Research

JAMA Dermatology | Original Investigation

Association Between Pediatric Psoriasis and Waist-to-Height

Ratio in the Absence of Obesity
A Multicenter Australian Study
Andrew Lee, MBBS, MMed; Saxon D. Smith, MBChB, MHL, GAICD, FACD; Esther Hong, MBBS, MPhil, FACD;
Sarah Garnett, BSc, MNutr Diet, PhD; Gayle Fischer, MBBS(Hons), MD, FACD

IMPORTANCE Increasing evidence suggests that psoriasis poses a cardiometabolic risk in

children, as in adults. The best way to screen for this has not yet been established.
Waist-to-height ratio (WtHR) can easily identify children with increased central adiposity and
is a simpler alternative to body mass index (BMI) that does not require growth charts or
percentiles. Having a WtHR of 0.5 or greater is associated with future cardiovascular risk.
OBJECTIVE To determine whether children with psoriasis are more likely to have increased
WtHR, obesity, and metabolic syndrome relative to children without psoriasis.
DESIGN, SETTING, AND PARTICIPANTS This multicenter cross-sectional prospective
case-control study was conducted from February 7, 2014, to July 15, 2015, in a tertiary referral
center pediatric dermatology clinic and in 2 private consultant rooms of specialist
dermatologists, all located in Sydney and Gosford, New South Wales, Australia. Participants
were children (110 girls and 98 boys) aged from 5 to 16 years, 135 children with psoriasis and
73 controls with noninflammatory skin conditions.
MAIN OUTCOMES AND MEASURES Increased central adiposity indicated by WtHR of 0.5 or
higher, metabolic syndrome, and increased BMI.
RESULTS Of the 208 children evaluated (110 girls and 98 boys) aged from 5 to 16 years (mean
age, 8.9 years), 135 had psoriasis and 73 were controls with noninflammatory skin conditions.
Children with psoriasis were more likely to have increased central adiposity, with WtHR of 0.5
or greater (29% [n = 39] vs 11% [n = 8]; P = .002). Four of 53 children older than 10 years
with psoriasis were found to have metabolic syndrome compared with none of 29 in the
control group (8% vs 0%; P = .29). Three of 15 children with moderate to severe psoriasis had
metabolic syndrome compared with 1 of 38 children with mild psoriasis (20% vs 3%;
P = .06). Children with moderate to severe psoriasis had a higher mean WtHR than children
with mild psoriasis (0.48 vs 0.46; P = .04). Overweight and obesity according to BMI did not
vary significantly between children with psoriasis and controls (17% [n = 23] vs 16% [n = 12];
P = .91).
CONCLUSIONS AND RELEVANCE In this Australian cohort of children with psoriasis, elevated
WtHR was significantly more common in patients with psoriasis than in controls, while
proportions of participants with metabolic syndrome or BMI-determined obesity were not
significantly different between the 2 groups.

JAMA Dermatol. doi:10.1001/jamadermatol.2016.3432

Published online September 28, 2016.

Author Affiliations: Department of

Dermatology, Kolling Institute,
Northern Sydney Local Health
District, St Leonards, New South
Wales, Australia (Lee, Smith, Hong,
Fischer); Department of
Dermatology, Royal North Shore
Hospital, St Leonards, New South
Wales, Australia (Lee, Smith, Hong,
Fischer); Sydney Medical School
Northern, The University of Sydney,
St Leonards, New South Wales,
Australia (Lee, Smith, Fischer);
Institute of Endocrinology and
Diabetes and Kids Research Institute
at the Childrens Hospital at
Westmead, Westmead, Australia
(Garnett); The Childrens Hospital at
Westmead Clinical School, University
of Sydney, Sydney, Australia (Garnett).
Corresponding Author: Andrew Lee,
MBBS, MMed, Department of
Dermatology, Royal North Shore
Hospital, Reserve Road, St Leonards,
NSW, 2065, Australia
(a.lee@sydney.edu.au).

