Ketogenic diet improves disease activity and cardiovascular risk in psoriatic arthritis: A proof of concept study

Abstract

Objectives: Very low-calorie ketogenic diet (VLCKD) is a low-carbohydrate, low-calorie regimen that leads to rapid weight loss and may reduce inflammation. This study assessed the impact of VLCKD on anthropometric measurements, inflammatory biomarkers, metabolic health, and cardiovascular risk in psoriatic arthritis (PsA) patients moderately overweight or in class I obesity.

Methods: A proof-of-concept single-arm monocentric study involved PsA patients undergoing a 9-week VLCKD treatment. Patients with Body Mass Index (BMI) ≥27 and <35, in stable (≥6 months) remission or low disease activity, as defined by Disease Activity in PSoriatic Arthritis (DAPSA) score, were included and underwent nutritional evaluations every 3 weeks. The study analyzed changes after the VLCKD intervention and the association between changes of anthropometric parameters and clinical and laboratory variables.

Results: Twenty patients were enrolled since April 2022 and completed the study in May 2023. Median baseline BMI was 30.9 (interquartile range 29.1-33) kg/m². All participants exhibited low baseline disease activity, which correlated with BMI (Spearman's correlation coefficient (rs)=0.59,p=0.007). Following VLCKD, significant improvements were observed in all anthropometric measures (BMI -3.5[-4;-2.6]), PsA activity (DAPSA -6.1[-16.8;3.7]), cardiovascular parameters (SCORE2 index -0.2[-0.7;0.1]), insulin resistance (Homeostatic Model Assessment-Insuline Resistance -2.1[-1.1;-3.0]), and lipid profile. Most inflammatory biomarkers remained within normal limits. BMI reduction correlated with changes in DAPSA scores (rs=0.52,p=0.020). Patients with higher baseline weight or clinical activity experienced more pronounced improvements.

Conclusions: VLCKD significantly improved PsA activity and metabolic health. Patients with a higher BMI and less controlled disease are particularly motivated and could benefit more from VLCKD compared to those with lower BMI or better disease control.

Fig 1. Food frequency modification during the study according to the food frequency questionnaire.

Significance refers to the Wilcoxon test, * p < 0.05, **p < 0.01. W0 week 0; W9 week 9. Although SBP and DBP were not significantly reduced, improvement in cardiovascular risk was significant: -0.2 (-0.7;0.1) units in SCORE2 10-year risk percentage.

Fig 2. Correlation matrix between modification of anthropometric measurements and modification of other variables during the study.

Values displayed refer to Spearman’s correlation coefficient r_s, negative correlations are in red, positive correlations are in blue. * p < 0.05, **p < 0.01, BMI, body mass index, DAPSA, disease activity in psoriatic arthritis; DAS28-CRP, disease activity score 28 with C reactive protein; ASDAS-CRP, Ankylosing Spondylitis Disease Activity Score – CRP; SPARCC, Spondyloarthritis Research Consortium of Canada; PASI, Psoriasis Area Severity Index; Physician Global Assessment; WPAI, Work Productivity and Activity Impairment questionnaire; hsCRP, High sensitivity CRP, ESR, Erythrocyte Sedimentation Rate; IL-1α; TNFα, Tumor Necrosis Factor alpha.

Fig 3. Correlation matrix between variables at W0 and the modification of main variables during the study.

Values displayed refer to Spearman’s correlation coefficient r_s, negative correlations are in red, positive correlations are in blue. * p < 0.05, **p < 0.01, BMI, body mass index, DAPSA, disease activity index in psoriatic arthritis; DAS28-CRP, disease activity score 28 with C reactive protein; ASDAS-CRP, Ankylosing Spondylitis Disease Activity Score – CRP; SPARCC, Spondyloarthritis Research Consortium of Canada; PASI, Psoriasis Area Severity Index; WPAI, Work Productivity and Activity Impairment questionnaire; hsCRP, High-sensitivity CRP, ESR, Erythrocyte Sedimentation Rate; IL-1α; TNFα, Tumor Necrosis Factor alpha.