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Almuammar S, Aljaaly E, Alqarni L, Alazwari H, Alsubhi R, Alatawi N. Evaluating Night-Eating Syndrome in bariatric surgery patients: A cross-sectional study. BMC Res Notes 2024; 17:118. [PMID: 38664745 PMCID: PMC11046776 DOI: 10.1186/s13104-024-06774-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 04/15/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Night-Eating Syndrome (NES) is a complex eating disorder that has gained recognition in the context of bariatric surgery. However, its prevalence and associated factors in this specific patient population remain understudied, particularly in the Saudi Arabian context. METHODS This cross-sectional study was conducted at King Abdulaziz University Hospital in Jeddah, Saudi Arabia, from June to November 2022. Adult patients who had undergone bariatric surgery with a postoperative follow-up of 6 months were included. NES was assessed using the Night Eating Questionnaire (NEQ). RESULTS A total of 154 patients were enrolled in the study, with a mean age of 38.8 ± 11.4 years. The mean BMI before surgery was 44.8 ± 8.2 kg/m2, which reduced to 28.9 ± 5.8 kg/m2 post-surgery. Of these, 52 patients (33.8%) met the criteria for NES based on NEQ scores. The prevalence of NES was significantly higher among female patients, with 35 out of 83 females (42.2%) compared to 17 out of 71 males (23.9%) experiencing NES. While NES was not significantly associated with age, nationality, diet adherence, BMI, or surgery type, chronic diseases-particularly diabetes-emerged as significant risk factors for NES in post-bariatric surgery patients. CONCLUSION NES is a prevalent concern among post-bariatric surgery patients, with distinct associations with gender and chronic diseases, particularly diabetes. This study provides valuable insights into NES prevalence and its risk factors in the Saudi Arabian context, highlighting the importance of addressing eating disorders within the framework of bariatric surgery care.
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Affiliation(s)
- Sarah Almuammar
- Family Medicine Department, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia.
| | - Elham Aljaaly
- Clinical Nutrition Department, Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Lama Alqarni
- Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Hadeel Alazwari
- Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Ruba Alsubhi
- Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Nouf Alatawi
- Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
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Law S, Dong S, Zhou F, Zheng D, Wang C, Dong Z. Bariatric surgery and mental health outcomes: an umbrella review. Front Endocrinol (Lausanne) 2023; 14:1283621. [PMID: 38027159 PMCID: PMC10653334 DOI: 10.3389/fendo.2023.1283621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 10/18/2023] [Indexed: 12/01/2023] Open
Abstract
Aims To evaluate the breadth, depth and effectiveness of the evidence quality of all existing studies on bariatric surgery and mental health outcomes. Design Umbrella review of existing Systematic review and meta-analyses. Data sources PubMed, Embase, Web of Science, and the Cochrane Liberally databases of Systematic review and meta-analyses, and hand searching the reference lists of eligible publications. Results The search identified nine studies and 20 mental health outcomes from 1251 studies. Evidence shows that bariatric surgery is associated with significant improvement in areas such as anxiety, depression and eating disorders (including binge-eating disorder), and there is a significant harmful association with suicide, self-harm and alcohol use disorder (AUD). Among them, the most studied outcome is depression (4 articles). High-quality evidence proves that the score of depressive symptoms can be significantly improved after bariatric surgery within a two-year follow-up period and is not affected by the follow-up time. Low-quality evidence shows that bariatric surgery can significantly reduce depressive symptoms regardless of age and BMI, with an odds ratio (OR) of 0.49. Regardless of the postoperative BMI, the anxiety symptoms of women over 40 still decreased significantly, with an OR of 0.58. Regardless of the type of surgery, surgery can significantly reduce the incidence of eating disorders and symptoms. However, there is no obvious change in the follow-up time of AUD in the first two years after bariatric surgery, and the risk increases obviously in the third year, with an OR of 1.825. The evidence of moderate research shows that the risk of suicide and self-harm increases after bariatric surgery. The odds ratios in the same population and the control group were 1.9 and 3.8 times, respectively. Conclusion Bariatric surgery is beneficial for improving most mental health-related outcomes. However, we should be cautious about the increased risk of adverse mental health after surgery, such as suicide, self-harm, and AUD.
