Navigating Nutrition Support For Patients With Atopic Dermatitis

The recent American College of Allergy, Asthma and Immunology (ACAAI) 2023 Annual Scientific Meeting in San Diego, California drummed up conversation about the need for nutrition support for patients with skin conditions, such as atopic dermatitis. Atoosa Kourosh, MD, MPH, is a board-certified pediatrician and allergy and immunology specialist overseeing a holistic clinic in Southlake, Texas. She spoke with Dermatology Times about opportunities for allergists and dermatologists to collaborate, her approach to cases, and patient resources.

Dermatology Times: Can you please discuss highlights from your ACAAI presentation?

Kourosh: We're actually really delighted the that the ACAAI, the American College of Asthma Allergy and Immunology, is taking an interest in offering integrative medicine in our annual meeting program. I think that's in response to the desire from the community of allergists that want to know about more about integrative medicine because they know their patients are using it and they're exploring integrative and holistic pathways.So our feeling is that they need to be in tune with that. Our committee is presenting a symposium on what the allergist needs to know about various integrative therapeutics, and I'm covering special diets.I'mprobably not the only doctor that gets a lot of questions about special diets;I'm sure primary care doctors, other allergists, dermatologists, rheumatologists, GI doctors, and a lot of specialties get questions from their patients about special diets. And there's certainly a lot of direct marketing going on by proponents of special diets and those who have programs to sell.

The most important thing about my presentation is it covers what these diets purport to do, or claim that they will do,and it covers the actual evidence that we have, if any—the evidence to support or to shed light on possible risks of partaking in these diets. One of the things that I always stress in my practice, which is a precision medicine practice tailored at the individual, is that we may have guidelines and we may have research, but recommendations—especially dietary recommendations—have to be individualized for the patient and the specific needs of the patient, and especially with allergies. We have a long history of doing that with our patients with food allergies, and helping them avoid their food allergens, but I think these special diets that are being marketed go above and beyond that to make health recommendations and health claims that they can either reverse disease or prevent disease. So,we'resort of exploring what evidence there is for that.

Dermatology Times: How do you suggest a clinician talk to their patient who comes in and wants to try a diet that maybe is not recommended or not beneficial?

Kourosh: One of the main things that would appeal to a patient when you're talking to them about adopting a diet or not is to take into account the risk-benefit ratio, and the cost effectiveness of implementing that diet, because a lot of these diets are going to be expensive. They're going to either going to require some kind of supplemental nutrition or require the patient to shop in a very specific way.So, taking into account the risks and benefits is one of the ways to approach that. 

The other is to take an approach of, “let's try it for a temporary time if you're very passionate about trying this diet and then assess your outcomes.” It should not be approached as a lifelong thing if we are trying to figure out if it's even working. So, for instance, if a patient is trying to impact their autoimmune disease by adopting a specific diet, it would be important to have current markers of that autoimmune disease and a possible endpoint in time to measure impact. A lot of times it's very difficult for primary care doctors to go into all of this if they only have a few minutes to speak with their patient. Referring patients to nutrition support might be a way to help with that, especially if those who have access to nutritional counseling. Sometimes insurance will cover nutritional support visits a couple of times a year, especially if a physician feels that it's necessary.

Another thing is to present from the perspective of the patient. What it is that they're hoping to gain and is that diet is the right diet to achieve those goals. Because, for instance, I have had patients come to me and say I'm trying this diet primarily to lose weight, but I hope that it will help me with my allergies, autoimmune disease, eczema, fill in the blank of what they're trying to achieve. I talk to them about how that diet was designed and whether they are nutritionally capable of handling that drastic change in the diet.

The other thing I talked to patients about is that there are 2 approaches to change in diet: One is a gradual step stepwise approach where things are changed gradually and another is sort of a cold turkey, turn-on-a-dime kind of change where everything has changed at once. And the issue with that is that sometimes our digestive system can't keep up with that level of drastic change. We sort of adapt to digesting the foods that we eat regularly. If, for instance, someone goes from eating mostly a starch-based processed food diet to an entirely plant-based, raw food diet, they might have some digestive distress, because it takes awhile for the digestive system to learn and adapt and be able to digest those fruits and vegetables, even though they're super healthy. It's not that the diet inherently is unhealthy, but that the patient might need adjustment time. I definitely discuss that with my patients and talk to them about methods of gradually introducing even positive changes into the diet.

There are there are certain things that patients can do cold turkey, like cut out processed sugar, but again, I talk to them about how if they are dependent on that processed sugar for an energy boost, they may find a feeling of fatigue or energy loss, and to adjust for that. I also never start a patient on a dietary change even if I feel like it's the right diet for them without some kind of intro time—a time of learning. I also advise them to start on a Friday so that they have the weekend—they have 2 days off on the weekend to sort of get their ducks in a row with doing that and prepare for the following week. Because a lot of times the life disruption that comes from trying to adapt a person's diet ends up creating so much life stress for the patient that they counteract the benefits of the positive changes they're trying to make, even with a balanced healthy diet.

Dermatology Times: What resources would you suggest for clinicians interested in learning more about integrating nutrition or diet into their patient support?

Kourosh: There are some resources from the American Academy of Pediatrics. They have a toolkit on pediatric healthy weight, and all of those recommendations are very evidence-based recommendations. There are resources also on the American Dietetic Association website about macros, what kind of calories, what kind of protein requirements, kind of carbohydrate and fat requirements are found there. And then I wouldtry resources that show an evidence base, like they have actually been curated at this moment. Most of the medical societies don't have a lot out there, but some do, such as the Society for Obesity Medicine.Societies like that have done a lot of deep dives into diets like weight loss diets.

AAs far as resources for general nutritional advice on diets, I would say that there's a few publications that do try to educate the public in general about diets and are not based on any corporate agenda. I would look to those.The American Academy of Pediatrics is what I primarily use because before I became an allergist, I was a pediatrician, and working very, very hard on childhood obesity prevention, and I use those resources and I tend to rely back on them. I also really look at the literature, because a lot of these diets have been reviewed.The National Institutes of Health has an arm or a division on Complementary and Integrative Medicine, and they also are turning their sights more not only into integrative therapeutics and supplementation, or supplements, but also toward dietary changes.

Dermatology Times: Do you have any closing thoughts about diet and nutrition?

Kourosh: I would encourage people to not embark on drastic changes in their diet without consulting either a nutritionist or dietitian or their physician, because a lot of times, I think people don't realize that they may be going down the wrong path and also that their system may require some changes or some support if they're going to do that.

I would recommend that diet drastic dietary change be undertaken with medical supervision, and although a lot of their publications and online resources are targeted at medical professionals, the Institute for Functional Medicine, also has a lot of resources for patient education, especially around healthy diets, and around the types of diets that are often promoted for medical- or health-related concerns. So, they have a lot on a hearthealthy diets. They have a lot onautoimmune diseases. So, I encourage people to check out the Institute for Functional Medicine website because a lot of those resources have been extensively researched and curated before they've been assembled into a series of blog posts and courses, some of which are available even if you're not a medical professional.