The psoriasis obesity connection

Photo Cred: Linda Prebreza/Pexels

By Kellie Blake, RDN, LD, IFNCP

The connection between psoriasis and obesity is undeniable, but still not well understood. Both involve a multifactorial pathogenesis and often less than ideal outcomes with standard treatments. While obesity has increased dramatically over the past several decades, autoimmune diseases like psoriasis, have also been on the rise. According to the National Institutes of Health, autoimmune diseases now affect up to 24 million Americans with an additional eight million U.S. adults carrying autoantibodies. Psoriasis alone affects seven and a half million American adults. The increase in rates of both obesity and psoriasis may be due in part to the Standard American Diet (SAD), which alters the landscape of the gut microbiome leading to an altered immune response.

Psoriasis is a relapsing and remitting inflammatory skin disease with environmental and genetic components, but it is also rooted in immune system dysfunction. Aside from the visible itchy, painful skin lesions, people with psoriasis experience an altered inflammatory response placing them at much greater risk of developing obesity, cardiovascular disease, metabolic syndrome, and psoriatic arthritis when compared to their healthy counterparts.

While there is no one cause of psoriasis, excess body weight is a risk factor that can also exacerbate existing psoriasis and hinder the conventional medications used to manage the disease. Each patient has a unique set of circumstances leading to the development of psoriasis, but significant improvement and even reversal is possible when weight is controlled and a healthy inflammatory response is restored.

Adipose tissue, once thought of as largely idle, is now known to be an important endocrine organ that secretes mediators such as cytokines, leptin, grehlin, adiponectin, and resistin that function in the maintenance of metabolic homeostasis. Altered levels of these mediators are a factor in the low-grade systemic inflammation characteristic of obesity and psoriasis but also contribute to comorbities such as metabolic syndrome and type 2 diabetes mellitus.

Obese patients with psoriasis tend to have higher levels of leptin and resistin and as reported in Dermatology, elevated levels of these mediators contribute to the secretion of pro-inflammatory cytokines like tumor necrosis factor alpha (TNF-α) and interleukin-8 (IL-8), both of which are involved in the pathogenesis of psoriasis. The upregulation of these pathways via obesity can lead to the development of psoriasis and the exacerbation of existing psoriasis, but also correlate with psoriasis severity. In addition, obesity may induce T-helper 17 cells (Th17) to secrete interleukin-17 (IL-17), a family of pro-inflammatory cytokines involved in the development of autoimmune diseases like psoriasis. Psoriasis is also characterized by the proliferation of Th1 and Th22 cells, which result in the production of pro-inflammatory mediators.

In addition to an altered inflammatory response, a major psoriasis susceptibility gene, HLA-Cw6 is also associated with obesity. As reported in Dermatology, obese patients with this gene are 35 times more likely to develop psoriasis than normal weight patients without the gene. Normal weight patients with the gene are 8.33 times more likely to develop psoriasis than normal weight patients without the gene.

Conventional treatments for psoriasis include ultraviolet light therapy, topical vitamin D cream, topical and systemic steroids, disease-modifying anti-rheumatic drugs (DMARDs), and injectable biologic medications. Interestingly, obese patients with psoriasis tend to have a lower response to biologics and systemic treatments. And in patients with moderate to severe psoriasis, biologic medications may cause weight gain by reducing leptin, which can affect appetite.

While the nutritional management of obesity is often accepted and recommended by conventional and integrative providers alike, the therapeutic benefits of nutrition therapy for psoriasis are just being recognized. Nutrition and lifestyle-related changes to address obesity can be powerful when it comes to reversing psoriasis symptoms.

Case Study

Heather is a 27-year-old female who has struggled with her weight since the age of five. While she has a family history of psoriasis, she didn’t develop symptoms until she was in her early twenties. Heather reported yo-yo dieting and binge eating until she gained a better understanding of nutrition while training to become a dietitian. She sought integrative nutrition therapy to improve her psoriasis symptoms, heal her relationship with food, and to find a healthy weight for herself. She was also planning to start a family and knew she would not be able to take her psoriasis medication while pregnant and she feared her symptoms would be miserable.

Heather is five foot eight inches tall and initially weighed 265 pounds. She reported her highest adult weight of 300 pounds but she had worked hard to recover from binge eating disorder and had lost a total of 35 pounds. Her initial symptom score of 63 indicated severe symptoms, mostly related to psoriasis on her hands, thinning hair, and digestive and emotional symptoms. She was taking hydrochlorothiazide for high blood pressure, otezla for psoriasis, vitamin D3, and a prenatal vitamin. Heather was eating four to five meals per day and while she did eat a variety of foods, she was consuming gluten, dairy, and sweets. She admitted to being hesitant to eliminate any foods although she knew this would likely be beneficial. Heather reported being treated for asthma as a child and she had received allergy shots. She did not sleep well and reported waking multiple times each night. She enjoyed powerlifting four to five days per week, but the psoriasis lesions on her hands made gripping weights painful and difficult.

Her initial lab work indicated vitamin D deficiency, with vitamin D level of 18ng/mL, a normal TSH of 1.13mU/L, normal blood sugar with hemoglobin A1c of 4.9 percent and glucose of 88mg/dL, elevated triglycerides of 161 mg/dL, and normal total cholesterol of 155 mg/dL, HDL of 47 mg/dL, and LDL of 76 mg/dL.

