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Steven Feldman, MD, PhD: Hi. I'm Dr Steve Feldman. Welcome to Medscape's InDiscussion series on psoriasis. Today, we'll discuss the management of psoriasis and obesity with a professor of medicine and medicine education in the Division of Endocrinology at Northwestern University Feinberg School of Medicine. Our guest is the former director of the Center for Lifestyle Medicine at Northwestern Medicine in Chicago.
As a highly respected international weight management expert, he's lectured around the world. He's the author or editor of 15 books, 65 book chapters, and 200 scientific articles on overweight, obesity, and nutrition. More importantly, he's also hosted a Medscape InDiscussion podcast series on obesity.
If you're interested in learning more about obesity care, you can find that series on the Medscape app or wherever you get your podcasts. It's my honor and pleasure to welcome Dr Robert Kushner to Psoriasis InDiscussion. Bob, thank you.
Robert Kushner, MD: Steve, thank you for the gracious introduction. I'm happy to be here.
Feldman: I want to know how you became an obesity care specialist.
Kushner: Folks in my field come to it through different avenues. Some are touched personally, either they had obesity or a family history of obesity, all the way to individuals who are trained in metabolism and endocrinology and then zeroed in on obesity. I took a different path. I'm trained in internal medicine but got interested in nutrition and diet as a medical student.
I went ahead and focused on that and did a fellowship in nutrition at the University of Chicago. I came to obesity through a lens of lifestyle medicine and nutrition and have evolved since then.
Feldman: That's great. How big an issue is obesity to people's health?
Kushner: It's a big issue. It is the most common noncommunicable disease, not only in the United States, but worldwide. It has now outpaced malnutrition or undernutrition. In the United States, over 40 % of adults are diagnosed or have obesity, at least by BMI. And most importantly, it takes a toll on our health.
It's associated with over 200 complications and comorbidities, including worsening quality of life. It touches upon every medical specialty I know of, and here it's touching upon dermatology, and I'm not surprised. It's a big deal, and we need to pay more attention to it.
Feldman: Yes, we see a lot of obesity in dermatology, what kind of screening should I be doing in my office?
Kushner: You know, that's a great question. We shouldn't rely on obesity specialists to screen and treat obesity. As I said, since it touches upon every medical specialty there is, I think, frankly, it's incumbent upon all clinicians to be aware of obesity and develop a language to use around it, which I think we'll talk about a little bit later, and provide support and care as necessary.
Clearly, specialists will focus on their particular area and that makes sense. Making the connection between obesity and the specialty area or disease that you're treating makes a lot of sense, but I wouldn't pawn it off on the primary care clinician. I would take charge of it, make the patient aware of the connection between the illness or condition and obesity, and take it from there.
Feldman: One of the issues is that obesity seems to be somewhat of a sensitive subject, and I know weight bias is pervasive. I noticed you've written about the need for increasing empathy, creating self-awareness of weight bias, and creating a bias-free culture. What kind of language and, maybe even more importantly, what kind of thinking should dermatologists have and use when talking to patients about obesity?
Kushner: Yeah, that's a great question — the key to broaching the topic of obesity. I'll take it for granted that most clinicians in medicine have empathy for our patients, and this is no different. But obesity is a little special, and words do matter. Unlike individuals with other conditions, there's a great deal of society bias, stigma, and discrimination among individuals living with obesity. The first thing is, and I just demonstrated this to you, Steve, is person-first language. I didn't say obese patients or obese people. I used people-first language, and that is saying "individuals living with obesity" or "a patient with obesity." People don't want to be labeled by their condition.
You can take it for granted that this is not their first rodeo. They have many other past experiences and encounters with clinicians who have not been as kind or as empathetic, using phrases like you need to lose weight.
You need to take on more responsibility. You need to be motivated. What is wrong with you? Eat less, push yourself away from the table and move more. That is not helpful for patients. So, it really begins with broaching the topic with nonjudgmental language. We recommend starting with a question.
It can go something like this: I've been treating you for psoriasis for several months or several years. We've been going through different treatments. We now know that having obesity or excess body fat is a risk factor for psoriasis and may impact the treatment that we are seeking. Is it okay if we have a conversation about obesity? So that's how I would actually bring it up by asking permission to bring up the topic.
Feldman: I have a feeling like when I know that a patient's acanthosis nigricans is being caused by their obesity. Do I really need their permission? Or is it my obligation to bring it up?
Kushner: That's a good point. As an internist, I don't always ask permission to talk to a person about their diabetes or hypertension, but you know what? Obesity is different. It is a different connotation and a life experience for individuals living with obesity. We think it shows empathy, kindness, and respect for autonomy to say, can we talk about your weight now? And you know what, Steve, a patient may say now is not a good time because I'm picking my kids up in an hour. I have to carpool. The traffic is terrible. It's not a good time to bring it up, right? It has nothing to do with you or the connotation of obesity.
