January 2020 Issue

CPE Monthly: Nutrition and Lifestyle Solutions to Female Hair Loss
By Alexandria Hardy, RDN, LDN
Today’s Dietitian
Vol. 22, No. 1, P. 44

Suggested CDR Learning Codes: 2090, 4180, 5120, 5280
Suggested CDR Performance Indicators: 4.1.2, 8.2.3, 8.3.6, 10.4.4
CPE Level 2

Take this course and earn 2 CEUs on our Continuing Education Learning Library

For most women, hair loss can lower self-esteem, increase stress, and impart considerable psychological distress, all of which can beget additional hair loss or thinning.1-4 Up to 60% of women experience some form of hair loss by the time they reach the age of 60, and less than 50% of women maintain a full head of hair throughout their lives.1,3 Hair loss in women manifests differently than it does in men, as women tend to lose volume due to initial thinning vs the receding hairline and bald patches typically seen in men.3,5

This continuing education course examines the impact of nutrition and lifestyle on acute and chronic hair loss in women.

Hair loss is caused by a variety of factors, which can make treating it a challenge. Life stage, weight loss, genetics, diet, stress, medications, illness, ethnicity, hair styles, and the use of hair styling tools all affect hair growth and loss.1,2,4,6 Typical daily hair loss is between 50 to 100 strands, according to the American Academy of Dermatology; an increased daily shedding of hair is clinically termed telogen effluvium.1,6 Excessive hair shedding can be a temporary stage (less than four months) following a state of stress or trauma, typically peaking at two to three months and then resuming the normal hair growth cycle. This is different from hair loss (anagen effluvium), which occurs when hair stops growing.6

Hair loss is biologically different than hair thinning; thinning typically precedes loss.7 Women who suffer from hair loss tend to lose hair initially from the middle part and then experience an overall thinning of hair follicles, which makes the loss difficult to conceal.3 This also negatively affects their ability to undergo hair transplantation, as there’s no scalp source from which a hair restoration surgeon easily can harvest hair.3,7 Hair transplantation is effective and permanent but uncommonly undertaken, as it requires one to three surgeries over the course of 18 months.3,8

Weathering, the “cumulative effect of environmental factors on the physicochemical structure of the hair,” also influences hair loss. Ultraviolet rays, humidity, and wind can decrease hair density, growth, and texture. White and Asian women are more susceptible to damage from weathering, while African Americans are more prone to damage from styling methods, chemical relaxers, and other products. An unhealthy scalp with inflammation and flaking also can contribute to hair loss, though the mechanism that causes this hasn’t yet been isolated.4

Hair Growth
Hair growth occurs in three distinctive cycles: the anagen, or growth, cycle; the catagen, or transition/regression, cycle; and the telogen, or rest, cycle.7 About 80% to 90% of hair is in the anagen phase at any given time, with 1% to 2% in the catagen phase, and the remaining 10% to 20% in the telogen phase.1,7,9 Per Rizer and colleagues, “Hair follicles exhibit enormous cellular activity and represent the body’s second or third highest turnover rate after gut epithelium and bone marrow.”2 The length of each cycle varies dramatically. Anagen can last from two to eight years, catagen two to three weeks, and telogen an average of three months.7,9 A healthy hair cycle yields a full turnover of old hair to new every three to five years.10

Growth can be affected by both chronologic aging (related to genetics and other fixed variables) and biologic aging, which is affected by diet quality.2

Women experiencing hair loss should be assessed by dietary history, medical history, and a physical exam to classify type of hair loss.11,12 Ideally, this would be done by a team comprising a dietitian, primary care physician, and hair care specialist, each discipline providing specific education and recommendations based on its field. A study published in the International Journal of Trichology found that the average woman waited more than four years to obtain the help of a hair specialist, or trichologist, for hair loss and unsuccessfully self-treated in the interim.13 Treating hair loss requires restarting the growth cycle by isolating the cause and remedying it; treatment should begin as soon as possible for the best outcome.6

Types of Hair Loss
Alopecia, the Latin-derived term for hair loss, manifests in different ways.7 The most common types of hair loss in women include telogen effluvium, androgenetic alopecia (AGA), alopecia areata, and traction alopecia.

