In the JournalsPerspective

Obesity in children with psoriasis contributes to comorbidities

Although children with psoriasis are at greater risk for developing various comorbidities than children without psoriasis, obesity is a stronger independent risk factor than psoriasis in comorbidity development, according to recently published study results in JAMA Dermatology.

“In recent years, it has become increasingly clear that psoriasis is more than a ‘skin-deep’ condition and that it may frequently be associated with other systemic comorbidities, even in children,” Megha M. Tollefson, MD, of the dermatology department at Mayo Clinic, Rochester, Minnesota, and colleagues wrote. “There is mounting evidence that children with psoriasis are more likely to be obese than children without psoriasis, but this finding begs the question of whether the systemic comorbidities that are seen in children with psoriasis are attributable to obesity, or whether psoriasis is an independent risk factor for these comorbidities.”

Tollefson and colleagues used data from the Optum Laboratories Data Warehouse, which includes data for 150 million privately insured and Medicare Advantage enrollees, to conduct a retrospective cohort study of 29,957 children diagnosed with psoriasis between 2004 and 2013 (affected children; average age, 12.0 years; 53.5% girls) and 29,957 children without psoriasis who were matched by age, sex and race. The cohorts were divided into four groups including, nonobese without psoriasis, nonobese with psoriasis, obese without psoriasis and obese with psoriasis.

There were more children in the affected children cohort who were obese (2.9%) compared with the nonaffected children (1.5%) at baseline (P < .001 for all comparisons). Children with psoriasis were significantly more likely to develop comorbidities including elevated lipid levels, hypertension, metabolic syndrome, polycystic ovarian syndrome, diabetes, nonalcoholic liver disease and elevated liver enzyme levels, than children without psoriasis (P < .01).

Even in children without psoriasis, obesity was a risk factor for each comorbidity developing (HR range = 2.26 to 18.11).

There was a 40% to 75% higher risk of comorbidities among nonobese children with psoriasis compared with nonobese children without psoriasis, including elevated lipid levels (HR = 1.42; 95% Ci, 1.25-1.62), hypertension (HR = 1.64; 95% CI, 1.40-1.93), diabetes (HR = 1.58; 95% CI, 1.27-1.95), metabolic syndrome (HR = 1.62; 95% CI, 1.13-2.33), polycystic ovarian syndrome (HR = 1.49; 95% CI, 1.18-1.88), nonalcoholic liver disease (HR = 1.76; 95% CI, 1.16-2.65) and elevated liver enzyme levels (HR = 1.46; 95% CI, 1.27-1.67).

Significant interaction did not occur between psoriasis and obesity regarding comorbidity risk except for hypertension (P = .03).

Children with psoriasis have higher rates of obesity, hyperlipidemia, hypertension, diabetes, metabolic syndrome, polycystic ovarian syndrome, nonalcoholic liver disease and elevated liver function enzyme levels than children who do not have psoriasis,” the authors concluded. “Children with psoriasis are also at increased risk to develop these comorbidities, irrespective of obesity status. However, these children who are obese are much more likely to develop comorbidities than those who are not obese, even in the population of children with psoriasis … Our results highlight the particular importance of screening obese patients because obesity is a much larger contributor to comorbidity development.” Bruce Thiel

 

Disclosures: The authors report no relevant financial disclosures.

Although children with psoriasis are at greater risk for developing various comorbidities than children without psoriasis, obesity is a stronger independent risk factor than psoriasis in comorbidity development, according to recently published study results in JAMA Dermatology.

“In recent years, it has become increasingly clear that psoriasis is more than a ‘skin-deep’ condition and that it may frequently be associated with other systemic comorbidities, even in children,” Megha M. Tollefson, MD, of the dermatology department at Mayo Clinic, Rochester, Minnesota, and colleagues wrote. “There is mounting evidence that children with psoriasis are more likely to be obese than children without psoriasis, but this finding begs the question of whether the systemic comorbidities that are seen in children with psoriasis are attributable to obesity, or whether psoriasis is an independent risk factor for these comorbidities.”

Tollefson and colleagues used data from the Optum Laboratories Data Warehouse, which includes data for 150 million privately insured and Medicare Advantage enrollees, to conduct a retrospective cohort study of 29,957 children diagnosed with psoriasis between 2004 and 2013 (affected children; average age, 12.0 years; 53.5% girls) and 29,957 children without psoriasis who were matched by age, sex and race. The cohorts were divided into four groups including, nonobese without psoriasis, nonobese with psoriasis, obese without psoriasis and obese with psoriasis.

