Handbook of Eating Disorders and Obesity

Handbook
of Eating Disorders
and Obesity
Stephan Herpertz
Martina de Zwaan
Stephan Zipfel
Editors
123
Handbook of Eating Disorders and
Obesity
Stephan Herpertz · Martina de Zwaan ·
Stephan Zipfel
Editors
Handbook of Eating
Disorders and Obesity
Editors
Stephan Herpertz Martina de Zwaan
Department of Psychosomatic Medicine Department of Psychosomatic
and Psychotherapy, LWL-University Medicine and Psychotherapy
Clinic, Ruhr-University Bochum Hannover Medical School
Bochum, Germany Hannover, Germany
Stephan Zipfel
Department of Psychosomatic Medicine
and Psychotherapy, Medical University
Hospital, Tübingen
Tübingen, Germany
ISBN 978-3-662-67661-5 ISBN 978-3-662-67662-2 (eBook)

https://doi.org/10.1007/978-3-662-67662-2
Translation from the German language edition: “Handbuch Essstörungen und Adipositas” by
Stephan Herpertz et al., © Der/die Herausgeber bzw. der/die Autor(en), exklusiv lizenziert
durch Springer-Verlag GmbH, DE, ein Teil von Springer Nature 2008, 2015, 2022. Published by
Springer Berlin Heidelberg. All Rights Reserved.
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer-Verlag
GmbH, DE, part of Springer Nature 2024
This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher,
whether the whole or part of the material is concerned, specifically the rights of translation,
reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any
other physical way, and transmission or information storage and retrieval, electronic adaptation,
computer software, or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in
this book are believed to be true and accurate at the date of publication. Neither the publisher
nor the authors or the editors give a warranty, expressed or implied, with respect to the material
contained herein or for any errors or omissions that may have been made. The publisher remains
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This Springer imprint is published by the registered company Springer-Verlag GmbH, DE, part
of Springer Nature.
The registered company address is: Heidelberger Platz 3, 14197 Berlin, Germany
Anorexia nervosa and bulimia nervosa
predominantly affect women. Therefore,
the editors decided to consistently use
the female personal designation in
Chapter I – Chapter VI, although a
large number of men are also affected
by binge eating disorder.
Preface to the 3rd Edition of the Handbook
In 2006, at a congress of the Eating Disorder Research Society (EDRS), an

international scientific society for the research of eating disorders and obe-
sity, the idea for this handbook was born in Port Douglas, a small Australian
town in the far tropical north of the state of Queensland, Australia. In the
fall of 2008, the book was published by Springer-Verlag with 59 chap-
ters and more than 70 authors. Seven years later, the second edition was
released, and now, in 2022, 14 years after the first publication of the hand-
book, the third edition can be published.
We, the editors, are very pleased that we were able to win back almost
all authors of the first edition after such a long time to revise their respec-
tive chapters according to the latest scientific findings. The third edition of
the handbook also contains additional chapters with new aspects on both the
diagnosis and treatment of eating disorders and obesity.
The handbook is intended as a reference work for clinics and practices,
as well as for systematic review by all professional groups involved and
interested in the care and research in the field of eating disorders and obe-
sity. It is also written for newcomers to the profession who want to learn
in-depth about the two diseases, as well as for experienced colleagues who
want to reflect on their insights in light of today's state of knowledge and the
perspectives presented. It is also aimed at teachers who have the ambition to
inform comprehensively.
Our thanks go to all authors for their active participation in the design of
the book and to Wilma McHugh from Springer Publishing for her compe-
tent support.
Bochum, Hannover, Tübingen Stephan Herpertz

April 09, 2022 Martina de Zwaan
Stephan Zipfel
vii
Contents
Part I Diagnosis of Eating Disorders

1 Classification and Diagnosis: A Historical Perspective. . . . . . . . 3
Tilmann Habermas
1.1 A Truly Biopsychosocial Phenomenon. . . . . . . . . . . . . . . . . 3
1.2 History of Obesity Diagnosis. . . . . . . . . . . . . . . . . . . . . . . . . 4
1.3 History of Anorexia Nervosa and its Diagnosis. . . . . . . . . . . 4
1.4 History of the Diagnosis of Binge Eating and
Overeating . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.5 History of Bulimia Nervosa and its Diagnosis. . . . . . . . . . . . 5
1.6 Influences of Medical Disease Concepts on Eating
Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.7 Developments in Classification and Diagnosis . . . . . . . . . . . 6
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
2 Dieting Behavior and Body Image in Societal Change . . . . . . . . 9
Romuald Brunner and Franz Resch
2.1 How Common are Body Image Problems and Dieting
Behavior? And How are They Related?. . . . . . . . . . . . . . . . . 10
2.2 Do Body-Related Attitudes and Eating Behavior
Change in the Transition from Adolescence to Young
Adulthood?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
3 Eating Disorders in the ICD-11 and DSM-5. . . . . . . . . . . . . . . . . 15
Gertraud Gradl-Dietsch, Manuel Föcker and
Johannes Hebebrand
3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
3.2 Anorexia Nervosa. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
3.3 Bulimia Nervosa. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
3.4 Binge Eating Disorder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
3.5 Avoidant/Restrictive Food Intake Disorder (ARFID) . . . . . . 21
3.6 Pica. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
3.7 Rumination and Regurgitation. . . . . . . . . . . . . . . . . . . . . . . . 22
3.8 “Other Specified Feeding or Eating Disorder” and
“Unspecified Feeding or Eating Disorder” . . . . . . . . . . . . . . 22
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
ix
x Contents
4 Clinical Aspects of Anorexia Nervosa, Bulimia Nervosa, and

Avoidant-Restrictive Food Intake Disorder in Adulthood. . . . . . 27
Martin Teufel, Eva-Maria Skoda and Stephan Zipfel
4.1 Classification of Anorexia Nervosa. . . . . . . . . . . . . . . . . . . . 27
4.2 Classification of Bulimia Nervosa. . . . . . . . . . . . . . . . . . . . . 29
4.3 Avoidant-Restrictive Food Intake Disorder. . . . . . . . . . . . . . 30
4.4 Compensatory Behaviors. . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
5 Clinical Aspects of Binge-Eating Disorder. . . . . . . . . . . . . . . . . . 33
Martina de Zwaan
5.1 Diagnostic Criteria. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
5.2 Further Psychopathological Features. . . . . . . . . . . . . . . . . . . 35
5.3 Epidemiology and Course . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
5.4 Comorbidities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
6 Atypical Eating Disorders and Eating Disorders
Not Otherwise Specified. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Astrid Müller and Andrea Sabrina Hartmann
6.1 Atypical, Subsyndromal Eating Disorders. . . . . . . . . . . . . . . 40
6.2 Purging Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
6.3 Night Eating Syndrome. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
6.4 Pica. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
6.5 Rumination Disorder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
6.6 Avoidant/Restrictive Food Intake Disorder (ARFID) . . . . . . 42
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
7 Orthorexia Nervosa. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Reinhard Pietrowsky
7.1 Concept and Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
7.2 Symptomatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
7.3 Nosological Classification. . . . . . . . . . . . . . . . . . . . . . . . . . . 46
7.4 Diagnosis and Epidemiology. . . . . . . . . . . . . . . . . . . . . . . . . 47
7.5 Etiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
7.6 Relation to Other Eating Disorders . . . . . . . . . . . . . . . . . . . . 48
7.7 Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
8 Body Image Disturbances. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Brunna Tuschen-Caffier and Jessica Werthmann
8.1 Body Image Issues in Eating Disorders. . . . . . . . . . . . . . . . . 51
8.2 Body Image Disturbance: Theoretical Conceptions
and Definition Attempts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
8.3 Body Image Disturbances as Core Symptoms of Eating
Disorders: Research Approaches and Empirical
Findings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
8.4 Evaluation of Existing Findings. . . . . . . . . . . . . . . . . . . . . . . 56
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Contents xi
9 Diagnosis of Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Ulrich Schweiger
9.1 Screening for Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . 59
9.2 Detailed Psychological Assessment for a Suspected
Eating Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
9.3 Medical Diagnostics for Eating Disorders. . . . . . . . . . . . . . . 63
9.4 Differential Diagnostic Considerations. . . . . . . . . . . . . . . . . 64
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Part II Epidemiology, Etiology, and Course of Eating Disorders

10 Prevalence and Incidence of Anorectic and Bulimic Eating
Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Manfred Fichter
10.1 Prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
10.2 Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
11 Course and Prognosis of Anorexia Nervosa. . . . . . . . . . . . . . . . . 79
Stephan Zipfel, Bernd Löwe and Wolfgang Herzog
11.1 Results of the Research on the Course of AN . . . . . . . . . . . . 80
11.2 Mortality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
11.3 Prognostic Indicators for a Poor Course . . . . . . . . . . . . . . . . 83
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
12 Course of Bulimia Nervosa and Binge-Eating Disorder. . . . . . . 85
Norbert Quadflieg and Manfred Fichter
12.1 Diagnosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
12.2 Course of Eating Disorder Symptoms. . . . . . . . . . . . . . . . . . 86
12.3 Comorbidity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
12.4 Social Factors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
12.5 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Further References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
13 Course and Prognosis of Binge Eating Disorder. . . . . . . . . . . . . 91
Kathrin Schag
13.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
13.2 Onset . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
13.3 Distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
13.4 Comorbidity—Quality of Life—Level of Functioning. . . . . 92
13.5 Disorder Duration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
13.6 Course of Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
13.7 Change of Eating Disorder Diagnosis. . . . . . . . . . . . . . . . . . 94
13.8 Mortality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
13.9 Prognosis: What Promotes and What Hinders a
Positive Course?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
xii Contents
14 Anorexia Nervosa in Childhood and Adolescence. . . . . . . . . . . . 97

Beate Herpertz-Dahlmann
14.1 Definition and Classification . . . . . . . . . . . . . . . . . . . . . . . . . 97
14.2 Epidemiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
14.3 Symptomatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
14.4 Comorbidity and Differential Diagnosis . . . . . . . . . . . . . . . . 99
14.5 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
14.6 Course . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
15 Eating Disorders in Men. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Barbara Mangweth-Matzek
15.1 General Information on Anorexia Nervosa and
Bulimia Nervosa in Men . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
15.2 Onset of the Disorder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
15.3 Disease Course. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
15.4 Treatment and Outcome. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
15.5 Atypical Eating Disorders and Binge Eating
Disorder (BED) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
16 Eating Disorders and Competitive Sports . . . . . . . . . . . . . . . . . . 111
Petra Platen
16.1 Body Weight and Body Composition in Competitive
Sports. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
16.2 Energy Balance in Competitive Sports . . . . . . . . . . . . . . . . . 113
16.3 Epidemiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
16.4 Risk Factors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
16.5 Pathophysiological Mechanisms. . . . . . . . . . . . . . . . . . . . . . 116
16.6 Health Consequences. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
16.7 Screening and Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
16.8 Prevention and Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
16.9 Performance-Optimized Weight Management
for Athletes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
Further Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
17 Cognitive Behavioral Therapy Models. . . . . . . . . . . . . . . . . . . . . 123
Gaby Resmark
17.1 Predisposing Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
17.2 Triggering Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
17.3 Maintaining Factors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
17.4 The Transdiagnostic Model. . . . . . . . . . . . . . . . . . . . . . . . . . 126
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
18 Psychodynamic Model Concepts. . . . . . . . . . . . . . . . . . . . . . . . . . 129
Stephan Herpertz
18.1 Operationalized Psychodynamic Diagnosis (OPD). . . . . . . . 130
18.2 Effectiveness of Psychodynamic Psychotherapy
Methods. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Contents xiii
19 Epidemiology, Etiology, and Course of Eating Disorders. . . . . . 135

Silke Naab
19.1 Systemic and Family Perspective. . . . . . . . . . . . . . . . . . . . . . 135
19.2 Does the Family Influence the Eating Disorder or
Vice Versa?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
19.3 Conclusions for Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
20 Genetic Aspects of Eating Disorders. . . . . . . . . . . . . . . . . . . . . . . 143
Helge Frieling, Stefan Bleich and Vanessa Buchholz
20.2 Bulimia Nervosa and Binge Eating Disorder. . . . . . . . . . . . . 145
20.3 Outlook—Gene-Environment Interactions and
Epigenetics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
21 Psychosocial Risk Factors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Eike Fittig and Corinna Jacobi
21.1 Anorexia nervosa. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
21.2 Bulimia nervosa. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
21.3 Binge Eating Disorder (BED) . . . . . . . . . . . . . . . . . . . . . . . . 154
21.4 Interaction of Risk Factors in the Development
of Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
21.5 Conclusion and Outlook. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
22 Sociocultural Aspects of Eating Disorders. . . . . . . . . . . . . . . . . . 159
Burkard Jäger
22.2 Bulimia nervosa. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
22.3 Cultural Factors in Weight Gain, Obesity, and
Binge Eating Disorder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
22.4 Common Factors: Upheaval and Migration, Religious
Orientation, and Role Expectations for Women. . . . . . . . . . . 164
22.5 Conclusion and Limitations. . . . . . . . . . . . . . . . . . . . . . . . . . 165
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
23 The Influence of Media on Body Image . . . . . . . . . . . . . . . . . . . . 167
Maya Götz
23.1 The Media Image of the Female Body. . . . . . . . . . . . . . . . . . 167
23.2 Television Shows and Eating Disorders. . . . . . . . . . . . . . . . . 168
23.3 Social Media and BodyDissatisfaction . . . . . . . . . . . . . . . . . 169
23.4 Social Media and Eating Disorders. . . . . . . . . . . . . . . . . . . . 169
23.5 What Might Help?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
xiv Contents
Part III Psychological Comorbidity

24 Affective Disorders and Anxiety Disorders. . . . . . . . . . . . . . . . . . 175
Jörn von Wietersheim
24.1 Comorbidity in Mental Disorders . . . . . . . . . . . . . . . . . . . . . 175
24.3 Bulimia nervosa. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
24.5 Obesity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
24.6 Summary and Conclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . 178
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
25 Psychological Comorbidity and Personality Disorders. . . . . . . . 181
Ulrich Schweiger
25.1 Prevalence of comorbidity between eating disorders
and other mental disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . 182
25.2 Delineation of Differential Diagnosis vs. Comorbidity. . . . . 183
25.3 Mechanisms of Interaction between Eating Disorders
and Other Mental Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . 184
25.4 Therapy for Comorbid Disorders Including Eating
Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
26 Non-Suicidal Self-Injury and Eating Disorders. . . . . . . . . . . . . . 189
Paul Plener
26.1 NSSI: An Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
26.2 Associations Between NSSI and Eating Disorders. . . . . . . . 190
26.3 Therapy for NSSI and Eating Disorders . . . . . . . . . . . . . . . . 192
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
27 Mechanisms of Addiction in Eating and Weight Disorders. . . . . 195
Sabine Steins-Loeber and Georgios Paslakis
27.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
27.2 Models of the Development and Maintenance of
Dependent Behavior. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196
27.3 Mechanisms of Dependent Behaviorin Eating and
Weight Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196
27.4 The Concept of “Food Addiction”. . . . . . . . . . . . . . . . . . . . . 198
27.5 Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
27.6 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
Part IV Biological and Medical Aspects of Eating Disorders

28 Hunger and Satiety. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
Reinhard Pietrowsky
28.1 The Process of Food Intake. . . . . . . . . . . . . . . . . . . . . . . . . . 205
28.2 Biological, Sensory, and Psychological Factors
of Hunger and Satiation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
Contents xv
28.3 Hunger and Satiety and the Regulation of Body

Weight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210
29 Peripheral Peptide Hormones, Neuropeptides, and
Neurotransmitters. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
Stefan Ehrlich and Friederike I. Tam
29.1 Peripheral Peptide Hormones and Neuropeptides. . . . . . . . . 213
29.2 Neurotransmitters. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
30 Reward System in Eating Disorders and Obesity . . . . . . . . . . . . 223
Joe J. Simon and Hans-Christoph Friederich
30.1 General Neural Reward Processing. . . . . . . . . . . . . . . . . . . . 223
30.2 Relationship between Neural Reward Processing
and EatingBehavior. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224
30.4 Bulimia nervosa. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
30.6 Obesity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228
31 Neuropsychological Findings in Eating Disorders. . . . . . . . . . . . 229
Martin Schulte-Rüther and Kerstin Konrad
31.1 Research Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
31.2 Attentional Bias. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230
31.3 Learning and Memory. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
31.4 Executive Functions, Reward Processing, and
Decision-Making. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232
31.5 Central Coherence and Theory of Mind. . . . . . . . . . . . . . . . . 233
31.6 Factors Influencing Neurocognitive Deficits. . . . . . . . . . . . . 234
31.7 Neuropsychological Findings in the Course of Therapy. . . . 235
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
32 Imaging Techniques in Eating Disorders . . . . . . . . . . . . . . . . . . . 239
Ursula Bailer
32.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
32.3 Bulimia nervosa. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
33 The Gut Microbiome in Anorexia Nervosa. . . . . . . . . . . . . . . . . . 247
Jochen Seitz
33.1 Weight development. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248
33.2 Immunology and Inflammation. . . . . . . . . . . . . . . . . . . . . . . 249
33.3 Gut-Brain Axis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
xvi Contents
Part V Medical Complications and Somatic Comorbidity

34 Medical Complications in Anorexia Nervosa and Bulimia
Nervosa. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
Hans-Christoph Friederich, Valentin Terhoeven and
Christoph Nikendei
34.1 Physical Complaints and Laboratory Chemical
Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
34.2 Organ Manifestations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260
35 Gynecological Aspects in Anorexia Nervosa and Bulimia
Nervosa. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263
Markus Anton Glass, Christiane Gerwing and
Anette Kersting
35.1 Hormonal Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263
35.2 Fertility and Reproduction. . . . . . . . . . . . . . . . . . . . . . . . . . . 265
35.3 Pregnancy and Birth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266
35.4 Conclusion and Recommendations . . . . . . . . . . . . . . . . . . . . 268
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
36 Eating Disorders and Diabetes Mellitus. . . . . . . . . . . . . . . . . . . . 271
Stephan Herpertz
36.1 Eating disorders and type 1 diabetes. . . . . . . . . . . . . . . . . . . 272
36.2 Diabetes Mellitus and Eating Disorders, a
Coincidental Coincidence?. . . . . . . . . . . . . . . . . . . . . . . . . . 272
36.3 Insulin Dose and Weight Regulation
(“Insulin Purging”). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273
36.4 Course of Eating Disorders in People with
Diabetes Mellitus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274
36.5 Diagnosis and Treatment of Patients with Diabetes
Mellitus and Eating Disorders. . . . . . . . . . . . . . . . . . . . . . . . 274
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
Part VI Treatment of Eating Disorders

37 Prevention of Eating Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . 279
Andreas Karwautz, Gudrun Wagner and Michael Zeiler
37.1 Types of Prevention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279
37.2 The “Diet Culture”. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279
37.3 Target Areas for Primary Prevention of Eating
Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280
37.4 Efficacy of Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286
38 Treatment of Eating Disorders in Childhood and
Adolescence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287
Beate Herpertz-Dahlmann and Brigitte Dahmen
38.1 Somatic rehabilitation and nutritional therapy. . . . . . . . . . . . 288
38.2 Individual Psychotherapeutic Treatment. . . . . . . . . . . . . . . . 289
38.3 Involvement of the Family. . . . . . . . . . . . . . . . . . . . . . . . . . . 290
Contents xvii
38.4 Treatment of Comorbidity and Medication. . . . . . . . . . . . . . 292

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
39 Alternatives to Inpatient Treatment of Anorexia Nervosa in
Childhood and Adolescence—Day Patient Treatment and
Home Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295
39.1 Disadvantages of inpatient treatment for children and
adolescents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295
39.2 Day Patient Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296
39.3 Home Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301
40 Family-Based Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303
Silke Naab
40.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303
40.2 Description of Family-Based Treatment . . . . . . . . . . . . . . . . 304
40.3 Efficacy of Family-Based Therapy. . . . . . . . . . . . . . . . . . . . . 304
40.4 Current Developments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
40.5 Limitations of the Application of Family-Based
Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307
40.6 Conclusion for Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308
41 Psychodynamic Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
Wolfgang Herzog, Hans-Christoph Friederich, Beate Wild,
Henning Schauenburg and Stephan Zipfel
41.1 Foundations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
41.2 Focal Psychodynamic Psychotherapy . . . . . . . . . . . . . . . . . . 312
41.3 Disorder-Specific Modifications of Psychodynamic
Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315
42 Cognitive Behavioral Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
Tanja Legenbauer
42.1 General Approach and Standard Elements in the
Treatment of Eating Disorders. . . . . . . . . . . . . . . . . . . . . . . . 318
42.2 Normalization of Eating Behavior. . . . . . . . . . . . . . . . . . . . . 319
42.3 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325
43 Interpersonal Psychotherapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327
Anja Hilbert
43.1 Basics of Interpersonal Psychotherapy for Eating
Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327
43.2 Eating Disorder Treatment through IPT. . . . . . . . . . . . . . . . . 328
43.3 Scientific Foundation of IPT . . . . . . . . . . . . . . . . . . . . . . . . . 329
43.4 Summary and Outlook. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 330
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
xviii Contents
44 Cognitive Remediation Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . 333

Timo Brockmeyer
44.1 Cognitive Inflexibility and Anorexia Nervosa. . . . . . . . . . . . 333
44.2 Set-shifting and Central Coherence. . . . . . . . . . . . . . . . . . . . 333
44.3 Translating Research Findings into a Targeted
Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334
44.4 Overview of the Intervention. . . . . . . . . . . . . . . . . . . . . . . . . 334
44.5 Modules of the Intervention. . . . . . . . . . . . . . . . . . . . . . . . . . 334
44.6 Metacognitive Level. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335
44.7 Example Presentation of the Exercises . . . . . . . . . . . . . . . . . 336
44.8 Evidence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337
44.9 Conclusion for Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 338
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 338
45 Treatment of Body Image Disorders. . . . . . . . . . . . . . . . . . . . . . . 341
Silja Vocks and Anika Bauer
45.1 Development of a Disturbance Model. . . . . . . . . . . . . . . . . . 342
45.2 Modification of Dysfunctional Body-Related
Cognitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342
45.3 Body Exposure via Mirror and Video . . . . . . . . . . . . . . . . . . 343
45.4 Exposure Exercises for Reducing Body-Related
Avoidance and Checking Behavior . . . . . . . . . . . . . . . . . . . . 344
45.5 Building Positive Body-Related Activities. . . . . . . . . . . . . . . 345
45.6 Findings on the Effectiveness of Cognitive-Behavioral
Interventions for Improving Body Image. . . . . . . . . . . . . . . 345
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347
46 Pharmacotherapy of Eating Disorders. . . . . . . . . . . . . . . . . . . . . 349
Martina de Zwaan and Jana Svitek
46.2 Bulimia Nervosa. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355
47 Neuromodulation in Eating Disorders . . . . . . . . . . . . . . . . . . . . . 357
Kathrin Schag
47.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357
47.2 Assumed Mechanisms of Action in the Treatment
of Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357
47.3 Introduction to Neuromodulation Methods. . . . . . . . . . . . . . 358
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 362
48 Inpatient and Day Hospital Treatment for
Eating Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
Almut Zeeck
48.1 Significance of Inpatient and Day Hospital Treatment . . . . . 365
48.3 Bulimia Nervosa. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 370
Contents xix

48.5 Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
49 Self-Help in Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373
Cornelia Thiels and Martina de Zwaan
49.1 Why Self-Help?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373
49.2 What is Self-Help?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374
49.3 Self-Help Guide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374
49.4 For Whom Is Self-Help Suitable? . . . . . . . . . . . . . . . . . . . . . 375
49.6 Bulimia Nervosa. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377
50 Use of Modern Media in Prevention and Treatment. . . . . . . . . . 379
Stephanie Bauer
50.1 Forms of Digital Interventions. . . . . . . . . . . . . . . . . . . . . . . . 379
50.2 Areas of Application for Digital Interventions. . . . . . . . . . . . 380
50.3 Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 382
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383
51 Involuntary Treatment in Anorexia Nervosa . . . . . . . . . . . . . . . . 385
Andreas Thiel and Thomas Paul
51.1 Forced Treatment Under Guardianship Law. . . . . . . . . . . . . 386
51.2 Coercive psychotherapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 386
51.3 Procedure for Coercive Measures . . . . . . . . . . . . . . . . . . . . . 387
51.4 Treatment With Respect. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 388
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 389
52 Treatment of Chronically Ill Patients. . . . . . . . . . . . . . . . . . . . . . 391
Thomas Paul and Andreas Thiel
52.1 Definition of Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391
52.2 Initial Situation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 392
52.3 Helpful Basic Principles in the Treatment of
Chronically Ill Patients. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 392
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 396
53 Working with Family Members. . . . . . . . . . . . . . . . . . . . . . . . . . . 397
Ulrike Schmidt
53.1 Definitions and Context. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 397
53.2 Why Work with Family Members? . . . . . . . . . . . . . . . . . . . . 398
53.3 Burden on Family Members. . . . . . . . . . . . . . . . . . . . . . . . . . 398
53.4 Needs of Family Members. . . . . . . . . . . . . . . . . . . . . . . . . . . 398
53.5 Goals and Contents of Working with Family Members. . . . . 399
53.6 Interventions for Family Members. . . . . . . . . . . . . . . . . . . . . 399
53.7 Summary and Outlook. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 400
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 400
xx Contents
54 Relapse Prevention in Anorexia Nervosa . . . . . . . . . . . . . . . . . . . 403

Katrin Giel and Ulrike Schmidt
54.1 Relapses in Anorexia Nervosa. . . . . . . . . . . . . . . . . . . . . . . . 403
54.2 Specifics of Relapse Prevention in AnorexiaNervosa . . . . . . 404
54.3 Therapy and Care Concepts. . . . . . . . . . . . . . . . . . . . . . . . . . 405
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 406
Part VII Definition, Classification, and Epidemiology of Obesity

55 Diagnosis and Etiology of Obesity. . . . . . . . . . . . . . . . . . . . . . . . . 411
Alfred Wirth
55.1 Diagnosis of Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411
55.2 Causes of Obesity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 413
55.3 Recording of Physical Activity . . . . . . . . . . . . . . . . . . . . . . . 418
55.4 Low Socioeconomic Status . . . . . . . . . . . . . . . . . . . . . . . . . . 419
55.5 Sleep Deprivation—Disturbed Sleep. . . . . . . . . . . . . . . . . . . 419
55.6 Diseases Associated With Obesity. . . . . . . . . . . . . . . . . . . . . 419
55.7 Drugs and Weight Gain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 420
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 422
56 Epidemiology of Obesity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 425
Katharina Nimptsch and Tobias Pischon
56.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 425
56.2 Definition of Obesity in Epidemiological Studies. . . . . . . . . 425
56.3 Global and Temporal Trends in Obesity Prevalence . . . . . . . 427
56.4 Development of Individual BMI Over the Life Course. . . . . 428
56.5 Determinants of the Rising Prevalence of Obesity . . . . . . . . 428
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 429
57 Psychosocial Factors of Obesity in Childhood and
Adolescence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 431
Petra Warschburger
57.1 Definition and Prevalence of Obesity. . . . . . . . . . . . . . . . . . . 431
57.2 Social Stigmatization, Teasing, and Obesity. . . . . . . . . . . . . 432
57.3 Psychological Disorders and Behavioral Problems. . . . . . . . 433
57.4 Quality of Life. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 434
57.5 Conclusion: Importance of Psychological Factors. . . . . . . . . 435
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 435
58 Socioeconomic Aspects of Obesity. . . . . . . . . . . . . . . . . . . . . . . . . 437
Sven Schneider and Bärbel Holzwarth
58.1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 437
58.2 Model Proposal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 439
58.3 Modern Explanatory Approaches—The Life Course
Perspective. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 441
58.4 Selection Thesis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 441
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 442
59 Genetic Aspects of Obesity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 445
Helge Frieling, Anke Hinney and Stefan Bleich
59.1 Twin and Adoption Studies . . . . . . . . . . . . . . . . . . . . . . . . . . 446
Contents xxi
59.2 Monogenic Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 447

59.3 Association Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 447
59.4 Polygenic Forms of Obesity. . . . . . . . . . . . . . . . . . . . . . . . . . 448
59.5 Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 449
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 449
60 Microbiome and Inflammation in Obesity. . . . . . . . . . . . . . . . . . 451
Isabelle Mack
60.1 Gastrointestinal (GI) Microbiota. . . . . . . . . . . . . . . . . . . . . . 451
60.2 GI Microbiota in Obesity. . . . . . . . . . . . . . . . . . . . . . . . . . . . 452
60.3 GI Microbiota and Inflammation in Obesity. . . . . . . . . . . . . 453
60.4 Influence of Diet and Lifestyle on the GI Microbiota
in Obesity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 453
60.5 Influence of Pro- and Prebiotics on GI Microbiota
in Obesity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 454
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 455
61 Risk Factors of Obesity in Childhood and Adolescence . . . . . . . 457
Wieland Kiess
61.1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 457
61.2 Risk Factors and Causes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 458
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 461
Part VIII Comorbidity of Obesity

62 Social and Psychosocial Consequences of Obesity:
Weight-Related Stigmatization and Discrimination . . . . . . . . . . 465
Anja Hilbert
62.1 Weight-related Stigmatization and Discrimination
in Obesity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 465
62.2 Psychosocial Consequences of Weight-Related
Stigmatization and Discrimination. . . . . . . . . . . . . . . . . . . . . 467
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 468
63 Obesity and Comorbid Mental Disorders. . . . . . . . . . . . . . . . . . . 471
Stephan Herpertz and Magdalena Pape
63.1 Mental Stress and Illnesses in Obesity. . . . . . . . . . . . . . . . . . 471
63.2 Psychosocial Stress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 471
63.3 Psychosomatic Aspects of Obesity. . . . . . . . . . . . . . . . . . . . 472
63.4 Obesity and Depression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 472
63.5 Pathological Hypercaloric Eating Behavior and
Binge Eating Disorder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 473
63.6 Obesity, Personality Traits, and Personality Disorders . . . . . 473
63.7 Obesity and Addiction Disorders. . . . . . . . . . . . . . . . . . . . . . 474
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 474
64 Metabolic Syndrome and Depression. . . . . . . . . . . . . . . . . . . . . . 477
Bernd Löwe
64.1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 477
64.2 Epidemiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 479
xxii Contents
64.3 Relationship Between Metabolic Syndrome and

Depression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 480
64.4 Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 481
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 483
65 Tobacco Dependence in Eating Disorders and Obesity. . . . . . . . 485
Marlen Brachthäuser and Anil Batra
65.1 Foundations of Tobacco Dependence. . . . . . . . . . . . . . . . . . . 486
65.2 Diagnosis of Tobacco Addiction . . . . . . . . . . . . . . . . . . . . . . 487
65.3 Tobacco Addiction and Eating Disorders. . . . . . . . . . . . . . . . 487
65.4 Factors Associated with Increased Smoking
Prevalence in Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . 488
65.5 Smoking and Obesity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 490
65.6 Weight Gain Due to Tobacco Abstinence. . . . . . . . . . . . . . . . 491
65.7 Treatment of Tobacco Dependence . . . . . . . . . . . . . . . . . . . . 492
65.8 Tobacco Cessation in Patients with Eating Disorders. . . . . . 493
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 494
66 Impulsivity and Obesity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 497
Astrid Müller
66.1 Impulsivity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 497
66.2 Impulsive Disorders and Obesity. . . . . . . . . . . . . . . . . . . . . . 498
66.3 Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 499
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 500
67 Obesity and Binge Eating Disorder. . . . . . . . . . . . . . . . . . . . . . . . 501
Sandra Becker
67.1 Obesity with Binge Eating Disorder . . . . . . . . . . . . . . . . . . . 501
67.2 Etiology of Binge Eating Disorder. . . . . . . . . . . . . . . . . . . . . 502
67.3 Specifics of Obesity with Binge Eating Disorder . . . . . . . . . 502
67.4 Psychotherapeutic Treatment Approaches for Obesity
with Binge Eating Disorder. . . . . . . . . . . . . . . . . . . . . . . . . . 503
67.5 Psychotherapeutic Treatment Approaches for Binge
Eating Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 504
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 504
Part IX The Treatment of Obesity

68 Prevention of Obesity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 509
Manfred J. Müller, Isabel Gaetjens and Anja Bosy-Westphal
68.1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 509
68.2 Concepts and Efficacy of Measures for Primary
Prevention of Obesity Relating to Lifestyle and Living
Environment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 511
68.3 Prevention of Obesity—What’s Next?. . . . . . . . . . . . . . . . . . 515
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 516
Contents xxiii
69 Treatment of Obesity in Childhood and Adolescence . . . . . . . . . 519

Martin Wabitsch
69.1 Indication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 519
69.2 Treatment Goals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 521
69.3 Approach and Treatment Components. . . . . . . . . . . . . . . . . . 521
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 523
70 Family-Based Approaches to Treatment. . . . . . . . . . . . . . . . . . . . 525
Susanna Wiegand and Martina Ernst
70.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 525
70.2 Family-Based Treatment Approaches . . . . . . . . . . . . . . . . . . 527
70.3 Problem Areas of Family-Based Approaches . . . . . . . . . . . . 530
70.4 Conclusion and Implications. . . . . . . . . . . . . . . . . . . . . . . . . 532
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 534
71 Fad Diets and Commercial Programs. . . . . . . . . . . . . . . . . . . . . . 537
Andreas Fritsche
71.1 Requirements for a Diet. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 537
71.2 Classification of Diets for Weight Loss. . . . . . . . . . . . . . . . . 538
71.3 Evaluation of Diet Programs . . . . . . . . . . . . . . . . . . . . . . . . . 539
71.4 Individualized Nutrition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 540
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 540
72 Nutritional Therapy for Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . 541
Hans Hauner
72.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 541
72.2 Basic considerations for nutrition therapy. . . . . . . . . . . . . . . 542
72.3 Possibilities of Nutritional Therapy. . . . . . . . . . . . . . . . . . . . 543
72.4 Very Low-Calorie Diet. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 545
72.5 Long-Term Weight Stabilization and Relapse
Prevention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 547
72.6 Nutritional Therapy in the German Healthcare System. . . . . 547
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 547
73 Treatment of Obesity—Sports and Physical Activity . . . . . . . . . 549
Petra Platen
73.1 Effects of Sports and Physical Activity in Adults
with Obesity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 550
73.2 Gender-Specific Aspects of Sports and Physical
Activity in Obesity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 552
73.3 Effects of Sports and Physical Activity in
Children with Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 552
73.4 General Recommendations for Physical Activity
and Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 553
73.5 Concrete Recommendations for Physical Activity. . . . . . . . 554
Further Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 557
74 Approaches to Eliminating Obesogenic Environments. . . . . . . . 559
74.1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 559
xxiv Contents
74.2 Conceptual Definitions: Definition of Obesogenic

Environments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 560
74.3 Systematization of Obesogenic Environments. . . . . . . . . . . . 560
74.4 Empirical Findings on Obesogenic Environments. . . . . . . . . 562
74.5 Methodological Challenges in the Study of Obesogenic
Environments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 563
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 564
75 Behavioral Therapy for Obesity. . . . . . . . . . . . . . . . . . . . . . . . . . 567
Andrea Benecke
75.1 Historical Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 567
75.2 Essential Components of Behavioral Therapy
for Obesity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 568
75.3 Relapse Prevention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 572
75.4 Maintaining the Lost Weight. . . . . . . . . . . . . . . . . . . . . . . . . 572
75.5 Collaboration with Other Relevant Professional
Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 572
75.6 Individual or Group Therapy. . . . . . . . . . . . . . . . . . . . . . . . . 572
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 573
76 Medication Therapy for Obesity. . . . . . . . . . . . . . . . . . . . . . . . . . 575
Marcus May and Jens Jordan
76.1 General Therapy Principles. . . . . . . . . . . . . . . . . . . . . . . . . . 576
76.2 Challenges in Drug Development for Obesity. . . . . . . . . . . . 576
76.3 Orlistat. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 577
76.4 Liraglutide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 578
76.5 Naltrexone and Bupropion. . . . . . . . . . . . . . . . . . . . . . . . . . . 579
76.6 Norpseudoephedrine/Cathin. . . . . . . . . . . . . . . . . . . . . . . . . . 579
76.7 Potential Future Obesity Medications. . . . . . . . . . . . . . . . . . 580
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 581
77 Weight Stabilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 583
Martina de Zwaan
77.1 What Does Weight Stabilization Mean? . . . . . . . . . . . . . . . . 583
77.2 Psychological Factors and Behavioral Aspects. . . . . . . . . . . 584
77.3 Therapeutic Approaches for Weight Stabilization. . . . . . . . 587
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 588
78 Bariatric Surgery and Metabolic Surgery . . . . . . . . . . . . . . . . . . 589
Arne Dietrich
78.1 Indication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 589
78.2 Surgical Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 591
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 599
79 Psychosomatic Aspects of Bariatric Surgery . . . . . . . . . . . . . . . . 601
Stephan Herpertz and Martina de Zwaan
79.1 On the Question of Indication . . . . . . . . . . . . . . . . . . . . . . . . 601
79.2 Surgical Approach. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 602
79.3 Preoperative Diagnostics. . . . . . . . . . . . . . . . . . . . . . . . . . . . 602
79.4 Mental Well-Being After Bariatric Surgery. . . . . . . . . . . . . . 603
Contents xxv
79.5 Bariatric Surgery and Eating Disorders. . . . . . . . . . . . . . . . . 604

79.6 Increase in Eating Behavior Disorders
(e.g., grazing, LOC eating). . . . . . . . . . . . . . . . . . . . . . . . . . 604
79.7 Self-Harming Behavior, Suicide, and Suicidality . . . . . . . . . 604
79.8 Bariatric Surgery and Addiction Behavior. . . . . . . . . . . . . . . 605
79.9 Psychological Predictors for Weight Development. . . . . . . . 605
79.10 Corrective Plastic Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . 606
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 606
80 New Media in Obesity Treatment . . . . . . . . . . . . . . . . . . . . . . . . . 609
Christina Holzapfel
80.1 Digitalization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 609
80.2 Telemedical Intervention. . . . . . . . . . . . . . . . . . . . . . . . . . . . 610
80.3 Telephone-based Intervention . . . . . . . . . . . . . . . . . . . . . . . . 611
80.4 Internet-based Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . 612
80.5 Use of Smartphones. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 614
80.6 Digitale-Versorgung-Gesetz. . . . . . . . . . . . . . . . . . . . . . . . . . 616
80.7 Outlook. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 617
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 618
Part I
Diagnosis of Eating Disorders
1
Classification
and Diagnosis: 1
A Historical Perspective
Tilmann Habermas
Contents
1.1 A Truly Biopsychosocial Phenomenon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.2 History of Obesity Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.3 History of Anorexia Nervosa and Its Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 4
1.4 History of the Diagnosis of Binge Eating and Overeating (Binge Eating) . . . 5
1.5 History of Bulimia Nervosa and Its Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 5
1.6 Influences of Medical Disease Concepts on Eating Disorders . . . . . . . . . . . 6
1.7 Developments in Classification and Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . 6
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.1 A Truly Biopsychosocial Eating behavior and body shapes, for exam-
Phenomenon ple, are influenced by economic conditions.
Only with the industrialization of food produc-
Like other mental disorders, eating disorders tion and the mechanization of transportation
are essentially caused by an interplay of social, in the 18th and 19th centuries was food sup-
psychological, and biological conditions. Eating ply ensured for the population of Europe. At
and body shape lie at the intersection of nature the same time, the decrease in physical labor
and culture. Therefore, the prevailing self- and, again, the mechanization of transport dur-
control norms and body ideals, as well as the ing the 19th and 20th centuries reduced indi-
prevailing medical discourses, are reflected viduals’ energy expenditure. The increase in the
in the perception of the limits of normal eat- availability of and the simultaneous decrease in
ing and body shape and in the perception of the need for food, together with a deritualiza-
the nature of pathological deviations. In histori- tion and individualization of food intake, freed
cal or cultural comparisons, it is much easier to it from economic and biological constraints
avoid the temptation to hypostatize the current and opened it up to other needs and purposes
understanding. (Habermas 1990; Chap. 2).
This chapter, however, is not about the soci-
ocultural framework conditions, but about the
T. Habermas (*) interpretation of variations in food intake and
International Psychoanalytic University, body weight that we now call eating disorders
Berlin, Germany and obesity. Both of these disease concepts
e-mail: [email protected]
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2024 3
S. Herpertz et al. (eds.), Handbook of Eating Disorders and Obesity,
https://doi.org/10.1007/978-3-662-67662-2_1
4 T. Habermas
emerged, in the narrower sense, in the 19th there was some backpedaling from an overly
century. restrictive to a more moderate medical definition
of overweight (BMI > 25) and obesity (BMI >
30 according to the WHO).
1.2 History of Obesity Diagnosis
Extreme obesity has preoccupied medicine 1.3 History of Anorexia Nervosa

since its very beginnings. Ancient Greek medi- and its Diagnosis
cine features many references to the need for
moderation in eating and physical exercise, as While obesity is defined merely by body weight
well as considerations that obesity predisposes in relation to body height, i.e., purely math-
to diseases. However, up until the 19th cen- ematically, anorexia nervosa (AN) is a men-
tury, medical attention remained focused on tal disorder, as it is defined not only by severe
extreme obesity. Excess was considered a prob- underweight (BMI < 18.5 or age-specific lowest
lem of self-control and morality, and gluttony 5% percentile) but also by a specific motivation
was famously one of the seven deadly sins in the to intentionally achieve and maintain this under-
Middle Ages. In the second half of the 19th cen- weight. This refers to the intense fear of being
tury, overweight became a growing public con- or becoming overweight despite being under-
cern. Weight control programs and weight loss weight. This central psychological criterion,
diets were commercially offered, and testimoni- which is essential from a differential diagnos-
als, polemics, and self-help literature appeared. tic perspective, dates back to the early French
Medicine addressed this popular concern by works of the 19th century (Habermas 1989) as
using formulas to expand the concept of obe- well as the works by Mara Selvini Palazzoli
sity from extreme overweight to more moderate (1984) and Hilde Bruch (1973) in the 1960s.
forms of overweight. Quételet’s formula Body The fixed idea of becoming overweight despite
weight in kg /(Body height in m)2. being underweight simultaneously motivates
Today, this is referred to as the body mass behaviors targeted at controlling body weight,
index (BMI) and was temporarily replaced in along with the otherwise atypical overactivity
the 20th century by the Broca Index and in for underweight, and a lack or only very partial
the 1950s by ideal weight tables. These were insight into the illness.
based on surveys conducted by life insurance In research on the history of AN, most Anglo-
companies. Saxon authors reject today’s psychological
diagnostic criteria, and retrospectively classify
 Important From the mid-19th to the mid- either all unexplained states of malnutrition, or
20th century, an increasingly restrictive medi- at least all malnutrition resulting from restricted
cal definition of overweight and obesity can food intake, as anorexic. From the resulting
be observed. historical distribution of cases, they then con-
clude that AN has always existed (e.g., Keel
These more restrictive limits reflect a lower- and Klump 2003). This is partly due to the fact
ing of medically unobjectionable weight. As that the fear of being overweight was very late
the tables of life insurance companies illustrate, to find its way into English-language sources,
part of this dynamic lies in the temporal stretch- but can already be found in French and German
ing of the concept of health risk up to death. In literature of the 19th century (Habermas 2015).
the name of health prevention, popular body On the other hand, it is also due to the convic-
weight norms were medically legitimized and tion of these authors that AN has a genetic basis
promoted. It was not until the 1970s—not least or even an essentially somatic cause. However,
due to the rampant rise in eating disorders—that the presence of genetic influences does not
1 Classification and Diagnosis: A Historical Perspective 5
necessarily manifest itself in historical con- is clearly different. These women were often not
stancy of the clinical picture and its frequency underweight and were sick and bedridden over
of occurrence. Any attempt to define AN solely many years (Habermas 1990).
through somatic aspects abandons its diagnostic
specificity and likens it to malnutrition due, for
example, to depression, delusions of poisoning, 1.4 History of the Diagnosis
cleanliness compulsions, or puberty asceticism. of Binge Eating and Overeating
 Important The diagnostic specificity of AN, Eating large amounts of food in a binge-
the fixed idea of being or becoming over- like manner has been known in medical his-
weight, can be related to the fasting-induced tory for over 2000 years. It has been referred
underweight from the second half of the 19th to as bulimia, fames canina, kynorexia, and
century (Habermas 1989). phagedena, and was considered an etiologi-
cally unspecific symptom, whereas polyphagia
This does not apply to the case descriptions of referred to the time-independent intake of large
the physician Gull and the psychiatrist Lasègue amounts of food (Ziolko and Schrader 1985).
from the 1870s, who are generally considered Binge eating was sometimes described as com-
as the orginators of the concept of AN. Gull’s pensatory behaviors in the face of impending
cases nowadays appear diagnostically ambigu- anxiety attacks. In relation to obesity, Stunkard
ous, while Lasègue described the typical denial (1959) described nocturnal eating (night eating
of illness and overactivity but not yet the “idée syndrome) as well as binge eating at irregular
fixe d’obésité” (Charcot). However, this idea intervals (binge eating syndrome). Only since
appears shortly afterwards in the literature, espe- the 19th century has binge eating, initially pre-
cially in articles originating from the Salpêtrière. dominantly described in men, become a symp-
Charcot mentioned it as early as 1883 in a lec- tom more commonly found in women.
ture. The fact that many authors did not notice
the intentionality of weight loss was signifi-  Important The symptom of eating large
cantly promoted by the fact that those affected amounts of food in a binge-like manner
hid their fear of being overweight and their low has long been known in medical history.
food intake in order to avoid attempts to make
them gain weight.
In historically earlier forms of intentionally 1.5 History of Bulimia Nervosa
induced extreme underweight (Vandereycken and its Diagnosis
et al. 1990), at least two types can be distin-
guished. Ascetic-mystical fasters followed a Bulimia nervosa (BN) is distinguishable from
model of female piety and even holiness (Saint binge-eating disorder. In addition to impulsive
Catherine of Siena), in which the “Imitatio binge-eating episodes, which are experienced as
Christi,” the denial of any physical satisfaction, alien and unwanted in retrospect, it is character-
and hunger-induced mystical experiences had a ized by concerns about becoming overweight
clear religious significance—the motive of fast- as a result of the binge-eating episodes, as well
ing was not aimed at body size or weight, but at as the practice of compensatory behaviors such
an approach to God. A second type of extreme as self-induced vomiting, abuse of laxatives,
fasting can be found among the rather hysteri- appetite suppressantsor diuretics, and finally—
cal-seeming “fasting miracles”, who survived sometimes excessive—physical exercise. Shame
without any food intake. While the first histori- due to the binge-eating episodes and immedi-
cal type shows psychological parallels with AN, ate compensatory behaviors typically lead to
as any extreme asceticism does, the second type the concealment of these practices and social
6 T. Habermas
withdrawal. BN is usually associated with nor- insofar as young women no longer individually
mal weight. If it occurs in combination with “invented” AN anew, but could unconsciously or
underweight, anorexia nervosa of the bulimic consciously imitate it. Thus, the psychodynam-
subtype is diagnosed, since, clinically speaking, ics typical of AN, which aimed at autonomy and
the underweight and and simultaneous fear of uniqueness, became less specific, as there were
overweight are more in the foreground than the now “me-too anorexics” (Bruch 1973).
bulimic symptoms. The defining of bulimic behaviors as a dis-
A case resembling BN was described by ease in 1980 changed the illness experience of
Binswanger in 1909, and the first probable cases those affected, as they were no longer held mor-
were reported by Wulff in 1932, who attributed ally responsible for their “weakness of will” and
them to the depressive spectrum. In the follow- “perversion,” and were relieved of responsibil-
ing decades, isolated case descriptions appeared ity as sick individuals. At the same time, their
(Habermas 1989), but it was not until 1979 that behavior also changed, as they were entitled
Russell’s description and naming of bulimia to medical help for the first time. However, a
nervosa attracted huge interest, especially since behavioral pattern was pathologized that many
it was immediately included in the DSM-III. still considered a proven miracle cure for com-
Suddenly, a phenomenon appeared in public and bining enjoyment and good looks (Habermas
medical perception that had hitherto remained 1994).
unnamed and thus unnoticed. Both anorexia and bulimia became publicly
identifiable phenomena through the dissemina-
tion of their respective disease concepts. This
1.6 Influences of Medical Disease made it possible to derive secondary benefits
Concepts on Eating Disorders from them, although this actually contradicts the
nature of fasting as a neurotic form of self-asser-
The distinctly modern eating disorders AN tion in anorexia and the nature of shame and
and BN emerged in the second half of the 19th guilt feelings in bulimia. Specialized treatment
and the first half of the 20th centuries, respec- centers and self-help groups had the unintended
tively. Compared to historically older eating side effect of forming communities that offered
disorders, they are characterized by excessive support but also served to exchange tips on los-
concerns about one’s body weight and cor- ing weight and hiding weight loss. Ultimately,
responding behaviors. The popular concern the medical diagnoses of anorexia and bulimia
about weight control and the cultural technique made it possible to choose them as primary
of dieting spread in Europe in parallel with the identities and even collectively develop them
emergence of anorexia in the second half of the into positive identities, as is the case on pro-ana
19th century. With the onset of medical engage- websites and on social media under correspond-
ment with overweight as a disease-predisposing ing hashtags.
condition, which itself required medical atten-
tion due to the preventive thinking of public
health policy, and the establishment of thresh- 1.7 Developments in Classification
olds of overweight based on medical author- and Diagnosis
ity, the predominantly aesthetically motivated
concerns regarding even moderate overweight Eating disorders and obesity are a heterogene-
gained additional legitimacy and probably also ous group of phenomena, as they are defined
additional momentum. This, in turn, may have either solely by body weight or additionally
contributed to the spread of AN and BN. With by behaviors or ultimately also by motives for
the growing frequency of AN in the 1960s behaviors, such as fears. As can be seen from
and 1970s, it increasingly became a publicly Table 1.1, this leads to overlaps. The distinc-
known disease. This changed the disease itself, tions are not systematic, but they still seem
1 Classification and Diagnosis: A Historical Perspective 7
Table 1.1  Definition criteria for diagnoses

Disorder Soma Actions Psyche
Body weight Eating behavior Body weight control Fear of over-
practices weight
Obesity +++
Binge-eating +++ to normal Binge eating episodes
Bulimia nervosa + to normal Binge eating episodes Purging (starving) Yes
Anorexia nervosa --- Restrictive (binge eating episodes) Purging (starving) Yes
Avoidant-restrictive − to normal Restrictive
food intake disorder
reasonably meaningful today according to the paranoid motivated food restriction, it will likely
clinical need for action. primarily capture phobic and compulsive moti-
Until the DSM-5 and ICD-11, the main prob- vated food restrictions. Lowering the required
lem was that up to over half of the eating dis- severity level in both diagnostic systems
orders assessed as clinically relevant did not achieves a certain reduction of unspecific diag-
fit into any of the categories and were there- noses and an expansion of treatment eligibility,
fore classified as unspecified eating disorders but at the expense of a loss of specificity, an
labeled. The introduction of binge eating dis- increase in comorbidities, a growing pathologi-
order only provides a place in the nosological zation of today’s adolescents, and a medicaliza-
system for a minority of atypical eating disor- tion of life problems.
ders. The eating disorders that did not fall into
any diagnostic category until then are predomi-
nantly young women whose symptoms are not References
severe enough to meet the criteria. The DSM-5
attempts to solve the problem by liberalizing Bruch H (1973) Eating disorders. Basic Books, New
York
the criteria for anorexia (flexibilization of the Habermas T (1989) The psychiatric history of anorexia
weight criterion, removal of the intentionality nervosa and bulimia nervosa. Weight-concerns and
of weight loss) and for bulimia nervosa (lower bulimic symptoms in early case-reports. Int J Eat
thresholds for frequency and duration of symp- Disord 8:259–283
Habermas T (1990) Heißhunger. Historische
toms) and by broadly defining binge eating Bedingungen der Bulimia nervosa. Fischer, Frankfurt
disorder. Habermas T (1994) Zur Geschichte der Magersucht.
The removal of the intentionality of weight Eine medizinpsychologische Rekonstruktion. Fischer,
loss corresponds to the trend of DSM-5 to define Frankfurt
Habermas T (2015) History of anorexia nervosa. In:
mental disorders without reference to mental Levine MP, Smolak L (Hrsg) The Wiley handbook of
aspects, thus blurring the specific features of eating disorders, Bd I. Wiley, New York, S 11–24
the respective mental disorders. The ICD-11 Keel PK, Klump KL (2003) Are eating disorders culture-
avoids this relinquishment of the specificity of bound syndromes? Implications for conceptualizing
their etiology. Psychol Bull 129:747–769
anorexia, as the intentionality of weight loss Selvini Palazzoli M (1984) Magersucht. Klett-Cotta,
remains a criterion, although the fear of weight Stuttgart (Original 1963/1974)
gain is no longer required. At the same time, a Stunkard AJ (1959) Eating patterns and obesity.
psychologically open category, avoidant-restric- Psychiatry Quart 33:284–295
Vandereycken W, van Deth R, Meermann R (1990)
tive food intake disorder, was created to include Hungerkünstler, Fastenwunder, Magersucht.
selective food intake for other motives, in order Biermann, Zülpich
to reduce the unspecified eating disorder diag- Ziolko H-U, Schrader HC (1985) Bulimie. Fortschr
noses. However, as it excludes depressive and Neurol Psychiatr 53:231–258
Dieting Behavior
and Body Image 2
in Societal Change
Romuald Brunner and Franz Resch
Contents
2.1 How Common are Body Image Problems and Dieting Behavior?
And How are They Related? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2.2 Do Attitudes Towards the Body and Eating Behavior Change in the
Transition from Adolescence to Young Adulthood? . . . . . . . . . . . . . . . . . . . 11
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Dissatisfaction with one’s physical appearance, disorder with anorexic and/or bulimic symp-
and especially feeling too fat, is a widespread toms, particularly in adolescents and young adult
phenomenon often associated with disordered women, but also—albeit much less frequently—
eating. Attempts to achieve the ideal norm—often in the male gender. Explanatory models for the
an unrealistic weight defined primarily by socio- unequal gender distribution range from sociocul-
cultural influences—lead to dieting attempts. tural to biological factors, although a sufficient
The combination of a disturbed body image and explanation for these cross-cultural gender differ-
dieting behavior often leads to a manifest eating ences is still lacking. However, the gender-spe-
cific difference is much less pronounced in partial
eating disorders. Weight-related problems such as
overweight, disordered eating, unhealthy weight
control measures, and “binge-eating” (repeated
R. Brunner (*)
Clinic for Child and Adolescent Psychiatry, episodes of binge eating with loss of control) rep-
Psychosomatics and Psychotherapy, University of resent a significant problem in healthcare due to
Regensburg, Regensburg, Germany their high prevalence and negative consequences
e-mail: [email protected] for physical and mental health. Data from the
F. Resch WHO (GBD 2018) indicate an increase in age-
Department of Child and Adolescent Psychiatry, standardized disease burden as a measure of mor-
Centre for Psychosocial Medicine, University of
Heidelberg, Heidelberg, Germany bidity (years lived with disability, YLDs) of 6%
e-mail: [email protected] for anorexia nervosa and 10% for bulimia ner-
vosa between 2007 and 2017.
https://doi.org/10.1007/978-3-662-67662-2_2
10 R. Brunner and F. Resch
2.1 How Common are Body of underweight girls (BMI < 17.5) still felt too
Image Problems and Dieting fat (1.6% overall prevalence). The subjectively
Behavior? And How are They perceived body image, particularly among girls,
Related? determines dieting behavior rather than objec-
tive weight. Almost all overweight individuals
According to a review by Ricciardelli and (85.7%, BMI > 24.5) had experiences of dieting,
McCabe (2001), epidemiological studies in but so too did nearly half of girls with normal
the English-speaking world show that 38.2– weight. Since being overweight in adolescence
49.9% of girls and 12.5–26% of boys have is a central risk factor for the development of a
tried to reduce their weight through dieting or manifest eating disorder (e.g., anorexia nervosa),
other methods. Investigating the frequency of early treatment of obesity is a central interven-
various weight loss strategies, the authors found tion to reduce this risk (see Jebeile et al. 2019).
that 20-49% of girls (7–8% of boys) skipped The Heidelberg School Study also demonstrated
meals, and 51–71% of girls (30–40% of boys) that satisfaction one’s with appearance was more
engaged in sports with the intention of losing strongly influenced by subjectively perceived
weight rather than to achieve fitness. The use physical attractiveness than by actual weight. In
of diet pills was found in up to 17% of girls general, only 24% of girls (compared to 45% of
and 5% of boys, and abuse of laxatives in about boys) were satisfied with their appearance.
2% of girls and boys. Self-induced vomiting
was reported in 1–8.3% of female adolescents  It is not the actual weight, but rather the
and 0.4–1.7% of boys. The frequency of binge- perception of being overweight, that is
eating behavior is considered insufficiently responsible for vulnerability to the devel-
studied; estimates suggest that 7–33% of boys opment of disturbed eating behavior.
and girls exhibit such behavior episodically.
Empirical studies show that engaging in sports The Heidelberg study further revealed clear cor-
with the goal of weight reduction and not fit- relations between a negative body image and
ness improvement is associated with manifest psychosocial factors (self-esteem; acceptance by
disordered eating behavior. Exercise addiction peers, etc.).
has also been described, with feelings of depres-
sion and guilt occurring when the activity is  Satisfaction with one’s outward appear-
interrupted. ance is associated with better relationships
With regard to the frequency of diet attempts with peers and fewer social and emotional
and disturbances in body image, data are avail- problems.
able from 5849 adolescents (average age
15.2 years) who were examined as part of the The emergence of dissatisfaction with one’s
Heidelberg School Study (Haffner et al. 2007). physical appearance as a vulnerability factor for
This representative study conducted in the the development of disturbed eating behavior
Rhein-Neckar district in Germany examined has been examined—also empirically—against
9th-grade students across all school types (from the background of sociocultural theory forma-
special education to higher-track secondary tion. Halliwell and Harwey (2006) postulated
school). Overall, 48% of the girls reported feel- that perceived pressure regarding appearance,
ing too fat, although they were of normal weight mediated by media, family, and peers, would
(body mass index, BMI: 17.5–24.5), demon- lead to a corresponding internalization of cul-
strating a discrepancy between the perceived tural ideals. Indeed, this internalization of cul-
and the desired body image in almost half of tural ideals led to dissatisfaction with one’s
the female students. In contrast, only 16.7% of physical appearance not only in girls but also
male adolescents felt too fat. Moreover, 15% in boys (predominantly in boys with low self-
esteem), with subsequent weight loss measures
2 Dieting Behavior and Body Image in Societal Change 11
 Physical appearance comparisons with  Problematic attitudes and behaviors

same-aged peers in both girls and boys already develop in early adolescence.
leads to dissatisfaction with one’s appear- Therefore, preventive efforts must start
ance and is associated with a susceptibility in prepuberty, before the internalization
to disturbed eating behavior. of sociocultural values begins and body
image problems develop.
The development of body dissatisfaction and
disturbed eating behavior in adolescence is not Longitudinal studies show that eating disor-
only related to the biological development dur- ders in adolescence—including subclinical
ing puberty but is also attributed to the fact manifestations—are associated with impaired
that adolescence represents a critical period development later in life, in terms of increased
in which the internalization of cultural ide- psychiatric morbidity such as substance-related
als regarding physical attractiveness is learned. disorders, suicidal and self-harm behavior, as
Nevertheless, according to empirical studies, well as pathological weight status and eating
adolescent girls feel greater pressure to regulate disorder-specific symptoms (Micali et al. 2015).
their weight compared to boys, compare them- The occurrence of the entire spectrum of eating
selves more with their peers, have higher levels disorders (anorexia nervosa; bulimia nervosa,
of body dissatisfaction, and show higher inter- binge eating disorder, atypical or otherwise
nalization of sociocultural attitudes regarding specified eating disorders, including purging
appearance as well as subsequent disturbed eat- behavior and subclinical bulimic symptoms)
ing behavior. Self-concept and self-esteem seem in mid-adolescence proved to be a particularly
to be more closely related to physical attractive- strong predictor for the occurrence of anxiety
ness in girls than in boys. Surprisingly, studies disorders and depressive disorders and self-
in the age range of 11–16 years showed no age- harming behaviors two years after the initial
dependent differences among girls, indicating examination (Micali et al. 2015, ALSPAC study;
that body image problems and associated issues N = 11,209 adolescents). A history of binge
develop at an early age. eating and bulimia nervosa was associated with
obesity, and anorexia nervosa with underweight.
 Exposure to role models of slim women Since subclinical disorders often do not lead to
can be sufficient to initiate weight loss treatment initiation and thus cannot counter-
measures in girls, even if they were not act a negative course, measures in the sense of
previously dissatisfied with their weight. indicated prevention in the general population
appear particularly important (see Micali et al.
Boys compare their appearance with same- 2015).
sex peers to a similar extent to girls. However,
while boys want to look as good as their attrac-
tive peers, girls want to look better than their 2.2 Do Body-Related Attitudes
attractive peers. Preventive approaches should and Eating Behavior
therefore convey realistic objects of comparison Change in the Transition
in order to protect adolescents from the develop- from Adolescence to Young
ment of body dissatisfaction. There is increasing Adulthood?
evidence that the availability of and communi-
cation on social media has a negative influence A decrease in problematic behaviors in the fur-
on the development of body image, resulting in ther course of development was postulated
disturbed eating behavior in adolescents (Uchôa under the assumption that adults derive their
et al. 2019), which has been found to be signifi- self-esteem less from body-related variables
cantly more pronounced in girls compared to and more from other sources. Heatherton et al.
boys.
(1997) argued that the decrease in disturbed eat- cultures was, however, only approximately equal
ing behavior also occurs against the background when excluding the diagnostic criterion “fear of
of a change in life goals, and the importance of becoming too fat.” Possible differences in the
physical attractiveness decreases. In a longitu- prevalence rates of eating disorders could also
dinal study, Keel et al. (2007) demonstrated that be partly due to culture-specific phenomenol-
disturbed eating behavior in females decreases ogy, as the established diagnostic classification
significantly from late adolescence to middle age schemes, ICD-11 and DSM-5, are more oriented
compared to males. Marriage and motherhood towards developments in industrialized socie-
are strong predictors of a decrease in dissatisfac- ties (Becker 2007). A study in the Fiji Islands
tion with physical appearance. However, devel- showed that the phenomenon of fear of becom-
opmental trajectories show that this is only a ing too fat as a reason for weight loss only
relative decrease, and women continue to have a developed under the influence of the Western
greater degree of dissatisfaction with their weight body ideal.The emphasis on the criterion of feel-
compared to men, engage in diets, and exhibit ing too fat has apparently pushed other motives
disturbed eating behavior. for weight loss into the background and led to
The apparent relationship between the the postulation of the Western culture-bound
thinness ideal prevalent in Western culture, syndrome. Keel and Klump (2003) conclude
a disturbed body image, and disturbed eat- from this that weight problems develop cul-
ing behavior—especially in girls and young ture-specifically in the sociocultural context of
women—has led to the question of whether the thinness ideal, but that there are also other
these phenomena, as well as the manifest eat- diverse motives and causes for the development
ing disorders anorexia nervosa (AN) and bulimia of eating disorders. Studies in the Asian region
nervosa (BN) represent culture-bound symp- show that “weight concerns” exist more in areas
toms or syndromes (cf. Garner and Garfinkel with high media influence and that there are
1980; Lee 1996). Although numerous studies fundamental differences in the urban-rural rela-
have demonstrated possible genetic influences tionship. Research on social change in China
in the development of manifest eating disor- suggests that exposure to the Western thinness
ders, the thesis of a culture-related syndrome is ideal through access to Western media has pro-
still maintained. A quantitative meta-analysis moted the development of body image problems
by Keel and Klump (2003) found that the inci- and dieting behavior in girls. However, the clini-
dence of AN has only increased very slightly cal manifestation of AN seems to vary in dif-
in recent decades, while the incidence of BN ferent cultures. For example, patients with AN
increased significantly in the second half of in China appear to have less pronounced body
the 20th century. Systematic analyses of his- image disturbances compared to Western cul-
torical cases of AN, however, indicate that AN tures and are characterized by less pronounced
was already common before the onset of the comorbid disorders (Keel and Klump 2003;
Western thinness ideal or thinness cult, albeit Soh and Walter 2013). While in Western cul-
with a differently accentuated phenomenology. tures, such as in England and Spain, increased
Only rarely were cases described that explicitly comorbid psychopathological symptoms such as
included a fear of becoming too fat. This phe- depressive disorders and anxiety symptoms were
nomenon seems to have developed later or under reported, patients in China seemed to report
the influence of the Western thinness ideal and these symptoms less or deny them, which was
become subject to globalization. Studies on the interpreted in the context of different social atti-
prevalence of AN in other cultures show that tudes (Agüera et al. 2017).
many countries, even without orientation to In contrast to AN, the occurrence of BN
the Western-influenced culture, have similarly seems to be more closely tied to exposure to
high prevalence rates of AN. The prevalence of the Western body ideal (Striegel-Moore et al.
AN in many Western and non-Western-oriented 1986). While self-intended weight loss can
2 Dieting Behavior and Body Image in Societal Change 13
occur in various cultural circles, the develop- proportion of sugar-rich and fat-rich foods and is
ment of bulimic symptoms seems to be linked being introduced worldwide by the food indus-
to the availability of food and exposure to a try and marketing strategies (cf. Sproesser et al.
body image in the context of the Western thin- 2019). From soft drinks to protein-rich supple-
ness ideal. Binge-eating/purging behavior ments to industrially produced ready meals,
seems to predominantly affect normal-weight eating habits have changed, especially those of
women with “weight problems.” The context children and adolescents. The consequences
of a Western body ideal and the self-percep- of this development on appetite and metabolic
tion of weight problems are prerequisites for processes and their significance for the devel-
the development of BN. Cross-cultural studies opment of disturbed eating behavior have so
show higher prevalence rates of AN than BN far been insufficiently investigated (Ayton and
in non-Western-oriented countries. Exposure Ibrahim 2020).
to the Western body ideal norm, living in urban
centers, earlier stays in Western countries, and
a higher socioeconomic status are often associ- Conclusion
ated with the development of eating disorders in
girls or young women in non-Western-oriented Body image issues and dieting are a com-
societies. Immigration to Western-oriented cul- mon phenomenon, particularly among female
tural circles promotes the occurrence of diet- children, adolescents, and young adults. This
ing behavior in women from different cultural phenomenon appears to be closely linked to
backgrounds, e.g., from the Arab world (Melisse societal factors, especially the promotion of
et al. 2020) and Eastern Europe (Shekriladze an unrealistic thinness ideal. Central risks
et al. 2019). Further studies on migrants point include the sociocultural idealization of thin-
to a culture-change syndrome, i.e., especially ness (internalization of the thinness ideal
young women often develop body image prob- through social pressure and expectations)
lems and eating disorders after moving to a and personality factors such as negative emo-
Western cultural circle. tionality and perfectionism tendencies (cf.
Culbert et al. 2015). The different condition-
 While the sociocultural influences on a ing framework requires an exact analysis of
disturbed body image and disturbed eating risk factors, which could also provide starting
behavior are considered well-established, points for preventive strategies. Since dieting
this is only very limited for the manifest behavior and disturbed eating in the context
eating disorders. While the influence of of body image disturbance can have harmful
sociocultural factors is very significant for health effects even without reaching a mani-
the occurrence of BN, the occurrence of fest eating disorder in the sense of a nosologi-
AN of the restrictive type only seems to be cal classification, initiatives for primary
culture-dependent to a very limited extent. prevention (e.g., school-based intervention
already in prepuberty) and secondary preven-
Within the context of globalization, the world tion (early provision of help through profes-
is continuing to undergo a transformation from sional counseling and therapy for affected
traditional to modern eating habits, which are children, adolescents, and young adults)
shaped by cultural factors and, above all, by should be intensified. The influence of social
the availability of industrially produced foods media, as well as changes in food supply and
and additives. What and how people will eat eating behavior in the context of globalization
in the future will undergo significant changes and the associated effects on the prevalence
(Sproesser et al. 2019). An “nutrition transi- and phenomenology of disturbed eating, must
tion” is emerging, characterized by a higher receive increased attention in the future.
References adolescents: a systematic review with meta-analysis.