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Research Original Investigation

Pediatric Psoriasis and Increased Waist-to-Height Ratio

soriasis is an autoimmune-mediated inflammatory and

hyperproliferative skin disorder in which both genetic
and environmental factors play a role. It affects up to
3% of the general population with up to a third of cases
beginning in childhood.1,2 Historically, psoriasis was seen as
a benign condition of skin and sometimes joints, but it is
now well established that adult patients with psoriasis
have an increased cardiometabolic risk. This includes an
increased risk of obesity, metabolic syndrome, hypertension, type 2 diabetes mellitus, myocardial infarction, and
peripheral vascular disease.1,3-9 One vital implication of psoriasis being identified as a multisystem disorder is that
assessment of cardiometabolic risk by dermatologists has
now become very relevant to clinical practice. Adults with
psoriasis have poorer metabolic and cardiovascular outcomes, and there is evidence to show that obesity and metabolic syndrome can be identified in patients with psoriasis
from childhood.3-15
The most common method of identifying children who
are overweight or obese is through the use of simple anthropometric measures such as height and weight to generate a
body mass index (BMI), in addition to the use of waist circumference. An increased BMI in children has been associated with risk for adverse long-term cardiovascular outcomes. However, it is often difficult in the clinical setting to
use BMI in children and at times also impractical because
the raw BMI values must be converted into percentiles specific for sex and age. This requires either a chart at the clinic
or the use of a BMI growth chart or program derived from
the Centers for Disease Control and Prevention (CDC), World
Health Organization, or BMI cutoffs from the International
Obesity Task Force. For this reason, in more recent times the
waist-to-height ratio (WtHR) has been proposed as an alternative to BMI. It is a simple measure that can easily identify
children who have increased central adiposity. It requires
the measurement of height and waist circumference only.
Multiple studies have shown that having a WtHR of 0.5 or
greater is associated with future cardiovascular risk in children and adolescents.16-20 However, this measure should be
limited to children older than 5 years and has not yet been
shown to be valid in younger children.
The correlation between psoriasis and obesity or metabolic syndrome in children has only been recently recognized, and as yet there are no guidelines for screening. Multiple international studies have demonstrated a link
between obesity risk and psoriasis in children, with the risk
of psoriasis increasing with severity of obesity, and risk of
obesity increasing with severity of psoriasis.10-15,21 These
studies all agree that further research in this field is needed
and that screening for obesity and metabolic syndrome is
warranted. It has also not been explored in an Australian
population. For this reason, we compared an Australian
cohort of children with psoriasis with a control group with
noninflammatory skin conditions. Our aims were to identify
whether children with psoriasis were at a higher risk of
having increased central adiposity, obesity, and metabolic
syndrome and whether these correlated with severity of
psoriasis.
E2

Key Points
Question Is psoriasis in children associated with an increased
waist-to-height ratio?
Findings In this prospective case-control study that included 135
children with psoriasis and 73 controls aged between 5 and 16
years, children with psoriasis were significantly more likely to have
increased central adiposity with waist-to-height ratio (WtHR) of
0.5 or greater.
Meaning Measuring WtHR may be warranted in children older
than 5 years with psoriasis as part of routine screening to identify
those at increased cardiovascular risk.

Methods
Study Design and Participants
A multicenter, cross-sectional study was performed to determine the relationship between childhood psoriasis, metabolic syndrome, and obesity. Patients were recruited from a
pediatric dermatology clinic in a tertiary referral center and 2
private consultant rooms of specialist dermatologists, all located in Sydney and Gosford, New South Wales, Australia. Consecutive patients presenting were screened for eligibility to participate in the study from February 7, 2014, to July 15, 2015.
Inclusion criteria included a diagnosis of psoriasis by a specialist dermatologist and patient age 5 to 16 years (n = 135). Controls (n = 73) were selected randomly from the same centers
from among patients with noninflammatory skin conditions
(such as benign nevi, acute bacterial infections, vascular lesions, insect bites, molluscum, viral exanthems, warts, pruritus, urticaria, and acne). Written informed consent was
obtained from the parents or legal guardians before participation. This study was approved by the human research ethics
committee at the Childrens Hospital at Westmead.

