Association Between Dietary Factors and Psoriasis: A Mendelian randomization analysis

doi:10.21203/rs.3.rs-3993952/v1

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Association Between Dietary Factors and Psoriasis: A Mendelian randomization analysis

https://doi.org/10.21203/rs.3.rs-3993952/v1

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The WHO recognizes psoriatic arthritis (PsA) as a severe non-communicable disease, with Europe having the highest prevalence worldwide, affecting around 6.4 million people. Though dietary factors are closely associated with psoriasis (PsO) in clinical studies, few researchers have explored this link through Mendelian randomization (MR). This investigation analyzes the causal association between psoriasis and dietary factors. This study used MR analysis with publicly available genome-wide association studies to uncover causal relationships. Causal inference and effect estimates were determined using the inverse variance weighted (IVW) method. Additionally, sensitivity analysis included weighted median and MR-Egger methods, with leave-one-out analysis to ensure reliability. It was found that bread intake was associated with increased psoriasis risk (OR: 1.008; 95% CI: 1.003–1.015; p = 0.004), while beef consumption (OR: 0.989; 95% CI: 0.979–0.999; p = 0.043), cooked vegetables (OR: 0.967; 95% CI: 0.936–0.999; p = 0.046), and pork (OR: 0.985; 95% CI: 0.973–0.997; p = 0.016) were protective against psoriasis. No causal link was observed between other dietary factors and psoriasis. Overall, the study found that bread intake increased psoriasis risk, while beef, cooked vegetables, and pork consumption reduced it. Other diets showed no causal association with psoriasis.

Diet

Nutrition

Psoriasis

Mendelian randomization

Beef

Bread

Cooked vegetable

Pork

Psoriasis is a recurrent immune-mediated chronic papular scaly skin disease, which brings a huge burden to the patients and society ⁽¹⁾. Its prevalence in European and American countries is 2–4% ⁽²⁾. Furthermore, it has been observed that the prevalence of psoriasis increases roughly linearly with growing age, from 0.12% at age 1 to 1.2% at age 18 ⁽³⁾. Moreover, its prevalence differs with different latitudes and races, and the prevalence of high latitudes and white people is higher ⁽⁴⁾. Psoriasis patients have an elevated risk of other serious and chronic comorbidities ⁽⁵⁾. Various complications are associated with psoriasis, such as cardiac metabolic diseases, psoriatic arthritis, kidney diseases, malignant tumors, gastrointestinal diseases, infections, and mood disorders ⁽⁶⁾. In 2014, the World Health Organization recognized psoriasis as a “chronic, non-communicable, painful, disfiguring, and disabling disease for which there is no cure” ⁽⁷⁾. Psoriasis causes significant psychosocial disorders and has a marked impact on patient’s quality of life ⁽⁸⁾.

Generally, psoriasis requires prolonged treatment with the goal of reducing its incidence and improving the quality of life ⁽⁹⁾. Psoriasis requires lifelong care, which increases the economic burden of the suffering individuals. In 2013, the annual US cost of psoriasis burden was approximately $112 billion ⁽¹⁰⁾. In the European countries, the total cost/annum for one patient in Italy, Sweden, Germany, and Canada is €8372, €11,928, €2866–6707, and CDN$7999, respectively ⁽¹¹⁾. Genetic, immune, and environmental factors (including diet) are considered to be essentially associated with the pathogenesis of psoriasis ⁽¹²⁾. Furthermore, fasting as well as low energy and vegetarian diet can improve its symptoms ^(13–14). Diets rich in n-3 polyunsaturated fatty acids such as in fish oil have also shown beneficial effects ⁽¹⁵⁾. Moreover, a Mediterranean diet rich in fiber, vitamins, and polyphenols may control the psoriasis symptoms ⁽¹⁶⁾. Individuals who take a Mediterranean diet are less likely to develop psoriasis than those who do not ⁽¹⁷⁾. Currently, most of the research associating dietary patterns and psoriasis are cross-sectional studies, and studies on the association between various dietary patterns and the risk of psoriasis are still rare. Understanding whether dietary changes are beneficial for psoriasis patients is of great significance for both the clinicians and the patients. Mendelian randomization (MR) studies using genetic variation as an instrumental variable (IVs) have advantages over other research methods ⁽¹⁸⁾. Therefore, this investigation conducted an MR analysis to elucidate the relationship of dietary factors with psoriasis.

2.1. Study design

The study design was based on genome-wide association studies (GWAS). Figure 1 illustrates the overview of the study design and the three key assumptions of MR.

