Children with Psoriasis Carry High Comorbidity Risks

Children with psoriasis are significantly more likely to develop obesity, hyperlipidemia, hypertension, diabetes, metabolic syndrome, polycystic ovarian syndrome, liver disease, and elevated liver enzymes than are children without the disease, according to a retrospective review of insurance claims data.

These risks are independent of obesity status: in non-obese children with psoriasis, the risk of comorbidities was 40% to 75% higher than in children without psoriasis, reported Megha M. Tollefson, MD, of the Mayo Clinic in Rochester, MN, and colleagues. But even in children without psoriasis, obesity was a much stronger contributor to comorbidities.

“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,” the researchers wrote online in JAMA Dermatology. “While the association in adult patients is well established, the patterns and predictors of the risk of comorbidities in children with psoriasis are still not clear.

“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 actually an independent risk factor for these comorbidities.”

In this study of claims from Optum Laboratories Data Warehouse, a Massachusetts-based Mayo Clinic partner, the researchers studied de-identified records of 29,957 children with psoriasis (affected children) and 29,957 children without psoriasis, matched for age, sex, and race, from 2004 through 2013.

The children, all under age 19, were divided into four groups:

  • Non-obese without psoriasis (reference cohort)
  • Non-obese with psoriasis
  • Obese without psoriasis
  • Obese with psoriasis

The average age of the children was 12.0, and 53.5% of the total were girls. At baseline, more affected children were obese than non-obese (2.9% versus 1.5%; P<0.001).

The average follow-up period for both groups was about 3 years. During this time, pediatric psoriasis patients were significantly more likely to develop comorbidities than those without psoriasis, with non-alcoholic liver disease, diabetes, and hypertension showing the highest risks.

Among non-obese children, the risk of comorbidities was significantly higher in those with psoriasis; these included elevated lipid levels (HR 1.42), hypertension (HR 1.64), diabetes (HR 1.58), metabolic syndrome (HR 1.62), polycystic ovarian syndrome (HR 1.49), non-alcoholic liver disease (HR 1.76), and elevated liver enzyme levels (HR 1.46).

Even in children without psoriasis, obesity was a much stronger contributor to comorbidities, carrying an 18-fold higher risk of non-alcoholic liver disease, a 16-fold higher risk of metabolic syndrome, a seven-fold higher risk of hypertension, a six-fold higher risk of hyperlipidemia, an almost three-fold higher risk of diabetes, and a 2.3-fold higher risk of elevated liver enzyme levels than the reference group; there was also a six-fold higher risk of polycystic ovarian syndrome in girls.

When the researchers analyzed the interaction between obesity and psoriasis, they found none, suggesting that while both obesity and psoriasis contribute to the development of pediatric comorbidities, the effect is additive, not exponential.

Asked for her perspective, Amy Paller, MD, chair of the Department of Dermatology at Northwestern Medicine Feinberg School of Medicine in Chicago, who was not involved with the study, noted that several studies have clearly demonstrated the association of obesity and pediatric psoriasis, and a large recent study also linked a high waist circumference to height ratio to more severe pediatric psoriasis. “The association of a variety of other ‘metabolic syndrome’ comorbidities has been controversial, however, and whether it is the obesity or psoriasis itself that increases the risk remains unknown.

“While there are issues with the use of a claims database, especially given the frequent misdiagnosis of psoriasis by non-dermatologists, several metabolic-related disorders were shown to be significantly increased in risk,” she said, adding that the fact that the associations were seen even among non-obese psoriasis patients suggests that early systemic intervention might lower risks.

The study has several limitations, Tollefson and colleagues noted. For example, it relies on data from administrative claims, and the diagnoses were not confirmed by medical record review. Also of possible concern are undercoding and misclassification of comorbidities. Extremely obese children would be more likely to have a corresponding obesity code than those with a body mass index of 25 to 40, the researchers added. “The lower prevalence of obesity in our cohort than in some others suggests that obesity may have been undercoded as a whole, with the resulting contribution from psoriasis being slightly overestimated.”

In addition, systemic medications used to treat psoriasis potentially might have influenced the risk of some comorbidities.

