**11. Obesity**

The first associations between psoriasis and obesity were reported in large epidemiological studies carried out in Europe (Duarte et al., 2010). A pioneering American study conducted in the state of Utah reports a 34% prevalence of obesity among individuals with psoriasis, which is much higher than the 18% reported in the general population (Herron et al., 2005)

Obesity is known to cause a state of chronic inflammation, with high levels of TNF-α, IL-6 and C-reactive protein, which are associated to the progressive increase in body mass index (BMI). In this state of chronic inflammation, alterations in resistance/sensitivity to insulin and greater oxidative stress, with the production of free radicals, lead to a greater likelihood of the development of diabetes and metabolic syndrome as well as the influence of these pro-inflammatory cytokines in the course and presentation of psoriasis (Hamminga et al., 2006; Wakkee et al., 2007). The association between obesity and psoriasis has been well established, as obesity can increase the risk of developing psoriasis and preexisting psoriasis can increase the risk of patients becoming obese (Farías et al., 2011).

Non-pharmacological treatment aimed at changes in lifestyle should be offered to all patients, especially those with a BMI ≥ 25 kg/m², for whom the goal is controlled, healthy weight loss (Farías et al., 2011). A low-calorie diet is recommended, following the Step I diet (Obesity Society, 2000) (Table 1), with a calorie restriction of 500 to 1000 kilocalories per day, based on the patient's energy expenditure, which can be determined through measurement

The first studies on the association between psoriasis and the consumption of alcoholic beverages emerged in 1963. While some investigations have failed to demonstrate such an association, recent studies have shown a significant correlation (Wolf et al., 1999). Besides contributing to the development of psoriatic plaque, alcohol intake is involved in triggering periods of exacerbation, associated with a reduced response to treatment and the risk of liver toxicity associated to the use of methotrexate (Gupta et al., 1993; Higgins et al., 1994;

The exact mechanism by which alcohol causes or aggravates psoriasis is not yet fully clarified. Some authors propose that alcohol induces immunological dysfunction, leading to immunosuppression, and increases the production of inflammatory cytokines and cell cycle activators, such as cyclin D1 and keratinocyte growth factor, which could lead to epidermal over-proliferation (Farkas et al., 2003; Ockenfels et al., 1996; Smith & Fenske, 2000). Moreover, the greater susceptibility to superficial infection observed in alcoholics, such as those caused by Streptococcus and trauma, has also been suggested in the development of

Data from literature indicates that alcohol is a risk factor for psoriasis in young and middleaged men and, while not a risk factor in women, alcohol intake aggravates the condition in this gender (Poikolainen et al., 1994). Patients with psoriasis are recommended to exercise with caution when consuming alcohol, especially during periods of exacerbation. Moreover, due to all possible effects, a number of authors recommend abstention (Behnam et al., 2005; Wolters, 2005). Thus, identifying this risk factor in patients with psoriasis could contribute toward a reduction in episodes of exacerbation, thereby achieving better treatment results

The first associations between psoriasis and obesity were reported in large epidemiological studies carried out in Europe (Duarte et al., 2010). A pioneering American study conducted in the state of Utah reports a 34% prevalence of obesity among individuals with psoriasis, which is much higher than the 18% reported in the general population (Herron et al., 2005) Obesity is known to cause a state of chronic inflammation, with high levels of TNF-α, IL-6 and C-reactive protein, which are associated to the progressive increase in body mass index (BMI). In this state of chronic inflammation, alterations in resistance/sensitivity to insulin and greater oxidative stress, with the production of free radicals, lead to a greater likelihood of the development of diabetes and metabolic syndrome as well as the influence of these pro-inflammatory cytokines in the course and presentation of psoriasis (Hamminga et al., 2006; Wakkee et al., 2007). The association between obesity and psoriasis has been well established, as obesity can increase the risk of developing psoriasis and preexisting psoriasis

Non-pharmacological treatment aimed at changes in lifestyle should be offered to all patients, especially those with a BMI ≥ 25 kg/m², for whom the goal is controlled, healthy weight loss (Farías et al., 2011). A low-calorie diet is recommended, following the Step I diet (Obesity Society, 2000) (Table 1), with a calorie restriction of 500 to 1000 kilocalories per day, based on the patient's energy expenditure, which can be determined through measurement

can increase the risk of patients becoming obese (Farías et al., 2011).

**10. Alcoholic beverages** 

psoriasis (Farkas et al., 2003).

(Kazakevich et al., 2011).

**11. Obesity** 

Liu et al., 2010; Qureshi et al., 2010; Smith & Fenske, 2000).

techniques such as indirect calorimetry or through mathematical formulas such as the Harris-Benedict equation (Table 2) (Frankenfield et al., 1998). For greater compliance to treatment and patient follow up, the participation of a nutritionist is needed to individualize the treatment, considering all socioeconomic and cultural aspects. Farías et al (2011) suggests the recommendations of the Nutrition Committee of the American Heart Association (Table 3 e Table 4).


Table 1. Diet Step 1 (Obesity Society, 2000).


Table 2. Basal metabolic rate according to the Harris Benedict formula.


Table 3. Diet and Lifestyle Recommendations for Cardiovascular Disease Risk Reduction (American Heart Association Commitee Nutrition, (AHA) 2006).

