|Year : 2014 | Volume
| Issue : 4 | Page : 225-229
Relation between metabolic syndrome and psoriasis: A multicenter, hospital-based, case-control study from West Bengal, India
Somak Kumar Das1, Tanusree Nath2, Anirban Ghosal3, Rajesh Kumar Mondal4, Chanchal Kumar Jana5
1 Departments of Medicine, College of Medicine and Jawaharlal Nehru Memorial Hospital, West Bengal University of Health Sciences, Kalyani, Nadia, West Bengal, India
2 Department of Medicine, ESI PGIMSR Hospital, Joka, West Bengal, India
3 Department of Neuromedicine, N. R. S. Medical College, West Bengal, India
4 Department of Dermatology, North Bengal Medical College, West Bengal, India
5 Department of Medicine, R. G. Kar Medical College, Kolkata, West Bengal, India
|Date of Submission||28-Aug-2014|
|Date of Decision||14-Oct-2014|
|Date of Acceptance||04-Nov-2014|
|Date of Web Publication||11-Dec-2014|
Somak Kumar Das
Millennium Apartment, 23, Kalibari Lane, Flat - A 10, Jadavpur, Kolkata - 700 032, West Bengal
Source of Support: None, Conflict of Interest: None
Introduction: Psoriasis is a chronic, inflammatory, immune-mediated skin disease affecting approximately 2-3% of the global population. Besides traditional co-morbidities associated with psoriasis, an emerging co-morbidity is metabolic syndrome. Psoriasis and metabolic syndrome are likely linked together due to underlying chronic inflammatory nature of psoriasis, in large part, to the increased tumor necrosis factor-alpha. Aim: To study the association between psoriasis and metabolic syndrome and its components. Materials and Methods: A case-control, hospital-based multicenter study was designed including 173 consecutive psoriatic patients and 184 nonpsoriatic subjects as control during a period of 2 years. In this study, we statistically compared the components of metabolic syndrome (using National Cholesterol Education Program Adult Treatment Panel criteria) in case and control groups. Results: Out of 173 psoriatic patients, there were 91 men (52.6%) and 82 women (44.56%); and in the control group, there were 93 men (50.54%) and 91 women (49.45%). We found a higher proportion of psoriatic patients having features of metabolic syndrome compared to the control group (40.46% vs. 22.28%), the difference was statistically significant (p < 0.0001). Prevalence of obesity in terms of waist circumference (p = 0.001) and body mass index (p = 0.001), and dyslipidemia (p = 0.004) were significantly associated with psoriasis, whereas prevalence of hypertension (p = 0.11) and diabetes (p = 0.93) were not associated with psoriasis. Conclusion: Psoriasis is statistically positively associated with metabolic syndrome in our study.
Keywords: Metabolic syndrome, national cholesterol education program adult treatment panel criteria, psoriasis, tumor necrosis factor-alpha
|How to cite this article:|
Das SK, Nath T, Ghosal A, Mondal RK, Jana CK. Relation between metabolic syndrome and psoriasis: A multicenter, hospital-based, case-control study from West Bengal, India. J Obes Metab Res 2014;1:225-9
|How to cite this URL:|
Das SK, Nath T, Ghosal A, Mondal RK, Jana CK. Relation between metabolic syndrome and psoriasis: A multicenter, hospital-based, case-control study from West Bengal, India. J Obes Metab Res [serial online] 2014 [cited 2021 May 15];1:225-9. Available from: https://www.jomrjournal.org/text.asp?2014/1/4/225/146801
| Introduction|| |
While heart disease remains a quiet killer, ignored for years by those at risk, psoriasis is a highly visible disease. Psoriasis is a chronic, inflammatory, immune-mediated, debilitating skin disease affecting approximately 2-3% of the global population and poses a lifelong burden for the affected individuals. ,, Psoriasis manifests as skin lesions with typical silvery scales and potentially, by arthritis. Psoriasis is associated with serious co-morbidities. Besides traditional conditions, emerging co-morbidities of psoriasis include cardiovascular diseases and metabolic syndrome. The relationship between psoriasis and psoriasis-associated co-morbidities such as metabolic syndrome is likely linked to underlying chronic inflammatory nature of psoriasis, in large part, to the increased level of pro-inflammatory factors, such as tumor necrosis factor-alpha (TNF-α). , Overproduction of inflammatory cytokines such as TNF-α, interleukin (IL)-1, IL-6, and IL-8 in adipose tissue is an important feature of obesity and may account for the pathogenesis of psoriasis.
Metabolic syndrome, a clustering of metabolic risk factors, is a strong predictor of future cardiovascular disease and diabetes. Adult Treatment Panel (ATP) III identified 6 components of metabolic syndrome-abdominal obesity, atherogenic dyslipidemia (low-density lipoprotein [LDL], high-density lipoprotein [HDL], high triglyceride (TG), small LDL), raised blood pressure (BP), glucose intolerance, pro-inflammatory state and prothrombotic state. 