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Affiliation(s)
- Saikam Law
- Department of Metabolic and Bariatric Surgery, First Affiliated Hospital of Jinan University, Guangzhou, China
- School of Medicine, Jinan University, Guangzhou, China
| | - Shiliang Dong
- Department of Metabolic and Bariatric Surgery, First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Fuqing Zhou
- Department of Metabolic and Bariatric Surgery, First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Dexi Zheng
- Gernaral Surgery, Dancheng County People’s Hospital, Zhoukou, China
| | - Cunchuan Wang
- Department of Metabolic and Bariatric Surgery, First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Zhiyong Dong
- Department of Metabolic and Bariatric Surgery, First Affiliated Hospital of Jinan University, Guangzhou, China
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Anbara T. The Impacts of Eating Disorders on Sleeve Gastrectomy Outcomes. SURGERY IN PRACTICE AND SCIENCE 2023. [DOI: 10.1016/j.sipas.2023.100165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2023] Open
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Associations of COVID-19 Lockdowns on Eating Behaviors and Body Mass Index in Patients with a History of Bariatric Surgery: a Cross-Sectional Analysis. Obes Surg 2023; 33:1099-1107. [PMID: 36763309 PMCID: PMC9912237 DOI: 10.1007/s11695-023-06460-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 01/10/2023] [Accepted: 01/17/2023] [Indexed: 02/11/2023]
Abstract
INTRODUCTION Few studies have explored the impact of the COVID-19 pandemic on the eating behaviors, dietary quality, and changes in weight of postoperative bariatric surgery patients. METHODS A cross-sectional survey on eating behaviors and attitudes toward food was emailed or given to patients who had bariatric surgery before March 2020. Patient charts were reviewed for weight measures. RESULTS Seventy-five (71.43%) patients experienced weight recurrence with an average increase in body mass index (BMI) of 2.83 kg/m2 (SD: 2.19). The majority of patients reported no symptoms of binge eating (n = 81, 77.14%) with 16 (15.24%) qualifying for loss of control eating (LOCE). LOCE was significantly associated with grazing behavior (p = 0.04), emotional over-eating (p = 0.001), and food responsiveness (p = 0.002). LOCE was negatively associated with dietary quality (p = 0.0009) and satiety responsiveness (p = 0.01). Grazing behavior was significantly associated with emotional over-eating (p < 0.0001) and food responsiveness (p < 0.0001) as well as negatively associated with dietary quality (p < 0.0001). Slow eating was negatively associated with grazing (p = 0.01), emotional over-eating (p = 0.003), and food responsiveness (p < 0.0001). When included in a regression model controlling for age and sex, emotional over-eating was a significant predictor of weight recurrence (β = 0.25; p = 0.04). CONCLUSION Our results suggest that maladaptive eating behaviors contributed to LOCE and poor dietary quality during the COVID-19 pandemic; however, slow eating may be protective against grazing, emotional over-eating, and food responsiveness.
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Praxedes DR, Silva-Júnior AE, Macena ML, Gearhardt AN, Bueno NB. Prevalence of food addiction among patients undergoing metabolic/bariatric surgery: A systematic review and meta-analysis. Obes Rev 2023; 24:e13529. [PMID: 36415030 DOI: 10.1111/obr.13529] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 08/01/2022] [Accepted: 10/23/2022] [Indexed: 11/24/2022]
Abstract
Candidates for metabolic/bariatric surgery show a high prevalence of food addiction (FA). However, few studies have investigated FA prevalence after bariatric surgery, especially using longitudinal studies. This systematic review with a meta-analysis aimed to determine pre- and postoperative prevalence of FA among patients undergoing metabolic/bariatric surgery. It included both cross-sectional and longitudinal studies that used the Yale Food Addiction Scale (YFAS). The following databases were searched: MEDLINE, ScienceDirect, LILACS, PsycArticles, CENTRAL, greylit.org, and opengrey.eu. Studies that used the YFAS to evaluate FA in pre- or postoperative patients were included. A random-effects meta-analysis was performed with cross-sectional studies to calculate the weighted prevalence of FA at the pre- and postoperative moments. For longitudinal studies, which measured FA at both time points for the same individuals, absolute prevalence reduction (APR) was calculated. Of the 6626 records, 40 studies were included in the meta-analysis. The preoperative weighted prevalence of FA was 32% (95% CI: 27-37%; 33 groups), whereas the postoperative prevalence was 15% (95% CI: 12-18%; 14 groups). Seven longitudinal studies showed a weighted APR of 26 p.p. (95% CI: 10-41 p.p.). Observational data suggest a reduction in the prevalence of FA among patients that undergo bariatric surgery. Interventional studies are needed to confirm these findings.