Telogen Effluvium
Acute telogen effluvium occurs approximately three months after a stressor or life event and the resulting hair loss lasts less than six months.11,14 Life events include rapid weight loss, stress, drug use, new hormone therapies or medications, endocrine disturbances, or inadequate protein consumption.9,11,14 Acute telogen effluvium is common in premenopausal women with poor diet quality and in the postpartum period.2

Chronic telogen effluvium commonly causes hair loss in older adults, as hair follicles spend less time in the growth phase of the hair cycle and longer in the rest phase; this can triple daily hair shedding.2 Symptoms of chronic telogen effluvium are similar to those of acute telogen effluvium (eg, nonscarring, diffuse hair loss), but they last several years.2,14 Both forms of telogen effluvium are marked by shedding but not a decrease in overall hair volume (ie, hair loss of <50% scalp hair).3,14 Contributing factors to chronic telogen effluvium other than age include thyroid disease, lupus, a drug reaction, or iron deficiency anemia.3 The most effective treatment is identifying the stressor that triggered telogen effluvium and making the necessary changes to eliminate the trigger.14

AGA, also called female pattern hair loss (FPHL), is a chronic condition that occurs when new hair grows in thinner than the initial strand.7 The conditions or life events that trigger telogen effluvium can precipitate AGA as well,9 but AGA typically is linked to hormonal changes. It’s most often recognized around menopause but can begin as early as puberty.1,7,9 Physiologically, FPHL occurs due to a shortened anagen phase and delayed new growth, resulting in an empty hair follicle.7 Typical signs of AGA include a widening part and decrease in overall hair volume.1 More than 64% of women with AGA experience a receding hairline and more than 60% of women older than 80 experience midfrontal hair loss.15 This is the most common cause of hair loss in women, and genetics may play a role in its development.1,3,7,9 Prevalence increases markedly from decade to decade of life. Statistics from the Brazilian Society of Dermatology show a 3% to 13% worldwide prevalence of AGA in women in their 30s and up to 54% for women in their 70s and older. Potential protective factors include breast-feeding, limited sun exposure, and short (<35 days) menstrual cycles; further research is needed to explain these possible links.7 Full hair regrowth typically isn’t seen with AGA due to the diminished hair follicles, but medication (eg, antiandrogens, minoxidil, combined oral contraceptives) or lasers can help stimulate regrowth and slow hair loss with continued usage/application.7,15

Alopecia Areata
Alopecia areata is an autoimmune response that occurs in otherwise healthy individuals.16 In alopecia areata, the immune system attacks hair follicles on the body and/or scalp, which results in partial to complete hair loss in the form of round or oval-shaped skin-colored patches.6,14,16 Individuals have a 2.1% lifetime risk of developing alopecia areata, and it typically presents in childhood and affects both genders and all ethnic groups. When alopecia areata is active, hair growth slows or stops as hair follicles shrink. Causes of alopecia areata are unknown, with research being conducted regarding both internal factors (eg, viruses) and environmental triggers.17 A cure for alopecia areata doesn’t exist, but oral, topical, injectable, and light treatments are available. Appropriate treatment depends on age, where the hair loss primarily occurs, and the percentage of total hair loss. For individuals who have lost <50% of their hair, corticosteroid injections are the most common treatment, followed by minoxidil, anthralin cream, and topical corticosteroids. For individuals who have lost >50% of their hair, oral corticosteroids, topical immunotherapy, and immunomodulatory drugs are used. Topical immunotherapies and injections generally are administered by dermatologists while the more frequent topical applications and oral dosages can be self-administered. Response to treatment is highly individualized, and research is needed to further determine appropriate dosages, duration of treatment, and related side effects.18