Food, Nutrition and Diet Therapy in Psoriasis 365

Metabolic syndrome is a set of metabolic alterations, particularly insulin resistance, which, together, lead to a greater risk of pro-inflammatory and pro-thrombotic alterations. A number of studies have suggested an increase in the prevalence of the components of metabolic syndrome in patients with psoriasis (Cohen et al., 2008; Neimann et al., 2006;

Patients with psoriasis have a greater prevalence of metabolic syndrome in comparison to those with other dermatological conditions (30.1% vs 20.6%; OR: 1.65; 95%CI: 1.16 to 2.35) (Gisondi et al., 2007). However, few studies have considered the possibility of associating the treatment for psoriasis with the components of metabolic syndrome (Fu &Vender, 2011). A case report of a patient with psoriasis and metabolic syndrome suggests that the treatment program designed by nutritionists and endocrinologists through the modification of diet and treatment of comorbidities provided an improvement in blood glucose, cholesterol and BMI, along with a clinical improvement in psoriasis (Saraceno et

Diet is an important factor in the etiology and pathogenesis of psoriasis. Low-calorie and vegetarian diets may be beneficial to the treatment of this condition. Although the results regarding the oral supplementation of fish oil are inconsistent, patients are recommended to consume fish rich in omega 3 PUFAs and parenteral infusions of PUFAs are recommended for patients hospitalized with acute psoriasis. Further studies are needed to clarify the role of a gluten-free diet, which may improve the severity of the disease in patients with IgA and/or IgG antigliadin antibodies. Moreover, the consumption of fruit and vegetables may be beneficial due to their high antioxidant content. Vitamin D is an important treatment option due to its immuno-regulating and anti-proliferation activity. Patients with psoriasis should not consume alcoholic beverages in order to avoid

Abenavoli, L.; Proietti, I.; Leggio, L.; Ferrulli, A.; Vonghia, L.; Capizzi, R.; Rotoli, M.;

Abramovits, W. (2009).Calcitriol 3 microg/g ointment: an effective and safe addition to the

Addolorato, G.; Parente, A.; De Lorenze, G.; D'angelo Di Paola ,M.E.; Abenavoli, L.; Leggio,

supplement 8, pp. s17–s22, ISSN 1545-9616.

Amerio, P.L.; Gasbarrini, G. & Addolorato, G. (2006). Cutaneous manifestations in celiac disease. *World Journal of Gastroenterology*, Vol.12, pp.843-52, ISSN 1007-

armamentarium in topical psoriasis therapy. *Journal of Drugs in Dermatology*, Vol. 8,

L.; Capristo, E.; De Simone, C.; Rotoli, M.; Rapaccini, G.L. & Gasbarrini, G. (2003). Rapid Regression of psoriasis in a coeliac patient after gluten-free diet. A case report and review of the literature. *Digestion*, Vol. 68, No.1, pp.9-12, ISSN 0012-

**12. Psoriasis and metabolic syndrome** 

Sommer et al., 2006).

al., 2008).

**13. Conclusion** 

exacerbation of the disease.

**14. References** 

9327.

2823.


Table 4. Practical Tips to Implement AHA 2006 Diet and Lifestyle Recommendations.

**Lifestyle**  Know your caloric needs to achieve and maintain a healthy

Prepare and eat smaller portions.

Do not smoke or use tobacco products.

calorie sauces and added salt and sugars.

Use liquid vegetable oils in place of solid fats.

wheat), millet, quinoa, and sorghum.

baked goods, that are reduced in salt; and - limiting condiments (eg, soy sauce, ketchup).

Grill, bake, or broil fish, meat, and poultry.

Table 4. Practical Tips to Implement AHA 2006 Diet and Lifestyle Recommendations.

muffins, doughnuts).

Reduce salt intake by

eating.

sodium.

recipes.

place of juices.

corn syrups, concentrated fruit juice, and honey.

products, fruits, and vegetables.

Replace high-calorie foods with fruits and vegetables.

Know the calorie content of the foods and beverages you

Track and, when possible, decrease screen time (eg, watching

 If you consume alcohol, do so in moderation (equivalent of no more than 1 drink in women or 2 drinks in men per day).

Use the nutrition facts panel and ingredients list when choosing

Eat fresh, frozen, and canned vegetables and fruits without high-

Increase fiber intake by eating beans (legumes), whole-grain

 Limit beverages and foods high in added sugars. Common forms of added sugars are sucrose, glucose, fructose, maltose, dextrose,

 Choose foods made with whole grains. Common forms of whole grains are whole wheat, oats/oatmeal, rye, barley, corn, popcorn, brown rice, wild rice, buckwheat, triticale, bulgur (cracked

Cut back on pastries and high-calorie bakery products (eg,


Use lean cuts of meat and remove skin from poultry before

Limit processed meats that are high in saturated fat and

Incorporate vegetable-based meat substitutes into favorite

Encourage the consumption of whole vegetables and fruits in

Select milk and dairy products that are either fat free or low fat.

Track your weight, physical activity, and calorie intake.

television, surfing the Web, playing computer games). Incorporate physical movement into habitual activities.

weight.

consume.

foods to buy.

**Food choices and preparation** 