2.2. Data sources

The genetic data of dietary factors and psoriasis were acquired from the UK Biobank of the publicly available GWAS project and published studies. The acquired GWAS genetic data was categorized into two types based on the exposure and outcomes.

Exposure factors: consumption of meat (beef, poultry, pork, processed meat, and lamb/mutton intake); fish (non-oily and oily fish intake); milchig (cheese); alcohol (intake frequency); tea and coffee (tea, green tea, herbal tea, and coffee intake); fruit (dried and fresh fruit intake); vegetable (cooked or salad/raw vegetable intake); staple food (cereal and bread intake). The outcome indicator was psoriasis. Table 1 indicated comprehensive details of outcome and exposure.

Table 1

Information on the exposures and outcome datasets.
Trait	GWAS ID	Year	Population	Author	Consortium	Sample size	Number of SNPs	Identified SNPs
Beef intake	ukb-b-2862	2018	European	Ben Elsworth	MRC-IEU	461,053	9,851,867	15
Poultry intake	ukb-b-8006	2018	European	Ben Elsworth	MRC-IEU	461,900	9,851,867	7
Pork intake	ukb-b-5640	2018	European	Ben Elsworth	MRC-IEU	460,162	9,851,867	14
Lamb/mutton intake	ukb-b-14179	2018	European	Ben Elsworth	MRC-IEU	460,006	9,851,867	31
Non-oily fish intake	ukb-b-17627	2018	European	Ben Elsworth	MRC-IEU	460,880	9,851,867	9
Oily fish intake	ukb-b-2209	2018	European	Ben Elsworth	MRC-IEU	460,443	9,851,867	60
Processed meat intake	ukb-b-6324	2018	European	Ben Elsworth	MRC-IEU	461,981	9,851,867	23
Cheese intake	ukb-b-1489	2018	European	Ben Elsworth	MRC-IEU	451,486	9,851,867	63
Alcohol intake frequency.	ukb-b-5779	2018	European	Ben Elsworth	MRC-IEU	462,346	9,851,867	95
Tea intake	ukb-b-6066	2018	European	Ben Elsworth	MRC-IEU	447,485	9,851,867	39
Green tea intake	ukb-b-4078	2018	European	Ben Elsworth	MRC-IEU	64,949	9,851,867	13
Herbal tea intake	ukb-b-13344	2018	European	Ben Elsworth	MRC-IEU	64,949	9,851,867	9
Coffee intake	ukb-b-5237	2018	European	Ben Elsworth	MRC-IEU	428,860	9,851,867	38
Cereal intake	ukb-b-15926	2018	European	Ben Elsworth	MRC-IEU	441,640	9,851,867	39
Dried fruit intake	ukb-b-16576	2018	European	Ben Elsworth	MRC-IEU	421,764	9,851,867	41
Fresh fruit intake	ukb-b-3881	2018	European	Ben Elsworth	MRC-IEU	446,462	9,851,867	53
Cooked vegetable intake	ukb-b-8089	2018	European	Ben Elsworth	MRC-IEU	448,651	9,851,867	17
Salad / raw vegetable intake	ukb-b-1996	2018	European	Ben Elsworth	MRC-IEU	435,435	9,851,867	19
Bread intake	ukb-b-11348	2018	European	Ben Elsworth	MRC-IEU	452,236	9,851,867	30
Psoriasis	ebi-a-GCST90038681	2021	NA	D < U + 00F6 > nerta < U + 015F > HM	NA	484,598	9,587,836	NA

2.3. The instrumental variables selection

In MR, genetic instruments comprised one or more genetic variants with properties that enable their use as IVs. Generally, IVs are genetic variations, of which the most frequently employed are Single nucleotide polymorphisms (SNPs) ⁽¹⁹⁾. Three guidelines were followed for the selection of SNPS: ① Correlation assumption: SNPs must be significantly related to the level of dietary factors (p < 5×10 − 8); ② Independence assumption: SNPs must be independent of the confounding psoriasis factors, with no pleiotropic association; ③ Exclusive hypothesis: SNPs can only affect psoriasis by affecting dietary factors, and cannot affect psoriasis through other ways.

2.4. Statistical method

Statistical measurements were conducted in three stages. First, Cochran’s Q test was carried out to elucidate the heterogeneity ⁽²⁰⁾, while the causal inference was assessed via the inverse variance weighted (IVW) method ⁽²¹⁾. Second, for sensitivity analyses, the MR-Egger method and weighted median were performed. Lastly, with the help of leave-one-out analysis, whether the IVW estimate is affected by any single SNP was determined.