Experts provide recommendations for combating liver disease in UK

Liver disease is the third most common cause of premature death in the United Kingdom, with mortality rates increasing by 400% since 1970. In a new report, Roger Williams, MD, director of the Institute of Hepatology in London, and colleagues provide recommendations for improving the standard of care for patients with liver disease in hospitals and create quality preventive measures for people with excessive alcohol use and obesity to reduce the mortality rate and burden of the disease.

“There is a human, social and financial imperative to act now if the UK’s burden of liver disease and all its consequences are to be tackled and the NHS is not to be overwhelmed by the cost of treating advanced stage liver disease,” Williams said in a press release. “The evidence outlined in the report, contributed by some of the UK’s leading experts in the field, should leave nobody in any doubt about the present unacceptable levels of premature death and the overall poor standards of care being afforded to liver patients.”

Key recommendations:

Improving the level of expertise and facilities in primary care settings

Important elements of this recommendation to strengthen early detection of liver disease and its treatments include: classifying liver disease as one of the “so-called Big Five” major diseases to use chronic disease management and generic lifestyle interventions to their highest level, checking aspartate aminotransferase/alanine aminotransferase ratios in liver function tests to avoid unnecessary referrals for hospitalization and using liver elastography as the No. 1 test in the detection of hepatic fibrosis.

Improve support services in high-risk patient communities

Patients should be able to access more options for care, such as screenings, through local services. The experts recommend more hepatologists and experts work in collaboration with district general hospitals and primary care offices for ensuring they have the proper and required services for liver patients.

Ensure all district general hospitals and regional specialist centers have liver units

This recommendation is based on an enhanced 7-day acute service currently in the liver units in district hospitals, according to the report. The liver units in the hospitals would be linked to regional specialist centers, ensuring acutely sick patients would get the proper and highly specialized treatment they needed. Additionally, a multidisciplinary alcohol team, available 7 days a week, should be mandatory in every hospital, as well as care bundles established for the management of cirrhosis for primary hepatocellular carcinoma.

National review of liver transplantation

Organ donations are expected to increase by 50% by 2020, according to the report, so the recommendation is that the transplantation centers would be reviewed to conclude whether there is available space and financing for the increasing number of donor organs.

Pump provides liver disease relief

pump diagram
The rechargeable pump sits underneath the skin and can be switched off at night

Patients at the Royal Free Hospital in London are testing a device that provides relief from a common side-effect of liver disease.

The pump siphons off excess fluid that can build up in the abdomen after liver failure and diverts it to the bladder so it can be urinated out.

A liver transplant may be the only option for patients with cirrhosis.

Doctors say the pump could buy time and may even allow the liver to recover, avoiding the need for a transplant.

“Start Quote

It can improve quality of life for patients and keep them out of hospital for longer”

Prof Rajiv Jalan

So far eight patients at the Royal Free have had one fitted.

The Alphapump sits beneath the skin of the abdomen and is connected to two small tubes that do the siphoning.


When patients have cirrhosis, the liver and kidneys stop working properly and fluid, known as ascites, can accumulate.

Litres of fluid can gather inside the abdominal cavity, making the patient appear pregnant as well as being painful.

Patients may have to make weekly or monthly trips to hospital to have the fluid drained.

Rajiv Jalan, professor of hepatology at University College London’s institute for liver and digestive health at the Royal Free, is the doctor running the trial.

He said: “With cirrhosis, patients can accumulate litres and litres of fluid. They might need to come to hospital fortnightly to have up to 20 litres drained from their tummy.

“The pump can avoid this by draining about 15 millilitres every 15 minutes. It means they’ll pass a little bit more urine but they can turn the pump off at night.

“It can improve quality of life for patients and keep them out of hospital for longer.”

More children are suffering from fatty liver disease.

DEAR MAYO CLINIC: I recently read that fatty liver disease is becoming common in young children. What’s the cause of this condition? How is it diagnosed, and can it be reversed?