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Affiliation(s)
- Dafiny R Praxedes
- Programa de Pós-Graduação em Nutrição (PPGNUT), Faculdade de Nutrição (FANUT), Universidade Federal de Alagoas (UFAL), Campus AC Simões, Av. Lourival Melo Mota, s/n, Cidade Universitária, Maceió, 57072-900, Brazil
| | - André E Silva-Júnior
- Programa de Pós-Graduação em Nutrição, Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Sena Madureira, n.° 1.500, Vila Clementino, São Paulo, 04021-001, Brazil
| | - Mateus L Macena
- Programa de Pós-Graduação em Nutrição (PPGNUT), Faculdade de Nutrição (FANUT), Universidade Federal de Alagoas (UFAL), Campus AC Simões, Av. Lourival Melo Mota, s/n, Cidade Universitária, Maceió, 57072-900, Brazil
| | - Ashley N Gearhardt
- Department of Psychology, University of Michigan, 530 Church Street, Ann Arbor, Michigan, 48109-1043, USA
| | - Nassib B Bueno
- Programa de Pós-Graduação em Nutrição (PPGNUT), Faculdade de Nutrição (FANUT), Universidade Federal de Alagoas (UFAL), Campus AC Simões, Av. Lourival Melo Mota, s/n, Cidade Universitária, Maceió, 57072-900, Brazil.,Programa de Pós-Graduação em Nutrição, Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Sena Madureira, n.° 1.500, Vila Clementino, São Paulo, 04021-001, Brazil
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Aylward L, Konsor M, Cox S. Binge Eating Before and After Bariatric Surgery. Curr Obes Rep 2022; 11:386-394. [PMID: 36287376 DOI: 10.1007/s13679-022-00486-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/22/2022] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW The purpose is to review the state of the literature of binge eating in the context of bariatric surgery including prevalence, conceptualization, assessment, course, and related sequela throughout the perioperative continuum, particularly highlighting new advancements and future directions. RECENT FINDINGS Accurate assessment of binge eating in bariatric samples is essential for optimization of patient outcomes. Binge eating is less prevalent after bariatric surgery; however, prevalence rates increase over time. Most studies do not find a relationship between pre-operative binge eating and suboptimal weight outcomes after surgery. Refinement in understanding and conceptualization of post-operative binge eating is needed; new conceptualizations have proposed such a definition. Emerging constructs relevant to binge eating for bariatric patients include food addiction and food insecurity. Despite the introduction of formal diagnostic criteria for binge eating disorder, many uncertainties regarding the prevalence, course, and effects of binge eating currently exist; varied assessment methods continue to be a barrier to research on binge eating in bariatric surgery samples. Consensus on operational definitions for post-operative binge eating and best practices for assessment are areas for future consideration.
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Affiliation(s)
- Laura Aylward
- West Virginia University School of Medicine, Department of Behavioral Medicine and Psychiatry, Morgantown, USA
| | - Madeline Konsor
- Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Stephanie Cox
- West Virginia University School of Medicine, Department of Behavioral Medicine and Psychiatry, Morgantown, USA.
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Stomatognathic System Changes in Obese Patients Undergoing Bariatric Surgery: A Systematic Review. J Pers Med 2022; 12:jpm12101541. [PMID: 36294680 PMCID: PMC9605559 DOI: 10.3390/jpm12101541] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 09/13/2022] [Accepted: 09/15/2022] [Indexed: 11/21/2022] Open
Abstract
Background: Obesity is a multifactorial chronic disease involving multiple organs, devices, and systems involving important changes in the stomatognathic system, such as in the orofacial muscles, temporomandibular joint, cheeks, nose, jaw, maxilla, oral cavity, lips, teeth, tongue, hard/soft palate, larynx, and pharynx. Patients with obesity indicated for bariatric surgery reportedly presented with abnormalities in the structures and function of the stomatognathic apparatus. This occurs through the accumulation of adipose tissue in the oral cavity and pharyngeal and laryngeal regions. Therefore, this systematic review aimed to elucidate the changes occurring in the stomatognathic system of patients with obesity after undergoing bariatric surgery. Method: Information was searched based on the equations developed with the descriptors obtained in DECS and MESH using the PRISMA methodology. Studies published between 2010 and October 2021 in databases including PubMed, ProQuest, Scielo, Dialnet, EBSCO, and Springer Link were considered. Results: Eighty articles met the inclusion criteria after evaluating the articles, thereby allowing for the determination of the morphophysiological correlation of the stomatognathic system with the population studied. At the morphological or structural level, changes were observed in the face, nose, cheeks, maxilla, jaw, lips, oral cavity, teeth, tongue, palate, temporomandibular joint, neck, muscles, head, shoulders, larynx, and pharynx. At the morphological level, the main changes occurred in, and the most information was obtained from, the labial structures, teeth, muscles, pharynx, and larynx. Physiological changes were in breathing, phonation, chewing, and swallowing, thereby revealing the imbalance in basic and vital functions. Conclusions: Analyzing the changes and structures of obese patients and candidates for bariatric surgery revealed that, in the preoperative period, the evidence is clear owing to the presence of a wide range of information. However, the information is more limited regarding the postoperative period; thus, further research focusing on characterization of the system postoperatively is warranted.