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Agüera Z, Brewin N, Chen J, Granero R, Kang Q,
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Eating Disorders
in the ICD-11 and DSM-5 3
Gertraud Gradl-Dietsch, Manuel Föcker and
Johannes Hebebrand
Contents
3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
3.2 norexia Nervosa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
A 16
3.3 Bulimia Nervosa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
3.4 Binge-Eating Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
3.5 Avoidant/Restrictive Food Intake Disorder (ARFID) . . . . . . . . . . . . . . . . . . 21
3.6 Pica . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
3.7 Rumination and Regurgitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
3.8 “Other Specified Feeding or Eating Disorder” and “Unspecified
Feeding or Eating Disorder” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
3.1 Introduction eating disorders. The ICD-11 follows the con-

solidation of feeding and eating disorders into
The transition to the eleventh revision of a higher-level category already established in
the International Statistical Classification of DSM-5, thus taking into account the entire lifes-
Diseases and Related Health Problems (ICD- pan for mental disorders predominantly related
11) entails significant changes for the chapter on to food intake. The chapter on behavioral and
emotional disorders with onset in childhood and
adolescence has been removed in the ICD-11.
While the order of disorders in the DSM-5
G. Gradl-Dietsch (*) · J. Hebebrand
Department of Child and Adolescent Psychiatry,
is based on the primary age of manifesta-
Psychosomatics and Psychotherapy, Center for tion, in the ICD-11, the disorders are arranged
Translational Neuro- and Behavioral Sciences, according to their psychopathology in relation
University Hospital Essen, University of Duisburg- to food intake. Regarding individual diagnoses,
Essen, Essen, Germany
it should be noted that “binge eating disorder”
has been included as a separate diagnosis. New,
J. Hebebrand
and again based on the DSM-5, is the inclusion
of “avoidant-restrictive food intake disorder”
M. Föcker
(ARFID) as a separate diagnosis.
University Hospital Münster, Münster, Germany Currently, the descriptions of the psycho-
e-mail: [email protected] pathology of individual disorders are still
https://doi.org/10.1007/978-3-662-67662-2_3
16 G. Gradl-Dietsch et al.
very brief and only partially helpful for a sys- based on BMI limits (so-called severity specifi-
tematic review to make an initial diagnosis. ers, BMI ranges) (APA 2013):
The “International Classification of Mental
Disorders” (Descriptions and Diagnostic – “Mild: BMI ≥ 17 kg/m2;
Guidelines [CDDG] for ICD-10 Mental and – Moderate: BMI 16–16.99 kg/m2;
Behavioural Disorders), with descriptions of the – Severe: BMI 15–15.99 kg/m2;
main clinical features and diagnostic guidelines, – Extreme: BMI <15 kg/m2.”
is expected to be published after the adoption
of the overall version. There is also no official For children and adolescents, the corresponding
translation of the glossary-like definitions of the BMI percentiles should be used here.
ICD-11 browser of the WHO; this has therefore The absolute weight criterion defined in
been done by the authors. the ICD-11—with a BMI cut-off below 18.5 kg/
m2 for adults and falling below the 5th age per-
centile for children and adolescents—appears to
3.2 Anorexia Nervosa be set too low for patients under 18 years of age.
This is particularly critical in view of the fact
Anorexia nervosa (AN) is differentiated further that the consequences of a chronic state of hun-
in the ICD-11, on the one hand according to ger are even more severe for children and ado-
body weight (“significantly low” and “danger- lescents than for adults (Herpertz-Dahlmann and
ously low”) and on the other hand based on the Hagenah 2015; Micali and Hebebrand 2015).
behavioral pattern (restrictive and binge-eating/ A larger proportion of those affected have
purging pattern). The latter was already found a BMI between the 5th and 10th age percen-
in the ICD-10 under the designations anorexia tile at the time of diagnosis (Engelhardt et al.
without active measures for weight loss (restric- 2021), and a Danish study also found anorexia-
tive form of anorexia; ICD-10: F50.0) and like symptoms in patients with a BMI above
anorexia with active measures for weight loss the 10th age percentile (Andersen et al. 2018).
(ICD-10: F50.01). Furthermore, the diagnosis of It seems important to be able to make the diag-
anorexia nervosa in remission with normal body nosis in order to quickly recognize the disorder
weight appears as a new diagnosis under 6B80.2. and provide appropriate treatment, especially
The A-criterion of ICD-10 (actual body since there is a significant positive correlation
weight at least 15% below the expected weight between weight at referral to inpatient treat-
[falling below the 10th age percentile in children ment and premorbid BMI percentile (Engelhardt
and adolescents] or BMI below 17.5 kg/m2) has et al. 2021).
been changed to a threshold value of weight for An excessively strict weight threshold means
adults of a BMI below 18.5 kg/m2 and for chil- on the one hand that treatment can only begin
dren and adolescents below the 5th BMI age once severe underweight is already present,
percentile. In the DSM-5, the same threshold and on the other hand that those affected are
values are only suggested; deviation is explicitly assigned to a diagnostic residual category and
allowed according to clinical assessment, and do not receive adequate treatment. Moreover,
the evaluation of body weight should be based setting a too low threshold has the disadvan-
on age, sex, previous development, and physical tage that both the patient and their family might
health. base recovery on this threshold. In this respect,
The subdivision into a dangerously low it would be sensible—if underweight is to be
weight (BMI < 14.0 kg/m2in adults or BMI maintained in the presence of anorexia ner-
< 0.3 age percentiles in children and adoles- vosa—to specify a relatively high weight cri-
cents) is not made in the DSM-5. However, in terion. Based on the available data, the 10th or
the American classification system, the current possibly even the 25th age percentile could be
severity level in adults can also be determined considered.
3 Eating Disorders in ICD-11 and DSM-5 17
Patients who were overweight premorbidly the disturbance of the reproductive axis was not
often present with normal weight upon initial detectable in all cases, and therefore the diag-
presentation, but with pronounced psychological nosis of atypical anorexia had to be used (Reed
and physical symptoms (such as bradycardia and et al. 2019). The criterion was also not applica-
amenorrhea). The diagnosis of anorexia nervosa ble to men, premenarchal and postmenopausal
should also be given to such patients, as they women, or women taking contraceptives (Knoll
have a similarly pronounced severity of the dis- et al. 2014).
order as patients who are below the weight cut- Regarding the description of the severity of
off (Swenne 2016). semi-starvation-related changes in the function
Severe underweight is a strong predictor of of various hormonal hypothalamic-pituitary
unfavorable prognosis and high mortality; it is axes, the leptin serum level would be a suit-
also often an indication for inpatient treatment able surrogate parameter for the impairment of
(Engelhardt et al. 2021). However, other studies, the hormonal axes. However, it has not yet been
including shorter time spans, found no empiri- included in the diagnostic criteria (Föcker et al.
cal evidence to support the severity classifica- 2011). In addition, the hyperactivity in patients
tion of AN according to DSM-5 criteria (Reas with AN seems to be at least partially attribut-
and Ro 2017; Smith et al. 2017), which might able to hypoleptinemia or the functions of leptin
also apply to the classification formulated in the (Hebebrand et al. 2019). Due to the importance
ICD-11. Using the ICD-11 classification of of hyperactivity as a complicating symptom for
severity according to the 0.3 BMI age percentile, successful refeeding, the introduction of a speci-
exactly half of all patients entered in the German fication of the diagnosis with “no hyperactivity”,
Registry for Anorexia Nervosa had a danger- “mild hyperactivity”, “moderate hyperactivity”
ously low weight at admission (Engelhardt et al. or “severe hyperactivity” would be important for
2021). It seems more than questionable whether initiating adequate therapy.
the application of this threshold value will Excessive physical activity is a character-
become clinically established. istic feature of the disease in a subgroup of
In contrast to the ICD-10 (self-induced patients, which should be taken into account
weight loss by avoiding “fattening” foods) and (Hebebrand and Bulik 2011). However, neither
DSM-5 (restriction of energy intake relative the ICD-10 nor the DSM-5 has formulated a
to requirements), the ICD-11 does not include corresponding criterion. In the ICD-11, a causal-
evaluations regarding the intentions and con- ity between anorexia nervosa and motor hyper-
trol of symptoms by the affected individuals activity is established, insofar as, in addition to
themselves (criterion B) and describes a signifi- low body weight, “persistent behavioral patterns
cantly low body weight in relation to height and to prevent the restoration of normal body weight
developmental stage, which is not attributable to (measures aimed at increasing energy expendi-
another disease or lack of food. ture, i.e. exaggerated physical activities)” are
To cover the entire spectrum of cultural described. However, empirical evidence of the
diversity regarding the rationale for restrictive presence of this criterion in all affected indi-
eating behavior and excessive preoccupation viduals of all age groups and in all stages of the
with one’s own body, the fear of weight gain disorder is lacking. The formulation of the diag-
(fat phobia) is no longer listed as a sine qua non nostic criteria should convey that hyperactiv-
criterion (Criterion C) according to the DSM-5 ity is at least partly biologically explainable by
(Uher and Rutter 2012). hormonal changes and pathophysiological con-
The D-criterion of ICD-10, comprehensive trol circuits (reward system, appetite-regulating
endocrine disorder of the hypothalamic-pitui- systems) as well as genetic factors, as other-
tary-gonadal axis, is no longer required in the wise an exclusively voluntarily controlled pro-
ICD-11, in line with the DSM-5. The reason for cess is assumed (Micali and Hebebrand 2015),
this removal is the evidence that amenorrhea or from which therapeutic approaches may also
be derived (Milos et al. 2020). Ultimately, the 3.3 Bulimia Nervosa

formulation in the ICD-11 conveys that patients
engage in physical activity in a goal-oriented Bulimia nervosa can be diagnosed according to
manner; however, patients may also experience the ICD-11 regardless of the patient’s current
hyperactivity as uncontrollable or compulsive. weight, as long as the BMI is not so low that the
In a rodent model, hypoleptinemia was criteria for anorexia nervosa are met (Reed et al.
identified as an amplifier of excessive physical 2019).
activity (Exner et al. 2000), and clinical stud- While according to the ICD-10, binge eat-
ies also found a correlation between low leptin ing episodes are required to occur at least twice
levels and higher activity levels (Holtkamp et al. a week over a period of three months, the diag-
2006). Ultimately, in a small case series (three nosis can be made according to the ICD-11
patients), it was shown that the urge to move can after a period of one month and a frequency of
improve under short-term treatment with recom- at least once a week. The DSM-5 also requires
binant leptin; the distinction from expectation only a once-weekly occurrence of binge eating
effects needs to be investigated in randomized episodes and compensatory behaviors. Several
controlled trials. However, to demonstrate such studies have shown that the severity and progno-
an effect, randomized controlled, double-blind sis of the disorder do not differ between higher
trials are required (Milos et al. 2020). or lower frequency symptoms (Attia et al. 2013).
The introduction of the diagnosis “Anorexia The diagnosis can also be based on subjec-
Nervosa in Recovery with normal body weight” tively perceived binge eating episodes, in which
addresses the problem that during the course the patient experiences a subjective loss of con-
of the disorder or increasing recovery, affected trol over eating and consumes significantly more
individuals go through phases in which they no or differently than usual, associated with dis-
longer meet the weight criterion. These patients tress, regardless of the actual amount of food
would have previously received a new diagno- consumed.
sis of the type “Eating Disorder, Not Otherwise These changes are intended to reduce the
Specified” according to DSM-5, which would frequency of assigning the ICD-11 diagnosis of
not have taken the course of the disorder into “Unspecified feeding and eating disorder.”
account, or an Atypical Anorexia nervosa The ICD-10 diagnoses “Atypical bulimia ner-
according to the ICD-10. vosa” (F50.3), “Overeating associated with
In DSM-5, there is a classification into par- other psychological disturbances” (F50.4), and
tial and full remission. In the context of partial “Vomiting associated with other psychological
remission, the weight criterion is no longer met disturbances” (F50.5) are not included in the
for an extended period, but criteria B or C are ICD-11.
still met. Full remission is characterized by the Overeating associated with other psychologi-
absence of all criteria for AN. cal disturbances can be coded using the ICD-11
The diagnosis Atypical Anorexia (F50.1) can category 21 “Symptoms, signs or clinical find-
no longer be assigned according to the ICD-11. ings, not elsewhere classified” and specifically
An eating disorder that does not meet all ICD- through MB29 (“Symptoms or signs involving
11 criteria for Anorexia nervosa would be coded eating and related behavior”) and the subcode
as Other specific Anorexia nervosa or Other MB29.1 (“Binge eating”).
Anorexia nervosa. According to the DSM-5, the In addition, DSM-5 introduces, as with AN,
weight criterion is not met in Atypical Anorexia the specification in partial and full remission
nervosa. and a severity grading based on the frequency of
Table 3.1 compares the ICD-11 and DSM-5 “compensatory behaviors” (e.g., vomiting) per
criteria. week (APA 2013):
Table 3.1  Comparison of diagnostic criteria ICD-11 and DSM-5 for Anorexia nervosa (APA 2013, 2015; Claudino
et al. 2019; WHO 2019)
ICD-11 Criteria DSM-5 Criteria
Significantly low body weight in relation to height A. Restriction of energy intake relative to requirements, lea-
and developmental stage (body mass index (BMI) ding to a significantly low body weight in the context of age,
below 18.5 kg/m2 in adults or below the fifth BMI sex, developmental trajectory, and physical health. Signifi-
age percentile in children and adolescents), which is cantly low weight is defined as a weight that is less than the
not due to another health condition or the unavailabi- minimum normal weight or, in children and adolescents, less
lity of food. than the minimally expected weight.
Persistent pattern of behaviors to prevent the restora- B. Intense fear of gaining weight or of becoming fat, or per-
tion of normal weight, associated with corresponding sistent behavior that interferes with weight gain, despite the
fear of weight gain. These include reduced calorie significantly low weight.
intake (restrictive eating behavior), purging behavior
(e.g., self-induced vomiting or laxative abuse),
and behaviors aimed at increasing energy expenditure
(excessive physical activities).
A low body weight and shape have an undue influ- C. Disturbance in the way one’s body weight or shape is
ence on the self-evaluation of those affected, or there experienced, undue influence of body weight or shape on
is a distorted perception regarding their own body in self-evaluation, or persistent lack of insight regarding the
the sense of inaccurately perveiving it to be normal seriousness of the current low body weight.
or overweight.
Additionally, the subtype should be specified:
Anorexia nervosa with significantly low body
weight
In anorexia nervosa with significantly low body
weight, all criteria for anorexia nervosa are met, and
the BMI is between 18.5 kg/m2and 14.0 kg/m2 for
adults or between the 5th and 0.3 age percentiles for
children and adolescents.
Anorexia nervosa with significantly low body Restrictive type: During the last three months, the person
weight, restrictive type has not had recurring binge eating episodes or purging
The restrictive type refers to individuals who meet behavior (i.e., self-induced vomiting or misuse of laxatives,
the diagnostic criteria for anorexia nervosa with diuretics, or enemas). This subtype describes manifestations
significantly low body weight and achieve weight in which weight loss is primarily achieved through dieting,
loss and maintenance of a low body weight through fasting, and/or excessive physical exercise.
restrictive eating behavior or fasting alone or in
combination with increased energy expenditure (e.g.,
through excessive physical activities) and do not
exhibit binge eating or inappropriate compensatory
behavior (binge-purging behavior).
Anorexia nervosa with significantly low body Binge-eating/purging type: During the last three months,
weight, binge-eating/purging type the person has had recurring binge eating episodes or purging
The binge-eating/purging type refers to individuals behavior (i.e., self-induced vomiting or misuse of laxatives,
who meet the diagnostic criteria for anorexia nervosa diuretics, or enemas).
with significantly low body weight and present with
binge eating or inappropriate compensatory behavior.
The affected individuals achieve weight loss and
maintenance of low weight through restrictive eating
behavior, accompanied by compensatory behavior to
dispose of ingested food (e.g., self-induced vomiting,
laxative abuse, enemas). This type also includes indi-
viduals who exhibit binge eating without compensa-
tory behavior.
(continued)
Table 3.1  (continued)
ICD-11 Criteria DSM-5 Criteria
Unspecified anorexia nervosa with significantly
low body weight
Anorexia nervosa with dangerously low body
weight
In the case of anorexia nervosa with dangerously
low body weight, all criteria for anorexia nervosa are
met, and the BMI is below 14.0 kg/m2 for adults or
below the 3rd BMI age percentile for children and
adolescents. Severe underweight is an important pro-
gnostic factor in the context of anorexia nervosa, as
underweight is associated with a high risk of physical
complications and increased mortality.
weight, restrictive type
weight, binge-eating/purging type
Unspecified anorexia nervosa with dangerously
low body weight
Anorexia nervosa in recovery with normal body Partial remission:
weight Criterion A has not been met for an extended period, while
either B or C is still met.
Full remission
None of the diagnostic criteria have been met for an extended
period
Other specific anorexia nervosa Atypical anorexia nervosa (AN): All criteria for AN are
Other anorexia nervosa met, but the person’s body weight, despite significant weight
loss, is within or above the normal range.
• Mild: 1–3 episodes both the DSM-5 and ICD 11. BED is character-
• Moderate: 4–7 episodes ized by frequent, recurring binge eating episodes
• Severe: 8–13 episodes (once a week or more for several months).
• Extreme: 14 or more episodes The frequency criterion according to
the DSM-5 is once a week for a period of three
A partial remission means that some, but not all, months.
criteria are met for an extended period. In the Binge eating episodes are characterized in
context of full remission, criteria for BN are no ICD-11 as a specific period during which the
longer met. patient experiences a subjective loss of control
over eating and consumes significantly more
or differently than usual, feeling unable to stop
3.4 Binge Eating Disorder or limit the type of food and amount of food.
Binge eating is perceived as very distressing and
Binge eating disorder (BED) was included is often associated with negative feelings such as
as a provisional diagnosis in the DSM-IV. guilt or disgust. Unlike BN, inappropriate com-
Numerous studies have provided sufficient evi- pensatory behaviors are not regularly taken after
dence for BED as a separate disorder category binge eating episodes.
(Wonderlich et al. 2009; Uher and Rutter 2012), Applying the diagnostic criteria to binge eat-
so it is listed as an independent diagnosis in ing episodes in childhood is viewed critically,
Table 3.2  Diagnostic criteria for Avoidant/Restrictive Food Intake Disorder according to ICD-11
1 Significant weight loss or lack of weight gain (other than expected in childhood or pregnancy)
2 Clinically significant nutrient deficiencies
3 Dependence on nutritional supplements or tube feeding
4 Or* other negative impacts on the health of the affected person or significant functional impairments
5 No concerns about body weight or shape
6 Restrictive eating behavior and its effects on weight, other health aspects, and performance cannot be better
explained by lack of availability of food, effects of medication or substance use, or another illness
*In addition to criterion 1, criterion 2 and 3 or 4 must be met
as it is difficult to determine the objectively demographic similarities: They are younger

excessive amount of food required for diag- than non-ARFID eating disorder patients (main
nosis in adolescents with varying nutrient and manifestation of ARFID in childhood, includ-
energy needs. For the exploration of binge eating infancy), they are more likely to be male,
ing episodes in childhood and adolescence, it and report an average longer duration of illness
therefore seems more appropriate to use the than those with AN or BN. The current under-
perceived loss of control over eating rather than standing of the disorder is based on studies with
the actual amount of food consumed as a crite- relatively small case numbers, which primarily
rion (Tanofsky-Kraff et al. 2008). A loss of con- included patients who presented themselves in
trol can also occur with smaller meals and has specific centers or to practitioners with exper-
proven to be more predictive of later overweight, tise in eating disorders. The disorder is charac-
as well as the development of depression and terized by abnormal eating or feeding behavior,
other mental disorders (Sonneville et al. 2013). resulting in the intake of an insufficient amount
The definition of partial remission in BED of food or variety of foods to cover adequate
includes that binge eating episodes occur on energy and nutrient content.
average less than once per week. Full remission An overview of the diagnostic criteria is pro-
is defined as the absence of all criteria over an vided in Table 3.2.
extended period, as with the aforementioned dis-
orders. The newly introduced severity grading is
based on the frequency of binge eating episodes 3.6 Pica
per week (APA 2013) and corresponds to that of
bulimia nervosa (see above). Pica is characterized by the regular consump-
A comparable classification is missing in the tion of inedible substances, such as objects or
ICD-11. materials (e.g., clay, soil, chalk, plaster, plastic,
metal, and paper) or raw foodstuffs (e.g., large
amounts of salt or cornmeal), which is persistent
3.5 Avoidant/Restrictive Food or severe enough to require clinical attention in
Intake Disorder (ARFID) individuals who have reached a developmental
age at which the distinction between edible and
Avoidant/restrictive food intake disorder inedible substances would be expected (about
(ARFID) was first officially recognized as two years). The behavior causes health dam-
a diagnosis in 2013 in the DSM-5 and has age, functional impairments, or poses significant
now also been included in the ICD-11. The risks due to the frequency, quantity, or type of
prevalence is reported in the literature as substances or objects consumed.
3–5%. Although a multifactorial genesis of In the DSM-5, a duration of occurrence of at
the disorder is assumed, patients show some least one month is required, without specifying
the frequency. In the ICD-11, the temporal cri- with the diagnosis of avoidant/restrictive food
terion is completely omitted. Regarding the age intake disorder (ARFID) (Hartmann et al. 2018).
of affected individuals, the ICD-10 specifies In the DSM-5, it is emphasized that the
a chronological and mental age of at least two symptoms of a rumination disorder in the pres-
years, which was changed to “approximately” ence of an intellectual developmental disorder
two years in the ICD-11. In the DSM-5, there is must be severe enough to warrant independent
no specific age indication, but rather a reference clinical attention.
that the behavior is not appropriate for the devel-
opmental level.
3.8 “Other Specified Feeding
or Eating Disorder”
3.7 Rumination and Regurgitation and “Unspecified Feeding
or Eating Disorder”
Lack of weight gain, weight loss, or other clear
health disturbances occur over a period of at Atypical and other specified feeding or eating
least one month. The onset of the disorder disorders (OSFED) include disorder patterns
occurs before the age of six. According to the that do not fully meet the criteria for a classic
DSM-5, the presence of symptoms for at least eating disorder (AN, BN, BED) but still show a
one month is also required. The criteria men- clear, burdensome fixation on weight and shape
tioned in the ICD-11 require frequent occur- as well as long-standing difficulties in dealing
rence of the behavior (at least several times per with food and eating.
week) over a duration of at least several weeks. In the ICD-11, both categories are not further
The diagnosis should only be given from a specified, and the following changes were made
developmental age of at least two years. in the development of the ICD-11 to reduce the
According to the DSM-5, the prevalence of assignment of unspecific diagnoses.
both disorder patterns in the general population
is unclear (APA 2013). Ambiguous prevalences • Expansion of the criteria for anorexia ner-
of rumination and regurgitation are due, on the vosa (e.g., removal of weight phobia and
one hand, to the different use of terms, e.g., endocrine disorder; significant weight loss
“regurgitation disorder” or “rumination syn- in a short period; new diagnosis “anorexia
drome,” to describe the same symptomatology nervosa in recovery”) and bulimia nervosa
and, on the other hand, to an unclear separation (expanded criterion binge eating) to include
between behaviors and the full manifestation of atypical and development-dependent varia-
the disorder or concealment of the symptoma- tions of the clinical picture.
tology due to shame. In the context of the LIFE • Inclusion of “binge eating disorder,” as
Child Study of the Leipzig Research Center patients with recurrent binge eating without
for Civilization Diseases, Pica and Rumination inappropriate compensatory behaviors repre-
were each explored with one question. Of 804 sent the largest group who received the diag-
children aged between 7 and 14 years, 12.5% nosis “other eating disorders and unspecified
reported at least one occurrence of Pica behav- eating disorder” according to the ICD-10
iors and 12% reported rumination. Repeated (Al-Adawi et al. 2013).
occurrences were described by 5% and 1.5% of • Inclusion of “avoidant/restrictive food intake
respondents, respectively. Pica occurred signifi- disorder” (ARFID), which can be under-
cantly more frequently in boys, whereas no gen- stood as an extension of the ICD-10 category
der differences were found for rumination. Both “feeding disorder in infancy and childhood”
disorder patterns were significantly associated and improves the clinical application of the
category across the lifespan (the diagnosis is criteria for AN and BN have been broadened.
to be given to children as well as adolescents Unfortunately, contrary to these efforts, for chil-
and adults) and maintains consistency with dren and adolescents, the weight criterion has
the DSM-5 (Uher and Rutter 2012; Al-Adawi become stricter in the ICD-11 (BMI < 5th per-
et al. 2013). centile), so that young patients with symptoms
corresponding to AN must resort to the diagno-
In the DSM-5 (APA 2013), the category sis of Specified or Unspecified AN if the BMI
“Unspecified Feeding or Eating Disorder” is is above the mentioned threshold. The defini-
also not further specified, whereas the category tion of BED as an independent disorder and the
“Other Specified Feeding or Eating Disorder” inclusion of “Avoidant/Restrictive Food Intake
includes Atypical AN, BN of low frequency Disorder” (ARFID) also result in a reduction in
the frequency of diagnoses of this new residual
and/or limited duration, and BED of low fre-
category (Claudino et al. 2019).
quency and/or limited duration. These three dis-
Whether DSM-5 proves to be practical for
orders exhibit the typical symptom patterns of
diagnosing eating disorders in clinical practice
the classic eating disorders AN, BN, and BED,
and research, especially for children and ado-
but not all diagnostic criteria are fully met (e.g.,
lescents, but also for adults, remains to be seen.
regarding body weight, frequency and dura-
Some formulations of the AN criteria offer a
tion of binge eating episodes, or compensatory
wide scope for interpretation, so that investiga-
weight control behaviors measures). In addition,
tors will arrive at different diagnoses depend-
the category “Other Specified Feeding or Eating
ing on a narrow versus broad interpretation. In
Disorder” also contains diagnostic criteria for
particular, the unclear separation regarding the
Night Eating Syndrome (NES) and Purging
fulfillment of the weight criterion for AN in con-
Disorder (Table 3.3).
trast to “atypical anorexia nervosa” could poten-
tially lead to low reliability, with implications
Summary
for research and clinical practice.
Previous research on DSM-5 and ICD-11 cri-
The ICD-11 working group on eating dis-
teria shows that the frequency of diagnoses
orders proposes using a “rapid weight loss in
of the residual categories “Other Specified
Feeding or Eating Disorder” and “Unspecified a short period” as a substitute criterion for the
Feeding or Eating Disorder” has decreased com- above-defined weight threshold (BMI 18.5 or
pared to the DSM-IV category Eating Disorder 5th BMI percentile) when all other criteria are
Not Otherwise Specified (EDNOS), as the met (Claudino et al. 2019). This makes sense in
Table 3.3  Comparison of the categories “Other Specified Feeding or Eating Disorder” and “Other Specified Feeding
or Eating Disorder” in ICD-11 and DSM-5
ICD-11 DSM-5
Other Specified Feeding or Eating Disorder Atypical Anorexia nervosa
Bulimia nervosa of low frequency and/or limited duration
Binge Eating Disorder of low frequency and/or limited duration
Purging Disorder
Night Eating Syndrome
Avoidant/Restrictive Food Intake Disorder (ARFID)
Rumination Disorder
Pica
order to take into account the increasing number Pilon DJ, Thiels C, Sharan P, Al-Adawi S, Reed GM
of patients who experience an acute and signifi- (2019) The classification of feeding and eating disor-
ders in the ICD-11: results of a field study compar-
cant weight loss from a (relatively) high starting proposed ICD-11 guidelines with existing ICD-10
ing weight without reaching the above-defined guidelines. BMC Med 17(1):93
threshold. Ultimately, this substitute criterion Engelhardt C, Föcker M, Bühren K, Dahmen B, Becker
could imply that a patient meets the diagnosis of K, Weber L, Correll CU, Egberts KM, Ehrlich S,
Roessner V, Fleischhaker C, von Gontard A, Hahn
both obesity and AN. F, Jenetzky E, Kaess M, Legenbauer T, Renner
The introduction of the diagnosis AN in TJ, Schulze UME, Sinzig J, Wessing I, Antony G,
recovery in ICD-11 with normal body weight Herpertz-Dahlmann B, Peters T, Hebebrand J (2021)
represents, in our opinion, an improvement over Age dependency of body mass index distribution in
childhood and adolescent inpatients with anorexia
the ICD-10 classification. A normal weight at nervosa with a focus on DSM-5 and ICD-11 weight
discharge from clinical treatment is not a suf- criteria and severity specifiers. Eur Child Adolesc
ficient criterion for recovery. In this respect, it Psychiatry 30(7):1081–1094
is also important for outpatient therapists to be Exner C, Hebebrand J, Remschmidt H, Wewetzer C,
Ziegler A, Herpertz S, Schweiger U, Blum WF,
able to assign this diagnosis to justify the contin- Preibisch G, Heldmaier G, Klingenspor M (2000)
uation of their treatment. The requirement of a Leptin suppresses semi-starvation induced hyperac-
remission period of approximately one year after tivity in rats: implications for anorexia nervosa. Mol
the end of intensive treatment seems reasonable Psychiatry 5(5):476–481
Föcker M, Timmesfeld N, Scherag S, Bühren K,
(Avnon et al. 2018) for the assessment of a full Langkamp M, Dempfle A, Sheridan EM, de Zwaan
remission. M, Fleischhaker C, Herzog W, Egberts K, Zipfel S,
Herpertz-Dahlmann B, Hebebrand J (2011) Screening
for anorexia nervosa via measurement of serum leptin
levels. J Neural Transm (Vienna) 118(4):571–578
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DJ, Rausch-Herscovici C, Reed GM, Rydelius chopathology: a population-based study. Eur Child
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Clinical Aspects of
Anorexia Nervosa, 4
Bulimia Nervosa, and
Avoidant-Restrictive
Food Intake Disorder in
Adulthood
Martin Teufel, Eva-Maria Skoda and Stephan Zipfel
Contents
4.1 Classification of Anorexia Nervosa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
4.2 Classification of Bulimia Nervosa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
4.3 Avoidant-Restrictive Eating Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
4.4 Compensatory Behaviors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
4.1 Classification of Anorexia can be perceived. There is a desire for weight

Nervosa loss, and there seems to be no lowest weight
limit. Weight loss is achieved through restric-
The initially most striking finding of anorexia tion of food intake, vomiting, excessive physical
nervosa (AN) is the reduced nutritional status activity, or the use of laxatives or diuretics.
with often drastic weight loss. Patients with It is striking that patients often cannot ade-
severe anorexia show a cachectic nutritional quately perceive their weight loss and deny it.
state. The outward appearance is pale, subcuta- In extreme cases, patients still feel too fat in the
neous fat tissue may be missing, so that individ- state of cachexia—predominantly affected are
ual bones as well as muscles and muscle tendons the abdomen, hips, and thighs. This disturbance
of the body image is a diagnostic criterion of
AN. In the context of disturbed body percep-
M. Teufel (*) · E.-M. Skoda
tion, there is often body-checking behavior, a
Department of Psychosomatic Medicine and behavior that patients often only admit to when
Psychotherapy, LVR University Hospital, Essen, asked. They check body proportions (e.g., limb
Germany circumferences, waist circumference) and feel
their bones for their own reassurance. In this
E.-M Skoda context, excessively frequent weighing behav-
ior can also be observed. There is a great fear of
S. Zipfel weight gain (weight phobia).
Department of Psychosomatic Medicine and
Psychotherapy, Medical University Hospital,
Significant changes in the DSM-5 American
Tübingen, Germany Psychiatric Association (2013) and the ICD-11
e-mail: [email protected] for AN include the abolition of formulations that
https://doi.org/10.1007/978-3-662-67662-2_4
28 M. Teufel et al.
suggest intentional or arbitrary behavior on the

part of patients, as it has been shown, among insulin units in individuals with dia-
other things, that both patients and their fami- betes mellitus. The behaviors may
lies suffer from stigmatization. The diagnostic also aim to increase energy expendi-
criterion of amenorrhea has been completely ture through excessive exercise, motor
omitted, as the absence of menstruation primar- hyperactivity, deliberate cold exposure,
ily represents an organic consequence of AN. or the intake of medications (e.g., stim-
In addition, the absence of menstruation cannot ulants, weight loss medications, herbal
be assessed before menarche, after menopause, products for weight reduction, thyroid
when taking contraceptives, and in men. hormones).
• Having a low body weight is of par-
ticular importance and is central to the
Diagnostic criteria for anorexia ner- person’s self-evaluation, or the per-
vosa, ICD-11 (Claudino et al. 2019) son inaccurately perceives their body
weight or body shape as normal or even
• Significantly low body weight for the
overweight. Preoccupation with weight
individual’s height, age, developmental
and shape can be expressed, even if not
stage, and weight history, not attribut-
explicitly addressed, through behav-
able to the unavailability of food and
iors such as repeated checking of body
not explained by another health condi-
weight (weighing), checking one’s body
tion. A commonly used guideline is a
shape (body-checking behavior) using
body mass index (BMI) of less than
measuring tapes or in the mirror, con-
18.5 kg/m2 for adults and age-related
stantly monitoring the calorie content
BMI below the 5th percentile for chil-
of foods, and seeking information on
dren and adolescents. Rapid weight
how to lose weight. On the other hand,
loss (e.g., more than 20% of total body
there may be pronounced avoidance
weight within 6 months) can replace
behavior, e.g., refusal to have mirrors
the low body weight-related guideline,
in the home, avoidance of tight-fitting
as long as other diagnostic require-
clothing, or refusal to know one’s own
ments are met. Children and adoles-
weight or to buy/wear clothing items
cents may, instead of weight loss, show
with specified sizing.
a a failure to gain weight as expected
based on their individual developmental
trajectory.
• A persistent pattern of restrictive eating 4.1.1 Subtypes of Anorexia Nervosa
behavior or other behaviors aimed at
achieving or maintaining an abnormally Restrictive type (ascetic form)
low body weight, typically associated In the restrictive type, there are no regular binge
with extreme fear of weight gain. The eating episodes. The underweight is achieved—
behaviors may aim to reduce energy without active behaviors for weight loss—
intake by fasting, selecting low-calorie through food restriction.
foods, excessively slow eating of small
amounts of food, and hiding or spitting Binge-eating/Purging type (bulimic form)
out food, as well as so-called “purging In this subtype, regular binge eating episodes are
behavior,” such as self-induced vomit- accompanied by compensatory behaviors such
ing and the use of laxatives, diuretics, as self-induced vomiting or the abuse of medica-
enemas, or the omission of necessary tions (to purge: cleanse).
4 Clinical Aspects of Anorexia Nervosa, Bulimia Nervosa, and Avoidant-Restrictive ... 29
4.2 Classification of Bulimia

Nervosa eating large amounts of food despite
a lack of hunger and eating faster than
In contrast to AN, where the main symptom of normal.
underweight can be recognized with just a few • Repeated, inappropriate compensatory
glances, patients with bulimia nervosa (BN) behaviors to prevent weight gain (e.g.,
initially appear inconspicuous, as they are of once a week or more over a period of
normal weight or overweight. In BN, there at least one month). The most com-
are typical binge eating episodes with loss mon compensatory behavior for weight
of control. Large amounts of food are hastily regulation is self-induced vomiting,
devoured without the possibility of stopping. which typically occurs within an hour
Subsequently, compensatory behavior occurs, of a binge eating episode. Other inap-
which allows patients to maintain their weight propriate compensatory behaviors
and not gain weight. The most common is vom- include fasting or taking diuretics, using
iting shortly after eating. In cases of maximum laxatives or enemas to reduce nutri-
symptom severity, the entire day can consist of ent absorption in the intestine, omitting
“cycles of eating and vomiting.” This often leads insulin units in individuals with dia-
to financial difficulties and problems associated betes mellitus, and excessive physical
with obtaining food. Similar to AN, there are activity to increase energy expenditure.
weight-phobic fears and a body schema distur- • Excessive preoccupation with body
bance. The disorder is often characterized by weight and shape. If not explicitly
secrecy and shame. Outwardly, patients may at addressed, the preoccupation with
most show swelling of the salivary glands. The weight and shape can manifest through
eating disorder may remain undetected in the behaviors such as repeated checking of
environment for years. body weight (weighing), checking one’s
own body shape (body-checking behav-
ior) using measuring tapes or in the mir-
Diagnostic criteria of Bulimia nervosa, ror, constantly monitoring the calorie
ICD-11 (Claudino et al. 2019) content of foods and seeking informa-
tion on how to lose weight. On the other
• Frequent, recurrent episodes of binge hand, there may be pronounced avoid-
eating (e.g., once a week or more over ance behavior, such as refusing to have
a period of at least one month). A binge mirrors in the home, avoiding tight-fit-
eating episode is defined as a discrete ting clothing, or refusing to know one’s
period of time during which the indi- own weight or to buy/wear clothing
vidual experiences a loss of control items with specified sizing.
over their eating behavior. A binge eat- • There is marked distress related to the
ing episode occurs when a person eats pattern of binge eating and inappro-
significantly more and/or differently priate compensatory behavior, or sig-
than usual and feels unable to stop eat- nificant impairment in personal, family,
ing or limit the type or amount of food social, educational, occupational, or
consumed. Additional characteristics of other important areas of life.
a binge eating episode may include: eat- • The symptoms do not meet the diagnos-
ing alone out of shame, not in company; tic criteria for anorexia nervosa.
eating foods that are not normally part
of the individual’s usual dietary habits;
30 M. Teufel et al.
4.2.1 Subtypes of Bulimia Nervosa

related to participating in social expe-
Only in DSM-IV was BN differentiated between riences involving eating).
the subtypes non-purging type and purging type. 2. The pattern of eating behavior is not
The clinical significance is controversial and motivated by preoccupation with body
was abandoned in the DSM-5. weight or shape or by a significant dis-
tortion of body image.
3. The restricted food intake and the
4.3 Avoidant-Restrictive Food resulting weight loss (or lack of weight
Intake Disorder gain) or other effects on physical health
are not due to the unavailability of food,
In the ICD-11, the form of avoidant-restrictive not to the manifestation of another
food intake disorder (ARFID) is described. medical condition (e.g., food allergies,
This is a clinical picture in which, in addition hyperthyroidism), not to the effect of a
to a reduction in the amount of food, malnutri- substance or medication (e.g., ampheta-
tion also occurs due to the limited variety. Those mine), including withdrawal, and not to
affected can often only be tube-fed, as balanced another mental disorder.
nutrition is no longer possible. Consequently,
restrictions in almost all areas of life are the
result. The focus is on avoidant restriction -
the cognitions about weight and shape typical 4.4 Compensatory Behaviors
for AN or BN (e.g., fear of weight gain, body
schema disturbance) are not present here. Patients with AN and BN exhibit similar behav-
It is characterized by the following diagnostic iors to prevent weight gain or to lose weight.
criteria. The individual methods and their “applica-
tion” are quickly disseminated today through
new media (internet forums and chats, blogs,
Diagnostic criteria for avoidant-restric- and social media). Those affected easily access
tive food intake disorder, ICD-11 disorder-typical dysfunctional information and
1. Avoidance or restriction of food intake, incorporate it into their behavioral repertoire.
leading to one or both of the following: The most common behaviors are explained
below.
1.1. Intake of an insufficient quantity or
variety of foods to meet an adequate
energy or nutrient requirements. 4.4.1 Fasting
Consequences are significant weight
loss, clinically significant nutritional Patients periodically abstain from food intake
deficiencies, dependence on oral (starvation) or are very restrictive in their eating
nutritional nutritional supplements or behavior. Often, patients themselves define “for-
tube feeding, or other negative con- bidden foods.” These are predominantly high in
sequences for the person’s physical calories. “Allowed” are rather low-calorie, low-
health fat products. In the context of binge eating, these
1.2. Significant impairment in personal, self-imposed rules and prohibitions are impul-
family, social, educational, occupa- sively broken, and uncontrolled consumption of
tional, or other important areas of otherwise mostly “forbidden foods” can occur.
life (e.g., due to avoidance or distress
4 Clinical Aspects of Anorexia Nervosa, Bulimia Nervosa, and Avoidant-Restrictive ... 31
4.4.2 Vomiting exercise and include both intentional athletic

activities and an increased level of involuntary
After food intake, self-induced vomiting serves movements.
to “get rid of” the ingested calories. It is also an
attempt to alleviate the quickly perceived feel-
ing of fullness and bloating. Vomiting occurs 4.4.5 Additional
by self-induced triggering of the gag reflex, Compensatory Behaviors
and in some cases, it can also happen spontane-
ously. The pressure to vomit ingested food can There are numerous other behaviors that enable
be so strong that social activities no longer take weight loss or prevent weight gain. This is usu-
place, as such behavior is not possible in these ally done with the aim of activating metabolism.
contexts. For example, patients may deliberately dress
lightly, keep room temperature low, take cold
showers, or consume ice cubes to increase their
4.4.3 Abuse of Medications basal metabolic rate.
The abuse of medications as compensatory

behavior primarily involves laxatives. Due to References
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respective medications. The use of laxative and SC, Rebello TJ, Bryant-Waugh R, Dai Y, Zhao M,
Matsumoto C, Herscovici CR, Mellor-Marsá B,
diuretic teas is also observed. In addition, appe- Stona AC, Kogan CS, Andrews HF, Monteleone P,
tite suppressants, diuretics, and metabolism-acti- Pilon DJ, Thiels C, Sharan P, Al-Adawi S, Reed GM
vating substances (e.g., thyroxine) are abused. (2019) The classification of feeding and eating disor-
ders in the ICD-11: results of a field study compar-
ing proposed ICD-11 guidelines with existing ICD-10
guidelines. BMC Med 17(1):93
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sively. The urge to move can lead to compulsive
Clinical Aspects
of Binge-Eating Disorder 5
Martina de Zwaan
Contents
5.1 Diagnostic Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
5.2 Further Psychopathological Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
5.3 Epidemiology and Course . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
5.4 Comorbidities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
5.1 Diagnostic Criteria yet sufficiently clarified, but it is a complex

mental disorder that is probably multifactorial
As early as (1959), Albert Stunkard described a and involves various mechanisms in its develop-
subgroup of overweight patients characterized ment as well as triggering and maintaining fac-
by repeated episodes of binge eating without tors (AWMF 2018).
compensatory behaviors. However, this form
of eating disorder only came into the focus of
scientific interest after the research criteria for Diagnostic Criteria for Binge Eating Dis
“binge Eating disorder (BED)” were included in order according to DSM-5 (APA 2013)
the DSM-IV in 1994 as an example of unspeci- A. Recurrent episodes of binge eating. A
fied eating disorders. In the DSM-5, BED has binge eating episode is characterized
finally been included as an independent diagno- by both of the following:
sis based on extensive research over many years. 1. Consumption of a large amount of
In the ICD-10 (WHO 1993), this diagnosis does food in a discrete period of time (e.g.,
not exist and can only be coded as “other eating within a period of two hours), which
disorder” (F50.8) or “unspecified eating disor- is significantly larger than the amount
der” (F50.9). The diagnosis will also be consid- most people would eat in a similar
ered in the ICD-11. The etiology of BED is not period under similar conditions.
2. Feeling a loss of control over eat-
ing behavior during the episode
M. de Zwaan (*) (e.g., feeling unable to stop eating or
having no control over the type and
Psychotherapy, Hannover Medical School,
Hannover, Germany amount of food).
https://doi.org/10.1007/978-3-662-67662-2_5
34 M. de Zwaan
all criteria for BED, classification can be made

B. The binge eating episodes are asso- through the category “Other Specified Feeding
ciated with three (or more) of the or Eating Disorders” by specifying the disor-
following: der, e.g., BED of low frequency and/or limited
1. Eating much more rapidly than duration. If there is not enough information for
normal. a more accurate diagnosis or the diagnostician
2. Eating until feeling uncomfortably does not want to acknowledge it, the category
full. “Unspecified Feeding or Eating Disorder” can
3. Eating large amounts of food when be used for classification.
not feeling physically hungry. Since binge eating episodes in individuals
4. Eating alone because of embar- with BED are not accompanied by compensatory
rassment about the amount of food behavior (e.g., vomiting, laxative use), they are
consumed. often difficult to distinguish. They can also mani-
5. Feeling disgusted with oneself, fest as continuous, day-long food intake (graz-
depressed, or very guilty after ing, nibbling) without fixed meals. To decide
overeating. whether a specific case constitutes a binge eating
C. Marked distress regarding binge eating episode or not, it is recommended to consider the
is present. context in which the eating occurs. For example,
D. The binge eating occurs, on average, most people eat significantly more at a family
at least once per week over a period of celebration than at regular meals. Accordingly,
three months. the amount of food consumed can be considered
E. The binge eating is not associated with an objectively large amount according to DSM-5
the recurrent use of inappropriate com- criteria in one context (e.g., during a regular
pensatory behaviors, as in bulimia ner- meal), while not in another context (e.g., at a
vosa, and not exclusively during the family celebration) (AWMF 2018). Binge eating
course of anorexia nervosa or bulimia episodes in overweight individuals with BED are
nervosa. typically smaller, ranging from 600–3000 kcal,
than in girls and women with BN. They mainly
consist of sugar- and fat-rich foods and occur on
 Binge eating disorder (BED) is classified
average 2.5–5 days per week.
as a syndrome in which regular binge eat-
In addition, the presence of certain behav-
ing episodes occur, according to the criteria
iors is required, which are considered signs of
described for bulimia nervosa (BN), but with-
impaired control (e.g., eating faster than usual,
out any compensatory behaviors.
eating until an uncomfortable feeling of fullness,
eating large amounts without being hungry, eat-
The severity of BED is determined by the fre-
ing alone, feelings of disgust, sadness, or guilt
quency of binge eating episodes (mild: 1–3
after eating).
episodes per week; moderate: 4–7 episodes
The main difference from BN is that in BED,
per week; severe: 8–13 episodes per week;
no regular behaviors are undertaken to counter-
extremely severe: 14 or more episodes per
act weight gain. Some studies equate “regular”
week). If the number of binge eating episodes
with an occurrence of at least once per week. As
met the diagnostic criterion at an earlier time (at
a result of the less frequent or non-existent com-
least one episode per week for three months),
pensatory behaviors, most patients with BED
but fewer episodes occur at the current time,
are overweight or obese. In contrast to BN and
DSM-5 refers to a partially remitted BED. If all
anorexia nervosa (AN), BED is also associated
diagnostic criteria were met at an earlier time
with a less pronounced and enduring restrained
and are no longer present, a fully remitted BED
eating behavior used for weight loss (APA
is referred to. If a person meets some, but not
2013). Restrictive eating behavior promotes the
5 Clinical Aspects of Binge-Eating Disorder 35
occurrence of binge eating episodes, and the not as small as in many other eating disorders.
likelihood of a binge eating episode increases Although women are more frequently affected
with the duration of attempted food restriction by BED than men, the proportion of men among
(Holmes et al. 2014). adults is 30–40%. BED is more common in
people who are being treated for overweight or
obesity.
5.2 Further Psychopathological Based on retrospective studies, the course
Features of untreated BED is classified as chronic and
persistent. However, the findings of a prospec-
Although it is not mentioned in the diagnostic tive longitudinal study on the untreated course
criteria, empirical findings suggest that individu- of BED over a period of six months suggest a
als with BED have an overvaluation of shape fluctuating course, which can include almost
and weight, as well as clinically relevant con- disorder-free phases as well as phases with pro-
cerns about shape and weight or dissatisfaction nounced symptomatology.
with shape and weight, which can be relevant to
self-esteem and precede binge eating episodes
(Citrom 2019; Guerdjikova et al. 2019). The Predisposing factors for BED (AWMF
overvaluation of shape and weight is also associ- guideline 2018; Hilbert et al. 2014;
ated with more pronounced eating disorder psy- Kessler et al. 2016)
chopathology and psychological distress and is • Genetic factors
negatively related to treatment success. BED is • Overweight or obesity in childhood
also often associated with self-esteem problems. • Critical life events (e.g., separation of
Low self-esteem in patients with BED is related parents)
to a strong overvaluation of shape and weight. • Neglect
Furthermore, interpersonal problems are charac- • Depressiveness or shyness
teristic of BED and are associated with more pro- • Restrained eating behavior
nounced symptomatology (Ivanova et al. 2015). • Emotional eating
Patients diagnosed with BED more frequently • Restrictive parental feeding practices
use dysfunctional and less frequently functional • Dissatisfaction with one’s figure
strategies for dealing with negative emotions. • Shape- and weight-related criticism
Recent findings show that in individuals with • Sexual and physical abuse
BED who exhibit a high degree of dysfunctional • Problems in the area of executive
emotion regulation strategies, the overvaluation functions, affecting decision-making,
of shape and weight is also highly pronounced impulse control, and action planning
(Harrison et al. 2016). Binge eating episodes can (Cury et al. 2020)
be triggered by negative affect and serve emotion
regulation (Leer et al. 2015); this has been dem-
onstrated meta-analytically across various diary
5.4 Comorbidities
studies. However, the affect after a binge eating
episode can also be more negative than before a
5.4.1 Mental Comorbidity
binge eating episode (Haedt-Matt and Keel 2011).
In total, over 70% of individuals with BED have

5.3 Epidemiology and Course at least one comorbid mental disorder (Keski-
Rahkonen and Mustelin 2016). These primar-
In BED, the 12-month prevalence among ily include affective disorders such as major
adults is 1.6% for women and 0.8% for men depression and bipolar disorder, as well as vari-
(Galmiche et al. 2019). The proportion of men is ous anxiety disorders (e.g., generalized anxiety
36 M. de Zwaan
pisorder, panic disorder, and various phobias). obesity and BED is higher both overall and spe-
Other, but apparently less common, comorbid cifically on days without binge eating.
disorders are substance use disorder, posttrau- Compared to people with obesity without
matic stress disorder, body dysmorphic disorder, BED, people with obesity and BED have an ear-
and various personality disorders (Kessler et al. lier onset of overweight, more frequent weight
2013). There is also evidence that individuals fluctuations, more pronounced body dissatisfac-
with BED have increased suicidality, even after tion, lower self-esteem, and lower quality of life.
controlling for existing depressive symptoms Depressive disorders, anxiety and phobic disor-
(Welch et al. 2016). Increased impulsivity is dis- ders, as well as harmful alcohol use and alcohol
cussed as a possible factor underlying both BED dependence are common comorbid disorders
and increased suicidality (Boswell et al. 2020; in individuals with obesity and BED (Citrome
Schag et al. 2013). Psychological abnormalities 2019; Guerdjikova et al. 2019). People with obe-
or comorbid disorders occur more frequently sity and BED also suffer more frequently from
in individuals with BED than in those without a comorbid personality disorder, with preva-
BED but with comparable body weight, suggest- lence estimates ranging between 7.5% and 30%
ing that the increased rate of other mental disor- (Gerlach et al. 2016).
ders may be associated with the extent of BED People with obesity and BED seem to show
in addition to potentially comorbid overweight less long-term weight loss in conservative
or obesity (Welch et al. 2016). weight loss programs than people with obesity
without BED. The assumption that an improve-
ment in psychological symptoms as well as
5.4.2 Obesity eating disorder symptoms is accompanied by
weight loss is not confirmed by the majority
In people with obesity who seek conservative of studies. Successful treatment of BED shows
weight loss treatment (clinical populations), only marginal long-term effects on weight
the prevalence of BED is estimated at 20–30% development (Hilbert et al. 2020), suggesting
(Aguera et al. 2020), and the likelihood of hav- that other factors, such as hypercaloric eating
ing BED seems to increase with higher BMI. behavior between episodes of binge eating, may
The prevalence of BED in people with obe- have a decisive influence on body weight.
sity before bariatric surgery is about 15–30%
(Dawes et al. 2016). Studies on the prevalence
of obesity in samples of individuals with BED References
report prevalence rates between 65% and 70%.
Kessler et al. (2013) compared the weight of Agüera Z, Lozano-Madrid M, Mallorquí-Bagué N,
Jiménez-Murcia S, Menchón JM, Fernández-Aranda
people with and without BED in their study of F (2020) A review of binge eating disorder and obe-
over 23,000 participants, and found that 32.8% sity. Neuropsychiatr (Online ahead of print)
to 41.7% of people with BED were obese, while American Psychiatric Association (2013) Diagnostic and
obesity was present in only about 16% of peo- statistical manual of mental disorders, 5th edn (DSM-
5). American Psychiatric Association, Washington, DC
ple without BED. Thus, there seems to be a AWMF (2018) S3 Leitlinie “Diagnostik und Therapie
close connection between obesity and BED, der Essstörungen”. Registernummer 051–026, Stand:
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cause or rather a consequence of overweight and Boswell RG, Potenza MN, Grilo CM (2020) The neuro-
biology of binge-eating disorder compared with obe-
obesity. BED is also common in patients with sity: implications for differential therapeutics. Clin
type 2 diabetes mellitus (Chevinsky et al. 2020). Ther S0149-2918(20):30510–30515
In contrast to people with obesity without Chevinsky JD, Wadden TA, Chao AM (2020) Binge
BED, food and energy intake in people with eating disorder in patients with type 2 diabetes:
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diagnostic and management challenges. Diabetes episodes by modelling chronicity of dietary restric-
Metab Syndr Obes 13:1117–1131 tion. Eur Eat Disord Rev 22(6):405–411
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Organization, Geneva
Atypical Eating
Disorders and Eating 6
Disorders Not Otherwise
Specified
Astrid Müller and Andrea Sabrina Hartmann
Contents
6.1 Atypical, Subsyndromal Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . 40
6.2 Purging Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
6.3 Night Eating Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
6.4 Pica . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
6.5 Rumination Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
6.6 Avoidant/Restrictive Food Intake Disorder (ARFID) . . . . . . . . . . . . . . . . . . 42
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Since most empirical studies have recruited as well as persistent problems with eating and
patients with the full picture of a classic eating weight-regulating behaviors, and a problematic,
disorder (anorexia nervosa, bulimia nervosa, inappropriate approach to certain foods. In addi-
binge eating disorder), knowledge about atypi- tion, there are other specified feeding and eat-
cal, subsyndromal, or other feeding and eating ing disorders and those that are mainly observed
disorders is still limited. However, the majority in children or people with developmental dis-
of therapy-seeking patients describe a persis- orders. These forms are also associated with
tent eating disorder symptomatology that does substantial negative consequences such as nutri-
not meet all diagnostic criteria for a classic eat- tional deficiencies.
ing disorder. Nevertheless, their eating disorder- The DSM-5 (American Psychiatric
related psychopathology also requires treatment Association, 2013) took these findings into
due to the strong fixation on weight and shape, account by significantly revising the chapter
on eating disorders and renaming it “Feeding
and Eating Disorders.” This category includes
A. Müller (*) anorexia nervosa (AN), bulimia nervosa (BN),
Department of Psychosomatic Medicine and and binge eating disorder (BED). As part of the
Psychotherapy, Hannover Medical School, restructuring, the following feeding and eating
Hannover, Germany
e-mail: [email protected] disorders that for the most part begin in infancy
or early childhood and sometimes persist into
A. S. Hartmann
Department of Psychology, Clinical Psychology adulthood were also included in this category:
and Psychotherapy of Childhood and Adolescence, Pica, rumination disorder, and avoidant/restric-
University of Konstanz, Konstanz, Germany tive food intake disorder. Additionally, there
https://doi.org/10.1007/978-3-662-67662-2_6
40 A. Müller and A.S. Hartmann
is a DSM-5 category “Other Specified Feeding Subthreshold bulimia nervosa of low fre-
and Eating Disorders,” which includes Atypical quency and/or limited duration, and Sub-
AN, BN and BED of limited frequency and/or threshold binge eating disorder of low fre-
limited duration, Purging Disorder and Night- quency and/or limited duration.
Eating Syndrome.
6.2 Purging Disorder

This chapter provides information on
atypical, subsyndromal forms of classic Although some patients show recurrent compen-
eating disorders, other specified feeding satory behavior for weight regulation, they do
and eating disorders (purging disorder, not report regular binge eating with the intake
night eating syndrome), as well as pica, of objectively large amounts of food and loss
rumination disorder, and avoidant/restric- of control (no binge eating), as is typical for
tive food intake disorder. BN. Since these patients already perceive small
meals as too large subjectively, they apply com-
pensatory measures—so-called purging behav-
ior—due to fear of weight gain (Keel 2019).
6.1 Atypical, Subsyndromal Eating This includes, for example, self-induced vomit-
Disorders ing and the abusive use of laxatives, diuretics,
or thyroid medications. While both binge and
In atypical, subsyndromal eating disorders, purging behavior occur in BN, purging behavior
characteristic features are present, but not the is the focus here, which is why the term purg-
full picture of AN, BN, or BED. If the weight ing disorder was chosen. Frequency estimates
remains in or above the normal range despite revealed prevalence rates between 0.2 and 4%,
weight loss, but all other criteria for AN are which can be explained by differently defined
met (see Chap. 3), it is referred to as Atypical diagnostic criteria and threshold values for a
AN. Subthreshold BN can be diagnosed if all clinically relevant purging disorder.
the characteristics of classic BN are present, but
the frequency and duration of eating episodes
and compensatory measures are lower (<1 time/ Proposed Criteria for Purging Disorder
week and/or <3 months). Therefore, this disor- (Keel et al. 2005)
der is also referred to as BN of low frequency A. Repeated compensatory measures to
and/or limited duration in the DSM-5. Similarly, regulate weight after normal meals
there is BED of low frequency and/or limited and snacks
duration. Here, apart from the frequency and B. Absence of objectively large binge
duration of eating episodes, which occur less eating episodes
frequently and for shorter periods (<1 time/week C. Absence of loss of control over eating
and/or <3 months), all features of the classic
BED are present (Chap. 5). The 12-month prev-
alence for atypical or subthreshold forms of eat-
ing disorders in middle-aged women was 0.35% 6.3 Night Eating Syndrome
for Atypical AN, 0.44% for Subthreshold BN,
and 0.38% for Subthreshold BED. Albert Stunkard et al. first described in 1955 in
25 overweight patients an eating behavior called
 Important Atypical, subsyndromal eating night eating syndrome (NES). NES is assumed
disorders include Atypical anorexia nervosa, when patients report recurrent episodes of
6 Atypical Eating Disorders and Eating Disorders Not Otherwise Specified 41
nocturnal eating of small amounts of food after

awakening from sleep (e.g., leftovers from day- B. The evening or nighttime event can be
time meals). The regular excessive intake of food remembered
after the actual dinner can also be classified as C. At least three of the following criteria:
NES. Affected individuals are aware of the noc-
• Low food consumption in the morning
turnal eating and can remember it. It should be
and/or skipping breakfast on four or
noted that the nocturnal eating episodes must be
more days per week
accompanied by clinically significant distress and
• Strong urge to eat between dinner and
impairment in psychosocial functioning.
falling asleep and/or during the night
The main criterion of NES seems to be a shift
• Difficulty falling asleep and staying
in the day/night rhythm regarding eating behav-
asleep on four or more nights per week
ior. There is probably a dissociation between
• Belief that one cannot fall (back) asleep
the circadian rhythm of sleep and food intake
without eating
(Shoar et al. 2019).
• Frequent depressive mood and/or mood
In 2010, diagnostic criteria for NES were
decline in the evening
proposed and published for further research
(Allison et al. 2010). The NES criteria in
D. Significant distress and/or decline in
DSM-5 are not as detailed. Either evening eat-
performance
ing (food intake after dinner) or nocturnal eat-
E. Duration of at least three months
ing (nocturnal awakening with food intake) or
F. Disorder is not a consequence of sub-
both can be present to meet the diagnostic cri-
stance abuse or dependence, somatic
teria for NES. Neither large amounts of food
diseases, medication side effects, or
are consumed during evening nor nocturnal eat-
mental disorders. The disturbed eating
ing episodes (in contrast to BED). NES must
behavior cannot be better explained by
therefore be distinguished from BED and from
a BED.
sleep-related eating disorder, which is described
in sleep medicine. Likewise, external influences
(shift work, regional social norms) as well as  Important Purging disorder and Night eating
physical illnesses or medications as a cause for syndrome are assigned to the category “Other
evening or nocturnal eating must be ruled out. specified feeding and eating disorders” in
The prevalence in the general population is DSM-5.
1–1.5%, with higher prevalence rates found in
individuals with obesity, diabetes mellitus, and
those with other mental disorders (de Zwaan 6.4 Pica
et al. 2014; Abbott et al. 2018; Bruzas and
Allison 2019). A typical feature of pica is the consumption of
non-nutritive substances that are not intended
for eating and therefore do not constitute food.
Proposed Criteria for Night Eating These include, for example, paper, hair, soil,
Syndrome (Allison et al. 2010) chalk, paint, or clay. This eating behavior is not
appropriate for the developmental level of the
A. Excessive eating in the evening/night: affected person and social norms. In most cases,
• >25% of daily calorie intake after din- there is no general aversion to conventional
ner and/or foods. The unusual cravings for the rather ined-
• Nighttime awakening with food intake ible substances may be related to the specific
at least two nights per week taste or the particular consistency of the respec-
tive substance or may be used for self-soothing,
42 A. Müller and A.S. Hartmann
e.g., in people with intellectual disabilities. disinterest in eating and food is usually not
Pica is rare (even if evidence of prevalence of based on significant body image concerns. Some
full-syndrome pica is missing), and occurs affected individuals avoid food due to its sen-
most likely in children. However, it can also be sory properties (e.g., consistency, color, smell,
observed in people with developmental disor- temperature, taste), while others do so due to an
ders or intellectual impairments, institutional- initial negative experience (such as choking) and
ized individuals, adult women during pregnancy the persistent fear of repetition, and a remain-
or postpartum period, and in regions with low ing rest simply has a lower interest in food and
socio-economic status. a smaller or non-existent appetite reaction. The
disorder must be distinguished from culturally
conditioned food avoidance (e.g., religious fast-
6.5 Rumination Disorder ing) and physical illnesses (e.g., gastrointestinal,
oncological) and should not occur exclusively
The predominant characteristic of rumination dis- in the context of AN or BN. The disorder with
order is the repeated regurgitation of previously avoidance or restriction of food intake is usually
swallowed and possibly partially digested food. first observed in early childhood, although there
The regurgitated food is chewed again, swal- is a lack of empirical findings on the prevalence
lowed, or spit out. Accompanying symptoms may of full-syndrome ARFID (Zimmermann and
include coughing and contractions of the tongue Fisher 2017).
or abdomen. In infants, this may also include
arching of the back, including jerky movements.  Important Pica, Rumination disorder, and
It is a voluntary process that is not a consequence ARFID are assigned to the DSM-5 category
of a physical illness (e.g., esophageal reflux, “Feeding and Eating Disorders,” which also
pyloric stenosis, nausea). If the symptoms occur includes atypical or subthreshold forms of the
exclusively in the context of AN, BN, BED , or classic eating disorders AN, BN, and BED.
avoidant/restrictive food intake disorder, these
diagnoses should be given. There are no reli-
able epidemiological data on the prevalence of References
full-syndrome rumination disorder, although
the disorder is more frequently observed in spe- Abbott S, Dindol N, Tahrani AA, Piya MK (2018) Binge
cific population groups (e.g., with intellectual eating disorder and night eating syndrome in adults
with type 2 diabetes: a systematic review. J Eat
impairments). Disord 6:36
Allison KC, Lundgren JD, O’Reardon JP, Geliebter A,
Gluck ME, Vinai P et al (2010) Proposed diagnostic
6.6 Avoidant/Restrictive Food criteria for night eating syndrome. Int J Eat Disord
43:241–247
Intake Disorder (ARFID) American Psychiatric Association (2013) Diagnostic
and statistical manual of mental disorders, 5. Aufl.
Avoidant/restrictive food intake disorder American Psychiatric Press, Washington, DC
(ARFID) represents an eating and feeding dis- Bruzas MB, Allison KC (2019) A review of the relation-
ship between night eating syndrome and body mass
order that results in significant nutritional defi-
index. Curr Obes Rep 8(2):145–155
ciency and negative health consequences, as the Keel PK (2019) Purging disorder: recent advances
food and energy requirements are persistently and future challenges. Curr Opin Psychiatry
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Keel PK, Haedt A, Edler C (2005) Purging disorder: an
weight loss, hypothermia, bradycardia, anemia,
ominous variant of bulimia nervosa? Int J Eat Disord
tooth decay, electrolyte imbalances, slowed 38:191–199
growth, the necessity of enteral nutrition , Shoar S, Naderan M, Mahmoodzadeh H, Shoar N, Lotfi
dependence on dietary supplements, and signifi- D (2019) Night eating syndrome: a psychiatric dis-
ease, a sleep disorder, a delayed circadian eating
cant psychosocial impairments. The pronounced
6 Atypical Eating Disorders and Eating Disorders Not Otherwise Specified 43
rhythm, and/or a metabolic condition? Expert Rev Zimmerman J, Fisher M (2017) Avoidant/restrictive food
Endocrinol Metab 14(5):351–358 intake disorder (ARFID). Curr Probl Pediatr Adolesc
Stunkard AJ, Grace WJ, Wolff HG (1955) The night-eat- Health Care 47(4):95–103
ing syndrome: a pattern of food intake among certain de Zwaan M, Müller A, Allison KC et al (2014)
obese patients. Am J Med 19:S78–S86 Prevalence and correlates of night eating in the
German general population. PLoS One 9(5):e97667
Orthorexia Nervosa
7
Reinhard Pietrowsky
Contents
7.1 Concept and Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
7.2 Symptomatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
7.3 Nosological Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
7.4 Diagnosis and Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
7.5 Etiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
7.6 Relation to Other Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
7.7 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
7.1 Concept and Definition (Bratman and Knight 2000). In orthorexia, the
focus is not on the amount of food consumed,
The term “orthorexia” derives from the Greek as is the case with anorexia, bulimia, or binge-
orthos, meaning “right, correct”, and orexis, eating disorder, but on its quality. Orthorexia
meaning appetite. The term “orthorexia ner- is currently not listed as an official disorder in
vosa” was coined by the US physician Steven the common classification systems of mental
Bratman and is intended to refer to a psycho- disorders.
genic eating disorder, analogous to anorexia ner-
vosa. Orthorexia nervosa is therefore understood  Important Orthorexic eating behavior refers
as an eating disorder characterized by extreme to an extreme (and possibly pathological) fix-
value placed on a supposedly healthy diet and ation on healthy eating.
the establishment of arbitrary dietary rules for
this purpose, the health benefits of which are
often questionable and can lead to malnutrition 7.2 Symptomatology
and psychosocial problems in extreme cases
The symptomatology of orthorexiastems from
the desire for supposedly healthy nutrition and
R. Pietrowsky (*) the rigid and sometimes compulsive imple-
Department of Clinical Psychology, Institute of
Experimental Psychology, Heinrich Heine University mentation of this extreme healthy diet. Thus,
Düsseldorf, Düsseldorf, Germany affected individuals establish dietary rules
e-mail: [email protected] that, in many cases, are exaggerated, bizarre,
https://doi.org/10.1007/978-3-662-67662-2_7
46 R. Pietrowsky
and not empirically supported, such as com-

pletely avoiding certain food components (e.g., • Creation of subjective, supposedly
fat), only consuming fruit within a maximum healthy dietary rules
of 15 minutes after harvest, or not eating cer- • Rigid adherence to these dietary rules
tain foods together but only at intervals of, for • Social restrictions due to following
example, one hour. The individual expression of these dietary rules
these dietary rules is very diverse and depends • Lack of insight into the disorder
on the subjective definition of healthy nutrition.
Experience shows that the subjective definition
of healthy nutrition becomes increasingly strict 7.3 Nosological Classification
over the course of the disorder, such that the
number of allowed foods is increasingly reduced Orthorexic eating behavior shows links to eat-
and the measures for food preparation become ing disorders, obesessive-compulsive behavior,
more differentiated (Barthels et al. 2015a). but also to somatoform disorders (Barthels et al.
These dietary rules are often derived from well- 2015a; Cena et al. 2019; Pietrowsky 2012). The
founded recommendations for healthy nutri- proximity to eating disorders is undoubtedly
tion but are exaggerated to such an extent that due to the fact that orthorexia is a conspicuous
the health-promoting effect turns into a harm- to disturbed eating behavior, in which the qual-
ful effect and can lead to malnutrition with life- ity of the food is more important than the quan-
threatening consequences. tity. However, recent studies have demonstrated
Another characteristic of orthorexia is that a close relationship between orthorexia and ano-
these dietary rules are followed in a rigid and rexia, insofar as a desire for weight reduction
often compulsive manner (Bratman and Knight was originally present in orthorexia, or ortho-
2000). Affected individuals find any deviation rexic eating behavior developed as a means of
from their own dietary rules unbearable, and weight regulation in (formerly) anorexic patients
therefore invest a lot of time and effort in imple- (Barthels et al. 2017a).
menting their dietary rules. This can lead to The proximity of orthorexic eating behavior
significant psychosocial problems, as individu- to obsessive-compulsive disorders is not clear.
als can no longer go to restaurants or eat with The rigid adherence to the established dietary
friends if they are not certain that their dietary rules has a partially compulsive character and
rules can be followed. In turn, this commonly can trigger extreme fears and concerns if the
results in a loss of social contacts or to social- rules are not followed. However, following the
izing only with like-minded people (Bratman dietary rules is experienced as ego-syntonic—
and Knight 2000). These characteristics are also in contrast to the ego-dystonic neutralizing
accompanied by a lack of insight into the disor- behavior in obsessive-compulsive disorders.
der. Sufferers consider their (pathological) eat- Studies also found no evidence of an increased
ing behavior to be correct and appropriate and tendency towards orthorexic attitudes in people
believe that people who do not eat like them are with obsessive-compulsive disorder (Barthels
making nutritional mistakes. Accordingly, it is et al. 2017b). Thus, from the aspect of obessive-
often difficult to convince them of the negative compulsivity, orthorexic behavior may be seen
health and psychological consequences of their more as ego-syntonic behavior, corresponding to
eating behavior (Barthels et al. 2015a). obsessive-compulsive personality disorder.
Relationships to somatoform disorders exist
primarily in the presence of hypochondriacal
Overview fearsand the preoccupation with physiologi-
In summary, orthorexic eating behavior is cal processes in orthorexia. Recent studies have
characterized by the following symptoms: shown that people with somatoform disorders
7 Orthorexia Nervosa 47
actually have an increased tendency towards

orthorexic eating behavior (Barthels et al. 2021). Criterion A is evidenced by the following
behaviors:
 Important In summary, orthorexia can pri- A1.
Compulsive behavior and/or men-
marily be seen as closely related to eating tal preoccupation regarding affirma-
disorders, but it also shows aspects of ego- tive and restrictive dietary practices
syntonic obsessive-compulsive symptoms believed by the individual to promote
and somatoform fears and concerns. optimum health
A2.
Violation of these self-imposed die-
tary rules causes exaggerated fear of
7.4 Diagnosis and Epidemiology disease, a sense of personal impuity
and/or negative physical sensations,
There are various screening instruments for accompanied by anxiety or shame
orthorexia. The first, introduced by Bratman, A3.
Dietary restrictions escalate over
was the “Orthorexia Self-Test,” which consists time, and my come to include elimina-
of ten questions (ORTO). However, the psycho- tion of entire food groups and involve
metric properties of this test and other derived progressively morefrequent and/
screening questionnaires are not convincing. The or severe “cleanses” (partial fasts)
independently developed Düsseldorf Orthorexia regarded as purifying or detoxify-
Scale (DOS, Barthels et al. 2015b) is a screening. This escalation commonly leads
ing questionnaire that likewise consists of ten to weight loss, but the desire to lose
items, shows good psychometric properties, weight is absent, hidden or subordi-
and is currently available in Chinese, English, nated to ideation about healthy eating.
German, Polish, and Spanish versions.
In addition to these screening instruments, Criterion B
there are several proposals for diagnostic criteria The compulsive behavior and mental pre-
for orthorexia (Cena et al. 2019), which show a occupation becomes clinically impairing
high correspondence with each other. by any of the following:
B1. Malnutrition, severe weight loss, or
other medical complications from
Overview restricted diet
The diagnostic criteria of Dunn and B2. Intrapersonal distress or impairment
Bratman (2016) are listed here by way of of social, academic or vocational
example. functioning secondary to beliefs or
behaviors about healthy diet
Criterion A B3. Positive body image, self-worth, iden-
(1) An obsessive focus on “healthy” eat- tity, and/or satisfaction excessively
ing, as defined by a dietary theory or dependent on compliance with self-
a set of beliefs whose specific details defined “healthy” eating behavior.
may vary;
(2) Marked by exaggerated emotional dis-
tress in relationship to food choices Some studies have shown a higher prevalence
perceived as unhealthy; in women while others found no gender differ-
(3) Weight loss may ensue as a result of ence in terms of prevalence. In men, orthorexic
dietary choices, but this is not the pri- behavior seems to be particularly associated
mary goal. with the practice of certain sports (especially
bodybuilding). Orthorexic behavior does not
48 R. Pietrowsky
appear to be predominantly present in specific and new, self-imposed dietary rules develop,
age groups. However, there is a tendency for which in the case of an obsessive-compulsive
orthorexic eating behavior to be observed at a personality structure, then assume the role of
younger age in women. ego-syntonic overvalued ideas, leading to the
The prevalence of orthorexia is difficult to development of orthorexia.
estimate. Based on surveys using the DOS, prev- On the other hand, health anxieties or preoc-
alence rates of 1–2% have been estimated for cupation with physical symptoms can lead indi-
Germany. Orthorexia appears to be more com- viduals to gain more control over their body and
mon in certain subgroups, particularly among what is ingested in order to reduce these fears
individuals who work professionally with and concerns. Orthorexia thus develops as a
nutrition (e.g., dietitians; cf. Kinzl et al. 2006; (dysfunctional) coping mechanism to gain con-
Korinth et al. 2010), athletes (Eriksson et al. trol over health and health anxieties. As with
2008), and individuals who follow a specific diet most mental disorders, a multifactorial etiology
for other reasons (e.g., vegetarians or vegans; can be assumed in the development of ortho-
Barthels et al. 2018). In addition to individuals rexia, in which cultural, social, and psychologi-
with current or past anorexia, orthorexic behav- cal factors interact. Currently, however, there is
ior is also frequently found in patients with no established etiological model for the develop-
somatoform disorders (Barthels et al. 2021). ment of orthorexia nervosa.
Surveys among nutritionists and dietitians also
appear to show an increase in the prevalence of
treatment (Barthels et al. 2019; Vandereycken 7.6 Relation to Other Eating
2011). Individuals with orthorexia are more Disorders
likely to seek help from nutritionists and dieti-
tians than from psychotherapists or physicians. Orthorexia, like other eating disorders, is char-
acterized by disturbed eating behavior that can
lead to physical and psychosocial problems.
7.5 Etiology However, unlike eating disorders, the disturbed
eating behavior in orthorexia is less about the
The desire to eat healthily undoubtedly arose quantity of food intake and more about its qual-
from the increasing industrial production of ity. These differences are minimized upon
food and the numerous food scandals of recent closer examination, as in bulimia nervosa and
years, as well as the societal emphasis on especially anorexia nervosa, the consumed or
healthy eating and the linking of psychological avoided foods are also selected based on qualita-
motives and social values with the type of diet tive (albeit not primarily health-related) aspects.
(Pietrowsky 2019). However, this alone cannot Moreover, aspects of body weight and physical
explain the transition from healthy to orthorexic appearance seem to be more significant in indi-
eating, and additional psychological factors viduals with orthorexic eatingthan originally
must be assumed. Two aspects seem relevant: assumed. Orthorexic eating behavior can develop
an obsessive-compulsive personality structure in formerly anorexic individuals as a way to con-
and/or control over one’s own body and health. tinue controlling their eating behavior in a very
Adhering to a healthy diet has a self-rewarding restrictive way through supposedly extremely
and self-reinforcing effect, leading to an inten- healthy nutrition. It can also develop primarily,
sification and extension of this behavior. Thus, as described above, to gain control over one’s
an initially healthy diet (characterized by a bal- body and appearance, which is also a fundamen-
anced diet) can become increasingly restricted, tal motive in anorexia and bulimia nervosa.
7 Orthorexia Nervosa 49
und Evaluation eines Fragebogens zur Erfassung