3.1. Instrumental variable

When the causal effects of 19 dietary exposure factors on psoriasis were estimated, the independence and linkage disequilibrium of genetic variation were considered instrumental variables. European population-based 7 to 95 SNPs with p-values < 5 × 10 − 8 indicated that these SNPs were highly correlated with dietary exposure factors. After searching the Phenoscanner database and removing outliers, all SNPs met the independence and exclusion hypothesis. F statistics of > 10 (range: 29.80 to 811.85) were set. Table 2 provides further details.

Table 2: Information on the exposures and outcome datasets.

3.2. The results of Mendel randomization analysis

The IVW analysis indicated that with psoriasis as the outcome data set, 4 dietary factors were positive (p < 0.05), while the remaining 15 were negative (p > 0.05). The dietary factors that negatively correlated with psoriasis included the intake of beef [after removing outliers (ARO), 95% confidence interval (CI): 0.979–0.999; odds ratio (OR) = 0.989; p = 0.043], pork (95% CI: 0.973–0.997; OR = 0.985; p = 0.016), and cooked vegetable (95% CI: 0.936–0.999; OR = 0.967;

p = 0.046). The positively correlated factor included the intake of bread (ARO, 95% CI: 1.003–1.015; OR = 1.009; p = 0.046). Furthermore, 15 non-significant dietary exposure factors were also identified, these included the intake of poultry (ARO, 95% CI: 0.986–1.018; OR = 1.001; p = 0.890), lamb/mutton (ARO, 95% CI: 0.984–1.001; OR = 0.993; p = 0.079), non-oily fish (ARO, 95% CI: 0.976–1.003; OR = 0.989; p = 0.121), oily fish (ARO, 95% CI: 0.996–1.005; OR = 1.000; p = 0.864), processed meat (95% CI: 0.985–1.000; OR = 0.993; p = 0.059), cheese (ARO, 95% CI: 0.993–1.004; OR = 0.998; p = 0.275), alcohol intake frequency (ARO, 95% CI: 0.997–1.001; OR = 0.999; p = 0.317), tea (ARO, 95% CI: 0.992–1.001; OR = 0.997; p = 0.117), green tea (95% CI: 0.999–1.000; OR = 0.999; p = 0.224), herbal tea (95% CI: 0.999-1.000; OR = 1.000; p = 0.512), coffee (ARO, 95% CI: 0.993–1.003; OR = 0.998; p = 0.492), cereal (ARO, 95% CI: 0.996–1.007; OR = 1.002; p = 0.509), dried fruit (ARO, 95% CI: 0.991–1.004; OR = 0.997; p = 0.411), fresh fruit (ARO, 95% CI: 0.993–1.013; OR = 1.003; p = 0.592), salad/raw vegetable (ARO, 95% CI: 0.989–1.045; OR = 1.017; p = 0.231). Table 2 and Table S2 present detailed results of MR analysis.

3.3. Sensitivity analysis results

The sensitivity analysis of the 4 positive results was carried out. Furthermore, according to the leave-one-out analysis, the overall causal estimation was not affected by any individual SNP, and there were no individual mononucleosides. To further assess the reliability of the above results, the funnel plot was of the causal effects generated which indicated symmetry, suggesting that it is not affected by potential factors. Further information is shown in Figs. 2–5.

This investigation included as many dietary factors as possible to verify the causal correlation of diet with psoriasis. It was found that the intake of beef, pork, cooked vegetables, and bread was associated with psoriasis. Furthermore, MR analysis confirmed that poultry, lamb/mutton, non-oil and oil fish, processed meat, cheese, dried and fresh fruit, tea, green tea, herbal tea, coffee, and grain intake, as well as alcohol intake frequency, were not causally related to psoriasis. Psoriasis can be combined with systemic diseases, which seriously affect a patient’s standard of life. This research can help clinicians improve health education for psoriasis patients and encourage them to alter their eating habits (such as reducing the intake of bread and increasing cooked vegetables in their diet). For high-risk psoriasis cohorts, adjusting dietary habits can reduce the incidence of the disease.

Bread intake is a risk factor for psoriasis, which may be related to its gluten component. Gluten is a protein found in barley, wheat, and rye and is also a special food allergen. More and more consumers around the world are beginning to avoid gluten-containing foods ^(22–23). Gluten-related diseases are gradually becoming an epidemiological phenomenon ^(24–26). Furthermore, celiac disease and wheat allergy have been widely studied ⁽²⁷⁾. Moreover, epidemiological and clinical research has indicated a link between psoriasis, celiac disease, and celiac disease markers. Psoriasis may be associated with gluten sensitivity (marked by antibody positivity) and it has been observed that patients with anti-gliadin antibodies can benefit from a gluten-free diet ⁽²⁸⁾. Therefore, psoriasis patients or those with positive prolamin antibodies should eat gluten-free bread and cereals.