Psoriasis Assessment
A psoriasis assessment was conducted to determine the type
and severity of psoriasis with the use of the accepted psoriasis measurement tools of psoriasis activity severity index
(PASI), static physicians global assessment (SPGA), and body
surface area (BSA) involvement. Children were graded as
having mild psoriasis if their BSA was less than 10; SPGA, 2 or
less; and PASI. less than 10; they were considered to have moderate to severe psoriasis if their BSA was 10 or higher; SPGA,
greater than 2; or PASI of 10 or higher. For the purposes of documenting severity, we used the worst severity recorded in the
patient files. Treatment regimens were documented as topical therapy, phototherapy, systemic oral therapy, or any
combination of these. Duration of psoriasis was determined
retrospectively from file review where available.

Anthropometric Measures
The anthropometric measures of height, weight, and waist circumference were measured at the clinic visit. Waist circumference was measured using a flexible polystyrene tape at the
midpoint of the lower costal margin and the iliac crest22; BMI

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Pediatric Psoriasis and Increased Waist-to-Height Ratio

was calculated as weight in kilograms divided by height in meters squared; and WtHR was determined by dividing waist circumference by height. Children with a WtHR of 0.5 or greater
were classified as having increased central adiposity. The most
recent International Diabetes Federation (IDF) definition of
metabolic syndrome in children was used, defined as the presence of increased central adiposity (90th percentile, adjusted for sex and race), in addition to 2 of the following
conditions: (1) triglyceride level of 1.7 mmol/L or higher;
(2) high-density lipoprotein cholesterol level (HDL-Chol) lower
than 1.03 in boys or 1.29 in girls or undergoing medical therapy
for low HDL-Chol; (3) systolic blood pressure of 130 mmHg or
higher or diastolic blood pressure of 85 mmHg or higher or undergoing treatment for previously diagnosed hypertension; or
(4) fasting glucose level of 5.6 mmol or higher or previously
diagnosed type 2 diabetes mellitus.23 Per the IDF definition,
metabolic syndrome can only be diagnosed in children 10 years
or older, and thus metabolic syndrome criteria were not applied to children younger than 10 years. Calculated BMI, height,
and weight z-scores adjusted for age and sex were determined from the CDC 2000 growth charts,24 and children were
classified as either nonoverweight (<85th percentile), overweight (85th and <95th percentile), or obese (95th percentile). The formula provided in the 2004 US report25 was used
to determine age-, sex-, and height-adjusted percentiles for systolic and diastolic blood pressure.

Biochemical Analysis
All participants 10 years or older underwent fasting blood tests
to determine total triglyceride, total cholesterol, HDL-Chol, and
low-density lipoprotein cholesterol levels; participants with
an elevated waist circumference also underwent a fasting blood
test for glucose level. These tests were conducted only in children older than 10 years because, per IDF guidelines, metabolic syndrome cannot be diagnosed in children younger than
10 years.

Statistical Analysis
Data were analyzed using SPSS software, version 22.0 (SPSS
Inc). Descriptive data are expressed as mean (SD) and frequencies as indicated. Differences between 2 groups were assessed by 2 or Fisher exact tests when cell counts were small.
Odds ratios (ORs) were calculated to measure associations
between variables of interest with 95% CIs.

Results
Demographic Data
Of the 208 children enrolled in the study, the control and psoriasis groups had similar demographic characteristics. The average age was 8.9 years in the psoriasis group and 9.3 years in
the control group, while the proportion of male participants
was 46% and 49% in the psoriasis and control groups, respectively. There were no significant differences in family history
of high cholesterol, hypertension, or diabetes. Children with
psoriasis were more likely to have a family history of cardiovascular disease (39% [n = 53] vs 23% [n = 17]; P = .02). The
jamadermatology.com

Original Investigation Research

most frequently encountered ethnic group was White (69.2%

of all participants [n = 144]). However, there was a similar
spread of ethnicities across both groups (Table 1). The average age of onset of psoriasis was 6.4 years, and the average
documented duration of disease of psoriasis at time of study
entry study was 36.3 months (this information was available
for 111 of the 135 participants with psoriasis).