Traction Alopecia
Traction alopecia is a form of gradual hair loss associated with hairstyles such as braids, cornrows, dreadlocks, tight ponytails, chignons, and weaves, or the wearing of religious head coverings or extensions.19,20 With frequent/prolonged wearing, these styles can cause tension at the base of the hair follicle, leading to hair loss, particularly around the front and sides of the head.19 African American women in particular are at risk of developing traction alopecia, though Hispanic and Japanese women and ballerinas who sport similar hairstyles also are at risk.19-21 African hair has less tensile strength and moisture and is more prone to surface damage and breaking due to its diameter and shape.19 Early-stage traction alopecia generally is reversible via patient education on safer hairstyling practices, but permanent hair loss can occur if lifestyle changes aren’t made.19-21

Central Centrifugal Cicatricial Alopecia
Central centrifugal cicatricial alopecia (CCCA) has gone by many names, including follicular degeneration syndrome and chemically induced scarring alopecia. CCCA presents as an outward spiral beginning at the top of the scalp, much like AGA. Unlike AGA, scarring occurs due to limited follicular openings. It’s a “chronic, progressive, and inflammatory form of hair loss” prominent in African American women, affecting 2.7% to 5.7%, and prevalence is thought to increase with age. The root cause is unknown, but hair texture, composition, and styling practices are all thought to contribute to hair loss.19 The primary treatment is to cease unhealthful or damaging hair practices (eg, braids, weaves, high heat styling, chemical relaxers) with a goal of stopping the spread of CCCA on the scalp and limiting permanent scarring, which inhibits regrowth. Additional therapies include topical or injectable corticosteroids, antibiotics, and antimalarials, which may relieve symptoms and slow progression. For women without scalp inflammation or heavy scarring and who are declared “stable disease controlled” after a successful year of medical therapy, hair transplantation is possible.19

Pharmacological Treatments
Common medications used to treat hair loss include minoxidil, a topical formula, and several medications that limit androgen activity and production such as finasteride and spironolactone.3,8,22 As FPHL is chronic and progressive, clients and patients must continue to use them throughout the lifespan to preserve hair, and it can take one to two years of use for clients to see initial results.3 An article in the International Journal of Women’s Health claims that many medical treatments are impermanent solutions with often disappointing results.8 Given the stringent adherence required, reports of overall efficacy are mixed.3,8,22

Low-level laser/light therapy (LLLT) is a home treatment option to stimulate hair growth.23 This methodology is most effective for individuals with AGA and has been FDA approved for women since 2011. LLLT increases the number of hair follicles in the anagen phase, perhaps by modifying cell metabolism. LLLT devices commonly include a laser comb or a helmet design with wavelengths of 635 to 650 nanometers, with light either pulsed or emitted continuously. They must be used daily or weekly for a specified period of time.24 Research released by Jimenez in the American Journal of Clinical Dermatology showed that six months of laser treatment yielded a statistically significant increase in hair density. These results were seen in both men and women experiencing hair loss with a more pronounced effect in the males, and there were no serious adverse effects. Further research specific to women is needed before a widespread recommendation can be made for LLLT usage to treat FPHL; as with any chronic hair loss treatment, continuous and consistent usage is needed to see results.23

Hair Loss and Related Conditions
Hair loss, particularly alopecia, is linked to several disease states and endocrine disorders. This section examines hair loss’ relationship with metabolic syndrome, hypothyroidism, type 2 diabetes, and polycystic ovarian syndrome (PCOS).