It is worth noting that this research indicated that red meat (beef and pork) is a protective factor for psoriasis, which is inconsistent with previous cognition and expected results. The previous literature suggests that red meat is not linked with various metabolic and immune-related diseases and is considered a risk factor ^(29–31). The high protein levels in red meat can be a good supplement for the low protein levels caused by increased desquamation in psoriasis. T cells that express cytokine interleukin 17 are also essentially involved with psoriasis ⁽³²⁾, while vitamin B12 in beef has immunomodulatory effects on T lymphocytes and cytokines ^(33–34). Vegetables are rich in vitamins, fibers, and other nutrients ⁽³⁵⁾. Cooked vegetables retain antioxidant compounds, carotene, and ascorbic acid well; therefore, the daily consumption of vitamins and polyphenols-rich cooked vegetables can produce antioxidant effects and may be beneficial to these patients ⁽³⁶⁾. The MR method can effectively overcome the bias caused by confounding factors and can be used as a powerful supplement to randomized controlled trials; however, it cannot replace them. Therefore, this conclusion must be further verified.

The mechanism of how dietary factors affect psoriasis is not fully understood, and the alterations and composition of gut microbiota might be an important variable. Some previous studies have also explored the characteristics of intestinal flora in psoriasis ^(37–38). Gut microbiota may have a certain effect on the association between diet and psoriasis ^(39–41). The effect and mechanism of regulating intestinal microbes through diet on psoriasis need to be further explored.

This research has certain advantages as well as limitations. MR can effectively overcome the bias caused by reverse causality and confusion. The sensitivity analysis was carried out to ensure the result’s accuracy. However, this investigation did not assess the combined effects of different diets and did not subdivide different types of dietary intake.

This two-sample MR study indicated that bread intake was linked with an elevated risk for psoriasis while taking beef, cooked vegetables, and pork in the diet was associated with decreased psoriasis risk. Furthermore, poultry, non-oily and oily fish, processed meat, cheese, tea, green tea, herbal tea, coffee, cereal, dried and fresh fruit, lamb/mutton, and salad/raw vegetable intake as well as alcohol intake frequency were negatively correlated with psoriasis.

WHO

World Health Organization

PsA

psoriatic arthritis

PsO

psoriasis

Mendelian randomization

IVW

inverse variance weighted

odds ratio

confidence interval

IVs

instrumental variable

GWAS

genome-wide association studies

SNPs

Single nucleotide polymorphisms.

Supplementary Materials

Table S2: Detailed results of MR analysis, including Cochrane's Q test, pleiotropy, IVW, weighted median, and MR-Egger statistical analyses.

Author contributions

ZYZ and XZL contributed to conceptualization, methodology, software handling, validation, formal analysis, data curation, and original draft writing. ZYZ, XZL, and LZY participated in original draft writing, manuscript review, and editing. JAL and LZY were associated with supervision, project administration, and funding acquisition.

Funding

This study was supported by the ' 14th Five-Year Plan ' for higher education of Chinese medicine ( YB-23-47 ). It is also supported by the Health Science and Technology Capability Improvement Project of Jilin Province, China ( 2022JC039 ).

Availability of data and materials

Data are available upon reasonable request.

Ethics Approval

Human subjects: The included studies had been approved by corresponding institutional review boards and ethical committees, and signed consent forms were acquired from all the participants.

Consent for Publication

Not applicable.

Conflicts of Interest

The authors declare no conflicts of interest.

Author details

Affiliation 1:Health Management College，Changchun University of Traditional Chinese Medicine，Changchun，Jilin，China;Affiliation 2:Traditional Chinese Medicine College,Changchun University of Traditional Chinese Medicine，Changchun，Jilin，China;Affiliation 3:Innovation and Entrepreneurship College,Changchun University of Traditional Chinese Medicine，Changchun，Jilin，China;Affiliation 4:Chinese Medicine Physician Qualification Certification Center,National Administration of Traditional Chinese Medicine,Beijing,China

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Association Between Dietary Factors and Psoriasis: A Mendelian randomization analysis

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Abstract

Figures

1. Introduction

2. Methods

2.1. Study design

2.2. Data sources

2.3. The instrumental variables selection

2.4. Statistical method

3. Results

3.1. Instrumental variable

3.2. The results of Mendel randomization analysis

3.3. Sensitivity analysis results

4. Discussion

5. Limitations

6. Conclusion

Abbreviations

Declarations

References

Additional Declarations

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