Treatments Used
The majority (84.4%) of children with psoriasis were managed with topical treatments only. A total of 97.0% reported
using topical treatments in addition to other modalities, with
6.7% treated with narrowband UV-B phototherapy and 8.9%
with systemic treatment (either acitretin or methotrexate). No
children in the study required a biological agent (Table 1).

Anthropometric Characteristics of Children

With Psoriasis vs Controls
There was a significantly increased prevalence of WtHR greater
than or equal to 0.5 in children with psoriasis (29%; n = 39) relative to controls (11%; n = 8) (P = .002) (Table 2). The OR for having a WtHR of 0.5 or greater in children with psoriasis
compared with controls was 3.30 (95% CI, 1.45-7.52). The prevalence of WtHR of 0.5 or greater was also higher in children with
moderate to severe psoriasis (35%; n = 13) at than in those with
mild psoriasis (27%; n = 26), but this difference was not significant (P = .40). Of the 39 children with psoriasis who had a
WtHR of 0.5 or higher, 51% (20 of 39) had a normal BMI, while
49% (19 of 39) had a BMI in the overweight or obese range
(P > .99). There was also no significant difference in the mean
WtHR between children with psoriasis and controls (0.47 vs
0.46; P = .36). Children with moderate to severe psoriasis had
a higher mean WtHR than children with mild psoriasis (0.48
vs 0.46; P = .04).
Four children with psoriasis were found to have metabolic syndrome compared with none in the control group
(P = .29). There were 3 children with moderate to severe psoriasis who had metabolic syndrome compared with 1 child with
mild psoriasis (20% vs 3%; P = .06). All of these children were
aged 13 to 14 years.
There was no significant difference in the prevalence of
BMI-determined overweight and obesity in children with psoriasis compared with the control group (Table 1). A total of 23
children with psoriasis were overweight (17%) compared with
12 controls (16%) (P = .91). Five children with psoriasis were
obese (4%) compared with 3 controls (4%) (P > .99). Children
with moderate or severe psoriasis had a slightly higher prevalence of BMI-determined overweight or obesity than children with mild psoriasis, but this difference was not significant (19% [n = 7] vs 16% [n = 16]; P = .72) (Table 3).

Discussion
The key finding of this study is the increased prevalence of
WtHR0.5 in children with psoriasis compared to those without. We found that 29% of children with psoriasis between the
ages of 5 and 16 years had a WtHR of 0.5 or greater (n = 39) com(Reprinted) JAMA Dermatology Published online September 28, 2016

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Research Original Investigation

Pediatric Psoriasis and Increased Waist-to-Height Ratio

Table 1. Characteristics of Study Participants

Participants, No. (%)
Characteristic

Psoriasis (n = 135)

Age, mean (SD), y

Control (n = 73)

P Value

8.9 (3)

9.3 (4)

.45

62 (46)

36 (49)

.66

White

92 (68)

52 (71)

Asian

29 (22)

11 (15)

Indian

11 (8)

6 (8)

Sex, male
Ethnicity

Hispanic

1 (<1)

4 (6)

Aboriginal

1 (<1)

Pacific Islander

1 (<1)

.25

Family history
T2DM

53 (39)

22 (30)

.12

High cholesterol

83 (62)

37 (51)

.14

CVD

53 (39)

17 (23)

.02

HTN

86 (64)

39 (53)

.18

Psoriasis severity
Mild

98 (73)

NA

Moderate to severe

37 (27)

NA

131 (97)

NA

9 (7)

NA

12 (9)

NA

NA

Treatment
Topical
Phototherapy
Systemic
Age at onset, mean (SD), y
Duration of disease, mean (SD), mo

