40 to 60 g of high-
  quality protein for women and 60 to 80 g for men).
• Nine servings of nutrient-dense fruits and vegetables per day
• Fiber intake was at least 35 to 50 grams. Recommended vegetables included salad
  and green leafy vegetables, cabbage, broccoli, cauliflower, radishes, turnips, Brussels sprouts, yellow gold or Russet potatoes, sweet potatoes, parsnips,
  kohlrabi, and squash. Recommended fruits included berries (all kinds, fresh or
  frozen), purple and red grapes, kiwis, apples, melons, citrus, and star fruit.
• Four servings of beans/legumes and grains (such as brown rice, buckwheat,
  amaranth, spelt, quinoa, and millet)
• Other foods and beverages included in the diet were sprouts, sea vegetables,
  nuts (such as walnuts, almonds, pine nuts, pistachios, pecans) and nut butters,
  seeds (such as sesame and pumpkin), soy products (tofu, tempeh, miso), onions
  and garlic, olive oil (extra virgin cold-pressed), coconut oil, flaxseed oil, walnut
  oil, avocado oil, spring or filtered water, herbal green teas, and grain beverages.
• Juices: participants consumed green and fruit juices at a ratio of five vegetable juices to one fruit juice. They started with one 10- to 16-ounce glass of juice per day in week 1 and built up to eight glasses per day in week 8. The green juice could be made with four ounces of dark and light green vegetables and six ounces of water, or one tablespoon of chlorophyll-rich green powder and ten ounces of water. To this, one ounce of aloe concentrate and one teaspoon of red fruit powder was added. Another option was to combine the green juice with six ounces of aloe vera, soy or rice protein, coconut oil, and flaxseed oil.

Emphasis on Phytonutrients
The "repair" portion of the program involves the hypothesis of the study: that the consumption of the high quantities of phytochemicals found in juices, vegetables, and fruits will support hair and skin health and optimize other aspects of bodily functioning, including the immune system. Phytonutrients are among the principal agents of DNA damage repair.^29-36

Participants were encouraged to consume antioxidant-rich foods and juices that help the body to stop inflammation, neutralize free-radical damage to DNA, and exceed genetic limitations causing hair and skin problems. Fruits containing a high level of antioxidants include blueberry, wild blueberry concentrate, tart cherry, black cherry, cranberry, boysenberry, mango, papaya, grape concentrate, and coffeeberry.

Another source of phytonutrients was the daily intake of juices required by the program, as described above. Juicing was a critical part of the nutritional protocols because of the health benefits it provides. Juices flood the body with restorative enzymes, help turn off inflammation, and detoxify the system. In addition to juices, participants also could obtain phytonutrients from powdered concentrates of juices, fruits, and vegetables. These concentrates are available in health food stores.

Supplementation
In addition to the dietary protocols, the lifestyle program recommended a broad-based intake of nutritional supplements. (See the "Literature Citations" included with this article for 14 references on supplementation.)

We recommended supplementation in a general fashion, because it would be difficult to monitor the exact dosages taken by participants. In addition, we did not specify a particular brand of supplements for use in the program, allowing people the freedom to determine which brands they liked and to comparison shop for better prices that would reduce the total cost of supplementation. We also advised participants to use supplements that did not contain ingredients that might produce an allergic or other reaction. These include sugar, starch, lactose, eggs, corn, yeast, wheat, and preservatives.

Our supplementation protocol included a variety of vitamins, minerals, and other nutrients. Some of the recommended nutrients were antioxidants that worked with the program's diet to supply the body with free radical scavengers.^37-38pecific nutrients may have their own antioxidant properties or may contribute to the body's production of antioxidant enzymes such as superoxide dismutase (which requires copper, zinc, and manganese) and glutathione peroxidase (which requires selenium).^39-41Table 1 provides an overview of the antioxidant nutrients recommended by our program.

Table 1. Recommended Antioxidant Supplements

Beyond the antioxidant nutrients, the program recommended a number of other supplements. These included comprehensive B complex, which was taken orally in divided doses throughout the day because it is water-soluble. This complex includes vitamin B1 (thiamin), vitamin B2 (riboflavin), vitamin B3 (niacinamide), vitamin B5 (pantothenic acid), vitamin B6 (pyridoxine), folic acid, biotin, choline, and para amino benzoic acid. Unlike the other B vitamins, vitamin B12 (cyanocobalamin) was to be taken sublingually because this method of absorption is more effective than the oral route.

A bioflavonoid complex, including quercetin, hesperidin, and rutin, was to be taken separately or in combination with vitamin C. Similarly, vitamin D3 (cholecalciferol) was to be taken separately or as part of a combined formula.

Healthy fats and oils recommended by the program included a fish oil-based supplement with eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). An alternative for participants who elected not to eat fish, which was optional in the diet, was a flaxseed oil supplement. Also recommended was gamma linolenic acid, found in borage oil, evening primrose oil, and black currant seed oil.

Three other recommended supplements were L-carnosine to promote the longevity of cells; L. acidophilus and B. bifidum to optimize the balance of the small and large intestines; and phosphatidylcholine to support brain and liver function.

Exercise
The exercise component of the intervention included both aerobic and resistance training. For the aerobic portion, the program recommended at least 45 minutes of cardiac conditioning a day in which participants sustained 70% of their optimal heart rate. We suggested power walking as one effective form of aerobic exercise.^42,43(See the "Literature Citations" included with this article for 44 more references on exercise.) Although exercise produces harmful free radicals, we corrected for that factor in the lifestyle program by emphasizing the consumption of antioxidants. Resistance training was to be done for a half-hour a day, working on every muscle group in the body.

Stress Management
The relaxation/meditation component recommended a minimum of two half-hour sessions per day of techniques such as Tai Chi,⁴⁴ qi gong,⁴⁵ meditation,⁴⁶ prayer,⁴⁷ yoga,⁴⁸ journal writing,⁴⁹ listening to calming music,⁵⁰ or walking. (See the "Literature Citations" included with this article for more than 65 references on stress management/relaxation techniques.)

Self-Actualization Leading to Self-Empowerment
Participants required emotional and physical support to adopt lifestyle behaviors that often differed from the habits that had negatively affected their health and contributed to hair and skin problems. We provided the necessary support through group counseling sessions, hands-on exercise demonstration, and a "buddy system" that allowed small groups of participants to talk and support each other throughout the study period. Coaching included education on the benefits of a vegetarian diet for greater health.

It also was important for participants to change their attitude toward the specific components of the program, such as vegetarian eating and daily exercise, and toward any toxic relationships they had in their lives. Those who developed a good attitude were better able to make the necessary changes and achieve positive results. In some cases, participants had to develop new social networks to comply with the nutritional requirements of the program because they differed so much from the standard American diet. They formed new relationships with people who would support their dietary and attitudinal changes.

Environmental Hygiene
For the personal environment component of the study, participants were asked to reduce their exposure to air pollutants, allergens, toxins, and electromagnetic fields in their living and work environments.^51,52Some participants had to do a complete overhaul of their living and work spaces to eliminate clutter, find nontoxic cleaning products, reduce dry cleaning, etc. Others had to evaluate their homes, workplaces, and neighborhoods and make major changes to lessen their environmental exposure to toxins.

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