ANSWER: The number of children who have fatty liver disease is rising. Currently, about 10 percent of children in the U.S. have this disease. It is the most common cause of childhood chronic liver disease in this country. The increase is linked to the childhood obesity epidemic, as fatty liver disease is often caused by excessive weight gain. If it is caught and treated early, the disease typically can be reversed through lifestyle changes, including diet and exercise.

The liver is one of the largest organs in the body. About the size of a football, it is located on the right side of the abdomen, behind the lower ribs. Fatty liver disease (also called nonalcoholic fatty liver disease) occurs when fat builds up in the liver of people who drink little or no alcohol.
Typically the disease causes few, if any, symptoms. Many people with fatty liver disease have it for years and don’t know it. It is important for the disease to be diagnosed, however. If left unchecked, it could eventually lead to liver function problems, especially in children.

The most common cause of fatty liver disease in children is obesity. In children who are at a healthy body weight, fatty liver disease can also be the result of rare metabolic disorders, such as Wilson’s disease or cystic fibrosis, among others.

A doctor may suspect fatty liver disease if a blood test shows that a child’s level of liver enzymes is higher than normal, especially if the child is overweight. The disease also may be discovered through an imaging exam, such as an ultrasound. A diagnosis of fatty liver disease can be confirmed by microscopic examination of a small sample of tissue removed from the liver, a procedure known as a liver biopsy.

If caught while still in the early stages, fatty liver disease may be reversible. In children who are overweight, weight loss often is key to treating the disease. Weight loss usually is best accomplished with a combination of a healthy diet and regular physical activity.

In general, there are some strategies all families can use to help children reach and maintain a healthy weight. For example, make sure you have lots of healthy food choices available in your home. Buy plenty of fruits and vegetables. Cut down on convenience foods, such as cookies, crackers and prepared meals that are high in sugar and fat. Limit sweetened beverages, including fruit juices. These drinks are high in calories and low in nutritional value. They also can make a child feel too full to eat healthier foods.

Encourage your child to be physically active. This not only helps with weight loss, but also builds strong bones and muscles and helps a child sleep better at night. Keep in mind that activity does not have to be structured exercise to burn calories and improve fitness. Playing outdoors, jumping rope and going for hikes can all be good ways for a child to be active.

It is very important that children and teens avoid using supplements to help with weight loss or building muscle. Some of these supplements have recently been associated with acute liver failure and other dangerous health outcomes.

Don’t start a child on a specific weight-loss program before talking with his or her health care provider. It’s important that a weight-loss approach be tailored to a child’s individual situation and needs, including the child’s age and if he or she has any other health problems. — Samar Ibrahim, M.B., Ch.B., Pediatric Gastroenterology, Mayo Clinic, Rochester, Minn.

Unhealthy lifestyles fuel liver disease rise.

High levels of drinking and obesity mean England is one of the few places in Europe seeing a major preventable disease getting worse, the chief medical officer says.

Prof Dame Sally Davies highlighted the rise in liver-disease deaths in the under-65s – up 20% in a decade – in her annual report.

In comparison, most of the rest of Europe has seen rates fall.

She said urgent action was needed to discourage harmful lifestyles.

She said three of the major causes of liver disease – obesity, alcohol abuse and undiagnosed hepatitis infection – were all preventable.

But despite that, premature deaths from liver disease in the under-65s had jumped by a fifth since 2000 to 10 per 100,000 people.

‘Minimum pricing’

Her study – the first volume of a two-part annual report – focused on a whole host of diseases from cancer to dementia.

But Dame Sally said it was the liver disease figures that most shocked her the most – and showed there needed to be investment in prevention, early diagnosis and effective treatment.

“I was struck by the data on liver disease particularly,” she said.

“This is the only major cause of preventative death that is on the increase in England that is generally falling in other comparable European nations.

“We must act to change this.”

The report comes after the government said earlier this year it would look to introduce a minimum price for alcohol. A consultation is expected to start soon.

Eric Appleby, chief executive of Alcohol Concern, said the situation with liver disease was “appalling”.

“It’s imperative that we come together now to act swiftly and decisively to tackle this problem,” he said.

“Setting a minimum unit price at 50p is one of a number of measures which will help protect those most vulnerable to the harm caused by alcohol misuse and I urge the government to act quickly on this.”