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Hilbert A, Staerk C, Strömer A, Mansfeld T, Sander J, Seyfried F, Kaiser S, Dietrich A, Mayr A. Nonnormative Eating Behaviors and Eating Disorders and Their Associations With Weight Loss and Quality of Life During 6 Years Following Obesity Surgery. JAMA Netw Open 2022; 5:e2226244. [PMID: 35951326 PMCID: PMC9372790 DOI: 10.1001/jamanetworkopen.2022.26244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Individuals with severe obesity presenting for obesity surgery (OS) frequently show nonnormative eating behaviors (NEBs) and eating disorders (EDs), but the long-term course and prospective associations with weight loss and health-related quality of life (HRQOL) remain unclear. OBJECTIVE To examine the prevalence and prospective relevance of presurgical and postsurgical NEBs and EDs according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, diagnosed through clinical interview, for weight loss and HRQOL up to 6 years following OS. DESIGN, SETTING, AND PARTICIPANTS In the prospective, multicenter Psychosocial Registry for Obesity Surgery cohort study, patients seeking OS were recruited at 6 OS centers in Germany and assessed at baseline before surgery and at 6 months and 1 to 6 years after surgery. From a consecutive sample of 1040 volunteers with planned OS from March 1, 2012, to December 31, 2020, a total of 748 (71.92%) were included in this study. Across follow-up, 93 of the 748 patients (12.43%) dropped out. Data were analyzed from April to November 2021. INTERVENTIONS Laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy. MAIN OUTCOMES AND MEASURES Both NEBs and EDs were identified using the Eating Disorder Examination interview. Main outcomes were the percentage of total body weight loss (%TBWL) and HRQOL (Impact of Weight on Quality of Life-Lite; range, 0-100, with 0 indicating worst and 100 indicating best). RESULTS In 748 patients undergoing OS (mean [SD] age, 46.26 [11.44] years; mean [SD] body mass index [calculated as weight in kilograms divided by height in meters squared], 48.38 [8.09]; 513 [68.58%] female), the mean (SD) %TBWL was 26.70% (9.61%), and the mean (SD) HRQOL improvement was 35.41 (20.63) percentage points across follow-up. Both NEBs and EDs were common before surgery, with postsurgical improvements of varying degrees. Whereas NEBs and EDs did not reveal significant prospective associations with %TBWL, loss-of-control eating at follow-up was concurrently associated with lower %TBWL (estimate, -0.09; 95% CI, -0.14 to -0.04). Loss-of-control eating (estimate, -0.10; 95% CI, -0.17 to -0.03 percentage points) and binge-eating disorder of low frequency and/or limited duration (estimate, -6.51; 95% CI, -12.69 to -0.34 percentage points) at follow-up showed significant prospective associations with lower HRQOL. CONCLUSIONS AND RELEVANCE This cohort study found prospective relevance of loss-of-control eating and binge-eating disorder of low frequency and/or limited duration for reduced long-term HRQOL following OS. These findings underline the importance of monitoring both NEBs, especially loss-of-control eating, and EDs in the long term postsurgically to identify patients in need of targeted prevention or psychotherapy.
