“The Metabolic Collision and How You Can Take Control with Psoriatic Disease” Transcript

0:23 EPISODE INTRODUCTION by moderator Corinne: My name is Corinne Rukowski and I'll be your moderator for today's discussion about metabolic disease, diet, and what you can do to impact your overall health with psoriasis and psoriatic arthritis. As a graduating medical student from the New York Institute of Technology, College of Osteopathic Medicine, I'll be entering residency soon and this is definitely an area of interest to me. Joining me is leading dermatologist and Vice Chair of the NPF Medical Board, Dr. Ronald Prussick, who is the medical director of Washington Dermatology Center in Rockville and Frederick, Maryland, where he specializes in the treatment of psoriasis, along with other diseases of the skin, hair, and nails. Dr. Prussick is also a clinical associate professor in dermatology at George Washington University in Washington, D.C. Joining Dr. Prussick is Danielle Cahalan, a registered dietician and coach who provides services virtually to help her clients find that balance with food choices that support overall health and longevity. Welcome Dr. Prussick and Danielle. It's a pleasure having you both on Psoriasis Uncovered.

1:27 Corinee Let's start with a basic question. Dr. Prussick, what is metabolic disease or metabolic syndrome and why are those who have psoriasis or psoriatic arthritis at increased risk for metabolic disease?

1:40 Dr. Prussick: Well, I just wanted to thank you for inviting us to do this podcast. I'm really excited to do it. Metabolic syndrome is a group of conditions that together raise your risk of coronary heart disease, stroke, and diabetes. It's characterized by insulin resistance. What that means is that insulin brings down your blood sugars and insulin resistance means you need more and more insulin over time to actually achieve that. And so this disease is characterized by insulin resistance and chronic inflammation. It's diagnosed -- you need to have at least three out of five diagnoses. So you need to have central obesity, elevated triglycerides, reduced HDL. HDL is the good cholesterol that prevents heart disease. You need to have elevated blood pressure and elevated fasting glucose. So if you have at least three out of the five, you get diagnosed with metabolic syndrome. And the reason why people with psoriasis and psoriatic disease are more predisposed to getting metabolic syndrome is because many of the inflammatory cytokines that cause psoriatic disease also cause metabolic syndrome, such as elevated TNF-alpha, elevated interleukin-23, elevated IL-17, so elevated interleukin 6. So those are all present in both conditions.

3:11 Corinne: Thanks for that information. And given this bi-directional relationship, how does that impact the management of psoriatic disease?

3:19 Dr. Prussick: Well when you say bidirectional, the psoriasis worsens obesity and metabolic syndrome, and also obesity and metabolic syndrome worsens psoriasis. So that's what we mean by bidirectional. What we found when we looked at the Nurses Health Study is we found nurses with the largest BMI’s had the highest risk of eventually developing psoriasis. And nurses that ran for 100 minutes a week and had low BMI’s had a 25 % reduced chance of developing psoriasis. So we know that the visceral fat, which means that the fat in the center of the body is metabolically active and causes a lot of the elevated cytokines that trigger the psoriasis and psoriatic arthritis, such as, like I said, TNF-alpha, interleukin-17, interleukin-23, and interleukin-6. Now what we found when we looked at the NPF CorEvitas Registry, and this was published in the Journal of the American Academy of Dermatology in 2022, was that patients who had obesity had a 30 % reduced chance of eventually getting a PASI 90 score in their psoriasis when they were treated with biologics, which means that it's harder to treat people with psoriasis who have obesity and metabolic syndrome. They don't achieve the PASI 90 and 100 as easily. Also, there's more switching, so drug survival is shorter. So they take a medicine, it stops working, then they have to switch to another medicine. You're more likely to have that with metabolic syndrome and obesity. There's also an increased risk of developing psoriatic arthritis if you have metabolic syndrome and if you have increased BMI's. And this has been shown in a large study looking at the UK General Practice Database over 16 years. What they found was that psoriasis patients with BMI, if they start out normal at 25 or less and went to 30, they had a 13 % increased chance of getting psoriatic arthritis. But the opposite happens as well. If they lose weight and their BMI drops from 30 to 25, then they have a 13 % reduced chance of developing psoriatic arthritis. So the central obesity causing the inflammation really is a trigger for having difficulty getting your psoriasis under control and developing psoriatic arthritis. One other thing about how we would monitor patients who have psoriatic disease with metabolic syndrome. So what we mean by monitoring is there are some guidelines that were published through the AAD and the National Psoriasis Foundation. And just quickly we recommended that the patients get a blood pressure on almost every exam if possible, but at least yearly. They should get a lipid panel with at least a glucose and hemoglobin A1C. That should be done baseline and then every three to five years in low-risk patients and yearly in high-risk patients. And also, the guidelines also said that patients with moderate severe disease and a family history of heart disease should really get a cardiovascular risk score. So they have to see a cardiologist and get a risk score and that gives them an idea of how much of a chance they have of developing a heart attack or a stroke.