As studies have shown, there seems to be orthorektischen Ernährungsverhaltens. Zeitschrift
Klinische Psychol Psychotherapie 44:97–105
a particular closeness between orthorexia
Barthels F, Meyer F, Huber T, Pietrowsky R (2017a)
and anorexia nervosa, and a continuum Orthorexic eating behavior as a coping strategy in
between these two disorders can be sus- patients with anorexia nervosa. Eating Weight Disord
pected (Barthels et al. 2017a). 22:269–276
Barthels F, Meyer F, Huber T, Pietrowsky R (2017b)
Analyse des orthorektischen Ernährungsverhaltens
von Patienten mit Essstörungen und mit
Zwangsstörungen. Zeitschrift für Klinische
7.7 Treatment Psychologie und Psychotherapie 46:32–41
Barthels F, Meyer F, Pietrowsky R (2018) Orthorexic
and restrained eating behaviour in vegans, vegetar-
Currently, only a few statements can be made ians, and individuals on a diet. Eating Weight Disord
about the treatment of individuals with ortho- 23:159–166
rexic eating behavior. This is because affected Barthels F, Lavendel S, Müller R, Pietrowsky R (2019)
Relevance of orthorexic eating behavior in nutrition
individuals rarely consult physicians or psycho- counseling and nutrition therapy: results of a nation-
therapists, partly due to a low awareness of the wide survey among German nutritionists. Ernährungs
disorder and a lack of differentiated treatment Umschau 66:236–241. https://doi.org/10.4455/
recommendations given that it is not an offi- eu.2019.048
Barthels F, Müller R, Schüth T, Friederich H-C,
cially recognized disorder. The following treat- Pietrowsky R (2021) Orthorexic eating behavior in
ment measures seem sensible and appropriate: patients with somatoform disorders. Eating Weight
Disord 26:135–143
• Conveying a disorder model and psychoedu- Bratman S, Knight D (2000) Health food junkies:
overcoming the obsession with healthful eating.
cation about the disorder model Broadway Books, New York
• Promoting awareness of the disorder and Cena H, Barthels F, Cuzzolaro M, Bratman S, Brytek-
motivation to change eating behavior Matera A, Dunn T, Varga M, Missbach B, Donini LM
• Normalization of eating behavior through (2019) Definition and diagnostic criteria for ortho-
rexia nervosa: a narrative review of the literature.
nutrition plans, possibly involving nutrition- Eating Weight Disord 24:209–246
ists or dietitians, and breaking down rigid Dunn TM, Bratman S (2016) On orthorexia nervosa: a
dietary rules review of the literature and proposed diagnostic crite-
• Addressing underlying problem areas, such ria. Eating Behav 21:11–17
Eriksson L, Baigi A, Marklund B, Londgren EC (2008)
as illness anxiety or body dissatisfaction Social physique anxiety and sociocultural attitudes
• Developing functional alternatives for dealing toward appearance impact on orthorexia test in fitness
with illness anxieties or body dissatisfaction participants. Scand J Med Sci Sports 18:389–394
Kinzl JF, Hauer K, Traweger C, Kiefer I (2006)
Orthorexia nervosa in dieticians. Psychother
These measures can draw on the usual and suc- Psychosomat 75:395–396
cessful methods for treating eating disorders and Korinth A, Schiess S, Westenhoefer J (2010) Eating
somatoform disorders. In the future, concrete behaviour and eating disorders in students of nutri-
research on specifications and extensions of tion sciences. Public Health Nutr 13:32–37
Pietrowsky R (2012) Das Leiden am gesunden Essen—
these approaches for the treatment of orthorexia Untersuchungen zur Orthorexie. In: Siegl J,
would be desirable. Schmelzer D, Mackinger H (Hrsg) Horizonte der
Klinischen Psychologie und Psychotherapie. Pabst,
Lengerich, S 245–253
Pietrowsky R (2019) Ernährung und Gesundheit.
References In: Haring R (Hrsg) Gesundheitswissenschaften.
Springer, Berlin, S 323–332
Barthels F, Meyer F, Pietrowsky R (2015a) Orthorexic Vandereycken W (2011) Media hype, diagnostic
eating behavior. A new type of disordered eating. fad or genuine disorder? Professionals’ opinions
Ernährungs Umschau 62:156–161 about Night Eating Syndrome, Orthorexia, Muscle
Barthels F, Meyer F, Pietrowsky R (2015b) Die Dysmorphia, and Emetophobia. Eating Disord
Düsseldorfer Orthorexie Skala—Konstruktion 19:145–155
Body Image
Disturbances 8
Brunna Tuschen-Caffier and Jessica Werthmann
Contents
8.1 Body Image Issues in Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
8.2 ody Image Disturbance: Theoretical Conceptions and Definition
B
Attempts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
8.3 Body Image Disturbances as Core Symptoms of Eating Disorders:
Research Approaches and Empirical Findings . . . . . . . . . . . . . . . . . . . . . . . 53
8.4 Evaluation of Existing Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
8.1 Body Image Issues in Eating weight are mentioned as symptoms of body
Disorders image disorders in AN. In contrast, for BN, only
the undue influence of body shape or weight on
Body image disturbances are a central symptom self-evaluation is described as a diagnostic crite-
of the eating disorders anorexia nervosa (AN) rion regarding body image problems.
and bulimia nervosa (BN), and are thus a nec- In the clinical application context in German-
essary diagnostic criterion for AN and BN in speaking countries, the ICD classification sys-
the most recent classification system (DSM-5) tem (ICD; International Statistical Classification
of the American Psychiatric Association (APA of Diseases and Related Health Problems of
2013). According to the DSM-5 criteria, pro- the World Health Organization [WHO 2020])
nounced fears of weight gain, disturbance in the is more commonly employed. As in the DSM-
experience of body shape or weight, an undue 5, the latest version of the ICD (ICD-11)1 also
influence of weight or body shape on self-evalu- defines the central influence of low body weight
ation, and denial of the seriousness of low body or a corresponding body shape on self-evalua-
tion, or disturbances in the perception of one’s
own weight or body shape, as symptom criteria
B. Tuschen-Caffier (*) · J. Werthmann

Department of Clinical Psychology and 1 This is the latest version of the International
Psychotherapy, University of Freiburg,
Freiburg, Germany Classification of Diseases and Related Health Problems,
e-mail: [email protected] adopted by the World Health Organization (WHO) since
2019 and will come into force in 2022. It is not yet avail-
J. Werthmann able in German translation. The English version can be
e-mail: [email protected] accessed for free at www.who.int/classifications/icd/en/.
https://doi.org/10.1007/978-3-662-67662-2_8
52 B. Tuschen-Caffier and J. Werthmann
regarding body image disturbance in AN. For context, disturbances in body perception should
BN, preoccupation with body shape and weight manifest as an overestimation of the dimensions
is described as a symptom criterion related to of the body or parts of the body. However, in our
body image problems. view, the current understanding of perceptual
The clinical picture of binge eating disor- body image disturbances in terms of inaccurate
der (BED) is listed as a separate diagnosis in or faulty visual body width estimation is too nar-
both the DSM-5 and the ICD-11. Typical for row and ultimately not helpful. In addition to
BED are repeated binge eating episodes, which, the perceptual component, body image distur-
unlike BN, are usually not followed by com- bances are further characterized by other cog-
pensatory behavior. Symptoms related to body nitive processes, such as attention allocation
image disturbances are not provided as diag- (e.g. turning towards vs. turning away) towards
nostic criteria for BED in either the DSM-5 or one’s body (e.g. eye movements when viewing
ICD-11. However, some empirical findings sug- one’s body in the mirror). The extent to which
gest that at least in a subgroup of patients with these cognitive processes mediate the percep-
BED, there is an overvaluation of body shape tion of one’s own body and whether they occur
and weight, as well as clinically relevant preoc- voluntarily or involuntarily is currently being
cupation with body shape and weight or body researched in various research centers.
dissatisfaction, which can also be relevant to
self-esteem. In addition, body-related rumina-
tion is considered one of the most common trig- 8.2.2 Cognitive-Affective
gers for depressive moods before binge eating or Cognitive-Evaluative
episodes in patients with BED. Component
Cognitive processes of information process-

8.2 Body Image Disturbance: ing, such as attention allocation (see above)
Theoretical Conceptions and interpretation bias, regarding one’s
and Definition Attempts body are assigned to the cognitive compo-
nent of body image disturbances and, accord-
In the research literature on body image and ing to current research, play a significant role
body image problems, numerous terms and defi- in maintaining body image disturbances and
nitions of body image disturbance can be found associated dysfunctional thoughts and nega-
(e.g. body schema disturbance; body dissatis- tive feelings. Negative feelings (e.g. disgust,
faction). It is generally accepted as being mul- rejection) towards the body and corresponding
tidimensional in nature and conceptualized as dysfunctional thoughts and evaluations regard-
including ing one’s outward appearance also relate to
the cognitive-affective or cognitive-evaluative
• a perceptual component of body image, component of body image disturbances. In the
• a cognitive-affective or cognitive-evaluative relevant research literature on this aspect of
component, and body image problems, the reported findings are
• a behavior-related component. largely derived from surveys of affected indi-
viduals, based on the assumption that they are
able to provide information on cognitive-affec-
8.2.1 Perceptual Component tive or cognitive-evaluative aspects through
self-reflection. However, this is only true if
According to the studies conducted to date, individuals are consciously aware of the corre-
the perceptual component describes a distur- sponding processes, which is probably only par-
bance in the accuracy of perception of one’s tially the case. In particular, the question arises
body. Accordingly, in the clinical-psychological as to whether unintended cognitive-affective or
8 Body Image Disturbances 53
cognitive-evaluative aspects can also be captured avoidance or checking behavior). The dis-
by self-reports. It is currently being investigated tinction often found in the literature between
to what extent implicit-evaluative processes, perceptual vs. cognitive aspects of body
which relate to the cognitive-affective or cog- image disturbance is misleading insofar as
nitive-evaluative component of body image, perceptual processes are also an aspect of
can also be recorded on a more automatic a cognitive process. The definition of body
and therefore less voluntarily controlled level image disorders introduced here, with regard
using experimental-psychological paradigms to various phases of body-related informa-
(e.g. Brockmeyer et al. 2018; Legenbauer et al. tion processing, overcomes this conceptual
2020). imprecision.
8.2.3 Behavioral Component 8.3 Body Image Disturbances

as Core Symptoms of Eating
On the one hand, the behavioral component of Disorders: Research
body image disorders can manifest in the form Approaches and Empirical
of voluntary avoidance behavior. For instance, Findings
affected individuals may try to conceal nega-
tively evaluated body areas by wearing loose Research on body image disturbances in the
clothing., Moreover, individuals may avoid field of eating disorders initially focused on the
looking at their body as much as possible, and aspect of visual body width estimation or on
this avoidance behavior can be both conscious the investigation of distortions in body per-
and voluntary (e.g., not having mirrors in one’s ception. Various methods were developed and
apartment) or more or less involuntary (e.g., used for this purpose (e.g., video or photo dis-
turning one’s head away when accidentally tortion techniques). A meta-analysis (Cash and
catching one’s reflection in a shop window). A Deagle 1997) revealed, in line with expecta-
body image problem at the behavioral level can tion, that female patients with an eating disorder
further manifest in the opposite direction as diagnosis more frequently exhibit perceptual
preoccupation with one’s body or figure, e.g., distortions than do healthy control participants.
in checking behavior. Here too, there can be Control conditions for evaluating neutral objects
varying degrees of conscious control over these made it clear that the differences found in the
behaviors (e.g., weighing oneself several times perceptual component of body image distur-
a day; frequently checking relevant body parts bances (i.e., visual body width estimation) do
[body checking]). not reflect a general sensory-perceptual deficit
in patients with eating disorders, but specifically
relate to the perception of one’sbody. These
Body Image Disorders in the Context of results were replicated in a more recent meta-
Information Processing Theories analysis (Mölbert et al. 2017). Group differences
In summary, body image disorders are con- between individuals with an eating disorder and
ceptualized from the authors’ perspective individuals without any mental disorder diagno-
as cognitive-affective disturbances that can sis were particularly pronounced with regard to
manifest in various phases of body-related body dissatisfaction—in the sense of the cog-
information processing (e.g., attention, nitive-affective or evaluative aspect of a body
memory, inferential thinking), occur to vary- image disturbance. It may therefore be that the
ing degrees involuntarily or voluntarily, and cognitive-affective or evaluative aspect of body
can be accompanied by pronounced negative image disturbances takes precedence over the
emotions (e.g., anxiety, disgust, aversion) and perceptual component (i.e., visual body width
corresponding behavioral tendencies (e.g., estimation) in terms of clinical relevance. This
is also suggested by therapy studies in which pronounced the self-reported body dissatisfac-
patients with BN and AN did not differ in their tion, the stronger this attention pattern. A similar
estimation of body circumference before or after pattern of attention allocation was also shown in
therapy. However, it has also been shown that overweight women with BED compared to over-
certain attitudinal measures (e.g., dissatisfaction weight, healthy women (Svaldi et al. 2011a).
with one’s figure) do not consistently differen- This distortion of visual attention when view-
tiate between clinical groups and healthy con- ing one’s body was particularly observed after
trol groups, partly because dissatisfaction with an experimental induction of negative, compared
one’s figure can be as widespread among female to positive, mood in patients with AN (Svaldi
healthy control samples as in clinical groups et al. 2016) and BN (Naumann et al. 2019).
(Cash and Deagle 1997). This is particularly true Control subjects, on the other hand, did not
for questionnaire studies, while experimental show this pattern. This is particularly important
research methods have sometimes revealed sig- for therapeutic work, as it has also been shown
nificant group differences between women with that patients with AN and BN more frequently
an eating disorder and healthy control women use maladaptive strategies of emotion regulation
in terms of body-related thoughts and affects. (such as rumination) and therefore potentially
Experimental psychological methods might experience negative mood more frequently and/
therefore be more sensitive to detecting some or for longer periods (Naumann et al. 2016),
of these differences in body perception or in which in turn could lead to increased attention to
the processing of body-related information com- “ugly” body parts.
pared to self-report methods. This suggests a close interplay of affective
Consequently, more recent research on body and cognitive mechanisms in maintaining body
image disturbance has increasingly focused on image disturbances and body dissatisfaction.
experimental psychological methods that can Furthermore, we were able to show that
directly capture behavioral measures, for exam- patients with BED remember positive body-
ple, by examining selective attention processes related words less well than do overweight com-
towards the body. Previous research suggests parison subjects without a diagnosis of BED
a disorder-specific information processing (Svaldi et al. 2010). Another study showed that
(“negativity bias”) towards one’s body or fig- patients with AN, compared to controls, tend
ure in patients with eating disorders as well as to interpret ambiguous body-related informa-
in groups at risk of developing of an eating dis- tion more negatively (Brockmeyer et al. 2018).
order, which is presumably important for main- Overall, these empirical findings support the
taining body dissatisfaction. In eye-tracking role of evaluative-cognitive processes underly-
studies, we were able to show—analogous to ing body image disturbances.
the findings of Jansen et al. (2005) in women
with subclinical symptoms of an eating dis-  Important Selective memory, negative inter-
order—that during an experimental mirror pretation of body-related information, mala-
exposure task, patients with AN and BN prefer- daptive coping with negative mood, and at-
entially direct their gaze—i.e., longer and more tention allocation to negative body-related
frequently—to their self-evaluated “ugliest” information are factors that may contribute
body part, as compared to controls (Tuschen- to the maintenance of eating disorders and,
Caffier et al. 2015). Conversely, they showed in particular, symptoms of impaired body
a shorter and less frequent fixation pattern on image.
their self-evaluated“most beautiful” body part
A deficit orientation towards subjectively per- Furthermore, findings in patients with AN
ceived “ugly” body parts was also found in an and BN suggest that when presented with a
eye-tracking study in adolescent patients with photo of their own body (self-photo) versus a a
AN and BN (Bauer et al. 2017). The more photo of a matched control (other-photo; both
full-body images without the person’s face or unconscious, self-esteem induction demon-
head), patients with AN direct their attention strated a causal relationship between self-esteem
more quickly to self-photos than to other-pho- and body dissatisfaction. Implicit negative
tos (Blechert et al. 2010). This vigilance effect manipulation of self-esteem in women with
towards the self-photo was more pronounced the BED led to a significant increase in body dis-
more dissatisfied the women with AN were with satisfaction; in contrast, body dissatisfaction did
their bodies, i.e., dissatisfaction with one’s own not increase when there had been an implicit,
body was correlated with the speed of eye move- i.e., also unconscious, positive self-esteem influ-
ments towards the self-photos. Thus, rather than ence beforehand (Naumann et al. 2015). Results
showing avoidance behavior towards their bod- suggesting a causal relationship between self-
ies, patients with AN seem to fixate their bodies esteem and body satisfaction (Hoffmeister et al.
with their gaze. In relation to a “negativity bias” 2010; Svaldi et al. 2011b) have also been found
(focusing on subjectively perceived “ugly” body in preclinical studies in women with pronounced
areas), vigilance towards one’s own body could body dissatisfaction. This further supports etio-
contribute to the maintenance of body image logical assumptions regarding the development
disturbances in AN. of eating disorders, which draw on the relation
In contrast, women with BN showed a ten- between low self-esteem and the development of
dency for a reverse pattern: Eye movements body image problems. However, findings in this
were faster towards other-photos than towards area are still contradictory (e.g., Kästner et al.
self-photos, which might be interpreted as 2019; Linardon et al. 2019), underlining the
avoidance towards the perception of self-images need for more intensive research on the role of
(Blechert et al. 2010). Studies on experimen- self-esteem for eating disorder symptoms and, in
tal figure exposure have shown, among other particular, body image disturbances.
things, that particularly when using video-
based body exposure, which seems to allow  Important In the psychotherapy of body
less avoidance behavior than imagery-supported image disturbances, it is important to focus
exposure, pronounced negative affective reac- on avoidance behavior.
tions are evoked (Tuschen-Caffier et al. 2003).
Interestingly, it shown that patients with a BN However, based on the current state of research,
diagnosis took less time to describe so-called the mechanisms of maintaining and changing
problem areas (abdomen, hips, buttocks) than clinically relevant body image disorders are
did women in a control group who did not still largely unknown. In light of the definition
have an eating disorder diagnosis. This can be of body image disturbances as a disturbance in
interpreted as an indication that patients with various phases of body-related information pro-
BN show subtle forms of avoidance when con- cessing (see above), it seems reasonable to place
fronted with their perceived unattractive body more emphasis on the investigation of various
areas, despite the very direct exposure to their aspects of body-related information processing
bodies. Avoidance behavior may also contrib- (e.g., attention processes, implicit evaluative
ute to the intensification of the overvaluation processes) in future research.
of shape and weight and to the maintenance Previous findings suggest that, among other
of the psychopathology of eating disorders. things, a specific eye movement pattern (vigi-
Consequently, avoidance behavior might be an lance towards body areas perceived as unattrac-
important mechanism for maintaining clinically tive) may be partly responsible for maintaining
relevant body image disturbances, which in turn body image disturbances.
would have important implications for the psy- On the other hand, there is also evidence that
chotherapy of body image disturbances. avoidance behavior may be an important main-
Furthermore, a recent experimental study taining factor of body image disorders: It has
in women with BED using a subliminal, i.e., been shown that both body checking and body
avoidance are more pronounced and more fre- intervention strategies used, but also in the sense
quent in patients with eating disorders than of an empirical foundation of etiological mod-
in non-clinical individuals (Nikodijevic et al. els, then the evidence-based investigation of the
2018; Walker et al. 2018). Comparing one’s own maintaining mechanisms of body image disor-
body with that of others, touching the abdo- ders forms the necessary basis for deriving tai-
men and thighs, and inspecting them in the lored intervention principles for changing body
mirror are most frequently mentioned as check- image disturbances. With regard to the reported
ing behaviors by patients with eating disorders. findings on eye movement patterns in patients
In addition, meta-analyses have shown strong with eating disorders when confronted with their
correlations between avoidance and checking bodies, the question arises, for example, whether
behaviors and the overvaluation of shape and body image exposure can be the right form of
weight in both subclinical and clinical groups changing these gaze patterns that contribute to
with eating disorder pathology (Nikodijevic an unfavorable form of body-related informa-
et al. 2018; Walker et al. 2018). tion processing (e.g., directing attention to non-
As a working hypothesis, it can be concluded accepted body areas).
that both vigilance and checking (e.g., focus on In our opinion, this is the case if the exposure
negatively evaluated body areas) as well as the is carried out as therapeutically guided expo-
avoidance of body-related information may con- sure, in which the patient’s attention is directed
tribute to the maintenance of clinically relevant to both accepted and less accepted body areas.
body image disturbances in different phases of In this way, a balanced body-related information
information processing. processing can be established through exposure
(Hilbert and Tuschen Caffier 2004; Hilbert et al.
2002; Vocks et al. 2018). However, the effective-
Body Image Disturbances: Empirical Findings ness of body exposure can hardly be reduced to
on Maintenance Mechanisms extinction through habituation. It is likely that
In line with the definition of body image dis- the systematic directing of attention to accepted
turbances as disturbances in various phases of and less accepted body areas triggers informa-
body-related information processing, it seems tion processing processes that contribute to a
worthwhile to investigate processes of infor- more balanced body perception and evaluation.
mation processing, such as visual attention The question of the mechanisms of action of
towards or away from body-related informa- body therapy should be given increased attention
tion. Possibly, both vigilance and checking in future research.
behavior as well as avoidance behavior can
be considered as significant mechanisms in
the maintenance of clinically significant body References
image disturbances. Such knowledge from
basic research has important implications for American Psychiatric Association (APA) (2013)
Diagnostic and statistical manual of mental dis-
the psychotherapy of body image disorders. orders, 5th edn., DSM-5TM. American Psychiatric
Publishing, Washington, DC
Bauer A, Schneider S, Waldorf M, Braks K, Huber TJ,
Adolph D, Vocks S (2017) Selective visual attention
8.4 Evaluation of Existing Findings towards oneself and associated state body satisfac-
tion: an eye-tracking study in adolescents with differ-
In conclusion, the question arises as to what ent types of eating disorders. J Abnorm Child Psychol
45:1647–1661
contribution findings from basic research can Blechert J, Ansorge U, Tuschen-Caffier B (2010) A
make in optimizing body image therapies. If body-related dot-probe task reveals distinct atten-
one understands evidence-based psychother- tional patterns for bulimia nervosa and anorexia ner-
apy not only as the empirical foundation of the vosa. J Abnorm Psychol 119(3):575–585
Brockmeyer T, Anderle A, Schmidt H, Febry S, Wünsch- dissatisfaction in anorexia and bulimia nervosa. J
Leiteritz W, Leiteritz A, Friederich HC (2018) Body Psychiatr Res 82:119–125
image related negative interpretation bias in anorexia Naumann E, Biehl S, Svaldi J (2019) Eye-tracking study
nervosa. Behav Res Ther 104:69–73 on the effects of happiness and sadness on body dis-
Cash TF, Deagle EA (1997) The nature and extent of satisfaction and selective visual attention during mir-
body-image disturbance in anorexia nervosa and ror exposure in bulimia nervosa. Int J Eat Disord
bulimia nervosa: a meta-analysis. Int J Eat Disord 52(8):895–903
22:107–125 Nikodijevic A, Buck K, Fuller-Tyszkiewicz M, de Paoli
Hilbert A, Tuschen Caffier B (2004) Body image inter- T, Krug I (2018) Body checking and body avoidance
ventions in a cognitive-behavioural therapy of binge in eating disorders: systematic review and meta-anal-
eating disorder: a component analysis. Beh Res Ther ysis. Eur Eat Disord Rev 2018:1–27
42:1325–1339 Svaldi J, Bender C, Tuschen-Caffier B (2010) Explicit
Hilbert A, Tuschen-Caffier B, Vögele C (2002) Effects memory bias for positively valenced body-related
of prolonged and repeated body image exposure in cues in women with binge eating disorder. J Behav
binge-eating disorder. J Psychosom Res 52:137–144 Ther Exp Psychiatry 41(3):251–257
Hoffmeister K, Teige-Mocigemba S, Blechert J et al Svaldi J, Caffier D, Tuschen-Caffier B (2011a) Attention
(2010) Is implicit self-esteem linked to shape and for ugly body parts is increased in women with binge
weight concerns in restrained and unrestrained eat- eating disorder. Psychother Psychosom 80:186–188
ers? J Behav Ther Exp Psychiatry 41:31–38 Svaldi J, Zimmermann S, Naumann E (2011b) The
Jansen A, Nederkoorn C, Mulkens S (2005) Selective impact of an implicit manipulation of self-esteem on
visual attention for ugly and beautiful body parts in body dissatisfaction. J Behav Ther Exp Psychiatry
eating disorders. Beh Res Ther 43:183–196 43(1):581–586
Kästner D, Löwe B, Gumz A (2019) The role of self- Svaldi J, Bender C, Caffier D, Ivanova V, Mies N,
esteem in the treatment of patients with anorexia Fleischhaker C, Tuschen-Caffier B (2016) Negative
nervosa—A systematic review and meta-analysis. Int mood increases selective attention to negatively
J Eat Disord 52(2):1–16 valenced body parts in female adolescents with ano-
Legenbauer T, Radix AK, Naumann E, Blechert J (2020) rexia nervosa. PLoS One 11(4):e0154462
The body image approach test (BIAT): a potential Tuschen-Caffier B, Vögele C, Bracht S, Hilbert A
measure of the behavioral components of body image (2003) Psychological responses to body shape expo-
disturbance in anorexia and bulimia nervosa? Front sure in patients with bulimia nervosa. Beh Res Ther
Psychol 11:30 41:573–586
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Efficacy of psychotherapy for bulimia nervosa and Braks K, Svaldi J (2015) Selective visual attention
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Mölbert SC, Klein L, Thaler A, Mohler BJ, Brozzo C, Vocks S, Bauer A, Legenbauer T (2018)
Martus P … Giel KE (2017) Depictive and metric Körperbildtherapie bei Anorexia und Bulimia
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Naumann E, Tuschen-Caffier B, Voderholzer U, Schäfer Weltgesundheitsorganisation (WHO) (2020)
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ance and rumination on media-induced body and morbidity statistics, 11th edn. http://www.who.
int/classifications/icd/en/. Accessed 18. Aug. 2020
Diagnosis of Eating Disorders
9
Ulrich Schweiger
Contents
9.1 Screening for Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
9.2 Detailed Psychological Assessment for a Suspected Eating Disorder . . . . . 60
9.3 Medical Diagnostics for Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
9.4 Differential Diagnostic Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
9.1 Screening for Eating Disorders  Important Every doctor or psychologist

should consider the possibility of an eat-
To optimize the success of treating an eating ing disorder in new patients, determine
disorder, patients with eating disorders should height and weight, and ask some screening
receive help early on. Patients should not be iden- questions.
tified only when they themselves or persons close
to them show an active desire for change or when  Important For early detection of eating disor-
obvious health consequences have occurred. To ders in a general practitioner setting, the fol-
promote early detection, public availability of lowing two questions should be considered
valid information about the nature of eating dis- first:
orders and the possibilities for treatment is impor-
• “Do you have a problem with eating?”
tant. The first point of contact for patients with
• “Are you worried about your weight or
eating disorders is often not with psychiatrists,
psychosomatic specialists, or psychotherapists, your diet?”
but with other doctors, such as general practition-
ers, dentists, and gynecologists. Therefore, all of
these professional groups in the healthcare sector Possible additional screening questions
need to be vigilant to eating disorders. for the identification of eating disorders
• Are you satisfied with your eating
behavior?
Ulrich Schweiger is deceased • Do you have an eating problem?
• Are you worried about your weight or
your diet?
U. Schweiger (*)
University of Lübeck, Lübeck, Germany
https://doi.org/10.1007/978-3-662-67662-2_9
60 U. Schweiger
9.2 Detailed Psychological

• Does your weight affect your Assessment for a Suspected
self-esteem? Eating Disorder
• Are you concerned about your figure?
• Do you eat in secret? 9.2.1 Search for Physical,
• Do you vomit when you feel uncom- Psychological,
fortably full? or Behavioral
• Are you worried because you some- Characteristics of an
times can’t stop eating? Eating Disorder
If none of these questions are answered in the 9.2.1.1 Underweight or Overweight

affirmative, the false-negative rate is 8%; if at The patient should be weighed and measured in
least one question is answered in the affirmative, underwear and without shoes using calibrated
the false-positive rate is 44% (Mond et al. 2008). instruments. The evaluation and assessment
Special attention should be given to the fol- of the measured values should be carried out
lowing groups of people at risk. using suitable formulas (BMI = kg/m2), nor-
mal ranges, or age-related percentile curves. In
addition to the current weight, the weight course
Risk Groups for the Development of (e.g., speed of weight loss) is also significant.
Eating Disorders
• Patients with low body weight or sig- 9.2.1.2 Psychological and Behavioral
nificant weight loss Characteristics
• Patients with amenorrhea or infertility These include:
• Patients with dental damage
• Patients who attend a consultation with • intense mental preoccupation with food and
concerns about their weight but are of food-related topics,
normal weight • fear of being too fat—despite being under-
• Patients who are overweight and come weight or of normal weight—,
to the doctor, for example, because diets • undue influence of body weight on self-
have failed esteem—use of eating behavior for emotion
• Patients with gastrointestinal disor- regulation (e.g., restrictive eating to avoid
ders that cannot be clearly attributed to body-related shame despite normal weight).
another medical cause
• Children and adolescents with growth The assessment of the patient’s information
delay requires knowledge about normative age-
• Patients who work in the entertainment, related attitudes and the cultural background.
fashion, or nutrition industry Restrictive eating can also be motivated by
• Patients who engage in competitive ascetic ideals, i.e., the idea of approaching spir-
sports itual goals through self-control and renunciation.
• Children and adolescents whose parents Differential diagnosis should consider genuine
show concern about their weight and loss of appetite in the context of severe depres-
eating behavior sive episodes or physical illnesses.
The aspect of inappropriateness or pathology
does not arise solely from this self-appraisal, but
9 Diagnosis of Eating Disorders 61
from the fact that such thoughts occupy con- • Excessive consumption of fluids before meals
siderable space, the affected individuals cannot to limit food intake,
gain any critical distance from them, and the • Fluid restriction to limit food intake, e.g., by
self-esteem of the affected individuals is sig- causing a dry mouth,
nificantly reduced or significant dysfunctional • Selection and intake of unattractive food
behavior is maintained by these thoughts. or food rendered unattractive, for example by
adding excessive salt or hot spices,
 Important A self-assessment as “too fat” is • Use of disgust conditioning to block the
also common among healthy young women intake of attractive foods, e.g., imagining
and men in the Western world. chocolate being contaminated with mouse
droppings,
In patients with eating disorders, social compari- • Avoidance of eating in the company of oth-
son processes are often paramount in directing ers to avoid distraction during meals or other
attention. For example, when entering a room social influences,
or joining a group, they immediately establish • Use of constricting abdominal belts, restric-
a ranking of the figure of the present same-aged tive clothing, or tensing the muscles to create
women and compare themselves to the slimmest a premature feeling of fullness during meals,
person. • Use of tongue piercings or self-injury in the
oral cavity to make food intake more difficult.
9.2.1.3 Restriction of Calorie Intake
In eating disorders, there is typically a cluster 9.2.1.4 Binge Eating
of goal-oriented behaviors that serve to restrict The term “binge eating” describes an episode
calorie intake: of food intake in which the usual control over
eating behavior is lost or not exercised. In an
• Checking behavior, e.g., frequent weighing to objective binge eating episode, amounts of
closely monitor changes in body weight, food are consumed that, in terms of their calo-
• Avoidance of high-calorie, fatty, or carbohy- rie count, exceed the scope of a normal meal. An
drate-rich foods, exact calorie limit is not defined in the diagnos-
• Skipping meal components such as dessert or tic manuals of DSM or ICD. In scientific stud-
entire meals, ies, 1000 Kcal is often taken as the lower limit.
• Chewing and spitting out food, The typical calorie count is between 3000 and
• Balancing meals by acquiring calorie knowl- 4500 Kcal. Food intake that is unplanned or
edge and calorie counting, as well as weigh- unwanted, subjectively insufficiently controlled,
ing all food, but objectively does not represent excessive
• Avoidance of foods whose calorie content amounts, can also be perceived as binge eat-
cannot be clearly determined, such as coming. In the case of a long-standing eating disor-
plex dishes prepared by others, der, binge eating episodes are usually planned,
• Use of sweeteners, fat substitutes, and “diet” meaning that suitable foods are purchased,
products, stored, and care is taken to ensure that no one
• Use of pharmacological appetite suppres- disturbs the person during the binge eating
sants, nicotine, cocaine, or other stimulants episode.
for appetite control,
• Changes in mealtime schedules, for example 9.2.1.5 Compensatory Behavior
by limiting intake to a single meal per day or This refers to a spectrum of goal-oriented behav-
by imposing a self-imposed structure with a iors aimed at rapidly removing absorbed energy
multitude of small meals, or fluids from the organism:
62 U. Schweiger
• Vomiting can occur automatically, after suffering from an eating disorder, it is important
mechanical irritation of the pharynx, or sup- to also apply the diagnostic categories of atypi-
ported by chemical substances that promote cal eating disorders or eating disorders not oth-
vomiting, such as Radix Ipecacuanae or salt erwise specified.
solutions, Suitable for operationalized diagnostics are:
• Intake of plant-based or synthetically manu-
factured laxatives, Interview-based cross-disorder instruments
• Intake of plant-based or synthetically manu- for categorical diagnostics These instruments
factured diuretics, have the advantage of covering a broad spec-
• Intake of thyroid hormones (to increase basal trum of important comorbid conditions. They
metabolic rate), have the disadvantage of only querying the cri-
• Exercise and exposure to cold, teria relevant to DSM or ICD diagnoses, mak-
• Omission of insulin in patients with type 1 ing the detection of atypical eating disorders or
diabetes to induce renal loss of glucose. eating disorders not otherwise specified some-
what more difficult. Important examples are:
All measures that promote vomiting or diarrhea Structured Clinical Interview for DSM-5
are summarized as purging behavior. (SCID), Diagnostic Interview for Mental
Disorders (DIPS), International Diagnostic
Checklists (IDCL).
9.2.2 Assessment of Impairment
due to Disturbed Eating Interview-based eating disorder-specific cat-
Behavior egorical instruments These have the advantage
of not only covering the diagnostic criteria but
Individual behaviors that occur in eating dis- also accurately depicting various aspects of the
orders are also observed in healthy men and specific psychopathology of the eating disorder.
women, particularly in adolescence (e.g., diet- Symptoms that can be attributed to comorbid-
ing, induced vomiting, intense exercise for ity are also recorded, but there is no systematic
weight control). The assessment of behaviors as recording of the criteria for comorbid disor-
pathological cannot be based solely on frequen- ders. Important examples are: Eating Disorder
cies or intensities. Rather, in each individual Examination (EDE), Structured Inventory for
case, it must be examined whether the specific Anorexic and Bulimic Disorders for Expert
behavior results in a relevant impairment or Assessment (SIAB-EX).
endangerment of physical health, psychosocial
functioning, or significant subjective distress. Questionnaire-based instruments for dimen-
sional diagnostics in adults These instruments
are suitable for further detailed recording of
9.2.3 Operationalized Diagnostics the specific psychopathology of the eating dis-
order, also in the course of the disorder, and in
If the suspicion of an eating disorderpersists some cases also cover aspects that are not the
after the previous steps have been taken, it subject of the categorical interviews. Important
should be formally checked whether the cri- examples are: Eating Disorder Examination-
teria for an eating disorder according to an Questionnaire (EDE-Q), Eating Disorder
operationalized diagnostic system such as ICD- Inventory (EDI, EDI-2), Questionnaire on
11 or DSM-5 are met. Checklists or structured Eating Behavior (FEV), Structured Inventory
interviews are used for this purpose. In order to for Anorexic and Bulimic Eating Disorders
provide adequate help to all women and men for Self-Assessment (SIAB-S), Munich Eating
and Feeding Disorder Questionnaire (Munich between QTc prolongation and sudden cardiac
ED-Quest). death.
For a detailed description of the psychomet-
ric properties and the sources of these question- Body Temperature
naires, see the S3 Guideline Eating Disorders Hypothermia, with a temperature below 36.0 °C,
(Vocks et al. 2019). occurs in up to 22% of patients with AN.
Thorax
9.3 Medical Diagnostics Mitral valve prolapse is more common in AN.
for Eating Disorders
Abdomen
The main purpose of medical diagnostics is to Changes in gastrointestinal motility are common
prevent danger by detecting complications of the in all forms of eating disorders. Acute abdomen,
eating disorder, and in rarer cases, for differen- for example, due to acute gastric dilatation, is
tial diagnostic clarification. rare.
Anthropometry in eating disorders Vascular Status

Patients with the onset of an eating disorder in Acrocyanosis is common in AN.
adolescence often fall behind in their linear
growth. In adults with a BMI < 15 kg/m2, hos- Oral Cavity, Salivary Glands
pital treatment should be considered. A BMI Patients who vomit, in particular, have a higher
< 12 kg/m2 represents a particular risk factor frequency of tooth damage and enlargement of
for mortality. In children and adolescents, the the parotid glands and lingual salivary glands.
pubertal status should be assessed according to The concentration of salivary amylase in serum
the Tanner classification. is increased in patients with eating disorders
depending on the bulimic symptoms.
Heart Rate, Blood Pressure, and Orthostatic
Test Skin Surface
Bradycardia with a heart rate below 40 per min- Dry skin, hair loss, acne, skin pigmentation dis-
ute, tachycardia with a resting heart rate above orders, yellowing of the skin due to hyperca-
110 per minute, a blood pressure of less than rotinemia, petechiae, neurodermatitis changes,
90/60 mmHg, a drop in blood pressure of more livedo vasculitis, intertrigo, generalized itching,
than 20 mmHg, or an increase in heart rate of skin infections, and striae distensae are observed
more than 20 in the orthostatic test are risk indi- in all forms of eating disorders. Underweight
cators and should prompt a review of the need patients often have typical lanugo hair. Patients
for inpatient treatment. Approximately 43% of who induce vomiting may have calluses on the
patients with AN have a heart rate below 60 per back of the dominant hand (Russell’s sign).
minute, about 17% below 50 per minute .
Blood Count
Electrocardiogram About 34% of patients with AN have mild
A prolonged QTc interval can occur in leukopenia, rarely a pronounced leukope-
patients with eating disorders in connection nia. Thrombocytopenia occurs in about 5%.
with electrolyte disturbances caused by vom- Hematocrit and mean corpuscular volume
iting and other forms of purging behavior. (MCV) are usually in the lower reference range.
Psychopharmacotherapeutic interventions can
also contribute to QTc prolongation. The phe- Electrolytes
nomenon is relevant due to the association Rapid changes in electrolyte concentrations can
occur in the case of intense vomiting, but also
64 U. Schweiger
during refeeding. In particular, potassium in Sex Hormones

serum can be within the reference range dur- In AN, there are regularly reduced concentra-
ing dehydration, but intracellular potassium tions of estradiol, progesterone, and luteinizing
can be significantly reduced. About 20% of hormone (LH). Other forms of eating disorders
patients with eating disorders have hypoka- also often show disturbances in sex hormone
lemia, about 7% have hyponatremia, and secretion.
about 6% have low concentrations of calcium.
Hypophosphatemia mainly occurs during paren- Bone Density
teral refeeding but can also result from high car- Bone density is significantly reduced early on in
bohydrate consumption after a prolonged period AN.
of fasting. Similar associations also apply to
hypomagnesemia. Brain Imaging Studies
Common findings in AN and BN are enlarge-
Blood Glucose ments of the outer and inner cerebrospinal fluid
Even with severe malnutrition, blood glucose spaces.
is usually in the lower reference range. In com-
bination with other factors such as infectious
diseases or intoxications, life-threatening hypo- 9.4 Differential Diagnostic
glycemia can occur. A blood glucose level Considerations
lower than 60 mg/dl is considered an indicator
of risk.
The diagnosis of an eating disorder is rarely a
diagnosis of exclusion. AN is the most common
Kidneys cause of pronounced underweight in Western
Due to the reduced muscle mass, creatinine con- society. One difficulty lies in distinguishing
centrations in AN are typically in the low refer- AN with mild underweight from constitutional
ence range. Chronic hypokalemia, especially
forms of underweight. Women with constitu-
in the case of persistent vomiting and laxative
tional underweight are usually only borderline
abuse, can lead to kidney failure due to hypoka-
underweight. The psychological features of an
lemic nephropathy in individual patients with an
eating disorder are absent, endocrine functions
eating disorder.
are inconspicuous, and in particular, there is
no amenorrhea. It is difficult to distinguish
Liver
between BED and overweight that is not caused
About 12% of patients have elevated concentra-
tions of liver enzymes. Acute severe damage to by an eating disorder. In this case, it is impor-
the liver can occur in AN. tant to check whether the psychological features
of binge eating required by the DSM are actu-
ally present. Furthermore, it should be inves-
Adrenal Glands
tigated which risk factors for the development
The secretion of the stress hormone cortisol
is regularly increased in AN and in individual of obesity are present (e.g., physical activity,
cases of other forms of eating disorders . food quality, substance use, medical factors).
Neurological or endocrinological diseases that
mimic the physical and psychological features
Thyroid
Reduced concentrations of triiodothyronine (T3) of a bulimic eating disorder are rare.
( “Low T3 Syndrome”) are found regularly in
AN and in individual cases of BN.
However, the diseases mentioned in the over-

Differential diagnoses for underweight view rarely result in a similar temporal pattern
• Tumor diseases (brain, stomach, pan- of vomiting to that found in a typical eating
creas, lung, lymphomas, leukemia) disorder.
• Endocrine disorders (diabetes, hyper-
thyroidism, adrenal insufficiency)
• Gastrointestinal disorders (celiac dis- Differential Diagnoses for Overweight
ease, cystic fibrosis, esophageal steno- • Lack of exercise—sedentary life-
sis, chronic occlusion of the superior style, a large number of hours in front
mesenteric artery, Crohn’s disease, of a screen—, unfavorable dietary
ulcerative colitis) composition
• Infectious diseases (tuberculosis, para- • Poor food quality (“junk food”, sugary
sitic infections, systemic fungal infec- drinks, high-fat diet)
tions, HIV) • Consumption of alcohol, cannabis, or
• Psychiatric disorders (depression, other appetite-increasing substances
anxiety, and obsessive-compulsive • Endocrine disorders (Cushing’s syn-
disorders, somatoform disorders, drome, hypothyroidism, insulinomas)
schizophrenia) • Neurological disorders (dam-
• Drugs and substance abuse (multiple age to the medial hypothalamus,
drug use, heroin, amphetamines) craniopharyngioma)
• Genetic syndromes
Differential diagnoses for vomiting

• Brain tumor diseases (especially hypo- References
thalamic tumors)
Mond JM, Myers TC, Crosby RD, Hay PJ, Rodgers B,
• Endocrine diseases (diabetes, pregnancy Morgan JF, Lacey JH, Mitchell JE (2008) Screening
vomiting) for eating disorders in primary care: EDE-Q versus
• Gastrointestinal disorders (gastric or SCOFF. Behav Res Ther 46:612–622
duodenal ulcers, chronic pancreatitis, Vocks S, Schweiger U, Hilbert A, Hagenah U, Tuschen-
Caffier B (2019) Diagnostik von Essstörungen.
intestinal parasitic infections, connec- In: Herpertz S, Fichter M, Herpertz-Dahlmann B,
tive tissue disorders involving the gas- Hilbert A, Tuschen-Caffier B, Vocks S, Zeeck A
trointestinal tract such as scleroderma) (Hrsg) S3-Leitlinie Diagnostik und Behandlung der
Essstörungen. Springer, Berlin
Part II
Epidemiology, Etiology, and Course of
Eating Disorders
67
Prevalence and Incidence
of Anorectic and Bulimic 10
Eating Disorders
Manfred Fichter
Contents
10.1 Prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
10.2 Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Epidemiology deals with the distribution of illness upon questioning, case identification can
diseases in space and time and with factors become difficult.
that influence this distribution. In the follow- Other important terms in epidemiology are
ing, some important terms of epidemiology prevalence, incidence, and mortality rates.
are defined and explained. Often, epidemiol-
ogy is interested in the frequency and distribu- Prevalence Prevalence refers to the total num-
tion of certain diseases in complete populations ber of cases in the population (usually expressed
(e.g., all people aged 15 – 25 years). However, as a percentage). Depending on the time period
since complete surveys in large populations are to which the prevalence refers, we speak of
very complex, often one (or more) sample(s) is point prevalence (refers to a specific cross-sec-
drawn, which is supposed to be representative of tion of time, e.g., today) or period prevalence
the underlying population. If the sample is rep- (refers to a time period, e.g., one year). Thus,
resentative, the determined results can be gener- the one-year prevalence corresponds to the num-
ber of cases observed during one year. The life-
alized to the population. If we want to capture
time prevalence corresponds to the number of
a specific disease in a representative population
cases that occur during an entire lifespan. Since
sample, it is necessary that the disease is clearly
the prevalence rate includes the total number
defined and that measurement instruments are
of diseases at a specific point in time or a spe-
available that can reliably and validly capture
cific time period, it is important for planning in
this disease. In the case of a slightly under- healthcare.
weight anorexic person who also denies the
Incidence rate Another important term is the
incidence rate (new case rate). This is the num-
M. Fichter (*) ber of new cases of a specific disease in the pop-
Schoen Clinik Roseneck affiliated with the Medical
Faculty of the University of Munich (LMU), ulation occurring within a defined time period.
Prien, Germany A common unit for incidence is the number of
e-mail: [email protected] new cases per 100,000 people in the population
https://doi.org/10.1007/978-3-662-67662-2_10
70 M. Fichter
per year. The one-year prevalence corresponds • In some institutions, such as schools or col-
to the point prevalence plus the annual incidence leges, most individuals of certain age groups
rate. In some cases, conclusions about the eti- are grouped together, so that complete sur-
ology of a disease can be drawn from the inci- veys of one or more schools can make state-
dence rate. ments about the total population of this age
group. However, a high school class would
Mortality Regarding mortality, a distinction is not be representative of the total population
made between a “Crude Mortality Rate” (CMR) because most students of that age group do
and a “Standardized Mortality Ratio” (SMR). not attend high school. In addition, (sick) stu-
CMR is usually expressed as a percentage of dents may be absent at the time of the survey,
deceased persons in a sample. The standardized thus distorting the results.
mortality rate is the number of observed deaths
• The cleanest approach is to draw a represent-
in individuals with a specific disease compared
ative population sample from the municipal
to the expected death rate in the comparison
register, which is possible in Scandinavian
population.
countries and Germany due to the obligation
For a topic like eating disorders, the change
to register, if there is a demonstrable public
in prevalence, incidence, and mortality over time
interest in a study.
is also of interest. Are these diseases decreasing
or increasing? Are mortality rates decreasing
In some of these representative population
due to improved treatment options? When using
samples, all individuals of the total popula-
prevalence and incidence figures from other dec-
tion are examined (e.g., all women of a defined
ades, it should be noted that these were usually
age group in a city). Because this is very time-
recorded with different survey instruments and
consuming for large populations (= total popu-
diagnostic concepts, so the figures are often not
lation), a two-stage procedure is often used. In
directly comparable. Since bulimia nervosa was
the first stage, a screening can be carried out in
first described in 1979, there are no epidemio-
a population sample (e.g., recording of weight
logical studies on this disease before this time,
and height and completion of a questionnaire
which does not necessarily mean that it did
screening for eating disorders). In the second
not exist or only existed to a minor extent. The
stage, those individuals with weight abnormali-
question cannot be answered scientifically with
ties or questionnaire results above a cut-off in
precision.
the screening are personally re-examined using a
There are various methods to obtain a repre-
structured interview.
sentative sample as accurately as possible.
• Assuming that all patients will eventually

visit a doctor or clinic (which is not really 10.1 Prevalence
the case with eating disorders), case regis-
ters have been set up in various locations and Table 10.1 provides an overview of selected
maintained over many decades. Based on the important studies on the prevalence of anorexia
statistics of the case register, statements can nervosa (AN), bulimia nervosa (BN), binge-
then be made about the prevalence and inci- eating disorder (BED), and unspecified eating
dence of defined diseases. disorders (ED-NOS). The prevalence rates for
• In some countries, such as England, almost women with eating disorders are significantly
every citizen is assigned to a “General higher than for men. Particularly, men with ano-
Practitioner” (GP), and the register of the GP rexia or bulimia nervosa exhibit doctor-averse
or several combined GP registers is used as behavior. Many men with eating disorders avoid
the basis for calculating prevalence and inci- seeing a doctor or therapist altogether. The fre-
dence rates. quencies listed in the tables are mainly based
10
Table 10.1  Prevalence of anorexia nervosa (a), bulimia nervosa (b), and binge-eating disorder (c) according to the criteria of DSM-III-R, DSM-IV (TR), and DSM-5
(© M.M. Fichter)
Persons Method Prevalence
Authors Source Age (Y) N Screeninga) Criteria Total Men Women
a) Anorexia Nervosa
Wittchen et al. (1998) Population sample (Germany) 14–24 1528 M-CIDI DSM-IV 0.10b) 0.00b) 0.30b)
0.60c) 0.10c) 1.00c)
Fichter et al. (2005) Female students (Greece) 13–19 2920 ANIS/SIAB-EX DSM-IV 0.30a) 0.00a) 0.59a)
Bulik et al. (2006) Swedish twin cohort DSM-IV narrow diagnostic criteria - - 1.20 c)
1935–1958 broad diagnostic criteria 2.40c)
Wade et al. (2006) Australian twin cohort 28–39 DSM-IV narrow diagnostic criteria – - 1.90 c)
1935–1958 broad diagnostic criteria 4.30c)
Machado et al. (2007) Female students (Portugal) 12–23 2028 EDE-S DSM-IV – - 0.39a)
Hudson et al. (2007) Population sample (USA) >18 2980 WHO-CIDI DSM-IV 0.00b) 0.00b) 0.00b)
0.60c) 0.30c) 0.90c)
Jacobi et al. (2014) Population sample 18–79 5318 DEGS-CIDI DSM-IV 0.20 0.10 0.30
Keski-Rahkonen et al. (2007)/ Twin cohort (Finland) 25 2881 EDI/Short-SKID DSM-IV (narrow) – – 2.20c)
Raevuori et al. (2009)d) 1975–1979 DSM-IV (broad) – – 4.20c)
Prevalence and Incidence of Anorectic and Bulimic Eating …
Preti et al. (2009) Population sample (Europe) 18+ – 0.00c) 0.90c)

Swanson et al. (2011) Population sample (USA) 13–18 10,123 CIDI DSM-IV – 0.10b) 0.20b)
– 0.20c) 0.30c)
Favaro et al. (2003) Population sample (Italy) 18–25 934 SCID-I DSM-IV – – 2.00c)
Mohler-Kuo et al. (2016) Population sample (Switzerland) 15–60 10,038 – DSM-IV 0.7 0.2 1.7
Smink et al. (2014) Population sample (NL) Adolescence 2,149 – DSM-5 – 0.1 1.7
Lifetime prevalence
b) Bulimia Nervosa
Garfinkel et al. (1995) Population sample (Ontario) 15–65 8116 WHO-CIDI DSM-III-R – 0.10c) 1.10c)
Wittchen et al. (1998) Population sample (Germany) 14–24 1528 M-CIDI DSM-IV 0.30b) 0.00b) 0.70b)
14–24 1493 0.90c) 0.00c) 1.70c)
Favaro et al. (2003) Population sample (Italy) 18–25 934 SCID DSM-IV – – 4.60c)
(continued)
71
72
Persons Method Prevalence

Authors Source Age (Y) N Screeninga) Criteria Total Men Women
Fichter et al. (2005) Female students (Greece) 13–19 2920 ANIS/GHQ (DSM-IV) 0.93a) 0.68a) 1.18a)
Hudson et al. (2007) Population sample (USA) >18 2980 WHO-CIDI DSM-IV 0.30b) 0.10b) 0.50b)
1.00c) 0.50c)
Keel et al. (2006) College students College age 2491 EDI DSM-III-R – 1.1a) 4.20a)
1982 – 0.4a) 1.30a)
1992 – 0.0a) 1.70a)
2002
Swanson et al. (2011) Population sample (USA) 13–18 10,123 CIDI DSM-IV 0.60b) 0.30b) 0.90b)
0.90c) 0.50c) 1.30c)
Kessler et al. (2013) Population sample 14 countries >18 24,124 CIDI DSM-IV 0.40b) – –
1.00 c) – –
Smink et al. (2014) Population sample (NL) Adolescence 2149 – DSM-5 – 0.1 0.8
Lifetime prevalence
c) Binge-Eating Disorder (BED)
Favaro et al. (2003) Population sample (Italy) 18–25 934 SCID-I DSM-IV – – 0.60c)
Hudson et al. (2007) Population sample (USA) >18 2980 DSM-IV 1.20b) 0.80b) 1.60b)
2.80c) 2.00c) 3.50c)
Swanson et al. (2011) Population sample (USA) 13–18 10,123 CIDI DSM-IV 0.90b) 0.40b) 1.40b)
1.60c) 0.80c) 2.30c)
Kessler et al. (2013) Population sample 14 countries >18 24,124 CIDI DSM-IV 0.80b) – –
1.00c) – –
Keski-Rahkonen et al. (2009) Twin registry (Finland) 25 2881 EDI/Short-SCID DSM-IV narrow – – 1.70c)
DSM-IV broad – – 2.30c)
Swanson et al. (2011) Population sample 13–18 10,123 CIDI DSM-IV 0.20b) 0.20b) 0.10b)
0.30c) 0.30c) 0.30c)
Cossrow et al. (2016) Population sample (USA) >18 22,397 – DSM-IV – 0.92 2.07
Lifetime Prev.
(continued)
M. Fichter
10 Prevalence and Incidence of Anorectic and Bulimic Eating … 73
on the American DSM-IV criteria. The numbers
EAT = Eating Attitudes Test; EDE-S = Eating Disorders Examination, Screening Version; ANIS = Anorexia Nervosa Inventory Scale; BCDS = Bulimic Cognitive Distor-
Women
given in the tables vary considerably, as preva-
lence and incidence calculations are influenced
2.3
0.6
by several factors: definition of a disease, type
of detection (interview or questionnaire), com-
Men
position of the total population and sample,

0.7
0.3
and the time span to which a result refers. The
Prevalence
point prevalence of AN for women at risk age

Total
between 15 and 35 years is approximately 0.5%.

With the publication of the American DSM-5
–
criteria (American Psychiatric Association

2013), there was a significant change: 1. AN,
BN, and BED were defined somewhat more
broadly, 2. BED became a main category along-
side AN and BN, 3. the area of eating disor-
Criteria
DSM-5
DSM-5
ders was expanded by the area of “Feeding

Disorders.” Feeding Disorders according
to DSM-5 include (regardless of age) Pica,
Rumination Disorder, and “Avoidant/Restrictive
Screeninga)
tions Scale; DIS = Diagnostic Interview Schedule; CIDI = Composite International Diagnostic Interview
Food Intake Disorder (ARFID)” as well as the

Method
category “Other Specified Feeding or Eating

Disorder (OSFED).” The latter includes atypi-
–
cal AN, BN, and BED (not meeting all criteria)

and “Purging Disorder” (PD) and “Night Eating
Adolescence 2149
Adolescence 2149
N
Syndrome” (NES). With the broader definition

of AN, BN, and BED, the prevalence numbers
increased (artificially). The “Lifetime” preva-
Age (Y)
lence for women with AN was 1.2% accord-

ing to the DSM-IV criteria and increased in the
same Swiss sample to 1.9% (Mohler-Kuo et al.
a) Point prevalence, b) 12-month prevalence, c) Lifetime prevalence
2016).
For BN, the point prevalence is likely to be
Population sample (NL)
Population sample (NL)
around 1% (with the lifetime prevalence corre-

spondingly higher at around 1.5%). The BED is,
according to the DSM-IV-TR criteria, broadly
considered an eating disorder NOS and is
Persons
defined in more detail as BED in the appendix

Source
of DSM-IV. The one-year prevalence of DSM-

IV-BED, according to the few available results
for women, is around 1.6%. It is less common in
d) Other Specified Feeding or
men (0.8%) than in women, but the proportion

Eating Disorder (DSM-5)
of men is higher than in AN or BN.

The largest eating disorder group is probably

Smink et al. (2014)
Smink et al. (2014)
the residual group of ED-NOS. Since this is the

Lifetime Prev.
Lifetime Prev.
least defined, prevalence rates vary consider-

ably. In treated eating disorders, the proportion
Authors
of patients who do not meet the criteria for , AN,

BN, and BED accounts for more than 50%.
74 M. Fichter
 Important The point prevalence of anorexia the risk of developing AN may be increased in
nervosa for women at risk age between 15 identical twins.
and 35 years is approximately 0.5%. For bu-
limia nervosa, the point prevalence is likely  Important According to the results of re-
to be around 1% (with the lifetime prevalence cent studies, the incidence rates for AN were
correspondingly higher at around 1.5%). rather stable over the years or even slightly
increasing, especially for girls aged 10–14
years. For BN, the incidence rates decreased
10.2 Incidence somewhat over the years (2010–2016) (Reas
and Rø 2018; Smink et al. 2016; Zerwas et al.
Selected results of incidence studies on AN and 2015).
BN are presented in Table 10.2. The samples
were obtained from hospital archives, case reg- There is little data on the incidence of BN.
istries, and in the British study by Currin et al. Currin et al. (2005) reported an incidence rate
(2005) from the patient registry of general prac- for AN in women of 12.4 per 100,000 person-
titioners. The incidence rates are consistently years. For the Netherlands, van Son et al. 2006
shown for cases per year and per 100,000 peo- showed that for adolescent women aged 15 to
ple in the population. The higher this number, 17 years, incidence rates were much higher
the greater the incidence rate for AN, BN, and than in other age groups, and that there was
BED. The data from Theander (1970) for AN go a very significant increase in the incidence of
back to 1931. For the period from 1931 to 1960, AN from 1985–1989 to 1995–1999. Micali
there is a clear increase in treated cases (women et al. (2003) reported an annual incidence rate
with AN in southern Sweden). A similar trend of 13.6 per 100,000 people in the British popu-
is also evident for the 1960s compared to the lation. Incidence rates for BN are somewhat
1970s in the Monroe County case registry in the higher than for AN, with twin studies by Keski-
USA by Jones et al. (1980) (with information Rahkonen et al. (2009) and Isomaa et al. (2009)
also for men) and the Zurich study (Milos et al. distorting the picture upwards. Incidence rates
2004). In the Danish case registry by Møller- for BED and ED-NOS are not yet available.
Madsen and Nystrup (1992), the incidence rate
was still low in 1970, but significantly higher in Eating Disorders in Developing Countries
1980 and 1989. The study by Lucas et al. (1999) Results from Japan, Hong Kong, and Singapore
in Rochester/USA also shows a gradual increase indicate that eating disorders are similarly com-
in the incidence rate for AN from 1950 to 1989. mon in eastern industrialized regions as in
The implausible values for 1935 to 1949 may western industrialized nations. The situation is
be due to methodological artifacts. The more significantly different in developing and emerg-
recently published works from twin cohorts in ing countries such as Morocco, Iran, Malaysia,
Finland (Keski-Rahkonen et al. 2007, 2009), Fiji Islands, and Mexico, where the prevalence
Australia (Wade et al. 2006) and Sweden (Bulik of eating disorders is considerably lower but on
et al. 2006) show much higher values for inci- the rise.
dence and prevalence. There are several reasons
for this: 1) The samples consist of young women Eating Disorders in Specific Risk Groups
(no men, no elderly people, who have a lower According to several studies, black women living
prevalence of diseases). 2) The population is not in the United States or the Caribbean, although
the entire population, but consists exclusively of seemingly exposed to similar media pressure for
twins. 3) Case identification is different from, thinness as white women, have extremely rare
for example, the large American population cases of AN and less frequent cases of BN than
studies. 4) Due to difficulties in individuation, white women. In contrast, BED and other forms
10
Table 10.2  Annual incidence (new case rate) for anorexia nervosa and bulimia nervosa per year per 100,000 people in the population (© M.M. Fichter)
Authors Region Source Time period (Year) Age group Total Men Women
a) Anorexia Nervosa
Theander (1970) Southern Sweden Hospital archive 1931–1940 All – – 0.10
1941–1950 All – – 0.20
1951–1960 All – – 0.45
Jones et al. (1980) Monroe County Case registry + hospital archive 1960–1969 All 0.35 0.20 0.49
(USA) 1970–1976 All 0.64 0.09 1.16
Møller-Madsen and Nystrup Denmark Case registry 1970 15–24 0.42 3.37
(1992) 1980 15–24 1.36 11.96
1989 15–24 1.17 8.97
Lucas et al. (1999) Rochester, MN Hospital archive 1935–1949 All 9.10 3.40 15.00
1950–1959 All 4.30 0.80 7.60
1960–1969 All 7.00 1.20 12.80
1970–1979 All 7.90 1.40 14.50
1980–1989 All 12.00 1.20 22.90
Martz (2001) Zurich (CH) Hospital archive 1963–1965 12–25 0.55 6.76
Prevalence and Incidence of Anorectic and Bulimic Eating …
Milos et al. (2004) Zurich (CH) Hospital archive 1973–1975 12–25 1.12 16.75
Zurich (CH) Hospital archive 1983–1985 12–25 1.43 16.44
Zurich (CH) Hospital archive 1993–1995 12–25 1.17 19.72
Currin et al. (2005) England, Wales General practitioner (GP) 2000 All 4.70 0.70 8.60
Van Son et al. (2006) Netherlands General Practitioner (GP) Registry 1985–1989 All – – 13.40
15–19 – – 56.40
1995–1999 All – – 15.00
15–19 – – 109.20
Keski-Rahkonen et al. (2007) Finland Twin Registry Born 1975–1979 15–19 – Narrow diagnosis 270.00
– Broad diagnosis 490.00
Micali et al. (2003) United Kingdom General Practitioner Registry 2000–2009 10–49 7.9 1.3 13.60
Reas and Rø (2018) Norway National Patient Registry 2010–2016 10–49 18.8–20.4 – 36.3–42.3
75
(continued)
76 M. Fichter
of binge eating are equally prevalent among

black and white women. At-risk individuals
Women
are adolescent girls and young white women in
200.00
300.00
438.00
20.70
41.00
16.60
29.80
11.80
12.40 western industrialized countries who were overly
adapted in their childhood and could not develop
a positive self-esteem. They are therefore sus-
ceptible to societal norms and are more likely to
Dg. narrow
succumb to the pressure for thinness. They go
Dg. broad
Dg. broad
on diets, try other ways to lose weight, and may
Men
0.70
eventually develop an eating disorder.
1.6
–
–
–
–
There are specific groups that have been

shown to have an even higher risk of develop-
ing an eating disorder. People who engage in
Total
11.8
6.60
excessive sports or even competitive sports, and

–
–
–
–
–
–
–
those who practice classical ballet, are likely to

have an increased risk of developing AN due to
Time period (Year) Age group
the greater focus on their bodies. Sports and bal-

10–49
21–27
15–18
15–19
15–19
15–19
let dancing require a high level of physical fit-

All
All
All
ness, slimness, and body control. Jockeys have

an increased risk because they want to stay light
Born 1975–1979
and often fasted during adolescence to prevent

2000–2009
1985–1989
1995–1999
further growth in size and weight. Wrestlers

and boxers are divided into weight classes and
2000
often try to starve themselves down to a lower

weight class before competitions, which leads to
General Practitioner (GP) Registry
increased rates of eating disorders.

United Kingdom General practitioner registry
General Practitioner (GP)
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Course and Prognosis
of Anorexia Nervosa 11
Stephan Zipfel, Bernd Löwe and Wolfgang Herzog
Contents
11.1 Results of the Research on the Course of AN . . . . . . . . . . . . . . . . . . . . . . . . 80
11.2 Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
11.3 Prognostic Indicators for a Poor Course . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Anorexia nervosa (AN) has not lost its fasci- patients, Lasègue, on the other hand, already
nation since the early case studies by Richard held the opinion that in the case of a clinical
Morton and the subsequent detailed initial picture persisting for several weeks, the course
descriptions in 1873/74 by the then famous often ended chronically.
British physician Sir William Gull and the no Even today, a partly heterogeneous picture
less well-known Frenchman Charles Lasègue. emerges in the evaluation and assessment of the
However, the two initial describers already course of AN. This is due, among other things,
disagreed in their assessment of the course of to the fact that previous studies on the long-term
the disease. While the British Gull reached a course of AN often show common methodologi-
rather optimistic assessment for the majority of cal weaknesses. These points of criticism can be
summarized as follows:
S. Zipfel (*) • Bias due to preselection of the sample

Department of Psychosomatic Medicine and • Application of non-standardized diagnostic
Psychotherapy, Medical University Hospital
Tübingen, Tübingen, Germany
criteria
e-mail: [email protected] • Lack of explicit outcome criteria
B. Löwe
• Lack of consensus on outcome criteria
Institute and Outpatients Clinic for Psychosomatic • Insufficient research design or retrospective
Medicine and Psychotherapy, University Hospital studies
Hamburg-Eppendorf, Hamburg, Germany • High refusal rate
• Indirect follow-up methods
W. Herzog • Lack of sufficient information between meas-
Department of General Internal Medicine and
Psychosomatics, Medical Hospital, University of
urement points
Heidelberg, Heidelberg, Germany • Lack of consideration of previous therapeutic
e-mail: [email protected] interventions
https://doi.org/10.1007/978-3-662-67662-2_11
80 S. Zipfel et al.
11.1 Results of the Research on parameters had an influence on the overall

the Course of AN result:
In the past 100 years, more than 300 stud- • Dropout rate
ies have been conducted on the medium and • Age at onset of illness
long-term course of AN. These range from • Duration of the follow-up study
case-by-case descriptions to multicenter stud- • Time period from which the study originated
ies. A common characteristic of all studies in
patients with AN is the wide range of disease For the core symptoms of AN, a slightly more
spectrum in the long-term course. Steinhausen favorable picture emerged, with weight normal-
(2002) summarized 119 studies on the course ization in 59.6% of patients with AN, on aver-
of AN from the second half of the 20th cen- age 57% experienced a regular menstruation
tury. These included as many as 5590 patients. again, and 46.8% of patients with AN showed
Only one study exclusively covered the course a normalization of eating behavior. In general,
of male patients with AN, otherwise the major- the group of patients who first fell ill before the
ity of patients—as expected—were female. In age of 17 had a better course than the older com-
this review, the patients with AN were divided parison group on average. This group effect was
into two groups: One group was younger than detectable in all course categories. However, it
17 years at the onset of the disease, the second should be noted that a prepubertal onset of AN
group included a mixed group of younger and is associated with a very poor course.
older patients. The follow-up duration ranged As Fig. 11.2 shows, about a quarter of AN
from less than one year to a maximum of 29 patients suffered from affective disorders and
years. In general, the author criticized the lack anxiety disorders during the course of the dis-
of control conditions and an insufficient descrip- ease. Obsessive-compulsive disorders and
tion of therapeutic interventions. For the surviv- substance abuse also frequently occurred as
ing patients, the course was mostly divided into additional comorbid mental disorders. If all
the following three categories: a) global assess- forms of personality disorders, assessed accord-
ment, b) normalization of the core symptoms of ing to DSM-III, are added up, more than 60%
the eating disorder, c) psychiatric comorbidity. of the AN patients examined show a severe
With regard to the overall outcome, the distribu- psychiatric comorbidity with accompany-
tion shown in Fig. 11.1 was obtained. ing personality disorders. Steinhausen (2002)
A comparatively large number of studies also emphasizes that there is a large overlap
used the Morgan and Russell criteria, although between eating disorder pathology and psychiat-
other outcome parameters were also used in ric comorbidity during the course of the disease.
some cases. Due to the heterogeneous sample However, this study does not provide any indica-
sizes for the individual parameters, the per- tion of the direction of the interaction between
centages do not add up to 100%. The following the two factors.
Fig. 11.1  Long-term course 20.8 5 Mortality

of anorexia nervosa—the Recovery
percentages refer to different Improvement
Chron. course
sample sizes; black mortality,
white recovery, light gray
improvement, dark gray chronic 46.9
course. (Data from Steinhausen
2002) 33.5
11 Course and Prognosis of Anorexia Nervosa 81
70
65.4
60
50
40
30
24.1 25.5
20
12 14.6
10
4.6
0
rs
rd ety
or v e
e
de
ni
us
de
is si
s
r
so xi
re
or
de
Ab
er
D pul
r
di /an
ph
so
is
D
om
e
di
zo
tic
nc
ity
e
hi
ro
ta
iv
al
Sc
eu
ve
bs
ct
on
fe
si
Su
rs
Af
es
Pe
bs
O
Fig. 11.2  Psychiatric comorbidity in the course of anorexia nervosa. The percentages refer to different sample sizes.
(Data from Steinhausen 2002)
When examining the course and prognosis, overall remission rates of male and female AN
the initial question is about compelling indica- patients did not differ from each other (40 vs.
tors that are relevant for the decision for inpa- 41%) (Strobel et al. 2019). Our own long-term
tient treatment. In a review article (Zipfel et al. study with a follow-up interval of 21 years
2015), we identified three relevant areas: a) the showed a permanent recovery in just over 50%.
current weight and weight course (e.g., weight Approximately another quarter of the total group
< 14 kg/m2), b) the medical status (e.g., car- had an intermediate or poor course (Zipfel et al.
diac and electrolyte status), and c) other indica- 2000). However, both the working groups of
tors (e.g., severity of eating-related symptoms Herzog et al. (1997) and those of Strober et al.
and psychiatric comorbidity). Looking first (1997) were able to independently demonstrate
at the inpatient area, Fichter and Quadflieg for German and US-American patient groups
(1999) found in their 6-year follow-up study that it takes an average of 5–6 years until the
of women with AN that 55.4% of patients first complete remission.
were completely recovered. The same work- In the ANTOP study (Zipfel et al. 2014),
ing group examined the comparison of men and the world’s largest outpatient therapy study for
women with AN after an initial inpatient treat- adult patients with AN conducted in Germany,
ment. In the initial group of male AN patients, two of the currently recommended (Treasure
40% showed a clinical underweightand 2% et al. 2020) specific psychotherapy methods
showed obesity almost 6 years after inpatient (focal psychodynamic psychotherapy [FPT] vs.
treatment. Compared to the matched female enhanced cognitive-behavioral therapy [CBT-
AN patients, the men gained more weight E]) were compared. Although no superiority
and scored lower in eating disorder-specific was shown for either method, the good news
and general psychopathology. However, the from this study was that the majority of AN
82 S. Zipfel et al.
patients continued to gain weight even in the In our own 21-year follow-up, 16.7% of patients
year after the therapies that were limited to 40 died between the ages of 20 and 40 as a direct
sessions. The strongest predictor for a higher result of AN. In international comparison, mor-
BMI and complete recovery one year after the tality rates for AN range between 0.5 and 1%
end of therapy was primarily a higher start- per year of illness. Converted to the general pop-
ing weight. Negative predictors were an initial ulation, this means a standardized mortality rate
duration of the disease longer than six years as increased by a factor of 5–10. The most com-
a sign of an already chronic course and the pres- mon causes of death are infections with lethal
ence of a diagnosed depression before the start sepsis, electrolyte imbalances with subsequent
of treatment (Wild et al. 2016). A further analy- cardiovascular failure, and suicide (Zipfel et al.
sis showed that, regardless of the therapy form 2015).
applied, therapists should particularly push for A recent study from Sweden showed a sig-
the increased expression of negative emotions nificantly reduced mortality rate for a Swedish
during the middle phase of therapy (Friederich cohort of adolescent patients with AN from the
et al. 2017). In the process analysis of so-called years 1987–1991 compared to a cohort from
“sudden gains,” i.e., a first significant weight the years 1968-1977 (Lindblad et al. 2006). The
gain, we were able to show in the ANTOP authors concluded that the relative risk of dying
study for both therapy directions that a total of in the older group was 3.7 times higher than in
65.9% of AN patients showed such a sudden- the more recent cohort. This is despite the fact
gain weight gain and that the presence of such that general mortality among people with men-
events was associated with a better short- and tal illnesses in Sweden remained the same over
medium-term outcome. Moreover, we were able both survey periods. The authors infer from this
to demonstrate that those patients who showed that the significant decrease in mortality is likely
these phases in earlier stages of therapy had a the result of specialized treatment implemented
better overall course (Brockmeyer et al. 2019). in the meantime.
We were also able to show that both innovative The working group around Arcelus (2011)
manualized therapy forms (CBT-E and FPT) summarized data from 36 quantitative follow-up
were cost-efficient (Egger et al. 2016). studies. For AN, these studies yielded the fol-
lowing outcome during a total of 166,642 per-
 Important The data on the long-term course son-years: The weighted mortality rate for AN
of anorexia nervosa can thus be summarized (deaths per 1000 person-years) was 5.1, while
as follows: The good news is that about half the standardized mortality rate was 5.9. One in
of the patients achieve complete recovery. five deceased AN patients died as a result of sui-
The bad news, however, is that in the other cide. Van Hoeken and Hoek (2020) pointed out
half of cases, a chronic course with signifi- that mortality rates in combined studies, which
cant morbidity and mortality occurs. examined data from both primary and second-
ary medical care, showed a halving of mortality
rates. However, these authors added that patients
11.2 Mortality with AN, in particular, have a 9.4 times higher
rate of “years lived with disability” (YLDs)
In the study by Steinhausen cited above (2002), compared to their healthy age group.
a total of 5% of patients died as a result of AN.
In the differentiated evaluation, however, it was  Important Patients with AN, along with
shown that mortality in studies with a follow-up those with addiction disorders, have the high-
period of more than 10 years increased to 9.4%. est mortality rate among mental illnesses.
11 Course and Prognosis of Anorexia Nervosa 83
11.3 Prognostic Indicators for a social integration were indicators of a good

