ARTICLE
Auteur(s) : Emma
Altobelli1, Reimondo Petrocelli1, Mara
Maccarone2, Gianfranco Altomare3, Giuseppe
Argenziano4, Alberto Giannetti5, Andrea
Peserico6, Gino A Vena7, Sergio
Tiberti1, Sergio Chimenti8, Ketty
Peris9
1Department of Internal Medicine and Public
Health, University of L’Aquila, Coppito-Delta 6, 67100
L’Aquila, Italy
2Italian Association of Psoriasis Patients
(ADIPSO), Rome, Italy
3Institute of Dermatology, IRCCS, O. Galeazzi,
Milan, Italy
4Department of Dermatology, Second University
of Naples, Italy
5Department of Dermatology, University
of Modena and Reggio Emilia, Italy
6Department of Dermatology, University
of Padua, Italy
7Department of Dermatology, University
of Bari, Italy
8Department of Dermatology, University of Rome
Tor Vergata, Italy
9Department of Dermatology, University
of L’Aquila, Italy
accepté le 1 Janvier 2009
Chronic diseases are the leading cause of death in both males
and females in all WHO regions [1]. Approximately 72% of all
chronic diseases occur in people aged 30 years and older [2]. The
causes of the main chronic disease epidemics are well known, whilst
the most important modifiable risk factors are: unhealthy diet and
excessive calorie intake; physical inactivity, tobacco and alcohol
use. These causes are expressed through the intermediate risk
factors of increased blood pressure, raised glucose levels,
abnormal blood lipids and obesity. Individual characteristics (such
as gender, ethnicity and genetic predisposition) and health
protective factors (such as emotional resilience), together with
social, economic and environmental factors (such as income,
education, living geographic area and working conditions),
determine differences in exposure and vulnerability of individuals
to health-compromising conditions.
Psoriasis is a chronic, immune-mediated inflammatory disease
with a recognized genetic predisposition and an estimated
prevalence of 2% of the world’s population. The (psychosocial)
impact of psoriasis on patient’s quality of life (QoL) is
significant and is not always dependent on disease severity
[3].
Several recent studies showed that psoriasis is often associated
with other chronic disorders such as type 2 diabetes, obesity and
cardiovascular disease [4-11]. The presence of these co-morbidities
in psoriasis patients has important implications for their clinical
management. Attention towards this issue is also crucial to
decrease disease morbidity and mortality. In addition,
co-morbidities certainly represent an additional economic burden
for both patients and health care.
The aim of our study was to assess, in psoriasis patients, risk
factors like socio-demographic characteristics, smoking habits,
alcohol consumption and home location (rural/urban) that are
associated with hypertension, type 2 diabetes and obesity, in order
to plan health education programs aimed at preventing the onset or
progression of co-morbidities.
Material and methods
The study population consisted of 1376 patients with psoriasis,
aged 10-85 years (692 males and 684 females) who were consecutively
recruited into the study from December 2004 to January 2006, at 21
Italian Departments of Dermatology. The methods to estimate sample
size have been described elsewhere [12]. Verbal, informed consent
was obtained from each patient before the data were collected;
approximately 3% of the patients refused to be interviewed. Data
were collected through questionnaires which psoriasis patients
filled out at home and then returned to us. Patients reported on:
socio-demographic variables (gender, age, marital status,
education, occupational status and municipality of residence),
smoking habits and alcohol consumption. Patients were also
questioned on the presence of chronic diseases such as
hypertension, type 2 diabetes and obesity and whether or not they
were under specific treatment. To evaluate the effect of
geographical distribution on co-morbidity, we used the urban-rural
status of Italian municipalities, according to the classification
proposed by Anania et al. [13], which identifies the following six
groups: extremely urban, urban, weakly urban, weakly rural, rural
and extremely rural municipalities.
Patients were divided into three groups: 1) hypertension
patients (no. = 178), 2) diabetes patients (no. = 98) and 3)
obesity patients (no. = 142). Each group was compared to the group
without co-morbidities.
Evaluation of the risk of hypertension, type 2 diabetes and
obesity according to the various exposure variables was performed
using logistic regression models. Each risk was quoted with a 95%
confidence interval (CI) and calculated using Wald’s method. The
significance of the linear trend in risk was assessed by the Mantel
test at the level of p < 0.05.
SAS software was used for the statistical analysis [14].