6:54 Corinne: That's very interesting and definitely valuable information for our listeners to have.  Danielle, some of the factors that impact this bi-directional relationship are environmental and lifestyle, and this presents an opportunity for interventions. What types of interventions could be helpful to reduce metabolic risk?

7:14 Danielle: Thanks for the question, Corinne. So when I think about environmental and lifestyle interventions, I like to start with the four pillars of health. While that may seem oversimplified in nature, I do find that a lot of patients I see tend to overlook these four pillars -- which include diet, physical activity or exercise, sleep, and stress management. So I'll go through each one here. When we think about diet, changing our environment can be helpful in the sense of making whole foods readily available. If we think of why ultra processed foods are desirable to many people, not only are they tasty, they're hyper-palatable and they're easy to grab. So we really want to make whole foods more accessible and to make them more accessible they need to be in our sight of vision. So maybe fruit on the countertop or in your line of vision when you open the fridge, having pre-cut options or pre-batched and pre-made meals that are easy to grab. So making it more convenient for your environment to grab those whole food items. And we'll talk more about the Mediterranean Diet later, but some other quick tips would be maybe olives that are higher in healthy fats and nuts are pre-made options you don't even have to worry about. The second pillar of health is physical activity. The World Health Organization, or WHO for short, recommends 150 to 180 minutes of moderate physical activity per week, but even walking can improve insulin sensitivity. So going back to what Dr Prussick was speaking to of supporting your blood sugar, this is very, very important in reducing inflammation and supporting metabolic processes in the body. So if you're not physically active and you're able to walk, walking is a great starting point and then you can build upon it from there. Walking after meals in particular can help process some of that unused glucose in your body too, instead of just sitting or laying down after dinner. The third pillar of health is sleep. So, I'm sure most people think the general recommendation is 8 hours, but the range is typically 7 1/2 to 9 hours to get those full REM cycles. This also supports metabolic health in the sense that if you get less than 6 hours per night, you're more at risk for insulin resistance, or not being able to process carbs and sugar as efficiently the next day. So it's so interesting. You can eat the same meals and foods one day and then the second. But if one day you don't sleep as well, your blood sugar will be higher than the previous day, even though you ate the same meals and foods. So sleep is very important to lay as a foundation. And then the fourth pillar of health here is stress management. And I always joke with my patients, now, sometimes bringing up stress management stresses people out more. The goal isn't to completely eradicate stress. It's just to manage it, to make our body feel safe, to support our central nervous system, reduce any inflammation caused by excessive cortisol. And we can do that through a few ways, but you really have to figure out what works best for you. So breathing exercises are effective. Meditation, Yoga Nidra, (also known as non-sleep deep rest), or things to keep your mind preoccupied, like doing puzzles, adult coloring, knitting, something with your hands, creative outlets. The last thing, if people are listening and they're like, well, I have all those four pillars of health down pat, there's a lot of emerging evidence and research talking about endocrine disruptors. So endocrine is the system that regulates hormones in our body, and they can be disrupted by certain chemicals found in things like plastics, or things in our beauty and cleaning products. This can also be topically triggering when we're thinking about psoriatic disease for some people. And so what we put on our skin and body and what we absorb can impact our internal workings, but also external. So those would be the environmental and lifestyle suggestions I have.