NA

6.4 (3.6)

NA

36.3 (32.7)

NA

NA

Blood pressure, mean (SD), mm Hg

Systolic

104.6 (10.1)

102.8 (12.3)

.26

Diastolic

66.5 (5.8)

66.7 (7.1)

.80

BMI
Underweight/normal
Overweight

112 (83)

61 (84)

18 (13)

9 (12)

5 (4)

3 (4)

Obese

.97

Abbreviations: BMI, body mass index

(calculated as weight in kilograms
divided by height in meters squared);
CVD, cardiovascular disease; HTN,
hypertension; NA, not applicable;
T2DM, type 2 diabetes mellitus.

Table 2. Measures of Increased Cardiovascular Risk in Children With Psoriasis vs Controls

Participants, No. (%)
Measure
BMI-determined
overweight/obese

Psoriasis
(n = 135)

Control
(n = 73)

OR (95% CI)

P Value

23 (17)

12 (16)

1.04 (0.49-2.24)

.91

Mean WtHR

0.47

0.46

NA

.36

WtHR 0.5

39 (29)

8 (11)

3.30 (1.45-7.52)

.002

Metabolic syndromea

0 of 29

NAb

Only for children 10 years or older.

4 of 53 (8)

.29

Not estimable owing to 0 cell count.

pared with 11% of controls [n = 8], and the likelihood of this

occurring in children with psoriasis was 3.3 fold (P = .002). This
suggests that Australian children with psoriasis, even when not
clinically overweight or obese, and regardless of the severity
of the psoriasis, are more likely to have increased central adiposity starting from an early age and that this is objectively
identifiable. Thirteen children with moderate to severe psoriasis (35%) had a WtHR of 0.5 or greater compared with 26 children with mild psoriasis (27%), and there was also a difference found in the average WtHR between children with mild
vs moderate to severe psoriasis (0.46 vs 0.48; P = .04).
E4

Abbreviations: BMI, body mass index

(calculated as weight in kilograms
divided by height in meters squared);
NA, not applicable; OR, odds ratio;
WtHR, waist-to-height ratio.

These findings are similar to those of Paller et al,10 who reported that children with psoriasis were 3.1 times more likely
to have an increased WtHR than the control group, although
the cutoff used in that study was slightly different than ours,
0.539. Paller et al also showed that increased WtHR was independent of psoriasis severity, and this is in line with the findings of a recent French study of children with psoriasis, which
showed that obesity and increased waist circumference occurred independent of severity of psoriasis.21 However, our
study has shown that there may be correlation between increased WtHR and psoriasis severity.

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Pediatric Psoriasis and Increased Waist-to-Height Ratio

Original Investigation Research

Table 3. Measures of Increased Cardiovascular Risk in Children With Mild vs Severe Psoriasis
Participants With Psoriasis, No. (%)
Measure
BMI-determined
overweight/obese

Moderate/Severe
(n = 37)
7 (19)

Mild
(n = 98)

OR (95% CI)

P Value

16 (16)

1.20 (0.45-3.19)

.72

Mean WtHR

0.48

0.46

NA

.04

WtHR 0.5

13 (35)

26 (27)

1.50 (0.67-3.37)

.40

Metabolic syndromea

3 of 15 (20)

1 of 38 (3)

9.25 (0.88-97.48)

