Finding My Path to Managing Psoriatic Disease and Excess Weight Transcript

A Word of Warning

This episode contains information about the body, like body size, weight management, healthy eating, and lifestyle changes. If you have a history of disordered eating or are struggling with body-related mental health challenges, you might wish to explore some of our other helpful tools.

There are clinical terms used by our speakers about body size or body weight that you might find triggering. Key among them is the word ‘obesity.’ While it is the scientifically correct name for a disease and a common clinical term, NPF acknowledges that this word is triggering and problematic, and it is used only for the clearest of accuracy.

Jennifer:  My name is Jennifer Bomberger and I'll be your moderator for today's episode sponsored by Lilly where we'll discuss the challenge and connection between weight management and psoriatic disease. I'm so excited to be here with dermatologist Dr. Erin Boh, who is the Joseph Chastain Endowed Chair of Clinical Dermatology at Tulane University, School of Medicine, where she's also the Professor and Chairman of Dermatology. Also, here is Brian Lehrschall, who has lived with psoriatic disease for over 30 years and has successfully lost over 100 lbs. Let's learn more about his success story and the connection between excess weight and psoriatic disease from Dr. Boh. Welcome Brian and Dr. Boh. It's a pleasure having you on Psoriasis Uncovered. Brian, let's start our discussion by hearing more about your story. What were the challenges you faced when you were trying to manage your weight? I know there are many factors that impact trying to lose weight, and there's often a stigma associated with being seen differently. I've personally had my own challenges with that, and I know it can be a really long road. What were your challenges?

Brian: Well, the first challenge I had was that I didn't know first off at one point that I was diabetic until I got put in a hospital. I had a normal day and ended up feeling off. I ended up having profuse sweating and heart irregularities, like it felt like my heart was jumping out of my chest. Long story short, I got to the hospital and they took my blood sugar and they're like what have you taken for your diabetes? And I said “I'm not diabetic”. And they said, “Oh yes, you are. Your blood sugar is 800”.

Jennifer: Oh geez.

Brian: And so that was one of the first problems I had. The other problem I had, of course, was being on all the treatments that I had been on for psoriasis and psoriatic arthritis. And so the problem I had was I'd gained so much weight that it was painful to exercise.

Jennifer: Yeah, I had that issue too.

Brian: It was, you know, I'd start and stop a couple times. I'd try it. What used to work for me, it was a program and I'd start it and then I'd not be able to walk for three or four days.

Jennifer: Yes.

Brian: And then at one point, my doctor's like I'm referring you to the bariatric clinic for surgery. And I'm like, I'm not doing surgery. I went along with it. I got qualified and I think I was two weeks out from surgery and I called them and I said, “I want to talk, I want an appointment with the psychologist. I'm having serious issues here”. And so I met with her and I was completely honest. And she says, “well, yeah, then you don't need to have the surgery because if you don't think you're ready, then you can't. We can't in good conscience give it to you”.

Jennifer: Yes

Brian: And that's when I really got serious knowing that I wasn't going to do surgery. What are my other options?

Jennifer: And I'm sure you tried loads of diets before to lose weight?

Brian: Oh yeah, I did Weight Watchers. I did Tops. I did Body for Life. That one worked really well. But the problem is that program is really heavy on weightlifting.

Jennifer: Uh huh.

Brian: Well, that's a problem. When you have psoriatic arthritis in your hands, you can't really grip a dumbbell very well. So

Jennifer: Yeah.

Brian: that one was out. So I went to my rheumatologist and I was like, what can I do for exercise? And they were like, the biggest thing you can do is just try to walk in place or whatever. But that doesn't really do much. So I went to talk to my endocrinologist and she said “well, we've got these other meds we can try” and we went from there. 

Jennifer: So Dr. Boh, is what you heard from Brian and I know I agree with Brian, I've had similar challenges, typical of what you hear from other patients regarding their challenges losing weight?

Dr. Boh: Oh, it is so classic a scenario and I think the important thing to stress here is that obesity is just one of the comorbidities that are associated with psoriasis and psoriatic arthritis. So when we treat our patients for their skin and their joints, we have to play into this picture about treating these comorbidities. So people who are overweight that contributes a lot to their disease state and sometimes even to the lack of response of our biologics and other medicines that we use to treat psoriasis and arthritis. So it is a very common problem and one that I think we have to start thinking about when we talk to our patients. You have to think about psoriasis as the whole pie, psoriasis, psoriatic arthritis. There's all these slices and some of these slices are these comorbidities and they all contribute to this, the response that you get from your disease. They can make the disease worse, harder to manage. So we have to make sure that our patients are up to date with their other disease states and other things that they share because those disease states share inflammatory cytokines, which can make psoriasis and or arthritis flare. And then it becomes this vicious cycle. You can't exercise, so you're eating, but you're not exercising. Sometimes you're eating the wrong foods, which can contribute to the inflammation. So we really need to educate our patients and actually maybe many providers about looking at this whole picture.