11:17 Corinne: Thanks so much for sharing those suggestions. And when it comes to systemic inflammation, which is closely related to psoriatic disease, I wanted to ask you, is there truly an anti-inflammatory diet? You see on social media, on TV, a lot of these diet fads or information that may not be true. Some people feel diet is the answer to cure their disease. So, what are your thoughts about this? Is there a true anti-inflammatory diet?

11:49 Danielle: I love this question because I think a lot of people are looking for that magic bullet or to subscribe to one particular diet that lays out a rule or guideline on how to eat. Unfortunately, there is no one size fits all anti-inflammatory diet. The Mediterranean Diet would be the next best option that promotes anti-inflammatory nutrient dense foods, but there's not the anti-inflammatory diet that everyone can adhere to. And a good example of why I like to provide examples would be I work with a lot of women who may have gut issues, conditions like thyroid conditions, PCOS, endometriosis, and believe it or not, perceived healthy foods that we think of, fruits, vegetables, they may be sensitive to and have an immune mediated reaction. So just because we think of a food as healthy doesn't mean it's healthy and anti-inflammatory for everyone. It may be for the vast majority, but not every particular condition and individual. That's why nutrition is so personalized and should be, not just consulting with ChatGPT or Dr Google. Another example would be dairy. Dairy is actually anti-inflammatory in nature, but can be inflammatory to a lot of people who are sensitive, including those with autoimmune conditions, immune-mediated conditions like psoriatic disease. But it's really a trial and error of an elimination diet, figuring out is that person having symptoms related to consuming dairy. So rather than thinking in absolutes of all or nothing, I need to adhere to this diet without room for flexibility, I think it's better to think of what can I add to my diet that's anti-inflammatory that will support this reduction in elevated markers and to also individualize it based on clinical context and then the person's tolerance.

13:46 Corinne: Great, those are awesome tips. And actually, it's a perfect segue into our next topic, discussion of the Mediterranean Diet. I was wondering Danielle, if you could please explain what the Mediterranean Diet is, which we know has years of clinical research to support reducing risk associations with metabolic disease and actually has recently been shown to lower the risk of cognitive decline. So I would love to hear your thoughts about this diet.

14:13 Danielle: Of course, I'd be happy to explain. So if we think about the Mediterranean Diet, it's self-implied in the name that it's from the area of the Mediterranean Sea. So if we think of the countries and regions surrounding that, think Greece, Southern Italy, Spain, most of these are coastal areas and regions. And so they have easy access to things like seafood, which is the predominant animal protein in the Mediterranean Diet, supplemented with moderate amounts of poultry. so chicken, turkey, and very limited amounts of red meat, but it's not saying that you can't have red meat. In addition to that, if you've ever seen a visual of the Mediterranean Diet pyramid, or you can easily look it up, at the very bottom, which we want to eat the most of, you'll see a lot of fruits, vegetables, whole grains, beans, lentils, nuts and seeds, so primarily plants. So that's kind of the premise and foundation of the Mediterranean Diet is plant-based, supplemented with fish, poultry, limited amounts of red meat, moderate amounts of dairy, so think Greek yogurt. A lot of people will start their day in this region with Greek yogurt, berries, muesli, or cheese. If you think of a Greek salad with feta in it, that would be another example of eating dairy in moderation. And small amounts of red wine, believe it or not. It's cultural, it's traditional. It's not promoting alcohol by any means, but there is some flexibility in part of the Mediterranean Diet there. And some people are more sensitive to alcohol than others. So really it's a tolerance thing. When we compare it to a Western dietary pattern, the differences are quite striking in the sense that Western foods tend to be higher processed (so ultra processed foods), higher in saturated fat, low in fiber, high in refined carbs and sugar, things that may exacerbate or add to inflammation rather than reducing them. And so when we think of the comparison side by side, the Mediterranean Diet is really beneficial for overall health, metabolic health. And you mentioned that cognitive decline. So with the healthy fats and fiber, it will support neuro protection and prevention with things like Alzheimer's, dementia, and brain health.

