Obesity and dyslipidemia in patients with psoriasis treated at adermatologic clinic in Manaus*
Abstract
BACKGROUND
Psoriasis is a chronic inflammatory disease of multifactorial etiology, withparticipation of genetic, autoimmune and environmental factors. Recent studieshave demonstrated the role of inflammatory cells and mediators in the pathogenesisof psoriasis, which is now defined as a systemic and autoimmune inflammatorydisease that may be associated with other diseases of inflammatory nature.
OBJECTIVES
To evaluate the occurrence of obesity and dyslipidemia in patients with psoriasistreated at a dermatology clinic in Manaus.
METHODS
We performed a prospective descriptive study to assess the prevalence of obesityand dyslipidemia in patients with psoriasis. Besides the recommendeddermatological care, a physical examination was performed to measure weight,height and waist circumference.
RESULTS
We included 72 patients, 44 (61.1%) female and 28 (38.9%) male, with a mean ageof 51.0 years ± 15.9 years. As for body mass index (BMI), 16 (22.2%) wereoverweight and 20 (27.8%) were obese. In the analysis of waist circumference inrelation to gender, we found that 79.5% of women surveyed had central obesity, apercentage statistically higher than that observed among men (42.9%) at the 5%level of significance (p = 0.001). Regarding the diagnosis of dyslipidemia, 29(65.9%) females and 22 (78.6%) males showed alterations in lipid profile.
CONCLUSIONS
The occurrence of dyslipidemia and obesity in patients with psoriasis can affectlife quality and expectancy, increasing the risk of systemic and metabolicdiseases, which makes periodic investigation of these comorbidities in patientswith psoriasis mandatory.
INTRODUCTION
Psoriasis is a chronic inflammatory disease that may affect the skin, joints, nails andscalp.1 It has a multifactorialetiology, with participation of genetic, autoimmune and environmental factors.2,3,4 Recent studies have demonstrated the roleof inflammatory cells and mediators in the pathogenesis of psoriasis, which is nowdefined as a systemic and autoimmune inflammatory disease that may be associated withother inflammatory diseases, such as diabetes mellitus, obesity,cardiovascular diseases, hypertension and dyslipidemias.5,6 As of theeighties, epidemiological studies began to show the association between psoriasis andobesity.7,8 More recently, studies have demonstrated that in obesitythere is a mild inflammatory status, with increased levels of TNF-α and IL-6, whichmight trigger or exacerbate psoriatic lesions.9 On the other hand, studies reveal that patients with psoriasishave a greater chance of developing obesity due to metabolic unbalance derived from thechronic proinflammatory status.10,11 Other works suggest the associationbetween psoriasis and abnormalities in serum lipid concentrations.12,13 Psoriasis patients usually have a proatherogenic profile, withhypertriglyceridemia, elevation of LDL and VLDL concentrations and decrease of serum HDLlevels. All of these factors justify routine investigation and early treatment of thesecomorbidities, to offer psoriasis patients an enhanced quality of life.
Objectives
Assess the occurrence of dyslipidemia and obesity in patients with psoriasis treatedat an outpatient dermatology clinic in a reference hospital of Manaus.
METHODS
A descriptive and prospective study was conducted to assess the occurrence ofdyslipidemia and obesity in patients with psoriasis treated at a reference outpatientdermatology clinic, during the period between September 2011 and June 2012. Theinclusion of patients and sample size were established through spontaneous demand. Allpatients included underwent a physical examination and weight, height and abdominalcircumference were measured. The abdominal circumference measure was taken at half thedistance between the iliac crest and the lower costal margin. Weight and height measureswere used for calculation of the body mass index by means of the formula BMI =Weight/Height2 . WHO criteriafor obesity definition were used (Overweight: BMI between 25 and 29.99; Obese Class I:BMI between 30 and 34.9; Obese Class II: 35 to 39.9; Obese Class III: BMI ≥ 40).Abdominal circumference measure over 88cm in women and 102cm in men was defined ascentral obesity. Dyslipidemia was defined as Total serum cholesterol > 240mg/dL; HDLcholesterol < 40 mg/dL in men and < 50mg/dL in women; triglycerides > 150mg/dL; LDL > 160mg/dL. Patients answered a questionnaire about the clinical pictureof the disease, prior pathology history and lifestyle habits, such as cigarette smoking,alcohol consumption and regular practice of physical exercise. A complete lipid profilewas also requested and patients were oriented to have the sample collected after a 12hour- fast. Those with dyslipidemia or obesity diagnosis were referred for jointfollow-up with an endocrinologist.