Poor Course course. Franko et al. (2013) demonstrated in
their large 20-year follow-up study with a mean
Although sufficient weight restoration can now standardized mortality rate (SMR) of 4.4 that the
be achieved in most patients undergoing inten- highest risk of early death occurred within the
sified treatment, studies indicate relapse rates first ten years of illness (SMR 7.7). Prognostic
of up to 42%. Based on different definitions of indicators for increased mortality in this study
relapse and varying lengths of observation inter- were a long duration of illness, substance abuse,
vals, previous studies have shown that the high- low weight, and a reduced psychosocial func-
est risk of relapse occurs during the first year tioning level. The authors concluded that early
after inpatient treatment. Across all previous identification and treatment of those suffering
studies, the average relapse rate was approxi- from AN is necessary.
mately 30%.
Herzog et al. (1997) report that a shorter
duration of illness, younger age, and less pro- References
nounced purging behavior are associated with
a lower relapse rate. Strober and colleagues Arcelus J, Mitchell AJ, Wales J, Nielsen S (2011)
Mortality rates in patients with anorexia nervosa and
(1997) identified AN patients with a compulsion other eating disorders. A meta-analysis of 36 studies.
for excessive sports and exercise behavior as a Arch Gen Psychiatry 68(7):724–731
risk group for relapse. In the sample of patients Brockmeyer T, Michalek S, Zipfel S, Wild B, Resmark
with AN examined by Carter et al. (2004), G, Teufel M, Giel K, de Zwaan M, Dinkel A,
Herpertz S, Burgmer M, Löwe B, Tagay S,
patients with AN with a history of past suicide Rothermund E, Zeeck A, Herzog W, Friederich HC
attempts, more frequent specialized treatments (2019) Sudden gains in cognitive behavioural therapy
for eating disorders, and increased obsessive- and focal psychodynamic therapy for anorexia ner-
compulsive symptoms were also at increased vosa: findings from the ANTOP study. Psychother
Psychosom 88(4):241–243
risk for relapse. Carter JC, Blackmore E, Sutandar-Pinnock K, Woodside
DB (2004) Relapse in anorexia nervosa: a survival
 Important Up to 30% of patients with AN analysis. Psychol Med 34:671–679
experience a relapse in the first year after in- Egger N, Wild B, Zipfel S, Junne F, Konnopka A,
Schmidt U, de Zwaan M, Herpertz S, Zeeck A, Löwe
patient treatment. B, von Wietersheim J, Tagay S, Burgmer M, Dinkel
A, Herzog W, König HH (2016) Cost-effectiveness
A focus of follow-up studies revolves around the of focal psychodynamic therapy and enhanced cogni-
question of how individual risk groups or high- tive-behavioural therapy in out-patients with anorexia
nervosa. Psychol Med 46(16):3291–3301
risk patients can be identified early on. Despite Fichter MM, Quadflieg N (1999) Six-year course and
the problem of a multifactorial and complex outcome of anorexia nervosa. Int J Eating Disord
genesis of AN, the following course predictors 26:359–385
have been identified so far: Fichter MM, Quadflieg N, Hedlund S (2006) Twelve-
year course and outcome predictors of anorexia ner-
Predictors of a poor course were found to vosa. Int J Eating Disord 39:87–100
be low weight before therapy onset (especially Franko DL, Keshaviah A, Eddy KT, Krishna M, Davis
a BMI < 13) and at the end of therapy (BMI < MC, Keel PK, Herzog DB (2013) A longitudinal
15.5) (Hebebrand et al. 1997). Also predictive of investigation of mortality in anorexia nervosa and
bulimia nervosa. Am J Psychiatry 170(8):917–925
a poor outcome were a long duration of illness Friederich HC, Brockmeyer T, Wild B, Resmark G,
before therapy initiation and the presence of an de Zwaan M, Dinkel A, Herpertz S, Burgmer M,
additional mental disorder. The bulimic subtype Löwe B, Tagay S, Rothermund E, Zeeck A, Zipfel
was associated with a 2.5-fold increased risk for S, Herzog W (2017) Emotional expression predicts
treatment outcome in focal psychodynamic and cog-
a poor course. Conversely, an early onset of ill- nitive behavioural therapy for anorexia nervosa: find-
ness, a good parent-child relationship, and good ings from the ANTOP study. Psychother Psychosom
86(2):108–110
84 S. Zipfel et al.
Hebebrand J, Himmelmann GW, Herzog W, survival analysis of recovery, relapse, and outcome
HerpertzDahlmann BM, Steinhausen HC, Amstein predictors over 10–15 years in a prospective study.
M, Seidel R, Deter HC, Remschmidt H, Schafer H Int J Eating Disord 22:339–360
(1997) Prediction of low body weight at long-term Treasure J, Duarte TA, Schmidt U (2020) Eating disor-
follow-up in acute anorexia nervosa by low body ders. Lancet 395(10227):899–911
weight at referral. Am J Psychiatry 154:566–569 Wild B, Friederich HC, Zipfel S, Resmark G, Giel K,
Herzog W, Schellberg D, Deter HC (1997) First recovery Teufel M, Schellberg D, Löwe B, de Zwaan M, Zeeck
in anorexia nervosa patients in the long-term course: A, Herpertz S, Burgmer M, von Wietersheim J, Tagay
a discrete-time survival analysis. J Consult Clin S, Dinkel A, Herzog W (2016) Predictors of out-
Psychol 65:169–177 comes in outpatients with anorexia nervosa—results
van Hoeken D, Hoek HW (2020) Review of the burden from the ANTOP study. Psychiatry Res 244:45–50
of eating disorders: mortality, disability, costs, qual- Zipfel S, Lowe B, Reas DL, Deter HC, Herzog W (2000)
ity of life, and family burden. Curr Opin Psychiatry Long-term prognosis in anorexia nervosa: lessons
33(6):521–527 from a 21-year follow-up study. Lancet 355:721–722
Lindblad F, Lindberg L, Hjern A (2006) Improved sur- Zipfel S, Wild B, Groß G, Friederich HC, Teufel
vival in adolescent patients with anorexia nervosa: M, Schellberg D, Giel KE, de Zwaan M, Dinkel
a comparison of two Swedish national cohorts of A, Herpertz S, Burgmer M, Löwe B, Tagay S,
female inpatients. Am J Psychiatry 163:1433–14U1 von Wietersheim J, Zeeck A, Schade-Brittinger
Steinhausen HC (2002) The outcome of anorexia nervosa C, Schauenburg H, Herzog W (2014) ANTOP
in the 20th century. Am J Psychiatry 159:1284–1293 study group. Focal psychodynamic therapy, cog-
Strobel C, Quadflieg N, Naab S, Voderholzer U, Fichter nitive behaviour therapy, and optimised treat-
MM (2019) Long-term outcomes in treated males ment as usual in outpatients with anorexia nervosa
with anorexia nervosa and bulimia nervosa—a pro- (ANTOP study): randomised controlled trial. Lancet
spective, gender-matched study. Int J Eat Disord 383(9912):127–137
52(12):1353–1364 Zipfel S, Giel KE, Bulik CM, Hay P, Schmidt U (2015)
Strober M, Freeman R, Morrell W (1997) The long-term Anorexia nervosa: aetiology, assessment, and treat-
course of severe anorexia nervosa in adolescents: ment. Lancet Psychiatry 2(12):1099–1111
Course of Bulimia
Nervosa and Binge- 12
Eating Disorder
Norbert Quadflieg and Manfred Fichter
Contents
12.1 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
12.2 Course of Eating Disorder Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
12.3 Comorbidity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
12.4 Social Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
12.5 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Further References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
12.1 Diagnosis from individuals who had not undergone therapy

for their eating disorder.
Bulimia nervosa (BN) has been described as a Much less is known about the course of binge-
clinical picture since 1979, with more intensive eating disorder (BED). Patients with binge-eating
research on its course beginning in the last 30 episodes without inappropriate compensatory
years. Accordingly, there is a larger number of behaviors were classified in earlier versions of
findings on the short- to medium-term course, the criteria-based diagnostic systems in the cat-
but few on the long-term course of BN. Most egory of unspecified or atypical eating disorders,
insights have been gained from samples that along with a number of other atypical variants
underwent outpatient, and more rarely, inpatient of eating disorders, and were mostly ignored
therapy. Only very few studies obtained data by research. In the 5th edition of the Diagnostic
and Statistical Manual of Mental Disorders
published in 2013 by the American Psychiatric
Association (DSM-5), BED is classified as an
independent diagnosis alongside anorexia ner-
N. Quadflieg (*) vosa and bulimia nervosa. The ICD-11 has also
Department of Psychiatry and Psychotherapy, LMU adopted this classification. In the DSM-5, the
University Hospital, Munich, Germany diagnostic criterion for the frequency of binge-
e-mail: [email protected] eating episodes and—for BN—the compensatory
M. Fichter behaviors was lowered to at least once per week.
Schoen Clinik Roseneck affiliated with the Medical This means that more cases, which were previ-
Faculty of the University of Munich (LMU), Prien,
Germany ously considered as unspecified eating disorders,
e-mail: [email protected] fall into these main diagnostic categories. Most
https://doi.org/10.1007/978-3-662-67662-2_12
86 N. Quadflieg and M. Fichter
research findings refer to the stricter definition of therapeutic intervention, patients with BN show
the 4th edition of the Diagnostic and Statistical remission in about 30–50% of cases after 6–12
Manual of Mental Disorders (DSM-IV; binge- months (Fig. 12.1).
eating episodes and compensatory behaviors at Remission rates of about 50% are also
least twice per week). observed in the medium-term course over 2 to
Regarding BED, the study findings are still more than 5 years, with findings varying widely
insufficient. There are a number of studies that from 13–74%. The percentage of remitted cases
have mostly recruited individuals with over- correlates moderately (r = 0.20–0.30) with the
weight for a weight loss program with psycho- time elapsed since the initial measurement. In
therapy and have followed up small samples the long term (9–12 years), about 70% of cases
for up to twelve months after therapy. For the with BN were found to be in remission in sev-
longer-term course, there is one study on the eral studies. A small study found that 16 out of
3-year and one study on the 6-year course in 21 patients (76%) were in remission after 20
outpatients, as well as one study on the 5-year years. Improvements in symptoms are usually
course in the general population and one study associated with long-lasting intensive therapy.
on the 12-year course in inpatients. Although Temporal stability of symptom improvement in
BED is more frequently observed in men than BN is observed only after 5–6 years. A larger
other eating disorders, most published studies study on the course of BN in men 7.5 years after
are based on samples of women. Almost nothing inpatient treatment found a remission rate of
is known about prognostic factors in BED. 44%.
For BED, higher remission rates are found
 Important Most studies on bulimic eating in the first year after therapy (about 50%; val-
disorders focus on women. ues range from 30–93% in small sample sizes).
Little is known about the medium- and long-
term course. In outpatients, remission rates of
12.2 Course of Eating Disorder 32% after 3 years and 59% after 6 years were
Symptoms observed (each in one study). In inpatients (one
study), 80% were in remission 6 years after
12.2.1 Remission and Recovery therapy and 70% 12 years after therapy. A small
study from the general population confirms this
In the short-term course, which is usually asso- trend, with 76% remission after 5 years. Despite
ciated with an initial measurement during a the very optimistic results in the first year after
BED therapy, long-term remission rates for
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
0 1 2 3 4 5 6 7 8 9 10 11 12 13
Years after initial measurement
Fig. 12.1  Schematic representation of remission in bulimia nervosa in women. The curve represents a simplified,
idealized course of remission rates in BN—often accompanied by intensive therapy—based on current knowledge
12 Course of Bulimia Nervosa and Binge-Eating Disorder 87
both bulimic eating disorders are comparable 12 cross-sectional results, a meaningful distinction
years after inpatient treatment (70% for BN and between a chronic course without longer-lasting
67% for BED). In outpatients, there is evidence remission and clearly defined relapse episodes
that remission rates are higher for BED than for cannot be made.
BN in the medium term. For BED, relapse or chronicity rates of
43%, 14%, and more than 11% after one year
are reported by one study each. After 6–12
Remission years, 6–12% still or again suffer from BED .
In research on the course of bulimic eat- An unspecified or atypical eating disorder was
ing disorders, remission is generally found in 27% after one year and in 5–13% in the
defined as the absence of binge eating long-term course (one study each).
and inappropriate compensatory behav-
ior. Cognitive aspects such as constant
thoughts about food, nutrition, and calo- 12.2.3 Mortality
ries are given little consideration. A
common definition for remission is the Despite the increasing number of studies on the
absence of an eating disorder diagnosis, course of BN, the number of observed deaths
including unspecified or atypical eating remains very limited, so that statements on mor-
disorders. In the case of BED, remission tality are only possible to a limited extent. The
does not include the restitution of normal reported mortality rates vary greatly. Non-
weight, but the term usually refers to the standardized mortality rates of 1.1–5.8% are
absence of binge eating. reported, with longer-lasting studies after 10–12
years reporting non-standardized mortality rates
of about 2.3%, but also of 0.6%. The standard-
Even in remitted cases of bulimic eating disor- ized mortality rates are also very different across
ders, elevated values regarding the thinness ideal studies and range in meta-analyses between 0
and the relevance of weight for self-esteem and and 20.8. This includes all known deaths within
well-being are still found after many years com- the respective follow-up period of the study. An
pared to healthy controls who have never had an increased mortality due to bulimic behavior has
eating disorder. not yet been proven. There are indications of an
accumulation of suicides and fatal traffic acci-
dents, but the overall low number of reported
12.2.2 Relapse and Chronicity deaths does not allow for a definitive statement.
In a sample of male inpatients with BN, 11.1%
Many patients with BN end the index treat- had died after 9 years. The standardized mortal-
ment with still existing serious eating disorder ity rate was not significant and was 1.88 (5%
symptoms. Even in the long term, these patients confidence interval 0.86–3.58).
maintain pathological eating patterns and cogni- No empirically based statement can be made
tive thought patterns, which in about 15–20% of about the mortality of BED; individual indica-
cases justify the diagnosis of an unspecified or tions suggest a mortality comparable to BN.
atypical eating disorder even after more than 10
years. A relapse into a new phase of BN occurs Change of symptoms to another eating
in about 30% of patients within the time up to 6 disorder
years after the index treatment. The relapse rates Up to 14% of patients with BN develop anorexia
decrease over time and are about 20% 6–9 years nervosa (AN) in the further course of observa-
after treatment and about 10–15% after approxi- tion, with a small proportion showing restric-
mately 12 years. Since most studies only report tive symptoms without bulimic behaviors. After
more than 10 years, about 1–2% of patients (40% good, 18% moderate, and 42% poor).
originally treated for BN have AN. The change Even after 12 years, even remitted patients with
of diagnosis from BN to BED also seems to BN still show higher impairments in social inte-
range in this order of magnitude in the long gration and sexuality than healthy control per-
term. sons. Nevertheless, about 75–80% of patients
Evidence for the diagnostic change of BED is with BN marry during the observation period of
extremely scarce. The change from BED to AN the few studies, with almost half of these mar-
is reported only in very few individual cases. riages ending in separation or divorce. The few
One large study found no change of diagnosis available data suggest that there is no difference
from BED to AN over 12 years. About 3–10% between remitted and non-remitted patients.
of patients with BEDshow BN in the long term. About three-quarters of female patients with BN
become pregnant at least once within 12 years
 Important A diagnostic change from of the initial measurement. 83–98% of women
BN and BED to AN occurs only in a few have their menstrual period after 11–12 years.
cases. In the case of BED, social integration
improves at the earliest 3 years after index treat-
ment, while sexuality often remains impaired in
12.3 Comorbidity the long term. However, this may also be related
to body weight, as almost all patients with BED
Patients with BN and BED show a high degree remain in the weight category (obese, over-
of psychological comorbidity. This generally weight, or normal weight) they were in before
decreases with the eating disorder symptoma- treatment, despite weight loss programs.
tology, although the severity in general psycho-
pathology scales remains higher than in healthy
control subjects. A small proportion of patients 12.5 Prognosis
fall into chronic alcoholism or remain in a life-
style characterized by anxiety and avoidance of A large number of prognostic factors have been
social contacts. studied for BN, with only the most important
ones being mentioned here. For BED, prognos-
tic factors for the course have hardly been stud-
12.4 Social Factors ied at all, and in the following, only statements
in the sections on severity of eating disorder and
The evidence base for the aspect of social comorbidity are possible.
factors is generally weak. In general, an
improvement in eating disorder symptoms is
accompanied by an improvement in patients' 12.5.1 Age and Duration of Illness
social functioning. In the long term, patients
with BN show significant improvements in The age at the beginning of the study (usually
social integration, work capacity, leisure activi- the beginning of a treatment episode) is a little-
ties, and relationships with more distant relatives researched factor and seems to play no role in
and acquaintances, but less so with their—if pre- the course of BN. Although the age at the onset
sent—partner, parents, and close family. Some of BN is better studied, the evidence here is
findings suggest that a significant proportion of contradictory and unclear. There are some indi-
patients with BN continue to have significant cations that an earlier onset of the eating dis-
limitations in leisure activities and friendships order may lead to a better course. The results
(52% had a good outcome after 6 years, 22% a on prognosis by duration of illness also do not
moderate, and 26% a poor outcome). Regarding allow for a clear conclusion. However, it seems
a satisfying sex life, the results were even worse that a short duration of illness—and thus early
12 Course of Bulimia Nervosa and Binge-Eating Disorder 89
intervention in the disorder process—helps substance abuse or dependence, and suicidality

to improve the course of BN, with the narrow were a negative or no predictor; the findings on
empirical basis being emphasized once again. anxiety disorders are based on a still insufficient
empirical basis. If the various disorder groups
are combined into a variable that only provides
12.5.2 Severity of Eating Disorder information on the presence of any Axis-I dis-
and Treatment order, more meaningful prognosis models can
be created. In one study—and thus representing
BN patients with a high severity of eating dis- a narrow empirical basis—comorbidity in this
order, expressed in a high frequency of binge sense was identified as a strong predictor of an
eating and vomiting, have a poorer progno- unfavorable course of BN after 2, 6 and 12 years.
sis. However, there are also studies that do not There is also very little empirical evi-
confirm this. There are also no findings that an dence for the influence of personality disorders
intensive, often long-lasting therapy would not (Axis-II disorders) on the course of BN. There
be successful. A diagnosis of AN in the history are indications that the presence of a borderline
of BN is not relevant for the prognosis, but a personality disorder or a Cluster-B personality
low body weight is a predictor for a poor out- disorder (which includes borderline personality
come. Strongly pronounced eating rituals and disorder) is a negative predictor.
compulsive preoccupation with food increase In BED, findings from one study
the likelihood of relapse in BN. Recently, the show Cluster-B personality disorders as a pre-
difference between the highest reported weight dictor of an unfavorable course.
of the patient over their adult lifetime and the
weight at the beginning of treatment (“weight  Important Psychiatric comorbidity worsens
suppression”) has been considered as a risk fac- the prognosis of bulimic eating disorders.
tor, with the assumption that a higher difference
has a negative impact on the prognosis. The few
findings for BN in this regard suggest that high 12.5.4 Personality Traits
“weight suppression” is associated with more
binge eating and compensatory behaviors, as Two personality traits that have been better stud-
well as higher weight gain and longer time to ied in BN are self-esteem and impulsivity. Low
remission. The weight difference does not seem self-esteem, especially when accompanied by
to play a role in therapy adherence and ultimate perfectionism, is associated with an unfavorable
therapy success (also in a study on BED). prognosis. Impulsivity and impulsive behaviors,
In the case of BED, obesity is a predictor for including self-harming behavior, are also predic-
a less favorable course. tors of a poor course of BN.
12.5.3 Comorbidity 12.5.5 Family of Origin Characteristics
The empirical findings on the prognostic con- Although an association between the patient’s ill-
tribution of Axis-I comorbidity in BN are not ness and certain characteristics of their family of
clear, but some conclusions can be drawn. In a origin seems theoretically plausible, no such asso-
series of studies, individual disorder groups such ciation can be demonstrated for BN. The presence
as depression, substance use disorder (including of alcohol abuse in the family of origin has been
alcohol), or anxiety disorders were investigated. identified as a positive, negative, or no predictor
The results are contradictory, but no study found for the course of BN. The fact that a close rela-
evidence for Axis-I comorbidity as a predictor tive was in psychiatric treatment has no prognos-
of a favorable course of BN. Either depression, tic value. The presence of depression in the family
of origin is either no predictor or a predictor of a Fichter MM, Quadflieg N, Gnutzmann A (1998) Binge
poor course. Summing up the few findings, it can eating disorder: treatment outcome over a 6-year
course. J Psychosom Res 44:385–405
be stated that mental health problems in close Fichter MM, Quadflieg N, Hedlund S (2008) Long-term
relatives do not imply a poor prognosis. The lim- course of binge eating disorder and bulimia nervosa:
ited research on the role of the environment in the relevance for nosology and diagnostic criteria. Int J
family of origin has so far provided no tangible Eat Disord 41:577–586
Herzog DB, Dorer DJ, Keel PK et al (1999) Recovery
evidence of the relevance of this aspect for the and relapse in anorexia and bulimia nervosa: a 7.5-
prognosis of BN. The same applies to the socio- year follow-up study. J Am Acad Child Adolesc
economic status of the family of origin. Psychiatry 38:829–837
Keel PK, Mitchell JE (1997) Outcome in bulimia ner-
vosa. Am J Psychiatry 154:313–321
Keel PK, Mitchell JE, Miller KB et al (1999) Long-term
Conclusion outcome of bulimia nervosa. Arch Gen Psychiatry
• BN and BED show a very similar long- 56:63–69
term course and outcome, even though the Keel PK, Gravener JA, Joiner TE, Haedt AA (2010)
Twenty-year follow-up of bulimia nervosa and related
short-term course of BED is somewhat eating disorders not otherwise specified. Int J Eat
better. Disord 43:492–497
• In the long term, about 70% of BN and Milos G, Spindler A, Schnyder U, Fairburn CG (2005)
BED patients remit. Instability of eating disorder diagnoses: prospective
study. Br J Psychiatry 187:573–578
• Approximately 15% of patients retain a Pope HG, Lalonde JK, Pindyck LJ et al (2006) Binge
treatment-requiring eating disorder even eating disorder: a stable syndrome. Am J Psychiatry
after more than 10 years. 163:2181–2183
• The presence of other mental disorders Quadflieg N, Strobel C, Naab S, Voderholzer U, Fichter
MM (2019) Mortality in males treated for an eating
worsens the prognosis. disorder—a large prospective study. Int J Eat Disord
• As far as is known, the course of BN and 52:1365–1369
BED in men does not differ much from Steinhausen HC, Weber S (2009) The outcome of
that in women. bulimia nervosa: findings from one-quarter century of
research. Am J Psychiatry 166:1331–1341
Strobel C, Quadflieg N, Naab S, Voderholzer U, Fichter
MM (2019) Long-term outcomes in treated males
Further References with anorexia nervosa and bulimia nervosa—a pro-
spective, gender-matched study. Int J Eat Disord
Fichter MM, Quadflieg N (2004) Twelve-year course 52:1353–1364
and outcome of bulimia nervosa. Psychol Med Wilfley DE, Wilson GT, Agras WT (2003) The clinical
34:1395–1406 significance of binge eating disorder. Int J Eat Disord
Fichter MM, Quadflieg N (2007) Long-term stabil- 34:S96–S106
ity of eating disorder diagnoses. Int J Eat Disord
40:S61–S66
Course and Prognosis
of Binge Eating Disorder 13
Kathrin Schag
Contents
13.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
13.2 Onset . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
13.3 Distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
13.4 Comorbidity—Quality of Life—
Level of Functioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
13.5 Disorder Duration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
13.6 Course of Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
13.7 Change of Eating Disorder Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
13.8 Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
13.9 Prognosis: What Promotes and What Hinders a Positive Course? . . . . . . . 95
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
13.1 Introduction where at least two binge eating episodes per

week over a period of six months were required
Binge eating disorder (BED) has only recently for the diagnosis. The frequency of binge eat-
been recognized as an official diagnosis and ing episodes required to meet the diagnosis was
included in the ICD-11 (Claudino et al. 2019) reduced to once weekly within three months
and DSM-5 2013 (Association 2013). Therefore, in DSM-5 and ICD-11. In addition, many of
there are only a few studies on the course of the studies were conducted in samples of indi-
BED, especially on the long-term course and viduals with overweight or obesity, although
prognosis. The reported statistics, e.g., for body mass index (BMI) is not a diagnostic cri-
prevalence, vary widely across individual stud- terion for BED. Therefore, the previously col-
ies depending on the sample studied. Moreover, lected data on the course and prognosis of BED
many of the research findings still refer to the may be biased towards more severely affected
research criteria for BED according to DSM-IV, patients.
13.2 Onset
K. Schag (*)
Psychotherapy, Medical University Hospital With a lifetime prevalence of 1–2%, BED is
Tübingen, Tübingen, Germany the most common eating disorder according to
e-mail: [email protected] some large-scale studies (Keski-Rahkonen and
https://doi.org/10.1007/978-3-662-67662-2_13
92 K. Schag
Mustelin 2016; Kessler et al. 2013; Udo and Furthermore, patients with obesity or dia-
Grilo 2018). BED typically begins in late ado- betes type II show an increased risk for BED.
lescence and early adulthood with an average A threefold increased risk for BED with preva-
age of 23–24 years (Kessler et al. 2013; Udo and lence rates of 20–30% is reported for individu-
Grilo 2018). Thus, BED occurs on average later als with obesity (Agh et al. 2015; Hilbert et al.
than anorexia nervosa (AN) and bulimia nervosa 2018).
(BN).
However, BED also occurs in childhood and
adolescence, with an assumed lifetime preva- 13.4 Comorbidity—Quality of Life—
lence of 1–3% (Bohon 2019). The term “loss of Level of Functioning
control Eating” is often used in this context, as
it is particularly about the experienced loss of Although overweight and obesity are not a nec-
control during eating in children and the amount essary criterion for a diagnosis of BED accord-
of food consumed is less relevant or difficult ing to DSM-5 (Association 2013) and ICD-11
to quantify (Bohon 2019; Hilbert et al. 2018). (Claudino et al. 2019), they occur significantly
Therefore, a modification of the diagnostic cri- more frequently in comparison to the general
teria for BED in children and adolescents is population (Kessler et al. 2013). A large epide-
currently being discussed (Bohon 2019; Hilbert miological study showed a mean BMI of 35 kg/
et al. 2018). So far, there is very little research m2 in patients with BED (Udo and Grilo 2018).
on the course and prognosis in children. The prevalence rate for overweight in patients
with BED is over 30% and for obesity even over
40% (Kessler et al. 2013). In accordance with
13.3 Distribution this high prevalence of obesity, patients with
BED have a twofold increased risk for chronic
Approximately three times as many women as somatic diseases associated with obesity, such
men are affected by BED (Keski-Rahkonen and as diabetes, cardiovascular diseases, and pain
Mustelin 2016; Kessler et al. 2013; Udo and disorders (Keski-Rahkonen and Mustelin 2016;
Grilo 2018). However, compared to other eat- Kessler et al. 2013).
ing disorders, more men are affected by BED Regarding mental health, patients with BED
(Hilbert et al. 2018). Men show a less pro- also show a significantly reduced quality of
nounced eating disorder pathology (Lydecker life (Agh et al. 2015) and impaired functioning
et al. 2020). However, gender does not seem to (Kessler et al. 2013). This is evident to a similar
have a significant effect on the course of treat- extent as in other eating disorders and even more
ment, although male patients seem to lose more so than in individuals suffering from obesity but
weight during therapy (Lydecker et al. 2020). not from an eating disorder (Agh et al. 2015).
In addition, there may be cultural differences, Over 70% of patients with BED have at least
but the data on this are still weak and heteroge- one additional mental disorder (Keski-Rahkonen
neous (Agh et al. 2015). For example, there are and Mustelin 2016; Kessler et al. 2013). These
inconsistent results regarding the question of are mostly affective disorders or anxiety dis-
whether ethnic minorities are more frequently, orders (Keski-Rahkonen and Mustelin 2016;
equally often, or less frequently affected (Agh Welch et al. 2016). Disorders associated with
et al. 2015; Udo and Grilo 2018). The preva- increased impulsivity, such as attention-deficit/
lence rate for BED in the USA is slightly higher hyperactivity disorder, substance abuse, self-
than in Germany (Kessler et al. 2013). The dif- harm, and suicidality, are also more common
ferences may be related to different eating cul- in patients with BED (Keski-Rahkonen and
tures in the respective countries. Mustelin 2016; Welch et al. 2016).
13 Course and Prognosis of Binge-Eating Disorder 93
13.5 Disorder Duration and eating disorder pathology (Brownley et al.

2016; Hilbert et al. 2019). Thus, 50% of those
Recent studies suggest that BED often has a affected achieve abstinence after psychotherapy
chronic or long-lasting course: The average (Linardon 2018). Pharmacological interventions
duration of the disorder is 14–16 years, which also lead to symptom improvements (Brownley
is longer than the duration of other eating dis- et al. 2016), but these are usually inferior to
orders (Pope et al. 2006; Udo and Grilo 2018). treatment with psychotherapy (Hilbert et al.
Patients often retrospectively report a long-last- 2018).
ing phase beyond middle age, rather than several The long-term course after psychotherapeutic
shorter episodes (Pope et al. 2006). Earlier stud- treatment of BED has so far been little studied,
ies may have underestimated the risk of chronic- and the recorded parameters vary. An overview
ity, as they report shorter courses with stronger of various relevant studies can be found in
fluctuations in intensity and more spontaneous Table 13.1. A description of the different ter-
remissions (Hilbert et al. 2018). minology used can be found in the infobox.
For example, the remission rate of patients
with BED after inpatient treatment increased to
13.6 Course of Treatment 67% twelve years after treatment (Fichter et al.
2008). Several years after outpatient psychother-
Less than 50% of those affected seek treat- apy, two-thirds of patients also showed remis-
ment (Hilbert et al. 2018; Kessler et al. 2013), sion (Castellini et al. 2011; Fischer et al. 2014;
possibly due to a lack of awareness in society. Hilbert et al. 2012). In addition to improvements
However, with adequate treatment of BED, i.e., in eating disorder pathology, these studies also
psychotherapy, as recommended by the current showed a reduction in general psychopathol-
S3 guideline (Hilbert et al. 2018), significant ogy (Fichter et al. 2008; Hilbert et al. 2012).
and lasting improvements are seen regarding However, in almost a third of cases, only partial
binge eating episodes, diagnostic assignment, remission can be achieved, patients change to a
Table 13.1  Long-term course of BED after psychotherapy

Setting Remission BED Transmission/Par- Relapse
tial remission Mortality
Fichter et al. 12 years after inpati- 67.2 % 7.8 % (relapse 9.4 % BN, 3.1 %
(2008) ent psychotherapy or chronic) 12.5 % EDNOS
N = 68
Hilbert et al. 4 years after outpa- Remission: Chronic: Further symptoms: CBT 24 %
(2012) tient psychotherapy CBT 72.0 % CBT 12.0 % CBT 24 % IPT 10 %
(CBT vs. IPT) IPT 83.9 % IPT 9.4 % IPT 13.3 %
N = 90 Abstinence:
CBT 52.0 %
(27.3 % ongoing)
IPT 76.7 %
(22.2 % ongoing)
Fischer et al. 4 years after CBT 67 % 4.2 %
(2014) N = 41
Castellini 6 years after CBT 63.8 % 7.1 % BN 11.4 %
et al. (2011) N = 262
BN, Bulimia nervosa; BED, Binge Eating Disorder; EDNOS, Eating Disorder Not Otherwise Specified; IPT, Interper-
sonal Psychotherapy; CBT, Cognitive Behavioral Therapy
94 K. Schag
different diagnostic category, or the clinical pic- Therefore, treatment methods need to be fur-
ture becomes chronic (Fichter et al. 2008). The ther developed. For example, a therapy that
relapse rate is also considered high, at 10–24% more strongly targets the triggering and main-
in the long-term course (Castellini et al. 2011; taining factors is useful. Moreover, weight is
Hilbert et al. 2012). hardly improved immediately after psychother-
apy (Hilbert et al. 2018), and in the long term,
no more than a 5% reduction in BMI can be
Infobox for distinguishing different expected (Fichter et al. 2008).
terminologies
• Abstinence: No binge eating episodes
occur within a certain period (usually 13.7 Change of Eating Disorder
four weeks). Diagnosis
• Remission: The criteria for BED are no
longer met. Little is known so far about the transmission from
– A distinction must be made between BED to other eating disorders (see Table 13.1).
partial remission and full remission Overall, frequent changes between individual eat-
(Hilbert et al. 2018, p. 297): “If the ing disorder categories are assumed. Williamson
number of binge eating episodes met and colleagues (Wonderlich et al. 2007) postulate
the diagnostic criterion at an earlier in their transdiagnostic model that eating disor-
time (at least one binge eating epi- ders with binge eating episodes, in particular,
sode per week for three months), but can be assigned to one entity. A large-scale epi-
there are fewer binge eating episodes demiological study in the USA confirmed this
at the current time, DSM-5 refers to by observing that most changes occur between
a partially remitted BED. If all diag- BN and BED (Udo and Grilo2018). Welch and
nostic criteria were met at an earlier colleagues (2016) also reported in a large-scale
time and are no longer present, a study in the Swedish disease registry of a sig-
fully remitted BED is referred to.” nificant number of changes in the diagnostic cat-
– Furthermore, it should be considered egory from BED to other eating disorders (16%),
that patients with partial remission mainly to BN and EDNOS. Changes from BED
often receive the diagnosis EDNOS to AN are hardly known so far.
(“Eating Disorder Not Otherwise
Specified”), making it difficult to dis-
tinguish between partial remission 13.8 Mortality
and other EDNOS.
• Transmission: A transmission occurs Initial results indicate a significantly increased
when a patient’s diagnosis category suicide rate among patients with BED (Welch
changes from BED to another eating et al. 2016). Fichter and colleagues (2008)
disorder category (AN, BN, EDNOS). report a mortality rate of 3% or a 1.5-fold
• Relapse: The diagnosis of BED has increased risk. In addition, patients with
reoccurred after remission. BED show an increased prevalence of sui-
cidal thoughts (27.5%) and suicide attempts
(12.5%) (Carano et al. 2012). Furthermore, the
These studies show that psychotherapy is effec- increased mortality risk associated with obesity
tive in addressing the core pathology of BED. and its related diseases should also be consid-
However, half of those affected still suffer ered due to the high proportion of patients with
from (sub)clinical symptoms (Linardon 2018). BED.
13 Course and Prognosis of Binge-Eating Disorder 95
13.9 Prognosis: What Promotes quickly to therapy generally show the great-
and What Hinders a Positive est and most sustainable therapy successes
Course? (Linardon et al. 2016; Nazar et al. 2017).
Overall, the prognosis of untreated BED is
There is little evidence to date on the progno- unfavorable: without treatment, a chronic or
sis and possible influencing factors, particularly long-lasting course is often observed (see dura-
on the natural course of BED. For example, tion of illness). With adequate treatment and
according to a prospective study by Rohde and patient response to therapy, however, the course
colleagues (2015), dissatisfaction with one’s is somewhat more favorable than with AN and
body during adolescence is associated with the BN (Hilbert et al. 2018).
development of an eating disorder four years
later. Body dissatisfaction also appears to be an
important predictor for the course of therapy Conclusion
(Fichter et al. 2008). In contrast, there are con-
flicting data on the age of onset: Kessler and Binge eating disorder (BED) is the most
colleagues (2013) report in their large epide- common eating disorder, with far-reaching
miological study that an early age of onset leads consequences for somatic and psychological
to a favorable prognosis in the natural course, quality of life. If left untreated, the disorder
while other studies see a worse prognosis for the often follows a chronic or long-lasting course
course of therapy (e.g., Castellini et al. 2011). and is underdiagnosed. With adequate treat-
Specifically, regarding predictors for the ment in the form of psychotherapy, approxi-
course of therapy in BED, it can be assumed mately half of those affected can achieve
that, as with other mental disorders, milder remission.
courses and faster remission are achieved the The prognosis is worse for patients in
milder the severity of BED and the lower the whom treatment does not quickly take effect,
general psychopathology (Fichter et al. 2008). in cases of severe general psychopathology,
With regard to general psychopathology, psychi- and with strongly pronounced eating disorder
atric comorbidities, especially depression, but symptoms.
also certain personality traits such as increased
impulsivity and negative emotions, impede the
prognosis (Castellini et al. 2011; Fichter et al. References
2008; Peterson et al. 2005). Interpersonal prob-
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2014). A particularly important factor regard- 165(6):409–420
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ing the course of therapy is the so-called “rapid in a sample of patients with binge eating disorder. J
response.” This means that patients who respond Psychiatr Pract 18(1):5–11
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Castellini G et al (2011) Diagnostic crossover and out- Linardon J (2018) Rates of abstinence following psy-
come predictors in eating disorders according to chological or behavioral treatments for binge-eat-
DSM-IV and DSM-V proposed criteria: a 6-year fol- ing disorder: meta-analysis. Int J Eating Disord
low-up study. Psychosomat Med 73(3):270 51(8):785–797
Claudino AM et al (2019) The classification of feeding Linardon J, Brennan L, de la Piedad Garcia X (2016)
and eating disorders in the ICD-11: results of a field Rapid response to eating disorder treatment: a sys-
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Anorexia Nervosa
in Childhood 14
and Adolescence
Beate Herpertz-Dahlmann
Contents
14.1 Definition and Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
14.2 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
14.3 Symptomatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
14.4 Comorbidity and Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
14.5 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
14.6 Course . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
14.1 Definition and Classification months) is also taken into account, as long as the
other criteria are met. Among the subcategories
Anorexia nervosa (AN) is the third most com- “AN in recovery with normal body weight” is a
mon chronic disease in female adolescents after new diagnosis. In the DSM-5, the same weight
asthma and obesity (Gonzalez et al. 2007). threshold value (5th BMI percentile) is proposed
The classification of childhood and adolescent for children and adolescents, with a deviation
AN according to the ICD-11 (WHO 2018) and explicitly allowed without loss of diagnosis, if
DSM-5 (American Psychiatric Association other physiological parameters are altered by
2013) with their age-specific problems is pre- starvation. A further subtyping is not carried out
sented here. The ICD-11 divides AN into two in DSM-5, even though a subdivision by sever-
severity levels, with a BMI below the 5th perity is possible for adults (for an overview see
centile (significant underweight) and another Claudino et al. 2019; Gradl-Dietsch et al. 2021).
threshold value below the 0.3rd percentile In both classification systems, amenorrhea is no
(dangerously low underweight). In addition to longer a diagnostic criterion; this is particularly
the “absolute value” for weight, rapid weight important for childhood AN and the male sex.
loss (more than 20% of the initial weight in six
 Important While the weight criterion for
adults corresponds to the 10th BMI percen-
tile, the threshold value for children and ado-
B. Herpertz-Dahlmann (*)
lescents is the 5th percentile. This difference
Psychosomatics and Psychotherapy, RWTH Aachen is neither clinically nor scientifically com-
University, Aachen, Germany prehensible, as the effects of chronic under-
e-mail: [email protected] weight on a growing organism can be more
https://doi.org/10.1007/978-3-662-67662-2_14
98 B. Herpertz-Dahlmann
serious than in adult patients (for an overview same-aged peers (Nicholls et al. 2011; for an
see also Herpertz-Dahlmann and Dahmen overview, see Herpertz-Dahlmann and Dahmen
20519). 2019). In childhood, the disorder rate is slightly
shifted towards boys, at 1:5-6 (m: f).
The BMI and BMI percentiles based on KiGGs
data can be calculated online (https://www.
pedz.de/de/willkommen.html; Option KIGGS 14.3 Symptomatology
data).
In the USA, the “% EBW” (percent While in puberty, weight gain in males is pri-
expected body weight ) is increasingly used marily due to an increase in muscle mass, in
to assess weight loss (Le Grange et al. 2012). girls the proportion of fat mass in total body
The expected body weight corresponds to the weight increases from 17% to 24%. In addition,
50th age- and gender-adapted BMI percentile. the fat distribution pattern changes due to the
(Calculation: % EBW = current BMI/50th BMI influence of sex hormones.
percentile × 100).
Based on both classification systems, a dis-  Important Children have a significantly
tinction is made between the restrictive type lower fat mass than adolescents and adults, so
and the binge-eating/purging type (bulimic the physiological consequences of starvation
type) of AN. In childhood and adolescence, the in childhood AN are often severe.
restrictive type is significantly predominant, but
in the course of later adolescence, some patients While AN is “fulminant” (high weight loss
develop the binge eating/purging type. in a very short time) in a small proportion of
patients, it takes a more insidious course in the
majority (see also classification according to
14.2 Epidemiology ICD-11).
The lifetime prevalence of AN in adolescent

girls is 0.3–2% and in adolescent boys 0.1–0.3% Primary Symptoms of Eating Disorders
(Keski-Rahkonen and Silen 2019). While an in Children and Adolescents
incidence of 20/100,000 person-years is found • Increasing interest in food composition
in 10-14-year-olds, it is 100–200/100,000 per- and calorie content
son-years in 15-19-year-olds (for an overview, • Avoidance or refusal of main meals
see Keski-Rahkonen and Silen 2019). The first • Restriction to so-called “healthy” foods
peak of AN occurs at around 14 years of age. • Frequent weight checks
The gender ratio in adolescence corresponds to • Dissatisfaction with one’s own appear-
that of adulthood and amounts to  1:10–20 (m:f). ance and figure
• Increasingly sad or depressive mood
 Important Recent studies have shown an • Excessive physical hyperactivity
increase in the incidence rate in the age group • Increasing performance orientation and
of 15-18-year-olds. 40% of all new cases of isolation
AN occur at this age. • Primary or secondary amenorrhea
In recent years, an increase in childhood AN

has also been found. In Germany and the UK, Affected individuals first give up sweets/candy,
a significant increase in inpatient treatments cakes, and high-fat foods, preferring instead
for childhood anorexia has been reported. The so-called “healthy” foods such as fruit, whole-
incidence of childhood anorexia is 1-3/100,000 grain bread, vegetables, and "diet" food. Many
14 Anorexia Nervosa in Childhood and Adolescence 99
become vegetarians, usually justifying this with ambitious and diligent in school. Some patients
sympathy for animals. Rituals during meals are speak of a veritable work addiction.
typical. Some sufferers practically celebrate the
consumption of a meal, decorating the table
even for the smallest amounts of food, lighting 14.4 Comorbidity and Differential
a candle, etc. Diagnosis
In child patients, dehydration often leads
to hospital admission, as they fear weight gain 14.4.1 Psychological Comorbidity
from fluid intake and stop drinking. Some refuse
to swallow their own saliva, leading even more Epidemiological studies show that subclini-
quickly to dehydration. cal eating disorders in adolescence are often
accompanied by disturbances in self-esteem
 Important Severe dehydration in young and depressive psychopathology. In the BELLA
patients may require hospital admission. study conducted by the Robert Koch Institute,
which examined 1,800 children and adoles-
Others fear food intake, e.g., from spreadable cents aged 11 to 17 years, it was observed that
fats, through the skin and refuse to touch food. those with disturbed eating behavior reported
Many of the young patients are excessively significantly more frequent suicidal ideation
physically active, i.e., they engage in sports to and suicidal behavior than those without eating
accelerate weight loss. With increasing cachexia, disorders (Herpertz-Dahlmann et al. 2008). The
patients perceive restlessness as a “compulsion”; latest results of the study show, from a longi-
they must continue to be active despite physical tudinal perspective, that anxiety or depressive
exhaustion. Physical activity is not exclusively symptoms in childhood are significantly asso-
subject to cognitive control but is also influ- ciated with an eating disorder in adolescence
enced by hormonal regulatory mechanisms (e.g., (Herpertz-Dahlmann et al. 2015).
changes in the gastropeptide leptin). Some adolescent patients with AN have been
withdrawn and introverted since childhood and
 Important The younger the patients, the more exhibit anxious-avoidant personality traits (Cardi
difficult it is for them to access their own et al. 2018). Some report that their sad mood
experiences and fears related to the illness. improved at the beginning of anorexia. When
assessing depressive mood, the starvation effect
The weight phobia typical for AN in later ado- must be taken into account. Historically, separa-
lescence and adulthood is often not detectable tion anxiety can be detected in many adolescent
in prepubertal adolescents (Becker et al. 2009). patients with AN. Childhood anxiety disorders
They often experience the disorder as a “foreign with “social hypersensitivity” often develop
force” against which they cannot defend them- into a social phobia as a comorbid disorder of
selves. For instance, they may report that a voice AN. Mothers of patients with AN reported sig-
commands them to reduce food intake and not to nificantly more pronounced sleep disorders in
gain weight under any circumstances. However, their daughters during early childhood, signifi-
this “inner voice” should not be confused with cant separation anxiety, and a significantly later
the symptom of “hearing voices” in a schizo- age of the child at the “first sleepover away from
phrenic illness; rather, the patients perceive this home.” Comorbid obsessive-compulsive disor-
voice as something of their own. The major- ders, usually characterized by order and sorting
ity of adolescent patients with eating disorders compulsions, are also common in adolescent
become isolated during the course of the illness, anorexia, with one-fifth having the onset of the
neglect their hobbies, and many become more obsessive-compulsive disorder in childhood
before the onset of anorexia.
Conclusion The pseudoatrophia cerebri, which is also

Since anorexia in child and adolescent found in adults, depends, among other things, on
patients appears threatening to many parents the extent of brain volume loss and impairs con-
and therapists, comorbid psychological disor- centration and memory, which puts a great strain
ders—especially anxiety and obsessive-com- on the patients at school. Compared to adults,
pulsive disorders—are often overlooked. Due adolescent patients in the acute state show
to their importance for treatment, a diagnostic stronger changes in gray matter and fluid vol-
assessment of comorbid psychological disor- ume (liquor); these findings may be due to the
ders should be carried out at admission. greater plasticity of the brain at this age (Seitz
et al. 2018). In addition, it is still unclear which
effects a long-term sexual hormone deficiency
14.4.2 Somatic Comorbidity caused by AN has on brain growth. The develop-
ment of certain brain structures, such as the hip-
At this point, only the complications typical for pocampus, shows a clear dependence to estrogen
childhood and adolescent AN will be discussed. levels (Mainz et al. 2012). Further research is
urgently needed to determine the extent to
 Important As a rule of thumb, the somatic which chronic AN in childhood and adolescence
changes in AN are more severe the younger is associated with long-term changes in brain
the patients are and the more pronounced and structure and function. In chronically ill patients
rapid the weight loss is. Almost all affected with AN, a volume reduction of the cerebel-
individuals show a stagnation of pubertal lum is more frequently found (Seitz et al. 2018;
development. Fonville et al. 2014).
In child and adolescent patients with a chronic

course, growth is impaired (Herpertz-Dahlmann 14.5 Differential Diagnosis
et al. 2018). In some cases, growth is still com-
pleted very late after achieving normal weight; The younger the girl at the onset of the disor-
catch-up growth seems to be possible only if the der, the more difficult is the diagnosis The most
disorder does not persist for too long. In addition important psychiatric differential diagnosis is
to a restriction of growth, young patients have the “avoidant-restrictive food intake disorder,”
a high risk for the development of osteopenia or known in professional circles as ARFID. In
osteoporosis, which is based on reduced bone for- contrast to patients with AN, those with ARFID
mation with increased bone resorption and is asso- do not have body image disturbances; they are
ciated with an increased risk of fractures. often younger, show little interest in food, or
have sensory hypersensitivities during food
intake, e.g., towards solid food, or in response
Particular risk factors for osteoporosis to a mostly traumatic or unagreeable event
• Onset of eating disorder in prepuberty (e.g., Bryant-Waugh 2019). In prepubertal chil-
or adolescence dren, we also see eating disorder syndromes in
• Persistent cachexia the context of anxiety and obsessive-compulsive
• Long duration of amenorrhea disorders. The children fear, for example, chok-
• Relative physical inactivity ing, accidentally eating a dangerous or disgust-
ing object (e.g., a fly), or becoming infected
through contaminated food. This leads to the
If AN improves during the growth-active period intake of only very specific foods, prepared by
of life, the bone structure normalizes. This pro- a known person in a familiar environment (e.g.,
cess can be delayed by several years compared at home). Others stop eating because they fear
to age-typical girls (see Chap. 38). having to vomit in an embarrassing situation
14 Anorexia Nervosa in Childhood and Adolescence 101
(so-called emetophobia; Simons and Vloet S3 guidelines for eating disorders recommend
2018). Such behavior is usually observed in routine determination of calprotectin in stool
children who are triggered by previous expe- (Crohn's disease) as well as of autoantibodies
riences, e.g., in the presence of gastroesopha- against tissue transglutaminase IgA and total
geal reflux or another vomiting-related disease. IgA (celiac disease) (Herpertz et al. 2019).
Anorexia-like symptoms can occur in the con-
text of conversion disorders when the affected
individuals are confronted with patients with 14.6 Course
AN on the ward. In rare cases, the “pervasive
refusal syndrome” must also be considered in 7-
to 15-year-old girls , in which the children stop  Important The prognosis of adolescent AN is
almost all actions and functions in addition to more favorable than that of adult AN.
food intake, e.g., no longer speak, no longer get
out of bed, and do not take care of their physical In the majority of more recent 10-year follow-
hygiene (e.g., Otasowie et al. 2020). The cause up studies of adolescent patients, no deaths
is unclear: the symptoms usually occur in girls were found. The mortality rate for mixed sam-
with pre-existing other mental disorders; trig- ples of adolescent and adult patients, based on
gering factors can be infections or trauma. There a meta-analysis of 119 studies between 1953
is no evidence-based treatment. A multimodal and 1999, was 5.9%, whereas it was 1.8% in the
treatment program, including intensive involve- same study for exclusively adolescent samples
ment of the parents, is usually recommended. (Steinhausen 2002). In a recent Swedish long-
The differential diagnosis for somatic dis- term study of adolescent patients with a dura-
eases is shown in the following overview. tion of follow-up of 30 years, almost two-thirds
were without eating disorder symptoms at the
follow-up time point, and there were no deaths.
Differential diagnosis of anorexia ner- However, about 40% had another mental disor-
vosa for somatic diseases in children der at that time (Dobrescu et al. 2019).
and adolescents The rehospitalization rate in adolescence
• Crohn’s disease is very high: A quarter to half of all adolescent
• Ulcerative colitis patients with AN are treated as inpatients more
• Celiac disease than once. The adolescent patients of the study
• Hypothyroidism mentioned above suffered from an eating disor-
• Diabetes mellitus der for an average of about 10 years (Dobrescu
• Addison’s disease et al. 2019).
• Anterior pituitary insufficiency Negative prognostic factors include
• Hypothalamic tumors
• Malignant tumors • mental illnesses of the parents,
• Side effects of medications (e.g., • excessive physical hyperactivity,
amphetamines) • low weight gain during first hospitalization,
• longer duration of illness,
• a low BMI at admission or at discharge.
Recently, an association between the autoim-
mune diseases Crohn’s disease, celiac dis- After overcoming the eating disorder, many
ease, and diabetes mellitus and AN has been patients suffer from other mental disorders in
found, i.e., patients with AN have an increased adulthood, particularly affective disorders, anxi-
risk for these diseases and vice versa (Hedman ety and obsessive-compulsive as well as person-
et al. 2019). As a consequence, the German ality disorders (see above).
There are no clear research findings regard- Hedman A, Breithaupt L, Hübel C et al (2019)
ing the success of treatment in children com- Bidirectional relationship between eating disorders
and autoimmune diseases. J Child Psychol Psychiatry
pared to adolescent patients. According to our 60:803–812
own, more recent results, children show a worse Herpertz S, Fichter M, Herpertz-Dahlmann B et al (Eds)
outcome in terms of persistence of the eating (2019) S3-Leitlinie Diagnostik und Behandlung der
disorder and other mental disorders. Patients Essstörungen, 2nd edn. Springer, Berlin
Herpertz-Dahlmann B, Dahmen B (2019) Children in
with premenarchal AN have a worse outcome need—diagnostics, epidemiology, treatment and out-
regarding the resumption of menstruation come of early onset anorexia nervosa. Nutrients 11:1932
(Herpertz-Dahlmann et al. 2018). Herpertz-Dahlmann B, Wille N, Hölling H et al (2008)
Disordered eating behaviour and attitudes, associ-
ated psychopathology and health-related quality of
 Important The majority of patients who suf- life: results of the BELLA study. Eur Child Adolesc
fered from AN in childhood or adolescence Psychiatry 17:82–91
experience this retrospectively as a significant Herpertz-Dahlmann B, Dempfle A, Konrad K et al
turning point in their lives and emphasize that (2015) Eating disorder symptoms do not just disap-
pear: the implications of adolescent eating-disor-
the disorder deprived them of essential expe- dered behaviour for body weight and mental health
riences during this period of life. in young adulthood. Eur Child Adolesc Psychiatry
24:675–684
Herpertz-Dahlmann B, Dempfle A, Egberts KM et al
(2018) Outcome of childhood anorexia nervosa-the
results of a five- to ten-year follow-up study. Int J Eat
References Disord 51:295–304
Keski-Rahkonen A, Silén Y (2019) Incidence and preva-
American Psychiatric Association (2013) Diagnostic and lence of eating disorders among children and adoles-
statistical manual of mental disorders (DSM-5), 5th cents. In: Hebebrand J, Herpertz-Dahlmann B (Eds)
edn. American Psychiatric Association, Arlington Eating disorders and obesity in children and adoles-
Becker AE, Thomas JJ, Pike KM (2009) Should non-fat- cents. Elsevier, Missouri, S 53–62
phobic anorexia nervosa be included in DSM-V? Int J Le Grange D, Doyle PM, Swanson SA et al (2012)
Eat Disord 42:620–635 Calculation of expected body weight in adolescents
Bryant-Waugh R (2019) Avoidant/Restrictive food with eating disorders. Pediatrics 129:e438–e446
intake disorder. Child Adolesc Psychiatr Clin N Am Mainz V, Schulte-Rüther M, Fink GR et al (2012)
28:557–565 Structural brain abnormalities in adolescent anorexia
Cardi V, Tchanturia K, Treasure J (2018) Premorbid and nervosa before and after weight recovery and associ-
illness-related social difficulties in eating disorders: ated hormonal changes. Psychosom Med 74:574–582
an overview of the literature and treatment develop- Nicholls DE, Lynn R, Viner RM (2011) Childhood eat-
ments. Curr Neuropharmacol 16:1122–1130 ing disorders: British national surveillance study. Br J
Claudino AM, Pike KM, Hay P et al (2019) The classifi- Psychiatry 198:295–301
cation of feeding and eating disorders in the ICD-11: Otasowie J, Paraiso A, Bates G (2020) Pervasive refusal
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guidelines with existing ICD-10 guidelines. BMC Child Adolesc Psychiatry. https://doi.org/10.1007/
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Anorexia nervosa: 30-year outcome. Br J Psychiatry Extend, pathomechanism and clinical consequences
216:97–104 of brain volume changes in anorexia nervosa. Curr
Fonville L, Giampietro V, Williams SCR et al (2014) Neuropharmacol 16:1164–1173
Alterations in brain structure in adults with anorexia Simons M, Vloet TD (2018) Emetophobia—a metacog-
nervosa and the impact of illness duration. Psychol nitive therapeutic approach for an overlooked disor-
Med 44:1965–1975 der. Z Kinder Jugendpsychiatr Psychother 46:57–66
Gonzalez A, Kohn MR, Clarke SD (2007) Eating disor- Steinhausen H-C (2002) The outcome of anorexia
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Kinder-Jugendpsychiat Psychotherap (im Druck) tics. https://icd.who.int/browse11/l-m/en. Accessed
49:443–452 15. Juli 2020
Eating Disorders in Men
15
Barbara Mangweth-Matzek
Contents
15.1 General Information on Anorexia Nervosa and Bulimia Nervosa in Men . . . 103
15.2 Onset of the Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
15.3 Disease Course . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
15.4 Treatment and Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
15.5 Atypical Eating Disorders and Binge Eating Disorder (BED) . . . . . . . . . . . 108
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
15.1 General Information state of the nerves, of the stomach, and intes-
on Anorexia Nervosa tines …”. Robert Willan followed in 1790 with
and Bulimia Nervosa in Men another publication titled “A Remarkable Case
of Abstinence,” in which he portrayed the death
Although anorexia nervosa (AN) and bulimia of a young English man who fasted for 78 days.
nervosa (BN) are considered typical female dis- Epidemiological studies confirm a gender
orders, the first historical descriptions refer to ratio (female : male) of AN and BN of 10 : 1 and
male patients. 4 : 1, respectively . The DSM-5 (Hudson et al.
In 1689, the London physician Richard 2007; Jaworski et al. 2019) has opened up the
Morton described the drastic weight loss of a diagnosis of eating disorders (especially AN) to
16-year-old as “nervous consumption caused men and women of all age groups. This has led
by sadness and anxious cares.” In 1764, Robert to new research focuses and results that describe
Whytt published a case report on a 14-year-old disturbed eating behavior also in middle and
boy with AN, described as “nervous atrophy older age and present male-specific forms. The
(…) that proceeded from an unnatural or morbid proportion of scientific papers on men is still
very low compared to the available studies on
women (Strother et al. 2012). However, clear
B. Mangweth-Matzek (*) content focuses are evident: 1) The existing
University Hospital of Psychiatry II, Department data on eating disorders mainly refer to female-
of Psychiatry, Psychotherapy, Psychosomatics oriented survey instruments, which is why data
and Medical Psychology, Medical University of
on prevalence and symptom presentation in
Innsbruck, Innsbruck, Austria
men only questionably reflect reality; 2) what is
https://doi.org/10.1007/978-3-662-67662-2_15
104 B. Mangweth-Matzek
considered the core symptom of disturbed eat-

ing behavior in women, namely weight/fat pho- Risk Factor: Body dissatisfaction
bia (drive for thinness), seems to often exist in • Body dissatisfaction as a trigger for the
combination with “drive for muscularity” in desire for body change
men. “Muscularity-oriented disordered eating” • Desire for weight loss (= body fat
(Murray et al. 2019; Lavender et al. 2017) is reduction), weight gain (= muscle mass
described as a new form of eating disorder. increase)
• Means: (excessive) exercise and restric-
tive eating
15.1.1 “Muscularity-Oriented
Disordered Eating”
AN and BN often begin in adolescence. Although
This form of disturbed eating behavior aims young men show the first symptoms of these
at a male body ideal featuring muscularity eating disorders a few years later than young
and leanness and is characterized by muscle- women, puberty is often involved in the develop-
building sports and specific eating behavior. ment process of the disorder in men as well.
The dietary practice described as “bulk and Before the onset of puberty, girls and boys
cut" alternates between “bulking” as a phase hardly differ in terms of their body structure.
of excessive protein replenishment to increase During puberty, the male body shows increased
muscle mass in the body and “cutting,” the muscle growth, while the female body gains sig-
phase of restrictive eating behavior aimed at nificantly more body fat (body fat in boys approx.
reducing body fat. In between, “cheat meals” 14%, in girls approx. 24%). This often leads to
can occur, i.e., planned or spontaneous eating body dissatisfaction and, in combination with
phases that deviate significantly from the usual other factors (familial, biological, individual),
dietary regulations by consuming forbidden and often to initial dieting behavior. This essential
unhealthy food in large quantities (1000–9000 gender-specific distinction in body development
calories). These phases resemble bulimic binge in boys is discussed as a possible protective fac-
eating (Murray et al. 2019; Lavender et al. tor for the development of eating disorders and
2017; Gorrell 2019). serves as a possible explanatory factor for the
lower rates of eating disorders in men.
Although beauty ideals and appearance have
15.2 Onset of the Disorder long been associated with the female gender,
significant changes have emerged in recent dec-
15.2.1 Risk Factor: Body ades. While girls continue to strive for thinness
Dissatisfaction and weight loss, an increasing number of boys
and male adolescents desire an athletic, mus-
There are now clearly identified factors that, in cular body. Results from the “Massachusettes
their interaction, are discussed as putative risk Youth Risk Behavior Survey” show that more
factors for eating disorders. At the top of the than half of male adolescents try to change their
list of psychological and behavior-specific fac- body weight and appearance: 36.4% tried to
tors is body dissatisfaction, which is associated gain weight (muscle mass) and 22% tried to lose
with low self-esteem in both genders and often weight (fat mass), while girls were ten times
results in “dieting behavior,” “restrictive eating more likely to want to lose weight than to gain
behavior,” and increased exercise. Specifically weight. Boys engage in sports to gain weight or
for men, dissatisfaction with one’s muscularity increase their muscle mass, while girls engage
(= masculinity) is also described. in sports to lose weight or reduce their body
fat content. The method of dieting or restrictive
15 Eating Disorders in Men 105
eating is predominantly used by girls, regardless  Important Dissatisfaction with one’s body
of their weight. When boys start a diet or reduce and figure, which in men is often based
their food intake, it is usually the result of real on real overweight or a “not sufficiently
overweight, i.e., a BMI > 25 or extreme body masculine” body, leads to initial diet
dissatisfaction (perceiving one's body as not attempts and physical activity, with the
masculine enough). goal of shaping a sporty, muscular body.
Media of all kinds contribute to normal- “Muscuarity-oriented disordered eating”
weight children and adolescents of both genders has emerged as a new specific form of
feeling overweight, non-muscular, or “not fit- disturbed eating behavior in men. Eating
ting.” At the same time, the prevalence of over- disorders in men are no longer limited to
weight is increasing, especially among children adolescence but can occur throughout the
and adolescents. The result of this is that they entire lifespan.
want to change their bodies at a very early age
and manipulate the sensitive area of the hunger-
satiety mechanism through restrictive eating 15.2.2 Additional Risk Factors
or neglect other important areas of life through
extreme physical activity. Risk factor research combines many factors
Men not only control their eating behavior from different areas that contribute to the devel-
differently than women, but often also for dif- opment of eating disorders in women and men
ferent reasons. Diets in men are not only usu- (Jacobi et al. 2004):
ally aimed at a specific weight goal but also at
a body consistency with a high muscle content • general and social factors,
and/or extreme athleticism. • family factors,
Recent study findings have shown that eat- • developmental factors,
ing disorders can also occur in middle-aged • adverse life events,
and older men (Mangweth-Matzek and Hoek • psychological and behavior-specific factors,
2017). Even if they are not diagnostically the • biological factors.
typical forms of AN and BN, binge eating and
unspecified eating disorders often appear in The following risk factors have a particular
older populations. In addition, men (of all age significance:
groups) describe excessive exercise behavior
as a compensatory method after previous binge • sexuality: homosexual or bisexual orientation,
eating episodes, alongside typical bulimic symp- • professions and sports entailing a focus on
toms with vomiting. This form is often underes- the body, weight, figure, and/or performance,
timated in its severity, as sports are still mostly • childhood sexual abuse (not a specific risk
positively connotated (Mangweth-Matezek et al. factor for eating disorders in men, but shows
2016). significantly higher rates than in non-eating
Now that disturbed eating behavior is no disordered men, yet lower rates than in eating
longer exclusively associated with young age, disordered women).
other critical life events can be identified as
potential risk factors, such as midlife crisis, chil- All critical events throughout the lifespan (rela-
dren leaving home, separation of partnership, tionship changes, children leaving home, career
new relationship, professional or health reorien- changes, illnesses, aging, etc.) can cause vulner-
tation, etc. Although eating disorder symptoms ability to eating disorders in men.
in middle or older age can often be a continua-
tion of already existing symptoms from younger Sexuality Although the sexual orienta-
years, there is also the possibility of a late onset. tion of men with eating disorders has long
been controversially discussed, study findings behavior in the context of “sports addiction”
increasingly show a clear association between (not a recognized disease concept).
homosexuality or bisexuality and disturbed eat- Pope et al. (1993) described a new phenom-
ing behavior (Feldman and Meyer 2007). Men enon of disturbed body image or eating behavior
with eating disorders show significantly higher in 8% of the examined male bodybuilders, origi-
prevalences of homosexuality or bisexuality (10– nally called “reverse anorexia nervosa” and then
42%) compared to rates in the general population “muscle dysmorphia” (in the category: Body
(5–10%). Conversely, higher prevalence rates Dysmorphic Disorders. Although these men
of eating disorders were found in homosexual have oversized muscles according to their body-
(“effeminate”) men (2.1%) than in heterosexual builder status, they perceive themselves as weak
men (0.3%). Socioculturally, this phenomenon and non-muscular. The focus of their everyday
can be explained as follows: Homosexual and life is regular and intensive training, excessive
bisexual men place more emphasis on weight, eating, and anabolic steroid consumption—with
figure, clothing, cosmetics, and eating behavior the goal of creating an ideal body consisting of
than heterosexual men. Even though sexual ori- the highest muscle and lowest fat content. This
entation is discussed as a specific risk factor for is comparable, only “in reverse,” to the phenom-
eating disorders in men, the clear backgrounds enon of classical AN (Pope et al. 2000).
and relationships are not really known.
Childhood traumatization Men with eating
Profession Professions in which the body, fig- disorders show significantly higher rates of trau-
ure, weight, appearance, and physical perfor- matization during childhood than men without
mance play a significant role are more frequently eating disorders. Here, experiences of physi-
associated with disturbed eating behavior and cal violence, sexual abuse, and psychologi-
eating disorders than other occupational groups. cal neglect are particularly evident. Similar to
There are barely any gender-specific differ- affected women, traumatization is not a spe-
ences in this regard, as the profession of dancer cific risk factor for disturbed eating behav-
or model requires a slim (to thin) body for both. ior but rather a risk factor for mental illness in
In all these occupational areas, the body is general.
defined and specified in a clear ideal form, which
is usually not achievable without fasting, vomit-
ing, diuretic or laxative abuse, or extreme sports. Conclusion
Eating disorders have a multicausal patho-
Exercise Although exercise is fundamentally genesis. Critical events throughout the
healthy, in the context of eating disorders there lifespan can increase vulnerability to eat-
are often pathological forms of physical activity ing disorder symptoms. The risk factors
that are not based on health consciousness but mentioned here act in the context of other
on compulsiveness and often unattainable per- (biological, cultural, individual, situational)
formance goals. While the phenomenon of the factors. Factors such as “occupation” or
“athletic triad” has been described in women, “sports” are not only potential triggers, but
there is no comparable syndrome in men in often also stabilizers for already existing
competitive sports, but there is an increas- symptoms of disturbed eating behavior or
ing amount of literature on disturbed eating existing eating disorders.
15.3 Disease Course during the course of their illness, but also high
rates (60–80%) of psychiatric comorbidity:
mainly affective disorders (unipolar depression),
Disease Course anxiety disorders, substance abuse or depend-
• Clinical symptoms of AN and BN show ence. It is still unclear whether these additional
no gender-specific differences, with the psychiatric disorders occur before, during, or
exception of excessive exercise as a after the eating disorder. In addition, men with
compensatory measure in BN, which is eating disorders often have personality disorders
more common in men. (avoidant-self-conscious, dependent, borderline,
• High prevalence rates of comorbidity, paranoid, and schizoid).
especially affective disorders and sub-
stance abuse or dependence in men.
15.4 Treatment and Outcome
For a long time, the clinical picture of men with

AN was misunderstood, as AN was exclusively Treatment and Outcome
associated with women, and the diagnostic cri- • Treatment:
teria (especially DSM) required the existence – Since men with an eating disorder
of a 3-month amenorrhea. Today, the criterion experience double stigmatization,
of amenorrhea is seen as an epiphenomenon few seek treatment. Those who do are
for extreme underweight; accordingly, both often severely symptomatic.
the ICD-10 and DSM-5 have eliminated the gen- – The treatment of eating disorders is
der specificity of the criterion, making men and gender-neutral: weight rehabilita-
women of all age groups (i.e., also postmeno- tion, structuring and stabilization of
pausal) diagnosable. eating behavior in combination with
Once the anorexic or bulimic (especially psychotherapy
binge eating plus vomiting) symptoms have – Pharmacological and psychothera-
manifested, there are no gender-specific differ- peutic co-treatment of comorbidities
ences in clinical presentation. Men who engage • Course:
in extreme sports after binge eating to com- – Men with AN show no differences
pensate for excessive food intake often do not in long-term survival compared to
have the awareness of the disorder of those who women, but do show more frequent
vomit, and are therefore not the typical patients deaths immediately after inpatient
seeking treatment in the clinic. Weight phobia, stays.
body perfectionism, fear of eating, and psycho-
logical narrowing are in the foreground. In line
The gender-specific attribution of eating dis-
with the physical regression in AN, sexual fan-
orders is considered a major reason for the low
tasies and activity usually disappear. Affected
treatment willingness of men with eating dis-
individuals often live without relationships
orders. The disease “eating disorder” per se
and asexually. Medically, patients present with
is a stigma for many affected individuals, and
the same findings as in female patients: e.g.,
male gender in combination is often a second
cachexia, dry skin, lanugo hair, petechiae, acro-
stigma. Like women with AN and BN, affected
cyanosis, hypothermia, bradycardia, hypoten-
men also show a significant delay in treatment,
sion, osteopenia or osteoporosis, brain atrophy
i.e., months or years usually elapse between
in AN; e.g., arrhythmia, sialadenosis, dental
the onset of the first symptoms and the time
damage, constipation in BN.
when professional help is sought (Cottrell and
Men with eating disorders (Raevuori et al.
Williams 2016)
2014) show not only severe medical symptoms
Outpatient or inpatient treatment is based of atypical eating disorders. The gender ratio of
on the same principles for both genders. The female to male is approximately 3:2. Men with
most important aspect of therapy for men with BED do not differ from women with BED in
anorexia nervosa is weight gain with the aim of terms of symptomatology. Clinically dominant
body stabilization, including the return of libido is the frequent association with overweight or
or sexual function (= normalization of testos- obesity (over one third).
terone levels), comparable to the menstruation A number of studies on eating disorders in
weight in affected women. Data on the outcome women have shown that eating disorders can
for men with eating disorders are insufficient occur well into old age. While AN and BN are
due to the few studies available. typical for adolescent girls and young women,
BED and atypical eating disorders are more
 Important Long-term studies of the origi- common in middle and old age (from 40 years).
nally very small samples have proven Prevalence studies in middle-aged and older
extremely difficult and put the selection of men are still scarce.
the examined subjects in the foreground.
Results should therefore be considered in
light of these limitations. Conclusion
Eating disorders are rare in men but can
On the one hand, studies describe the course occur across all age groups. While they are
of eating disorders in men similarly to that often AN- and BN-typical in younger years,
of affected women, but on the other hand, the BED and eating disorders not otherwise spec-
increased mortality after discharge points to ified (= atypical) are more common in mid-
the need for immediate outpatient follow-up dle and older age. Recent research findings
care. Essential for remission are a short disease suggest the establishment of male-specific
course, early effective treatment, little comor- assessment tools to capture possible gender-
bidity, and a supportive social system. specific differences. “ Muscularity-oriented
disordered eating” is considered a new form
of male eating disorder. However, when AN
15.5 Atypical Eating Disorders or typical BN do occur, they show clinically
and Binge Eating Disorder the same symptomatology and a similar long-
(BED) term course as in affected women. Notable
are a premorbid overweight or extreme
This category of atypical eating disorders (Chap. body dissatisfaction and a high proportion
5) has gained significant importance after it of homosexual or bisexual orientation. The
was shown that a large proportion (50–70%) strong female association with disordered
of patients seeking treatment at eating disorder eating often leads to male sufferers deny-
clinics do not exhibit the full picture of AN or ing their symptomatology and consequently
BN, but rather show atypical eating disorders. not seeking treatment. On the side of profes-
The proportion of men in this eating disorder sionals, there is often a misinterpretation of
category is significantly higher than in the two the symptomatology or misdiagnoses, espe-
“typical” eating disorder categories. However, cially when sports activity is reported in con-
large studies are still lacking to describe precise text. BED, as the third main eating disorder,
epidemiological factors in men. has a significantly higher proportion of men
BED, which is an independent eating disor- than AN and BN and is often associated with
der in the DSM-5, is the best-described category overweight and obesity.
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Eating Disorders
and Competitive Sports 16
Petra Platen
Contents
16.1 Body Weight and Body Composition in Competitive Sports . . . . . . . . . . . . 112
16.2 Energy Balance in Competitive Sports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
16.3 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
16.4 Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
16.5 Pathophysiological Mechanisms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
16.6 Health Consequences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
16.7 Screening and Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
16.8 Prevention and Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
16.9 Performance-Optimized Weight Management for Athletes . . . . . . . . . . . . . 120
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Given the huge importance of physical activity have also been described in male athletes. In
for health, all people should regularly engage recent years, a so-called “Relative Energy
in physical activity and/or sports. Sometimes, Deficiency Syndrome (RED-S)” has been
however, athletic activity can be associated with applied to both genders. Due to the higher prev-
an increased health risk. This includes a non- alence, the focus is on female athletes.
demand-adjusted, hypocaloric diet, which can
affect the entire range of eating disorders up to
classical eating disorders. A hypocaloric diet Female Athlete Triad
can in turn be associated with disorders of the The ”female athlete triad“ refers to a
reproductive system and bone demineralization. symptom triad consisting of
In female athletes, this symptom triad is also
• chronically insufficient energy intake
referred to as the “female athlete triad”. Eating
with or without eating disorders,
disorders and reproductive system disorders
• menstrual cycle disorders, and
• low bone density up to osteoporosis.
P. Platen (*) Although there is little literature on male