Metabolic Syndrome
An interesting link has emerged between the development of metabolic syndrome, CVD, and FPHL or AGA.9,25 An association between males with AGA and CVD has been established, but few studies have looked at the relationship between females with AGA and CVD. A case-control study compared 37 female patients with early-onset AGA with 37 healthy control subjects in Spain, with a goal of isolating cardiac risk factors within the Adult Treatment Panel III criteria for metabolic syndrome. Nearly one-half (48.6%) of the female AGA patients vs 8.1% of the control group were clinically diagnosed with metabolic syndrome. The AGA group also had significantly higher levels of other cardiac risk factors, including C-reactive protein, fibrogen, aldosterone, and insulin levels, than the control group. Further research is needed to establish standardized screening methodology in women with AGA and to replicate findings in a broader population.25

Endocrine Disorders

Thyroid Disease
Diffuse alopecia areata presents as an overall thinning of scalp hair and is a common symptom in hypothyroidism. The exact mechanism that links the two isn’t known, but an article in the International Journal of Trichology hypothesizes it could be due to a reaction between thyroid hormones and androgens. In a cross-sectional study conducted in Kerala, India, women had a higher rate of thyroid dysfunction and were more likely to have alopecia. Routine screening by testing thyroid-stimulating hormone levels may help to identify alopecia sufferers with thyroid disease for early intervention and potential improved outcomes.26

Type 2 Diabetes
One of the most prevalent endocrine disorders globally is type 2 diabetes. Some individuals find that once they’re diagnosed with type 2 diabetes, they already have hyperglycemic complications from increasing A1c levels. An existing relationship between alopecia areata and insulin resistance in those without diabetes sparked research regarding impaired hair follicles and elevated blood glucose. The hypothesis of this research, published in Medical Hypotheses, was to determine whether hyperglycemic damage manifests in the hair follicle before a medical diagnosis of type 2 diabetes, thus providing an early screening and intervention technique. In AGA, insulin resistance is thought to cause harm at a microvascular level.27 Studying metabolic markers in those both with and without type 2 diabetes while evaluating hair growth may establish a definitive link between hair loss and diabetes.

PCOS is a common endocrine disorder among reproductive-age women that occurs when women produce higher levels of male hormones. Per research from the European Journal of Endocrinology, alopecia is a common complication of PCOS and both disorders share the symptom of increased androgen production. In the aforementioned study, 89 women with AGA were compared with a control group of 73 women without AGA. Sixty-seven percent of women with AGA also had PCOS, compared with 27% of the control group. Further research is warranted based on the small sample size, but this study suggests that there may be merit to screening women with PCOS for alopecia areata. There’s also a link between PCOS and type 2 diabetes, which makes understanding the role of hair loss in these two endocrine disorders paramount.28

Dietary Implications
Nutrition is an integral part of maintaining hair growth and preventing future loss or thinning, as nutrient deficiencies affect hair structure, strength, density, weight, and growth.1,2,9,11 Eating a well-balanced diet with a variety of high-quality sources of proteins, vitamins, and minerals supports the metabolic functions necessary to catalyze hair growth and prevents deficiencies associated with physiologic loss or thinning.1,2

Common nutrient deficiencies that affect hair growth include iron and vitamins A, B, and D.1 Zinc, selenium, and biotin also are associated with hair loss in patients with low serum values of these minerals.11,29

The role of iron in hair loss is complex and not fully understood, but one theory is that it regulates many of the genes present in hair follicles.11 Evidence is weak regarding at-risk populations, but many patients with hair loss are screened for iron deficiency or iron deficiency anemia (IDA), as there’s overlap in the populations who are at the highest risk of iron deficiency and hair loss. Many of the common causes of iron deficiency and IDA—pregnancy, lactation, childbirth, and menstruation—are specific to women. Iron deficiency can be difficult to diagnose, as individuals may be asymptomatic, but it can present as chronic diffuse telogen hair loss, or hair loss caused by medications or external stressors.30 Iron deficiency and IDA may merit dietary inclusion of high-iron foods as well as assessment of ferritin serum, low levels of which are a direct indication of low intracellular ferritin and body stores of iron.9-11

Dietary iron is found in two forms, heme and nonheme. Heme iron, found in animal proteins, is readily absorbed, while nonheme iron is less bioavailable and is found in plant foods such as legumes, fortified grains, vegetables, and nuts. As such, those following vegetarian or vegan diets have a higher risk of iron deficiency, but consuming high-iron plant foods with a source of vitamin C can increase absorption.2,11 The Recommended Dietary Allowance (RDA) is 18 mg for adult women—shifting to 27 mg during pregnancy, then 9 mg during lactation—and 8 mg for women older than 51.31