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Affiliation(s)
- Anja Hilbert
- Integrated Research and Treatment Center AdiposityDiseases, Behavioral Medicine Research Unit, Department of Psychosomatic Medicine and Psychotherapy, University of Leipzig Medical Center, Leipzig, Germany
| | - Christian Staerk
- Integrated Research and Treatment Center AdiposityDiseases, Behavioral Medicine Research Unit, Department of Psychosomatic Medicine and Psychotherapy, University of Leipzig Medical Center, Leipzig, Germany
- Department of Medical Biometrics, Informatics and Epidemiology, University Hospital Bonn, Bonn, Germany
| | - Annika Strömer
- Integrated Research and Treatment Center AdiposityDiseases, Behavioral Medicine Research Unit, Department of Psychosomatic Medicine and Psychotherapy, University of Leipzig Medical Center, Leipzig, Germany
- Department of Medical Biometrics, Informatics and Epidemiology, University Hospital Bonn, Bonn, Germany
| | - Thomas Mansfeld
- Department of General Surgery, Asklepios Clinic, Hamburg, Germany
| | - Johannes Sander
- Schön Klinik Hamburg Eilbek, Obesity Clinic, Hamburg, Germany
| | - Florian Seyfried
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital, University of Würzburg, Würzburg, Germany
| | - Stefan Kaiser
- Department of Visceral, Pediatric and Vascular Surgery, Hospital Konstanz, Konstanz, Germany
| | - Arne Dietrich
- Department of Surgery, Clinic for Visceral, Transplantation, Thoracic and Vascular Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Andreas Mayr
- Department of Medical Biometrics, Informatics and Epidemiology, University Hospital Bonn, Bonn, Germany
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Giel KE, Bulik CM, Fernandez-Aranda F, Hay P, Keski-Rahkonen A, Schag K, Schmidt U, Zipfel S. Binge eating disorder. Nat Rev Dis Primers 2022; 8:16. [PMID: 35301358 PMCID: PMC9793802 DOI: 10.1038/s41572-022-00344-y] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/28/2022] [Indexed: 12/30/2022]
Abstract
Binge eating disorder (BED) is characterized by regular binge eating episodes during which individuals ingest comparably large amounts of food and experience loss of control over their eating behaviour. The worldwide prevalence of BED for the years 2018-2020 is estimated to be 0.6-1.8% in adult women and 0.3-0.7% in adult men. BED is commonly associated with obesity and with somatic and mental health comorbidities. People with BED experience considerable burden and impairments in quality of life, and, at the same time, BED often goes undetected and untreated. The aetiology of BED is complex, including genetic and environmental factors as well as neuroendocrinological and neurobiological contributions. Neurobiological findings highlight impairments in reward processing, inhibitory control and emotion regulation in people with BED, and these neurobiological domains are targets for emerging treatment approaches. Psychotherapy is the first-line treatment for BED. Recognition and research on BED has increased since its inclusion into DSM-5; however, continuing efforts are needed to understand underlying mechanisms of BED and to improve prevention and treatment outcomes for this disorder. These efforts should also include screening, identification and implementation of evidence-based interventions in routine clinical practice settings such as primary care and mental health outpatient clinics.
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Affiliation(s)
- Katrin E Giel
- Department of Psychosomatic Medicine and Psychotherapy, Medical University Hospital Tübingen, Tübingen, Germany.
- Center of Excellence for Eating Disorders (KOMET), Tübingen, Germany.
| | - Cynthia M Bulik
- Department of Psychiatry, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Fernando Fernandez-Aranda
- Department of Psychiatry, Bellvitge University Hospital-IDIBELL, Barcelona, Spain
- Ciber Fisiopatología Obesidad y Nutrición (CIBERObn), Instituto Salud Carlos III, Madrid, Spain
- Department of Clinical Sciences, School of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
| | - Phillipa Hay
- Translational Health Research Institute, Western Sydney University, Sydney, NSW, Australia
- Camden and Campbelltown Hospitals, SWSLHD, Campbelltown, NSW, Australia
| | | | - Kathrin Schag
- Department of Psychosomatic Medicine and Psychotherapy, Medical University Hospital Tübingen, Tübingen, Germany
- Center of Excellence for Eating Disorders (KOMET), Tübingen, Germany
| | - Ulrike Schmidt
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Stephan Zipfel
- Department of Psychosomatic Medicine and Psychotherapy, Medical University Hospital Tübingen, Tübingen, Germany
- Center of Excellence for Eating Disorders (KOMET), Tübingen, Germany
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