Department of Sports Medicine and Sports Nutrition, athletes due to the lower prevalence, the
Faculty of Sport Science, Ruhr-University Bochum, corresponding publications show that a
Bochum, Germany chronic calorie deficit can also lead to
https://doi.org/10.1007/978-3-662-67662-2_16
112 P. Platen
disorders of the reproductive system and Weight-sensitive sports

bone demineralization in male athletes. 1. Sports in which gravity plays a role,
where the body has to be moved against
gravity and a high body weight there-
Competitive sports represent a specific social fore reduces performance; these include
sphere. The pressure on athletes to increase – long-distance running,
performance, conform to an aesthetic norm, – cross-country skiing,
or achieve a lower weight class is very high. – road cycling and mountain bike
Failure to reach a certain weight class can lead racing,
to exclusion from the team or a ban on compet- – ski jumping and
ing. This, in turn, can lead to changes in eating – the jumping disciplines in athletics;
behavior that take on pathological traits and can 2. Sports in which weight classes exist,
develop into classical eating disorders. such as
– combat sports like judo, boxing, taek-
wondo, as well as
16.1 Body Weight and Body – weightlifting and lightweight rowing;
Composition in Competitive 3. aesthetic sports such as
Sports
– rhythmic gymnastics and floor and
Body weight and body composition are two of apparatus gymnastics,
the many factors that can influence performance. – figure skating and ice dancing,
The body weighthas an impact on maximum – platform high diving and synchro-
running speed, endurance, and strength, while nized swimming.
the body composition affects aesthetics and agil-
ity. An optimal power-to-weight ratio determines Gravity-sensitive sports In gravity-sensitive
performance in many sports. Since the body fat sports, the body weight has to be carried, so
percentage has a negative effect on the power- only slim-built athletes can be successful. Here,
to-weight ratio, many athletes strive for the low- diets are often used to try to lose excess body
est possible body fat percentage. However, a too mass. However, both body fat and muscle mass
low body fat percentage has negative health are lost under pronounced dieting behavior, so
effects and can also lead to a deterioration in performance can actually deteriorate.
performance. Moreover, it is not the only per-
formance-relevant parameter, and a high perfor- Weight class sports In weight class sports, ath-
mance does not automatically result from low letes are forced to either gain or lose weight if
body fat alone. they want to compete in the supposedly optimal
In some sports, the pressure to achieve a weight class for them.
certain body weight and/or the lowest possible
body fat percentage, and thus potentially nega- Aesthetic sports In aesthetic sports, athletes
tive health consequences, is particularly high. must have a slim stature to be successful and
Some athletes have a genetically determined often develop dieting behavior, even if their cur-
almost ideal body anthropometry for their sport- rent body height-weight ratio seems to be opti-
specific requirements, but many athletes undergo mal from a health and performance perspective.
partially extreme diets when trying to achieve
optimal conditions for high performance in their  Important An optimal competition weight
sport, for which they may not be constitutionally and optimal body composition should be
optimally suited.
16 Eating Disorders and Competitive Sports 113
determined individually. It is important to clinical eating disorders is wide. The issue of a

ensure that the athlete is or stays healthy and positive energy balance is addressed elsewhere
can achieve his or her individual maximum (Chap. 65, “Obesity and Sports”).
performance. In this context, energy availability is defined
as the difference between energy intake and
energy expenditure through physical training
Strategies for body weight control in and represents the amount of energy available to
sports the organism for other body functions. If energy
• Realistic goals for weight and body availability becomes too low—specifically, if
composition should be pursued. The it falls below 40–45 kcal/kg of fat-free body
following questions arise: mass—the organism implements energy-saving
– What maximum weight would be measures, e.g., in cell metabolism, thermoregu-
acceptable? lation, and reproduction. This partially and tem-
– What was the last weight without porarily compensates for the energy deficit and
dieting? ensures survival, but impairs health if it persists
– How was the target weight achieved? for an extended period. This applies equally to
– At what weight was the highest per- men and women.
formance capacity? Some athletes with conspicuous energy bal-
• Is great importance placed on healthy ances reduce their energy availability by increas-
behavior, including good stress manage- ing energy expenditure through physical training
ment and healthy eating habits? more than energy intake from food. Other ath-
• Are progressions, e.g., regarding per- letes reduce their energy availability by decreas-
formance increase, energy balance, ing energy intake more than energy expenditure
injury prevention, normalization of the through sports. Others still use specific forms
menstrual cycle, and general well-being of eating behavior, such as fasting or purging
documented? methods such as the use of laxatives, diuretics,
or emetics.
Athletes need support in their efforts to Another group exhibits clinical forms of eat-
make lifestyle changes for themselves ing disorders, which are often accompanied by
and not for their sport, their coaches, their other mental illnesses. In cases of proven sports
sports environment, or for proving anything. addiction, there is a disproportionately high fre-
quency of a combination with disturbed eating
behavior.
Insufficient energy availability (with or with-
16.2 Energy Balance in Competitive out eating disorders), functional hypothalamic
Sports amenorrheaor a hypothalamically induced
reduction in testosterone production, and bone
In recent years, the term relative energy defi- demineralization, either alone or in combina-
ciency in sports (RED-S) has been increasingly tion, have significant health consequences for
used in dealing with the issue of eating disor- the affected athletes. Therefore, effective pre-
ders or disturbed eating behavior in competitive vention, early diagnosis, and consistent therapy
sports. In contrast to the female athlete triad, should be pursued.
this term includes the male gender and does not Each of these three fully developed clini-
only cover clinical eating disorders. Rather, the cal conditions is to be understood as the end of
spectrum between optimal energy intake for a spectrum of interrelated conditions between
the performance of competitive sports activities complete health and illness. For each individual,
and insufficient energy intake with or without any of the three conditions can move at different
114 P. Platen
speeds along the various spectra, depending “anti-gravity sports” like high jump and climb-
on the current nutritional situation and training ing, compared to 6% in a non-training compari-
behavior. son group of women. Another large study found
A moderate or only recently established clinically relevant eating disorders in 25% of
calorie deficit can trigger subclinical forms of female athletes in endurance and aesthetic sports
menstrual cycle disorders, such as anovulatory as well as weight-class sports, compared to 9%
cycles or luteal insufficiencies, or only minor in non-training women. The differences in prev-
changes in metabolic hormones. Energy balance alence between the studies can be explained,
can vary from day to day, but changes in the among other things, by differences in the sur-
menstrual cycle with chronic decreases in estro- vey instruments employed. Larger studies in
gen levels may only become apparent after one male athletes found eating disorders in 2–4%
or more months. Effects on bone density may of athletes from sports with high pressure for a
not be detectable until after a year or later, and lean physique, compared to 0% in non-training
metabolic effects may not be apparent for many controls.
years. It is important to note that neither male nor
female athletes from “non-risk sports”, such as
ball sports, technical disciplines, and strength
16.3 Epidemiology sports, showed an increased risk for eating dis-
orders compared to non-training controls.
The prevalence of individual components of the The prevalence of eating disorders is reported
triad of the female athlete varies considerably in in the literature to be up to almost 45% in
existing studies. Information on the frequency female athletes and up to 13% in male athletes.
of a possibly latent chronic negative calorie bal- Estimates for an increased risk of developing
ance is completely lacking. an eating disorder are even as high as 90% for
Overall, subclinical and clinical eating disor- female athletes. Sport-specific differences in the
ders are more common in adult female and male prevalence of eating disorders are not yet found
athletes than in non-elite sports participants, in young athletes, possibly because the duration
with the prevalence being higher in female ath- of high performance pressure has not prevailed
letes, especially in endurance and aesthetic for very long and therefore sport-specific pat-
sports, than in male athletes, while the issue is terns have not yet been able to develop.
particularly relevant for male athletes in weight-
class sports. How this issue presents itself in  Important In those sports where there is high
elite para sports is still completely unknown. pressure for a lean physique, there is an in-
Large, well-designed epidemiological studies creased risk for the occurrence of eating dis-
report the prevalence of clinical eating disorders orders, ranging from subclinical to clinically
(anorexia nervosa, bulimia nervosa and other manifest eating disorders. In other sports,
eating disorders) in female athletes in so-called there is no increased risk.
risk sports at almost 50%. One study, using
structured interviews among other methods,
diagnosed eating disorders in 46.5% of female Risk Sports Regarding Eating Disorders
athletes with the need for a lean physique, in • Sports with a high aesthetic character;
19.8% of female athletes without weight pres- this group can be divided into three fur-
sure, and in 21.4% of a non-training control ther areas:
group. Another study found eating disorders – Sports in which performance and aes-
in 31% of women in sports where a lean phy- thetics are partly subjectively judged
sique is desired, such as endurance sports, aes- (examples: figure skating, danc-
thetic sports, weight-class sports, and so-called ing, rhythmic gymnastics, artistic
gymnastics, synchronized swimming) General risk factors

– Sports in which a childlike habitus 1. Predisposing factors
offers biomechanical advantages – Genetics
(examples: artistic gymnastics, rhyth- – Age
mic gymnastics) – Pubertal developmental status
– Sports in which body-conscious – Psychosocial factors (dissatisfac-
clothing is worn (examples: artistic tion with one’s body, low self-
gymnastics, diving) esteem, personality factors such as
• Endurance sports in which body weight perfectionism)
must be carried (examples: triathlon, – Sociocultural factors (eating dis-
long-distance running, cross-country orders in the family, pressure from
skiing, road cycling, and mountain sports peers, influence of the media,
biking) bullying)
• Weight class sports (examples: wres- 2. Trigger factors
tling, judo, rowing, boxing, horse racing – Negative comments regarding body
[jockeys]) weight and/or body proportions
• Other sports in which weight affects – Traumatic experiences etc.
performance (“anti-gravity sports”) 3. Maintaining factors
(examples: ski jumping, climbing, high – Lack of recognition by the coach or
jump) other important persons
– Physiological effects of starvation
– Initial success no longer occurs etc.
16.4 Risk Factors
The risk factors that can contribute to the devel- Sport-specific risk factors
opment of eating disorders in female athletes are • Sports with high pressure for a lean
multifactorial in nature. General risk factors can physique (risk sports, Sect. 16.3)
essentially be divided into three categories: • Aspired high performance level
• Beginning of training before menarche
• predisposing factors, • Significant fluctuations in body weight
• “trigger” factors, • External pressure to follow a diet
• maintaining factors. • Lack of support in losing weight
• Calorie deficit and/or loss of appetite
Furthermore, experiences of abuse as well as due to increased training volume
sports- and gender-specific aspects are among • Personality profile
the risk factors. • Early start of sport-specific training
Dietary behavior appears to be an important • Traumatic events such as illnesses,
entry point towards the development of a mani- change or loss of the coach, injuries,
fest eating disorder. Noticeable disturbances in problems at school or in the social
eating behavior lead disproportionately often to surroundings
clinically manifest eating disorders, so their • Behavior of the coach
presence should be closely monitored in a pre- • Poor educational level of the coach
ventive sense. • Rules and regulations in sports
116 P. Platen
availability below which significant alterations

Gender-specific risk factors, especially of the GnRH or downstream pituitary pulses of
in male athletes luteinizing hormone (LH) occur. This threshold
• Need for a muscular physique is at about 30 kcal/kg fat-free mass energy per
• Abuse of anabolic steroid hormones day, which is still available to the organism after
• Homosexuality deducting the training-related energy expendi-
ture. This corresponds to the resting metabolic
rate of a healthy person.
Insufficient energetic availability, whether in
16.5 Pathophysiological
connection with a disturbance of eating behav-
Mechanisms
ior, a manifest eating disorder, or high energy
expenditure due to performance training with
16.5.1 Eating Disorders
inadequate nutrition, can lead to changes in
metabolic hormones and substrates. These, in
There is no known specific cause for the devel- turn, serve as metabolic signals to the GnRH-
opment of eating disorders in competitive sports. secreting neurons. It is unclear whether there are
Rather, an interaction of several risk factors is specific mechanisms at work in female or male
assumed (Sect. 16.4). From a pathophysiologi- competitive athletes.
cal perspective, it seems significant that a nega-
tive energy balance, which is achieved by food
restriction alone (dieting behavior), triggers a 16.5.3 Low Bone Density
feeling of hunger, while this does not occur with
increased physical activity. There seems to be Female athletes with functional amenorrhea and
no internal “sensor” for adjusting food energy male athletes with reduced testosterone blood
intake to a training-related increased energy levels show pathological bone remodeling. Bone
expenditure. Moreover, the energy deficits to be formation is suppressed and bone resorption is
achieved through food restriction appear to be increased. So far, antiresorptive drug therapy
greater when there is a high carbohydrate con- has not been able to normalize bone density in
tent in the diet, as is typical for athletes. affected female athletes. This is probably due to
other relevant factors, such as an overall more
or less pronounced calorie deficit. In a prospec-
16.5.2 Menstrual Cycle Disorders tive study with female athletes, a 5-day calorie
and Reduction of Testosterone restriction led to an energy availability of less
Levels than 30 kcal/kg fat-free body mass per day, an
increase in bone resorption, and a decrease in
Disorders of the menstrual cycle or reduc- formation. The increase in resorption is likely an
tion of testosterone production in connection effect of reduced estradiol concentrations, while
with insufficient calorie intake are triggered by the decrease in formation is likely an effect of
alterations of the gonadotropin-releasing hor- changes in insulin, T3, and IGF-1 or other hor-
mone pulse generator (GnRH pulse generator) mones such as cortisol and leptin. Low bone
at the hypothalamic level and are among the so- density values have also been described in male
called functional disorders of the gonadal axis. athletes with reduced testosterone concentra-
There seems to be a “threshold” of energetic tions related to calorie deficiency.
16.6 Health Consequences 16.7 Screening and Diagnosis
16.6.1 Medical Consequences 16.7.1 Screening
Eating disorders in sports, as well as all aspects The screening for disturbed eating behavior and
involved in sports, lead to various health conse- clinically manifest eating disorders in competi-
quences. Depending on the severity and duration tive sports athletes requires both an awareness of
of the eating disorder, significant somatic health the continuity of the disease spectrum between
consequences can occur (Chap. 3, “Clinical only slightly noticeable behavior and severe
Aspects of Anorexia and Bulimia Nervosa”). clinical manifestations, as well as an under-
standing of the pathophysiological relationships
between the three components of the female ath-
16.6.2 Psychological and Social lete triad.
Consequences Ideally, screening for disturbed eating behav-
ior or manifest eating disorders should be per-
Eating disorders have profound psychologi- formed both during the initial sports medicine
cal and social consequences, significantly dete- examination before starting competitive sports
riorating the quality of life of those affected. training (sports entry examination) and during
People with eating disorders increasingly the annual squad examination. Furthermore, a
lose their zest for life, their self-confidence specific investigation for disturbed eating behav-
decreases, and their interest in their environment ior or eating disorders should also be conducted
diminishes. Over 5% of female athletes with when athletes present with health problems that
eating disorders report suicidal intent. The con- might be related to eating disorders, such as
stant stress experienced by those affected and amenorrhea, stress fractures, or repeated injuries
the fear that others will discover the disordered or illnesses.
eating behavior (especially in bulimia) lead to A standardized instrument should be used for
increased irritability and withdrawal. At the screening, e.g., the Eating Disorder Inventory
same time, concentration, overall performance, (EDI). In the case of conspicuous values on the
and interest in sexuality decrease. The transmis- individual subscales, targeted questions about
sion between nerve cells in the brain (e.g., due eating behavior and abnormalities related to the
to serotonin deficiency) can change and thus other components of the triad should be asked in
negatively affect mood. Severe depression and a personal conversation. Even though eating dis-
anxiety disorders can result. orders are more common in the aforementioned
In competitive sports, eating disorders lead risk sports (Sect. 16.4), they can still be present
to a further increase in the already high emo- in any other sport. Therefore, appropriate screen-
tional pressure faced by athletes, not only during ing should be initiated at the first slight suspicion.
competitions. From the perspective of bulimic
athletes, courses, training camps, and compe-
titions are particularly stressful, as they have 16.7.2 Diagnostic Procedure
little opportunity for solitude and thus secret
vomiting. Athletes with anorexic tendencies 16.7.2.1 Anamnesis
can hardly hide their very low food intake. The The anamnesis should include information
result is depressive processing disorders, lack of on food intake, diet behavior, weight fluctua-
motivation, sleep disorders, and consequently tions, and training-related calorie consumption.
further loss of performance and worsening of The BMI should be above 17.5 kg/m2 or, in the
the eating disorder.
118 P. Platen
case of adolescents, above 85% of the expected hip region. In the case of abnormal values, fur-
value. Furthermore, the menstrual history should ther methods such as high-resolution computed
be taken, and if abnormalities are found, a tomography can be used.
(sports) gynecological examination should be
initiated. It is important to specifically ask about
factors that may indicate low bone density, such 16.8 Prevention and Therapy
as the occurrence of stress fractures. If eating
disorders are suspected, further psychosomatic Due to the interaction of the three components
or psychological clarification should be carried of the female athlete triad or the athlete with
out to rule out or diagnose a clinically mani- reduced energy availability, effective preven-
fest eating disorder. The examination follows tion and therapy require a functioning team
the usual standards for non-athletes. During the from the fields of sports medicine/sports gyne-
physical examination of the athlete, signs indi- cology/sports andrology, nutrition counseling,
cating an eating disorder should be looked for. and sports psychology. This team should also
These include: bradycardia (a typical finding in include coaches, parents, and other individuals
healthy endurance athletes), orthostatic dysregu- from the athletes’ personal environment.
lation, cold, bluish hands and feet, lanugo hair, The mortality rate due to the consequences
and enlarged salivary glands. of severe anorexia is also increased for (former)
elite athletes. In addition, disturbances in eating
16.7.2.2 Bone Density Measurement behavior or manifest eating disorders and asso-
The bone density should be measured ciated disturbances in the menstrual cycle also
lead to predominantly irreversible decreases in
• in the presence of disturbed eating behavior bone density in female athletes, with the corre-
or a clinically manifest eating disorder, sponding long-term health consequences for the
• with a BMI ≤ 17.5 kg/m2 or <85% of the affected athletes. For these reasons, consistent
expected weight or with a recent weight loss preventive and effective therapeutic measures
of >10% in one month, should be used, particularly in high-risk sports.
• with reduced testosterone blood levels in
male athletes,
• with menarche at the age of over 16 years or 16.8.1 Prevention
with menstrual cycle disorders lasting longer
than six months, and In modern performance sports, victories are par-
• if a stress fracture has already occurred. ticularly important. Athletes develop the feeling
that they are only as valuable as the performance
Furthermore, a bone density measurement they deliver. All too often, athletes are told, or
should be performed if several of the mentioned they themselves feel, that they are not interest-
factors are present to a less pronounced extent. ing as individuals.
The measurement method of choice is still a Regarding the prevention of eating disorders,
DXA measurement, which is widely available in the primary concern must be to help athletes
Germany. The diagnosis of low bone density is develop a mature, autonomous, and self-con-
based on the lowest Z-score of the vertebral fident personality or to offer them support in
bodies (pa-view) or the hip region (femoral neck developing in this direction. They must be pro-
or total hip). It should be noted that the range tected from defining themselves solely by their
of bone density values in amenorrheic athletes performance and achievements, and they must
is considerable and can vary greatly from sport not allow others to do so either.
to sport and between different skeletal sections. Athletes should have the opportunity to
In athletes, bone density may be normal at the develop into self-confident women and men. To
radius but pathologically reduced at the spine or do this, they should be able to optimally develop
their own abilities, realistically assess them, and expenditure. The latter will probably be difficult
recognize and accept their limits. They should to achieve in high-performance sports.
also develop and implement their own goals
and needs and be able to accept criticism. With  Important The most important therapeutic
such a developed personality, they are equipped measure is the normalization of the energy
to adequately defend themselves against “inap- balance or energy availability, respectively.
propriate” criticism, such as overly critical com-
ments about their figure. The specific recommendations for interven-
Athletes should attach an appropriate level tions in athletes with insufficient energy intake
of importance to performance and success and depend on how the insufficient energy intake has
understand it as one part of the qualities that dis- developed. If the energy deficit has developed
tinguish them as individuals. They should learn unintentionally, intensive sports counseling or
to openly show and articulate their feelings. nutritional counseling is sufficient. If the energy
They should also be able to work cooperatively deficiency is based on disturbed eating behav-
in a community, as performance sports always ior, medical consultation in combination with
take place within a community. nutritional counseling should be provided. If the
energy deficit was deliberately induced without
 Important Stabilizing the personality is an disturbed eating behavior, intensive nutritional
important component of prevention against counseling is also sufficient. In cases where a
the development of eating disorders. In clinical eating disorder is the cause, treatment
the case of uncertainties and problems, ath- should include medical care, nutritional coun-
letes, parents, and people from their environ- seling, and medical or psychological or psycho-
ment should consult experts in the field of therapeutic treatment.
sports psychology. A nutritional counseling should aim for an
adequate intake of calcium (1000–1500 mg/
day), vitamin D (800 IU/day), and vitamin
16.8.2 Therapy K (60–90 ug/day) in addition to optimizing
the energy balance. Supplementation may be
The overarching goals for athletes with dis- necessary.
turbed eating behavior or manifest eating disor-
ders are the normalization of nutritional status,  Important Clinically manifest eating disor-
normalization of eating behavior, and changing ders in athletes should be treated according
the thought patterns that lead to or maintain the to the same medical and psychotherapeutic
eating disorder. The younger the athlete, the standards as in non-athletes.
more the family should be involved in therapy.
In amenorrheic female athletes, an increase in A female athlete affected by a manifest eating
body weight leads to increases in bone density disorder should only continue her training and
of about 5% per year. In women with anorexia participate in competitions if she meets minimal
nervosa, some studies have shown an increase in requirements. This includes good compliance,
bone density of 2–3% per year with an increase combined with close monitoring. She must pri-
in body weight. oritize treatment over training and competing,
For affected athletes, the most important and she must be willing to modify her training
measure to normalize the menstrual cycle or tes- in terms of type, duration, and intensity if nec-
tosterone blood levels and increase bone density, essary. If this is not successful, the athlete must
depending on compliance, should be a modifica- be excluded from training and competing but
tion of the diet with an increase in calorie intake should remain under therapeutic supervision.
and/or a reduction in training-related calorie
120 P. Platen
The pharmacological therapy of female ath- the level of calorie deficit and the composition
letes with clinically manifest eating disorders of the diet, particularly the amount and quality
includes the spectrum of medications used for of protein intake, determine whether (almost)
non-athletes, particularly the group of antide- exclusively carbohydrate and fat stores or body
pressants. Current doping regulations may need proteins (muscle mass) are targeted.
to be considered when using medications. In order to maintain the highest possible
Normalization of eating behavior without performance, it is of great importance in com-
pharmacological measures can only achieve petitive sports that, during a reduction of body
complete normalization of bone density in weight, muscle mass is preserved as much as
athletes with hypothalamic amenorrhea or in possible when body fat percentage is reduced.
women with anorexia nervosa if the eating dis- However, any calorie deficit in sports leads to a
order does not last too long and normalization decrease in glycogen stores in the liver and mus-
of eating behavior is achieved at a young age. cles. This means that only a very small amount
Pharmacological measures without simultane- of carbohydrates is available for physical train-
ous normalization of eating behavior do not lead ing. Intensive exertion, in which mainly carbo-
to an increase in bone mass. This also applies hydrates are metabolized, can therefore only be
to hormone replacement therapy or oral con- sustained for a limited time, and performance
traceptives. In athletes older than 16 years with in many sports is restricted. Consequently, no
reduced bone density and in whom amenor- diet should be undertaken immediately before a
rhea persists despite general treatment attempts, competition.
oral contraception can be used in the hope of Rapid weight loss or excessive restriction of
preventing further decrease in bone density. energy from food over several days and weeks
Biphosphonates should not be used in young is always accompanied by a significant loss of
athletes with hypothalamic amenorrhea or muscle mass. Therefore, ideally, weight loss
should only be considered after intensive review should not exceed 500 g per week.
of the individual risk constellation. It is of great importance to maintain a high
fluid/water intake during a diet. Enough should
be drunk such that the urine is pale yellow
16.9 Performance-Optimized and clear. Dark yellow or even brownish urine
Weight Management color is a clear sign of insufficient fluid intake.
for Athletes The total amount of fluid intake depends on
the training volume and environmental condi-
In competitive sports, it is common for an ath- tions. Restricting water intake leads to a short-
lete to want to lose or gain body weight in order term decrease in body weight, which can cause
to meet the demands of the sport and achieve serious health problems in sports, including
the best possible performance (Sects. 16.1 and overheating, fainting, and death, and should
16.2). In both cases, weight changes should therefore not be carried out.
occur over the long term during competition Furthermore, it should be noted that the
breaks or in the season preparation, before com- increased need for vitamins, minerals, and trace
petitions take place. elements in sports must be adequately covered
during a diet to avoid health problems. This is
often only achievable through additional supple-
16.9.1 Guidelines for Appropriate mentation, e.g., with a good multivitamin/multi-
Weight Loss mineral preparation.
Weight loss occurs whenever more calories are

consumed than are added through food. Both
sports, containing about 25% of energy from fat

Recommendations for Sensible Weight and 60% from carbohydrates.
Loss The increased food intake must be combined
• Avoid significant weight fluctuations; with additional strength training or strength-
lose weight during the pre-season, not focused training to actually build more muscle
during the competition phase; expect tissue and not store the energy sources in fat
reduced performance during the diet tissue. The speed at which an increase in body
phase; weight can be achieved depends on many dif-
• Do not lose more than half a kg/week, ferent factors, such as genetic predisposition,
so do not choose too large a calorie surplus of supplied energy, number of rest and
deficit; recovery days, and the type, duration, and inten-
• Reduce total calorie intake, mainly by sity of training.
reducing fat intake, but do not go below
15% of total energy intake from fats;
choose high-quality fats (mono- and Conclusion
polyunsaturated fatty acids, found in An insufficient energy intake from food and/
marine fish, olive oil, linseed oil); or too high energy consumption through
• Do not fall below a protein intake of 1.2 competitive sports training with or without
g/kg body weight; choose high-quality clinically manifest eating disorders, hypo-
protein (fish, lean meat, poultry, whole thalamic amenorrhea or hypothalamically
grain cereal, low-fat milk and dairy induced reduction of testosterone produc-
products, eggs, soy products, legumes, tion, and pathologically low bone density
etc.); values, either alone or in combination, have
• Eat at least five portions of vegetables significant health consequences for the
and fruits per day; affected athletes. Therefore, both preventive
• Drink plenty of fluids, especially mag- and therapeutic measures should be consist-
nesium-rich water (>150 mg/l), and ently applied, especially in high-risk sports,
consume calcium-enriched fruit juices; in addition to raising awareness of the prob-
restricting fluid intake is not a suitable lem. Only in this way can athletes derive the
method for weight loss; optimal health benefits from their sporting
• Take a multivitamin/multimineral sup- activities.
plement during a longer diet phase
(longer than 1 week).
Further Reading
American College of Sports Medicine (2000) Position
16.9.2 Guidelines for Performance- stand: nutrition and athletic performance. Med Sci
Enhancing Weight Gain Sport Exer 32(12):2130–2145
American College of Sports Medicine (2007) Position
stand: the female athlete triad. Med Sci Sport Exer
An increase in body weight can be achieved by Spec Commun 39:1837–1882
the additional intake of energy sources in the Bratland-Sanda S, Sundgot-Borgen J (2013) Eating
diet (about 500–1000 kcal/day). Protein should disorders in athletes: overview of prevalence, risk
amount to approx. 1.5–1.8 g/kg body weight. factors and recommendations for prevention and
treatment. Eur J Sport Sci 13(5):499–508
The intake of protein supplements is not neces- Byrne S, McLean N (2002) Elite athletes: effects of the
sary with a balanced and varied diet. The com- pressure to be thin. J Sci Med Sport 5(2):80–94
position of the diet should otherwise meet the Danielle M, Logue Sharon M, Madigan Anna, Melin
general recommendations for a healthy diet in Eamonn, Delahunt Mirjam, Heinen Sarah-Jane
Mc, Donnell Clare A, Corish (2020) Low energy
122 P. Platen
availability in athletes 2020: an updated narra- Melin AK, Heikura IA, Tenforde A, Mountjoy M (2019)
tive review of prevalence risk within-day energy Energy availability in athletics: health, perfor-
balance knowledge and impact on sports performance, and physique. Int J Sport Nutr Exerc Metab
mance. Nutrients 12(3):835. https://doi.org/10.3390/ 29(2):152–164
nu12030835 Platen P (2000) Störungen des Essverhaltens bei
De Souza MJ, Nattiv A, Joy E et al (2014) Female ath- Sportlerinnen. Dt Z Sportmed 51(3):105–106
lete triad coalition consensus statement on treat- Slater J, Brown R, McLay-Cooke R, Black K (2017)
ment and return to play of the female athlete triad: Low energy availability in exercising women: his-
1st International Conference held in San Francisco, torical perspectives and future directions. Sports Med
California, May 2012, and 2nd International 47(2):207–202
Conference held in Indianapolis, Indiana, May 2013. Sundgot-Borgen J, Meyer NL, Lohman TG et al (2013)
Br J Sports Med 48:289–309 How to minimise the health risks to athletes who
De Souza MJ, Koltun KJ, Etter CV, Southmayd EA compete in weight-sensitive sports review and posi-
(2017) Current status of the female athlete triad: tion statement on behalf of the Ad Hoc Research
update and future directions. Curr Osteoporos Rep Working Group on Body Composition, Health and
15(6):577–587 Performance, under the auspices of the IOC Medical
El Ghoch M, Soave F, Calugi S, Grave RD (2013) Eating Commission. Br J Sports Med 47:1012–1022
disorders, physical fitness and sport performance: a Torstveit MK, Rosenvinge JH, Sundgot-Borgen J
systematic review. Nutrients 5:5140–5160 (2008) Prevalence of eating disorders and the pre-
Manore MM (1996) Chronic dieting in active women: dictive power of risk models in female elite ath-
what are the health consequences? Women Health Iss letes: a controlled study. Scand J Med Sci Sports
6:332–341 18(1):108–118
Cognitive Behavioral Therapy
Models 17
Gaby Resmark
Contents
17.1 Predisposing Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
17.2 Triggering Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
17.3 Maintaining Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
17.4 The Transdiagnostic Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
There are a variety of theoretical models that

attempt to explain the development of eat- 17.1 Predisposing Factors
ing disorders. However, there is no uniform,
empirically proven model for the pathogenesis Predisposing or vulnerability factors are endur-
and maintenance of anorexia nervosa (AN) and ing personal characteristics or environmental
bulimia nervosa (BN). In the sense of a heuristic conditions that form the basis for the develop-
concept, etiological ideas of cognitive behavio- ment of an eating disorder. They are character-
ral therapy are based on a multifactorial model ized by having existed for a long time before the
in which 3 main classes of “causes” play a role: onset of the disorder and may continue to be
predisposing, triggering and maintaining factors effective even after the onset of the disease. Their
(Laessle 2018). presence can increase the risk of developing an
eating disorder in the course of life, but they do
not allow for a specific causality assumption
Multifactorial Model in Eating Disorders or even prediction of an exact onset of the dis-
• Predisposing factors ease. In longitudinal and cross-sectional studies,
• Triggering factors according to Jacobi et al. (2004), the following
• Maintaining factors risk factors for eating disorders were found.
Risk factors for eating disorders (Jacobi

G. Resmark (*) et al. 2004)
Psychotherapy, University Hospital Tübingen, • Female gender
Tübingen, Germany • Ethnicity (non-Asian)
https://doi.org/10.1007/978-3-662-67662-2_17
124 G. Resmark
as a housewife and mother) (Jacobi et al. 2016).

• Early childhood nutritional and gastro- Not least due to the rapidly increased influence of
intestinal disorders social media and modern television shows (Götz
• Increased weight and shape concern et al. 2015), sociocultural factors have gained even
• Negative self-evaluation more importance (Wilksch et al. 2020).
• Sexual abuse and other psychologically
stressful experiences
• General psychiatric disorders 17.1.3 Family Factors
In many families of patients with eating disor-

Predisposing factors can be divided into four ders, pathological relationship patterns can be
subcategories: found, although it is often difficult to determine
whether these may have arisen secondarily, i.e.,
1. biological, as a result of the eating disorder. Significant
2. sociocultural, factors are the regulation of boundaries, social
3. familial, deficits, and the dependence of adolescents on
4. individual factors. the primary family. Specific interaction pat-
terns such as enmeshment, rigidity, overprotec-
tion, conflict avoidance, and changing coalitions
17.1.1 Biological Factors lead to difficulties in the development of a stable
identity, autonomy, and the formation of a posi-
Biological factors that can promote the develop- tive self-esteem in children and adolescents.
ment of an eating disorder include
• genetic factors, 17.1.4 Individual Factors

• neurobiological changes (e.g., hypothalamic
dysfunctions), Among the individual factors that can predispose a
• changes in serotonin metabolism, person to an eating disorder are, among others, low
• physical factors (e.g., higher set-point weight, self-esteem, perfectionism, impulsivity and cogni-
early menarche), tive deficits. The latter play a particularly impor-
• nutritional factors (e.g., disturbances in hun- tant role in behavioral therapy models. Eating
ger and satiety regulation). disorder-specific dysfunctional core beliefs favor
certain situation-related “automatic” thoughts
that contain “thinking errors” in the sense of typi-
17.1.2 Sociocultural Factors cal anorexic cognitions (Table 17.1). Distortions
such as secondary consequences of cachexia,
The growing discrepancy between the prevail- unconscious psychological defense, conscious
ing, increasingly unrealistic thinness ideal in denial, or a combination of these mechanisms are
industrialized countries and the actual body sizes discussed as possible causes for such cognitive
of average women forms another basis for the impairments (Meermann and Borgart 2006).
development of eating disorders. Women who are In the two-factor model of Connors (1996), the
particularly at risk are those who, due to low self- interaction of two components represents a prereq-
esteem, tend to internalize this ideal more strongly uisite for the development of an eating disorder:
and try to compensate for personally experienced
deficits through weight loss. Another sociocultural • negative body image, excessive preoccupa-
factor concerns the high, sometimes irreconcil- tion with weight and dieting,
able expectations that modern society places on • disturbance of self-regulation including
women, which can lead to pronounced role con- affective dysregulation, low self-esteem, and
flicts (e.g., professional success vs. satisfaction attachment insecurity.
17 Cognitive Behavioral Therapy Models 125
Table 17.1  Thinking errors. (Modified according to Garner and Bemis 1982)

Category Automatic Thought
Selective Abstraction “Only when I am thin am I something special.”
Tendency to isolate single facts from the context and overesti-
mate them, while ignoring other, more significant features
Overgeneralization “I used to have a normal weight, and I was not
Derivation of rules based on a single event happy. Therefore, I know that I will not feel better
if I gain weight.”
Dichotomous/all-or-nothing thinking “If I don’t plan my daily routine down to the
Assignment of experiences to two mutually exclusive catego- minute, everything becomes chaotic, and I achieve
ries, without perceiving any gradations (“black and white”) nothing.”
Personalization “Someone laughed as I walked past him. Surely he
Overestimating the extent to which events have to do with was making fun of my ridiculous shape .”
oneself and/or excessive assumption of responsibility
Catastrophizing “If I don’t constantly control my weight, I will keep
Designation of an event as a catastrophe without reason going up.”
Both factors separately are not specific to eating problems that led to the development of the eat-
disorders and can individually lead to “normal” ing disorder and are thus closely related to the
dieting behavior and “normal” dissatisfaction predisposing factors. On the other hand, the
with one’s own figure without mental illness disturbed eating behavior leads to a variety of
(component 1) or other mental disorders (com- biological and psychological changes that can
ponent 2). contribute to the maintenance of the eating dis-
order, even if other factors originally involved in
the development are no longer relevant. Via pos-
17.2 Triggering Factors itive reinforcement, they lead to a vicious cycle
from which the affected individuals often cannot
Triggering factors include the totality of cir- escape without help. According to Legenbauer
cumstances that provoke the first occurrence of and Vocks (2014), maintaining factors include
an eating disorder and determine the timing of restrained eating, deficient coping behavior,
the onset of the disorder. These include, simi- and dysfunctional information processing.
larly to other mental disorders, so-called critical Restrained eating corresponds to self-imposed
life events such as separations and losses, new food deprivation aimed at achieving or maintain-
demands, fear of failure, or physical illnesses. ing a weight below one’s own set-point (opti-
The affected individuals are not able to meet the mal, presumably biologically determined body
necessary adjustment requirements in these situ- weight). Deficits in coping with stress and chal-
ations. Further triggering factors can be a strict lenging situations represent another maintaining
diet or physical activity. factor. Finally, dysfunctional cognitions play an
important role not only in the development of
an eating disorder but also in its maintenance,
17.3 Maintaining Factors as they impair a person’s ability to act. Fig. 17.1
shows the vicious cycle of bulimia as a model
Maintaining factors are conditions that contrib- for maintaining pathological eating behavior
ute to the continuation of an eating disorder. involving binge eating.
They are often a consequence of the underlying
126 G. Resmark
by common “transdiagnostic” mechanisms and

Restrained eating, combines all three disorder pictures in his model
purging behavior
(Fig. 17.2). In some cases (e.g., in some patients
with binge-eating disorder), only a few of the
maintaining processes of the model are active,
Fear of weight Increase of while in other cases, most processes are active
gain hunger and (e.g., in patients with AN of the purging type).
appetite
The transdiagnostic perspective simultaneously
highlights the aspects that should be considered
in the behavioral therapeutic treatment of eating
Binge eating disorders and supports therapists in designing an
adequate therapy plan tailored to the individual
psychopathology of each patient.
Fig. 17.1  The vicious cycle of bulimia. (Modified
according to Jacobi et al. 2008; with kind permission of
Beltz-Verlag)
Over-evaluation of shape
and weight and their control
Strict dieting; non-compensatory

weight-control behavior
Events and
associated mood Binge eating Characteristics of restrictive
change eating behavior and
low weight
Self-induced vomiting/
laxative abuse
Fig. 17.2  The Transdiagnostic Model. (Adapted from Fairburn 2012; with kind permission of Guilford Press)
17.4 The Transdiagnostic Model References

In his so-called “transdiagnostic” model, which Connors ME (1996) Developmental vulnerabilities for
primarily represents a model of maintenance, eating disorders. In: Smolak L, Levine MP, Striegel-
Fairburn summarizes the most important aspects Moore R (Eds) The developmental psychopathology
of eating disorders: implications for research, preven-
of the cognitive behavioral perspective (Fairburn
tion, and treatment. Lawrence Erlbaum, Hillsdale,
et al. 2003; Fairburn 2012). The core pathol- S 285–310
ogy of AN, BN, and eating disorder NOS (not Fairburn CG (2012) Kognitive Verhaltenstherapie und
otherwise specified) show great similarities, Essstörungen. Schattauer, Stuttgart, S 9–27
Fairburn CG, Cooper Z, Shafran R (2003) Cognitive
and patients often migrate between the differ-
behaviour therapy for eating disorders: a “trans-
ent diagnoses. Therefore, Fairburn assumes diagnostic” theory and treatment. Beh Res Ther
that the various eating disorders are maintained 41:509–528
17 Cognitive Behavioral Therapy Models 127
Garner DM, Bemis K (1982) A cognitive-behavio- Laessle RG (2018) Anorexia nervosa und Bulimia ner-
ral approach to anorexia nervosa. Cogn Ther Res vosa. In: Margraf J, Schneider S (Eds) Lehrbuch der
6:123–150 Verhaltenstherapie, Bd 2. Springer, Heidelberg, S
Götz M, Mendel C, Malewski S (2015) “Dafür muss ich 277–290
nur noch abnehmen”. Die Rolle von Germany’s Next Legenbauer T, Vocks S (2014) Manual der kogni-
Topmodel und anderen Fernsehsendungen bei psycho- tiven Verhaltenstherapie bei Anorexie und Bulimie.
somatischen Essstörungen. TelevIZIon 28(1):61–67 Springer, Heidelberg
Jacobi C, Hayward C, de Zwaan M et al (2004) Coming Meermann R, Borgart E-J (2006) Essstörungen: Anorexie
to terms with risk factors for eating disorders: appli- und Bulimie. Ein kognitiv-verhaltenstherapeutischer
cation of risk terminology and suggestions for a gen- Leitfaden für Therapeuten. Kohlhammer, Stuttgart
eral taxonomy. Psychol Bull 130:19–65 Wilksch SM, O’Shea A, Ho P, Byrne S, Wade TD (2020)
Jacobi C, Thiel A, Beintner I (2016) Anorexia und The relationship between social media use and disor-
Bulimia nervosa. Ein kognitiv-verhaltenstherapeuti dered eating in young adolescents. Int J Eat Disord
sches Behandlungsprogramm. Beltz, Weinheim 53:96–106
Jacobi C, Thiel A, Paul T (2008) Kognitive Verhalten
stherapie bei Anorexia und Bulimia nervosa. Beltz,
Weinheim
Psychodynamic Model
Concepts 18
Stephan Herpertz
Contents
18.1 Operationalized Psychodynamic Diagnosis (OPD) . . . . . . . . . . . . . . . . . . . . 130
18.2 Effectiveness of Psychodynamic Psychotherapy Methods . . . . . . . . . . . . . . 132
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Psychodynamic psychotherapy has its roots derived perspectives and interpretations of one’s
in psychoanalysis, which can be described in own person, other people, or interpersonal
a clinical context as a personality, illness, and events. Psychoanalytic treatment is primarily
treatment theory. In this context, the uncon- not aimed at treating a symptom, but at resolv-
scious is of central importance both in the func- ing the underlying structural disorder or uncon-
tioning of a healthy personality and in mental scious conflict.
disorders. The basic assumption of psychoanal- The proportion of psychoanalytic therapies
ysis is that the main structures of a personality among treated patients in outpatient psycho-
develop from “an interplay of individual predis- therapeutic care in Germany is low, at around
position and interpersonal relationships in the 2.4% compared to almost 45% psychodynamic
first years of a person’s life through internaliza- psychology and 50% cognitive behavior ther-
tion processes” (Hau and Leuzinger-Bohleber apy (Multmeier and Tenckhoff 2014). Despite
2004), whereby the processes of structure for- many similarities with psychoanalysis (basic
mation are not accessible to consciousness. theoretical concepts, treatment techniques),
The focus of the psychoanalytic theory of ill- psychodynamic psychotherapy differs in terms
ness is the structural and/or conflictual genesis of the therapeutic stance, treatment frequency
of mental disorders. An important characteristic and duration, and setting. Compared to psy-
of mental disorders is specific, biographically choanalysis, less space is given to regression,
as well as to free association, in order to give
preference to an active therapeutic approach.
S. Herpertz (*) The subject of therapy is not so much the analy-
Psychotherapy, LWL-University Clinic, Ruhr-University
sis of transference, but rather current life events
Bochum, Bochum, Germany and conflict-related transference patterns in the
e-mail: [email protected] external relationships of the patient, the here
https://doi.org/10.1007/978-3-662-67662-2_18
130 S. Herpertz
and now of real relationships. Psychodynamic dimensions (OPD Working Group 2006). The
psychotherapy-oriented treatment is a time- multiaxial psychodynamic diagnosis is based
limited treatment, which makes focusing on a on five axes: “Experience of illness and treat-
specific issue in therapy absolutely essential. In ment prerequisites”, “Relationship”, “Conflict”,
order to determine the focus, a psychodynamic “Structure”, and “Mental and psychosomatic
diagnosis of the conflict situation underlying the disorders according to Chapter V (F) of the
patient’s current disorder, such as self-esteem ICD-10”. Thus, eating disorders such as ano-
problems, is required. The focus should refer to rexia nervosa (AN), bulimia nervosa (BN), or
an unconscious pathogenic conflict that, accord- binge-eating disorder (BED) are represented in
ing to psychoanalytic theory of neurosis, arises the categorical classification systems DSM and
in childhood and adolescence and is reactivated ICD on the descriptive axis 5 of the OPD. The
in adulthood by certain triggering events. At the description of the patient and her psyche or psy-
same time, the focus should include an interpre- chopathology according to the important psy-
tation or an interpretive explanation of this con- choanalytic concepts of personality structure,
flict, which contains a clinical hypothesis about intrapsychic conflict, and transference is carried
the unconscious meaning of the patient’s symp- out on the four psychodynamic axes, underlin-
tomatology. In this context, the patient’s state- ing the continuous, dimensional approach of this
ments are specifically addressed with regard to concept, which borrows more from the social
this focus, and psychodynamic aspects of the sciences.
disorder and expressions of the patient that are In recent decades, important psychodynamic
not related to the focal theme are selectively hypotheses regarding the development of BN
neglected. The focus is on conflicts that occur and AN, such as separation disorders in the
in the present and in the patient’s everyday life mother-child relationship, early traumatic expe-
environment, especially in her interpersonal riences, loss of support, and conflictual oedipal
relationships. bonds, had to be abandoned due to a lack of
With the introduction of the descriptive clas- specificity. The same applied to an affect psy-
sification systems DSM-III-R, DSM-IV, and chology inherent in eating disorders, which
DSM-V as well as the ICD-10 and ICD-11 interpreted eating behavior as a regulatory
(Claudino et al. 2019), the neurosis concept mechanism of an unstable self and as a projec-
important for psychodynamic psychotherapy- tive disposal of negative self-parts.
oriented psychotherapies was abandoned in favor A cardinal symptom of all eating disorders is
of phenomenological and biologically oriented undoubtedly the lack of self-confidence and neg-
etiology concepts. Undoubtedly, these classifica- ative self-image, which Hilde Bruch, a pioneer
tion systems contribute to greater diagnostic reli- in the field of eating disorders, highlighted in
ability, albeit at the expense of lower validity. her published book “The Golden Cage” (Bruch
1973). The “all-pervasive feeling of one’s own
inadequacy” describes the self-esteem prob-
18.1 Operationalized lems that are pathognomonic for both eating
Psychodynamic Diagnosis disorders AN and BN, which usually have their
(OPD) origin in interpersonal problems and possess
mutual reinforcement functions. The result is a
Within psychodynamic psychotherapy, the OPD considerable vulnerability. Instead of clarifying
was developed in the early 1990s, and the first the interpersonal situation, there is a break in
diagnostic manual was published in 1996. The the relationship and social withdrawal. Lack of
aim of the OPD is to expand the symptoma- self-confidence and a negative self-image result
tologically descriptive classification of men- in a high dependency on external evaluations,
tal disorders, as provided by the DSM or ICD, such as the ideal of slimness, which is conveyed
to include the fundamental psychodynamic through media, family, and peers.
18 Psychodynamic Model Concepts 131
 Important Modern psychodynamic psycho- that every decision in favor of something also
therapy concepts understand mental disorders means, or at least can mean, a decision against
such as eating disorders in an interpersonal something, becomes noticeable in various areas
context, based on the assumption that the of life. Therefore, a therapeutic stance can be
psychosocial and interpersonal experiences recommended that sees no insurmountable dif-
of the patient have a decisive influence on ferences between a reflected, committed partial-
the treatment. In this context, psychodynamic ity and the necessary abstinence and can allow
psychotherapy focuses on the underlying a dynamic interplay of psychoeducational and
conflict of the symptomatology, with particu- genuinely psychotherapeutic treatment strate-
lar consideration of the object relationship gies. This includes empathic solidarity as well
level. as “putting one’s foot down” in the sense of a
structuring measure. The auxiliary ego function
According to object relations theory, (infan- of the therapist can also be just as significant
tile) conflicts arise in interaction with develop- in important decision-making processes in the
mentally early significant caregivers and can here and now as the interpretation and working
be re-enacted in current relationship situations. through of repetitive neurotic, especially inter-
Symptom formation is thus an expression of a personal, behavioral patterns.
suboptimal solution to the conflict. The con-
flict is associated with considerable anxiety and  Important The autonomy-dependency con-
tension, so a means of tension discharge must flict characteristic of this life phase and the
be found, which can lead to the development ambivalently experienced father or mother re-
of symptoms. Psychodynamic psychotherapy lationship are usually found in the therapeutic
methods pursue, among other things, the goal of relationship and can be used productively.
at least tentatively enabling conflict repetitions
in the therapeutic relationship. The basis for this In particular, the unspecific predictor variables
is the establishment of a basal relationship. The of the psychotherapy process, such as interest,
therapist empathizes with the role unconsciously curiosity, commitment, authenticity, and reliabil-
assigned to him/her by the patient and inter- ity, are subjected to a very critical examination
venes from this role understanding. against the background of parent transference
(“Is the interest really directed at me, is it genu-
 Important The treatment of AN or BN is usu- ine, can I rely on him or her?”).
ally a treatment of young people, especially
adolescent girls or young women, which has  Important Significant conflicts of self-worth,
significant treatment implications, particu- as are pathognomonic for patients with eat-
larly for the psychodynamically important ing disorders, also require a resource-oriented
transference processes between therapist and psychotherapy. It is not so much the deficits
patient. in previous development that need to be ad-
dressed, but rather the abilities and achieve-
Adolescence or young adulthood poses signifi- ments already accomplished.
cant psychosexual and social challenges. The
constitution of self-image (self-worth) is a con- At the same time, it is necessary to work out
tinuous process that originates from early child- the genesis of the self-worth problem, which is
hood, but certainly entails the most demanding usually to be found in interpersonal conflicts,
developmental steps for the individual in the life especially with parents (high performance
phase of puberty, adolescence, and early adult- expectations, “I can only get recognition and
hood. In terms of shaping one’s own “private” affection through performance”), in order to ulti-
as well as professional life, significant decisions mately be able to make corrective experiences.
are required, and the “adult” life experience A benevolent, resource-promoting (e.g., paternal
132 S. Herpertz
or maternal) transference relationship offers the arms studied, the FPT arm was superior to the
opportunity to make positive corrections to self- TAU arm in terms of remission rates after one
worth, which can then be transferred from ther- year. The methodological quality of the study
apy to other relationships. and the comparatively high number of cases
(n = 80) supports the assumption that FPT is
effective.
18.2 Effectiveness
of Psychodynamic Bulimia nervosa Neither for classical psy-
Psychotherapy Methods choanalytic nor for psychodynamically based
psychotherapies are there data with a passive/
Anorexia nervosa According to the guidelines placebo-controlled control group. A randomized
“Diagnosis and Therapy of Eating Disorders” psychoanalytic study (Poulsen et al. 2014) and a
of the Working Group of Scientific Medical psychodynamic study (Stefini et al. 2017) allow
Societies (AWMF; https://www.awmf.org/ both a pre-post and a pre-follow-up comparison
leitlinien/detail/ll/051-026.html), there is no (Svaldi et al. 2019). Poulsen et al. (2014) report
empirical evidence for the effectiveness of a a cessation of binge eating in 6% of cases after
classical psychoanalytic treatment of AN. therapy, while Stefini et al. report it in 31% of
Older depth psychological studies suggest cases. Both studies describe a weak to moderate
that there is effectiveness in terms of weight reduction in binge eating, a comparable reduc-
gain as the primary goal of treatment for AN. tion in compensatory behavior, and a moder-
However, the meta-analysis by Zeeck et al., pub- ate reduction in self-reported eating pathology,
lished in 2018, which also included naturalistic results that could also be replicated at follow-up.
studies, could not demonstrate the superiority When compared to CBT, no differences were
of one psychotherapy method over another (out- observed in a psychodynamic treatment (Stefini
come criterion: weight gain). In the absence of et al. 2017) with a mean therapy duration of 36
studies with untreated control groups, an evalu- hours. Both methods were equally effective,
ation of the effectiveness of a specific method with large effect sizes (d = 1.2) and a remis-
for AN was only possible to a limited extent. sion rate at the end of therapy of 32%. In the
The results of the studies could only be evalu- study by Poulsen and colleagues (2014; psycho-
ated based on weight (BMI), as other parameters analytic psychotherapy compared to cognitive
(eating disorder pathology, depression, quality behavioral therapy), however, there were sig-
of life, etc.) were either not collected or col- nificant differences in the two therapy methods.
lected using different instruments. After five months (end of CBT), 42% of patients
A newer, manualized psychodynamic ther- treated with CBT were completely abstinent
apy approach (Focal Psychodynamic Therapy, regarding eating disorder symptoms, while
FPT) designed for AN patients with moder- this was the case for only 6% of patients who
ate underweight (BMI > 15 kg/m2) (Friederich received psychoanalytic treatment. Even two
et al. 2014) proved effective in a multicenter, years after the start of treatment, 44% of patients
randomized controlled trial compared to cogni- in the CBT arm and only 15% in the psychoana-
tive behavioral therapy (CBT) and a treatment- lytic arm were completely remitted regarding
as-usual control group (TAU control group) eating disorder symptoms—despite a signifi-
(guideline psychotherapy in outpatient psy- cantly higher therapy dose of the psychoanalytic
chotherapeutic practices) with regard to weight method (weekly psychoanalytic treatment over
gain and a combined outcome measure (weight two years compared to 20 sessions of CBT over
and eating disorder-specific psychopathol- a total of five months). Both in terms of eating
ogy) at 1-year follow-up (Zipfel et al. 2014). disorder symptoms and general psychopathol-
Although there was no significant difference ogy, CBT was clearly superior to psychoanalytic
in weight course between the three therapy treatment after five months and also after two
18 Psychodynamic Model Concepts 133
years, whereas psychodynamically based psy- Hau S, Leuzinger-Bohleber M (2004) Psychoanalytische

chotherapy appeared to be comparable in effec- Therapie. Eine Stellungnahme für die wissenschaftliche
Öffentlichkeit und für den Wissenschaftlichen Beirat
tiveness to CBT. Psychotherapie. Forum der Psychoanalyse 20:13–125
Multmeier J, Tenckhoff B (2014) Psychotherapeutische
Binge eating disorder There is not suffi- Versorgung: Autonomere Therapieplanung kann
cient research on psychoanalytic or psychody- Wartezeiten abbauen. Deutsches Ärzteblatt 13:110
Poulsen S, Lunn S, Daniel SI, Folke S, Mathiesen BB,
namic therapy of BED to perform an adequate Katznelson H, Fairburn CG (2014) A randomized
assessment. controlled trial of psychoanalytic psychotherapy or
cognitive-behavioral therapy for bulimia nervosa. Am
 Important With regard to the treatment of AN, J Psychiatry 171(1):109–116
Stefini A, Salzer S, Reich G, Horn H, Winkelmann K,
no psychotherapy method seems to be supe- Bents H, Rutz U, Frost U, von Boetticher A, Ruhl
rior to another. There is no strong evidence U, Specht N, Kronmuller KT (2017) Cognitive-
for either the psychodynamic or the psycho- behavioral and psychodynamic therapy in female
analytic treatment of BN—not least due to adolescents with bulimia nervosa: a randomized con-
trolled trial. J Am Acad Child Adolesc Psychiatry
the small number of studies. In a randomized 56(4):329–335
study, psychoanalytic treatment was found to Svaldi J, Hartmann-Firnkorn A, Legenbauer T, von
be significantly inferior to CBT. No difference Wietersheim J, de Zwaan M, Tuschen-Caffier B
was found between CBT and psychodynamic (2019) Bulimia nervosa. In: Herpertz, Fichter M,
Herpertz-Dahlmann B, Hilbert A, Tuschen-Caffier
treatment in adolescents with BN. B, Vocks S, Zeeck A (Eds) S3-Leitlinien Diagnostik
und Therapie der Essstörungen. AWMF. https://
www.awmf.org/leitlinien/detail/ll/051-026.html .
Zugegriffen im 2018
References Zeeck A, Herpertz-Dahlmann B, Friederich HC,
Brockmeyer T, Resmark G, Hagenah U, Ehrlich
Arbeitskreis OPD (2006) Operationalisierte Psycho S, Cuntz U, Zipfel S, Hartmann A (2018)
dynamische Diagnostik OPD-2. Das Manual für Psychotherapeutic treatment for anorexia nervosa:
Diagnostik und Therapieplanung. Huber, Bern a systematic review and network meta-analysis.
Bruch H (1973) Eating disorders: obesity, anorexia ner- Front Psychiatry 1(9):158. https://doi.org/10.3389/
vosa, and the person within. Basic books, New York fpsyt.2018.00158
Claudino AM, Pike KM, Hay P, Keeley JW, Evans SC, Zipfel S, Wild B, Gross G, Friederich HC, Teufel
Rebello TH, Bryant-Waugh R, Dai Y, Zhao M, M, Schellberg D, Giel KE, de Zwaan M, Dinkel
Matsumoto C, Rausch Herscovici C, Mellor-Marsá A, Herpertz S, Burgmer M, Löwe B, Tagay S,
B, Stona A-C, Kogan CS, Andrews HF, Monteleone von Wietersheim J, Zeeck A, Schade-Brittinger
P, Pilon DJ, Thiels C, Sharan P, Al-Adawi S, Reed C, Schauenburg H, Herzog W, ANTOP Study
GM (2019) The classification of feeding and eat- Group (2014) Focal psychodynamic therapy, cog-
ing disorders in the ICD-11: results of a field study nitive behaviour therapy, and optimised treat-
comparing proposed ICD-11 guidelines with exist- ment as usual in outpatients with anorexia nervosa
ing ICD-10 guidelines. BMC Med. https://doi. (ANTOP study): randomised controlled trial. Lancet
org/10.1186/s12916-019-1327-4 383(9912):127–137
Friederich H-C, Herzog W, Wild B, Zipfel S, Schauenburg
H (2014) Anorexia nervosa. Fokale Psychodynamische
Psychotherapie. Hogrefe, Göttingen
Epidemiology, Etiology,
and Course of Eating 19
Disorders
Silke Naab
Contents
19.1 Systemic and Family Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
19.2 Does the Family Influence the Eating Disorder or Vice Versa? . . . . . . . . . . 137
19.3 Conclusion for Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
19.1 Systemic and Family emerged that understood the family as a holis-
Perspective tic system and, based on systemic theoretical
considerations, assumed specific family interac-
19.1.1 Historical Development tion patterns and conflicts as the genesis of eat-
ing disorders in adolescents (“systemic family
In the second half of the 19th century, William therapy,” cf. Minuchin et al. 1975 and Selvini-
Gull, Ernest-Charles Lasègue, and Pierre Janet Palazoli 1978). The eating disorder of the so-
described anorexia and advised, due to the lack called “index patients” was seen as an indicator
of therapy options, removing patients from of a dysfunctional family and at the same time
their social environment for a certain period. as a desperate attempt to maintain the status
This approach was called “parentectomy,” and quo. Specific patterns (especially in anorexic
the family was attributed responsibility for the families) were described and interpreted as the
development of the eating disorder (Fichter basis of the pathology:
2008). In later works, mothers were described
as dominant, intrusive, and ambivalent, fathers • “Enmeshment” of family members with
as passive and weak-willed (Vandereycken et al. extreme closeness and intensity, weak bound-
1988). In the 1970s, a family therapy movement aries of family members
• Overprotectiveness,
• Rigidity (rigid norm and performance orien-
tation and maintaining the status quo),
• Conflict avoidance and deficient conflict
S. Naab (*)
Clinic of Psychosomatics and Psychotherapy, Schön
management,
Klinik Roseneck, Prien am Chiemsee, Germany • Involvement of the symptom bearer in the
e-mail: [email protected] (hidden) couple or family conflict.
https://doi.org/10.1007/978-3-662-67662-2_19
136 S. Naab
Family relationship patterns of adolescent  Important Empirical studies in the following

patients with bulimia nervosa were described years showed that attitudes in the family, eat-
through conflict-laden family interactions, lack ing and dieting behavior, weight, appearance,
of parental affection and recognition, and impul- and family relationships have a potential in-
sive, uncontrolled behavior of family members fluence on the development and course of eat-
(Minuchin et al. 1978; Root et al. 1986). ing disorders and can reinforce or weaken ge-
Although the descriptions of typical fam- netic, sociocultural, and personality influences
ily systems helped to sharpen clinical observa- (Tetzlaff and Hilbert 2014; Reich 2003).
tion and incorporate corresponding findings into
therapy, the narrowing of therapeutic observa-
tion to the “typical eating disorder family” was 19.1.2 The Family as a “Risk Factor”
criticized.
The described family interaction patterns  Important Family relationships as risk fac-
have only been empirically proven in a few tors in the development and maintenance of
families to date, and general statements regard- eating disorders have been widely demon-
ing the families of patients with eating disor- strated (reviews by Fairburn and Harrison
ders cannot be drawn (Kog et al. 1987; Kog 2003; Reich 2003; Jacobi et al. 2004; Stice
and Vandereycken 1988; Vandereycken 1995). 2002). A higher socioeconomic status, in-
Over the following years, a more differentiated creased occurrence of physical illnesses and
picture of the influence of the family on the mental disorders (especially eating disor-
development and maintenance of eating disorders and affective disorders) in the family,
ders emerged, facilitated by numerous scientific as well as mutually controlling family re-
studies. According to current research, the etio- lationships—combined with parental disa-
logical significance of observed abnormalities greement—were found to be characteristic
in families is entirely unclear, and there are very features of families of patients with AN and
different interaction patterns and styles in fami- BN in cross-sectional and longitudinal stud-
lies with family members with eating disorders, ies (Jacobi and Neubert 2005; Kog and Van-
without clear and consistently observable differ- dereycken 1988).
ences between families with bulimic, anorexic,
or other disturbed eating behavior and those Compared to healthy adults, individuals with
without clinical problems (Herzog 2002). AN and BN retrospectively report a higher
The relationship between familial influences degree of parental conflicts, criticism, high
and eating disorders was described in 1996 in expectations, lower parental affection, and less
the “Dual-Process Family Model” (Leung et al. care (Fairburn et al. 1997, 1999). An insecure
1996): The family’s preoccupation with weight attachment style has also been described in
and appearance has direct effects on body dis- individuals with eating disorders (Ward et al.
satisfaction and eating disorder symptoms, and 2000). High parental education and high paren-
body dissatisfaction, in turn, has a direct effect tal expectations are also associated with a higher
on self-esteem deficits and eating disorder risk of eating disorders in children (Bould et al.
symptoms. General family dysfunction had a 2015a).
direct influence on negative self-esteem and an
indirect influence on eating disorder and other
psychiatric symptoms. The dual-process phase 19.1.3 The Family as a Resilience-
model describes how dysfunctional family rela- Promoting Institution
tionships and family preoccupation with weight
and appearance predispose girls (and boys) to Numerous studies have shown that family func-
the development of eating disorder pathology. tioning, along with positive parental behavior, is
19 Epidemiology, Etiology, and Course of Eating Disorders 137
associated with the well-being of growing chil- The majority of previous longitudinal studies
dren (Haines et al. 2016). In particular, positive also do not allow it to be differentiated whether
emotional relationships between family mem- certain family structures and interactions pose a
bers represent a central aspect for the emotional risk for the development of AN or BN or are a
well-being of children, especially during adoles- consequence of the disease (Cierpka and Reich
cence (Henry et al. 2006). 2001; Calam and Waller 1998; Button et al.
1996; Attie and Brooks-Gunn 1989). Cross-
 Important Adolescents who report emotional sectional surveys suggest that pathological fam-
support from their parents seem less likely to ily structures and functions are more likely to
develop weight preoccupation, body dissatis- be associated with the severity and chronicity of
faction, and high thinness ideals, and to adopt anorexia nervosa and are less etiologically sig-
bulimic behavior (Hasenboehler et al. 2009). nificant (Jacobi et al. 2004).
A strong family bond appears to protect ado-
lescents from emotional stress and is associ-  Important The strong mental and psycho-
ated with healthy behavior (Croll et al. 2002). logical strain on relatives due to the illness of
The relationship between positive family life their daughter or son can be reflected in emo-
and healthy eating behavior and the positive tional reactions and corresponding changes in
perception of family relationships as an im- family interactions, which do not necessar-
portant and protective factor for the risk of ily cause the eating disorder but are a conse-
developing disordered eating behavior is well quence of it (Treasure et al. 2008).
documented (Neumark-Sztainer et al. 2009;
Wisotsky et al. 2003).
19.3 Conclusions for Practice
In the following Table 19.1, empirical findings
on specific areas concerning the family of The importance of family and familial relation-
patients with eating disorders are summarized ships in the development and maintenance of
(adapted from Herzog 2002). eating disorders is confirmed. However, the
results of scientific studies are so diverse that no
definitive statements can be made about causal
19.2 Does the Family Influence relationships. Some, but not all, results of studies
the Eating Disorder or Vice in families of individuals with eating disorders
Versa? support the psychosomatic family constellation
described by Minuchin (enmeshed, overprotec-
It is often difficult to determine whether the tive, rigid, conflict-avoidant, poor problem-solv-
described family factors were present before the ing capacity). However, there are no substantial
manifestation of the eating disorder or whether data today that confirm the empirical model of
they only developed secondarily, i.e., as a reac- the psychosomatic family, as conceived by the
tion to the disorder, within the family (Jacobi pioneers of family therapy. A multifactorial gen-
et al. 2008). For example, patients with BN were esis of eating disorders is nowadays assumed, in
found to perceive lower emotional connected- which, in addition to genetic and other factors,
ness within their families even before the onset the family also plays a role (Erriu et al. 2020).
of the eating disorder, whereas for patients with More recent empirical studies have identified
AN, the low perceived autonomy seemed to be factors that view the role of the family in a more
a consequence of the disease (Huemer et al. differentiated manner and also support the inclu-
2012). sion of the family in therapy.
138 S. Naab
Table 19.1  Label: empirical findings on specific areas concerning the family of patients with eating disorders
Stressful life events Loss of parents through death or separation are probably not more
frequent than in control groups (possibly in BN)
Sexual abuse is as common as in other mental disorders, not specific to
eating disorders (Esman 1994; Vize and Cooper 1995), often associated
with further problems such as alcohol abuse, theft, and suicide attempts
Traumatic childhood experiences in patients with BN are as common
as in severe depression, patients with AN rather comparable to general
population (Webster and Palmer 2000)
Childhood maltreatment, e.g. harsh physical punishment, physical
abuse, sexual abuse, emotional abuse, physical neglect, and threat by
intimate partner are associated with increased occurrence of AN, BN,
and BED in adulthood (Afifi et al. 2017)
Parental intrusiveness and/or withdrawal from contacts with
children in the first five years of life may promote the development
of eating disorders in puberty, especially if parents have experienced
traumatic events and physical or psychological abuse in their own lives
(Le Grange et al. 2010)
Personality and attitude of parents Stereotypes: Mother dominating, over-involved, emotionally less avai-
lable, fathers emotionally distant, weak and passive, not empirically
confirmed
Parents of patients with BN, who may more frequently have weight
problems or show preoccupation with nutrition
Promotion of negative attitudes towards one’s own body through
critical comments on figure, weight, and eating behavior (Stice and
Agras 1998; Van den Berg et al. 2002; Laghi et al. 2016)
Eating disorders and other mental In siblings, anorexic eating disorders and weight problems are more
disorders in the family common than expected, especially
Affective, substance-induced (in BN) and obsessive-compulsive dis-
orders (in AN) are more common than expected, probably independent
of predisposition to eating disorders, compulsiveness as a risk factor for
AN (Lilenfeld et al. 1998)
Parental mental illness, especially bipolar disorder, personality disor-
der, anxiety, and depression increase the risk of developing an eating
disorder in the child (Bould et al. 2015b)
Depression and anxiety disorders in mothers predispose to the
development of an eating disorder (Crandall et al. 2015; Cimino et al.
2015)
Burden of mental disorders, especially depression and addiction in
parents, is increased in patients with BN (Fairburn et al. 1997)
Prevalence of eating disorders and obesity increased in the family of
origin (Strober et al. 2000)
Maternal eating disorders combined with comorbid psychopatho-
logy increase the risk of psychiatric disorders in childhood and early
adolescence, especially for emotional disorders (Micali et al. 2014)
Prenatal and perinatal influences High prenatal stress in the mother as a possible risk factor
Death of an older child or partner six months before pregnancy
associated with a higher risk of eating disorders in children (Su et al.
2015, 2016)
Anxiety disorder of the mother during pregnancy associated with an
increased risk of eating disorder (Goodman et al. 2014)
Prenatal and perinatal factors influence the development of eating
disorders such as AN and BED (Watson et al. 2019)
(continued)
Parent-child relationship, family struc- Families with weak cohesion, low emotional expression, and
ture and interaction excessive interpersonal dependency have a high risk of developing
pathological eating behavior (Lyke and Matsen 2013; Goossens et al.
2012; Hoste et al. 2007; Steinhausen et al. 2005)
Adolescents with eating disorders experience unsatisfactory family
relationships, low parental acceptance (family warmth, empathy,
emotional support) and limited independence among family members
(Laghi et al. 2012).
Rigid family rules with restrictions on discussion, addressing pro-
blematic topics, problem-solving (Pauls and Daniels 2000; Kog and
Vandereycken 1989)
Critical attitude and family pressure regarding body and shape
with negative influence on eating behavior and disorder development—
physical shape is an indicator of involvement and family rigidity, which
strongly affects the development of the disorder, and the adoption of
inadequate eating habits (Stice and Agras 1998; Van den Berg et al.
2002; Laghi et al. 2016).
Increased family conflicts and feelings of stress and depression in
parents (especially of patients with AN) (Sim et al. 2009)
Symbiotic relationship patterns, fixed role patterns, oriented
towards traditional value systems (Pauls and Daniels 2000; Kog and
Vandereycken 1989)
Studies with the Expressed-Emotion construct showed overall relati-
vely low parental hostility and criticism (Hodes and Le Grange 1993)
Eating disordered partners Couples with an eating disordered partner are less relaxed in their
interactions than non-affected couples, but more competent at commu-
nication than couples with explicitly disturbed couple relationships
Eating behavior of mothers Mothers of patients with BN have a history of repeated dieting pha-
ses, serving as a model for so-called “restrained eating behavior” (Pike
and Rodin 1991)
Influence on therapy course Evidence in family therapeutic intervention studies that pathological
family interactions are associated with negative therapy outcomes (Her-
zog et al. 2000; Russel et al. 1987; Robin et al. 1999; Eisler et al. 2000)
 Important The lack of empirical evidence current S3 guidelines “Diagnosis and Therapy
for the etiological role of systemic and famil- of Eating Disorders” for the treatment of AN
ial factors in the etiology of eating disorders and BN, family therapeutic interventions or
does not contradict the important significance the inclusion of parents or family in therapy
and empirical evidence for the effectiveness were recommended (Arbeitsgemeinschaft
of family therapeutic approaches. However, it der Wissenschaftlichen Medizinischen
is likely that the influencing factors of family Fachgesellschaften 2020). In the treatment of
therapeutic interventions are based more on binge eating disorder (BED) in children and
resource activation and support of the family adolescents, these recommendations have not
in therapy (family as co-therapists) than on been described so far.
the remediation (or resolution) of question- In family therapeutic interventions for
able causal systemic factors. patients with eating disorders, knowledge about
certain familial influencing factors can be help-
Due to their importance, familial factors have ful. A lack of meal structure within the family
also been included in therapeutic interventions can lead to problems in developing healthy eat-
in childhood and adolescence. Thus, in the ing behavior in children and adolescents and to
140 S. Naab
the maintenance of these problems, critical com- Bould H, Sovio U, Koupil I, Dalman C, Micali N, Lewis
ments within the family regarding weight and G, Magnusson C (2015a) Do eating disorders in par-
ents predict eating disorders in children? Evidence
figure have a direct influence on the evaluation from a Swedish cohort. Acta Psychiatr Scand
of patients and can make it difficult to develop 132(1):51–59
a positive body image, family relationships, Bould H, Koupil I, Dalman C et al (2015b) Parental men-
attachment experiences, and autonomy conflicts tal disorders and eating disorders in offspring. Int J
Eat Disord 48:383–391
play an essential role in the development of self- Bould H, De Stavola B, Magnusson C, Micali N, Dal H,
esteem and identity. Evans J, Dalman C, Lewis G (2016) The influence of
Research findings on familial influencing fac- school on wheter girls develop eating disorders. Int J
tors are essential, not only for therapy but also Epidemiol 45(2):480–488
Button EJ, Sonuga-Barke EJ, Davies J, Thompson M
for possible preventive measures. (1996) A prospective study of self-esteem in the
For the therapy of patients with eating disor- prediction of eating problems in adolescent school-
ders, it is necessary to comprehensively analyze girls: questionanaire findings. Br J Clin Psychol
familial interaction patterns and use them for 35(2):193–203
Calam R, Waller G (1998) Are eating and psychosocial
therapeutic intervention, as familial relationship characteristics in early teenage years useful predic-
patterns decisively influence self-esteem, auton- tors of eating characteristics in early adulthood?
omy striving, identity formation, and thinking A 7-year longitudinal study. Int J Eat Disord
and behavioral patterns of patients. 24:351–362
Cierpka M, Reich G (2001) Die familientherapeutische
Regular and accompanying involvement of Behandlung von Anorexie und Bulimie. In: Cierpka
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depression, anxiety or eating disorders: Outcomes on
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involved as a resource in coping with the illness profiles. Child Psychiatry Hum Dev 46:228–236
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Treasure et al. 2008), and/or by arranging fur- (2000) Family therapy for adolescent anorexia ner-
ther family therapeutic support. vosa: the results of a controlled comparison of two
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Genetic Aspects of Eating
Disorders 20
Helge Frieling, Stefan Bleich and Vanessa Buchholz
Contents
20.1 Anorexia Nervosa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
20.2 Bulimia Nervosa and Binge Eating Disorder . . . . . . . . . . . . . . . . . . . . . . . . 145
20.3 Outlook—Gene-Environment Interactions and Epigenetics . . . . . . . . . . . . 145
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
that numerous genetic variants contribute to the