Statistical Analysis
The statistical analysis was done by calculating absolute and relative frequencies.For the central tendency measures, the mean, median and standard deviation (SD) werecalculated. In the analysis of categorical variables the Chi Square test ofPearson was used; in cases where this was not feasible, Fisherexact test was applied. The comparison of means was done by applying the Student's ttest when data presented normal distribution and the nonparametricMann-Whitney test, when the normality assumption was notguaranteed. The software used for analysis was Epi-Info version 3.5.3 for Windows andthe test significance level was established as 5%.
Ethical Aspects
This study was approved by the Research Ethics Committee of the Tropical MedicineFoundation Dr. Heitor Vieira Dourado, under number CAE 0035.0.114.000-11.
RESULTS
Seventy-two patients were included, 44 (61.1%) female and 28 (38.9%) male, with a meanage of 51.0 years ± 15.9 years. The median time for psoriasis diagnosis was 5.0 years,varying from 1 month to 20 years (Table 1). Themost frequently found clinical form of the disease was psoriasisvulgaris, with small and large plaques. Of the 72 patients, 21 hadconcomitant joint involvement and four had nail involvement exclusively. As regards thetreatments employed, 14 patients used only topical medications and 58 systemic therapy(32 used methrotrexate, 18 acitretin, two cyclosporine and six immunobiologics). Inrelation to prior pathology history, 25 (34.7%) had hypertension and 14 (19.4%) werebeing treated for diabetes. In the comparison of median time since diagnosis regardingprior diagnosis of diabetes, a statistically significant difference was found incomparison with patients that did not present this comorbidity (Table 2). As for the body mass index (BMI), 16 (22.2%) presentedoverweight and 20 (27.8%) were obese. The abdominal circumference measure analysisrelated to gender revealed that 79.5% of the women examined presented central obesity, apercentage statistically higher than that found among men (42.9%), at the 5%significance level (p= 0.001). Regarding the dyslipidemia diagnosis, 29 (65.9%) of thefemales and 22 (78.6%) of the males presented lipid profile alterations (Table 3). Of the patients with dyslipidemia, eighthad high total cholesterol, 35 high triglycerides and six, high LDL. As for HDLcholesterol, 28 female and 16 male patients presented HDL lower than 50 mg/dL and40mg/dL, respectively (Table 4). Of the 51patients with dyslipidemia, eight (15.7%) were cigarette smokers, twelve (23.5%) werealcohol consumers and only eight (15.7%) practiced regular physical exercise. Of the 20patients with obesity according to the BMI, only two (10.0%) practiced physicalexercises regularly, six (30.0%) were alcohol consumers and nine (45.0%) were smokers.Of the 72 patients, six (8.3%) had HIV/AIDS and two of them had been usingantiretroviral therapy for more than two years. Only one of them presenteddyslipidemia.
| Variable n=72 | f1 | % |
| Gender | ||
| Female | 44 | 61.1 |
| Male | 28 | 38.9 |
| Age (years) | ||
| < 25 | 3 | 4.2 |
| 25 |--- 35 | 8 | 11.1 |
| 35 |--- 45 | 15 | 20.8 |
| 45 |--- 55 | 13 | 18.1 |
| 55 |--- 65 | 19 | 26.4 |
| ≥ 65 | 14 | 19.4 |
| Mean ±SD | 51.0 ± 15.9 | |
| Time since diagnosis (years) | ||
| < 01 | 13 | |
| 01 |--- 05 | 19 | |
| 05 |--- 10 | 15 | |
| 10 |--- 20 | 17 | |
| ≥ 20 | 8 | |
| Median | 5.0 | |
| Q1-Q3 | 01-10 |
| Variables (n=72) | n | Median | Q1 - Q3 | p* |
| Hypertensive | 0.099 | |||
| Yes | 25 | 8.0 | 1-12 | |
| No | 47 | 3.0 | 1-10 | |
| Diabetes | 0.041 | |||
| Yes | 14 | 8.5 | 6-11 | |
| No | 58 | 3.0 | 1-10 |
f1 = simple absolute frequency.