.06

Our study identified 4 children aged 13 to 14 years of the 135

children with psoriasis who had metabolic syndrome. None of
the 73 controls had metabolic syndrome. However, we did not
find a significant difference in the prevalence of metabolic syndrome between children with psoriasis and children without
psoriasis (8% vs 0%; P = .29). The low prevalence of metabolic
syndrome in our large cohort of children with psoriasis is markedly in contrast to the results of Goldminz et al,15 who found
that 6 of 20 children with psoriatic disease had metabolic syndrome. The reason for this is not clear, but it may related to the
generally lower rates of metabolic syndrome in the catchment
area from which we recruited our participants. Another contributing reason could be that the average burden of psoriatic
disease in our cohort was lower than that of the patients in the
study by Goldminz et al. Although we found no significant difference in rates of metabolic syndrome between the psoriasis
and control groups, when we stratified patients with psoriasis
by disease severity, there was a correlation between more severe disease and greater metabolic syndrome risk (mild psoriasis, 3% [n = 1] vs severe psoriasis, 20% [n = 3]; P = .06). Although this difference was not statistically significant, it
supports the notion that there may be an increased risk of
metabolic disease with increased severity of psoriasis.
The utility of the WtHR tool was highlighted in a large prospective study in the United Kingdom of children documented over a period of 6 to 8 years.17 This study demonstrated that a WtHR of 0.5 or greater in childhood was
associated with an increased cardiometabolic risk later in life.
Results from this study indicated that children with a WtHR
of0.5 or greater were between 2 and 5 times more likely to have
cardiometabolic risk factors than children with a WtHR less
than 0.5. The WtHR metric was also found to be a better predictor than BMI of cardiovascular risk factors in another study
of 1987 children.26 As a tool, it has been validated and is more
appropriate to use than BMI in accounting for body fat distribution and predicting future cardiovascular risk.27 It is also potentially a simpler tool than BMI because it does not require
the use of sex and age percentiles.
Our cohort was drawn from clinics seeing patients with the
full range of psoriatic severity. Unlike previously published international studies on metabolic syndrome and psoriasis, the
majority of children in our study had mild to moderate psoriasis, and this may be a reflection that in Australia, where chil-

ARTICLE INFORMATION
Accepted for Publication: July 27, 2016.

jamadermatology.com

Abbreviations: BMI, body mass index

(calculated as weight in kilograms
divided by height in meters squared);
NA, not applicable; OR, odds ratio;
WtHR, waist-to-height ratio.
a

Only for children 10 years or older.

dren are possibly more highly exposed to the effects of UV light,

the prevalence of severe psoriasis is less common than in other
international locations.10,11
The limitations of our study included the potential for selection bias, with a hospital being included as a study site in
addition to the rooms of specialist dermatologists. The children with psoriasis in this cohort may have a greater burden
of psoriatic disease than those in the community managed by
nonspecialists. In addition, there were twice the number of
patients with psoriasis than controls, which, although not ideal,
was a consequence of excluding a large proportion of patients who came to the specialist clinics with other inflammatory skin conditions, in particular atopic dermatitis. Despite
this, the control and psoriasis groups were relatively well
matched across most demographic data, making comparisons between the 2 groups reasonable.

Conclusions
Our findings suggest that in a cohort of children with mostly
mild psoriasis, BMI may not be appropriate as the sole tool for
identifying children at risk of cardiovascular disease. Many
such children do not necessarily appear any more overweight
than their counterparts without psoriasis, but they are still at
increased risk. Furthermore, BMI in children with psoriasis may
not be the best measure of obesity or the best tool to identify
those children at increased risk of greater central adiposity.
Waist circumference and WtHR of 0.5 or greater may be a better and more accurate metric to identify at-risk children.
The WtHR is a simple and valid tool to identify children
with increased central adiposity. It has been shown to be associated with future cardiometabolic risk; it is easy to perform in children presenting with psoriasis; and we propose that
is should be part of a standard workup. Children with psoriasis who are not overweight according to BMI are still more likely
to have a WtHR of 0.5 or higher than children without psoriasis. This finding in a child with psoriasis is an opportunity to
counsel the family about healthy lifestyle choices and is an opportunity for early intervention. For children older than 10 years
who are identified to have increased central adiposity, it is appropriate to perform cardiometabolic screening in addition to
counselling regarding the risks of obesity.