Brian: Yeah.

Jennifer: And I know people don't typically go to the dermatologist and think they're gonna have a conversation about weight loss. So how do you initiate that conversation? Because it's such a sensitive subject with some people.

Dr. Boh: It is a sensitive subject, but the way that I like to approach it and everybody has their different ways of doing it. When I see a patient who's got really bad psoriasis with/without arthritis, with other comorbidities, the first thing I want to do is get their skin, their joints, and their head in a better place. So the way that I do that is I tell them we're going to start with getting the disease under control and then we're going to look at all these other things that make your disease harder to control. Then, I move on as soon as I get them on a biologic or something where they're really improving, I then sit down with them and say, you know you have other diseases that we have to deal with. Obesity is a disease. It's not a mindset. It can be worsened with lifestyle, but it's a disease and I think we have to look at it as a disease state and it's driven by inflammation and inflammatory cytokines. So we say let's treat the disease and then I think coming to the realization that we have all these tools that we can use for weight loss. But Brian kind of hit the nail on the head, maybe without realizing it, is that mentally you've got to be ready to do this because none of these treatments are you get on a diet and you get better. This is about changing your lifestyle. Changing how you eat, changing what you eat, doing different things. So I think it starts with getting the skin and the joints under a little bit better control so that patients can start now looking at the other things that are driving the psoriasis. And one of those things very commonly is obesity, which is one of the comorbidities that we see with psoriasis very commonly.

Jennifer: Let's talk a little bit more about the connection between excess weight and psoriatic disease. Dr. Boh, I know you were part of a paper published in the Professional Journal from the National Psoriasis Foundation, Journal of Psoriasis and Psoriatic Arthritis, addressing diet and inflammation in psoriasis. Can you expand on the inflammatory pathway and the causal relationship between excess weight and psoriatic disease?

Dr. Boh: Well, you know, I think they're very integrally related and we have known for years that when patients have, if they have better health in general, their psoriasis becomes a little bit better to control as a general rule. So years ago, we looked at just having patients do dietary manipulation and look at calories in, calories out, and different types of diets. And we reviewed the literature and we saw that as in a general rule patients who were significantly obese, who lost weight, their psoriasis seemed to be better in control, responded better to therapies. Then we started looking deeper into this when we broke this code on the immune regulatory pathways that are involved in making psoriasis and contributing to arthritis and so you know when we broke the code on the human genome we were able to find out that there's certain genes that are altered in psoriasis. And so it’s not just that people don't feel good, they eat more. That's why they have obesity and psoriasis. No, what we found out was the same cytokines, the ones that we're familiar with today – TNF-alpha, IL-17, IL-23. Those inflammatory cytokines are overproduced in obese patients because the fat cells are a great source of inflammatory cytokines. So they're contributing to making the psoriasis. So we had to start looking at obesity and exercise and psoriasis a little bit differently. We found that these comorbidities, the psoriasis, the arthritis, obesity, shared common inflammatory cytokines. They may come from different sources in the skin, the T-cells make too much TNF, IL-17, 23, sometimes IL-1 and in the joints a different array but similar type of inflammatory cytokines are being made by the bone cells and in the skin the fat cells make these same cytokines. So they overproduce TNF, IL-17, both of which can drive psoriasis. They overproduce a cytokine called leptin which maintains sort of like your satiety levels and stuff. So those things are overexpressed in obese patients and then if you add in your genetic sort of risks for your psoriasis, they're also overproducing these same cytokines. So if we can target the cytokines and the sources from which they come, we can improve response to therapy. And I think that's what we've seen over the years and many of these diets which we'll talk about in a minute, can do some of that. But I think we have to think about the patient and what they're able to do with just simple weight loss. So it's not just simply lose your weight, your psoriasis will get better or go away. It's maintaining that and that's where the lifestyle changes have to come in.

Jennifer: And are there any other critical points? I know you mentioned lifestyle changes, you mentioned inflammatory pathways, the relationship between obesity and psoriatic disease. Any other critical points you feel that the listener should know about these pathways and managing these diseases?

Dr. Boh: Well, I think we want to look at all this, the potential sources of these inflammatory cytokines. We want to kind of take the whole picture. So patients may not have all of these comorbidities, because there are thin people who have terrible psoriasis, right. So we have to take each patient as their Individual unit and look at the things that contribute to the production of the inflammatory cytokines. And then we can choose medicines not only from the psoriasis and the arthritis side that will target these inflammatory cytokines, we now have medicines that can decrease the fat cells from producing these inflammatory cytokines. So there's a whole host of ways that a patient can go about decreasing these inflammatory cytokines. Sometimes on their own with simple weight reduction. But it's not only weight reduction, it's the types of foods you eat. So you want to get on to looking at the foods which are pro-inflammatory, anti-inflammatory, and we can use all of the information to make the whole picture so that you can kind of make the whole package. And then I think it makes it a little bit easier to understand.