It's not a good time to bring it up, but by asking, I think you're getting buy-in from the patients to have an open-ended, nonjudgmental conversation about their weight. That's when you can ask them, "Do you know the association between psoriasis and having extra body weight?"
They may go, you know, no I don't. Then you begin with that shared information with the patient and open it up for their values, their experiences, and their readiness to take on a weight loss or weight management program. You could take it from there, whether it's a referral to a registered dietitian, to the primary care clinician and obesity specialist, or take on some of the responsibility yourself if you're so inclined as a dermatologist.
Feldman: Perhaps like many physicians, I got into medicine by being good at performing on standardized tests, not by my touchy-feely empathy skills. But I do care about my patients. My approach has been to say something like "different people, different families are meant to be different sizes. I don't know if this is the right size for you or not. Is this an issue for you?"
Is that a reasonable approach?
Kushner: Steve, if I'm not mistaken, that was a question you asked the patient. You still ask permission but in your own words. I think the bottom line, Steve, between what you say and what I say is to remember that words matter. Patients remember those things. If you say you're fat, or you've got to do something about yourself, you're morbidly obese, those are hurtful terms that that individual has listened to and heard for years if not decades.
Change the conversation. Be inquisitive, be polite, be respectful, and assume the autonomy of that patient, whether they wish to do something or not, and give them that opportunity. Steve, really, I think it's a win-win.
Feldman: I get the sense that the advancements in treatments for obesity have been one of the most exciting areas in all of medicine. It's so important in many ways to our health system that it's on the cover of the newspapers. Is this something I should be doing or is it something I should be referring to a specialist for?
Kushner: We are living in a breakthrough in the treatment of obesity, and I've been involved in this field, believe it or not, for four decades. And it has never been as exciting, especially for me as someone seasoned in this area. Everyone knows the word Ozempic, and everyone is looking for a biological treatment for obesity.
If you think about psoriasis, right? I liken it to that breakthrough of the tumor necrosis factor (TNF)-alpha blockers and interleukin 17 (IL-17), interleukin 23 (IL-23). All of a sudden, every commercial is about psoriasis, rheumatoid arthritis, inflammatory bowel disease, or asthma, because you found that target that's really effective. We have done the same thing for obesity.
We finally found a highly effective target, and that's called the gut-brain axis. It's harnessing gut hormones, in this case glucagon-like peptide 1 receptor agonists (GLP-1), other ones like glucose-dependent insulinotropic polypeptide (GIP), that we have used for diabetes care, but now at higher doses, we're using it for obesity. The good news for dermatologists is that diseases like psoriasis or hidradenitis suppurativa (HS) or acanthosis nigricans really will be affected and improved with weight loss, you now have a biological treatment with these medications to help patients achieve those goals.
Feldman: Should I be prescribing that or should I refer them back to their primary care, to my weight loss colleagues?
Kushner: Well, here's, here's my take on this, Steve. There aren't enough obesity specialists to manage the number of individuals who need help for their obesity. There are about 8000, board-certified obesity medicine specialists across the country. And although it's growing every year, over 40% of the adult population has obesity.
Not that they all need treatment, but that's the denominator we're dealing with. So, we have got to identify who is competent and interested in treating obesity and not just refer. Now, if I put a hierarchical list together, I don't think dermatologists would be the highest on the list to take this on.
Not because of lack of skill, but because of the focus of what you do with your specialty. But primary care clinicians need to take this on. Cardiologists, hepatologists, endocrinologists, some Ob/Gyns, and pediatricians, for their patients need to take this on. I think a proper role for a dermatologist is to broach the topic, just like we talked about, Steve, in an empathetic, nonjudgmental way.
Make sure the patient understands the connection between their excess body weight and their medical problem. In this case, psoriasis or HS, which is, I commonly see as well. Ask the patient what they would like to do. Are they interested in getting control of their weight? And then make that referral. It could be a registered dietitian; it could be a primary care physician.
It could be a commercial program. Maybe many of them would do well with their telehealth program. There're a lot of options. It's very difficult for them to tackle this by themselves because of the complexity of the disease and the difficulty in managing weight long term. But making sure you make a connection with a referral would be a good role for a dermatologist.
Feldman: Is there any role for me to treat or follow patients on obesity drugs?
Kushner: I think there is a role. I think what you can do is continue to link the patient's weight loss management to a health outcome. All too often, patients think the health outcome is: how low can I go on the scale? And they value their self-worth and every other outcome based on that. And what we need to do is focus on the health of the individual and the quality of life.