The scientific literature linking psoriasis to metabolic syndrome and its components, as well as atherosclerosis and myocardial infarction, has rapidly expanded. Increasingly, epidemiological studies are establishing the directionality of these associations and the role of psoriasis as an independent risk factor in developing metabolic syndrome.  Several recent reports have demonstrated a possible association between psoriasis, obesity, hypertension, diabetes and ischemic heart disease. A large cohort of psoriasis patients was introduced in the study, published by Henseler and Christophers, who showed an association among psoriasis, diabetes, obesity, heart failure and hypertension. , Almost all of these studies were done on patients of western countries and Israel.
Although psoriasis and metabolic syndrome both are quite common in India, lack of detailed studies on this association from our country prompted us to undertake the present study. In this current study, our purpose was to determine the association between psoriasis and metabolic syndrome in patients from Kolkata and its adjacent districts.
| Materials and methods|| |
A multicenter hospital-based case-control study was conducted at three tertiary medical college hospitals, one in R. G. Kar Medical College, Kolkata (RGKMCH), one at College of Medicine and JNM Hospital, West Bengal University of Health Sciences, Kalyani, Nadia district (COM and JNMH), West Bengal and another being North Bengal Medical College (NBMC). We included hospital-based patients as samples from three parts of West Bengal - Northern West Bengal (NBMC), middle portion of Bengal (COM and JNMH) and the southern part (RGKMCH) so that the result can be extrapolated to population of whole West Bengal. In this study, during 2-year period, we included consecutive adult patients (>16 years of age) of both sexes attending the out-patient department (OPD) and/or in-door of Department of Medicine and Dermatology OPD. Cases were defined as patients (>16 years of age) with a diagnosis of psoriasis. The controls were defined as age- and gender-matched patients (>16 years) attending medicine OPD/in-door without a diagnosis of psoriasis. Case and control groups were diagnosed as metabolic syndrome according to National Cholesterol Education Program (NCEP) - ATP III criteria  - if ≥ 3 of the following features are present.
- Increased waist circumference (WC), ≥ 102 cm in men and ≥ 88 cm in women
- Elevated serum TG ≥ 150 mg/dl or receiving drug(s) treatment for elevated TG
- Reduced serum HDL cholesterol <40 mg/dl in men and <50 mg/dl in women or receiving drug treatment for reduced HDL cholesterol
- Elevated BP, ≥ 130 mmHg systolic and/or ≥ ≥ 85 mmHg diastolic or anti-hypertensive drug treatment in patients with histories of hypertension; and
- Elevated fasting blood glucose (FBG) ≥ 100 mg/dl or drug treatment for elevated glucose.
All patients gave a written consent, and the Institutional review board at the University of Health Sciences approved the study protocol.
Clinical histories including hypertension or antihypertensive medications, previously diagnosed diabetes or antidiabetic medications, any other drug histories were taken in both groups. Clinical variables include weight (kg), height (cm), body mass index (BMI), WC (cm), BP (mmHg). Body weight (kg) and height (cm) were measured using standardized techniques and equipment. The BMI was calculated as weight divided by squared height (kg/m 2 ). The WC was measured with a paper tape horizontally at the level of umbilicus in the standing position. The hip circumference was measured at the level of the greater trochanter. BP was measured from the left arm in a sitting position with apparatus at the level of the heart. Venous blood samples were taken after 12 h of fasting. FBG levels (reference range, 60-100 mg/dl) were estimated by the glucose oxidase-peroxidase method using a glucose analyzer. Fasting serum concentrations of TG and HDL were measured using commercially available kits.
After collecting all the data, statistical analysis was performed using IBM SPSS software (version 20) for analysis of data. p < 0.05 was taken as statistically significant.
| Results|| |
In the patient group, there were 91 men (52.6%) and 82 women (44.56%). In the control group, there were 93 men (50.54%) and 91 women (49.45%). The mean age of the patient group was 42.77 years (standard deviation [SD] =14.93 years, range: 17-83 years) and that of the control group was 46.38 years (SD = 14.21 years, range: 20-85 years). We found the majority of patients having plaque-type of psoriasis (64.15%) followed by palmoplantar psoriasis (33.84%), and erythrodermic type being least in numbers (1.62%). Metabolic syndrome was more prevalent in chronic plaque psoriasis (25.76%) followed by palmoplantar psoriasis (18.98%). Patients with chronic plaque psoriasis with body surface area >10% were less associated with metabolic syndrome than patients with chronic plaque psoriasis BSA <10% (8.79% vs. 15.06%). Female psoriatics were more affected with metabolic syndrome than male psoriasis in this study. Majority of the psoriasis patients who fulfilled criteria for metabolic syndrome had disease duration of at least >1-year.