Jennifer: Yeah, thank you. I know we're gonna get a little bit more into different kinds of diet and anti-inflammatory diets in a minute. So thank you so much for that update. Brian, with this information about the connection between psoriasis and related conditions especially obesity and excess weight from Dr Boh, have you heard of that connection before?

Brian: Yeah, my doctor he's really done a good job of keeping me up to date on this and has taken the time to make sure that I understand the connection between my disease and my weight. I think that's why my dermatologist and my endocrinologist both really put time and effort into really explaining this to me so that I understood “hey, there's this connection here. Let's make sure that you're able to take advantage of it”.

Jennifer: And with this connection in terms of how you approached your lifestyle and your disease management, did you notice any issues with the effectiveness of your initial medications? How did you manage that lifestyle and medication kind of balance?

Brian: So before I had started on the meds I had cursory looked at some diets and tried that and it didn't really work. I've never really noticed with my skin if I eat inflammatory foods that it bothers my skin, however I definitely notice that it'll bother my arthritis, so I've always been real careful about that.

Jennifer: Yeah, I've had the same experience.

Brian: About what I eat there.

Jennifer: Yeah, I I totally agree that that's something that bothers me as well.

Brian: Cause I can go from normal one day to not being able to move one whole hand the next day just because I ate something wrong.

Jennifer: Yeah, exactly. I'm the same way. My arthritis is mainly in my feet and I can go one day from being able to jog, the other day like not even being able to walk without a cane. So I totally understand.

Brian: Right.

Jennifer: So when the medication isn't working well, psoriatic disease can get out of control, which can lead to emotional issues. Anxiety, worry, depression, eating, isolation. Emotional eating may lead to issues with excess weight causing a cyclic effect. Having one of these diseases is challenging enough, but having multiple together can be overwhelming and I know I've also struggled with this. So Brian, do you have any tips for our listeners about how to lessen the impact of such diseases, especially when you're living with multiple?

Brian: The biggest thing I would say is listen to your body. We have pain for a reason. If you're hurting, then after doing something, then maybe you shouldn't be doing it right now. That was the hard one for me. I'm 43 now, but I was in my 20s and 30s and I'd be like, I want to go do this with my friends and they'd want to go out on a 20 mile backpacking hike and I'd be two miles in and I'd be feeling like I couldn't make it. So I guess the biggest thing I could say is definitely listen to your body.

Jennifer: Yeah, thank you. I've had the same struggles and being able to give yourself some grace to potentially not do as much as you want to do or, you know, the struggles you have with your disease is hard for everyone I know.

Brian: Yeah, and don't put yourself down if you can't do something.

Jennifer: Yeah, totally agree. And it's really hard not to get into that kind of cycle, right?

Brian: Oh, absolutely, absolutely. You're like, I should be able to do this. I'm only so and so. Well, you should if you were a normal aged person, but you know you're not,

Jennifer: Yeah.

Brian: so relax.

Jennifer: Yeah. Totally agree. Dr Boh what about you? What tips do you offer your patients who have psoriasis and psoriatic arthritis and excess weight dealing with emotional eating and potentially depression? Do you refer them to nutritionists, counselors? Any other tips?

Dr. Boh: There's a couple of things that I do that I think are important and also important to emphasize. One is we do know that major depression is a serious problem amongst bad psoriasis and arthritis patients. And partly because of what Brian's talking about, you're limited in what you can do, your social activities, your physical activity. So I think first and foremost, I tell that to people. I said, you know, you have a reason to be depressed. I call it reactive depression. So you have to take it with knowing your limitations to begin with, until you can get better or get on the right medicines that may improve you so that you can do other things. So recognizing the limitations is very important. You can partly do that if you start to understand the causes of why you can't walk a 20 mile hike. You know you've got arthritis. So maybe instead of doing the 20 mile hike, I suggest to people start with yoga. Yoga can be relaxing. It can put your mind at a different level and it's not as strenuous. Now it can be a little bit because if you're really obese, it might be tough. But that's where I think it's important to then could talk to I would say a weight trainer, but there's lots of easy yoga things you can do. There's chair yoga. There's things that you can do just to put your mind in the right place and your body. It's so understanding the causes of why you are where you are. Limitations, recognize that they exist until you can change those limitations and then you can start I think better to implement lifestyle changes which may help you also in understanding your limitations and it may make you feel better. When I see patients who are severely depressed and have issues because they say “I'm so miserable, I eat..” blah blah blah, I do consider putting them on an anti-anxiolytic, an anti-depressive agent, and I do that and sometimes it's just for the short run, until I can get people's brains and their bodies in the right place. But I think it's dealing with the whole picture. That's the most important thing here is you can't just say I'm 43 and I should be able to do this because not all 43 year olds can. It's really about your baggage and what you're able to do and then recognize what you're able to do and do corrective measures based on what your limitations are to start with.