Prof Mark Bellis, of the Faculty of Public Health, agreed, saying the figures were “embarrassing” and that tougher action was need on advertising as well as the introduction of minimum pricing.

Andrew Langford, chief executive of the British Liver Disease Trust, said the government needed to get the NHS to be more proactive too.

“We need to ensure GPs have far more awareness of liver disease and can recognise lifestyles that might be changed and early symptoms of liver disease so that effective treatments can be started,” he said.






Potent “Superfoods” That Can Improve Your Health and Increase Longevity

One of your most basic health principles is to eat a diet of whole, nutritious foods rather than processed fare. Cutting out grains and sugar (particularly fructose) — which happens more or less naturally once you ditch processed foods from your diet — will take you a long way toward normalizing your weight and improving your health.

But what are the best foods to eat in place of foods you shouldn’t eat?

In her new book The Drop 10 Diet, Lucy Danziger, editor-in-chief of Self Magazine, describes how focusing on so-called “superfoods” might change the way you look at weight loss. And she certainly has a good point.

Feeding your body the right nutrients rather than stuffing it with “empty” calories will beannot only help you lose unwanted pounds, it’s a key ingredient for living a long and healthy life. Believe it or not, many people who are obese area actually profoundly malnourished.

“At the end of the day, you invest in your wardrobe and your hair and your car and everything else. So invest in your body. Because it’s supposed to last for 100 years,” she recently told CNN Health.1

According to the featured article, the term “superfood” was coined in 2004 by Dr. Steven Pratt, author of Superfoods Rx: Fourteen Foods That Will Change Your Life. He, like Danziger, points out that this kind of eating goes beyond the idea of dieting. It’s really a way of life. “It’s the non-diet diet. It’s food you can eat for a lifetime,” he tells CNN.2

According to Pratt, a superfood fulfills three qualifications:

  1. Are readily available
  2. Contain nutrients known to enhance longevity, and
  3. Have health benefits backed by peer-reviewed, scientific studies

Pratt’s website lists a total of 20 examples, which include:

  1. Wild-caught salmon
  2. Broccoli
  3. Spinach
  4. Berries, and
  5. Green tea

Four “Superfoods” that are Actually Best Avoided…

While I agree with the vast majority of Pratt’s selections, especially the five listed above, I disagree with the following four, as I believe these may have more harmful than beneficial effects for most people:

  1. Beans. The primary concern with beans is that they are relatively high in carbohydrates and are loaded with lectins that may be incompatible with many people. It is also high in phytic acid which is a potent mineral chelator. If you are going to use beans they need to be soaked for 24 hours or longer and frequently changing the water. They are not perniciously deadly foods, but they in no way shape or form qualify as a superfood.
  2. Low-fat yoghurt: Not only is the low-fat ideology completely false, low-fat yoghurt is also pasteurized and typically loaded with added fructose. Taken together, these three factors put commercial low-fat yoghurt squarely on my list of items to avoid.

To reap the benefits that real yoghurt can provide, opt for homemade fermented yoghurt, using either raw, ideally pastured organic raw milk, full fat organic milk (not low fat or skim).

  1. Soy: If you were to carefully review the thousands of studies published on soy, I strongly believe you would reach the same conclusion as I have — which is, the risks of consuming unfermented soy products far outweigh any possible benefits. Furthermore, genetically engineered soy pose additional health hazards over and beyond the damage caused by unfermented soy itself. The only type of soy I recommend is traditionally fermented organic soy products
  2. Dried fruits: While whole fruits are excellent sources of nutrients and antioxidants if consumed in moderation, they also tend to be high in fructose, and dried fruits even more so. If you are in the minority of people who are not struggling with insulin resistance, then small amounts of dried fruit would probably be fine, but if you have type 2 diabetes, are pre-diabetic, obese, hypertensive, or have symptoms of heart disease, you’re better off avoiding dried fruits until your weight and insulin levels have normalized

Four Commonly Overlooked Superfoods

Avocado made Pratt’s list, and its status as a superfood cannot be overemphasized. Besides being rich in potassium (twice as much as that of a banana), avocados are a great source of healthful monounsaturated fat, which is easily burned for energy. This makes it an excellent replacement for grain carbs and other sources of sugar. Remember, when cutting out carbs, you need to replace those calories with healthy fat, which is actually a far better source of energy for your body and brain than carbohydrates.