* Chi Square Test of Pearson. Value of p in bold indicates statisticalassociation at the 5% significance level
| Gender | ||||||
| Physical | Female | Male | ||||
| Examination | (n = 44) | (n = 28) | ||||
| fl | % | fl | % | Total | p* | |
| Obesity (IMC≥30) | 0.904 | |||||
| Yes | 12 | 16.7 | 8 | 11.1 | 20 | |
| Overweight (IMC 25 - 29.9) | 0.803 | |||||
| Yes | 10 | 13.8 | 6 | 8.3 | 16 | |
| Abdominal | ||||||
| Circumference | 0.001 | |||||
| Obese | 35 | 79.5 | 12 | 42.9 | 47 | |
| Normal | 9 | 20.5 | 16 | 57.1 | 25 | |
| Dyslipidemia | 0.249 | |||||
| Yes | 29 | 65.9 | 22 | 78.6 | 51 | |
| No | 15 | 34.1 | 6 | 21.4 | 21 | |
f1 = simple absolute frequency.
* Chi Square Test of Pearson. Value of p in bold indicates statisticalassociation at the 5% significance level
| Variables (n+72) | f1 | % |
| Cholesterol >240 | ||
| Yes | 8 | 11.1 |
| No | 64 | 88.9 |
| HDL <50 in Women (n+44) | ||
| Yes | 28 | 63.6 |
| No | 16 | 36.4 |
| HDL < 40 in Men (n=28) | ||
| Yes | 16 | 57.1 |
| No | 12 | 42.9 |
| Triglycerides>150 | ||
| Yes | 35 | 49.3 |
| No | 36 | 50.7 |
| LDL>160 | ||
| Yes | 6 | 8.3 |
| No | 66 | 91.7 |
DISCUSSION
Psoriasis is currently defined as an inflammatory and autoimmune skin disease, that mayprogress with articular manifestations and systemic comorbidities.14 The cause for association betweenpsoriasis and these comorbidities has still not been fully elucidated, but studies pointto a chronic proinflammatory status. This proinflammatory status is mediated by Tlymphocytes, especially T helper 1 (Th-1) lymphocyte, which produces inflammatorycytokines, as the tumor necrosis factor α (TNF-α), interleukin 2 (IL2) and interferon ϒ(IFN-ϒ).15 Other studies showthat these comorbidities occur more often in psoriatic patients who are in an older agegroup, with longer time of disease progression, as well as in moderate and severe formsof the disease.16 Of the 72 patientswith psoriasis included in the study, 51 (70.8%) presented dyslipidemia, 20 obesity(27.8%) and 47 (65.2%) central obesity; these had a longer time of psoriasis progressionthan patients who did not have these comorbidities. The above data coincide with whatwas found in the literature, demonstrating that the time of psoriasis progressionincreases chances for development of metabolic alterations (Table 5). Other factors seem to play a relevant role in the onset ofobesity and dyslipidemia in psoriasis patients, such as sedentary lifestyle, smokinghabit and alcohol consumption. Of the 20 patients who were obese according to the BMI,only two (10.0%) practiced physical exercises regularly, six (30.0%) were alcoholconsumers and nine (45.0%) were cigarette smokers, demonstrating that multiple factorsmay contribute to the onset of these comorbidities in patients with psoriasis.
| Variables (n=72) | n | Median | Q1 - Q3 | P* |
| Obesity (BMI >30 | 0,714 | |||
| Yes | 20 | 5.0 | 1-11 | |
| No | 52 | 5.0 | 1-10 | |
| Abdominal Obesity | 0.022 | |||
| Yes | 47 | 7.0 | 1-10 | |
| No | 25 | 1.0 | 0-10 | |
| Dyslipidemia | 0.132 | |||
| Yes | 51 | 8.0 | 1-12 | |
| No | 21 | 3.0 | 1-5 |
f1 = simple absolute frequency;
*Nonparametric Mann-Whitney Test. Value of p in bold italic indicatesstatistical association at the 5% significance level
CONCLUSION
The occurrence of dyslipidemia and obesity in patients with psoriasis may alter thequality and expectancy of life of these patients, increasing the risk for cardiovasculardiseases, making periodic investigation of these comorbidities mandatory, in addition toa multidisciplinary patient follow-up.
Footnotes
* Work carried out at the Dermatology Clinic of the Tropical Medicine Foundation(Fundação de Medicina Tropical Dr. Heitor Vieira Dourado - FMTAM) - Manaus (AM),Brazil.
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