20.1 Anorexia Nervosa pathology to varying degrees.
Although the etiology of eating disorders and  Definition Molecular genetic research
specifically anorexia nervosa (AN) was long approaches
considered to be predominantly psychosocially In molecular genetics, various approaches
determined, in recent years, formal and molecu- are used to investigate genetic influences on
lar genetic studies have shown that hereditary disorders/diseases:
influences also play a significant role. The inves- Candidate gene studies. Genes whose pro-
tigation of the genetics of complex phenotypes tein products are suspected to have an influence
such as AN, which can be broken down into on the investigated phenotypes are analyzed
numerous subtypes, endo- and subphenotypes, using the candidate gene approach. Candidates
each showing their own genetic characteris- are derived from animal models, pharmaco-
tics, is fraught with immense difficulties. AN logical studies, biochemical or physiological
is not a monogenic disease; rather, it is likely considerations. Initially, a mutation screen can
help clarify the genetic variability at the gene.
Associations of the found variants (alleles, geno-
H. Frieling (*) · S. Bleich · V. Buchholz types) with investigated phenotypes can then be
Department of Psychiatry, Socialpsychiatry and determined using association studies.
Psychotherapy, Hannover Medical School (MHH),
Hannover, Germany
Association studies. In association studies,
e-mail: [email protected] genetic variants (polymorphisms) in candidate
S. Bleich
genes are specifically investigated. Usually, a
e-mail: [email protected] patient cohort is compared with a healthy con-
V. Buchholz
trol cohort. Positive association results must
e-mail: [email protected] be independently replicated before an ‘actual’
https://doi.org/10.1007/978-3-662-67662-2_20
144 H. Frieling et al.
association with the investigated disorder can be discovered genes is neuronatin (NNAT), which
assumed. appears to play a role in AN mainly in men.
Genome-wide association studies. In this NNAT encodes a proteolipid that is important
special case of association studies, no candi- for brain development. In other cases, rare vari-
date genes are initially pursued. Genome-wide ants have been described in genes involved in
searches are conducted for genetic factors rel- dopaminergic metabolism, the reward system,
evant to the investigated phenotypes. All genes neurotrophins, and epigenetically relevant genes
located in the identified chromosomal regions such as histone deacetylase 4.
are then examined more closely; a positional
candidate gene analysis follows. Modern, chip-
based analysis methods can simultaneously 20.1.3 Genome-wide Association
analyze millions of individual polymorphisms. Studies (GWAS)
Furthermore, it is possible to detect changes
in larger chromosome segments (so-called In recent years, several genome-wide asso-
copy number cariations—CNV). Meanwhile, ciation studies (GWAS) on AN have been pub-
sequencing of complete expressed portions of lished. The largest GWAS to date included
the genome (“exome”) up to complete genome samples from the Anorexia Nervosa Genetic
sequencing is also possible. Initiative (ANGI) (Bulik et al. 2020), the
There is no “anorexia gene”! Genetic Consortium for Anorexia Nervosa
(GCAN), the Wellcome Trust Case Control
Consortium-3 (WTCCC-3), and the UK
20.1.1 Family and Twin Studies Biobank, comparing 16,992 cases with 55,525
controls from 17 European countries. In this
The important role of a hereditary component study, 8 significant loci were found in sin-
in the etiology of AN was determined through gle genes, with the best results for the genes
family and twin studies. First-degree relatives CADM1 (cell adhesion molecule 1), MGMT
of patients with AN have an approximately (Methylated o6-methylguanine-DNA-meth-
10-fold increased risk of developing AN them- yltransferase), FOXP1 (Forkhead box protein
selves compared to individuals without a family 1), and PTBP2 (Polypyrimidine tract-binding
history. Furthermore, the risk for other eating protein 2) (Watson et al. 2019). As expected,
disorders is also significantly increased. Twin strong genetic correlations were found with
studies quantified the hereditary proportion of other mental disorders such as compulsion,
AN at 30–80%, with the most recent and exten- depression, anxiety disorders, and schizophre-
sive analyses reporting around 50%. Here too, nia, while a negative correlation was observed
the captured phenotype plays an important role. with metabolic and anthropometric traits. These
If sub-syndromal characteristics of AN are also relationships, as well as a suspected genetic pre-
recorded in addition to the DSM IV criteria, the disposition for increased physical activity, are
genetic proportion increases to about 75%. currently leading to a re-conceptualization of
our understanding of eating disorders.
20.1.2 Rare Variants

Conclusion
In recent years, thanks to advances in sequenc- So far, there are only a few confirmed
ing technology, initial genetic variants with genes (gene variants) for anorexia nervosa.
high penetrance segregating in families have However, a genetic predisposition to the dis-
been discovered, some of which followed a ease mediated by numerous genes is con-
Mendelian inheritance pattern. One of the firmed, as is a genetic relationship of AN
20 Genetic Aspects of Eating Disorders 145
with other mental disorders. The risk variants 20.2.3 Genome-wide Association
of genes identified so far can help to better Studies
understand the pathophysiological basis of
AN (Stern and Bulik 2020). There are no published GWAS for BN so far.
However, bulimic behaviors have already been
investigated in various GWAS. To date, no risk
20.2 Bulimia Nervosa variants with genome-wide significance have
and Binge Eating Disorder been identified.
20.2.1 Family and Twin Studies

20.3 Outlook—Gene-
As with AN, the estimates for the heredi- Environment Interactions
tary component of bulimia nervosa (BN) and and Epigenetics
binge eating disorder (BED) vary consider-
ably. For BN, values between 28% and 83% are In recent years, studies on various mental disor-
reported, while a study in BED estimates the ders have demonstrated the immense importance
hereditary contribution to the phenotype at 41% . of so-called gene-environment interactions. In
many cases, risk genes only turn out to be such
under very specific environmental conditions,
20.2.2 Association Studies while under other circumstances they are either
harmless or even possess protective properties.
To date, several association studies have been For example, it has been shown that carriers of
conducted for BN and BED, but none have the less active s-allele of 5-HTTLPR have an
included sufficiently large cohorts. Only in increased risk of becoming depressed after stress
a few cases were initially positive findings exposure. People who experienced early child-
replicated. Among the most frequently stud- hood trauma had a significantly increased risk
ied genes are those encoding the serotonin of developing depression if they were homozy-
transporter (5-HTTLPR), serotonin receptors gous for the same variant (5-HTTLPRs). A
(mainly 5-HT2A, 5-HT2C) and dopamine recep- recent study showed that patients with BN who
tors (DRD2). An association with the Val66Met both carried the s-variant of 5-HTTLPR and had
polymorphism in the BDNF gene with bulimic experienced severe childhood abuse reported
behaviors has also been reported, but an inde- stronger sensation seeking and developed a
pendent replication of this association also more insecure attachment style. In patients with
failed. There may be an association between AN, an interaction between psychosocial stress
binge-eating and variants in the melanocortin-4 factors such as high parental control and disease
receptor gene (MC4R). Mutations in MC4R, risk was also found primarily in carriers of the
which lead to a functional restriction, are associ- s-allele of 5-HTTLPR. However, few studies
ated with obesity (Chap. 43). have specifically investigated the role of gene-
The data situation appears somewhat more environment interactionsin the context of eating
favorable when considering subphenotypes disorders, although malnutrition and/or under-
or disease-specific phenotypes: For example, nutrition would lend themselves particularly
increased affective instability, impulsivity, bor- well to such an association. It seems essential
derline personality traits, and harm avoidance for future studies to also standardize the record-
were found in patients with BN with the short ing of various environmental conditions dur-
allele (S-allele) of the 5-HTTLPR. Other stud- ing development. Even if the first results raise
ies revealed an association between increased hopes of better understanding the etiology of
impulsivity and the 5-HT2A gene in BN. eating disorders, caution is warranted and hasty
conclusions must be avoided. The studies men- in recent years, but as expected, it has not led
tioned here also include small case numbers and to the discovery of the “anorexia gene.” The
have not been replicated. Only when these dis- current study data underline that eating disor-
advantages of the studies are remedied will it be ders are complex diseases in which genetics
possible to assess the relevance of gene-environ- also play a role.
ment interactions in a well-founded manner.
Molecular genetic analyses based on
sequence information can only provide a static References
picture. However, genetic regulation is a highly
dynamic process that can respond plastically Bulik C, Kennedy M, Wade T (2020) ANGI—anorexia
to changes and thus also compensate for cer- nervosa genetics initiative. Twin Res Hum Genet
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tain less favorable genotypes. Essential for this Cross-Disorder Group of the Psychiatric Genomics
dynamic are the so-called epigenetic mecha- Consortium (2019) Genomic relationships, novel
nisms, which control the activity of individual loci, and pleiotropic mechanisms across eight psy-
genes over a longer period. Essentially, this chiatric disorders. Cell 179(7):1469–1482.e11.
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that influence chromatin structure and micro- Epigenetics in eating disorders: a systematic
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after transcription. DNA methylation, in par- PMID: 30353170; PMCID: PMC6544542
ticular, is strongly influenced by nutritional fac- Neyazi A, Buchholz V, Burkert A, Hillemacher T, de
tors, so it is not surprising that changes in global Zwaan M, Herzog W, Jahn K, Giel K, Herpertz S,
DNA methylation have been found in patients Buchholz CA, Dinkel A, Burgmer M, Zeeck A,
Bleich S, Zipfel S, Frieling H (2019) Association
with AN. However, specific changes in the form of leptin gene DNA methylation with diagno-
of increased methylation of individual gene pro- sis and treatment outcome of anorexia nervosa.
moters have also been described for AN and BN. Front Psychiatry 10:197. https://doi.org/10.3389/
So far, however, these are individual, rarely rep- fpsyt.2019.00197. PMID: 31031654; PMCID:
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cross-sectional studies. There are at least initial Fletcher E, Labbe A, Joober R, Israël M, Szyf M,
indications that methylation changes could be Agellon LB, Gauvin L, St-Hilaire A, Rossi E (2019)
used as prognostic markers (Neyazi et al. 2019). A longitudinal, epigenome-wide study of DNA
methylation in anorexia nervosa: results in actively
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been completed. However, the studies pub- non-eating-disordered women. J Psychiatry Neurosci
lished so far are all highly heterogeneous and 44(3):205–213. https://doi.org/10.1503/jpn.170242.
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The investigation of genetic aspects of eat- PMCID: PMC6779477
ing disorders has made significant progress
Psychosocial Risk Factors
21
Eike Fittig and Corinna Jacobi
Contents
21.1 Anorexia nervosa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
21.2 Bulimia nervosa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
21.3 Binge-Eating Disorder (BED) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
21.4 Interaction of Risk Factors in the Development of Eating Disorders . . . . . 156
21.5 Conclusion and Outlook . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
In the last 20 years, the number of studies on

risk factors has increased rapidly. In this pro- Definition of Risk Factors
cess, the term “risk factor” has been used A risk factor is the measurable characteris-
excessively and inconsistently, which can tic of a person in a specific population that
be attributed to the lack of clear definitions.
• precedes an event (e.g., onset of illness)
Proposals for clearer definitions were created by
and
Kraemer et al. (1997) and are nowadays widely
• increases the risk of the event
accepted. Since the corresponding definition for
occurring.
the term risk factor also underlies this chapter,
the term will be introduced first.
Risk factors that are not changeable, such
as gender or ethnic affiliation, are referred
to as “fixed markers.” If the temporal
sequence of a factor cannot be demon-
strated by longitudinal studies or by defi-
nition (ethnic affiliation, age), it is referred
to as a correlate or a retrospective cor-
E. Fittig (*) relate if the relevant factor was recorded
Celenus Klinik Carolabad, Chemnitz, Germany retrospectively in studies with a cross-sec-
e-mail: [email protected] tional design.
C. Jacobi
Faculty of Clinical Psychology and E-Mental Health,
TUD Dresden University of Technology, Dresden, In the following, the results of empirical studies
Germany on psychosocial risk factors and retrospective
https://doi.org/10.1007/978-3-662-67662-2_21
148 E. Fittig and C. Jacobi
correlates for anorexia nervosa (AN), bulimia was observed. In a study by Larsen et al.
nervosa (BN), and binge eating disorder (BED) (2020), a complete survey of births in Denmark
are presented. between 1989 and 2010 was conducted. This
study also confirmed that preterm births were
associated with the development of AN and
21.1 Anorexia nervosa BN. Furthermore, the authors report that higher
parental age and maternal nicotine consumption
21.1.1 Gender could be classified as risk factors. These fac-
tors can be considered as specific fixed markers
Numerous studies show that AN and BN occur for AN and BN.
significantly more frequently in women in both The results regarding the timing of birth as
clinical and non-clinical samples. The preva- a marker are highly contradictory. While sev-
lence of eating disorders differs only margin- eral studies classified births in the spring as a
ally in girls and boys aged 10–12 years. In marker, other studies found no difference, and
adulthood, the prevalence of eating disorders in one study found that participants born between
women is then increased by a factor of 10. Since October and November had an increased risk of
female gender is also considered a risk factor for underweight and restrictive eating behavior at
numerous other mental disorders, it is classified the age of 25–43 years.
as a non-specific marker.
21.1.4 Eating and Feeding Problems

21.1.2 Ethnicity and Age
In four longitudinal studies, the role of early
Although eating disorders have traditionally eating and feeding problems was investigated.
been seen primarily as a problem in Caucasian Based on these studies, picky eating, under-
ethnicities, a review shows that increased or weight in childhood, difficulties in feeding, and
equally high rates of eating disorders were also conflicts and struggles around food can be clas-
found among “native Americans” and persons sified as risk factors for AN that are already rel-
of Hispanic ethnicity. Lower prevalences were evant in early childhood.
found among persons of African American or
Asian ethnicity. Non-Asian ethnicity can there-
fore be classified as a marker for both AN and 21.1.5 Mother’s Educational Level
BN. Numerous studies report the highest inci-
dence of eating disorders from adolescence In a Swedish cohort study (birth year 1953) with
to early adulthood, so this time period can be over 14,000 participants (22 participants with
referred to as a variable risk factor. AN who were treated in hospital), the authors
classified a higher educational level of the
mother and “frequent comparisons of one’s own
21.1.3 Factors Related to Pregnancy future perspective with others” as a risk factor
and Birth for the development of AN.
Based on several studies that retrospectively

examined the frequency of complications dur- 21.1.6 Preoccupation with Shape
ing pregnancy and birth using hospital registers, and Weight/Dieting/Body
an increased occurrence of preterm births, low Weight, Body Dissatisfaction
birth weight, birth trauma, cephalohematomas,
preeclampsia, and heart problems in newborns The relationship of dieting, a negative body
image, and a preoccupation with shape and
21 Psychosocial Risk Factors 149
weight with the likelihood of developing an eat- 21.1.9 Attachment Style and Family
ing disorder is one of the most frequently dis- Climate
cussed associations in the context of etiological
theories of eating disorders. Although numerous Attachment style, family climate, and the inter-
studies have found evidence for this association action between family members are attributed
in AN using a cross-sectional design (sometimes great importance in etiological models of eating
also retrospectively assessed), most patients in disorders, especially from a historical perspec-
longitudinal studies meet the diagnosis of BN. tive. In the majority of studies, patients with AN
At the time of the new edition of this book, there and BN evaluate various aspects of their fam-
are now six longitudinal studies that confirm the ily structure (interaction, cohesion, communi-
relationship of dieting and preoccupation with cation, emotionality, attachment, etc.) as more
shape and weight with the development of AN. disturbed, conflict-ridden, pathological, or dys-
Stice and Desjardins (2018) reported that a low functional compared to healthy controls. Since
BMI was the most important risk factor for the the diagnosis of AN was not recorded as an out-
development of AN and was further exacerbated come in any of the longitudinal studies in which
by a high degree of body dissatisfaction. these variables were assessed, there is currently
no evidence that these variables represent risk
factors for the development of AN. A highly
21.1.7 Acculturation overprotective parenting style was reported in a
cross-sectional study in patients with AN prior
In addition, the role of cultural adaptation to the onset of the disorder, so this factor can at
(acculturation) in the development of an eat- least be described as a retrospective correlate. It
ing disorder is increasingly being discussed. is also postulated that adopted or foster children
The influence of this factor on the develop- have an increased risk of developing an eating
ment of AN was confirmed in a cross-sectional disorder. A study examining the role of this fac-
study in which acculturation was retrospectively tor in a Swedish hospital registry confirmed that
assessed. adoption or foster care placement is a risk factor
for the development of AN.
21.1.8 Sexual Abuse

21.1.10 Family Psychopathology
In the context of the etiology of eating disor-
ders, great attention is also given to the role of A significant number of studies have also dealt
sexual abuse in childhood and adolescence. In with the role of family psychopathology in the
several cross-sectional studies, sexual abuse development of AN. Clear evidence is primar-
has been identified as a retrospective corre- ily available for the role of eating disorders
late. However, there are also studies that do not (AN and BN), affective disorders, anxiety dis-
report this relationship. In a more recent retro- orders (panic disorder, generalized anxiety
spective study (Monteleone et al. 2019), the disorder, obsessive-compulsive disorder), and
association with all dimensions of abuse was an obsessive-compulsive personality disorder.
mediated by “emotional abuse.” To date, only However, none of the studies provided evidence
one longitudinal study has addressed this ques- for a clear temporal sequence of these factors.
tion, in which only one patient with AN was Based on these studies, family psychopathol-
identified. ogy can only be described as a (retrospective)
correlate. However, in three cohort studies with
several million participants, maternal depressive
symptoms, parental eating disorders, and pater- perfectionistic behaviors. From a biopsycho-
nal panic disorder were classified as risk fac- logical perspective, perfectionistic personality
tors for the development of AN. In one of the characteristics have been primarily associated
studies, a higher weight of the mother was also with changes in serotonin levels. A series of
a protective factor with regard to the develop- cross-sectional studies confirm that perfection-
ment of AN. ism is increased in remitted AN patients and can
thus be described as a retrospective correlate. In
a longitudinal Swedish cohort study (N = 1.8
21.1.11 Own Psychopathology million) by Sundquist et al. (2016), the authors
reported an association between good school
The psychopathology or the presence of other achievement and the development of AN. In a
mental disorders in the subjects themselves is longitudinal study, increased neuroticism values
also attributed a significant role in both etiologi- were also classified as a risk factor for the devel-
cal theories and scientific studies. To date, there opment of AN.
are several longitudinal studies in which general
psychiatric morbidity, psychopathology, or neg-
ative emotionality were investigated as potential 21.1.14 Occupational Groups and Risk
risk factors. In a retrospective twin study, the Sports
authors reported that patients with restrictive AN
often had internalizing psychopathology (e.g., The question of whether occupational groups
social withdrawal, depression) before their ill- (models, actors) and various athletes (e.g., bal-
ness, whereas patients with BN were more likely let dancers, gymnasts, jockeys, ski jumpers), in
to have externalizing problems (e.g., emotional which the importance of figure and low weight
instability, conflicts). is emphasized, can be considered high-risk
In the few available longitudinal studies, groups for the development of an eating dis-
depressive symptoms as well as anxiety and order, has been discussed for over 20 years.
obsessive-compulsive disorders were classified Although eating disorder-related symptoms and
as risk factors for AN. behaviors can often be observed in elite athletes,
the prevalence of full-syndrome eating disorders
(AN and BN) usually does not exceed that of
21.1.12 Self-esteem control groups. Numerous cross-sectional stud-
ies also deal with the role of excessive exercise
Low self-esteem, a negative self-concept, or in the development and maintenance of an eat-
“ineffectiveness” are likewise seen as influencing disorder. Only one study retrospectively
ing the development of AN. These assumptions assessed the extent of exercise before the onset
have been consistently confirmed in cross-sec- of the eating disorder. In this study, anorexic and
tional studies. So far, however, only one longitu- bulimic patients reported higher exercise than
dinal cohort study has provided evidence for this healthy control subjects.
risk factor.
Psychosocial risk factors and retrospec-

21.1.13 Perfectionism and Neuroticism tive correlates (in italics) for AN
• Birth
Perfectionism is particularly associated with – Female gender
AN from a clinical perspective. Patients with – Non-Asian ethnicity
AN often show rigid, stereotyped, ritualized, or
21.2 Bulimia nervosa

– Complications during pregnancy and
birth (esp. preterm births) 21.2.1 Gender, Ethnicity, Time
– Higher educational level of the of Birth, and Age
mother
• Childhood The roles of gender, ethnicity, and age have
– Age (adolescence to early adulthood) already been discussed in Sect. 21.1 as risk
– Health problems factors for AN. Thus, female gender and non-
– Picky eating, anorexic symptoms in Asian ethnicity can be considered as fixed
childhood markers and age between adolescence and early
– Feeding difficulties, conflicts and adulthood as variable risk factors for BN. The
struggles over food time of birth seems to play little or no role in the
– Adoption or foster care development of BN. The findings in this regard
– Sleep problems are even more inconsistent than in the context of
– Maternal depression, parental eating AN, and the majority of studies found no associ-
disorder, paternal panic disorder ation between month of birth and the occurrence
– Low weight of the mother of BN. In three cross-sectional, retrospective
– Overprotective parenting style studies, early onset of puberty was also classi-
– Childhood sleep disorder fied as a fixed marker for BN.
– Childhood anxiety disorder
– Obsessive-compulsive personality
disorder 21.2.2 Eating and Feeding Problems
– Sexual abuse
– High levels of loneliness and shyness The role of early eating and feeding problems
– Internalizing psychopathology has also been investigated in the context of the
development of BN. Three longitudinal studies
• Adolescence provided empirical evidence that Pica, insuf-
– Preoccupation with shape and ficient food intake, and health problems in tod-
weight/dieting, low BMI dlers—as with AN—can be considered risk
– Psychopathology (anxiety and obses- factors for the development of BN.
sive-compulsive disorders, depressive
symptoms)
– Neuroticism 21.2.3 Preoccupation with Shape
– Negative self-esteem and Weight/Dieting/Body
– Frequent comparisons of one’s own Weight
future prospects with others
– Good academic achievement As in the context of the development of AN,
– Acculturation dieting, a negative body image, and preoccupa-
– Excessive exercise tion with shape and weight are also attributed
– Psychopathology beyond the above- great importance in the development of BN.
mentioned risk factors While this relationship was mainly confirmed
– A higher level of risk-laden personal, empirically in cross-sectional studies for AN,
diet-related, and environmental fac- there are about 20 longitudinal studies for BN.
tors (e.g., sports and professional The results of these studies clearly underline the
groups; perfectionism) role of this factor, such that preoccupation with
weight and shape can also be considered a risk
factor. In our own longitudinal study, we found 21.2.6 Family Psychopathology

a strong association between weight and shape
concerns and the subsequent occurrence of (pre- In the majority of cross-sectional studies, fam-
dominantly) bulimic eating disorders, as well ily psychopathology is likewise increased in
as a potent relationship between initial com- BN compared to the parental psychopathology
pensatory behaviors and the subsequent occur- of healthy control subjects. Parents of patients
rence of an eating disorder (Jacobi et al. 2011). with BN show a higher prevalence of eating
With regard to weight, the results of longitudi- disorders, affective disorders, substance disor-
nal studies suggest that a higher body weight is ders, and cluster-B personality disorders (e.g.,
associated with the development of BN. In the borderline disorders) compared to the parents
aforementioned study by Stice and Desjardins of healthy control persons. Unfortunately, the
(2018), this is further reinforced by the presence temporal sequence is not sufficiently proven in
of increased weight and shape concerns and the any of these studies. There are several cross-
desire to be thin. sectional studies in which family problems such
as alcoholism, depression, drug abuse, and obe-
sity were retrospectively assessed and can there-
21.2.4 Acculturation fore be classified as retrospective correlates. In
two longitudinal studies, a relationship between
Cross-sectional studies have also demonstrated parental eating disorders and anxiety disorders
a relationship between retrospectively assessed was reported.
acculturation and the development of BN.
21.2.7 Sexual Abuse

21.2.5 Own Psychopathology
Sexual abuse, especially during childhood,
As already mentioned in Sect. 21.1, there are has been discussed in many studies and review
numerous studies investigating the role of psy- articles as a risk factor for the development
chopathology or negative affect in the develop- of BN. In cross-sectional, retrospective stud-
ment of eating disorders. Although the majority ies, consistently higher rates of sexual abuse
of these studies only have a cross-sectional are reported for patients with BN compared to
design, there are also some longitudinal stud- healthy control persons. As already described in
ies. These studies documented an influence of the context of AN, the association with all types
general psychopathology, social problems, nega- of abuse seems to be mediated by the dimension
tive affect (e.g., suicidal thoughts), emotional of “emotional abuse.” In the only longitudinal
instability, and depression, such that preceding study on this topic, an influence of negative life
psychopathology can be classified as a risk fac- events (including sexual abuse) and physical
tor for the development of BN based on these neglect was demonstrated in a large representa-
studies. Increased alcohol consumption within tive population sample. Based on this study, sex-
the last 30 days was also associated with the ual abuse can be classified as a risk factor for the
subsequent occurrence of an eating disorder in development of BN.
our own longitudinal study. Further retrospec-
tive correlates include an overanxious disorder
and overweight during childhood, social phobia
prior to BN, and externalizing psychopathology
(e.g., emotional instability, conflicts).
21.2.8 Attachment Style and Family 21.2.10 Perfectionism and Neuroticism

Climate, Negative Comments
about Food, Weight, and Body The role of perfectionism in the development
Shape of BN has been analyzed in several longitudinal
studies. However, only one of these studies was
Consistent with findings from AN risk fac- able to demonstrate an influence of perfection-
tor studies on attachment style, family climate, ism over time. This study also found that the
and family member interaction, in cross-sec- development of BN or a subclinical eating dis-
tional studies, patients with BN describe vari- order showed a significant positive association
ous aspects of their family structure as more with the EDI subscale “Fear of Growing Up”
disturbed than do healthy control partici- and, surprisingly, a negative association with the
pants. Noteworthy in this regard are negative subscale “Mistrust” . Higher academic achieve-
comments about weight, body shape, and food. ment (Sect. 21.1.13) was also associated with
In a longitudinal study, for example, the authors the development of BN. In another longitudinal
reported that being perceived as overweight by study, subjects who showed higher neuroticism
a parent was more strongly associated with the scores also had a higher likelihood of develop-
occurrence of an eating disorder than actual ing BN.
overweight. In our own longitudinal study,
we found that negative comments about diet,
weight, and body shape from siblings, teachers, 21.2.11 Professional Groups and Risk
or coaches were the most potent risk factors. Sports
Overall, the importance of teasing and negative
comments about food, weight, and body shape There is currently no longitudinal study inves-
is well documented in longitudinal studies. One tigating the influence of various professional
longitudinal study demonstrated an influence of groups or sports on the development of BN. In
various family variables (such as unsatisfactory terms of cross-sectional studies, the results are
family interaction or insufficient parental affec- similar to those described in the previous section
tion); therefore, disturbed family interaction can for AN.
be considered a risk factor based on this work.
Another longitudinal study identified stress
within the family as a non-specific risk factor for Psychosocial Risk Factors and
eating disorders (predominantly BN and partial Retrospective Correlates (in italics) for
eating disorders). High maternal care was a pro- BN
tective factor for the development of BN in the • Birth
longitudinal study by Micali et al. (2017). – Female gender
– Non-Asian ethnicity
– Complications during pregnancy and
21.2.9 Problems with Self-Esteem birth (premature births, birth traumas,
cephalohematomas, preeclampsia,
In contrast to risk factor studies for AN, there and heart problems in newborns)
are several longitudinal studies investigating • Childhood
the influence of low self-esteem, negative self- – Higher weight, perceived as over-
concept, or “ineffectiveness” or low self-efficacy weight by parents
expectation on the development of BN inves- – Health problems
tigate. Since a large part of these studies report – Anxiety—Depression
that these factors increase the likelihood of BN, – Sexual abuse, physical neglect
they can be considered risk factors. – Pica, difficulties in feeding
21.2.12 Additional factors

– Disorder with overanxiousness
– Childhood sleep disorder A number of other factors have been classi-
– Obesity, higher weight fied as risk factors for the development of BN
– Externalizing psychopathology in various longitudinal studies. This concerned
• Adolescence the two Youth Self-Report subscales “aggres-
– Early onset of puberty sive” and “unpopular” as well as alcohol con-
– Worries/dissatisfaction regarding sumption within the last 30 days, delinquency
weight and shape, dieting or substance abuse, avoidant and externaliz-
– Negative comments about food, ing coping as well as low social support. The
weight, and shape, teasing results of two longitudinal studies also suggest
– Prodromal symptoms (compensatory that in addition to unfavorable coping strategies,
behavior) the increased occurrence of critical life events
– Negative emotionality, emotional should be considered as a risk factor for the
instability, general psychopathology, development of BN.
social problems, major depression
– Low self-esteem, ineffectiveness, low
self-efficacy expectation 21.3 Binge Eating Disorder (BED)
– Unfavorable interaction patterns in
the family, stress in the family, nega- Before the introduction of BED as a separate
tive comments about weight and diagnosis in the DSM-5, there were only a few
shape from siblings, teachers, or studies that explicitly investigated risk factors
coaches for the development of BED, and they predomi-
– Maternal care protective nantly only considered “unspecified eating dis-
– Alcohol consumption within the last orders”. However, this category is likely to have
30 days included a substantal proportion of patients with
– Youth-Self-Report “aggressive”, BED.
“unpopular” The outcome of longitudinal risk factor stud-
– High neuroticism scores ies is often a mixture of bulimic and binge-
– Good academic achievement eating syndromes, so it can be assumed that a
– EDI scales: increased “fear of grow- number of factors presented in Sect. 21.2 as risk
ing up” and low “mistrust” factors for the development of BN may also be
– Low interoceptive perception relevant in the development of BED. Therefore,
– Negative life events only the results of longitudinal and cross-sec-
– Avoidant coping, distraction as tional studies will be presented in the following,
coping where it can be ensured that the research criteria
– Low social support for BED were explicitly used as the outcome.
– Acculturation
– Sexual abuse, unfavorable life events
– A higher level of risk-laden personal, 21.3.1 Findings from Longitudinal
diet-related, and environmental fac- Studies
tors (higher athletic activity, unfa-
vorable family experiences, parental In contrast to low birth weight as a risk fac-
alcohol dependence, depression, drug tor for AN, the results of a recent longitudinal
addiction; parental obesity; negative study suggest an association between high birth
comments about weight and shape) weight and the development of BED (Watson
– Social phobia et al. 2019).
In a longitudinal study, sexual abuse or phys- 21.3.2 Findings from Cross-sectional

ical neglect (assessed through a central register Studies
or interviews with mothers) was identified as a
risk factor for the development of an eating dis- In addition to the listed longitudinal studies,
order (BED and BN) . there are three studies in which potential risk
The influence of low self-esteem, high body- factors for the development of BED were retro-
related concerns, as well as avoidant coping spectively assessed.
and external control beliefs on the develop- In the first study, increased scores or frequen-
ment of BED has also been documented in sev- cies were found for patients with BES compared
eral longitudinal studies. In the aforementioned to healthy control subjects for
study by Stice and Desjardins (2018), body dis-
satisfaction, exacerbated by overeating, was the • a negative self-concept,
most significant risk factor for the development • a major depression,
of BED. Overeating in childhood was also asso- • difficult social behavior,
ciated with the development of BED in the lon- • self-harm behavior,
gitudinal study by Herle et al. (2020). • parental criticism,
A factor that includes concerns about weight, • high expectations,
shape, and eating, as well as societal pressure • low affection,
to be thin, significantly predicted the develop- • low parental involvement,
ment of an eating disorder in another longitu- • low maternal care, and
dinal study. Furthermore, this study also found • high overprotection.
an increase in negative life events prior to the
onset of the disease. Since both BN and BED In addition, patients with BED reported higher
patients were identified in this study, these men- prevalences of sexual abuse, repeated physical
tioned factors can also be considered risk fac- abuse, intimidation within the family (bully-
tors for the development of BED. In the study ing), negative comments and teasing about body
already presented in the context of risk factors shape, weight, and eating. Low parental involve-
for BN, 21 out of 96 participants with an eating ment, negative comments about body shape,
disorder met the criteria for BED. weight, and eating, as well as childhood obesity
In this study, the following factors were asso- appear to be specific retrospective correlates for
ciated with the onset of an eating disorder: the development of BED.
In this second study, women with BED
• drug use by the mother during pregnancy, were compared to women without eating disor-
• high weight or being perceived as overweight ders with and without obesity in terms of their
by parents, perception of their parents. Women who met
• stress in the family, the diagnosis of BED reported more paternal
• dieting, neglect and rejection than did women without
• social problems, and obesity. Paternal neglect and rejection can there-
• low self-efficacy. fore be described as retrospective correlates.
The frequencies of retrospectively recorded
In further longitudinal studies, external control sexual and physical abuse, as well as intimida-
beliefs, low self-esteem, teasing, body dissat- tion and discrimination based on ethnic affilia-
isfaction, and high socioeconomic status were tion, were compared in the third study among
confirmed as risk factors. women with BED with healthy controls and
controls with mental disorders. Although women
with BED reported higher prevalences of sexual 21.4 Interaction of Risk Factors
and physical abuse, bullying by peers, and dis- in the Development of Eating
crimination than did the healthy control sub- Disorders
jects, they only differed from controls with other
mental disorders with respect to discrimination. At the time of the first publication of this book,
a substantial criticism of the existing state of
knowledge about psychosocial risk factors in
Psychosocial risk factors and retrospec- the context of the development of eating disor-
tive correlates (in italics) for BED ders was that individual studies hardly made
• Birth any statements about the interaction of the vari-
– Maternal drug use during pregnancy ous risk factors. In recent years, an increasing
– Higher birth weight number of studies have been devoted to this
• Childhood issue, some of which will be summarized in
– Higher weight, being perceived as this section. Some interactions of risk factors
overweight by parents have already been reported above. In the study
– Sexual abuse, physical neglect by Stice and Desjardins (2018), for example, an
– Perceived neglect and rejection by interaction of dieting (AN) or overeating (BN
parents and BES) with the risk factor body dissatisfac-
– Obesity during childhood tion was shown in the development of both AN
• Adolescence and BN and BED. The authors also consider
– Dieting these results as an indication of the relevance
– Overeating of the “dual pathway model”.
– Body dissatisfaction This model states that the internalization of a
– Low self-esteem, low self-efficacy slim body ideal and the societal pressure to be
expectation thin lead to dissatisfaction with one’s body.
– Worries about weight, shape, and eat- This dissatisfaction can lead to the devel-
ing, societal pressure to be thin opment of an eating disorder through two
– Negative life events pathways:
– Coping (avoidant coping; eating to
regulate emotions), external control • by the affected person increasingly dieting,
beliefs which subsequently leads to binge eating and
– Low social support, social problems compensatory measures;
– Stress in the family • by dissatisfaction with one’s own body
– Sexual abuse, repeated physical abuse leading to increasing negative affect (up to
– A higher level of risk-laden personal, depression) and binge eating as well as com-
diet-related, and environmental fac- pensatory behaviors being used as emotion
tors (e.g., negative self-esteem; major regulation strategies.
depression; difficult social behav-
ior; self-harm behavior; parental In our own work, we also found indications for
criticism, high expectations, minimal the validity of the model: In a longitudinal study,
affection, low parental engagement, a history of depression prior to the eating disor-
as well as low maternal care and der on the one hand and weight and shape con-
high overprotection) cerns on the other hand represented independent
– Bullying within the family and by risk factors (Jacobi et al. 2011).
peers, discrimination, negative com-
ments and teasing about shape,
weight, and eating
In the unpublished dissertation of the first represent both the most potent and the best-
author of this chapter, there were also indica- confirmed psychosocial risk factors for the
tions that weight and shape concerns act as development of an eating disorder. Since some
mediators between negative comments about of the risk factors presented here were classi-
weight and shape and the development of an eat- fied only on the basis of one study, they are in
ing disorder. This finding underlines the central, need of replication. Likewise, the retrospective
possibly causal role of the risk factor weight and correlates require further examination within
shape concerns. the framework of future longitudinal studies. In
addition, it seems appropriate to examine the
 Important The risk factor weight and shape causal influence of the presented risk factors
concerns/dieting plays a central role in the on the development of eating disorders in rand-
development of an eating disorder. omized and controlled prevention and interven-
tion studies.
21.5 Conclusion and Outlook

References
Although numerous studies on risk factors for
eating disorders are now available, some limita- Herle M, Stavola B, Hübel C, Abdulkadir M, Ferreira
DS, Loos RJF, Bryant-Waugh R, Bulik CM, Micali
tions must be mentioned: As with the 3rd edi- N (2020) A longitudinal study of eating behaviours
tion of this book, the majority of so-called risk in childhood and later eating disorder behaviours and
studies come from studies with cross-sectional diagnoses. Br J Psychiatry 216(2):113–119
designs, so the results from these investigations Jacobi C, Fittig E, Bryson C et al (2011) Who is really at
risk: identifying the risk factors for eating disorders
can only be interpreted as correlates. Although in a high risk sample. Psychol Med 31:1–11
most of the longitudinal studies were conducted Kraemer HC, Kazdin AE, Offord DD et al (1997)
with large sample sizes, the number of identified Coming to terms with the terms of risk. Arch Gen
subjects with eating disorders is still too low to Psychiatry 54:337–343
Larsen JT, Bulik CM, Thornton LM, Koch SV, Petersen
make general statements about the significance L (2020) Prenatal and perinatal factors and risk of
of the identified factors. Therefore, replication eating disorders [published online ahead of print,
of many results is absolutely necessary. The evi- 2020 Jan 8]. Psychol Med 1–11
dence from longitudinal studies is significantly Micali N, Martini MG, Thomas JJ et al (2017) Lifetime
and 12-month prevalence of eating disorders amongst
better for BN and BED than for AN, which women in mid-life: a population-based study of diag-
is not least due to the low prevalence of AN. noses and risk factors. BMC Med 15(1):12
Finally, in the longitudinal studies, the various Monteleone AM, Cascino G, Pellegrino F et al (2019)
diagnoses as well as full-syndromal and partial The association between childhood maltreatment
and eating disorder psychopathology: a mixed-model
disorders are mostly mixed. In the majority of investigation. Eur Psychiatry 61:111–118
the works, only eating disorders are recorded as Stice E, Desjardins CD (2018) Interactions between risk
outcomes, so the specificity of many of the risk factors in the prediction of onset of eating disorders:
factors described in this chapter is questionable. exploratory hypothesis generating analyses. Behav
Res Ther 105:52–62
For example, there are a number of longitudinal Sundquist J, Ohlsson H, Winkleby MA, Sundquist K,
studies that demonstrate that a preceding psy- Crump C (2016) School achievement and risk of eat-
chopathology is also relevant as a risk factor for ing disorders in a Swedish National Cohort. J Am
the development of affective disorders. Acad Child Adolesc Psychiatry 55(1):41–46
Watson HJ, Diemer EW, Zerwas S et al (2019) Prenatal
In summary, it can be stated that female gen- and perinatal risk factors for eating disorders in
der, concerns about shape and weight, dieting women: a population cohort study. Int J Eat Disord
and overeating, as well as a negative self-esteem 52(6):643–651
Sociocultural Aspects
of Eating Disorders 22
Burkard Jäger
Contents
22.2 Bulimia nervosa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
22.3 Cultural Factors in Weight Gain, Obesity, and Binge Eating Disorder . . . 164
22.4 Common Factors: Upheaval and Migration, Religious Orientation,
and Role Expectations for Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
22.5 Conclusion and Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
The occurrence of eating disorders varies con- by the media and the social environment (peers
siderably between different sociocultural groups and family). Sociocultural factors are thus to be
and over time in a changing cultural environ- assigned to the risk factors for the development
ment. There are differences between various of eating disorders and are in competition and
ethnic groups as well as differences between dif- interaction with other factors (see Chap. 21).
ferent cultures and between social subgroups in However, the importance of the various socio-
the otherwise same cultural-spatial environment, cultural characteristics is differently pronounced
clearly independent of purely genetic influences. for the different diagnoses.
The most important aspect of these cultural fac- While eating disorders have long been con-
tors seems to be the Western-influenced societal sidered predominantly as diseases of Western
pressure to be slim, which is mainly conveyed industrialized nations, today—with the excep-
tion of natural societies, as far as they still
exist—a worldwide distribution can be assumed.
In particular, countries that have adapted more
or less rapidly to Western values seem to have
a particular vulnerability to eating disorders and
now show very similar prevalence rates.
B. Jäger (*)
 Important Recent studies are increasingly
Psychotherapy, Hannover Medical School, Hannover, demonstrating a worldwide distribution of
Germany eating disorders.
https://doi.org/10.1007/978-3-662-67662-2_22
160 B. Jäger
22.1 Anorexia nervosa the few valid studies on sociocultural changes

show an increase, particularly in emerging
22.1.1 Cultural-historical countries. A difference between “Western” and
perspective other countries is also found for anorexia, with
a lifetime prevalence (women, DSM-IV criteria)
Individual cases of obvious anorexic illnesses, for Anorexia nervosa (AN) between 0.3% and
albeit not yet called as such, have been reported 2.2% in Western countries compared to a rate of
since medieval historiography at least. The cir- 0.002-0.9% in non-Western or non-developed
cumstance of getting by with almost no food countries (Makino et al. 2004). Hoek (2016)
was usually explained as the implementation of cites a prevalence rate of 1.05% for women
the Christian-clerical ideal of pious asceticism. in China, 0.43% for Japan, 0.1% for South
The case of Catarina of Siena (around 1347– America, and a very low value of <.01% for
1380), a patroness of the Dominican Order and Africa; the low prevalence for African-American
temporary advisor to Pope Gregory XI, is con- women is also confirmed for anorexia diagnoses
sidered prototypical. She owed her popularity according to the DSM-5 (Cheng et al. 2019).
and her later political influence to an alleged
prophetic gift and her strict fasting, which
began in adolescence and continued until her 22.1.3 Influences of the Thin Body Ideal
death, which was partly caused by it. The rec-
ognition offered by such an “achievement” was The desire to conform to the prevailing beauty
able to establish a career as a nun or even as a ideal is not the main focus of anorexic ill-
“saint” and thus support a detachment from the ness; the pathological aspect lies on an intrapsy-
family—a role offer that no longer exists in this chic or interpersonal level and is not associated
form today. with a desire for conformity. Due to the absence
The cases of anorexics from the Middle Ages of this characteristic in historical reports and
and the beginning of modern times already in Asian countries, it has also been discussed
include the characteristic of role model function whether the fear of body fat represents an addi-
or “social contagion,” as we know it in today’s tional feature alongside the common criteria of
manifestations of eating disorders. However, AN. Nevertheless, the mentioned increases in
the clinical pictures—or their representation— the prevalence of the disease often run parallel
regularly lack the characteristic of an overvalued to industrialization and the adoption of Western
desire for thinness, which was only described beauty ideals.
around the beginning of the last century.
 Important Anorexia is not tied to the desire
for thinness but is supported and legitimized
22.1.2 Prevalence in Different Cultures by it. It can also be triggered by fashion-con-
scious diet attempts, but in the further pro-
Hilde Bruch (1980) initially assumed that ano- gression of the disorder, it clearly separates
rexia was practically absent in People of Color, from an orientation towards societal ideals.
as opposed to White people. This position is no
longer tenable today, at least for People of Color
in Western-oriented countries, even if critical 22.1.4 Other Sociocultural Influencing
attitudes towards one’s body seem to be less Factors
pronounced compared to other ethnicities (see
below). Cases of anorexic disorders are reported The long-reported observation that anorexia
from all cultures and all religious groups, but predominantly occurs in higher socioeconomic
22 Sociocultural Aspects of Eating Disorders 161
classes (see Gard and Freeman 1996) is repeat- 22.2.2 Prevalence in Cultures with and
edly confirmed in more recent works, with even without Connection to Western
the generation of grandparents showing an influ- Media Content
ence (Ahren-Moonga et al. 2009).
As “Anorexia athletica”, anorexic disorders Much more clearly than in anorexia, there is a
are referred to in the context of sports where clustering of the disease in countries and cul-
a low weight promises a competitive advan- tures under the influence of a Western-shaped
tage, such as gymnastics, ballet, and endur- beauty ideal with the outstanding importance of
ance sports, and for men additionally ski the ideal of thinness (Makino et al. 2004). Just a
jumping. Only recently has the generation of few decades ago, bulimic eating disorders were
middle-aged adults received attention regarding unknown in countries other than those cultur-
the prevalence of eating disorders, which were ally influenced by the West, whereas prevalence
previously considered firmly tied to adolescence rates of up to 20% were estimated for the risk
and young adulthood. population in the USA. As far as natural socie-
ties without significant Western influence can
still be found at all, there is or was a widespread
22.2 Bulimia nervosa abstinence from the ideal of slimness: Peruvian
Indians, who were shown female silhouettes
22.2.1 Cultural-Historical of model proportions, judged their health sta-
Perspective tus as “almost dead” (Yu and Shepard 1998).
In Western cultures, occurrence rates of 0.3%–
The origin of the term from Greek and the 7.3% are reported, in non-Western countries
translation as “ox hunger” already suggests 0.46–3.2% (Makino et al. 2004). Hoek (2016)
a historical root. Hedonistic, bulimic ritu- cites a prevalence of 2.98% for China, 2.32% for
als with feasting and subsequent, deliberately Japan, 1.16% for Latin America, and 0.87% for
induced vomiting are known, for example, from Africa (women).
pre-Christian Egypt, Greece, and the Roman A wealth of studies have examined attitudes
Empire; however, these lack the characteristic towards slimness and the frequency of bulimia
of using these practices as a means of weight nervosa (BN) among Americans or Britons of
control. From about the middle of the 19th cen- different ethnic origins. While a different ethnic-
tury, rare case reports of insatiable hunger are cultural background was once considered a pro-
described, which often had a psychiatric or neu- tective factor, Latin American, Asian, or African
rological background and were not followed by women now show a similarly high degree of
deliberate vomiting or another measure of regu- body dissatisfaction and bulimic attitudes as
lating energy intake (Habermas 1990). Despite Caucasian women (Cheng et al. 2019). Again,
initial contrary speculations, it is now assumed people with Black skin color show the lowest
that the syndrome of bulimia, in contrast to frequency, which is explained by the fact that
anorexia, has actually only developed with sig- the African subculture may provide protection
nificant frequency since the 1950s. The first against negative, body-related cognitions. When
comprehensive description is known to be from assessing these relationships, it should be noted
1979, and the first recognition as a disease entity that the risks for a pathogenic desire for thin-
occurred in 1980. The question arises whether ness increase with an elevated BMI, which can
the recognition as a disease has contributed as be genetically, socio-culturally, or behaviorally
an iatrogenic factor to the epidemic spread. based.
162 B. Jäger
22.2.3 Influences of the Thin Body Ideal

already launched in 1962, and its older,
In the case of AN, there is a stable and difficult- German-born sister (and patent model)
to-treat internalization of the ideal of a (too-) “Lilli” (Fig. 22.1) even as early as 1955,
thin body, which is also recognized as an impor- i.e., at the time of the beginning of a pros-
tant risk factor for the disease even with critical perous post-war economy and a then wel-
reception (Culbert et al. 2015). There is hardly comed, again macronutrient-rich cooking
a patient with a bulimic disorder who does not culture.
have a career of years of more or less frustrated
attempts at weight control and weight loss.
Role of Peers A similarly significant role
Role of the Media The ubiquitous desire for to mass media is played by peers, i.e., same-
thinness in Western societies is inconceivable sex and approximately same-age adolescents,
without the widespread and aggressive market- as well as the model of parents. In Western-
ing of a thin ideal. Here, the classic print and oriented countries, the ideal of slimness and
film media, but especially the internet media
with the prevailing promotion of aesthetically
optimistic life plans and templates for individual
identification figures, are of great importance.
Media consumption is considered an acknowl-
edged risk factor for eating disorders in women
(Culbert et al. 2015) (see Chap. 23).
 Important The causal link between the recep-

tion of overly thin models and the develop-
ment of bulimic symptoms can be considered
well-established.
Barbie’s Big Sister

There is a wealth of research on the ques-
tion of when the thin body was idealized
and accepted as an undisputed model.
Although the extremely thin model
“Twiggy” (approx. 1966–1971) was still
admired as an exception to the norm, vari-
ous authors have shown that not only the
bodies depicted in fashion magazines and
men’s magazines became increasingly
thinner, especially towards the end of the
1970s and the beginning of the 1980s, but
also—in association with the increasing
prevalence of obesity—increasingly devi-
ated from the realistic body image of the
age-matched female population. On the
other hand, Mattel®’s Barbie doll, with its Fig. 22.1  
“Lilli”, big sister and patent model of
clearly anorectic body proportions, was the Barbie doll. (© Thomas Goldschmidt, Badisches
Landesmuseum Karlsruhe, with kind permission)
symptomatic behavior are conveyed through models or casting film roles can be considered
pronounced social comparison within peers male-influenced, but studies on body image
(Keski-Rahkonen and Mustelin 2016). This consistently show that the female ideal figure
problematic behavior has been further promoted from a male perspective is less thin than from
by social networking sites, which are particu- a female perspective! One explanation is that
larly popular among young people. Here, the the thin body, in addition to the component of
limiting function of interpersonal ethics (con- social advantages, seems to have its own inher-
sideration, politeness, etc.) seems to be particu- ent attractiveness and an inherent “promise of
larly suspended in the face of open defamation salvation.”
of non-ideal physicality. The parental influence
on the development of an eating disorder should
not be underestimated either. Parents’ dissatis- 22.2.4 Further sociocultural influencing
faction with their own weight and rigid weight factors
control measures predispose to incorrect model
learning, especially when this is associated with For bulimia nervosa, the correlation with a
criticism of the child’s body weight is. higher socioeconomic status—unlike ano-
Fig. 22.2 shows body self-evaluation and rexia—is not found, and there is evidence that
desire for thinness in 14 national and ethnic increased prevalence rates are more likely to be
groups of female student populations (n = 2468) found with low family income and educational
in the empirical relative of a silhouette scale. level (see Gard and Freeman 1996). Lower soci-
oeconomic status is relatively well-established
The Role of Men The role of men is contro- as being linked to an increased risk of over-
versial. On the one hand, in a still male-domi- weight, which in turn has a pathogenic effect
nated society, most decisions about employing towards bulimia. Finally, in Western European
19 20 21 22 23 24 25 BMI
Sweden 0.80
Germany 1.01
France Spain 1.35
Great Britain 1.15
South Italy 1.14
North Italy 1.12
South Africa 1.36
(white) 1.53
Tunisia 0.85
Iran 0.63
South Africa (sw.) 1.67
Ghana -.26
Gabon 0.21
India 0.33
2.0 2.5 3.0 3.5 4.0 4.5 5.0

Selected silhouette width 1 2 3 4 5 6 7 8 9 10
Fig. 22.2  Body self-evaluation and desire for thinness in 14 national and ethnic groups of female student populations
(n = 2,468) in the empirical relative of a silhouette scale. Shown are the averaged results for participants’ current self-
evaluation (black ovals) and how she would like to look in the body silhouette (white ovals). In addition, the evalua-
tion of an “attractive” female silhouette by men of the same culture (N = 1,757) is shown (white triangles) as well as
the average BMI of the sample (white rectangles). The difference between “current” and “ideal” self-evaluation is cal-
culated as “desire for thinness” (gray hatched fields). There are striking differences [F(df = 13) = 15.1; p < 0.001] in
the desire for thinness, corresponding to the degree of orientation towards Western culture, with particularly extreme
expressions in the European Mediterranean countries. Only in South Africa can the extreme desire for thinness be
explained by an increased BMI in both White and Black subjects. As expected, hardly any desire for thinness, or even
a “negative” desire for thinness, is formed in Central Africa and India, while the societies in transition in Tunisia and
Iran take a middle position (see Jäger et al. 2002).
164 B. Jäger
countries, both dancers and practitioners of  Important The extent of societal stigmati-
weight-class sports (e.g., martial arts) or sports zation of overweight is comprehensive and
with a clear advantage at low weight form sub- hardly limited by conventions or taboos.
cultures with an increased likelihood of bulimia.
Systematic studies have also relativized the The characteristic of being overweight is
influence of adolescent age as a high-risk fac- associated with traits such as sluggish, lazy,
tor: a similar proportion of illnesses is found in uncontrolled, undisciplined, and stupid. Social
middle adulthood as in younger people (Slevec psychological experiments show that overweight
and Tiggemann 2011). Body dissatisfaction individuals in our Western-influenced cultures,
even increases with age, with the effect almost for example, earn less, are less likely to get a
entirely explained by the increasing BMI. job, are less likely to be accepted as tenants, and
receive longer prison sentences. Even kinder-
garten children prefer a ragged doll to a fat one
22.3 Cultural Factors in Weight and attribute great importance to body weight
Gain, Obesity, and Binge for social position—and among children, these
Eating Disorder assimilated attitudes are particularly unmitigated
by primary or social secondary virtues. Teachers
22.3.1 The Role of Norms rate school essays by overweight children—
and Ideals in Media within the framework of a controlled experi-
and Public Morality ment—worse than those by normal-weight
children, and representatives of health disci-
The risk of adopting an increased body weight plines unfortunately often contribute to the per-
is significantly higher in Western countries and, petuation of the corresponding prejudices. While
in addition to being a prerequisite for develop- the negative physical long-term consequences
ing obesity, also poses a risk for bulimia and of obesity often only occur after a disease dura-
binge eating disorder (BED). In addition to the tion of 10–20 years, the psychological exclusion
significant influence of genetic predisposition, and stigmatization begin immediately with the
the culture-specific abundance of calorie-dense onset! At best, in selected social niches—top
food combined with a lack of exercise is primar- male politicians, male business leaders—a resi-
ily responsible for the epidemic weight gain. due of the association “weighty = powerful =
The average daily TV consumption is signifi- successful” handed down from the Middle Ages
cantly positively associated with increased body still remains.
weight. For BED, the distribution pattern across
ethnic groups does not follow the pattern seen in
anorexia or bulimia. BED is much more depend- 22.4 Common Factors: Upheaval
ent on body weight and thus possibly on bio- and Migration, Religious
logical-genetic factors. Hoek (2016) found the Orientation, and Role
highest prevalence of 4.45% among Africans, Expectations for Women
similarly found among African Americans in the
USA (Cheng et al. 2019; DSM-5 diagnoses). Regardless of ethnic origin or cultural envi-
Unlike the thin ideal, a voluminous body ronment, it regularly becomes apparent that
ideal has not been actively promoted and has not migration—more precisely, acculturative
been associated with positive values for at least stress—represents an independent risk factor
60 years—on the contrary, the role of the media (Warren and Akoury 2020). There is increasing
is mostly limited to unrealistically propagat- data from Eastern European countries (espe-
ing the feasibility of substantial weight loss and cially Poland, Hungary, Czech Republic, and the
repeating the popular, negative associations with territory of the former GDR) indicating a further
obesity. convergence of eating disorder-specific attitudes
since the time of political upheaval. Studies significant effect of these ideals, which are
from the United Arab Emirates point in a simi- also disseminated through mass media, can be
lar direction. Several studies from Iran show an observed for bulimia, whereas the occurrence
increasing convergence with the data of Western of anorexia is not tied to a widespread desire for
countries over time, which seems particularly thinness but is apparently legitimized and rein-
interesting for this culturally “ambivalent” forced by it.
country regarding eating disorders. Regarding For other sociocultural influences, such as
the influence of religious values orientation— socioeconomic status, the available findings are
Christian and Jewish—the following seems to less clear.
apply: A firm and secure attachment to faith is The relationships referred to here are pre-
associated with less eating disorder pathology sented with a strong focus on women. This is
and greater satisfaction with one’s body, thus partly because the cultural body ideal of men,
providing protection against eating disorders, encompassing leanness and muscularity, has
but this protection does not exist in an insecure two partly contradictory and partly difficult-to-
or superficial relationship (Akrawi et al. 2015). distinguish characteristics, and the results are
Similar results are found for the comparison of less clear. On the other hand, the still signifi-
veiled vs. non-veiled Muslim women (Wilhelm cantly higher prevalence rates suggest focusing
et al. 2018). on women.
Sociological and feminist explanations focus When comparing epidemiological data across
on the still high gender specificity of eating cultures and continents, it should also be noted
disorders. Popular theses from the 1970s and that this is fraught with particular methodologi-
1980s, stating that those with eating disorders cal uncertainties, which affect case definitions
were particularly feminine in the sense of a pas- and sample selection, as well as difficult-to-
sive-dependent attitude, have been empirically control influences such as semantic uncertainties
refined to show that those affected orient them- and translation effects in questionnaires (Chap.
selves particularly strongly towards prevailing 10).
ideal conceptions and have a more pronounced Dealing with cultural norms also points to an
need for social recognition. Migration move- ethical dimension of this issue. If one accepts—
ments, in turn, are often associated with changes with the above-mentioned limitations—the dis-
in women’s roles, which primarily involve an ease-promoting influence of a uniform thinness
unfavorable expansion of role expectations (the ideal, a political response similar to national ini-
“pressure to conform” plus the “pressure to tiatives banning the depiction of anorexic mod-
compete”). els should be considered. Beliefs and norms can
be changed, as the example of the populariza-
tion of basic ecological beliefs shows. In princi-
22.5 Conclusion and Limitations ple, this should also be possible with regard to
the esteem for thinness of one’s own and other
On the one hand, a worldwide prevalence of people’s bodies.
eating disorders can be observed in the socio-
cultural comparison, while on the other hand,
meaningful interpretable differences can be References
found, which can essentially be explained by
the degree of Western vs. traditional orienta- Ahrens-Moonga J, Silverwood R, af Klinteberg B,
Koupil I (2009) Association of higher parental and
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The originally Western ideal of thinness plays a with risk of hospitalization for eating disorders in
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as causal based on a multitude of findings from Akrawi D, Bartrop R, Potter U, Touyz S (2015)
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The Influence of Media
on Body Image 23
Maya Götz
Contents
23.1 The Media Image of the Female Body . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
23.2 Television Shows and Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
23.3 Social Media and BodyDissatisfaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
23.4 Social Media and Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
23.5 What Might Help? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Media is a part of everyday life for children as happens in “Fitspiration” and “Pro-Ana”
and adolescents and can play an important role communities, people can be led into an eating
in the development of internalized body ideals, disorder and unhealthy eating behavior can be
a healthy lifestyle, etc. The basic problem: For promoted.
the most part, only young and very slim women
are shown in the media. This starts with chil-
dren’s television and continues with shows like 23.1 The Media Image of the Female
the international “Next Top Model” franchise Body
and on social media platforms like Instagram.
The almost consistent hidden message is: Only Women are significantly underrepresented in
women who are stereotypically beautiful, almost all media. On television, for example,
young, and exceptionally thin have a happy and they play only half as many leading roles as
successful life. If girls and women internalize men and are then almost exclusively young,
this image, the likelihood of them being dissatis- stereotypically beautiful, and slim (Prommer
fied with their own bodies is high. If the need for and Linke 2019). The normal diversity of body
constant self-optimization is propagated and any and appearance is hardly ever seen on television
deviation from this body image is pathologized, and in film. This tendency runs through vari-
ous media and is also clearly evident in maga-
zines, advertising, and the fashion industry (for
a summary, see for example, Kiehl 2010). Over
M. Götz (*)
International Central Institute for Youth and Educational
the decades, there has been an increasing “slim-
Television (IZI), Munich, Germany ming down” in the media: While thirty years
e-mail: [email protected] ago, photo models were only about 8% thinner
https://doi.org/10.1007/978-3-662-67662-2_23
168 M. Götz
than an average woman, they are now are about BFE 2016). Television also creates spaces where
23% slimmer (Derenne and Beresin 2006). As the topic of “eating” does not have to be thought
a result, only an estimated 4% of all women about, at least temporarily (Märschel 2007). In
would be physically able to meet the beauty the phase of active coping with the eating dis-
ideal, and only one in 40,000 women would order, the unmasking of media stereotypes and
meet the requirements of a professional model the demarcation from the underweight beauty
in terms of size, shape, and weight (Hawkins ideals, the “diet terror” and the contradictory
et al. 2004). advertising messages can play a significant role
The dominance of ultra-thin girl and women (Baumann 2009).
figures already begins in children’s media. On In the last decade, the show Germany’s Next
children’s television, half of all cartoon char- Topmodel (GNTM) has played a prominent role
acters are drawn with a waist so slim that it is in this context. Almost a third of 9-year-old girls
not naturally possible (Linke et al. 2017). For have watched the show at least sometimes, ris-
internationally marketed cartoon characters rep- ing to two thirds of 10-year-olds, and nine in
resenting a teenage girl or woman, it is even ten 16-year-olds (Götz et al. 2015). There is a
three-quarters (Götz and Herche 2013). This high, significant correlation between thoughts of
means that girls grow up with a body image that being too fat and watching GNTM. In particular,
they can never achieve. In some girls, seeing underweight girls who watch GNTM are almost
such images leads, as experimental studies have five times more likely to have thoughts of being
shown, to a spontaneous decline in satisfaction too fat compared to underweight girls who
with their own bodies (e.g., Bell and Dittmar never watch GNTM(Götz et al. 2015). In a sur-
2011). The crucial factor is the extent to which vey of people (mostly women) undergoing treat-
girls and women have internalized the ideal of a ment for an eating disorder, just under one third
very thin body (Harrison 2013). attributed a “very strong” influence of GNTM
on the development of their illness, and another
 Important The body imageof women shown just under one third attributed at least “some”
in the media is unattainable for most. If girls influence. The impact of the show is predicated,
and women internalize this image, the likeli- among other factors, by conveying the impres-
hood of them being dissatisfied with their sion that the contestants are “ordinary girls.” In
own bodies is high. fact, the cast participants are physical excep-
tions, all with a minimum height of 1.76 m and
a maximum clothing size of 36. The girls watch-
23.2 Television Shows and Eating ing them in front of their television or laptop
Disorders take this appearance as a role model and com-
pare their bodies in detail with the staged bodies
The importance of media for people’s inter- of the contestants. If they then follow the central
nal images does not follow a simple stimulus- narrative patterns of the show, that only uncon-
response logic, but is a form of appropriation ditional self-optimization and adaptation to mar-
and subjective attribution of meaning in eve- ket demands bring success and recognition, this
ryday life (Mikos 2015). Media can be part of can reinforce disordered eating behavior (Götz
the development, course, and coping with dis- and Mendel 2016a; Götz et al. 2015).
ordered eating. In the development phase, in
a number of patients, it is shown that girls and  Important Shows like Germany’s Next
women feel inferior to the thin beauty ideal of Topmodel can influence the development
the media, feel helpless and trapped by the of an eating disorder because they pro-
images. During the course of the illness, they mote an unattainable body image for most
then take guidance from various shows on how women as normal, and encourage constant
to manipulate their weight (Baumann 2009; IZI/ self-optimization.
23 The Influence of Media on Body Image 169
23.3 Social Media recommendations. However, “being healthy and

and BodyDissatisfaction fit” here primarily means “looking healthy and
fit.” Anorexia and Adonis complex are declared
Stereotypical role models of women and a very cultural phenomena, and people who do not
limited image of the female body also domi- conform to this ideal are stigmatized and pathol-
nate in social media. Influencers stage them- ogized. The constant calculation of calorie con-
selves in the same poses over and over again tent in food, e.g., with corresponding tracking
(Götz and Becker 2019). Girls imitate this and, apps, the renunciation of sugar, and excessive
where their physicality is not enough, use digi- physical activity, including daily photograph-
tal filters to smooth hair and skin, lengthen legs, ing and posting of one’s own flat stomach, are
and make the stomach flatter (Götz 2019a, b). promoted. These potentially compulsive behav-
The use of social media can be associated with iors have the potential to accompany women
a change in self-perception and dissatisfaction into depression and eating disorders (Klapp and
with one’s body. Studies on Facebook have fre- Klotter 2019).
quently demonstrated a spontaneous association
between viewing images of thin women and  Important Social media, especially the very
increased criticism of and dissatisfaction with image-oriented sites like Instagram, can
one’s own body (Cohen and Blaszczynski 2015; promote a decrease in satisfaction with one-
Eckler et al. 2017; Frost and Rickwood 2017; self. In particular, “Fitspiration” communi-
Mingoia et al. 2017). Frequent use of social ties pathologize any deviation from the ideal
media increases the likelihood of increased body body, which is unattainable for most people.
dissatisfaction and susceptibility to feedback
from peers in both girls and boys (De Vries et al.
2016). Girls are significantly more affected than 23.4 Social Media and Eating
boys (Hartas 2021). This effect is mitigated, for Disorders
example, by a good relationship with the mother,
but the effect cannot be completely eradicated In a meta-analysis, Holland and Tiggemann con-
(De Vries and Vossen 2019), as the crucial factor cluded that the use of social media (at that time
is probably the extent to which girls and women mostly Facebook) can be associated with disor-
compare themselves with body images they con- dered eating behavior (Holland and Tiggemann
sider attractive (Hogue and Mills 2019). 2016). Girls who regularly post pictures of
In the so-called “highly-visual social media” themselves on social media show a higher
(HVSM) such as Instagram and Snapchat, the internalization of the thin ideal, more often
association between use and body dissatisfac- take measures to control their eating behav-
tion is even more consistent (Marengo et al. ior (McLean et al. 2015), and show more fre-
2018). Increased use of Instagram among young quent bulimic symptoms (Cohen et al. 2018).
women is associated with higher self-objectifi- This is particularly evident in communities
cation, comparison with influencers, and inter- where disordered eating behavior is the focus
nalization of a thin body image (Brown and or where the eating disorder itself is promoted,
Tiggemann 2016; Cohen et al. 2017). Fitness such as the “Pro-ANA” movement (Eikey and
communities are of particular relevance, as the Booth 2017). Websites in the “Fitspiration” and
higher their use, the higher the tendency towards “Thinspiration” areas promote comparing one’s
body dissatisfaction (Fardouly et al. 2018). In own body with the very thin bodies depicted and
“Fitspiration” communities, very thin, fit peo- can thus trigger symptomatic behavior in people
ple present their bodies as ideal and construct with eating disorders (Griffiths et al. 2018).
knowledge about health that initially seems In studies with people undergoing treatment
to correspond to common health and nutrition for eating disorders, it becomes clear that social
170 M. Götz
media fits into the thoughts promoting eating of “Body Positivity.” Posts with hashtags like
disorders. Affected individuals compare them- #BodyPositivity, #healthateverysize, and #fit-
selves online particularly often with others and famGermany criticize the dominant beauty
are more concerned with food, weight, and body ideal and advocate for an evidence-based para-
image (Bachner-Melman et al. 2018). When digm shift in health promotion and more diver-
studies address the subjective perspective of sity in body image (Klapp and Klotter 2019;
women with eating disorders, it becomes clear Cwynar-Horta 2016; Webba et al. 2017). While
that Instagram is currently the preferred plat- the goal of the fitness community is self-optimi-
form. The world of beautiful and perfect images zation, the body positivity community is about
fits particularly well into the disease symptoms. self-love (Klapp and Klotter 2019, p. 364).
The images uploaded by women affected by an Another approach is the promotion of media
eating disorder are primarily body-related, and literacy, a critical examination of formats like
seven out of ten women use digital filters to Germany’s Next Topmodel (Götz and Mendel
improve their images—significantly more than 2016a, 2016b) or the exposure of digital altera-
people without a diagnosed eating disorder. The tions of images on social networks. However,
affected individuals describe, in part, a negative knowing that the images have been altered does
spiral in which they experience themselves as not provide relief on its own. When young peo-
deficient and strive for perfect images, combined ple know that an image has been retouched and
with a self-critical view of their own posts, a idealized, it even increases the spontaneous
special attribution of importance to likes and effect of body dissatisfaction regarding their
comments, and following influencers (Götz et al. own appearance (Harrison and Hefner 2014).
2019; Wunderer et al. 2020). In a study on the “Instagram vs. Reality” cam-
paign, in which influencers published a combi-
 Important The use of social media and espe- nation of their original images and the staged
cially communities like “Pro-ANA” can ac- and digitally altered images, a generally positive
company people into an eating disorder and (but not significant) effect on self-esteem and
promote harmful eating behavior. appreciation of one’s own body was observed.
The surveyed women recognized the idea and
intention behind the campaign (“Nobody is
23.5 What Might Help? perfect,” “The images on Instagram are mostly
fake”), but this does not protect them from being
The one-sided, mostly extremely thin image of unsettled by the idealized images in their own
the female body puts immense pressure on girls body feeling (Tiggemann and Anderberg 2019).
and women and promotes body dissatisfaction. One of the few empirically proven and effec-
Accordingly, there is an urgent need for more tive moderating factors in increased body dis-
diversity in body shapes, a minimum BMI, and satisfaction after using and viewing idealized
breaking the repeatedly postulated claim that a images on social media is knowledge of femi-
slim figure is a prerequisite for happiness and nist content and the need for equality (Feltman
social success. Responsible media professionals and Szymanski 2018). In this respect, there is
avoid discrimination based on weight and deval- much to be said for introducing girls and young
uation and criticism of body weight and individ- women to thoughts and knowledge about gender.
ual body parts, and instead promote engagement
with healthy nutrition (IZI/BFE 2016, p. 158 f.).  Important Promoting critical media literacy,
An important expansion to the dominant feminist knowledge, and the appreciation
thin, athletic, and partly underweight bod- of counter-images like #BodyPositivity can
ies are contributions and websites on the topic help.
23 The Influence of Media on Body Image 171
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Part III
Psychological Comorbidity
173
Affective Disorders
and Anxiety Disorders 24
Jörn von Wietersheim
Contents
24.1 Comorbidity in Mental Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
24.3 Bulimia nervosa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
24.4 Binge Eating Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
24.5 Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
24.6 Summary and Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
24.1 Comorbidity in Mental To investigate comorbidity, different meth-

Disorders odological approaches can be chosen. For
instance, a distinction is made between cross-
In the field of mental disorders, comorbidi- sectional, longitudinal, and family studies.
ties, i.e., the simultaneous presence of sev- Each of these approaches offers advantages
eral mental disorders, are relatively common. and disadvantages. Cross-sectional studies are
Here, the diagnostic criteria of several disor- most commonly used, asking whether differ-
ders apply simultaneously. From the data of the ent disorder patterns are present simultaneously
German Federal Health Survey 1998 (Wittchen or have been present in the past. Longitudinal
and Jacobi 2001), it can be seen that 52% of studies, on the other hand, offer the possibility
diagnosed cases had only one disorder, while of tracking how disorders can also replace each
48% met the criteria for two or more disorders other. In family-related studies, it can be exam-
simultaneously. These relatively high comor- ined to what extent disorders occur more fre-
bidities lead to discussions about the extent to quently in families. It must also be taken into
which the descriptive diagnostic schemes such account which methods are used to determine
as ICD-10/11 or DSM-IV and DSM-5 really the presence of a diagnosis. Often, this is done
capture independent diagnoses. with clinical or semi-standardized interviews;
sometimes, the diagnosis is made only on the
basis of questionnaires filled out by the patients.
J. von Wietersheim (*) Scientifically more accurate are the standardized
Department of Psychosomatic Medicine and interviews (e.g., “Structured Clinical Interview
Psychotherapy, Ulm University Medical Center,
Ulm, Germany
for DSM-5 [SCID]”) for capturing the diagno-
e-mail: [email protected] sis. Furthermore, it must be considered which
https://doi.org/10.1007/978-3-662-67662-2_24
176 J. von Wietersheim
sample was examined. Studies on treatment- dysthymia or persistent depression. Given the
seeking patients or patients in treatment often high rate of depression, the question arises
yield different results than population-based whether these are really separate disorders or
studies. Patients in treatment are usually some- whether, for example, depression can also be
what more severely ill. On the other hand, it is a consequence of malnutrition. On the other
often difficult to conduct population-based stud- hand, depression may also occur before the
ies. Older patients show higher rates of comor- onset of AN symptoms. It is likely that there is
bidity than younger ones. The region in which a complex interaction rather than a one-sided
the studies were conducted may also play a role. causation in one direction or the other. Bipolar
Another problem is the question of a control disorders (manic-depressive disorders) are rather
or comparison group. It would be necessary to rare in patients with AN, with a prevalence of
investigate how often a diagnosis, e.g., depres- less than 10%. Anxiety disorders, however, are
sion, occurs in the general population in order very common in patients with AN. A lifetime
to then examine whether patients with eating comorbidity rate of about 65% is reported, with
disorders have a higher rate of depression than social phobia and obsessive-compulsive disor-
would be expected from the general population. der being the most common conditions. With
The concept of so-called lifetime diagnosisis of improvement of or recovery from ANsymptoms,
particular importance. This means that patients comorbid symptoms often also decrease.
have met the criteria for the diagnosed disorder Table 24.1 shows some studies on comor-
at least once in their life. bidity in AN. These show comorbidities
This chapter focuses on the comorbidities (lifetime) between 40% and 80% with depres-
of eating disorders and obesity with affective sion and between 20% and 60% with anxiety
disorders and anxiety disorders. Affective dis- disorders. Comorbidities with obsessive-com-
orders include, in particular, depression in its pulsive disorders are significantly rarer, but still
various manifestations (depressive episodes, at a generally high level, of up to 20%. Patients
recurrent depressive disorder, dysthymia or with restrictive AN show somewhat fewer
persistent depression). There are also various comorbidities than patients with binge-eating/
forms of anxiety disorders (phobias, general- purging type AN.
ized anxiety disorder, panic disorder). Many
studies have assessed comorbidities in eating
disorders. However, the change from DSM-IV 24.3 Bulimia nervosa
to DSM-5 must be taken into account: The cri-
teria for eating disorders as well as definitions Bulimia nervosa (BN) also shows high comor-
for depressive and anxiety disorders have been bidity rates with affective and anxiety disorders.
changed. As a result, the study results are only The lifetime prevalence of comorbid affec-
partially comparable, and the respective diag- tive disorders in BN is reported to be between
nostic codes used need to be considered. 50–80%. Major depression ranges between 40%
and 60%. In a community-based cross-sectional
study, 38% of patients with BN showed evi-
24.2 Anorexia nervosa dence of at least one depression in their life-
time; this was three times higher than the rate in
Depression (“major depression” according to individuals without a psychiatric diagnosis. In
DSM) is the most common comorbid disorder one study, it was found that in 60% of patients
in patients with anorexia nervosa (AN), with with BN, the affective disorder was already pre-
most studies reporting a mean lifetime comor- sent before the onset of BN, in 34% it followed
bidity of about 50–70%. An additional 35–40% the onset of BN, and in 5% it began simultane-
of patients with AN have a history of milder ously with BN. High rates of comorbid anxiety
depressive episodes (“minor depression”),
24 Affective Disorders and Anxiety Disorders 177
Table 24.1  Comorbidity in anorexia nervosa (lifetime diagnoses)