Vitamin A
Vitamin A is thought to stimulate the growth of hair follicle stem cells.11 Commonly consumed sources of vitamin A include fortified cereals with skim milk, eggs, and dark green, orange, or yellow produce rich in beta-carotene. The RDA for adult women is 700 mcg Retinol Activity Equivalents (RAE), increasing to 770 mcg RAE during pregnancy and 1,300 mcg during lactation. (RAE is replacing the current International Unit, or IU, metric. Conversion between the two depends on the source and type of vitamin A.32)

Deficiency of vitamin B3 (niacin), called pellagra, is commonly caused by alcoholism and malabsorptive disorders and is clinically associated with alopecia. There are currently no clinical trials available on the effects of niacin deficiency on hair loss.11 Niacin is predominantly found in protein-rich foods, including vegetarian sources such as nuts, seeds, legumes, and fortified cereals. The RDA for adult women is 14 mg niacin equivalents (NE), increasing to 17 and 18 mg NE for lactating and pregnant women, respectively. NEs are either 1 mg niacin or 60 mg tryptophan, which can be converted into niacin.33

Vitamin D
Vitamin D is involved primarily in the growth phase of the hair follicle and affects the cells that form the outer root sheath.11 Rodent studies have indicated a potential link between rickets—a form of vitamin D deficiency—and hair loss, and these results were replicated in a study conducted involving women with either telogen effluvium or FPHL.11,34 Serum ferritin and vitamin D2 levels were measured in the 40 adult women with hair loss and compared with a control group of 40 adult women without hair loss. Women in the control group had significantly higher ferritin and vitamin D2 levels, and serum levels in the experimental group were inversely proportional to the severity of the hair loss.34 A review published in the International Journal of Molecular Sciences suggests that vitamin D’s immunomodulatory effect may influence the pathogenesis of alopecia areata. Serum levels of vitamin D <30 ng/mL are thought to contribute to alopecia areata.14

Topical application of a solution containing vitamin D (calcipotriol) for three months resulted in full hair regrowth and no loss at six months in a 7-year-old boy with alopecia areata. Further research is needed to see whether similar results can be replicated in a study of a larger, more diverse population.14 Dietary sources of vitamin D are minimal but include fatty fish, liver, cheese, egg yolks, and fortified foods such as dairy, cereal, nondairy milks, and mushrooms. The RDA for adult women is 600 IU, increasing to 800 IU if older than age 70.35

Zinc assists other nutrients in their functionality, and dietary consumption is essential, as the body doesn’t have a zinc storehouse. Zinc deficiency has been linked to telogen effluvium and changes in hair structure, but hair loss can be reversed with adequate dietary consumption. Animal proteins, particularly oysters, red meat, and poultry, as well as a few plant foods such as fortified cereal and baked beans, are good to excellent sources of dietary zinc. However, phytate-containing foods such as whole grain breads and legumes can limit zinc’s absorptivity when consumed concurrently with zinc-containing foods and thus potentially contribute to hair loss.11

In a study published in Annals of Dermatology, serum zinc was compared in four different hair loss patient groups: alopecia areata (44 men, 50 women); male pattern hair loss (84 men, 0 women); FPHL (0 men, 77 women); and telogen effluvium (11 men, 36 women). All four groups were compared with a control group of 32 healthy individuals not suffering from hair loss (14 men, 18 women). Mean serum zinc concentrations across all four hair loss groups was 84.33 ± 22.88 mcg/dL, while the control group exhibited a significantly higher zinc value of 97.94 ± 21.05 mcg/dL. When directly compared, the alopecia areata and telogen effluvium groups had the lowest zinc concentrations. Further research may be helpful to identify whether supplementation before serum zinc falls below 70 mcg/dL—the threshold for deficiency—may help prevent acute-onset hair loss.29