Results
The mean age of patients was 47.9 (standard deviation [SD] ± 14.8)
years in males and 47.2 (standard deviation [SD] ± 15.0) years in
females. The frequency of the associated chronic diseases in
psoriasis patients was: 12.9% (178/1376 patients) hypertension,
10.3% (142/1376) obesity and 7.1% (98/1376) type 2 diabetes. The
results related to risk of hypertension, type 2 diabetes and
obesity in psoriasis patients according to socio-demographic
variables are summarized in table 1. In
our series, the proportion of patients with hypertension was higher
in males (107/692 [15.5%]) than females (71/613 [9.6%]) (z = 3.108,
p = 0.002). Using females as the reference category, a 1.5 fold
increase in hypertension risk was observed for males. The
proportion of obese patients, on the other hand, was higher in
females (84/684 [12.3%]) than in males (58/692 [8.3%]). Using males
as the reference category, a 1.5 fold increase in obesity risk was
found in females. No differences in risk between genders was found
for type 2 diabetes. In order to evaluate the risk associated with
age, patients were divided into 3 groups: ≤ 39 years (no. = 455),
40-59 years (no. = 597) and ≥ 60 years (no. = 324). The risk of
either hypertension or diabetes was directly related to the age
group; it increased with increasing age. Using the ≤ 39 age group
as the reference category, the odds ratio (OR) for hypertension was
7.92 (CI 4.19-15.84) and 10.9 (CI 5.91-22.16) for the 40-59 years
and ≥ 60 years age groups, respectively. The OR for diabetes was
3.91 (CI 1.90-9.08) and 10.20 (CI 5.03-23.55) for 40-59 years and ≥
60 years age groups, respectively. Obesity risk was highest in the
40-59 years age group (OR = 1.70; CI 1.10-2.58). No associations
were found between marital status and either diabetes or obesity;
whilst married psoriasis patients had a higher risk of hypertension
(OR = 2.11, CI 1.49-2.99) as compared to not-married patients.
Interestingly, houseworkers had a 2.4 and 2.6 fold increased risk
of hypertension and diabetes respectively as compared to manual
workers. Finally, we evaluated the occurrence of hypertension,
diabetes and obesity in psoriasis patients according to urban or
rural home location. No differences in risk were found for
hypertension, however, psoriasis patients living in extremely urban
areas showed the highest risk of diabetes (OR = 1.99, CI 1.06-5.23)
and obesity (OR = 2.60, CI 1.11-6.12). None of the patients in our
population lived in extremely rural municipalities.
Table 2 shows the risk of
hypertension, type 2 diabetes and obesity in psoriasis patients in
relation to smoking habits and alcohol consumption. The OR for
hypertension was higher for both smokers (> 15 cigarettes
per day) and drinkers (> 2 glasses/day of wine). The OR for
either diabetes or obesity was higher for drinkers: 1 drink/day (OR
= 1.93) and > 1 drink/day of spirits (OR = 2.90)
respectively.
There were no patients with more then one co-morbidity
(hypertension ± diabetes ± obesity), and therefore it was not
possible to estimate the effects of two or more disease linked to
the risk factors.
Table 1 Risk of hypertension, type 2 diabetes and
obesity in psoriasis patients according to socio-demographic
characteristics
|
- Psoriasis patients with hypertension§
- No. Cases %
|