Study Recruitment N AN Depression Anxiety disorder Obsessive-com-
pulsive disorder
Godart et al. Inpatients and outpatients, 111 44% MD 49% GAD 17%
(2004) restrictive type 31% SP
14% AP
Godart et al. Inpatients and ouptients, 55 49% MD 46% GAD 22%
(2004) binge-eating/purging type 20% AP
Bühren et al. First diagnoses with AN 148 38% MD 7% SP 8%
(2014) 5% DY 1% GAD
2% specific
phobias
Ulfvebrand et al. Eating disorder centers 889 25% MD 28% GAD 7%
(2015) in Sweden, patients with 2% DY 14% SP
restrictive AN, current 13% specific
comorbidity phobias
Ulfvebrand et al. Eating disorder centers in 454 38% MD 35% GAD 8%
(2015) Sweden, patients with bin- 4% DY 17% SP
ge-eating/purging AN, 16% specific
current comorbidity phobias
Udo and Grilo Population sample, survey 276 50% MD 22% GAD n/a
(2019) with SCID for DSM-5 25% DY 21% PD
15% SP
N AN Number of patients with anorexia nervosa, MD Major depression, DY Persistent depression (dysthymia), SP
social phobia, GAD generalized anxiety disorder, AP agoraphobia, PD panic disorder, n/a no information
Table 24.2  Comorbidity in bulimia nervosa (lifetime diagnoses)

Study Recruitment N BN Depression Anxiety disorder OCD
Kaye et al. (2004) Patients from various centers 282 Not recorded 16 % SP 40 %
8 % GAD
Spindler and Milos (2004) Patients seeking treatment 126 53 % MD 50 % (not subdivided) –
Ulfvebrand et al. (2015) Eating disorder centers in 2279 36 % MD 32 % GAD 4%
Sweden, current comorbidity 4 % DY 14 % SP
16 % spec. Phobias
Udo and Grilo (2019) Population sample, assess- 92 77 % MD 26 % GAD n/a
ment with SCID for DSM-5 35 % DY 18 % PD
14 % SP
14 % spec. Phobia
N BN Number of patients with Bulimia nervosa, KG Control group, MD Major depression, DY Persistent Depression
(Dysthymia), SP social phobia, GAD generalized anxiety disorder, PD Panic disorder, n/a no information
disorders are also found in BN, with reported 24.4 Binge Eating Disorder
rates of 40–60%. The most common anxiety dis-
order is generalized anxiety disorder. Table 24.2 Comorbidities are also common in binge-eat-
summarizes some studies on the comorbidity of ing disorder (BED) (Table 24.3). In particular,
BN. In one study, a relatively high rate of obses- comorbidities with major depression (rates of
sive-compulsive disorders was also found. 50–60%) and anxiety disorders (20–50%) are
178 J. von Wietersheim
Table 24.3  Comorbidity in binge eating disorder (lifetime diagnoses)

Study Recruitment N BES Depression Anxiety Disorder OCD
Bulik et al. (2002) Population study, female 59 48% MD 49% –
twins, BMI >30
Grilo et al. (2009) Population study 404 47% MD 37% 3%
7% DY
Wilfley et al. (2000) Patients with BES in treat- 162 58% MD 29 % 1%
ment
Ulfvebrand et al. (2015) Eating disorder centers in 498 33% MD 26% GAD 2%
Sweden, current comorbi- 6% DY 20% SP
dity 22% specific phobias
Udo and Grilo (2019) Population sample, 318 70% MD 33% GAD n/a
assessment with SCID 33% DY 23% PD
for DSM-5 21% SP
24% specific phobia
N BES Number of patients with binge-eating disorder, KG Control group, MD Major depression, DY Persistent
depression (dysthymia), GAS Generalized anxiety disorder, PD Panic disorder, SP Social phobia, n/a no information
found. Obsessive-compulsive disorders hardly BMI, treatment desire). However, more recent
occur. Compared to healthy control subjects, studies have mostly confirmed a positive rela-
patients with BED show significantly higher tionship between overweight or obesity and the
rates of depression and anxiety disorders. prevalence of mental disorders. In these stud-
Overall, the comorbidity rates are similar to ies, affective disorders and anxiety disorders
those of other eating disorders. are most prominent (Herpertz et al. 2006). This
relationship appears to be more pronounced in
 Important The eating disorders anorexia women than in men and increases with increas-
nervosa, bulimia nervosa, and binge eating ing overweight/obesity. Patients with obesity
disorder are associated with approximately seeking treatment for weight loss show signifi-
the same number of comorbidities, primar- cantly higher psychological comorbidity than
ily depression and anxiety disorders. About people with obesity or normal weight in the
50% of patients can be expected to have such general population.
comorbidities.
It remains to be considered whether BN 24.6 Summary and Conclusions

and BED, in particular, could also be seen as
“modern” expressions of depression or anxiety Comorbidities with affective disorders, espe-
disorders. Changed sociocultural factors (spread cially depression, and anxiety disorders are
of media, increased thinness ideal) might have common in patients with eating disorders. In
led to these new psychological manifestations. clinical practice, it can be assumed that more
than half of those affected currently meet or
have previously met the criteria for another
24.5 Obesity mental disorder diagnosis. Depression and anxi-
ety disorders are most likely to be expected.
Obesity is often associated with psychosocial Depending on the current severity of these addi-
stress and problems. Comparisons of people tional symptoms, psychotherapeutic or pharma-
with and without obesity in the general popu- cological treatments should be adjusted. During
lation have led to somewhat different results, treatment, it should be noted that symptoms may
depending on the samples studied (age, gender, change and shift, e.g., eating disorder symptoms
24 Affective Disorders and Anxiety Disorders 179
may decrease, but depressive symptoms may Grilo CM, White MA, Masheb RM (2009) DSM-IV
increase. The discussion of whether the triad of psychiatric disorder comorbidity and its correlates in
binge eating disorder. Int J Eat Disord 42:228–234
eating disorders, depression, and anxiety disor- Herpertz S, Burgmer R, Stang A et al (2006) Prevalence
ders really represent different disorders or are of mental disorders in normal-weight and obese
rather expressions of a common underlying dis- individuals with and without weight loss treatment
order should continue. in an German urban population. J Psychosom Res
61:95–103
Kaye WH, Bulik CM, Thornton L et al (2004)
Comorbidity of anxiety disorders with anorexia and
Conclusion bulimia nervosa. Am J Psychiatry 161:2215–2221
Spindler A, Milos G (2004) Psychiatric comorbidity and
Comorbidities, especially depression and
inpatient treatment history in bulimic subjects. Gen
anxiety disorders, are common in eating dis- Hosp Psychiatry 26:18–23
orders. Depending on the severity, psycho- Udo T, Grilo CM (2019) Psychiatric and medical corre-
therapeutic and pharmacological treatments lates of DSM-5 eating disorders in a nationally rep-
resentative sample of adults in the Unites States. Int J
should be adjusted accordingly.
Ulfvebrand S, Birgegård A, Norring C, Högdahl L, von
Hausswolff-Juhlin Y (2015) Psychiatric comor-
bidity in women and men with eating disorders –
References results from a large clinical database. Psychiatry Res
230:294–299
Bühren K, Schwarte R, Fluck F et al (2014) Comorbid Wilfley DE, Friedmann MA, Dounchis JZ et al (2000)
psychiatric disorders in female adolescents with first- Comorbid psychopathology in binge eating disorder:
onset anorexia nervosa. Eur Eat Disord Rev 22:39–44 relation to eating disorder severity at baseline and fol-
Bulik CM, Sullivan PF, Kendler KS (2002) Medical and lowing treatment. J Consult Clin Psychol 68:641–649
psychiatric morbidity in obese women with and with- Wittchen HU, Jacobi F (2001) Die Versorgungssituation
out binge eating. Int J Eat Disord 32:72–80 psychischer Störungen in Deutschland. Eine kli-
Godart NT, Curt F, Lang F et al (2004) Predictive factors nisch-epidemiologische Abschätzung anhand des
of social disability in anorexic and bulimic patients. Bundes-Gesundheitssurveys. Bundesgesundheitsbl-
Eat Weight Disord 9:249–257 Gesundheitsforsch-Gesundheitsschutz 10:993–1000
Psychological
Comorbidity 25
and Personality
Disorders
Ulrich Schweiger
Contents
25.1 revalence of comorbidity between eating disorders and other mental
P
disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
25.2 Delineation of Differential Diagnosis vs. Comorbidity . . . . . . . . . . . . . . . . . 183
25.3 Mechanisms of Interaction between Eating Disorders and Other Mental
Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184
25.4 Therapy for Comorbid Disorders Including Eating Disorders . . . . . . . . . . 185
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
Mental disorders can be observed as isolated, For example, in the German DEGS1-MH study,
individual disorders, but they can also occur at least one mental disorder was diagnosed in
together with other mental or medical condi- 28% of participants, with 56% having one, 22%
tions (comorbidity). Traditional European clas- having two, 10% having three, 6% having four,
sification systems have attempted to summarize and 7% having five or more disorders (Jacobi
a person’s illness and symptomatology in a main et al. 2014). The majority of severe disorders can
diagnosis, preferably based on etiology. In con- be found among participants with high comorbid-
trast, the descriptive, operationalized criteria- ity (Kessler et al. 1994). This association between
oriented American DSM system allows for a comorbidity and disease severity was also con-
multitude of simultaneous (comorbid) diagnoses firmed in the NCS replication study (Kessler
of mental disorders. et al. 2005). While 22% of individuals with only
one mental disorder were classified as seriously
 Important Comorbid disorders are not rare ill, this figure was 50% for those with three or
exceptions in patients with eating disorders more diagnoses. This finding is consistent with
(Udo and Grilo 2018). the observation that comorbid patients make up
the vast majority of individuals in many treat-
ment centers in the area of inpatient treatment.
Comorbidity has a significant impact on
Ulrich Schweiger is deceased treatment and therapy planning. In general, the
evidence base for therapeutic procedures only
U. Schweiger (*) applies to the populations defined in the respec-
University of Lübeck, Lübeck, Germany tive controlled studies. Both in pharmacothera-
e-mail: [email protected] peutic research and in most psychotherapy
https://doi.org/10.1007/978-3-662-67662-2_25
182 U. Schweiger
studies, comorbid patients are often excluded disorder and a personality disorder. In the tem-
or underrepresented due to the inclusion and poral development, the eating disorder usually
exclusion criteria. Strictly speaking, the conclu- precedes the depressive disorder.
sions from such studies cannot be transferred to
comorbid populations.
25.1.2 Eating Disorders and Anxiety
 Important If psychotherapy X is found to be Disorders
effective in (monomorbid) patients with an
eating disorder in several controlled studies, About 41% of patients with AN, 45% of those
the conclusions about the effectiveness of with BN, and 59% of those with BED have a
this treatment cannot necessarily be extended lifetime diagnosis of one or more anxiety disor-
to patients suffering from an eating disorder ders (Udo and Grilo 2018). Specific prevalences
plus major depression or addiction. are, for generalized anxiety disorder: AN 22%,
BN 26%, and BED 33%; for panic disorder:
The difficulty in finding an evidence base for the AN 21%, BN 18%, and BED 23%; for agora-
treatment of comorbid groups lies in the large phobia: AN 11%, BN 10%, and BED 13%; for
number of possible permutations in the combina- social anxiety disorder: AN 9%, BN 14%, and
tion of mental disorders. In the replication of the BED 23%; for specific phobias: AN 15%, BN
NCS, for example, 19 diagnoses were assessed, 14%, and BED 24%. In the development of
which already represents a significant reduction eating disorders from childhood, adolescence,
of the over 300 possible diagnoses in the DSM. and adulthood, the eating disorder is often pre-
From these 19 diagnoses, 524,288 possible per- ceded by perfectionism, emotion avoidance, and
mutations result, of which 433 were actually anxiety.
observed in the study (Kessler et al. 2005).
25.1.3 Eating Disorders and Obsessive-

25.1 Prevalence of comorbidity Compulsive Disorders
between eating disorders
and other mental disorders About 41% of patients with an eating disorder
have a lifetime diagnosis of obsessive-compul-
25.1.1 Eating Disorders sive disorder (Kaye et al. 2004): AN 35% and
and Depressive Disorders BN 40%. Conversely, about 10% of patients
with obsessive-compulsive disorder suffer from
About 50% of patients with AN, 76% of those an eating disorder. Possible bridges between the
with BN, and 66% of those with BED have a disorders are difficulties in dealing with intru-
lifetime diagnosis of major depressive disorder. sive thoughts from the realm of compulsion
The numbers for chronic depression (persistent (e.g., contamination, catastrophes, symmetry,
depressive disorder, PDD) are also very high: ethical or religious themes) and eating behavior
AN 22%, BN 35%, and BED 33% (Udo and (e.g., weight, nutrition) (Meier et al. 2020).
Grilo 2018). The point prevalence of depres-
sive disorders is higher when acute eating disor-
der symptoms are present. In long-term studies, 25.1.4 Eating Disorders
patients who no longer meet the criteria for an and Posttraumatic Stress
eating disorder also show a lower frequency of Disorder
depressive disorders. The prevalence of comor-
bid depressive disorders is higher in bulimic eat- About 23% of patients with AN, 32% of those
ing disorders and in patients with both an eating with BN, and 32% of those with BED have
a lifetime diagnosis of posttraumatic stress
25 Psychological Comorbidity and Personality Disorders 183
disorder (Udo and Grilo 2018). In particular, have a lifetime diagnosis of a personality disor-
adverse experiences in childhood are associated der (Udo and Grilo 2018). The most common
with all subtypes of eating disorders. The asso- personality disorders are avoidant, obsessive-
ciation between eating disorders and PTSD may compulsive, and borderline personality disor-
be mediated by difficulties in emotion regulation der (BPD). Patients with a personality disorder
(Rijkers et al. 2019). have a significantly increased risk of develop-
ing disturbed eating behavior (Johnson et al.
2006). The intensity of personality disorder
25.1.5 Eating Disorders and Disorders symptoms decreases when there is a remis-
with Psychotropic Substances sion of the eating disorder. The presence of a
personality disorder is associated with a lower
Approximately 60% of patients with AN, 67% likelihood of remission of an eating disorder.
of those with BN, and 68% of those with BED Regarding comorbidity with eating disorders
have a lifetime diagnosis of a disorder related to from the perspective of another mental disorder
psychotropic substances (Udo and Grilo 2018). in the direction of eating disorder, studies have
Alcohol (AN 49%, BN 61%, and BED 52%) mainly reported on BPD. Here, about 54% also
and nicotine (AN 39%, BN 43%, and BED suffer from an eating disorder (Zanarini et al.
40%) are particularly significant, but disorders 2010). While initially, AN, BN, and BED were
with the entire spectrum of legal and illegal similarly common, patients with comorbid BED
substances are also observed. Possible common predominated in the long-term course. Patients
mechanisms lie in the areas of emotion regula- with a Cluster-C personality disorderare also
tion, impulsivity, and difficulties in establishing more likely than chance to suffer from an eating
value-oriented behavior (Claudat et al. 2020). disorder.
Patients with the combination of eating disor-
der and substance abuse also show a higher fre-
quency of other mental disorders on Axis I and 25.1.8 Cluster Analyses of Comorbid
personality disorders. Disorders in Eating Disorders
Cluster analyses in groups of patients with eat-

25.1.6 Eating Disorders and Sexual ing disorders lead to a classification into three
Disorders groups, the largest of which is characterized by
the absence of significant comorbidity. The sec-
There are no studies on comorbidity with sexual ond group can best be characterized by comor-
disorders based on diagnostic interviews. The bidity with a Cluster-C personality disorder. In
available studies are limited to small, clinical this group, there is a moderate level of func-
samples. A majority of underweight patients tional impairment. The particularly severely
with AN, BN, and BED describe a broad spec- ill group can be described by comorbidity with
trum of sexual dysfunctions (Dunkley et al. BPD (Wonderlich et al. 2005; Thompson-
2020). Possible moderating factors exist in the Brenner and Westen 2005).
areas of psychoendocrinology, body satisfaction,
sexual traumatization, and emotion regulation.
25.2 Delineation of Differential
Diagnosis vs. Comorbidity
25.1.7 Eating Disorders and Personality
Disorders In the differential diagnosis of eating disorders,
it should be noted that almost all diagnostic
Approximately 35% of patients with AN, 51% groups of mental disorders can be associated
of those with BN, and 56% of those with BED with changes in eating behavior. In order to
184 U. Schweiger
diagnose an eating disorder, an abnormality in The loss of appetite associated with depres-
eating behavior must be at the center of a men- sive disorders can become independent in a
tal disorder and explain a significant portion specific context through operant learning pro-
of the impairment in psychosocial functioning cesses. Bulimic eating behavior can bring about
caused by a mental disorder, and not be com- a pronounced reduction in anxiety and tension.
pletely derived from the symptoms of the other Restrictive eating behavior can antagonize intru-
disorder. In a typical depressive episode with sive thought content through the resulting atten-
loss of appetite and weight loss, an eating dis- tional focus on food-related topics, leading to
order is not automatically diagnosed. However, a significant reduction in subjective suffering.
if, for example, an intense association between Successful control over eating behavior can also
low weight and emotion regulation is evident become a significant support for self-confidence,
in the affected patient and there was already which has been impaired by other illnesses.
an intense restrictive eating behavior before These short-term favorable effects, which reduce
the depressive episode, both diagnoses must tension and subjective suffering, can lead to neg-
be considered. Depressive disorders can also ative reinforcement of disturbed eating behavior
lead to significant weight gain (atypical depres- in the sense of a learning process.
sion). Dementia syndromes can be associated
with significant weight loss. Cannabis use regu-
larly leads to binge eating. In contrast, the use 25.3.2 Comorbid Disorders as a
of cocaine, amphetamines, or opiates can lead Complication of Eating
to restrictive eating behavior and underweight. Disorders
In schizophrenia, food-related delusions, such
as poisoning delusions, can result in massive Due to the secrecy associated with eating dis-
weight loss. Food-related compulsive actions or orders and the high expenditure of time and
specific phobias can have a significant impact on money, an eating disorder can lead to an
nutrition and body weight. Patients with obses- increase in unpleasant interpersonal experi-
sive-compulsive disorders have a lower average ences, feelings of failure, financial distress, and
body weight than comparison groups. a decline in social support over the long term.
Chronic eating disorders often result in patients
being excluded from the lives of their peers,
25.3 Mechanisms of Interaction leading to deficits in social competence. These,
between Eating Disorders in turn, are important conditions for the develop-
and Other Mental Disorders ment of comorbid mental disorders, particularly
depressive disorders and anxiety disorders.
25.3.1 Comorbid Disorders Furthermore, it is likely that neurochemical
as a Specific Risk Factor mechanisms play an important role in comor-
for Eating Disorders bid disorders . Continuous or intermittent mal-
nutrition, which is characteristic of all forms
Substance-related disorders, depressive disor- of eating disorders, interferes with a variety of
ders, anxiety disorders, or personality disorders neurotransmitter and neuropeptide systems.
can increase the risk of developing an eating Particularly well-described are changes in the
disorder. serotonergic, noradrenergic, and limbic-hypo-
thalamic-pituitary-adrenal (LHPA) systems, the
 Important In particular, substance-related stress hormone, reward, and allocation systems.
disorders or borderline personality disorder In many places in the neuroendocrine system,
can lead to a destabilization of behavioral there is an overlap between systems that regulate
control and thus promote bulimic symptoms. food intake and allocation of metabolic energy
to the brain and various organ functions, and
systems responsible for the regulation of behav- psychosocial impairment, which is reduced by
ior and emotions. indication-specific treatments but remains at an
elevated level compared to non-comorbid popu-
lations. Overall, this results in a significantly
25.3.3 Common Risk Factors for Eating poorer level of psychosocial functioning in
Disorders and Comorbid comorbid populations after therapy. This often
Disorders also leads to greater difficulties in obtaining a
therapy place with a disorder-specific offer.
Changes in the serotonergic system can promote At the level of therapy planning, various
both dysregulation of eating behavior and mood, approaches to deal with the problem of comor-
as well as compulsive or insecure behavior . bidity are conceivable. One obvious possibil-
Similarly, transdiagnostic factors could increase ity is the addition of therapy methods. Patients
the risk for a broad spectrum of mental disor- with an eating disorder and a Cluster-C per-
ders, such as neuroticism, perfectionism, distur- sonality disorder, for example, receive eating
bances in interoception, disturbances in emotion disorder-specific treatment, supplemented by
regulation, emotional instability, emotion avoid- training in interpersonal skills or a specific pro-
ance, difficulties in delaying reward, limited gram for treating social phobia. An alternative
social cognitive skills, including mentalization, is to focus on a strategically important common
and limited metacognitive skills. In this spec- risk factor. In this case, overcoming perfec-
trum model, it is assumed that various mental tionism or acquiring emotion regulation skills
disorders represent expressions of quantitative could be at the center of therapeutic efforts. To
variations with identical etiology and pathophys- prioritize therapy goals, there is the pragmatic
iology (pathoplasty). The model is supported by consideration that behaviors that endanger ther-
findings that when exploring the factor structure apy, hinder learning processes, or jeopardize
of a spectrum of mental disorders, the assump- the implementation of other therapy elements
tion of a general factor of psychopathology should be addressed first. For example, a comor-
(p-factor) is a plausible solution (Rosenstrom bid dependence on benzodiazepines would be
et al. 2019). However, there is no consensus on given high priority, as this group of substances
the exact nature of this factor. is capable of significantly slowing down learn-
ing processes.
 Important Various genetic or psychological
variables can represent common risk factors
for the development of both eating disorders 25.4.1 Treatment for Eating Disorders
and comorbid disorders. and Depressive Disorder
The depressive disorder often decisively justi-

25.4 Therapy for Comorbid fies the therapy motivation. Clinical experience
Disorders Including Eating shows that overcoming depressive symptoms
Disorders without normalizing eating behavior is unlikely.
Learning processes as the basis of cognitive-
So far, only a small number of studies have behavioral interventions and psychopharmaco-
systematically considered the influence of logical interventions with antidepressants are
comorbidity on the therapy process in eating potentially disrupted by a malnutrition situation.
disorders. Comorbid disorders do not seem to The pronounced focus of attention on food and
systematically influence the extent of symptom malnutrition-related neurochemical changes
reduction in indication-specific eating disorder can be cited as explanations for this block-
treatment. However, comorbid patients show an ing of the therapeutic effect. Interventions for
increased extent of general symptom burden and patients with the combination of eating disorder
186 U. Schweiger
and depressive disorder should always combine psychoeducation, additional elements of cogni-
interventions to normalize eating behavior with tive therapy and exposure tailored to the obses-
other antidepressant strategies. sive-compulsive disorder, and interventions that
can improve dealing with perfectionism are
required (Shafran et al. 2002). In the treatment
25.4.2 Treatment for Eating Disorders of patients with eating disorders and PTSD, a
and Cluster-C Personality method of eating disorder treatment is usually
Disorder offered first, followed by a specific method for
treating PTSD. It should be noted that relin-
Many treatment programs include elements that quishing problematic eating behavior can ini-
target perfectionism, interpersonal skills, and tially lead to a worsening of PTSD symptoms,
emotion regulation, thus addressing transdiag- e.g., in the form of intrusions. Conversely, prob-
nostic mechanisms between eating disorders and lematic eating behavior can weaken the effec-
Cluster-C personality disorder. tiveness of the exposure components of PTSD
treatment.
25.4.3 Treatment for Eating Disorders

and Cluster-B Personality 25.4.5 Eating Disorders and Disorders
Disorder with Psychotropic Substances
This group represents a particular problem Abstinence from substance use is an essential
group, as they fit poorly into programs that are prerequisite for the effectiveness of psychothera-
predominantly geared towards the needs of peutic interventions and for improving behavio-
patients with eating disorders and Cluster-C per- ral control in patients with eating disorders. Due
sonality disorders. Initial treatment approaches to its effectiveness in both eating disorders and
for this patient group use a combination of ele- substance use disorders, the use of dialectical
ments from dialectical behavior therapy(DBT) behavior therapy has been suggested for this tar-
and elements from classical approaches to disor- get group (Claudat et al. 2020). In cases of high
der-specific treatment of eating disorders. severity of the addictive disorder, abstinence-
oriented therapy in a specialized clinic may be
necessary as a first measure. Otherwise, it is rec-
25.4.4 Treatment for Eating Disorders, ommended to integrate substance abuse-focused
Anxiety Disorders, Obsessive- interventions into outpatient or inpatient eating
Compulsive Disorder, and PTSD disorder treatment.
For the treatment of comorbid panic disor-

der with agoraphobia, social phobia, and spe- 25.4.6 Eating Disorders and Sexual
cific phobias, similar principles apply to those Disorders
already described for the comorbid Cluster-C
personality disorder. The focus is on the addi- Systematic studies are not available. Case stud-
tional use of exposure techniques and the train- ies describe pronounced difficulties in imple-
ing of emotion regulation and interpersonal menting classical sexual therapeutic concepts in
skills. The combination of an eating disorder the target group of women with eating disorders.
with an obsessive-compulsive disorder repre- Normalization of weight leads to an increase in
sents a particular problem situation. Specific sexual drive.
References comorbidity of 12-month DSM-IV disorders in the

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Non-Suicidal Self-Injury
and Eating Disorders 26
Paul Plener
Contents
26.1 NSSI: An Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
26.2 Associations Between NSSI and Eating Disorders . . . . . . . . . . . . . . . . . . . . 190
26.3 Therapy for NSSI and Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
When considering the subject areas of 26.1 NSSI: An Overview

Nonsuicidal Self-injury (NSSI) and eat-
ing disorders, it is noticeable that both NSSI is defined as self-inflicted, direct damage
disorders usually begin in adolescence, are to body tissue that is undertaken without sui-
more frequently found in female patients, cidal intent. This includes socially unacceptable
and also have in common that there is body tissue damage. Tattoos, piercings, dermal
damage to the body that is consciously anchors, or other forms of body modification,
sought or at least willingly accepted. are excluded from this definition (Plener et al.
While this book extensively addresses var- 2018). NSSI is not found as a disease entity
ious aspects of eating disorders, this chap- in the ICD-10, ICD-11, or DSM-5. However,
ter will primarily focus on the connections the DSM-5, Section 3 (the “conditions for fur-
to NSSI, so that a brief overview of NSSI ther study”) provides a definition describing an
will be provided first, before the connec- NSSI syndrome. It also stipulates that a certain
tions to eating disorders and therapeutic frequency (on five or more days within the last
interventions are discussed in more detail twelve months) must be present to reach the
in a second step. NSSI syndrome (APA 2013).
Adolescents usually begin to injure them-
selves at around the age of 13, with a peak fre-
quency at 15-16 years, and a decrease can be
described as they enter young adulthood (Plener
et al. 2015). In a recent meta-analysis, the life-
P. Plener (*) time prevalence of NSSI in adolescents was
Department of Child and Adolescent Psychiatry, reported to lie at about 23%, based on over
Medical University of Vienna, Vienna, Austria 200 studies conducted worldwide (Gillies et al.
https://doi.org/10.1007/978-3-662-67662-2_26
190 P. Plener
2018). It was found that self-injurious behavior study of 118 participants showed that two-thirds
is more common in girls than in boys. It was of people with NSSI had exhibited at least one
also shown that the prevalence has increased disturbed eating behavior within the last week,
since the 1990s (Gillies et al. 2018). Looking with the most frequent behaviors being at least
at the situation in Germany, studies in school weekly binge eating or fasting (each 57.6%)
populations among adolescents have reported a (Yiu et al. 2014). In a British longitudinal study,
lifetime prevalence between 25 and 35%, which it was shown that NSSI two or more times at the
clearly shows that Germany is also one of the age of 14 was a strong predictor for the devel-
nations with the highest prevalence rates within opment of an eating disorder at the age of 17
Europe (for an overview see Plener et al. 2018). (Wilkinson et al. 2018). Regarding the sever-
In terms of the functionality of and motives ity of NSSI and eating disorders, it was shown
for NSSI, the literature points to both intraper- that an increase in the frequency of NSSI was
sonal and interpersonal functions of NSSI (Nock also associated with a greater severity of the eat-
2010). The main motive for NSSI found in most ing disorder. It was also found that an increase
studies is an emotion regulation function in the in eating disorder symptoms led to a worsening
sense that negative affect can be controlled by of NSSI symptoms, with this relationship being
NSSI. A function in the sense of self-punish- moderated by the presence of emotional dys-
ment is also frequently mentioned in studies on regulation. An analysis by Muehlenkamp et al.
NSSI motives. In addition, there are interper- (2011) of 422 young adult women treated for an
sonal functions that can influence the mainte- eating disorder found an association between
nance or initiation of NSSI (Taylor et al. 2018). traumatic experiences in childhood and NSSI.
In this context, NSSI can serve to set a social This connection was mediated by lower self-
signal and communicate a negative emotional esteem, increased levels of psychopathologi-
state through the injury. It can also help secure cal abnormalities, and dissociative phenomena.
attention or recognition in some peer groups. In An association also emerged between reduced
this case, intra- and interpersonal motives do not self-esteem due to traumatic events and body
exclude each other, but often, an interpersonal dissatisfaction, which also influenced NSSI
conflict situation triggers an aversive emotional (Muehlenkamp et al. 2011). In a study of 93
state that can then be controlled by NSSI. NSSI patients with AN, BN, and other eating dis-
thus serves as a (dysfunctional) coping strategy orders who had a history of NSSI or suicide
in the sense of emotion regulation. attempts, the factor of increased impulsivity
was particularly associated with NSSI in the
context of eating disorders (Sagiv and Gvion
26.2 Associations Between NSSI 2020). Higher anxiety traits were also found in
and Eating Disorders those eating disorder patients who had NSSI
(Giner-Bartolome et al. 2017). In another study
When examining the question of an associa- of a large clinical population (N = 648), patients
tion between NSSI and eating disorders, a high with a combination of NSSI and eating disor-
comorbidity with NSSI was found in patients ders exhibited higher emotional reactivity than
who had suffered from an eating disorder. In patients with an eating disorder without accom-
the meta-analysis by Cucchi and colleagues panying NSSI. Among those patients with eat-
(2016), 27.3% of patients with an eating dis- ing disorders, higher emotional reactivity and
order were described as having NSSI, with more frequent NSSI were found especially in
a higher percentage of NSSI among those patients with BN compared to patients with AN
with BN (32.7%) than among those with AN (Smith et al. 2017). In terms of the association
(21.8%), and patients with binge eating dis- with suicidal behavior, a study of approximately
order (BED) lying in between. Looking at the 500 college students clearly demonstrated that
prevalence rates from the perspective of NSSI, a those students who had a combination of NSSI
26 Non-Suicidal Self-Injury and Eating Disorders 191
and suicidal thoughts were more affected by perfectionism, or increased impulsivity. These
eating disorder pathology than those who only interact with predisposing social factors such as
had NSSI (Eichen et al. 2016). Overall, it can cultural influences (unrealistic body stereotypes
be summarized that the relationship between or self-objectification) or the family environ-
NSSI and eating disorders is likely to be bidirec- ment (high levels of control and criticism with
tional (for an overview, see Kiekens and Claes low family connectedness and low emotional
2020), with the assumption that risk factors may support). Traumatic events, such as abuse, mis-
overlap. treatment, or bullying, also seem to play a role
When examining the co-occurrence of in the genesis of both NSSI and eating disorders
NSSI and eating disorders, the question arises (Claes and Muehlenkamp 2014).
as to whether there is a common etiology that Proximal risk factors may include emotional
assumes different forms at the symptom level. dysregulation, cognitive distortions (such as
Claes and Muehlenkamp proposed a risk factor low self-esteem or strong self-criticism), low
model in 2014 (Fig. 26.1). The model consid- acceptance of one’s body, dissociative phe-
ers whether common proximal and distal risk nomena, the influence of peers, and psychiat-
factors play a role, which can then lead to the ric disorders. When stressful life events occur,
onset and maintenance of both NSSI and eating NSSI or eating disorder symptoms are activated
disorders. as a (dysfunctional) way to cope with these
Distal risk factors encompass individual-spe- events. This strategy must also be understood
cific factors, such as temperament and person- in terms of an interaction, insofar as the trig-
ality traits, including high emotional reactivity, gering proximal factors can be maintained by
a reduced ability to tolerate negative affective the chosen “problem-solving” approach (Claes
states, as well as compulsive personality traits, and Muehlenkamp 2014). This perspective is
Distal factors Proximal factors Thoughts & Behavior
Individual
Predisposing
Factors Specific risk
factors
Temperament
Emotional dysregulation
Personality
cognitive distortions Onset and
maintenance
Stressful
of NSSI &
Lower body-esteem life events
Eating
Social Disorder
Predisposing dissociation
Factors
Peer influence/
Family environment contagion
Traumatic experiences Psychiatric disorders
cultural pressures
Fig. 26.1  Model of the development of NSSI and eating disorders. (Modified from Claes and Muehlenkamp 2014)
192 P. Plener
particularly interesting in light of the findings be understood how a high comorbidity of NSSI
from the Benefits and Barriers model by Hooley and eating disorder behavior can develop under
and Franklin (2018). Here, specifically for similar risk conditions and with comparable
NSSI, a negative self-association is also placed functionality in controlling intrapersonal and
at the focus of the genesis of NSSV, which can interpersonal stressors. In both disorder patterns,
be understood as overlapping with the model by insufficient emotion regulation against the back-
Claes and Muehlenkamp (2014). NSSI (as well ground of a negative self-association plays a sig-
as eating disorders) thus becomes a compensa- nificant role.
tory mechanism that serves to maintain the indi- Moving away from the common genesis
vidual under stress. towards possible long-term consequences, the
A possible overlap in the functions of NSSI question remains to what extent NSSI and eating
and eating disorders was also investigated by disorders can have common “end stages.” Both
Muehlenkamp et al. (2019) in 676 adult patients behavioral disorders show increased rates of sui-
(about half of whom had either NSSI or an cidality. Furthermore, Kiekens and Claes (2020)
eating disorder). While a general overlap in pointed out that both NSSI and the presence
motives was shown, a further examination also of an eating disorder represent a risk factor for
revealed differences in the subjective salience of future additional mental illnesses. Associations
individual functions for the respective behaviors. can be found with impaired family functioning,
Affect regulation, anti-dissociative effects, com- reduced emotion regulation ability, identity dis-
munication of stress, and interpersonal influ- orders, lower self-esteem, lower quality of life,
ence were identified as functions with higher stigma, and academic problems (Kiekens and
relevance for NSSI. Among the functions with Claes 2020).
higher relevance for eating disorders were inter-
personal boundary setting, peer belonging, and
autonomy. The function of self-punishment was 26.3 Therapy for NSSI and Eating
equally relevant for both NSSI and eating disor- Disorders
ders (Muehlenkamp et al. 2019).
Research on the triggering condi- When dealing with therapeutic dimensions in
tions of NSSI and eating disorder behavior, NSSI, it can be noted that there is now good evi-
which in recent years has increasingly employed dence for various psychotherapeutic methods in
ecological momentary assessment (EMA) para- reducing NSSI (Kothgassner et al. 2020). In this
digms, demonstrates the functionality of NSSI context, particular attention should be paid to
and eating disorder behavior in everyday life. the effectiveness of cognitive behavioral therapy
This involves the regulation of intrapersonal (CBT), dialectical behavior therapy for adoles-
difficulties (especially the reduction of nega- cents (DBT-A), and mentalization-based therapy
tive affect) as well as the regulation of interper- for adolescents (MBT-A). Kiekens and Claes
sonal difficulties in daily life (Kiekens and Claes (2020) pointed to the effectiveness of CBT and
2020). In a diary study with young adults, it was family-based therapy (FBT) in the psychothera-
shown that NSSI usually followed a feeling of peutic treatment of eating disorders. This raises
rejection or interpersonal conflicts. Binge-eating the question of what a therapeutic approach for
episodes were more common after watching tel- comorbid NSSI and eating disorders might look
evision or experiencing feelings of self-hatred. like. So far, there are no good data for such an
On days when NSSI was performed, there was assessment, as therapy studies have focused
a significantly worse mood in the evening, espe- either on NSSI or on eating disorders as the final
cially compared to days when dieting was prac- outcome.
ticed (Turner et al. 2016). In relation to the joint For adults, Marino et al. (2020) proposed
model of Claes and Muehlenkamp (2014), it can a decision-making model, according to which
26 Non-Suicidal Self-Injury and Eating Disorders 193
dialectical behavior therapy appears to be indi- In the context of the joint treatment of eating
cated when a personality disorder is in the fore- disorders and NSSI, a new development in the
ground. This is understandable in the context of field of online therapy should also be mentioned.
treating underlying personality traits that per- In an initial pilot study, Bjureberg et al. (2018)
manently influence eating disorder dynamics. demonstrated that the application of an online
In addition to the good effectiveness of DBT in version of “Emotion Regulation Individual
treating NSSV, there are also modifications of Therapy for Adolescents” (ERITA) led to a
DBT for treating eating disorders, and it seems reduction in NSSV, while at the same time
possible to address both disorder areas well reducing accompanying self-harm symptoms
within the concept of a DBT treatment (Walsh (in the form of binge-eating behavior). This is
and Eaton 2014). particularly relevant in the context of resource
In clinical practice, situations will often arise allocation and overcoming barriers to accessing
where prioritization based on clinical urgency psychotherapeutic help for adolescents. As noted
is necessary, and the treatment focus must be by Kiekens and Claes (2020), DBT is indeed
set accordingly. In cases of severe starvation, considered effective, but is often not widely
which severely impair physical health and may available and requires significant resources. The
even lead to a threat to life, these must be treated further development of online therapy formats
as a priority. In these cases, it will be appropri- could occupy a place in the sense of a stepped-
ate to focus primarily on the immediate treat- care approach and offer a resource-saving and—
ment of the eating disorder and ensure adequate due to the low threshold for access, especially
food intake and physical stabilization. Once the for adolescents—an interesting therapeutic
immediate danger, such as food deprivation, option.
subsides, the focus should then shift to other
self-harm behaviors (such as NSSI). If NSSI Conclusion
and suicidality are the primary acute methods
of self-harm, this behavior should be at the fore- Both NSSI and eating disorders involve harm
front. This is also in line with the idea of a hier- to the body, and overlapping mechanisms are
archy of treatment goals in DBT. often reported in the literature on risk factors.
In therapeutic work, overlapping underlying In light of this consideration, both eating dis-
mechanisms that ultimately manifest in eating order symptoms and NSSI can be understood
disorder symptoms or NSSI will often be iden- as attempts at (dysfunctional) coping with
tified at this point. Recognizing these parallels stressful events, which are often based on a
can also be important in order to proactively longer-lasting history of distal and proximal
address potential symptom shifts. This point is risk factors. Due to the similar conditions
also emphasized by Peats (2014) regarding the of origin, it is also understandable why the
combined psychotherapeutic intervention for emphasis in joint therapeutic approaches is
eating disorders and NSSI using CBT. As in the on acquiring emotional regulation skills and
specific treatment of NSSI and eating disorders, identifying and addressing dysfunctional cog-
the goal is to identify cognitive distortions and nitions. Particularly in the field of CBT and
work with them. In addition, alternative behav- DBT, existing approaches to treating NSSI
ioral strategies must be developed. Peats (2014) or eating disorders seem to complement each
also emphasizes that the two problem areas must other well. Given the increased prevalence of
be considered as interconnected. Here, the focus NSSI and eating disorders in the adolescent
is primarily on the need to identify automatic age group, special attention should be paid to
assumptions that influence negative affect and the expansion of (online) therapy options with
resulting maladaptive behaviors. low-threshold access.
194 P. Plener
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Mechanisms of Addiction
in Eating and Weight 27
Disorders
Sabine Steins-Loeber and Georgios Paslakis
Contents
27.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
27.2 Models of the Development and Maintenance of Dependent Behavior . . . 196
27.3 Mechanisms of Dependent Behaviorin Eating and Weight Disorders . . . . 196
27.4 The Concept of “Food Addiction” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198
27.5 Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
27.6 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
27.1 Introduction with alcohol use disorders in studies (Bahji

et al. 2019). Much of the research focuses on the
Eating and weight disorders are associated with comorbidity of clinically diagnosed substance
a variety of comorbid disorders (Chaps. 24–26 use disorders and eating and weight disorders.
in this book). There is clear evidence of an asso- However, symptom-level investigations provide
ciation between overweight or obesity, eating important insights. For example, several stud-
disorders, and alcohol use disorder. In particu- ies showed a negative relationship between the
lar, binge eating disorder (BED) and bulimia frequency of drinking alcohol and BMI, but a
nervosa (BN), i.e., those eating disorders asso- positive relationship between the intensity of
ciated with binge eating, seem to be associated consumption (“binge drinking”) and BMI. The
with alcohol consumption, while anorexia ner- results of these studies suggest that the comor-
vosa (AN) is not or to a lesser extent associated bidities between eating and weight disorders and
substance use disorders observed at the diagnos-
tic level could be due to pathological behavioral
patterns based on similar mechanisms and being
S. Steins-Loeber (*)
Department of Clinical Psychology and attributable to similar underlying vulnerability
Psychotherapy, Otto-Friedrich-University of factors. Against this background, this chapter
Bamberg, Bamberg, Germany aims to provide an overview of the current state
e-mail: [email protected] of research on the importance of mechanisms of
G. Paslakis addictive behavior in the development of eating
University Clinic for Psychosomatic Medicine and and weight disorders. Furthermore, the concept
Psychotherapy, Medical Faculty, Campus East-
Westphalia, Ruhr-University Bochum, Lübbecke, of “food addiction” will be addressed. Finally,
Germany treatment options will be discussed.
https://doi.org/10.1007/978-3-662-67662-2_27
196 S. Steins-Loeber and G. Paslakis
27.2 Models of the Development leads to an increased instrumental response to

and Maintenance obtain a nicotine- or alcohol-associated reward,
of Dependent Behavior a so-called PIT effect. Similar effects are also
found in relation to gaming or internet shopping
Based on studies in animal models, neuro- applications (V. Vogel et al. 2018).
biological explanatory approaches postulate a
subcortical sensitization of dopaminergic neuro-  Important In addiction development, auto-
transmission in the mesolimbic reward system. mated behavioral responses triggered by con-
This sensitization leads to this system becom- ditioned stimuli, along with the inability to
ing hypersensitive to reward-associated stimuli, inhibit these responses may play an important
such as alcohol and alcohol-associated stimuli. role.
Through processes of classical conditioning,
substance-associated stimuli appear particularly
salient (“rewarding”), and affected individuals 27.3 Mechanisms of Dependent
show changes in mesolimbic-mesocortical sys- Behaviorin Eating and Weight
tems when confronted with addiction-associated Disorders
stimuli (e.g., images of alcoholic beverages,
images from online games, shopping-associated A number of empirical studies have used para-
stimuli). It has been shown that these changes digms from addiction research to investigate
are associated with reported craving and relapse whether similar mechanisms are important in
frequency (B. Vogel et al. 2019; Vollstädt-Klein the development and maintenance of eating
et al. 2012). and weight disorders. These are experimental
Of great importance for the maintenance of paradigms that can be used to investigate pro-
dependent behavior are also impairments of cesses of reward processing and cognitive con-
those cognitive functions that enable self-reg- trol and regulatory functions. In our own work,
ulated and goal-directed behavior and override for example, we have dealt with the salience of
automatic reactions. In the course of addiction alcohol-associated and food-associated stimuli
development, there is a transition from volun- and the impairment of cognitive control and
tary pleasure-driven habits to highly automated, regulatory functions in alcohol use disorder,
habitual, and compulsive behaviors character- obesity, and BED. It was found that subjects
ized by a loss of control. These cognitive control with obesity showed comparable activation pat-
processes include, for example, the regulation terns in the mesolimbic-mesocortical system
of attention, the weighing of action alternatives, when presented with food-associated stimuli
or the inhibition of inappropriate (unfavora- as alcohol-dependent patients when presented
ble) behavioral responses. Deficits in inhibition with alcohol-associated stimuli (Grosshans
ability when confronted with addiction-asso- et al. 2012). In subjects with obesity, a posi-
ciated stimuli are a central predictor of relapse tive correlation between the level of neural
frequency in alcohol-dependent patients after activation, the plasma concentration of the
qualified withdrawal treatment (Czapla et al. appetite-regulating hormone leptin, and BMI
2016). Furthermore, both substance-related and was also demonstrated. These results suggest
non-substance-related addictions have been that, in addition to the salience of food stimuli
shown to influence instrumental addiction- in the control of food intake, homeostatic con-
associated behavior when confronted with control circuits also seem to play an important role.
ditioned addiction-associated stimuli using the Patients with obesity and BED show deficits in
Pavlovian-to-Instrumental-Transfer (PIT) para- inhibition when presented with food-associated
digm. For example, the experimental presenta- stimuli (Kollei et al. 2018). This illustrates that
tion of a nicotine- or alcohol-associated stimulus there is an interaction between the salience
27 Mechanisms of Addiction in Eating and Weight Disorders 197
of food-associated stimuli and self-regulation particularly in the ventral striatum, during self-
abilities. There also seems to be an association related processing of images of underweight
between the plasma concentration responses of bodies compared to normal-weight bodies; the
leptin after a glucose tolerance test and deficits opposite pattern was found in healthy partici-
in inhibitory ability when presented with food- pants. In both EEG and eye-tracking studies,
associated stimuli; however, no differences were as well as studies in which the blink reflex was
found between women with a diagnosis of recorded as a measure of appetitive valence,
AN, BN, or BED and healthy control subjects women with AN showed an attentional bias
(Wollenhaupt et al. 2019). Regarding a pre- for images of underweight female bodies and
ferred attentional reaction (so-called attentional images of physical activity, or a positive pro-
bias) when presented with images of high-cal- cessing of underweight bodies or physical
orie foods, a parallel can be observed between activity. Accordingly, O’Hara and colleagues
patients with BN and BED and the attentional (O’Hara et al. 2015) postulate a “reward-cen-
bias towards alcohol images in alcohol-depend- tered” model of AN, which assumes that food-
ent patients. associated stimuli are experienced as aversive,
Recently, initial review articles have been while disorder-compatible stimuli (such as
published arguing that mechanisms of depend- underweight body images, physical activity) are
ent behavior may also be important in the devel- processed positively and activate the mesolim-
opment and maintenance of AN. So far, the bic reward system. As a result, restrictive eat-
majority of studies on the mesolimbic reward ing behavior and disorder-compatible behaviors
system in AN have largely focused on disor- (e.g., fasting, physical activity, frequent weigh-
der-independent, generally rewarding stimuli, ing, etc.) may more easily acquire the character
such as winning money or being presented with of automatic habitual behaviors and contribute
tasty foods (see also the corresponding Chap. to the maintenance of the disorder. Comparable
30 in this book). Imaging studies in this con- to addiction disorders, there would thus be a
text point to an aversive-anxious processing transition from goal-directed to automated habit-
of high-calorie foods and an increased activa- ual behaviors in response to confrontation with
tion in brain regions associated with inhibitory disorder-compatible stimuli.
control. In women with AN, an avoidance bias
regarding food and overweight bodies can also  Important In a series of studies, clear paral-
be observed (Paslakis et al. 2016). Thus, “con- lels were demonstrated between eating and
ventional” and “disorder-incompatible” reward weight disorders and addiction disorders.
stimuli may not sufficiently address the reward These particularly concern stimulus-depend-
system of patients. ent appetitive reactions and impairments of
In the current discussion regarding the devel- cognitive control and regulatory functions.
opment and maintenance of AN, the hypoth-
esis is also put forward that disorder-compatible Despite the parallels shown between addiction
stimuli (e.g., images of underweight female bod- disorders and eating and weight disorders, it
ies, images of physical activity) are processed is also necessary to explicitly point out differ-
appetitively, leading to a sensitization of the ences between these two groups of disorders.
reward system that maintains problematic These include, for example, personality traits
behavior patterns. For instance, when female (pathological perfectionism, anxious-compul-
participants were instructed to imagine that their sive traits, increased rigidity and over-control
own body corresponded to a presented body vs. increased impulsivity, risk-taking behav-
(either underweight or normal weight) and then ior, “novelty seeking”) and the socio-economic
report on their feelings, women with AN showed conditioning framework (e.g., prevailing soci-
stronger activations in reward system structures, etal thinness ideal vs. negative perception of
substance use). The relationship is further com- Whether a specific type of food can be
plicated by the fact that eating is essential for “addictive” is not conclusively proven. Animal
life and is controlled by a network of homeo- studies have shown that a high sugar or fat con-
static mechanisms, separate from the dopa- tent in food or the highly palatable combination
minergic reward system. Finally, psychotropic of high sugar and fat content is associated with
substances activate the dopaminergic reward reduced dopamine receptor function and that
system much more strongly than natural rein- withdrawal from sugar in animal experiments
forcers such as food. However, it should also be leads to increased anxiety. Such results shaped
considered that similar mechanisms are at work the concept of “sugar addiction”. Human stud-
in behavioral addictions as in substance-related ies provided evidence more for the combination
dependence. This leads to the currently unre- of high fat content and processed sugar as an
solved question of whether addiction aspects in addiction-promoting factor in food - compared
eating and weight disorders correspond more to to sugar as a single component (Markus et al.
a substance-related or a substance-independent 2017). Crucial in the animal studies was that the
(behavioral) addiction. experimental manipulation of the food compo-
sition only led to addiction-like patterns in the
animals in conjunction with variations in avail-
27.4 The Concept of “Food ability. It was therefore the intermittent avail-
Addiction” ability of food that served as a factor for the
development of compulsive eating - rather than a
The concept of “Food Addiction” (FA) was genuinely addictive property of sugar. This was
originally used as an explanatory approach for also supported by findings in rats that constant
obesity. This was based on studies that showed access to highly palatable food did not lead to
reduced striatal dopamine receptor activity in activation patterns in the dorsolateral striatum,
obesity, similar to observations in substance- in contrast to rats that received the same food
related addiction disorders. However, stud- under intermittent conditions (Furlong et al.
ies have often failed to replicate this finding. 2014). Such prerequisites for the development of
As described in the previous section, there are food addiction are not found in today’s humans
clinical-phenomenological similarities between mostly due to the present-day unrestricted avail-
eating or the tendency to overeat and addic- ability of food.
tion disorders. Patients often report phenomena Of course, it is true that both addictive sub-
such as craving for certain types of food, diffi- stances and energy-rich, highly palatable food
culties in limiting food intake (loss of control), are associated with increased activity in the
or continuing to eat/overeat even though their striatum in both animals and humans. Similarly,
health condition would not actually allow it. weight gain is associated with altered striatal
Occasionally, there are reports that patients react activation in response to the consumption of
nervously or even in an anxious-depressed man- highly palatable food or even just stimuli that
ner if they do not consume certain types of food predict the availability of such food. Other
(as if they were going through “withdrawal”) - brain regions involved in the pathomechanisms
or conversely, that patients use food to regulate of addiction (prefrontal cortex, amygdala) also
themselves emotionally, and also that they con- show changes regarding the consumption of
stantly need to eat more to achieve such effects highly palatable food and in obesity. Ultimately,
(which could be considered a manifestation of however, these phenomena are not specific to
“tolerance”). For all of these aspects, which addiction disorders. To account for the possibil-
point to symptoms of dependence on food, ity of addictive eating behavior despite the lack
there is already a series of empirical findings in of clear evidence for the presence of an addic-
humans. tion-causing food component, some authors
have suggested the term “eating addiction” disorder-inherent appetitive reactions or to

(instead of “food addiction”). convert approach reactions to salient stimuli
The Yale Food Addiction Scale (YFAS) was into preferred avoidance reactions (“avoidance
developed to assess FA, and has now also been bias”). Originally developed as an add-on train-
developed and evaluated based on the DSM-5 ing in the standard treatment of patients with
criteria for addiction. While studies found that alcohol use disorder, with positive results in
up to 88% of participants with FA had obesity reducing drinking amounts and relapse rates,
(Pedram et al. 2013), FA is by no means spe- such training has also been successfully used
cific to obesity. Among people with overweight/ in other substance use disorders (e.g., nicotine,
obesity, 24.9% show symptoms of FA; this cannabis) and eating disorders (Loijen et al.
is also the case for 11.1% of healthy individu- 2020). Nevertheless, these are essentially experi-
als (Pursey et al. 2014). Further studies showed mental studies, the methodology of which has
overlaps between FA and BN, FA and BED, and often been questioned (small case numbers, lack
FA and OSFED (Jiménez-Murcia et al. 2019). of or inadequate control groups, etc.) and whose
Although the clinical phenotype of binge eating effectiveness requires further evidence.
and FA shows overlaps, they are still two sepa- Research is also concerned with targeting
rate entities. specific brain regions using novel interventions
In summary, it can be stated that the construct such as real-time fMRI-guided neurofeedback,
of FA is not definitively established. There are transcranial magnetic stimulation (TMS), and
arguments both for and against the adoption of transcranial direct current stimulation (tDCS),
this construct, with the overall arguments for Chap. 32 in this book. As described in detail
its adoption seeming to outweigh those against. in the previous section, both in AN, BN, and
It seems clear that FA and obesity or a clinical BED as well as in obesity and addiction disor-
phenotype characterized by binge eating (e.g., ders, two systems in the brain seem to be essen-
in the context of BED) represent separate con- tially involved; on the one hand, the system that
cepts, the specific etiologies of which have yet causes hypersensitivity to salient/rewarding
to be clarified. Thus, FA remains an exciting and stimuli (e.g., ventral striatum, amygdala, anterior
steadily growing field of research. insular region, ventromedial prefrontal cortex
including orbitofrontal cortex), and on the other
hand, the system that ensures sufficient cogni-
27.5 Therapy tive control over food or addictive substances
(e.g., anterior cingulate, lateral prefrontal cortex
Based on the demonstrated importance of mech- including dorsolateral prefrontal cortex) (Val-
anism-dependent behavior in eating and weight Laillet et al. 2015). Some studies have shown
disorders and the concept of “food addiction,” positive effects of TMS on bulimic and anorec-
the relevance of other and new treatment con- tic psychopathology through treatment proto-
cepts for eating and weight disorders is increas- cols targeting the dorsolateral prefrontal cortex.
ing. Conventional treatments such as cognitive Invasive methods, such as deep brain stimulation
behavioral therapy may not adequately address (DBS) in reward-relevant brain regions (such as
highly automated processes, which are asso- the nucleus accumbens), have also been success-
ciated with the desire for food and associated fully applied in patients with AN. Despite some
dysfunctional behavioral responses, especially negative study results, the preliminary results of
in the early phase of information processing. this type of research in eating and weight disor-
From such considerations, stimulus exposure ders suggest that these methods could make a
trainings (“food cue exposure”) and computer- significant contribution to expanding the treat-
ized trainings (e.g., Approach Bias Modification ment arsenal available to us today (Dalton et al.
Training, ABM) were developed. The aim of 2017). The underlying mechanism of effective-
these training types is to extinguish assumed ness remains unclear (e.g., change in attentional
bias vs. modification of inhibitory control), and Furlong TM, Jayaweera HK, Balleine BW, Corbit
the results need to be further verified through LH (2014) Binge-like consumption of a palatable
food accelerates habitual control of behavior and is
placebo-controlled studies. dependent on activation of the dorsolateral striatum. J
Neurosci 34(14):5012–5022. https://doi.org/10.1523/
 Important Therapeutic interventions that JNEUROSCI.3707-13.2014
address automated habitual behavioral re- Grosshans M, Vollmert C, Dt-Klein SV, Tost H, Leber S,
Bach P … Kiefer F (2012) Association of leptin with
sponses may also play an important role in food cue-induced activation in human reward path-
the treatment of eating and weight disorders. ways. Arch Gen Psychiatry 69(5):529–537. https://
doi.org/10.1001/archgenpsychiatry.2011.1586
Jiménez-Murcia S, Agüera Z, Paslakis G, Munguia
L, Granero R, Sánchez-González J … Fernández-
27.6 Summary Aranda F (2019) Food addiction in eating disorders
and obesity: analysis of clusters and implications for
There are overlaps between eating and weight treatment. Nutrients 11(11). https://doi.org/10.3390/
disorders and addiction disorders in terms of phe- nu11112633
Kollei I, Rustemeier M, Schroeder S, Jongen S, Herpertz
nomenology, comorbidity, pathophysiology, neu- S, Loeber S (2018) Cognitive control functions in
robiology, and treatment options. In this chapter, individuals with obesity with and without binge-
arguments for and against the conceptualization eating disorder. Int J Eating Disord 51(3):233–240.
of eating and weight disorders as addiction-like https://doi.org/10.1002/eat.22824
Loijen A, Vrijsen JN, Egger JIM, Becker ES, Rinck M
behaviors are presented. The controversial concept (2020) Biased approach-avoidance tendencies in psy-
of “food addiction” is also introduced. Overall, chopathology: a systematic review of their assess-
eating and weight disorders can be considered as ment and modification. Clin Psychol Rev 77. https://
addiction disorders for at least a portion of those doi.org/10.1016/j.cpr.2020.101825
Markus CR, Rogers PJ, Brouns F, Schepers R (2017)
affected. Since the treatment of eating and weight Eating dependence and weight gain; no human evi-
disorders remains a major challenge from a thera- dence for a ‚sugar-addiction‘ model of overweight.
peutic perspective, expanding our understanding Appetite 114:64–72. https://doi.org/10.1016/j.
of the significance of dependent behavior mecha- appet.2017.03.024
O’Hara CB, Campbell IC, Schmidt U (2015) A reward-
nisms may represent enormous progress for treat- centred model of anorexia nervosa: a focussed
ment. Novel treatment methods such as stimulus narrative review of the neurological and psychophysi-
exposure and computer-assisted trainings, as well ological literature. Neurosci Biobehav Rev 52:131–
as various methods of neurostimulation could 152. https://doi.org/10.1016/j.neubiorev.2015.02.012
Paslakis G, Kühn S, Schaubschläger A, Schieber K,
make significant contributions. Röder K, Rauh E, Erim Y (2016) Explicit and
implicit approach vs. avoidance tendencies towards
high vs. low calorie food cues in patients with ano-
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bbr.2018.03.009 doi.org/10.1016/j.psychres.2019.05.001
Part IV
Biological and Medical Aspects of
Eating Disorders
203
Hunger and Satiety
28
Reinhard Pietrowsky
Contents
28.1 The Process of Food Intake . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
28.2 iological, Sensory, and Psychological Factors of Hunger
B
and Satiation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
28.3 Hunger and Satiety and the Regulation of Body Weight . . . . . . . . . . . . . . . 209
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210
From a biological perspective, food intake is con- is even more pronounced. This applies not only
trolled by hunger and satiety. Hunger leads to the to healthy, undisturbed eating behavior but also,
initiation of appropriate appetitive behaviors that to a particularly high degree, to disturbed eating
prepare for food intake, eventually resulting in behavior.
food consumption. This triggers the activation of In the following, an overview of the indi-
satiation processes, which lead to the termination vidual phases of food intake and the associated
of food intake and a period of satiety. In addition satiation processes will be given first. Then,
to these more short-term regulatory processes, biological, sensory, and psychological factors
long-term regulatory processes control the main- of hunger and satiety will be presented. Finally,
tenance or achievement of a certain body weight central nervous mechanisms of hunger and sati-
through hunger and satiety. ety regulation in relation to the regulation of
Although food intake is thus a basic biologi- body weightwill be described.
cal activity, its regulation is not solely controlled
by physiological, metabolic, and sensory fac-
tors, but also by a multitude of psychological 28.1 The Process of Food Intake
processes. Numerous examples of social control
of food intake can already be found in the ani- The process of food intake can be divided into
mal kingdom. In humans, the susceptibility of different phases, each of which is associated
food intake to psychological and social factors with specific biological or psychological aspects
of satiation:
R. Pietrowsky (*)
• cephalic phase,
Department of Clinical Psychology, Institute of
Experimental Psychology, Heinrich Heine University • gastric phase,
Düsseldorf, Düsseldorf, Germany • intestinal phase.
https://doi.org/10.1007/978-3-662-67662-2_28
206 R. Pietrowsky
28.1.1 Cephalic Phase somatostatin. These hormones perform essential

functions in food utilization and are also impor-
In the cephalic phase, there is not yet any direct tant peripheral satiation signals (below). The
contact of the food with the digestive organs. presence of small amounts of food in the intes-
Sensory stimuli emanating from the food (opti- tine leads to satiation. This effect is independent
cal, olfactory, gustatory, possibly acoustic) cause of stomach distension. It is mediated neurally
the body to prepare for food utilization via the and humorally, with CCK being considered the
central nervous system (CNS). The importance essential humoral factor. The satiating effect of
of the cephalic phase is emphasized by the CCK is dependent on prior cephalic stimulation
fact that, for example, the mere sight, smell, or (Pietrowsky et al. 1988).
expectation of food can already cause 50% of
the maximum possible gastric acid secretion.
In addition to an increased secretion of gastric Conclusion
acid, there is also an increased release of gas- The process of food intake thus triggers a
trin and somatostatin from the stomach during cascade of biological and psychological pro-
the cephalic phase. Furthermore, an increased cesses, starting with the first sensory contact
release of insulin can be observed (Pietrowsky with the food. These lead to the termination
et al. 1988). The nervous and endocrine mecha- of food intake (satiation) and a period with-
nisms initiated in the cephalic phase lead, on the out hunger and without further food intake
one hand, to an increased sensation of hunger, (satiety).
and on the other hand, to the activation of endo-
crine mechanisms that result in centrally medi-
ated satiation. This means that food intake is 28.2 Biological, Sensory,
terminated a certain time after it has begun, even and Psychological Factors
if the physiological imbalance caused by food of Hunger and Satiation
deprivation has not yet been compensated for.
28.2.1 Biological Factors
28.1.2 Gastric Phase Biological factors that influence hunger and

satietycan be found both in the periphery and in
The gastric phase, characterized by the pres- the CNS. Peripheral factors include the filling
ence of food components in the stomach, usu- state of the stomach, the amount of macronutri-
ally overlaps with the cephalic phase, as central ents in the blood, and hormonal regulatory pro-
functions are already activated by this preced- cesses that originate in the gastrointestinal tract.
ing phase. During the gastric phase, there is Central influencing factors are hormonal and
further gastric acid secretion. The stretching central nervous regulatory processes that origi-
of the stomach also causes a decreased sensi- nate in the brain, and the central nervous con-
tivity of the CNS to olfactory and taste stimuli trol of body weight. It is likely that all of these
(Pietrowsky et al. 1988). factors play a role in the development of hunger
and satiety, without any single factor being able
to explain eating behavior on its own.
28.1.3 Intestinal Phase The filling state of the stomach appears to
be a crucial factor for the occurrence of hunger.
During the intestinal phase, i.e., the pres- However, it has been shown that signals from
ence of food in the intestine, various pep- the stomach are not necessary for the develop-
tides are released from the intestinal mucosa, ment of hunger sensation, as hunger feelings
e.g., cholecystokinin (CCK), neurotensin, and are also described after gastric resection. A
28 Hunger and Satiety 207
reduction in dietary macronutrients (glucose, insulin, and amylin are released in proportion
fat, proteins) in the blood below a certain level is to the amount of body fat and cause a decreased
also considered a central indicator for triggering food intake. Thus, they fulfill the function of
a hunger sensation, and accordingly, there are regulating body weight. In addition, insulin, lep-
glucostatic, lipostatic, and aminostatic theories tin, and CCK interact synergistically in the sense
of hunger, each of which considers the level of that the satiating effect of CCK is more pro-
the respective nutrient as central for the trigger- nounced at high insulin or leptin levels (Drazen
ing of hunger and food intake (Pietrowsky et al. and Woods 2003).
1988). However, these theories cannot explain
why hunger persists in some cases despite high 28.2.1.2 Central Nervous Hunger
levels of the respective substances. and Satiety Regulation
The central nervous hunger and satietyregulation
28.2.1.1 Peripheral Hormonal describes those structures and processes in the
Regulatory Processes brain in which the corresponding motivational
Of particular importance for the regulation sensations (hunger, satiety) and the associated
of hungerand satiety are peripheral hormonal homeostatic behaviors (food intake or termina-
regulatory processes. These include hormones tion of food) are triggered. Triggers can be sen-
that are released in the digestive tract by food sory events (e.g., the sight of food) or the release
intake and act as satiety signals in the brain. of the mentioned satiety hormones.
The most important of these hormones is chol- The so-called dual-center theory assumes
ecystokinin (CCK), which is released from the that the hypothalamic areas of the lateral
intestine by the intake of food, especially fat, hypothalamus (LH) and the ventromedial
but also already in the cephalic phase. Using the hypothalamus(VMH) are responsible for the
example of CCK, a mechanism of peripheral- emergence of hunger and satiety. Thus, the LH
hormonal satiety regulation will be illustrated. is considered the hunger center, because its acti-
CCK fulfills important functions for fat diges- vation leads to increased food intake, while the
tion. At the same time, information about the VMH is considered the satiety center, because
level of CCK in the blood reaches the brain via its activation triggers the termination of food
CCK receptors on vagus afferents, and the circu- intake (Pietrowsky et al. 1988). It can also be
lating CCK can also cross the blood-brain bar- assumed that the LH is under a tonic inhibi-
rier via so-called circumventricular organs and tory influence of the VMH. Recently, other core
enter the brain itself. In the brain, CCK induces areas of the hypothalamus have been recog-
satiety processes via numerous CCK receptors nized as important for the control of food intake.
located there or via the vagus stimulation trig- These are, in particular, the arcuate nucleus
gered by CCK, which ultimately leads to the (infundibularis) and the paraventricular nucleus.
cessation of food intake. These satiety processes In these nuclei, the processing of information
consist of both a reduced feeling of hunger and from adipose tissue or the pancreas seems to
psychological changes, such as reduced atten- take place (Woods et al. 2000).
tion and decreased appetence for food stimuli The importance of the hypothalamus for
(Pietrowsky 1990). The satiating effect of CCK hunger and satiety regulation has also been
seems to depend on stimulation with food stim- confirmed by imaging studies. In the hungry
uli (cephalic phase). state (compared to the satiated state), there is
In addition to hormones from the gastroin- an increased regional cerebral blood flow in the
testinal tract that induce central nervous satiety hypothalamus. In addition, under conditions
(CCK, somatostatin, glucagon-like peptide 1, of hunger, other brain regions were found to
peptide YY), hormones from the body’s fat cells be more strongly activated: insular cortex, ante-
(leptin) and the pancreas (insulin, amylin) can rior cingulate, hippocampus, thalamus, caudate
also trigger centrally mediated satiety. Leptin, nucleus, and cerebellum (Tataranni et al. 1999).
208 R. Pietrowsky
Under conditions of satiety, the prefrontal cortex appetite loss caused by the LH lesion, i.e., very
was more strongly activated than under condi- palatable food is still consumed, whereas sen-
tions of hunger. While the activation of the insu- sorily less appealing food is not (Pietrowsky
lar cortex under conditions of hunger probably 1990).
indicates emotional and gastrointestinal reac- However, even after destruction of the VMH,
tions to hunger, the activation of the prefrontal i.e., the satiety center where animals exhibit
cortex under conditions of satiety may be an excessive overeating, the animals eat particu-
expression of memory processes, such as those larly large amounts when the food is especially
that occur in connection with food intake (e.g., palatable (Pietrowsky 1990). This is reflected
encoding the location of food finding). in the "cephalic phase hypothesis", which states
that hyperphagia after VMH lesion is under
28.2.1.3 Genetic Factors strong sensory control. Reflex reactions of the
The importance of biological factors in hunger cephalic phase of food intake, such as salivation
and satiety regulation is also evident in the role or insulin secretion, are, according to this theory,
of genetic factors. It has been known for sev- excessively pronounced in the VMH syndrome.
eral years that genetic defects can lead to a loss A VMH lesion, therefore, does not lead to a gen-
of satiety behavior and thus to a loss of control eral lack of satiety according to this hypothesis,
over eating behavior. Animal experimental stud- but to an increased food intake upon exposure to
ies with genetically modified mice, which have (palatable) foods.
a disturbance in leptin production (so-called ob/ In addition to its influence on conditioned
ob mice), were able to show that these animals processes of food intake, the sensory qual-
gain an extreme amount of weight due to the ity of food also has an important function for
lack of leptin formation, as leptin is missing as its reinforcement value. The work by Rolls
a long-term effective satiety signal (Sect. 28.3). and colleagues showed that the sensory stim-
In humans, the Prader-Willi Syndrome (dis- uli emanating from food lead to an increase in
order on chromosome 15) is associated with a excitation of hypothalamic neurons associated
genetically determined overproduction of the with the reward value of food (Rolls 1975).
appetite-increasing hormone ghrelin (Sect. 28.3) Sensory stimuli originating from food thus have
and leads to massive weight gain after the 12th a rewarding character as discriminative cues. It
month of life. was also shown that the rewarding effect of food
can be differentially conditioned to previously
neutral stimuli (Rolls 1985).
28.2.2 Sensory Factors In general, the more palatable a dish is,
the more of it is eaten (Sørensen et al. 2003).
Sensory factors play a significant role in food However, the effects of palatable food on hun-
intakeand for hunger and satiety. They assume ger or satiety are not trivial. For example, palat-
an intermediate position between biological able food can cause people to feel hungrier after
and psychological factors of hunger and satiety consumption than less palatable food. Another
regulation, as they interact with both. Sensory effect is that palatable food is more satiating
characteristics of food, such as taste, smell, than an energy-equivalent amount of less palat-
appearance, etc., lead to food being perceived able food (Sørensen et al. 2003).
as more or less palatable. The palatability of
food, as the sum of its sensory characteristics,
is directly related to the hypothalamiccontrol of 28.2.3 Psychological Factors
food intake. Thus, a lesion of the LH, i.e., the
hunger center, leads to a loss of food intake that Psychological factors that constitute hunger and
depends on the palatability of the offered food. satietyare essentially emotional and cognitive
The more palatable the food is, the weaker the processes. In addition, social factors, which
are mediated through psychological attribu- characterized by a lack of a decrease in cogni-

tion processes, also influence hunger and sati- tive fixation on food stimuli after food intake.
ety. The cognitive and emotional factors can be
considered psychological correlates of hunger 28.2.3.2 Emotional Factors
or satiety, which are suitable for facilitating the Similar to the cognitive characteristics of hun-
corresponding need satisfaction. ger and satiety, emotional factors, such as the
appetitive evaluation of food stimuli, can also
28.2.3.1 Cognitive Factors be understood as an expression of the acti-
Cognitive factors that influence hunger and vation of corresponding memory structures.
satietyare primarily selective attention to food Hunger is accompanied by a need-specific
stimuli (and resulting in more intensive process- activation of positively-valenced aspects of
ing of these stimuli) and an increased cognitive these memory structures. Under satiety, this
fixation on food stimuli, which is reflected in activation decreases and can turn into a nega-
increased mental engagement with food stimuli. tively-valenced evaluation, i.e., food items are
Increased selective attention to food stimuli is perceived as aversive. The emotional evaluation
a central characteristic of hunger and an essen- of food-related stimuli is an important aspect of
tial psychological component of it. It leads to hunger and satiety, which in turn naturally also
food stimuli being recognized or discovered influences the cognitive processing of food-rele-
more quickly. Ambiguous stimuli are also more vant stimuli. It is important to note that the rela-
likely to be assessed as food-related. Satiety, in tionship between hunger and satiety on the one
turn, leads to a decrease in selective attention to hand and their cognitive and emotional charac-
food stimuli which no longer have a processing teristics on the other hand is not unidirectional,
advantage over other stimuli. Such a reduction but that these cognitive and emotional charac-
in selective attention to food stimuli is a specific teristics also constitute the extent of hunger and
characteristic of satiety induced by satiating hor- satiety.
mones (Pietrowsky 1990). Many of these cogni-
tive processes occur preattentively, so they are 28.2.3.3 Social Factors
not accessible to conscious experience. Social factors, such as social norms, social com-
Increased mental engagement with food stim- parison processes, and cultural influences, can
uli is an expression of a tonically increased acti- influence hunger and satiety indirectly through
vation of the corresponding memory networks attribution processes, in addition to their direct
under conditions of hunger, which constitute influence on eating behavior. Although psycho-
semantic and primarily episodic content related logical factors can directly influence hunger and
to eating, food, fasting, etc. Since many people satiety, their impact on other influencing fac-
with eating disorders also have a strong cogni- tors of eating behavior is even stronger than
tive fixation on their own body and appearance, their direct effect on hunger and satiety
it can be assumed that the mental representa- (Pietrowsky 2006).
tions of the figure and body are associatively
activated in these individuals. Using experimen-
tal psychological paradigms (e.g., emotional 28.3 Hunger and Satiety and the
Stroop test, Dot-Probe paradigm), the cognitive Regulation of Body Weight
aspects of hunger and satiety can be precisely
quantified. Disturbances of these cognitive char- In the hypothalamus, humoral signals reflect-
acteristics of hunger and satiety are a typical ing the fat content and thus the body weight are
feature in patients with eating disorders and are incorporated into the control of satiety and eat-
likely to be partly responsible for the developing behavior. In the arcuate and paraventricu-
ment or maintenance of the eating disorder. For lar nuclei, this information is processed with
example, individuals with eating disorders are the involvement of local peptides, ultimately
210 R. Pietrowsky
resulting in the induction of hunger or satiety Conclusion

to maintain long-term body weight stability. In In summary, it can be stated that hunger and
the case of too low body weight, hunger is gen- satiety are indeed basic biological deter-
erated, leading to increased food intake and an minants of eating behavior; however, in
increase in body weight. In the case of too high humans, they are only one aspect of many
body weight, satiety processes are initiated, that control eating behavior. Ultimately, hun-
leading to reduced food intake and a decrease in ger and satiety are also psychologically deter-
body weight. mined constructs that are operationalized
The control processes in the arcuate and through corresponding behaviors. In the sim-
paraventricular nuclei exert their influence plest case, this occurs through food intake.
on food intake through the hypothalamic core However, when mediating psychological pro-
areas of the lateral and ventromedial hypo- cesses are taken into account, a much more
thalamus (Sect. 28.2.1.2). If these processes complex picture emerges. Hunger and satiety
result in a signal for reduced food intake, this also have a motivational-emotional compo-
activates the VMH; if they result in a signal for nent, which is reflected in both the desire to
increased food intake, this activates the LH. It eat or not to eat, as well as in the emotional
is crucial that both LH and VMH induce hun- and cognitive evaluation of food stimuli and
ger or satiety by modulating the satiety signals the resulting cognitive processing of food
from the peripheral humoral satiety system. stimuli. Finally, these cognitive processes
Activation of the VMH leads to an enhance- can be considered not only as a consequence
ment of the satiety signals, while activation of of hunger and satiety, but as their essential
the LH leads to a weakening of the humoral determinants. These psychological processes
satiety signals. This modulation appears to can become so significant that they – as in the
take place in the nucleus tractus solitarius of case of eating disorders – overlay the biologi-
the brainstem, to which the peripheral satiety cal hunger or satiety signals and lead to path-
signals project via afferent nerves (Drazen and ological fasting or overeating.
Woods 2003).
Thus, a closed control loop emerges:
Humoral satiety signals (e.g., CCK) regulate
the amount of food consumed in the short term. References
The current nutritional state determines, via lep-
tin, ghrelin, and insulin, a higher-level goal for Drazen DL, Woods SC (2003) Peripheral signals in
increased or decreased food intake in a hypo- the control of satiety and hunger. Curr Opin Nutr
thalamic control system, and this modulates the Metabol Care 6:621–629
Pietrowsky R (1990) Regulation von Hunger und
effect of the humoral satiety signals. Through Sättigung durch Cholecystokinin. Profil, München
the cumulative effect of enhanced or weak- Pietrowsky R (2006) Ernährung. In: Renneberg B,
ened satiety signals, long-term changes in body Hammelstein P (Hrsg) Gesundheitspsychologie.
weight occur. Since the effects of satiety signals Springer, Berlin, S 173–194
Pietrowsky R, Born J, Fehm HL (1988) Endokrine
are not only physiological but also psychologi- und neurokrine Regulation des Appetit- und
cal, the current nutritional state modulates the Sättigungsverhaltens. Verhaltensmod Verhaltensmed
cognitive and emotional correlates of hunger 9:243–274
and satiety via leptin and insulin. For a more Rolls ET (1975) The brain and reward. Pergamon,
Oxford, UK
detailed description of the very complex pro- Rolls ET (1985) The neurophysiology of feed-
cesses of hypothalamic satiety regulation, I refer ing. In: Sandler M, Silverstone T (Hrsg)
to the contribution by Ehrlich and Tam in this Psychopharmacology and food. Oxford University
book (Chap. 29). Press, Oxford, UK, S 1–16
Sørensen LB, Møller P, Flint A et al (2003) Effect of in humans using positron emission tomography. Proc
sensory perception of foods on appetite and food Natl Acad Sci USA 96:4569–4574
intake: a review on studies on humans. Int J Obes Woods SC, Schwartz MW, Baskin DG, Seeley RJ (2000)
27:1152–1166 Food intake and the regulation of body weight. Annu
Tataranni PA, Gautier J-F, Chen K et al (1999) Rev Psychol 51:255–277
Neuroanatomical correlates of hunger and satiation
Peripheral Peptide
Hormones, 29
Neuropeptides,
and Neurotransmitters
Stefan Ehrlich and Friederike I. Tam
Contents
29.1 Peripheral Peptide Hormones and Neuropeptides . . . . . . . . . . . . . . . . . . . . 213
29.2 Neurotransmitters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
29.1 Peripheral Peptide Hormones in vivo investigation of central nervous mecha-

and Neuropeptides nisms of weight regulation in humans are lim-
ited. The findings described below are therefore
29.1.1 Basics based predominantly on results from animal
experimental studies. Numerous peripheral pep-
The neuronal control circuits of appetite regu- tide hormonesand neuropeptides are involved in
lation involve complicated and often redundant the regulation of food intake (Table 29.1).
systems with interactions of peripheral (e.g., The peripheral peptide hormones are secreted
gustatory and afferent vagal stimulation as well by adipose tissue (leptin) or the gastrointestinal
as secretion of gastrointestinal peptide hormones tract (ghrelin, peptide YY [PYY], cholecysto-
and peptides from adipose tissue) and central kinin [CCK]). Leptin (anorexigenic) and ghre-
mechanisms (e.g., the secretion of neuropep- lin (orexigenic) represent important, opposing
tides). The most important anatomical locus of systemic mediators in the neurobiological regu-
weight regulation is the hypothalamus, particu- lation of food intake and energy homeostasis.
larly the nucleus arcuatus. The possibilities for Leptin is produced in white adipose tissue in
adipocytes and secreted pulsatilely. The level of
serum leptin is dependent on body fat mass and
energy intake (positive correlation). Ghrelin is
S. Ehrlich (*) · F. Tam mainly synthesized in enteroendocrine cells of
Division of Psychological and Social Medicine and
Developmental Neurosciences & Eating Disorder
the stomach, but also in the rest of the gastroin-
Treatment and Research Center at the Department testinal tract. It occurs in two forms in the body
of Child and Adolescent Psychiatry, Faculty of (deacylated and acylated), with its appetite-stim-
Medicine, Technische Universität Dresden, Dresden, ulating function being exerted by the acylated
Germany
form. In the fastingstate, ghrelin levels correlate
negatively with BMI and body fat mass. Ghrelin
F. Tam
levels and, to a lesser extent, leptin levels are
https://doi.org/10.1007/978-3-662-67662-2_29
214 S. Ehrlich and F. Tam
Table 29.1  Important peripheral peptide hormones (secreted in the gastrointestinal tract and adipose tissue) and cen-
tral neuropeptides of weight regulation
Anorexigenic Orexigenic
Central Melanocyte-stimulating hormone (α-MSH) Neuropeptide-Y (NPY)
Corticotropin-releasing hormone (CRH) Agouti-related peptide (AgRP)
Oxytocin Melanin-concentrating hormone (MCH)
Orexin-A
Peripheral Leptin Ghrelin
Peptide YY (PYY)
Cholecystokinin (CCK)
subject to a presumably food intake-dependent The exact physiological effect of the hormones
circadian rhythm. Before meals, ghrelin concen- PYY and CCK, formed in the endocrine L-cells
tration rises steeply and falls again at the end of of the distal small intestine and colon, is the sub-
food intake. This suggests a role for ghrelin in ject of intensive research. The serum levels of
the initiation of food intake. both hormones rise steeply postprandially and
remain elevated for several hours. This suggests
 Important The most important ana- that the meal-related increase in PYY and CCK
tomical locus of weight regulation is the represents a short-term satiety signal. PYY also
hypothalamus. reduces intestinal motility and the secretion of
ghrelin (Fig. 29.1). The neuropeptide oxytocin
Leptin probably causes a reduction in the secre- is primarily formed in the hypothalamus and
tion of the highly potent orexigenic neuropep- appears to lead to a reduction in food intake and
tides neuropeptide-Y (NPY), agouti-related body weight, in addition to a variety of other
peptide (AgRP), and orexin-A by deactivat- central and systemic effects.
ing orexin- and NPY/AgRP neurons and an
increase in the secretion of the anorexigenic
melanocyte-stimulating hormone (α-MSH) by 29.1.2 Findings in Eating Disorders
activating proopiomelanocortin/cocaine-amphet-
amine-regulated transcript neurons (POMC/ The most important findings on changes in
CART neurons). In addition to its anorexi- peripheral peptide hormones and neuropeptides
genic effect, leptin also initiates an increase in in anorexia nervosa (AN) and bulimia nervosa
energy expenditure, thermogenesis, and lipoly- (BN) are summarized in Table 29.2. There are
sis. Ghrelin probably binds to NPY/AgRP and numerous studies on the peripherally secreted
POMC/CART neurons in the arcuate nucleus peptide hormones, which will be discussed in
via growth hormone (GH)-secretagogue recep- the following.
tors. In contrast to leptin, ghrelin increases the
secretion of the orexigenic neuropeptides NPY 29.1.2.1 Leptin
and AgRP and inhibits POMC/CART neurons. The anorexigenic leptin plays an important
Furthermore, ghrelin stimulates the secretion of role in the hypothalamic control of weight
GH. regulation. Untreated patients with AN in the
acute phase of the disorder show reduced lep-
 Important In the fasting state, rising ghre- tin serum and cerebrospinal fluid levels due to
lin levels together with falling leptin levels decreased body fat content and low food intake
are likely crucial for the central induction of (Monteleone and Maj 2013). In contrast, the
hunger. concentration of the soluble leptin receptor
in the blood is increased, which could lead to
29 Peripheral Peptide Hormones, Neuropeptides … 215
Appetite/food intake
Hypothalamus
Orexin-A MCH NPY α-MSH CRH
Nucleus arcuatus
Para-
Lateral NPY/ ArGP POMC/CART
ventricular
hypothalamus Neurons Neurons
nucleus
Glucose Leptin Peptide YY Ghrelin