16:32 Corinne: Thanks Danielle. It sounds like the Mediterranean Diet has a lot of great benefits. Dr. Prussick, you’ve done some research around the use of the Mediterranean Diet in relation to psoriasis. Can you please share what you have found with regards to reducing the impact of systemic inflammation?

16:50 Dr. Prussick: Sure. Well, what’s important about the Mediterranean Diet is that people actually lose weight. And one of the things about losing weight is you reduce the central obesity, which is the source of a lot of the inflammatory mediators that trigger psoriasis and psoriatic arthritis. You improve your gut microbiome, which we'll talk about a little bit more later. You increase your insulin sensitivity, decrease hypertension, improve your lipid profile. You also, by eating more omega 3’s and less omega 6, it improves your anti-inflammatory prostaglandins and decreases your pro-inflammatory prostaglandins. So really, psoriasis improves, the PASI scores improve. And there was a study coming out of Madrid, which looked at an open label, single evaluator, blinded, randomized controlled trial that was published in the JAMA Dermatology in December of 2025. This was a 16 week study where half the patients were given a dietitian guided Mediterranean Diet with olive oil, etc, versus a low fat diet. That was the control group. What they found after just 16 weeks was the psoriasis PASI scores improved by about 3 1/2 and about 47% of the patients achieved a PASI 75, means that their psoriasis scores improved by 75 % just with the Mediterranean Diet in 16 weeks. Compared to the control group where there was no improvement in the skin at all on a low fat Western diet. There was also a significant decrease in the hemoglobin A1C, so their glycemic control got better and they had reduced insulin resistance.

18:41 Corinne: Those are great findings. Thank you for sharing, Dr. Prussick. And you mentioned earlier the link between weight, severity of psoriatic disease, and the impact on the effectiveness of medications for psoriatic disease. So I wanted to ask a question to the both of you, how effective do you feel the Mediterranean Diet is in losing weight and the ability to manipulate diet for better health outcomes?

19:08 Dr. Prussick: Well I guess I could start. Back in 2004, there was a pivotal trial looking at Mediterranean Diet and metabolic syndrome. This wasn't in psoriasis patients, but in metabolic syndrome. So it was a randomized controlled trial of 180 people over three years in Italy, both males and females. What they found after the three years was that there was an improvement in what they call endothelial function scores. So the blood vessel got better. There was a reduction in CRP, which means their inflammatory mediators were better. Their insulin sensitivity got better. The inflammatory interleukins like IL-6 and IL-17 got better. They lost more weight, and there was decrease in patients with metabolic syndrome. So we know from these large randomized controlled trials that patients do lose weight and they are healthier.

20:06 Danielle: I would agree with that and I really appreciate you providing all of these studies to refer to and the details they provide. I read the same exact study from the end of 2025 and found the results to be very compelling in terms of modest but meaningful improvements in weight, inflammatory markers, all of those metrics that you just mentioned Dr. Prussick. And it's interesting because the Mediterranean Diet isn't necessarily promoted as a weight loss diet. It's for overall health. So it's not inherently just for weight loss. It's for all these other benefits as well, but weight loss does come with it too. And so when we take the emphasis off of just being restrictive, there is a psychological component of having things in moderation, which I can elaborate on later. But overall, to answer your direct question, yes, it is beneficial for weight loss and in managing those metabolic and inflammatory signalings.

21:03 Corinne: I agree. These results are very, very good to see and I thank you for sharing them with  our listeners. Danielle, you mentioned previously that with the Mediterranean Diet, has a lot of nutrients that are beneficial such as omega-3’s and these healthy fats, also called monounsaturated fats that can help reduce bad cholesterol or your cholesterol that's called LDL or your triglycerides while helping to raise your good cholesterol, HDL. Could you offer some tips and maybe some examples of foods that offer omega-3’s and monounsaturated fats?