The initial plan included:

1. A full elimination diet for a minimum of eight weeks to remove top food allergens, inflammatory and processed foods, and sugar to target the gut microbiome and inflammation.
2. Overnight fasting for 12 hours every night to avoid excess snacking and overeating.
3. Supplements to include 5,000 international units (IUs) vitamin D3 per day, a prenatal multivitamin, 2,000 mg/day of omega-3 fatty acids, a multi-strain probiotic, and 240 mg magnesium glycinate daily before bed.
4. Meditation for five minutes upon waking and five minutes mid-day to target the stress response.
5. Sleep hygiene techniques to include magnesium glycinate 30 minutes before bed, no blue light for one hour before bed, and a sleep routine.
6. Labs and testing: fasting insulin, homocysteine, full thyroid panel with antibodies, vitamin D, CBC, CMP, folate, ferritin, and hsCRP. Consider a GI Map stool test, salivary cortisol testing, and organic acids testing in the future if desired.

After four weeks, Heather’s symptom score was down to 10 and she had lost 18 pounds. She said she had much more energy and noticed less inflammation and pain. She had implemented the overnight fasting and was following the meal plan closely. Heather found she was drinking more water and was continuing to strength train three to five times per week. She had made sleep a priority by creating a calming routine before bed. Heather was using the magnesium glycinate, but had also started using lavender essential oil, a sleep mask, meditation with prayer, and a sleep machine. She was able to sleep for six to seven hours per night without interruption.

Heather reported a random flare of her symptoms during her menstrual cycle, but her skin symptoms were much better overall with only a few bubbles here and there. She did have some unexplained diarrhea and wondered if she had a nightshade intolerance and she also noted she experienced a flare of symptoms when she did not use gloves while cleaning her house. Heather had cut her psoriasis medication dose in half.

Labwork indicated optimal thyroid function and negative thyroid antibodies, the vitamin D level had improved to 40 ng/mL, however her fasting glucose was higher than optimal at 96mg/dL and her fasting insulin of 18.58 mIU/L indicated insulin resistance. The homocysteine of 7.5 mcmol/L was normal, but her folate level was elevated at >20nmol/L indicating possible vitamin B12 deficiency. The ferritin of 57.8 ng/mL was borderline low and hsCRP of 1.83 was normal.

The follow up plan included:

1. A continuation of the elimination diet for four more weeks.
2. Seek out non-toxic body care and cleaning products.
3. Add berberine 400 milligrams TID, walk for 10 minutes after each meal, and add in two high intensity interval training (HIIT) sessions weekly to target insulin resistance.
4. Add gut-healing supplements and continue for three months: prebiotic fiber 1 scoop per day, comprehensive gut healing powder 1 scoop per day, continue the multi-strain probiotic and add in Bifidobacterium lactis B-420
5. Continue all other supplements and consider having methylmalonic acid or serum B12 level checked.

After a total of eight weeks, Heather’s symptom score was 14 indicating she still had some symptoms but was doing well overall. Her weight was down another eight pounds to 238 pounds and the psoriasis lesions on her hands were mostly gone with only a few bubbles here and there. Heather reported following the meal plan very closely and she had noticed a flare of symptoms when she ate a large serving of tomatoes. She felt she did well with other nightshade vegetables however. She had incorporated HIIT training twice weekly in addition to her strength training routine, and she felt her sleep was better.

 Heather decided to stop her psoriasis medication and had also discontinued use of the berberine as she was planning to become pregnant and was worried about possible side effects.  She was somewhat discouraged that she began to notice more psoriasis symptoms on her hands three days after discontinuing her medication, but she admitted the symptoms were much less severe than previously when she was on her full dose of medication without the nutrition and lifestyle changes.

The follow up plan included:

1. A systematic reintroduction of eliminated foods with the continued avoidance of gluten and dairy. Avoid tomatoes for another three months due to negative reaction.
2. Transition to an anti-inflammatory, low-glycemic, gluten and dairy-free, low-grain, moderate healthy fat meal plan.
3. Add one-half teaspoon of ground cinnamon, two tablespoons of olive oil, one-half cup of raw walnuts, and four tablespoons of ground flaxseeds per day to target insulin resistance and glucose.
4. Continue all previous goals with the exception of the berberine.

Heather has made remarkable progress and is hopeful that continuing on the current path will allow her to remain off of prescription medication, completely reverse her psoriasis symptoms, obtain and maintain a healthy weight, and experience a healthy pregnancy. She plans to move forward with the GI Map testing after eight more weeks on the protocol if her symptoms have not completely resolved.

Resources:

Armstrong, A. (2021) Psoriasis Prevalence in Adults in the United States. JAMA Dermatology. Retrieved from: https://jamanetwork.com/journals/jamadermatology/article-abstract/2781378

Jensen, P. (2016) Psoriasis and Obesity. Dermatology. Retrieved from: https://www.karger.com/Article/FullText/455840#

National Institutes of Health. Autoimmune Diseases. Retrieved from: https://www.niehs.nih.gov/health/topics/conditions/autoimmune/index.cfm  Accessed August 17, 2021.

Paroutoglou, K. (2020). Deciphering the Association Between Psoriasis and Obesity: Current Evidence and Treatment Considerations. Current obesity reports. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/32418186/