- Psoriasis patients without hypertension§
- No. Cases %
|
OR
|
95% CI
|
- Psoriasis patients with type2
- diabetes§
- No. Cases %
|
- Psoriasis patients without type2
diabetes§
- No. Cases %
|
OR
|
95% CI
|
- Psoriasis patients with obesity§
- No. Cases %
|
- Psoriasis patients without obesity§
- No. Cases %
|
OR
|
95% CI
|
|
Gender
|
|
Males
|
107
|
60.1
|
585
|
48.8
|
1.58
|
1.2-2.2
|
47
|
48.0
|
645
|
50.5
|
1*
|
-
|
58
|
40.4
|
634
|
51.4
|
1*
|
-
|
|
Females
|
71
|
39.9
|
613
|
51.2
|
1*
|
-
|
51
|
52.0
|
633
|
49.5
|
1.13
|
0.75-1.71
|
84
|
59.6
|
600
|
48.6
|
1.53
|
1.08-2.19
|
|
Age group (years)**
|
|
≤ 39
|
11
|
6.1
|
444
|
37.1
|
1*
|
-
|
8
|
8.2
|
447
|
35.0
|
1*
|
-
|
35
|
24.7
|
420
|
34.0
|
1*
|
-
|
|
40-59
|
98
|
55.1
|
499
|
41.6
|
7.92
|
4.19-15.84
|
39
|
40.2
|
558
|
43.6
|
3.91
|
1.90-9.08
|
73
|
51.4
|
524
|
42.5
|
1.70
|
1.10-2.58
|
|
60+
|
69
|
38.8
|
255
|
21.3
|
10.9
|
5.91-22.16
|
50
|
43.6
|
274
|
21.4
|
10.2
|
5.03-23.55
|
34
|
23.9
|
290
|
23.5
|
1.41
|
0.86-2.31
|
|
Marital status
|
|
Not married
|
49
|
27.6
|
533
|
45.5
|
1*
|
-
|
58
|
59.8
|
736
|
57.4
|
1.1
|
0.72-1.68
|
83
|
58.5
|
711
|
42.4
|
1.04
|
0.73-1.48
|
|
Married
|
129
|
72.4
|
665
|
55.5
|
2.11
|
1.49-2.99
|
39
|
40.2
|
543
|
42.6
|
1*
|
-
|
59
|
41.5
|
523
|
57.6
|
1*
|
-
|
|
Education
|
|
Primary school
|
54
|
30.7
|
293
|
24.7
|
1*
|
-
|
26
|
26.8
|
321
|
25.4
|
1*
|
-
|
36
|
25.5
|
311
|
25.4
|
1*
|
-
|
|
Junior school
|
63
|
35.8
|
510
|
43.0
|
0.67
|
0.45-1.0
|
30
|
30.9
|
543
|
42.9
|
0.71
|
0.41-1.22
|
64
|
45.4
|
509
|
41.6
|
1.02
|
0.58-1.75
|
|
High school
|
23
|
13.1
|
206
|
17.3
|
0.61
|
0.36-1.0
|
11
|
11.4
|
218
|
17.2
|
0.65
|
0.31-1.34
|
18
|
12.8
|
211
|
17.3
|
0.94
|
0.56-1.52
|
|
University
|
36
|
20.4
|
178
|
15.0
|
1.1
|
0.69-1.73
|
30
|
30.9
|
184
|
14.5
|
2.1
|
1.20-3.65
|
23
|
16.3
|
191
|
15.6
|
1.38
|
0.73-2.66
|
|
Occupational status
|
|
Manual worker
|
31
|
17.7
|
183
|
15.6
|
1*
|
-
|
15
|
15.6
|
199
|
15.9
|
1*
|
-
|
24
|
17.3
|
190
|
15.7
|
1*
|
-
|
|
Office or professional worker
|
33
|
18.9
|
280
|
23.9
|
0.90
|
0.54-1.48
|
19
|
19.8
|
294
|
23.5
|
0.89
|
0.47-1.69
|
35
|
25.2
|
278
|
23.0
|
0.99
|
0.58-1.70
|
|
Houseworker
|
32
|
18.3
|
100
|
8.5
|
2.44
|
1.44-4.13
|
21
|
21.9
|
111
|
8.9
|
2.60
|
1.37-4.95
|
14
|
10.1
|
118
|
9.8
|
1.05
|
0.54-2.15
|
|
Retired
|
61
|
34.9
|
410
|
35.0
|
1.13
|
0.73-1.76
|
25
|
26.0
|
446
|
35.6
|
0.77
|
0.42-1.40
|
40
|
28.7
|
431
|
35.6
|
1.35
|
0.80-2.25
|
|
Other
|
18
|
10.2
|
200
|
17.0
|
0.91
|
0.49-1.70
|
16
|
16.7
|
202
|
16.1
|
1.09
|
0.51-2.32
|
26
|
18.7
|
192
|
15.9
|
0.93
|
0.59-1.65
|
|
Degree of urbanization
|
|
Rural
|
4
|
2.3
|
18
|
1.5
|
1*
|
-
|
0
|
0.0
|
22
|
1.7
|
-
|
-
|
0
|
0.0
|
22
|
1.8
|
-
|
-
|
|
Weakly-rural
|
16
|
9.0
|
92
|
7.7
|
0.78
|
0.23-2.62
|
6
|
6.1
|
102
|
8.0
|
1*
|
-
|
6
|
4.2
|
102
|
8.2
|
1*
|
-
|
|
Weakly-urban
|
44
|
24.7
|
319
|
26.6
|
0.62
|
0.20-1.92
|
22
|
22.4
|
341
|
26.7
|
1.33
|
0.56-3.68
|
34
|
23.9
|
329
|
26.7
|
2.14
|
0.87-5.21
|
|
Urban
|
42
|
23.6
|
179
|
14.9
|
1.06
|
0.34-3.28
|
12
|
12.2
|
209
|
16.3
|
1.19
|
0.45-3.48
|
28
|
19.7
|
193
|
15.6
|
3.0
|
1.21-7.45
|
|
Extremely urban
|
72
|
40.4
|
590
|
49.3
|
0.55
|
0.18-1.67
|
58
|
59.2
|
604
|
47.3
|
1.99
|
1.06-5.23
|
74
|
52.1
|
588
|
47.7
|
2.60
|
1.1-16.12
|
*Reference category.