Four additional superfoods not on Pratt’s list, which I believe most people could benefit from, are:

  1. Coconut oil: 50 percent of the fat content in coconut oil is a fat rarely found in nature called lauric acid that your body converts into monolaurin, which has anti-viral, anti-bacterial and anti-protozoa properties. Coconut oil is about 2/3 medium-chain fatty acids (MCFAs), which produce a whole host of health benefits, including stimulating your metabolism. MCFA’s are also immediately converted to energy — a function usually served in the diet by simple carbohydrates — so like avocados, coconut oil is an ideal replacement for unhealthy grain carbs.
  2. Bone broth: Simmering leftover bones over low heat for an entire day will create one of the most nutritious and healing foods there is. You can use this broth for soups, stews, or drink it straight. The “skin” that forms on the top is the best part. It contains valuable nutrients, such as sulfur, along with healthful fats, so just stir it back into the broth.
  3. Fermented vegetables: Almost everyone has damaged gut flora these days, unless you’re part of the minority that eats a strict organic whole foods diet and avoids antibiotics. Fermented vegetables are one of the most palatable fermented foods that can provide you with a robust dose of beneficial bacteria, known as probiotics, which are critically important for optimal physical and mental health. Additionally, fermented foods are very potent detoxifiers, capable of drawing out a wide range of toxins and heavy metals, including some pesticides.
  4. Raw macadamia nuts are a powerhouse of a nut, containing a wide variety of critical nutrients,3 including high amounts of vitamin B1, magnesium, manganese and healthful monounsaturated fat, just to name a few.

Gastrointestinal Cancers Likely Reduced by Consumption of Green Tea

In related news, green tea has once again demonstrated why it deserves being ranked as a superfood. Research published in the American Journal of Clinical Nutrition4 found that regular green tea consumption, defined as drinking green tea at least three times a week for more than six months, was associated with a 17 percent reduced risk of all digestive cancers combined.

The study included approximately 75,000 middle-aged and senior women enrolled in the Shanghai Women’s Health Study. Mean follow-up was 11 years. The digestive cancers most strongly reduced by regular green tea consumption were stomach/esophageal and colorectal cancers. (Women who had ever smoked or who drank alcohol were excluded from the study.)

Women with higher rates of consumption, drinking two to three cups per day, had an even greater risk reduction — 21 percent — for for all cancers of the digestive system, and, those who had been drinking green tea for at least 20 years had a reduced cancer risk totaling 27 percent.

These results suggest long-term cumulative exposure may be particularly important,” lead researcher Sarah Nechuta, Ph.D., MPH told Medical News Today.5

This certainly isn’t the first time green tea has been associated with reduced cancer risk. Previous tests of one of the active ingredients in green tea, called epigallocatechin-3-gallate (EGCG), showed it could kill cancer cells in samples of skin, lymph system, and prostate tissue taken from both humans and mice, while leaving healthy cells unharmed. Previous studies have also indicated that EGCG may be helpful in preventing:

  • Dementia
  • High blood lipid
  • Arteriosclerosis
  • Cerebral thrombus
  • Pain and inflammation related to rheumatoid arthritis

Green Tea Lowers Blood Sugar Spikes and May Aid Weight Loss

Yet another study, published in the journal Molecular Nutrition & Food Research,6 found that EGCG found in green tea had a significant impact on blood glucose levels in rats when consumed in combination with starchy foods. Blood glucose levels in rats given the equivalent of one and a half cups of green tea for a human were about half as low as in the controls that received the same food but no EGCG. Interestingly, the compound was most effective when given simultaneously with corn starch. No effect was seen when administered with glucose or maltose.