If you're seeing a patient with psoriasis and really commenting about the treatment response, the duration of response, how quickly the response is occurring, how effective the medication is with all the psoriasis markers you use and complimenting the patient on that and reinforcing the health benefit for the weight loss, that would be very valuable.
Feldman: You're really on top of psoriasis. I mean, to know about TNF, IL-17, IL-23, that's fabulous. Before we had those drugs, we had to pay massive attention to treatment adherence. To get patients well with creams and things. I suspect that one of the biggest potential interfaces between what you and I do is the importance of treatment adherence.
And maybe it's not as important now with some of the biologics as it was before, when you were trying to deal primarily with lifestyle modification changes. How do you get people to adhere to that?
Kushner: Adherence is the key to any management of any chronic disease and obesity, probably, above many of them because it is a lifestyle change, even though we're using highly effective, weekly injectable medications now, like Wegovy and Zepbound, these gut hormone mimics. We are still dealing with side effects, changing of the diet so they tolerate the medication better, becoming more physically active, and thinking about this as a lifelong change, not just a short-term cure, which we can't do, is very important.
And so, we always talk about things like team-based care and shared decision-making. We use motivational interviewing. These are all these terms that, depending on when you went to medical school, you may have not been exposed to, reinforcing the changes they're making rather than chastising them for not doing something, so acknowledging their success.
And that's something that a dermatologist can also do, not only focusing on the improvement in psoriasis, which reinforces adherence to what they're doing, but also praising them for the changes they are making in their lifestyle. If I'm not mistaken, Steve, there may be some dietary factors with psoriasis as well.
It may not just be excess body weight. It may be food, food in the environment, and so on. Reinforcing that would also be helpful. And lastly, I just wanted to come back to the inflammation. Thank you for complimenting me on knowing about the biologics. The link most likely between psoriasis and obesity is systemic inflammation.
We're talking about the same thing. These drugs don't directly affect the inflammatory response because they're not antibodies, but by reducing body fat and reducing the adipokines, which are inflammatory markers from the fat cell, we are reducing overall systemic inflammation.
Feldman: One of the things that, I believe it's been the case about adherence, is the focus on behavioral interventions, behavioral psychology. Whereas I've come to believe the way you get people to do things is through social interactions. People floss their teeth right before they go to the dentist.
You know that sense of accountability you have to your provider or to others, may be the biggest driver and I could be mistaken. But I have the sense that I don't know if it was recognized within the weight management world, but I think within the House of Medicine, the only people using these social interactions were the weight management people bringing together small groups of people who have a weight problem and them being beholden to one another, getting on the scales at the same time of tracking each other's progress.
Is that the case?
Kushner: Well, accountability is important. I think that's a lot of what I do when I see patients. And patients want to please their doctor, right? They want to be acknowledged, and they want to have that recognition. So that's part of it. But I provide guidance and support and goal setting and so on.
I think that the early commercial programs, Weight Watchers, would be an example of that, where individuals would seek a common cause and get support from each other. But I think that's true with other diseases, diabetes, juvenile diabetes, and Crohn's disease; there're groups that get together and we still do group support in obesity as well.
But ultimately, we want to get away from what we call external accountability, right? And move it to internal values. That's why reinforcing what the patient's goals are and where they want to go. Is it more important than pleasing me? What do you want out of your life? And make it part of your own personal quality of life.
Feldman: Today, we've had a wonderful interdisciplinary discussion with Dr Robert Kushner about psoriasis and obesity. We learned about the importance of obesity, how it's the most common noncommunicable disease on the planet now, and it's associated with 200 complications. Screening should not rely on obesity specialists.
In dermatology, our patients may not even be seeing a primary care provider. We dermatologists should have empathy when we bring this up with patients. They've been suffering with societal bias, stigma, and discrimination. There's just been all these awesome, exciting developments in obesity management and the gut-brain axis.
Biological treatments are available now that rival the things that we do for our psoriasis patients. Rather than treat patients ourselves, it may be best for us to refer these patients to somebody with experience in the use of these treatments. And then finally, we talked about adherence, which is the key to the management of chronic diseases, especially those that require lifestyle changes.
If you want to know more about Dr Kushner, check him out on the web at drrobertkushner.com. And thank you so much for joining us today. This is Dr Steve Feldman for InDiscussion.
Listen to additional seasons of this podcast.
Resources
Medscape InDiscussion: Obesity
Update on Obesity in Psoriasis Patients
Obesity and Severe Obesity Prevalence in Adults: United States, August 2021-August 2023
The Link Between Obesity and the Skin
Medications for Obesity: A Review
Role of the Gut-Brain Axis in Energy and Glucose Metabolism
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Cite this: For Psoriasis, Should Dermatologists Treat Obesity? - Medscape - Mar 18, 2025.
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