**χ2 trend: < 0.0001
(hypertension, diabetes), 0.04 (obesity).
§ICD = IX Classification Diseases.
Table 2 Risk of hypertension, type 2 diabetes and
obesity in psoriasis patients according to smoking habits and
alcohol consumption
|
- Psoriasis patients with hypertension§
- No. Cases
- %
|
- Psoriasis patients without hypertension§
- No. Cases
- %
|
OR
|
95%CI
|
- Psoriasis patients with type2
- diabetes§
- No. Cases
- %
|
- Psoriasis patients without type2
- diabetes§
- No. Cases
- %
|
OR
|
95%CI
|
- Psoriasis patients with obesity§
- No. Cases
- %
|
- Psoriasis patients without obesity§
- No. Cases
- %
|
OR
|
95% CI
|
|
Smoking consumption
|
|
Non smoker
|
109
|
61.2
|
713
|
59.5
|
1*
|
-
|
65
|
67.0
|
757
|
59.2
|
1*
|
-
|
76
|
53.5
|
746
|
60.4
|
1*
|
-
|
|
≤ 15 cigarettes/day
|
27
|
15.2
|
285
|
23.8
|
0.62
|
0.40-1.00
|
20
|
20.6
|
292
|
22.8
|
0.80
|
0.46-1.31
|
34
|
24.0
|
278
|
22.5
|
1.20
|
0.78-1.83
|
|
> 15 cigarettes/day
|
42
|
23.6
|
200
|
16.7
|
1.37
|
1.01-2.03
|
12
|
12.4
|
230
|
18.0
|
0.61
|
0.31-1.10
|
32
|
22.5
|
210
|
17.1
|
1.50
|
0.95-2.30
|
|
Wine consumption
|
|
No consumption
|
73
|
41.0
|
688
|
57.4
|
1*
|
-
|
59
|
60.8
|
702
|
54.9
|
1*
|
-
|
71
|
50.0
|
690
|
55.9
|
1*
|
-
|
|
1-2 glasses/day
|
77
|
43.3
|
385
|
32.2
|
1.88
|
1.34-2.66
|
26
|
12.4
|
436
|
11.0
|
0.71
|
0.43-1.13
|
51
|
36.0
|
411
|
33.3
|
1.46
|
0.84-2.44
|
|
> 2 glasses/day
|
28
|
15.7
|
125
|
10.4
|
2.11
|
1.31-3.40
|
12
|
26.8
|
141
|
34.1
|
1.01
|
0.51-1.87
|
20
|
14.0
|
133
|
10.8
|
1.21
|
0.82-1.76
|
|
Beer consumption
|
|
No consumption
|
165
|
92.7
|
1039
|
86.7
|
1*
|
-
|
86
|
88.7
|
1118
|
87.4
|
1*
|
-
|
123
|
86.6
|
1081
|
87.6
|
1*
|
-
|
|
1-2 glasses/day
|
11
|
6.2
|
141
|
11.8
|
0.49
|
0.25-0.89
|
11
|
11.3
|
141
|
11.0
|
1.01
|
0.53-1.87
|
17
|
12.0
|
135
|
10.9
|
1.11
|
0.66-1.85
|
|
> 2 glasses/day
|
2
|
1.1
|
18
|
1.5
|
0.70
|
0.11-2.45
|
0
|
0.0
|
20
|
1.6
|
-
|
-
|
2
|
1.4
|
18
|
1.5
|
0.98
|
0.15-3.43
|
|
Spirits consumption
|
|
No consumption
|
159
|
89.3
|
1074
|
89.6
|
1*
|
-
|
83
|
87.6
|
1148
|
89.8
|
1*
|
-
|
118
|
83.1
|
1115
|
90.4
|
1*
|
-
|
|
1 drink/day
|
17
|
9.6
|
79
|
6.6
|
1.45
|
0.84-2.52
|
12
|
12.4
|
84
|
6.5
|
1.93
|
1.01-3.67
|
13
|
9.1
|
83
|
6.7
|
1.48
|
0.80-2.65
|
|
> 1 drink/day
|
2
|
1.1
|
45
|
3.8
|
0.30
|
0.07-1.25
|
0
|
0.0
|
47
|
3.7
|
-
|
-
|
11
|
7.8
|
36
|
2.9
|
2.90
|
1.43-5.82
|
*Reference category.