The research raises the possibility that green tea might help you control blood sugar spikes associated with starchy foods when consumed simultaneously. Keep in mind that adding sugar to your tea will likely negate this beneficial effect. And, besides that, no amount of green tea in the world will ever negate the overall detrimental impact of donuts and bagels…

That said, green tea has repeatedly been shown to have a beneficial impact on weight by improving fat burning and metabolism. A couple of the proposed mechanisms for this effect include the activation of hepatic lipid catabolism, which involves the release of energy resulting in the breakdown of complex materials, and increased levels of fat oxidation and thermogenesis, where your body burns fuel such as fat to create heat.

My personal favorite is Matcha green tea, as it has a wonderful flavor and superior nutrient content as it has not been damaged through processing. The best Matcha green tea comes from Japan and is steamed, rather than roasted or pan-fried. As a result, Matcha green tea retains all the nutrient-rich value possible from the tea leaf.

Source: Dr. Mercola






Intricate Interplay.

In our latest Clinical Problem-Solving article, a 55-year-old man presented with sinus congestion, headaches, chills, mild nausea, fatigue, and a “foggy” sensation that had lasted approximately 1 week. He reported darker urine than usual and had noticed that his eyes were turning yellow.

Although generally regarded as a chronic liver disease, autoimmune hepatitis is manifested as an acute illness in about 25% of patients.

Clinical Pearls

What is the differential diagnosis for severe aminotransferase elevations?

In contrast to the broad differential diagnosis for elevations in serum aminotransferase levels that are less than 5 times the upper limit of the normal range, the causes of severe aminotransferase elevations (>20 times the upper limit of the normal range) are more limited and include Wilson’s disease, acute biliary obstruction, and viral, toxic, ischemic, and autoimmune hepatitis.

What are the two types of autoimmune hepatitis?

Two types of autoimmune hepatitis have been proposed; type 1 is defined by positive results on testing for antinuclear antibodies and smooth-muscle antibodies, and type 2 by positive results on testing for antibodies against liver-kidney microsome type 1 and liver cytosol type 1. Type 2 autoimmune hepatitis has been described mainly in children in Europe and is rare in the United States. Among patients with type 1 disease, the reported prevalence of antinuclear antibodies alone is 13%, smooth-muscle antibodies alone 33%, and both 54%. Autoantibodies develop later in the disease in some patients who are seronegative on initial evaluation. Autoantibody-negative autoimmune hepatitis is important to recognize because patients with this condition typically have a favorable response to glucocorticoid therapy.

Morning Report Questions

Q: What is the standard treatment for severe cases of autoimmune hepatitis?

A: Treatment with either prednisone alone (at a dose of 60 mg daily) or a combination of prednisone (at a dose of 30 mg daily) and azathioprine (at a dose of 50 mg, or 1 to 2 mg per kilogram of body weight, daily) is recommended in cases of severe autoimmune hepatitis, on the basis of data from randomized clinical trials; combination therapy is generally preferred because the lower dose of glucocorticoid reduces side effects. Prednisolone in equivalent doses can be substituted for prednisone. Glucocorticoids are tapered over a 4-week period to a level required to maintain a biochemical remission, and this maintenance regimen is then continued until disease resolution (defined as biochemical remission for a minimum of 24 months), unless there is treatment failure or drug toxicity.

Q: What are the characteristics of nonalcoholic fatty liver disease?

A: Nonalcoholic fatty liver disease is one of the most common causes of asymptomatic aminotransferase elevations and chronic liver disease in Western countries. It encompasses a spectrum of disorders, from simple steatosis to fibrosing steatohepatitis that can progress to cirrhosis and its complications, including hepatocellular carcinoma. Aminotransferase levels can wax and wane, often into the normal range. Associated features include insulin resistance, central adiposity, dyslipidemia, and hypertension. The diagnosis of nonalcoholic fatty liver disease requires that there is no history of substantial alcohol consumption, although the definition of substantial alcohol consumption and the effect of obesity on thresholds for the development of alcoholic fatty liver disease remain unclear. Statins can be safely used in patients with nonalcoholic fatty liver disease and, in the majority of patients with this condition, are associated with improvement in liver enzyme abnormalities.

Source: NEJM