Published Online: September 28, 2016.

doi:10.1001/jamadermatol.2016.3432

Author Contributions: Drs Fischer and Lee had full

access to all of the data in the study and take

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Research Original Investigation

Pediatric Psoriasis and Increased Waist-to-Height Ratio

responsibility for the integrity of the data and the

accuracy of the data analysis.
Study concept and design: Lee, Garnett, Fischer.
Acquisition, analysis, or interpretation of data: All
Authors.
Drafting of the manuscript: Lee, Smith, Hong,
Fischer.
Critical revision of the manuscript for important
intellectual content: Lee, Garnett, Fischer.
Statistical analysis: Lee, Garnett.
Administrative, technical, or material support: Lee,
Fischer.
Study supervision: Hong, Garnett, Fischer.

7. Armstrong AW, Harskamp CT, Armstrong EJ.

Psoriasis and metabolic syndrome: a systematic
review and meta-analysis of observational studies.
J Am Acad Dermatol. 2013;68(4):654-662.

Conflict of Interest Disclosures: None reported.

8. Prodanovich S, Kirsner RS, Kravetz JD, Ma F,

Martinez L, Federman DG. Association of psoriasis
with coronary artery, cerebrovascular, and
peripheral vascular diseases and mortality. Arch
Dermatol. 2009;145(6):700-703.

Funding/Support: This study was supported in

part by the Dermatology Department of Royal
North Shore Hospital for the submission of the
project for ethics review. No other funding or
support was provided for this study.

9. Tam LS, Tomlinson B, Chu TT, et al.

Cardiovascular risk profile of patients with psoriatic
arthritis compared to controls: the role of
inflammation. Rheumatology (Oxford). 2008;47(5):
718-723.

Role of the Funder/Sponsor: The funder had no

role in the design and conduct of the study;
collection, management, analysis, and
interpretation of the data; preparation, review, or
approval of the manuscript; and decision to submit
the manuscript for publication.

10. Paller AS, Mercy K, Kwasny MJ, et al.

Association of pediatric psoriasis severity with
excess and central adiposity: an international
cross-sectional study. JAMA Dermatol. 2013;149(2):
166-176.

Additional Contributions: We are indebted to

Rachel OConnell, PhD, MMedStat, of the Kolling
Research Institute, St Leonards, Australia for
statistical support. She received no compensation
for her contributions.

E6

6. Armstrong AW, Harskamp CT, Armstrong EJ. The

association between psoriasis and hypertension:
a systematic review and meta-analysis of
observational studies. J Hypertens. 2013;31(3):433442.

11. Boccardi D, Menni S, La Vecchia C, et al.

Overweight and childhood psoriasis. Br J Dermatol.
2009;161(2):484-486.

18. Goulding A, Taylor RW, Grant AM, Parnell WR,

Wilson NC, Williams SM. Waist-to-height ratios in
relation to BMI z-scores in three ethnic groups from
a representative sample of New Zealand children
aged 5-14 years. Int J Obes (Lond). 2010;34(7):11881190.
19. Browning LM, Hsieh SD, Ashwell M. A
systematic review of waist-to-height ratio as a
screening tool for the prediction of cardiovascular
disease and diabetes: 05 could be a suitable global
boundary value. Nutr Res Rev. 2010;23(2):247-269.
20. Ashwell M, Hsieh SD. Six reasons why the
waist-to-height ratio is a rapid and effective global
indicator for health risks of obesity and how its use
could simplify the international public health
message on obesity. Int J Food Sci Nutr. 2005;56(5):
303-307.
21. Mah E, Beauchet A, Bodemer C, et al; Groupe
de Recherche de la Socit Franaise de
Dermatologie Pdiatrique. Psoriasis and obesity in
French children: a case-control, multicentre study.
Br J Dermatol. 2015;172(6):1593-1600.
22. Norton K, Olds T. Anthropometrica. Sydney,
Australia: University of NSW Press; 1996.
23. Zimmet P, Alberti KG, Kaufman F, et al; IDF
Consensus Group. The metabolic syndrome in
children and adolescents: an IDF consensus report.
Pediatr Diabetes. 2007;8(5):299-306.

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