§ICD = IX Classification Diseases.
Discussion
The present study characterized Italian psoriasis patients with
regards to socio-demographic variables, smoking habits, alcohol
consumption, and related risk of co-morbidities. Our study provides
further evidence that hypertension, obesity and type 2 diabetes are
associated with psoriasis. Previous reports have, indeed, tried to
establish whether associated diseases such as diabetes,
hypertension and obesity precede the occurrence of psoriasis or are
the consequence of it [4, 6, 8].
In line with previous reports [11, 15], we showed that
hypertension was found to be the chronic disease most frequently
associated with psoriasis.
In our study, a higher risk of hypertension was found in
psoriasis patients aged > 40 years and in males. On the
basis of our results showing an increased hypertension frequency
with increasing age, it would be reasonable to assume that this
might be linked to lifestyle rather than genetic factors. It should
also be considered that the increase of hypertension with age might
be due to a direct relationship with increased atherosclerosis.
Psoriasis patients who smoke more than 15 cigarettes per day and
regularly drink more than 2 glasses of wine per day are at greater
risk of hypertension. In these patients lifestyle modification is
crucial, since myocardial infarction has a higher incidence in
psoriasis patients as compared to general population [15].
Moreover, Mallbris et al. [16] reported that in psoriasis patients
with a history of hospital admission due to psoriasis, there is an
increase in cardiovascular death as compared to the general
population.
In our study, the second disease most frequently associated with
psoriasis was obesity, which is known to be a risk factor for both
hypertension and type 2 diabetes. Females in the 40-59 year age
group were found to be at greatest risk of obesity. A further
significant finding that also emerged was that patients living in
urban and extremely urban areas are at a higher risk of obesity.
This is in line with the results of a large population-based study
[17] that highlighted obesity in middle-aged women living in urban
areas. This could be due to the fact that urban populations are
becoming increasingly sedentary as a result of rapidly increasing
levels of motorized transport, urban sprawl and reduced
opportunities for daily physical activity in housing and
occupational settings. Our modern “obsesogenic” environments, with
the combination of unhealthy diet and physical inactivity, have
serious implications for obesity levels, as well as the
contribution they bring to other chronic diseases such as type 2
diabetes. Diabetes has been estimated to be the fifth leading cause
of death globally [18]. Our results show that the risk of diabetes
is higher for patients living in urban and extremely urban areas
and increases with age. This higher risk could probably be linked
to the changes in dietary patterns, physical activity and lifestyle
that are associated with urbanization. Recent clinical trials
provide evidence that physical activity associated with diet and
weight loss can prevent diabetes in different populations and age
groups [19-21]. Exercise training studies add evidence that
physical activity improves insulin sensitivity, independently of
any effect on weight loss and fat distribution [22].
The overall results of our study emphasize the need to detect
psoriasis patients with different susceptibilities to
co-morbidities, make patients aware of this and change their
lifestyles. Planning a campaign to change the lifestyle of patients
with psoriasis and co-morbidities requires a multidisciplinary
approach, involving diabetologists, cardiologists and general
practitioners, as well as than dermatologists. Concerted action is
needed to re-orientate health systems and policies to provide
long-term preventive care.
Acknowledgements
Financial support: none. Conflict of interest: none. The Authors
wish to thank Dr. Franca Daniele MD for her language revision and
are grateful to the following dermatologists for their
participation in the study: Fabio Arcangeli (Cesena), Mario Aricò
(Palermo), Ugo Bottoni (Catanzaro), Giuliano Brandozzi (Ascoli
Piceno), Pier Giacomo Calzavara Pinton (Brescia), Francesco Cusano
(Benevento), Santo Dattola (Reggio Calabria), Antonia Galluccio
(Benevento), Giampiero Girolomoni (Verona), Giovanni Lo Scocco
(Prato), Torello Lotti (Firenze), Patrizia Martini (Lucca),
Giuseppe Micali (Catania), Iria Neri (Bologna), Pietro Santoianni
(Napoli).
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