21:42 Danielle: Sure, I'd be happy to. So in the context of the Mediterranean Diet, we're thinking about two groups of healthy fats. There's the omega-3’s that are highly anti-inflammatory and monounsaturated fats, like you mentioned. So we'll start by breaking down the omega-3’s. These are biologically active compounds that work to reduce inflammation, but also support brain, heart, and gut health. There are three different types and forms I don't think people are aware of. So there's EPA, DHA, and ALA. And EPA and DHA in a ratio of two to one is the most effective to consume, mainly because it's most bioavailable to the body and we can use the most of it. ALA is not as converted. So if we think about where EPA and DHA come from in our diet, that primarily comes from seafood or fatty fish such as salmon, tuna, herring, sardines and anchovies, which about 50% of my clients will roll their eyes and be like, I don't eat seafood, what else can I do? A good second option to that would be omega-3 supplementation. It is effective. There are more studies coming out that its just as effective, if not better than some dietary omega-3 options. And it does help in lowering triglycerides, supporting cardiovascular health and modulating those inflammatory pathways. If we're thinking about ALA, so I don't like to dismiss if someone is vegan, vegetarian, so on with their diet, you can get omega-3’s through plant-based foods, but once again, those are ALA and they're not as converted as easy to DHA and EPA, which in that case you can get from walnuts, chia seeds, flax seeds, and vegetable oils. However, in addition to that, there is supplementation that's more vegan, vegetarian, which would be algae and krill. Actually, I think krill would still be like pescetarian, but algae-based would be an option. And then the other fat that we need to talk about and recognize in the Mediterranean Diet, you can't talk about the Mediterranean Diet without olive oil. So the primary source of monounsaturated fat that's so good for your heart health is extra virgin olive oil. If you have one to two tablespoons a day, that would be adequate. There are some people I know who just mix it with lemon and drink it straight, or they'll add it to salad dressing. That's a practical application or cook with it. The only thing to note is that it has a lower smoke point of around 350 to 375 degrees Fahrenheit. So if you do tend to cook at higher temperatures, it can oxidate some of those healthy fat properties, in which case I would reserve that maybe for lower cooking temps or just salad dressings, maybe things that you wouldn't heat up as much. So some alternatives then would be avocado oil, ghee. There are some other healthier cooking options. And these fats overall, just to conclude here, support cardiovascular health, improve lipid profiles, and they reduce, kind of offset saturated fats in the diet then, which is also helpful.

24:50 Corinne: Great, thanks for giving us all those great options. Dr Prussick, a recent twist on the Mediterranean Diet is the use of a high polyphenol Mediterranean Diet. I was wondering if you could speak on what polyphenols are and why they are so important to what we eat?

25:07 Dr. Prussick: Well, that's a great question. Polyphenols are plant compounds with very potent antioxidant and anti-inflammatory effects. Some examples are flavonoids in green tea, phenolic acids you see in caffeine, resveratrol, which is in a lot of berries, lignans, and seeds. And what they really do is they have an effect, we call it an epigenetic effect. So it turns on genes, it turns off genes and it has an effect on for example, your Th17 cells. And those are very important cells in psoriasis because when they become activated, they produce a lot of the inflammatory cytokines which trigger psoriasis and psoriatic arthritis. They also increase what they call T-regulator cells. So you can think of those cells as being sort of the stop gap and what they do is they actually suppress an overactive immune system. So it's very important for those cells to be functioning properly and the polyphenols can help with that. They also modulate adipose tissue. So what we talked about how the cells in the fat of the center of the body produce all these inflammatory cytokines, well, the polyphenols can reduce that. Also what they do as an antioxidant, patients who have an overactive immune system deplete their antioxidants more than people who don't. So what happens is a main antioxidant, for example, glutathione gets depleted. and that puts more stress on your immune system. So when you eat polyphenols, you will replace the antioxidants and it acts as an antioxidant to protect your glutathione. So those are all the things that the polyphenols will do to your immune system to help you with your psoriasis.

27:03 Corinne: Thanks Dr. Prussick, for those explanations. Danielle, can you provide some examples of foods that are high in polyphenols?