Metabolic syndrome and its components
All the data on mean WC, BMI, systolic BP, diastolic BP, fasting blood sugar (FBS), TG, HDL of the case group having psoriasis (Group 1) and control group (Group 2) is shown in [Table 1]. Case group had mean LDL level of 120.64 ± SD 39.87 mg/dl and control group had mean 94.37 ± SD 20.36 mg/dl.
|Table 1: Summary of components of metabolic syndrome in individuals with psoriasis (Group 1) and controls (Group 2) |
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Prevalence of increased WC in the case group was 45.08% (n = 78) and that in the control group was 23.36% (n = 43). Prevalence of high BMI (>24.9) in case group was 40.04% (n = 70) and that was in control group was 19.02% (n = 35). 49.13% (n = 85) psoriatic patients had BP more or equal to 130/85 mmHg compared to 48.36% (n = 89) in control group. In Group 1, 39.88% (n = 69) psoriatic patients had FBS ≥ 100 mg/dl and in Group 2, 34.23% (n = 63) controls had FBS ≥ 100 mg/dl. Among the cases, 21.38% (n = 37) were overt diabetic and among control group 23.91% (n = 44) had FBS ≥ 126 mg/dl. Among the psoriasis cases, 46.82% (n = 81) had TG > 150 mg/dl compared to 21.19% (n = 39) in controls. Among the psoriasis cases, 36.99% (n = 64) had low HDL according to sex, compared to 33.69% (n = 62) in controls; low HDL according to sex, being an inclusion criteria for metabolic syndrome according to NCEP - ATP III.
Summary of the proportion of components of metabolic syndrome according to NCEP - ATP III in patients with psoriasis and in the control group (age- and sex-adjusted) - univariate analysis is described in [Table 2].
|Table 2: Summary of proportion of components of metabolic syndrome in patients with psoriasis and in the control group (age- and sex-adjusted) nivariate analysis |
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In our study, 40.46% (n = 70) patients with psoriasis fulfilled the criteria for metabolic syndrome, whereas 22.28% (n = 41) control patients had metabolic syndrome. A higher proportion of psoriatic patients had features of metabolic syndrome compared to the control group (40.46% vs. 22.28%), the difference was statistically significant (p < 0.0001). Hence, psoriasis is strongly and positively associated with metabolic syndrome (Pearson's R and Spearman's correlation = +0.196; p < 0.00001). Female psoriasis patients were found to have metabolic syndrome more than male counterpart (22.54% vs. 17.91%). Young and middle age group (26-55 years) were the major victims in our study.
| Discussion|| |
Consistent with the pro-inflammatory nature of both psoriasis and metabolic syndrome, several large studies have demonstrated that patients with psoriasis incur an increased risk for metabolic syndrome and its components. In 1995, Henseler and Christophers performed a large cohort study demonstrating that inpatients with psoriasis (n = 2941) are 1.5-2.0-fold more likely to be obese or have hypertension or diabetes compared with inpatients with other dermatologic disorders.  In a hospital-based case-control study, Gisondi et al. reported that adult patients with chronic plaque psoriasis have a significantly higher prevalence of metabolic syndrome than controls after age 40 (30.1% vs. 20.6%, odds ratio [OR]: 1.65; 95% confidence interval (CI): 1.16-2.35; p = 0.005).  Cohen et al. in 2007 and in 2008, Alsufyani et al. in 2010 published their research data showing relation among psoriasis and metabolic syndrome. ,, The study conducted by Cohen et al. including 16,851 patients with psoriasis and 48,681 demonstrated that psoriasis was associated with the metabolic syndrome (OR = 1.3, 95% CI = 1.1-1.4), ischemic heart disease (OR = 1.1, 95% CI = 1.0-1.2), diabetes mellitus (OR = 1.2, 95% CI = 1.0-1.3), hypertension (OR = 1.3, 95% CI = 1.2-1.5) and obesity (OR = 1.7, 95% CI = 1.5-1.9). 
In contrast to previous studies (except for Gisondi et al.), we found a significant association of obesity and dyslipidemia with psoriasis. Diabetes and hypertension did not pose statistical association with psoriasis. In our study, 40.46% (n = 70) patients with psoriasis fulfilled the criteria for metabolic syndrome, whereas 22.28% (n = 41) control patients had metabolic syndrome. A higher proportion of psoriatic patients had features of metabolic syndrome compared to the control group (40.46% vs. 22.28%), the difference was statistically significant (p < 0.0001). Hence, psoriasis is strongly and positively associated with metabolic syndrome (Pearson's R and Spearman's correlation correlation = +0.196; p < 0.00001). In India, there were three important studies conducted in Mumbai, Kashmir, and in Chennai. ,, Our data support the data of those studies.