There were more children in the affected children cohort who were obese (2.9%) compared with the nonaffected children (1.5%) at baseline (P < .001 for all comparisons). Children with psoriasis were significantly more likely to develop comorbidities including elevated lipid levels, hypertension, metabolic syndrome, polycystic ovarian syndrome, diabetes, nonalcoholic liver disease and elevated liver enzyme levels, than children without psoriasis (P < .01).

Even in children without psoriasis, obesity was a risk factor for each comorbidity developing (HR range = 2.26 to 18.11).

There was a 40% to 75% higher risk of comorbidities among nonobese children with psoriasis compared with nonobese children without psoriasis, including elevated lipid levels (HR = 1.42; 95% Ci, 1.25-1.62), hypertension (HR = 1.64; 95% CI, 1.40-1.93), diabetes (HR = 1.58; 95% CI, 1.27-1.95), metabolic syndrome (HR = 1.62; 95% CI, 1.13-2.33), polycystic ovarian syndrome (HR = 1.49; 95% CI, 1.18-1.88), nonalcoholic liver disease (HR = 1.76; 95% CI, 1.16-2.65) and elevated liver enzyme levels (HR = 1.46; 95% CI, 1.27-1.67).

Significant interaction did not occur between psoriasis and obesity regarding comorbidity risk except for hypertension (P = .03).

Children with psoriasis have higher rates of obesity, hyperlipidemia, hypertension, diabetes, metabolic syndrome, polycystic ovarian syndrome, nonalcoholic liver disease and elevated liver function enzyme levels than children who do not have psoriasis,” the authors concluded. “Children with psoriasis are also at increased risk to develop these comorbidities, irrespective of obesity status. However, these children who are obese are much more likely to develop comorbidities than those who are not obese, even in the population of children with psoriasis … Our results highlight the particular importance of screening obese patients because obesity is a much larger contributor to comorbidity development.” Bruce Thiel

 

Disclosures: The authors report no relevant financial disclosures.

    Perspective
    Lawrence F. Eichenfield

    Lawrence F. Eichenfield

    Over the past decade there has been a large body of evidence showing that psoriasis is associated with significant comorbidities in adults, and that psoriasis is an inflammatory skin condition that may affect other organs other than the skin. Data have shown higher rates of heart attacks and strokes, metabolic syndrome, evidence of vascular inflammation on imaging, arthritis, and higher rates of nonalcoholic fatty liver disease, obesity, depression and anxiety. As many of these risks are seen in even younger adults, it has directed interest in assessing what comorbidities may be seen in children and adolescents with psoriasis. Prior studies of pediatric psoriasis have shown higher rates of obesity, metabolic syndrome, depression and anxiety, arthritis and possibly Crohn’s disease. Children who are overweight or obese are more likely to have psoriasis, and obesity appears to be an important risk factor for the development of psoriasis.

     So, what is the driver of the risk in patients with psoriasis?  Is it psoriasis?  Or is it obesity?

     The study by Tollefson et al used a large administrative claims database of outpatient inpatient and pharmacy services to assess pediatric patients (up to 19 years of age) diagnosed with psoriasis to assess what the factors contributing to comorbidities might be. The study showed that obesity and psoriasis are independent risk factors for comorbidity development, and, similar to findings of other studies, that obesity was more common in psoriasis patients.

    Children with psoriasis did have higher risks of comorbidities than those without psoriasis (40%-70%), including high lipid levels, diabetes, metabolic syndrome, hypertension, and hepatic disease. This is consistent with data is adults, as well as studies that have shown cholesterol processing abnormalities in children with psoriasis that was proportionate to psoriasis severity. The study also showed that obesity was a stronger risk factor for development of each comorbidity, even in those with psoriasis. 

     My take away: Children with psoriasis should be screened for comorbidities. There are recently published guidelines from the Pediatric Dermatology Research Alliance (PeDRA) and the National Psoriasis Foundation which recommend this (Osier E. et al, JAMA Dermatol. 2017;doi:10.1001/jamadermatol.2017.0499.).

    Obesity in a psoriasis patient is a sign of high rates of comorbidities, and comorbidity screening is appropriate in this population as well, as well as a discussion of the medical risks of obesity, and the potentially complicating factor of having psoriasis. The engagement of the patient and family so they are aware of the risks is part of the benefit of screening.  It may be quite helpful to lay out the issues so that the health care practitioner, whether primary care practitioner or specialist, can work with the family to optimize care and minimize the impact of psoriasis, and/or obesity, over the lifetime of the individual.

    • Lawrence F. Eichenfield, MD
    • Editorial board member, Infectious Diseases in Children Professor of dermatology and pediatrics Chief, Pediatric and Adolescent Dermatology Vice chair, Department of Dermatology University of California, San Diego and Rady Children’s Hospital, San Diego

    Disclosures: Eichenfield reports no relevant financial disclosures.