The relationship between serum copper concentrations and hair loss also was examined, as zinc and copper share a transport channel in the small intestine; no conclusive results were found between serum copper and hair loss.29 The RDA for adult women is 8 mg, increasing to 11 mg during pregnancy and 12 mg during lactation.36

Selenium aids in the formation of hair follicles and protection against damage; deficiency is rare in healthy adults living in developed countries. Much of the current research on selenium and alopecia has been conducted on rats, with limited applications in humans.11 Typically consumed dietary sources of selenium are protein-rich foods such as poultry, beef, eggs, seafood, legumes, and soyfoods. The RDA for adult women is 55 mcg, increasing to 60 to 70 mcg in women who are pregnant or lactating.37

Biotin deficiency is uncommon, as the body can produce it in the gut. No studies show the efficacy of using biotin to remedy hair shedding or loss, but many of the available supplements promising improved hair growth include biotin. Supplementation without a diagnosed biotin deficiency isn’t recommended.11 Biotin is found in beef liver, canned salmon and tuna, eggs, seeds, nuts, and sweet potatoes. The RDA for adult women is 30 mcg, increasing to 35 mcg while lactating.38

Fatty Acids
Inadequate consumption of omega-3 and omega-6 fatty acids is associated with hair loss both from the scalp and eyebrows and lightening of hair color. Consumption of dietary polyunsaturated fatty acids has been linked to hair growth due to proliferation of hair follicle cells and a mechanism similar to that of the FDA-approved drug finasteride, which is used to treat alopecia.11 The most common dietary sources of unsaturated fatty acids are oils and fatty fish. The Adequate Intake for omega-3 fatty acids for women is 1.1 g, increasing to 1.4 g during pregnancy and 1.3 g during lactation.39 For omega-6 fatty acids, the Adequate Intake is 12 g for most women, 11 g for women older than 51, and 13 g for all pregnant and lactating women.40

Supplement Treatments
Supplementation is common in women who suffer from hair loss, but such supplements aren’t always supported by research, nor are they clinically recommended. Patients could use supplements inconsistently or without disclosing usage to medical professionals; this can yield inconsistent, harmful, or nil results.11 Supplementation should be used only in the case of a verified nutrient deficiency, as excessive intake or supplementation of fat-soluble vitamins, iron, and selenium can cause hair loss or other serious maladies in nutritionally sufficient individuals.4,11

Alopecia areata and hair texture and strength may be improved by supplementation in those with clinically low levels of zinc. Using a topical supplement rich in polyunsaturated fatty acids and antioxidants may increase hair growth, but researchers couldn’t isolate the variable responsible for the growth.11 Vitamin D supplementation is recommended in cases when lab values for iron and vitamin D2 are low, but protocol for supplementation levels hasn’t yet been established.34 Iron supplementation in women diagnosed with IDA is indicated, but monitoring and assessment of lab values by the medical care team is necessary to ensure adequate ferritin levels (50 mcg/L in iron deficiency and 70 mcg/L in IDA) and prevent iron overload.11 Supplementation of vitamin A is harmful if it exceeds 5,000 IU/day.4

Rizer and colleagues investigated the use of a marine protein–based dietary supplement on 72 adult women with self-perceived thinning hair over a six-month period to determine the efficacy of supplementation. The supplement, Viviscal, was taken in tablet form three times per day by the treatment group of 37 women, while the control group received a placebo. Viviscal contains a proprietary complex with protein molecules from fish, as well as biotin, niacin, iron, vitamin C, and zinc. Participants measured hair loss by adhering to specific washing and styling instructions and using cheesecloth to gather shed hairs.2