Asian-Indians are unique in their genetic diversity. These populations are much more prone to develop early hypertension, diabetes, insulin resistance (IR). India is also called as "diabetes capital." Prevalence of diabetes, hypertension and obesity are rapidly increasing in India. Childhood obesity is another burning issue as a precursor of future diabetes. Metabolic syndrome, the precursor of future cardiovascular disease, diabetes and other co-morbidities, is about to engulf the entire nation, particularly the young and middle-aged subjects. High prevalence of diabetes and hypertension in Asian-Indian population might have an impact on this result.  In India, young generations and middle-aged subjects are highly predisposed to develop metabolic syndrome. The prevalence of metabolic syndrome is increasing day by day. In our country, recent changes in life-style, sedentary habits, more use of electronic gadgets and "fast-food" or so-called junk food intake particularly in urban and semi-urban young and middle-aged population probably contribute to the obesity, diabetes and hypertension epidemic in India. Moreover, International Diabetes Federation definition for metabolic syndrome includes separate sets of WC measurement for Indian, which is much lower than that in NCEP - ATP III criteria. So, if we include this criterion, we can get more realistic data on psoriasis and metabolic syndrome.
The study conducted was a small, case-control study without any randomization and blinding. It is important to emphasize that the association alone, and not causality, was proven. The major culprit of metabolic syndrome is IR that is best measured by euglycemic clamp technique (e.g., homeostatic model assessment-IR). We did not measure that one. Most of the psoriasis patients, included in the study, were not treatment naïve patients. Control patients were not disease free; rather the patients included from medical OPD and inpatient department had associated illness that might falsely contribute the burden of metabolic syndrome.
| Conclusion|| |
We found that a higher proportion of psoriatic patients having features of metabolic syndrome compared to the control group (40.46% vs. 22.28%), the difference was statistically significant (p < 0.0001). Hence, psoriasis is strongly and positively associated with metabolic syndrome. Though there was strong association between psoriasis and obesity and dyslipidemia; diabetes and hypertension were not statistically associated with psoriasis in our study. According to our country's trend, we have got relevant results indicating emergent epidemics of stressful life, obesity, diabetes, hypertension and high blood level of TNF-α. We hope there will be lots of prospective, randomized control trials to prove or unprove this association in the future.
| References|| |
Gelfand JM, Stern RS, Nijsten T, Feldman SR, Thomas J, Kist J, et al. The prevalence of psoriasis in African Americans: Results from a population-based study. J Am Acad Dermatol 2005;52:23-6.
Gelfand JM, Weinstein R, Porter SB, Neimann AL, Berlin JA, Margolis DJ. Prevalence and treatment of psoriasis in the United Kingdom: A population-based study. Arch Dermatol 2005;141:1537-41.
Schön MP, Boehncke WH. Psoriasis. N Engl J Med 2005;352:1899-912.
National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III) final report. Circulation 2002;106:3143-421.
Henseler T, Christophers E. Disease concomitance in psoriasis. J Am Acad Dermatol 1995;32:982-6.
Azfar RS, Gelfand JM. Psoriasis and metabolic disease: Epidemiology and pathophysiology. Curr Opin Rheumatol 2008;20:416-22.
Gisondi P, Tessari G, Conti A, Piaserico S, Schianchi S, Peserico A, et al. Prevalence of metabolic syndrome in patients with psoriasis: A hospital-based case-control study. Br J Dermatol 2007;157:68-73.
Cohen AD, Gilutz H, Henkin Y, Zahger D, Shapiro J, Bonneh DY, et al. Psoriasis and the metabolic syndrome. Acta Derm Venereol 2007;87:506-9.
Cohen AD, Sherf M, Vidavsky L, Vardy DA, Shapiro J, Meyerovitch J. Association between psoriasis and the metabolic syndrome. A cross-sectional study. Dermatology 2008;216:152-5.
Alsufyani MA, Golant AK, Lebwohl M. Psoriasis and the metabolic syndrome. Dermatol Ther 2010;23:137-43.
Madanagobalane S, Anandan S. Prevalence of metabolic syndrome in South Indian patients with psoriasis vulgaris and the relation between disease severity and metabolic syndrome: A hospital-based case-control study. Indian J Dermatol 2012;57:353-7.
Nisa N, Qazi MA. Prevalence of metabolic syndrome in patients with psoriasis. Indian J Dermatol Venereol Leprol 2010;76:662-5.
Pereira RR, Amladi ST, Varthakavi PK. A study of the prevalence of diabetes, insulin resistance, lipid abnormalities, and cardiovascular risk factors in patients with chronic plaque psoriasis. Indian J Dermatol 2011;56:520-6.
[Table 1], [Table 2]