At the conclusion of the study, the treatment group that received the supplement had lost significantly fewer total hairs and experienced statistically significantly less shedding overall. The control group reported a more than 50% increase in shedding at the midpoint of the study and a roughly 8% increase at six months; the treatment group experienced a 20% decrease in hair shedding at both months three and six. Hair diameter also increased for those in the treatment group, with a statistically significant increase in vellus hair (the fine hair that covers the majority of the body, also known as “peach fuzz”). The type of hair growth is of particular note, as vellus hair can transition into the thicker, darker, longer terminal hair. The best example of this biological transition is when a male grows facial hair during puberty. The researchers theorized that the supplement altered the hair cycle by transitioning follicles from telogen to anagen. The authors emphasize that this is the first double-blinded, multisite, placebo-controlled trial of a marine-based supplement for hair growth using qualitative and quantitative measurements of hair loss and growth. Further research on a larger population is needed to develop recommendations for use.2

Cosmetic Approaches
Lifestyle changes can be made to disguise or minimize hair loss. Camouflaging products and techniques aren’t permanent solutions. Creative hairstyling tricks, including keeping hair shorter than shoulder length, coloring hair (which temporarily thickens the strands), and matching the color of hair to the scalp can all help mask hair loss and shedding. Incorporating waves, curls, layers, or a side part are other techniques that can disguise thinning or loss. There are also myriad thickening and growth-promoting lotions, shampoos, sprays, and other products that may help to physically cover bald patches on the scalp.3 Allowing hair to air dry, not combing when wet, regularly wearing a hat to protect hair from the sun, and not engaging in damaging practices such as perming or chemically straightening hair can benefit overall hair health.3,19 In severe cases of hair loss, a wig, hairpiece, turban, or scarf can be worn.3

Role of the RD
Dietitians can play a role in the multidisciplinary hair loss treatment team by assessing nutrient deficiencies and working with patients to eliminate dietary gaps that may affect hair health. Developing a broad understanding of a client’s eating history is essential, as a sudden change to the dietary pattern (eg, becoming vegan) can trigger hair loss.12 Research shows inadequate consumption of overall energy, protein, and micronutrients may limit hair growth.11 Dietitians may need to work closely with a dermatologist or trichologist for referrals to determine the best course of action and ensure continuity of care across specialties.

Women suffering from hair loss who consume a plant-based diet may benefit from nutrition education regarding adequate iron intake and dietary sources of iron, as well as iron-rich recipes and preparation methods. Women following plant-based diets have nearly double the dietary requirement of women who eat meat due to decreased bioavailability.11 Pregnant or lactating women with hair loss or shedding also may benefit from the same iron nutrition education, as their needs are higher than those of the average adult woman.

Adequate dietary protein also may help improve hair health. Hair fibers are mainly protein, which suggests that adequate dietary protein intake is essential for strong, healthy hair.2 Many of the nutrients necessary for hair growth are found in protein-rich foods, and incorporation of these foods may shift hair into the growth cycle.

Hair growth clinicians are assessing the impact of diets high in salt, fat, sugar, and processed foods on hair health. Hair loss patients who follow unhealthful dietary patterns may require basic nutrition education and help exchanging nutritionally poor foods for nutrient-dense foods. This is particularly true for women experiencing FPHL, as they may be at an increased risk of developing metabolic syndrome or CVD.9

Hope Remains
Any form of hair loss or thinning can be distressing to the point of causing social anxiety and isolation for women.1-3,7,10 Society places great value and importance on physical appearance, in which hair plays a large role.1,2,7,10 A Brazilian study found that women had an equivalent fear of experiencing a heart attack and baldness,7 and Glamour magazine reports that more than 50% of women feel that a bad hair day can make them feel unattractive. Women may engage in compensation or concealment techniques to cope with feelings of distress or inadequacy.3 Practicing healthful hair behaviors and consuming a nutrient-dense, balanced diet may decrease thinning or loss over time. For best outcomes, women with self-perceived hair loss or thinning should be assessed by a medical professional to determine the most effective treatment plan as soon as they begin to notice hair loss.3,4,9

— Alexandria Hardy, RDN, LDN, is a consultant in corporate wellness and a freelance food and nutrition writer based in Pennsylvania.

Learning Objectives
After completing this continuing education course, nutrition professionals should be better able to:
1. Distinguish three common nutrient deficiencies linked to hair loss.
2. Assess lifestyle factors that affect normal daily hair loss, acute hair loss, and chronic hair loss.
3. Explain the hair growth cycle.
4. Contrast the different types of hair loss.
5. Evaluate the pros and cons of dietary supplements for hair loss.

CPE Monthly Examination

1. Women of what ethnicity are most commonly affected by traction alopecia?
a. Asian
b. White
c. Hispanic
d. African American

2. What percentage of women maintains a full head of hair throughout their lives?
a. <50%
b. <60%
c. <70%
d. <80%

3. How much hair loss is considered typical by the American Academy of Dermatology?
a. 0 to 50 strands per day
b. 50 to 100 strands per day
c. 100 to 150 strands per day
d. 150 to 200 strands per day

4. Which phase of hair growth is the longest?
a. Anagen
b. Catagen
c. Telogen
d. Regression

5. What type of hair loss is also known as female pattern hair loss and is the most common form of hair loss?
a. Androgenetic alopecia (AGA)
b. Traction alopecia
c. Alopecia areata
d. Telogen effluvium

6. Serum vitamin D levels below 30 ng/mL are thought to contribute to what type of hair loss?
a. AGA
b. Traction alopecia
c. Alopecia areata
d. Telogen effluvium

7. Which of the following micronutrients helps to form hair follicles and shields them from damage?
a. Copper
b. Zinc
c. Biotin
d. Selenium

8. In the study on the marine protein–based supplement Viviscal, what percentage decrease in hair shedding did the treatment group experience?
a. 10%
b. 20%
c. 30%
d. 40%

9. What is a healthful hairstyling practice for women with hair loss or thinning?
a. Wearing loose braids or ponytails
b. Brushing wet hair gently
c. Letting hair air dry
d. Flat ironing hair

10. What part of the scalp do women initially lose hair from?
a. Middle part
b. Lower back
c. Left and right lobes
d. Hairline

1. Goluch-Koniuszy ZS. Nutrition of women with hair loss problem during the period of menopause. Prz Menopauzalny. 2016;15(1):56-61.

2. Rizer RL, Stephens TJ, Herndon JH, Sperber BR, Murphy J, Ablon GR. A marine protein-based dietary supplement for subclinical hair thinning/loss: results of a multisite, double-blind, placebo-controlled clinical trial. Int J Trichology. 2015;7(4):156-166.

3. Dinh QQ, Sinclair R. Female pattern hair loss: current treatment concepts. Clin Interv Aging. 2007;2(2):189-199.

4. Monselise A, Cohen DE, Wanser R, Shapiro J. What ages hair? Int J Womens Dermatol. 2017;3(1 Suppl):S52-S57.

5. Pratt CH, King LE Jr, Messenger AG, Christiano AM, Sundberg JP. Alopecia areata. Nat Rev Dis Primers. 2017;3:17011.

6. Do you have hair loss or hair shedding? American Academy of Dermatology Association website. https://www.aad.org/public/skin-hair-nails/hair-care/hair-loss-vs-hair-shedding. Accessed August 25, 2018.

7. Ramos PM, Miot HA. Female pattern hair loss: a clinical and pathophysiological review. An Bras Dermatol. 2015;90(4):529-543.

8. Levy LL, Emer JJ. Female pattern alopecia: current perspectives. Int J Womens Health. 2013;5:541-556.

9. Herskovitz I, Tosti A. Female pattern hair loss. Int J Endocrinol Metab. 2013;11(4):e9860.

10. Malkud S. A hospital-based study to determine causes of diffuse hair loss in women. J Clin Diagn Res. 2015;9(8):WC01-WC04.

11. Guo EL, Katta R. Diet and hair loss: effects of nutrient deficiency and supplement use. Dermatol Pract Concept. 2017;7(1):1-10.

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