N. vagus
White
Blood Small intestine Stomach
fat tissue
Fasting
Fig. 29.1  Simplified representation of the neuroendocrine regulatory mechanisms of weight regulation during fast-
ing. The long arrows indicate the influence of the mediators (dashed arrow = inhibitory influence, solid arrow =
stimulating influence). The small arrows next to the mediators indicate the changes in the fasting state (↑ = concen-
tration increased, ↓ = concentration decreased); mediators with appetite-increasing effects are in bold. For example,
the glucose concentration is decreased in the fasting state, reducing its inhibitory effect on the lateral hypothalamus.
Due to the partial removal of this inhibition, more appetite-increasing orexin-A is released, thereby stimulating food
intake. Abbreviations: AgRP = agouti-related peptide, CRH = corticotropin-releasing hormone, MCH = melanin-
concentrating hormone, α-MSH = melanocyte-stimulating hormone, NPY = neuropeptide-Y
reduced bioavailability of free leptin as a pro- promote short-term weight loss (Monteleone
tective mechanism (Smitka et al. 2013). During and Maj 2013; Holtkamp et al. 2004).
inpatient treatment, leptin levels increase in Excessive physical activity occurs in approxi-
patients with AN depending on premorbid mately 30-80% of patients with AN and in a
weight and the rate of weight gain, whereby a proportion of patients with BN during the acute
very steep increase in leptin may potentially stage of the disorder (Hebebrand et al. 2003).
lead to difficulties in further weight gain and The semi-starvation-induced hyperactivity of
Table 29.2  Neuroendocrine changes in AN and BN during the acute phase of the disorder (↑ = concentration
increased, ↓ = concentration decreased, n= concentration normal, in CSF. = in cerebrospinal fluid, in bl. = in blood,
i.e., in serum or plasma, – = no findings). If studies had produced different findings, multiple concentration values are
shown (e.g., ↑ ↓ n, if some studies showed increased and others decreased or normal concentrations). In the case of
postprandial findings, the concentration values ↑, ↓, or n indicate the absolute concentration after food intake, with
the underlying mechanism described in parentheses
AN BN
Peripheral Pep- Leptin in CSF ↓ -
tide Hormones Leptin in bl. ↓ ↓n
Soluble Leptin Receptor in bl. ↑ ↑n
Ghrelin in bl. ↑ ↑n
Ghrelin in bl. postprandial ↑(with increased basal concentrations ↑(with reduced post-
despite relative postprandial decrease) prandial decrease) or n
PYY in bl. ↑n n
PYY in bl. postprandial ↑(with increased basal concentrations ↑ ↓(with reduced or
or increased postprandial increase) increased postprandial
or n increase) or n
CCK in bl. ↑n ↓n
CCK in bl. postprandial ↑(increased basal concentrations and ↓(with reduced post-
increased postprandial increase) or n prandial increase) or n
Neuropeptides NPY in CSF ↑ n
NPY in bl. ↑↓n ↑
AgRP in bl. ↑ -
Orexin-A in bl. ↑↓n -
α-MSH in bl. ↓n -
Oxytocin in CSF ↓n n
Oxytocin in bl. ↓n n
Neurotransmit- Serotonin metabolite 5-HIES in ↓n n
ters CSF
Dopamine metabolite HVS in ↓n n
CSF
Dopamine metabolite HVS in bl. ↑ ↑
Norepinephrine or metabolite n ↓
MHPG in CSF
Norepinephrine or metabolite ↑ n
MHPG in bl.
rats serves as a biological model for increased leptin level during the acute phase of the disor-
physical activity during fasting (Hebebrand et al. der correlates with a high degree of excessive
2003). This behavioral change in rats under food physical movement and restlessness (Ehrlich
restriction appears to be mediated by the fasting- et al. 2009; Holtkamp et al. 2006). This suggests
related decrease in leptin levels. Administration that a reduced leptin level may also be involved
of recombinant leptin in rats leads to a complete in the development of increased physical activity
suppression of starvation-induced hyperactivity in patients with eating disorders.
(Exner et al. 2000). In patients with AN, a low
The majority of patients with BN show et al. 2016; Eddy et al. 2015). The question of
reduced or normal leptin levels in the blood dur- whether increased PYY concentrations have a
ing the acute phase of the disorder (Smitka et al. pathophysiological significance in AN (anorexi-
2013). However, patients with frequent binge- genic stimulation) needs further investigation.
purge episodes show reduced leptin concentra- For acutely ill patients with BN, predominantly
tions despite a normal body mass index (BMI). normal PYY concentrations are described in the
Some patients continue to have low leptin levels fasting state (Culbert et al. 2016). Study results
even after overcoming BN. It remains unclear on the postprandial PYY concentration course
whether there is a connection to a high pre- are heterogeneous for both patients with AN and
morbid weight and a tendency for weight gain BN (Berner et al. 2018). In patients with BN,
(Smitka et al. 2013). a decreased PYY secretion in response to food
intake could promote the occurrence of binge
29.1.2.2 Ghrelin eating (Culbert et al. 2016).
In the acute state of AN, ghrelin concentrations
in the fasting state are increased (orexigenic 29.1.2.4 CCK
stimulation), and it is possible that patients with The data on CCK in the fasting state and post-
AN in the cachectic state have a reduced sen- prandially in patients with acute AN is con-
sitivity to ghrelin’s appetite-enhancing effect tradictory (Culbert et al. 2016). Increased or
(Bernardoni et al. 2020; Culbert et al. 2016). normal basal CCK levels have been reported.
As in normal-weight control subjects, external In BN, basal CCK levels have been reported
application of ghrelin analogs in patients with as normal or decreased, and the postprandial
AN could, however, lead to an increase in food increase seems to be disturbed (Culbert et al.
intake (Hotta et al. 2009; Fazeli et al. 2018). 2016). This could contribute to the maintenance
Although no differences in the relative post- of the disorder by a reduced feeling of satiety
prandial decrease in ghrelin levels were found after food intake (Smitka et al. 2013).
in patients with AN, absolute ghrelin levels are
also increased postprandially (Monteleone and 29.1.2.5 Centrally Secreted
Maj 2013). Neuropeptides of Weight
Patients with BN in the acute state of the Regulation
disorder show normal or increased ghrelin lev- The data on the central mediators—the orexi-
els in the fasting state (Smitka et al. 2013). genic NPY, AgRP, and orexin-A, as well as
Data on the postprandial concentration course the anorexigenic α-MSH—is less reliable. It is
of ghrelin in patients with BN is also heteroge- not always clear to what extent measurements
neous (Culbert et al. 2016). However, particu- of these partially relatively unstable param-
larly in the cephalic phase of digestion, when eters in peripheral blood reflect the concen-
food intake is expected, there seems to be an tration or effect in hypothalamic tissue, and
increased ghrelin secretion, which could lead secretion of the aforementioned mediators has
to a strong feeling of hunger and thus promote been detected at low concentrations in periph-
binge eating (Culbert et al. 2016). eral tissues. While measurements in cerebro-
spinal fluid indicated increased NPY levels in
29.1.2.3 PYY acute AN, the data on NPY concentrations in
Studies on the anorexigenic peptide hormone the blood of patients with AN is contradictory
PYY in patients with AN have yielded incon- (Smitka et al. 2013). In BN, there is evidence
sistent results (Berner et al. 2018). So far, of increased peripheral NPY concentrations
predominantly increased or normal PYY con- (Smitka et al. 2013). Peripheral AgRP levels in
centrations have been described in the acute AN have been described as elevated and nor-
stage of AN (Tam et al. 2020; Fernández-Aranda malize with weight gain (Merle et al. 2011).
There is no data on BN so far. In summary, the 29.2.2 Findings in Eating Disorders

findings on NPY and AgRP in AN can best be
explained as a compensatory counter-regulation Changes in neurotransmitter systems in AN
in the underweight state. The findings on orexi- and BN can be investigated either indirectly—
genic orexin-A and anorexigenic α-MSH in AN in cerebrospinal fluid, blood, or by means of
are also contradictory. Autoantibodies against metabolites in urine—or directly using positron
α-MSH may play a role in AN and BN (Fetissov emission tomography (PET) or single-photon
and Hökfelt 2019). The anorexigenic oxytocin emission computed tomography (SPECT).
has been described as reduced or normal in the Studies using functional magnetic resonance
blood of patients with AN in the fasting state, imaging (fMRI) can also provide insights into
while a reduction in cerebrospinal fluid was neurotransmitter systems by applying specific
only found for patients with the restrictive but behavioral paradigms and mathematical mod-
not with the binge/purge subtype (Plessow et al. els. The use of PET and fMRI has increased in
2018). Initial studies are investigating whether recent years in research on eating disorders. The
intranasally administered oxytocin could influ- results are described in detail in Chaps. 30 and
ence the eating behavior of patients with AN. So 32. The most important findings on changes in
far, there is no evidence of changes in oxytocin neurotransmitters in AN and BN based on find-
concentration in BN (Plessow et al. 2018). ings in cerebrospinal fluid, blood, and urine are
summarized in Table 29.2. Only a few studies
so far have investigated to what extent abnor-
29.2 Neurotransmitters malities in neurotransmitter systems persist
after overcoming AN and BN. Disturbances
29.2.1 Basics that persist after remission of the disorder
could correspond to an intrinsic vulnerability
In addition to the peripheral peptide hormones (“trait-marker”).
and neuropeptides, the monoaminergic neu-
rotransmitters (serotonin, dopamine, norepi- 29.2.2.1 Serotonin
nephrine) are involved in the regulation of food In the acute stage of the disorder, reduced or
intake. A drug-induced increase in intrasynaptic normal concentrations of the 5-HT metabo-
serotonin (5-HT) or direct activation of 5-HT lite 5-hydroxyindoleacetic acid (5-HIES) were
receptors results in a reduction of food intake, detected in the cerebrospinal fluid of patients
whereas a decrease in serotonergic neurotrans- with AN, while normal concentrations were
mission seems to be associated with increased found in patients with BN (Kaye 2008; Gerner
food intake and weight gain. In contrast to sero- et al. 1984). In contrast, increased 5-HIES con-
tonin, central administration of norepinephrine centrations in the cerebrospinal fluid were meas-
results in increased food intake via stimulation ured in weight-rehabilitated, former patients
of α-adrenergic receptors in the paraventricu- with AN and individuals recovered from BN
lar hypothalamus. In addition, a ß-adrenergic (Kaye 2008). These persistent abnormalities in
satiety-activating system seems to exist in the recovered AN and BN could indicate increased
pernifocal region of the hypothalamus. Thus, serotonin activity as a “trait-marker” in the
norepinephrine stimulates or inhibits food sense of a common intrinsic vulnerability of the
intake depending on the site of stimulation. serotonin system. Deviations in serotonergic
Dopamine metabolism plays an important role markers measured in blood platelets in former
in the rewarding and reinforcing aspects of food patients with AN support such an assumption
intake. The application of low doses of dopa- (Ehrlich et al. 2010). Temperament factors, such
mine stimulates food intake, while higher doses as conflict avoidance, behavioral inhibition, and
have anorexigenic effects. anxiety and tension, are also associated with
the serotonin system. In patients who devel- dopamine metabolite homovanillic acid (HVA)
oped anorectic symptoms during adolescence, in cerebrospinal fluid, but increased HVA levels
such temperament factors as well as persis- in blood (Kaye et al. 1984; Gerner et al. 1984;
tence (ability to stick to something, but also Castro-Fornieles et al. 2008). In the acute stage
rigid behaviors) were described in childhood. of BN, patients had normal HVA concentrations
Former AN and some BN patients are charac- in cerebrospinal fluid, whereby frequent binge
terized by compulsiveness, perfectionism, and eating episodes were associated with reduced
negative affect. Behaviors described in patients HVA levels (Kaye et al. 1990). In blood,
with AN before and after overcoming the eat- increased HVA concentrations were detected
ing disorder seem similar to those associated in active BN (Bowers et al. 1994). For weight-
with a hyperserotonergic state. Based on this, rehabilitated former patients with AN, reduced
Kaye (2008) developed a pathophysiologi- or normal HVA concentrations were described
cal model for the development of AN, in which compared to healthy control participants, and
calorie reduction at the beginning of the dis- for recovered patients with BN, normal HVA
order improves such symptoms by reducing concentrations were reported (Kaye et al. 1984,
tryptophan (as an essential amino acid for the 1999). It is not yet clear whether the neuro-
synthesis of serotonin) and thus positively rein- biological changes in the reward system in the
forces weight loss. In line with this, a tempo- acute stage of AN or BN should be considered
rary experimental reduction of central serotonin as adaptations to the acute disorder or as “trait
synthesis by acute tryptophan depletion has an markers” (Monteleone et al. 2018).
anxiety-reducing effect in former patients with
AN (Kaye et al. 2003). In contrast, acute tryp- 29.2.2.3 Norepinephrine
tophan depletion in patients with BN tended to For norepinephrine or its metabolite 3-methoxy-
exacerbate symptoms (Bruce et al. 2009; Kaye 4-hydroxyphenylglycol (MHPG), normal cer-
et al. 2000). Impulsive behaviors and transitions ebrospinal fluid levels were found in the acute
to borderline personality disorders are also com- stage of AN, but increased concentrations were
mon in patients with BN, so different subgroups measured in serum (Kaye et al. 1984; Gerner
may need to be considered. In line with a dys- et al. 1984; Bowers et al. 1994). Patients with
functional serotonergic neurotransmitter system BN show reduced norepinephrine concentrations
are findings on the pharmacological efficacy of in cerebrospinal fluid in the acute stage but nor-
selective serotonin reuptake inhibitors (SSRI) in mal MHPG concentrations in blood (Kaye et al.
eating disorders. The effect of SSRIs in reducing 1990; Bowers et al. 1994). For former, weight-
binge-eating episodes in BN is well documented rehabilitated patients with AN and individuals
(McElroy et al. 2019). In contrast, the benefit of recovered from BN, normal MHPG concentra-
SSRIs in the context of relapse prevention in AN tions were described compared to healthy con-
is not well established. trol participants (Kaye et al. 1999).
29.2.2.2 Dopamine
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Reward System in Eating
Disorders and Obesity 30
Joe J. Simon and Hans-Christoph Friederich
Contents
30.1 General Neural Reward Processing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
30.2 Relationship between Neural Reward Processing and EatingBehavior . . . 224
30.4 Bulimia nervosa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
30.6 Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228
30.1 General Neural Reward tegmental area in the midbrain and projects via
Processing dopaminergic neurons to the ventral striatum,
with the nucleus accumbens as another core
Survival-essential behavior is ensured by pri- region.
mary, natural reward stimuli, such as food and The pleasure of receiving a reward, the “lik-
water. In the neural processing of reward stim- ing”, is mainly modulated by opioid projections
uli, essentially three components can be distin- in prefrontal/orbitofrontal brain regions and is
guished, which can also be differentiated at the typically associated with activation of the gus-
neurobiological level. tatory cortices in the orbitofrontal cortex (sec-
The desire for a reward, the “want- ondary gustatory cortex) and the insular region
ing”, describes the behavioral salience of a (primary gustatory cortex) for food stimuli.
reward stimulus, which is modulated by dopa- These brain regions are essential for the con-
minergic neurotransmission in the mesolimbic scious perception of the hedonic aspect of food
system. This system originates in the ventral intake.
The third component, “reward-depend-
ent learning”, is based on a prediction error
between “wanting” (reward expectation) and
J. J. Simon (*) · H.-C. Friederich “liking” (received reward). Whenever a reward
Department of General Internal Medicine and
Psychosomatics, Medical Hospital, University of
is higher than expected, a phasic increase in
Heidelberg, Heidelberg, Germany dopaminergic firing rate in the mesolimbic
e-mail: [email protected] reward system can be observed. This pha-
H.-C Friederich sic dopamine signal serves action monitoring,
e-mail: [email protected] learning gain, and behavior optimization. In
https://doi.org/10.1007/978-3-662-67662-2_30
224 J. J. Simon and H.-C. Friederich
experimental brain imaging, the desire for food loss. Conversely, overfeeding and weight gain
(“wanting”) is usually provoked using visual appear to cause a desensitization of dopamin-
reward stimuli, while the hedonic component ergic neurotransmission. The extent to which
(“liking”) is investigated by receiving food or these neuroplastic changes in the reward system
enjoying a food item. are influenced by hormones of short-term (e.g.,
ghrelin) and long-term energy regulation (e.g.,
leptin) is currently being intensively investi-
30.2 Relationship between Neural gated. Initial findings show that in AN, not only
Reward Processing is the hypothalamus’ response to food stimuli
and EatingBehavior reduced, but also the cooperation between the
hypothalamus and reward network is severely
In recent research literature, the influence of limited. This suggests a reduced influence of
changes in the neural reward network is inten- homeostatic signals on reward-associated neu-
sively discussed as a relevant factor for the ronal reactivity in AN. In line with animal
development and maintenance of eating disor- experimental studies, patients with AN show
ders and obesity. The reward system is closely increased responsiveness of the reward system
interconnected with the lateral hypothalamus as to unexpected taste stimuli compared to over-
a core region of homeostatic hunger-satiety reg- weight controls. The extent to which patients
ulation. Food intake is stimulated by the antici- with AN, independent of weight and compared
pated or experienced pleasure of food, which is to normal-weight controls, show increased acti-
mediated by the activation of the reward system. vation of the reward system in response to food
The reward value of food can be influenced by stimuli is currently unclear, and findings are
both metabolic factors (e.g., fasting) and psy- contradictory. However, increased activation
chological factors (e.g., depressive episode). An of the reward system in response to starvation-
altered reward experience for food stimuli is associated stimuli (e.g., images of underweight
considered a fundamental mechanism for dis- women or women engaging in excessive exer-
turbed eating behavior. cise) was also demonstrated compared to nor-
mal-weight controls using functional imaging.
 Important The reward network represents an It is assumed that the excessive exercise despite
important component in the development and severe underweight is mediated by the dopa-
maintenance of eating disorders. minergic reward system. The fatal combination
of persistent hunger and hyperactivity has long
been known from animal experimental stud-
30.3 Anorexia nervosa ies. In an environment with limited food avail-
ability and free access to a running wheel, rats
Patients with anorexia nervosa (AN) are char- show an inverse relationship between activ-
acterized by a decreased desire for food and ity level and consumed food amount. If the
sexuality (inappetence) as well as a loss of experiment is not terminated, the rats die from
enjoyment of life (anhedonia). Both aspects the persistent negative energy balance. This
are associated with a dysfunction of the dopa- phenomenon is referred to as the “auto-addic-
minergic reward system. Thus, it was initially tion” model of anorexia. Thus, the assump-
assumed that AN patients have a generally tion of a generally reduced responsiveness of
reduced responsiveness of the reward sys- the reward system in patients with AN has not
tem. This assumption is contradicted in part been confirmed. Rather, it can be assumed that
by animal experimental studies, which dem- the underweight leads to an increased respon-
onstrated a sensitization of the dopaminergic siveness of the patients’ reward system, which
reward system under food restriction and weight may positively reinforce the pursuit of thinness
30 Reward System in Eating Disorders and Obesity 225
and hyperactivity. At the same time, there is an This central dopamine deficiency is most likely
increased activation of neuronal control regions a result of downregulation of the dopamine
in response to food-associated stimuli. An system due to excessive binge-purge episodes.
increased influence of control regions on gen- If recovery occurs with normalization of eat-
eral reward reactivity is also evident in remitted ing behavior, these changes are reversible. In a
patients with AN. functional brain imaging study, the majority of
In addition to the mentioned model, the acutely ill patients with BN showed a decreased
so-called “reward contamination theory” is responsiveness of the reward system to visual
discussed in the literature. This assumes that food stimuli and gustatory stimuli, including
patients with AN primarily perceive rewarding sugar. Furthermore, patients with BN showed a
stimuli, such as food, as aversive, whereas they decreased striatal dopamine release under prov-
experience punishing (aversive) stimuli, such as ocation with amphetamines and a decreased
hunger, excessive physical exercise, or images binding to μ-opioid receptors in the temporoin-
of emaciated bodies, as rewarding. It is note- sular cortex in a positron emission tomography
worthy that under the striatal release of dopa- study (PET ligand study). Thus, patients with
mine, patients with AN paradoxically experience BN seem to specifically compensate for their
increased anxiety instead of joy. These still pre- hyporesponsive reward system through recurring
liminary findings suggest that the altered dopa- binge eating episodes to achieve a comparable
minergic reward processingis directly related to pleasure experience. For other reward stimuli
the increased anxiety in patients with AN dur- (e.g., monetary rewards), there were no differ-
ing food intake. This might also explain why ences between patients with BN and healthy
patients with AN have problems discriminating controls. However, it is unclear whether the
between positive and negative rewards. In sum- decreased responsiveness of the reward system
mary, current findings indicate that underweight to food is a cause or consequence of the recur-
and food restriction lead to a sensitization of ring binge eating episodes. Studies in remitted
the reward system, with specific conditioning BN patients show an increased reactivity of the
for starvation-associated stimuli. These changes primary gustatory cortex to food stimuli. This
provide a potential neurobiological explanation might indicate an exaggerated perception of
for patients’ restrictive eating behavior and the hunger signals and thus represent a triggering
pursuit of the lowest possible weight. factor for the development of BN. The recur-
ring binge eating episodes may then lead to a
 Important The “starvation” in patients with desensitization of the reward system for food, as
AN seems to be positively motivated and re- observed in functional imaging studies.
inforced (reward through starvation). This In animal experiments, binge eating can be
contradicts the previous hypothesis that re- imitated through a specific feeding schedule.
strictive eating behavior is primarily an ex- Rats that are intermittently given access to a
pression of anhedonia. high-calorie sugar solution exhibit binge crav-
ings for sugar over time, induced by repeated
deprivation. The behavior of the rats corre-
30.4 Bulimia nervosa sponds well to the characteristic vicious cycle
of restrictive eating behavior and binge eat-
The clinical picture of bulimia nervosa (BN) is ing in patients with BN. Furthermore, the
characterized by recurrent binge eating episodes, food consumed by patients with BN during a
accompanied by a feeling of loss of control over binge is usually characterized by a high calo-
food intake. Patients with frequent binge-purge rie content (e.g., high sugar content). In ani-
episodes show decreased levels of dopamine mal experiments, it has been demonstrated that
breakdown products in the cerebrospinal fluid. the intermittently offered high-calorie sugar
solution leads to a sensitization of the reward 30.5 Binge Eating Disorder

system. The sugar-dependent rats also show
cross-sensitization to other drugs such as alco- The clinical picture of binge eating disorder
hol, amphetamines, etc. Over the course of (BED) also has binge eating as its core pathol-
recurring sugar cravings, a tolerance develops, ogy, but unlike BN, it is not followed by com-
which is accompanied by an increase in the size pensatory behaviors. Furthermore, there are
(calorie content) and frequency of the “binge minor differences between BN and BED regard-
eating” episodes. Acute abstinence or adminis- ing the phenomenology of binge eating. While
tration of naloxone (opioid antagonist) leads to patients with BN typically consume large
typical somatic and psychological withdrawal amounts of food very quickly and over a very
symptoms in these animals. short period of time, patients with BED much
In summary, the animal experimental find- more often consume a large amount of food over
ings suggest that bulimic eating behavior can a longer period of time, which is referred to as
lead to neuroplastic changes in the reward sys- “grazing” or “nibbling” in the Anglo-American
tem, which has parallels with classical addiction context. Moreover, restrictive eating behavior
disorders. However, it should be noted that sen- does not regularly precede the binge eatingin
sitization of the reward system in rats has only patients with BED. So far, there have been very
been demonstrated for sugar and not generally few studies on the reward system regarding
for high-calorie foods. the clinical picture of BED. In an fMRI study,
Furthermore, it has been shown that the patients with BEDshowed increased activa-
responsiveness of the reward system to food tion in the medial orbitofrontal cortex during
stimuli in patients with BN is significantly exposure to high-calorie food images compared
dependent on affective mood. In phases of nega- to healthy controls and patients with BN.
tive mood, there is an increase in the experi- Furthermore, it was shown that the receipt of
enced reward value for food stimuli. Patients food-associated rewards is also associated with
with BN, therefore, deliberately use food increased activation in this region. The medial
to reduce negative emotions, which further orbitofrontal cortex encodes the reward value
enhances the rewarding effect of eating. of a stimulus and is also relevant for the enjoy-
The behavior of patients with BN shows ment of food. Recent findings suggest that a
numerous parallels with classical addiction dis- reduced influence of control regions on hedonic
orders. Animal experimental studies confirm that reactivity represents a core aspect of BED. The
disturbed eating behavior with a typical alterna- “craving” typical for BED (i.e., strong desire)
tion of restrictive eating behavior and excessive is seen as a result of the imbalance between
binge eating, accompanied by “purging” behav- reward sensation and impulsivity. Furthermore,
ior, can lead to addiction-like changes in the overweight individuals with BED more often
reward system. So far, it is still unclear to what have the G-allele of the μ-opioid receptor gene
extent findings of a hypo- and hyperresponsive (OPRM1) compared to individuals without
reward system represent different stages of the BED. This allele is associated with an increased
disorder in patients with BN. enjoyment experience when consuming food.
These still very preliminary findings indicate a
 Important Bulimia nervosa shows parallels hyperresponsive reward system to food stimuli
to addiction disorders in terms of symptoms in patients with BED. The differential activation
and in the results of neuronal research . patterns of the reward system between BN and
BED may explain differences in the behavioral
30 Reward System in Eating Disorders and Obesity 227
manifestation of binge eating between the two obese individuals show abnormal connectivity
clinical pictures. between different regions of the reward system.
A weakened connectivity between the amygdala
 Important The recurring binge eating of and the reward network can lead to a dysfunc-
patients with BED may be based on an in- tional modulation of the emotional component
creased enjoyment experience (hedonia). of food stimuli. This results in an imbalance,
with a predominance of hedonically motivated
food intake encoded by the reward system.
30.6 Obesity Additionally, studies in obese individuals show
that hunger selectively increases the activation
The eating behavior of obese patients without of the reward system for high-calorie stimuli.
eating disorders is characterized by overeat- The role of peripheral satiety signals is
ing without loss of control while maintaining a increasingly coming to the fore in theories on
regular meal structure. These individuals show the development and maintenance of obesity due
increased activation in the gustatory and soma- to their strong influence on the neural reward
tosensory cortexduring anticipation (“wanting”) network. In addition to a dysfunctional energy
and receipt (“liking”) of a food stimulus. At the homeostasis, there is a weakened response of
same time, however, a lower activation in the the hypothalamus to satiety hormones - a phe-
dorsal striatum is observed during the receipt nomenon that further reinforces the influence of
of a reward. One explanation for this would be hedonic food intake.
a “dynamic vulnerability model” of obesity,
which postulates that an initial hyperresponsiv-  Important In obesity, a reward-deficit hy-
ity of both somatosensory/gustatory regions pothesis is currently assumed, insofar as the
and the ventral striatum leads to increased food increased food intake serves primarily to
intake and preference for high-calorie foods. stimulate a hyporesponsive reward system.
For example, adolescents at high risk for obesity
show a hyperactive reward system that reacts
more strongly not only to food stimuli but also Conclusion
to monetary rewards. As a result of the over- The findings listed here illustrate the rel-
nutrition resulting from this, some individuals evance of the neural reward network in the
experience a downregulation of dopaminergic development and maintenance of eating dis-
D2 receptors in the ventral striatum, resulting orders and obesity. Due to the still prelimi-
in a weakened striatal response to food stimuli. nary nature of the results and the sometimes
However, it has been shown that cue stimuli contradictory findings, further studies are
indicating impending food intake are associ- needed to create a more accurate picture of
ated with an increased response of the reward these relationships. Future studies will focus
system, thus increasing the motivation for food more on differentiating between the desire
intake. (“wanting”) and the enjoyment of consuming
Furthermore, genetic studies show that obese food (“liking”). Furthermore, there are hardly
individuals with BED, in contrast to obese indi- any longitudinal studies to date that allow
viduals without BED, have a more frequent differentiation as to whether the described
occurrence of the Taq1A allele of the D2 recep- changes in the reward system are a cause,
tor gene. This allele is associated with a 30-40% consequence, or “scar effect” of the respec-
reduction in striatal D2 receptors. Thus, obese tive disorder. Of particular interest in the lon-
individuals seem to consume more food to gitudinal course are also additional aspects of
achieve the same rewarding effect. In addition, habit formation, which maintain the disorder
despite negative consequences. The disturbed Keating C, Tilbrook AJ, Rossell SL et al (2012) Reward
eating behavior and weight changes in indi- processing in anorexia nervosa. Neuropsychologia
50:567–575
viduals with eating disorders and obesity lead Kessler RM, Hutson PH, Herman BK, Potenza MN
to metabolic changes that are closely inter- (2016) The neurobiological basis of binge-eating dis-
related with the reward system. The aim of order. Neurosci Biobehav Rev 63:223–238
future studies should be to better understand Leslie M, Lambert E, Treasure J (2019) Towards a trans-
lational approach to food addiction: implications for
these relationships and interactions. bulimia nervosa. Curr Addict Rep 6(3):258–265
Scheurink AJW, Boersma GJ et al (2010) Neurobiology
of hyperactivity and reward: agreeable restlessness in
anorexia nervosa. Physiol Behav 100:490–495
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Neuropsychological
Findings in Eating 31
Disorders
Martin Schulte-Rüther and Kerstin Konrad
Contents
31.1 Research Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
31.2 Attentional Bias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230
31.3 Learning and Memory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
31.4 Executive Functions, Reward Processing, and Decision-Making . . . . . . . . 232
31.5 Central Coherence and Theory of Mind . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
31.6 Factors Influencing Neurocognitive Deficits . . . . . . . . . . . . . . . . . . . . . . . . . 234
31.7 Neuropsychological Findings in the Course of Therapy . . . . . . . . . . . . . . . 235
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
31.1 Research Questions relatively stable academic and professional per-

formance over a long period. In contrast, patients
The thinking of patients with anorexia ner- with bulimia nervosa (BN) and binge eating dis-
vosa (AN) in the acute state of starvation usu- order (BED) are often described as impulsive,
ally appears to be severely restricted and rigid. and it is assumed that increased impulsivity,
Psychotherapeutic measures are therefore some- together with increased reward sensitivity, can
times difficult or less effective in this phase. It contribute to uncontrolled eating behavior.
is therefore all the more astonishing that a large For many years, neuropsychological stud-
proportion of patients still manage to maintain ies have been investigating cognitive perfor-
mance in patients with eating disorders and
the question of whether deficits represent trait
characteristics of the disorder and contribute to
M. Schulte-Rüther (*) its development or only occur during the acute
Department of Child and Adolescent Psychiatry phase (e.g., due to starvation effects) or are
and Psychotherapy, University Medical Center, long-term consequences of the disorder.
Göttingen, Germany
e-mail: [email protected] While early studies focused on general cog-
nitive deficits, a large part of the subsequent
M. Schulte-Rüther · K. Konrad
Child Neuropsychology Section, Department of research has taken a closer look at specific fac-
Child and Adolescent Psychiatry, Psychosomatics and ets of neurocognitive function. Functions that
Psychotherapy, University Hospital, RWTH Aachen, are believed to directly contribute to the psy-
Aachen, Germany chopathology of eating disorders, particularly in
https://doi.org/10.1007/978-3-662-67662-2_31
230 M. Schulte-Rüther and K. Konrad
the areas of inhibitory control, decision-making, and overweight without further eating disorder
central coherence, cognitive flexibility, atten- symptoms.
tional bias, and working memory, have been pri-
marily investigated. Most studies on inhibitory
control have focused on eating disorders charac- 31.2 Attentional Bias
terized by binge eating, whereas set-shifting and
central coherence have been primarily studied Attention processes can be involved in the
in patients with AN. Studies on attentional bias generation and amplification of emotions.
and decision-making have been conducted more Conversely, the conscious control or redirec-
evenly across different eating disorder diagnoses. tion of attention processes also has a regulatory
However, many of the existing studies are effect on emotions. In particular, attentional
characterized by heterogeneous samples in bias, i.e., the tendency to over-focus on certain
terms of severity, chronicity, diagnostic criteria, information in the environment, is relevant for
and existing comorbidities, making the interpre- eating disorders, as the excessive preoccupa-
tation of the findings difficult. More recent stud- tion with body- and food-related stimuli may
ies show a greater focus on specific functions contribute to the maintenance of eating disor-
and allow for a hypothesis-driven analysis of der symptomatology by directing the limited
even more subtle neuropsychological deficits. In cognitive resources to disorder-relevant stimuli
addition, extensive meta-analyses are now avail- and thus distorting the perception and interpre-
able for certain areas of functioning, providing a tation of the environment. The most commonly
clearer picture of cognitive deficits. used assessment methods for evaluating atten-
The following presents the individual find- tional bias in eating disorders are the modified
ings for various areas of functioning. The Stroop task (Stroop 1935, p. 1935) and variants
majority of studies focus on AN and BN, but of the dot-probe task (MacLeod et al. 1986)
there is an increasing number of studies inves- (Fig. 31.1). The modified Stroop interference
tigating cognitive functions in BED, obesity, task measures the time it takes to name the
a b
Fixation + Fixation
Probe
+ Stimulus
● ●
Biscuit Fixation
Fixation
+
+ Stimulus
Probe
Chair
● ●
until response
Fig. 31.1  a,b. a Example of a dot-probe paradigm with food-related stimuli modified according to Meule and
Platte 2016). Images of high-calorie and low-calorie foods are presented, and participants must respond with a left
or right button press depending on the position of the dot. b Example of a STROOP paradigm with food-related
stimuli (modified from Van Holst et al. 2018). Food and neutral words are presented, and participants must indicate
the color of the word by pressing the button that reflects this color
31 Neuropsychological Findings in Eating Disorders 231
color of a written word when the word itself is avoidance of neutral stimuli. Additionally, there
either neutral (e.g., “hat”) or disorder-sensitive is limited evidence suggesting that women with
(e.g., “fat”). An attentional bias is inferred if the BN have difficulty disengaging from images of
presence of a disorder-sensitive word increases other women with a low BMI and tend to avoid
the time it takes to name the color of the word. images of people with a high BMI.
In the dot-probe task, pairs of stimuli (e.g.,
an image related to food or body and a neutral  Important Overall, there is fairly reliable
image) are presented, followed by a dot (the evidence for an attentional bias in women
probe) at one of the two locations previously with eating disorders compared to control
occupied by an image. Participants are then participants.
asked to make a quick response to the position
of the dot. An attentional bias is indicated if However, research suggests that the presence
reaction times (RTs) are reduced in trials where of an attentional bias and whether it is primar-
the dot appears at the location of the disorder- ily characterized by hypervigilance or avoidance
relevant stimulus or, conversely, increased when tendencies likely depends on a combination of
the dot appears at a different location, suggest- several factors (e.g., stimulus timing, type of
ing that attention was automatically shifted to stimulus, and diagnosis) (see review by Smith
the location of the disorder-relevant stimulus. et al. 2018).
Several systematic reviews and meta-analyses Based on experimental findings on atten-
focusing on comparisons of adults with AN, BN, tional bias, treatment approaches have recently
and BED with normal weight or control partici- been formulated that aim to modify the selec-
pants found relatively consistent evidence for tive attentional bias in patients with eating disor-
an attentional bias in AN and BN compared to ders (Attentional Bias Modification Treatment,
healthy controls (HC) towards food words in ABMT; see Renwick et al. 2013). The goal of the
the Stroop task with overall effect sizes in the intervention is conscious attentional control, i.e.,
small to medium range (AN d = .38; BN d = diverting attention away from anxiety-provoking
.43). Similarly, a systematic review found con- thoughts. Initial results suggest that modifying
sistent evidence for biases towards food stim- attentional biases can lead to improvements in
uli in BED without compensatory behaviors, binge eating and other eating disorder symptoms
albeit with more inconsistent evidence in BN. (Boutelle et al. 2016). A recent meta-analysis
However, a more consistent pattern in BN was showed that a single training session of inhibi-
found for Stroop studies with weight/shape and tory control in a laboratory study led to a signifi-
threat stimuli, which reported a greater atten- cant reduction in the selection or consumption of
tional bias in BN compared to controls. A meta- food and alcohol (Jones et al. 2016). However,
analysis of dot-probe task performance revealed there is still little research on the long-term trans-
a large attentional bias towards negative shape- fer of such effects to everyday life.
related stimuli (d = .80) and away from positive
eating and shape-related stimuli (d = −.83) in
AN and BN compared to controls. Finally, sev- 31.3 Learning and Memory
eral systematic reviews included studies that
measured attentional biases in eating disorders Findings on impaired learning and memory
by tracking eye movements during the view- functions are mainly available for AN, but
ing of disorder-relevant versus neutral stimuli. are overall inconsistent. A few studies point
Although the overall results are quite heteroge- to deficits in the area of implicit learning, e.g.,
neous, they suggest that women who engage in when learning number sequences (“Hebb’s
binge eating have difficulty disengaging from Digit Recurring Sequences”), visual-spatial
food cues, whereas women with BN exhibit sequences (“Corsi block- tapping test”) or cat-
both an attentional bias towards food images and egory membership. In conditioned associative
learning of words and geometric shapes (“con- Decision-making is closely linked to reward
ditional-associative learning”), patients with processing, as it involves the evaluation of
AN (but not patients with BN) showed deficits action options based on previously experienced
when emotionally neutral target words were positive or negative events. There are now
used, but not when using disorder-specific tar- numerous studies in this area as well, which fur-
get words (e.g., from the area of high-calorie ther examine deficits in eating disorders.
foods). Several studies discuss deficits in explicit Studies in AN show clear impairments in
memory functions in the area of working set-shifting with medium effect sizes. This is
memory. In individual studies, acutely under- usually investigated using the “Trail Making
weight patients with AN have shown poorer Test”, the “Wisconsin Card Sorting Test”, and
performance in visual-spatial rather than ver- the “Haptic Illusion Task” (Wu et al. 2014). The
bal short-term memory. For the executive com- deficits seem to be more pronounced for patients
ponent of working memory, more consistent with restrictive symptoms and less pronounced
impairments seem to emerge, which is in line for patients with binge/purging symptoms.
with the findings on attention (Sect. 31.4) and Patients whose weight has stabilized or who no
executive functions (Sect. 31.5). Thus, poorer longer show symptoms of an eating disorder
performance in memory tasks with higher com- usually show some improvement, but the major-
plexity (e.g., “Dual Span Memory Task”) or ity of studies point to a persistent deficit.
increasing demands on learning performance is Deficits related to reward processing and
found in patients with eating disorders compared decision-making have been mainly investi-
to healthy control subjects. In several studies, gated using the “Iowa Gambling Task”. In this
poorer memory performance was demonstrated task, participants typically learn to make advan-
for the immediate and delayed recall of more tageous decisions after a few rounds by prefer-
extensive verbal material (such as longer number ring a small gain with low risk and avoiding
sequences, word lists, factual texts, or stories). and minimizing the risk of long-term losses
despite a possible high gain. Patients with AN
show lower performance (medium effect size)
31.4 Executive Functions, Reward (Wu et al. 2016), which is more pronounced in
Processing, and Decision- the restrictive subtype than in the binge/purging
Making subtype and more pronounced in the acute phase
than after weight rehabilitation (Guillaume et al.
“Executive functions” enable flexible action 2015). Consistent with this, patients with AN
control and self-regulation. They refer to cogni- prefer long-term higher gains in the future over
tive functions for the control and coordination of immediate lower gain options in studies using
mental processes that serve the achievement of delay-discounting paradigms (Steinglass et al.
defined, overarching goals. Executive functions 2017). However, it should be noted that such
have been the focus of many studies in recent tasks require not only the ability for prospec-
years, and several comprehensive meta-analyses tive decision-making but also learning from
are already available. Paradigms for measuring reward contingencies.
cognitive flexibility, i.e., the ability to switch In addition, there are findings that sug-
back and forth between different tasks, cogni- gest general abnormalities in the dopaminergic
tive operations, or rule patterns and coordinate reward systemin patients with AN (see Chap.
them flexibly (set-shifting), as well as paradigms 30). Besides individual studies on general defi-
of inhibitory control, are well studied. In con- cits in learning reward contingencies and devia-
junction with motivational factors, particularly tions in approach and avoidance learning in
reward processing (Chap. 30), executive func- the context of food stimuli, there are numerous
tions play a crucial role in more complex pro- imaging findings that show atypical activation
cesses of decision-making and problem-solving. patterns in striatal regions for reinforcement
learning paradigms.
It should be noted that the vast majority of expense of holistic processing of information.
findings on deficits in cognitive functions in AN Here, there are relatively clear findings of defi-
and weight-rehabilitated AN are based on stud- cits in tasks that examine central coherence in
ies in adults. The findings in children and ado- AN (e.g., “Embedded Figures Test,” “Rey
lescents are much more inconsistent. Possible Osterrieth Complex Figures Test,” “Modified
explanations for this could be that some neu- Block Design Test,” etc., see also Lang et al.
ropsychological deficits either fully develop only 2014). The results show both deficits in global
after a longer period of illness or become more information processing (medium to large effect
detectable with the complete maturation of cog- sizes) and advantages in processing details
nitive functions in adulthood (Bentz et al. 2017). (medium effect sizes). There are also indications
In BN, deficits in “set-shifting” and signs of of weak central coherence in patients with BN,
weak central coherence are also evident, with with similar effect sizes as in AN (Lang et al.
effect sizes similar to those in AN (Lang et al. 2014; Wu et al. 2014).
2014; Wu et al. 2014). Another meta-analysis Current research also focuses on studies on
showed clear deficits in inhibitory control in Theory of Mind (ToM) in eating disorders. This
eating disorders with bulimic symptoms, with refers to the ability to recognize the mental states
“Stroop,” “Go-NoGo,” or “Stop-Signal” tasks of others and to empathize with other people.
commonly used (Wu et al. 2013). Large effect Since ToM abilities play a significant role in the
sizes were found for BN specifically in tasks success of social interactions and interpersonal
related to disease-related stimuli, and small relationships, which are crucial for the course
effect sizes for general tasks. In AN (binge/purg- of eating disorders, numerous studies in recent
ing subtype), a large effect size was also found years have investigated possible ToM deficits in
for general tasks, while no significant effect was various eating disorders. In a recent meta-anal-
observed for BED across all studies. However, ysis with 15 studies (677 individuals with AN or
it should be noted that there are relatively few BN and 514 controls), it was shown that AN was
studies available for AN and BED. Deficits associated with significant ToM deficits, which
can also be demonstrated for BN in the “Iowa were more pronounced in the acute stage of the
Gambling Task” (Wu et al. 2016). disorder. Minor deficits in ToM were observed
For patients with BED or obesity, a number in patients with BN and in weight-rehabilitated
of studies are now also available. Here, deficits patients with AN. Both cognitive perspective-
in cognitive flexibility and decision-making are taking and decoding mental states (ToM decod-
also indicated for patients with BED, which in ing) were found to be impaired in acute AN.
some studies are even more pronounced than The impairment of ToM decoding in BN was
in AN, but overall, the findings are inconsistent moderate, and there was no evidence of a sig-
(Cury et al. 2020). There is also evidence that nificant deficit in ToM perspective-taking (Bora
obesity and overweight (without further eating and Köse 2016). Thus, the observed ToM defi-
disorder symptoms) are also associated with cits could be particularly relevant for the treat-
neurocognitive abnormalities, particularly in ment of AN and may be related to poor insight
terms of inhibitory control. into the disorder, treatment resistance, and social
impairments of the patients.
It has been discussed whether abnormalities
31.5 Central Coherence and Theory in the areas of “central coherence” and “set-
of Mind shifting” might represent a neuropsychological
endophenotype of the eating disorder, as abnor-
Furthermore, there is a series of studies on malities are often found in clinically remitted
“weak central coherence” in eating disorders. patients as well as in healthy first-degree rela-
Weak central coherence describes a cognitive tives. Results from twin studies also suggest a
style that prefers the processing of details at the certain genetic component.
long-term weight stabilization, it is still open

Cognitive remediation therapy whether neurobiological and neuropsycho-
This is a relatively new complementary logical abnormalities are consequences of the
therapy approach for AN with the aim of disorder or already occur premorbidly.
modifying characteristic neuropsycho-
logical profiles and associated cognitive The exact relationship between neurobiological
thinking styles. Building on the findings of markers and neuropsychological performance
neurocognitive deficits, especially in the deficits is also still largely unexplored. There are
area of executive functions, this approach studies that reported significant but weak corre-
aims to specifically train neuropsychologi- lations between structural changes and cognitive
cal functions. The combination of specific deficits, but these findings were not replicated in
training and practical exercises with eve- other studies.
ryday relevance is intended to break up A possible explanation for the heterogeneous
rigid thought patterns and promote flex- neuropsychological findings in eating disorders
ibility and holistic information processing, may also lie in differences in neuroendocrine
as well as train metacognitive abilities. changes. Initial studies have therefore investi-
Initial randomized controlled trials show gated the relationship between neurohormonal
improvements in neurocognitive abilities and cognitive changes in patients with AN. So
such as “set-shifting” and tasks related far, the influence of estrogens, cortisol, allopreg-
to central coherence, as well as improve- nanolone, and dehydroepiandrosterone has been
ments in eating disorder symptomatology examined, and the influence of neuropeptides in
(Dahlgren and Rø 2014). However, fur- animal experimental studies (ghrelin, leptin,
ther longitudinal studies with larger sam- peptide YY). Initial findings suggest interesting
ples and longer follow-up intervals are relationships of learning and memory processes
needed to adequately assess the durability with steroid and neuropeptide levels, confirming
and generalizability of the effects, as well the fundamental importance of neurosteroids for
as the optimal therapeutic dose of such hippocampal functions. In line with this, recent
training. imaging studies have also shown that the nor-
malization of hormonal factors may be a better
predictor of the normalization of abnormalities
in brain structure in patients with eating disor-
31.6 Factors Influencing ders than weight rehabilitation itself (Chui et al.
Neurocognitive Deficits 2008)
The majority of all patients with eating dis-
Many studies have found evidence of structural orders show symptoms of a depressive or dys-
brain changes and changes in brain metabolism thymic disorder during the course of the illness.
in patients with eating disorders, especially Moreover, patients with AN in particular show
in the state of acute starvation. It is unclear an increased likelihood of symptoms of gener-
whether these abnormalities are completely alized anxiety disorder or obsessive-compul-
reversible after weight rehabilitation and long- sive disorder. One may therefore assume that
term weight stabilization, particularly after pro- reported neuropsychological abnormalities do
longed starvation during the critical pre- and not specifically occur in patients with eating
peripubertal developmental phase (Chap. 32). disorders, but are at least partially attributable
to comorbid symptoms., especially as a large
 Important Since structural and functional number of studies do not adequately control
brain changes may not be completely re- for comorbid disorders. In terms of depression,
versible even after weight rehabilitation and many studies show a relationship between the
extent of symptoms and cognitive deficits, but flexibility (e.g., “set-shifting”). Cross-sectional
this usually cannot explain observed group dif- studies have reached similar findings, with clini-
ferences alone (Abbate-Daga et al. 2015). There cally remitted patients often showing slightly
is also evidence for a correlation between neu- better neuropsychological performance com-
ropsychological test performance and dispo- pared to acute patients; however, differences
sitional anxiety, with inconsistent findings on compared to healthy controls can often still be
the influence of anxiety levels at the time of the detected in this group.
examination. The question of whether neurocognitive
For obvious reasons, there is very little lit- deficits in eating disorders represent stable trait
erature on the question of whether long-term characteristics or rather fluctuate in a state-
malnutrition per se can lead to neuropsychologi- dependent manner can be better answered in the
cal abnormalities. Long-term deprivation (up to future by using new methods, such as “ecologi-
24 weeks) has only minimal and fully revers- cal momentary assessments” (EMA), in inten-
ible effects on cognitive abilities (Minnesota sive longitudinal designs. EMA assessments,
Starvation Experiment, Keys et al. 1950). Single for example, allow the recording of binge eating
case studies in AN show that even with extreme episodes using repeated smartphone-based diary
underweight, cognitive functions can largely queries and short neurocognitive tasks that can
remain within the normal range. Short-term food also be performed in the patients’ everyday lives
deprivation (up to 24 hours) in participants with- on their smartphones. In individuals without
out eating disorders appears to have no general eating disorders, it has already been shown that
negative effects on cognitive performance, but inhibition deficits are strongly situation-depend-
subtle deficits are occasionally found in tasks ent, raising the question of which neurocognitive
related to executive functions (e.g., “set-shift- deficits in eating disorders reflect state or trait
ing,” “central coherence”; Sect. 31.4). phenomena and what are the momentary ante-
cedents or consequences of such deficits in rela-
tion to the occurrence of specific eating disorder
31.7 Neuropsychological Findings symptoms.
in the Course of Therapy
Some longitudinal studies collect neuropsycho- 31.7.1 Can Neuropsychological

logical data not only during the acute phase of Performance Predict the Course
illness (Hemmingsen et al. 2020). However, of the Eating Disorder?
the determination of a second assessment time
point after successful therapy varies consider- Usually, no direct correlations are found
ably depending on the study, limiting the com- between the neuropsychological functional
parability of the findings, and not all studies level and the course of the eating disorder or the
take into account possible practice effects for response to treatment. In corresponding stud-
the tasks used. Some studies reported no or only ies, no consistent reliable predictors for therapy
weak unspecific improvements across all exam- success after a defined period (usually defined
ined functional areas, and occasionally even as successful weight rehabilitation) or discharge
deteriorations in certain test results, while oth- from the clinic were identified based on neu-
ers found improvements after successful weight ropsychological test results. There is evidence
rehabilitation. In children and adolescents with that patients who still show consistent neuropsy-
AN, relatively consistent improvements in gen- chological deficits in several areas at discharge
eral processing speed are found. Persisting defi- are more likely to relapse.
cits are mainly found in the area of cognitive
31.8 Conclusion and Outlook References
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Imaging Techniques
in Eating Disorders 32
Ursula Bailer
Contents
32.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
32.3 Bulimia nervosa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
32.1 Overview  Important Imaging techniques for visualizing

the brain make it possible to measure both re-
The use of modern neuroradiological and gional brain activity and the function of neu-
nuclear medicine examination methods in the roreceptors in vivo, and subsequently identify
investigation of the pathophysiology of eating neuronal circuits that contribute to eating
disorders has gained increasing importance over disorder-specific symptoms such as restric-
the past two decades. There is now ample evi- tive eating behavior, body image disturbance,
dence that changes in central nervous serotonin “binge-purging,” etc.
and dopamine metabolism may play a role in the
pathogenesis of eating disorders. However, this A variety of examination methods are avail-
evidence comes primarily from studies that use able for this purpose. Structural examination
indirect methods to characterize central nervous methods such as computed tomography (CT)
neurotransmission, such as the determination of or magnetic resonance imaging (MRI) provide
the concentration of certain neurotransmitters or general information about structural deviations
their breakdown products in cerebrospinal fluid of the brain, e.g., regarding the volume of indi-
or the hormonal response to specific pharmaco- vidual brain regions. Magnetic resonance spec-
logical stimulation tests. troscopy (MRS) allows the investigation of brain
metabolism by identifying and quantifying spe-
cific metabolites. Positron emission tomogra-
phy (PET), Single-Photon Emission Computed
Tomography (SPECT), and functional magnetic
U. Bailer (*)
resonance imaging (fMRI) allow for statements
Vinzenz von Paul Hospital, Department for
Psychiatry and Psychotherapy, Rottweil, Germany about changes in regional cerebral blood flow
e-mail: [email protected] or glucose metabolism. These examinations can
https://doi.org/10.1007/978-3-662-67662-2_32
240 U. Bailer
be performed either with or without activation, Conclusion

depending on the research question, i.e., with or
The structural changes found appear to be
without a specific provocation test. The function
rather unspecific; at least, no connection
of neurotransmitter receptors and transporters
with neuropsychological variables such as
can be investigated using SPECT and PET and
anxiety, depression, attention, or memory has
corresponding specific radioligands (so-called
been found in the studies conducted so far.
tracers).
Likewise, the atrophy present in the disor-
dered state seems to be completely reversible
within the context of a longer remission and
32.2 Anorexia nervosa
weight normalization. Furthermore, it is not
certain whether these are generalized changes
32.2.1 Computed Tomography
in the brain or whether there are regional
and Magnetic Resonance
differences.
Imaging
From CT and MRI examinations, it is known 32.2.2 Magnetic Resonance

that patients with anorexia nervosa (AN) in the Spectroscopy
disordered state have enlarged sulci and ventri-
cles and a reduced brain volume. However, it MRS provides information about possible nerve
remains unclear whether these deviations in the cell damage by determining metabolites such as
disordered state are attributable to changes in choline-containing substances, N-acetylaspartate
white or gray matter or the extracellular space. (NAA), creatine and phosphocreatine, gluta-
A reduction in gray matter has been repeatedly mate/glutamine, and myo-inositol. In adolescent
found, both in the disordered and in the remitted patients with AN, increased choline-containing
state of the disorder; the results regarding white substances were found in relation to creatine,
matter are inconsistent. More recent studies on while the NAA: choline ratio in the occipi-
the integrity of white matter using “diffusion tal white matter was reduced. These changes,
tensor imaging” have found losses in some brain which can be interpreted as disturbed cell mem-
regions, but the case numbers are still small and brane turnover, were reversible after the patients’
do not yet allow for a conclusive assessment, recovery. Two other studies showed reduced
and the exclusion of possible artifacts (e.g., values for phospholipids in frontal and occipi-
enlarged ventricles or other cerebrospinal fluid tal regions, which in turn correlated positively
spaces that could lead to an artificially reduced with the body mass index (BMI), and a posi-
integrity of white matter) requires further meth- tive correlation between reduced myo-inositol
odological clarification and possibly re-analysis in the frontal white matter and BMI. Reduced
of previous studies. Deficits in gray matter were values for NAA and creatine in the dorsolateral
found mainly in the limbic system, particularly prefrontal cortex seem to be associated with a
in the amygdala, hippocampus, and cingulum, reduced attention performance in these patients,
i.e., regions of emotion processing, as well as in especially for NAA.
the putamen, a structure in the basal ganglia that
plays a role in learning but also in the regulation
of the dopaminergic system.
32 Imaging Techniques in Eating Disorders 241
32.2.3 Positron Emission Tomography Conclusion

(Single-Photon Emission
In previous studies on cerebral blood flow
Computed Tomography)
and glucose metabolism, changes in the form
of hypoperfusion or hypometabolism in fron-
tal, temporal, and parietal regions were found
32.2.3.1 Without Activation
in AN in the disordered state. Normalization
The majority of studies used SPECT to measure
seems to occur after weight gain. Small case
cerebral blood flow. Here, hypoperfusion in the
numbers, lack of subdivision into subtypes
temporal lobe was found in 13 out of a total of
of AN (restrictive vs. binge/purge type), and
15 examined patients with AN, which persisted
methodological differences render it difficult
even after the patients had gained weight. In a
to make a final assessment, especially for the
case report of two patients with AN, bilateral
disordered state. With the availability of func-
hypoperfusion in frontal, temporal, and parietal
tional magnetic resonance imaging (fMRI)
regions was observed, which regressed after
for the representation of functional differ-
3 months of remission of the eating disorder.
ences, these aforementioned examination
Hypoperfusion in the medial prefrontal cortex,
methods have also increasingly receded into
anterior cingulate, insular region, and temporo-
the background.
parietal, occipital, and orbitofrontal cortex was
also confirmed by other studies with compara-
tively larger case numbers. Only one study so
32.2.3.2 With Activation
far has found hyperperfusion in the thalamus
Only a small number of PET or SPECT studies
and in the area of the amygdala and hippocam-
have used a provocation test to investigate neu-
pus. There is only one PET study on the rep-
ronal activity. The consumption of cake resulted
resentation of cerebral blood flow in patients
in increased brain activity in frontal, parietal,
with AN in the disordered state. In contrast to
temporal, and occipital regions in patients with
the SPECT studies, this study found no signifi-
AN compared to healthy controls. Merely view-
cant difference compared to healthy controls,
ing food showed increased activity in the right
in terms of either hypo- or hyperperfusion in
parietal and prefrontal areas in patients with AN
the aforementioned regions. To what extent the
of the binge/purge type compared to healthy
hypoperfusion found in the SPECT studies con-
controls and patients with AN of the restrictive
ducted so far in various regions is also a conse-
type. In a PET study, viewing high-calorie foods
quence of methodological differences needs to
led to greater temporo-occipital activation com-
be further clarified.
pared to viewing low-calorie foods.
Follow-up studies that included patients in the
underweight state and after weight gain gener-
ally showed an increase in perfusion in the dor-
32.2.4 Functional Magnetic Resonance
solateral and medial prefrontal cortex and, with
Imaging
limitations, in the anterior cingulate. Complete
normalization also seems to occur after a longer-
Studies have also been conducted using fMRI,
lasting remission of the eating disorder (>1 year),
in which the viewing of food was used as a
similar to the study on cerebral atrophy.
stimulus. It has been shown relatively consist-
A series of PET studies focused on glucose
ently that patients with AN, compared to healthy
metabolism in AN patients and found fron-
controls, have increased activity in the medial
tal and parietal hypometabolism in the disor-
prefrontal cortex, anterior cingulate, and stria-
dered state, which normalized after weight gain
tum. A decreased neuronal activity in the insular
occurred.
region in response to a taste stimulus (sucrose
242 U. Bailer
vs. water) also indicates a change in taste per- the temporal and prefrontal cortex and cingu-
ception in these patients. The provocation with late. These regions are crucially involved in
disorder-specific foods and taste stimuli mainly the regulation of emotions and fear. To what
shows an increased neuronal response in both extent these changes are specific to AN needs
the emotion and fear networks in AN patients, to be further clarified, as similar changes
which presumably leads to avoidance behavior. have also been found in obsessive-compul-
Body schema disorders play an important sive disorders. The activity in the parietal cor-
role in the pathophysiology of eating disorders, tex and insula also appear to be regions that
so imaging techniques using fMRI have also distinguish patients with AN from healthy
addressed this issue. In patients with AN, view- controls, thus providing a possible explana-
ing their own, but digitally distorted bodies, led tion for the altered body perception. Patients
to increased activation in regions associated with AN seem to have a reduced response to
with the frontal visual system and attention net- taste stimuli and other reward stimuli; this
work (Brodmann area 9) as well as the inferior reduced stimulus response could possibly
parietal lobe, while viewing similarly distorted enable them to drastically reduce food intake,
bodies of other people did not result in such especially with regard to otherwise reward-
specific activation. In comparison, healthy con- ing, mostly high-calorie foods.
trols showed no corresponding differentiation
in this experimental setup. Thus, patients with
AN seem to have a different visual-spatial pro-
cessing of stimuli compared to healthy controls. 32.2.5 Neurotransmitter Studies using
Furthermore, it was found that women who SPECT and PET
compared their own body with that of another
person showed increased activity in striatal, The use of specific radioligands in conjunction
medial prefrontal regions and the insular region with SPECT or PET allows for the visualization
compared to men, in the sense of a gender- of serotonergic and dopaminergic receptors in
specific brain response, which might be related the brain and, subsequently, for the development
to the higher prevalence of eating disorders in of a better understanding of neurotransmitter
women. activity and their relationship to human behav-
Another study investigating the reward sys- ior. Several radioligands exist for the seroton-
tem showed that remitted patients with the ergic system, and the most frequently studied
restrictive type of AN have difficulty differen- receptor is the serotonin(5-HT)2A receptor, a
tiating between positive and negative feedback postsynaptic receptor that is involved in the reg-
in the anteroventral striatum and perceiving the ulation of food intake, mood, and anxiety, and
emotional significance of a stimulus compared also plays a role in the action of antidepressants.
to healthy controls. Instead, these patients seem It has been shown that patients exhibit reduced
to have increased activity in the dorsal caudate, 5-HT2A receptor binding, both in the disordered
a brain area associated with planning and conse- state and after remission. Remitted AN patients
quences, and the activity in this region was cor- of the binge/purge subtype show reduced bind-
related with anxiety. ing in the subgenual cingulum, as well as in the
parietal and occipital cortex compared to healthy
controls. Remitted patients of the restrictive
Conclusion subtype show additional reduced binding in the
It is difficult to compare the various fMRI mesiotemporal cortex.
studies in AN, as the studies differ in both Another serotonin receptor is the 5-HT1A
imaging methodology and the stimulus used. receptor, a pre- and postsynaptic receptor that
Nevertheless, healthy controls and patients also plays an important role in the regulation of
with AN seem to differ mainly in activity in anxiety, mood, impulsivity, and food intake and
has a significant function in the action of anti- extent of released dopamine in the anteroven-
depressants. It has been found that remitted AN tral striatum. The enjoyment of palatable food,
patients of the binge/purge subtype have signifi- which also leads to increased dopamine release,
cantly increased 5-HT1A binding in frontal, pre- could therefore be experienced as anxiety-induc-
frontal, temporal, and parietal regions, as well ing by patients with AN and might explain why
as in the supra- and pregenual cingulum and they primarily avoid this food. Moreover, stud-
in the dorsal raphe nuclei compared to healthy ies have shown that certain characteristics fre-
controls. Remitted AN patients of the restrictive quently found in patients with eating disorders,
subtype, on the other hand, did not differ signifi- such as “harm avoidance” (a measure of anxi-
cantly in 5-HT1A binding from healthy controls. ety) or the desire to be thin, correlate with these
In the disordered state, the 5-HT1A receptor aforementioned neural changes.
binding is even more pronounced both pre- and
postsynaptically. This could be a possible cause
for the known lack of response of AN to, for Conclusion
example, selective serotonin reuptake inhibitors It can be assumed that the observed changes
(SSRI) in the disordered state, as a down-regula- reflect a complex dysregulation of these neu-
tion of the 5-HT1A receptors, which is essential ral circuits rather than representing the exact
for the action of SSRI, may not be possible to a etiology. However, previous studies have
sufficient extent. shown serotonergic and dopaminergic dys-
Remitted AN patients of the restrictive sub- regulation in brain regions associated with
type showed increased serotonin transporter(5- the limbic system. In general, these changes
HTT) binding, whereas remitted AN patients seem to be present in both the disordered and
of the binge/purge subtype exhibited reduced remitted states. The respective 5-HT receptor
5-HTT binding. Regarding dopaminergic D2/D3 binding patterns differ between the different
binding, only remitted AN patients of the restric- eating disorder subtypes in the remitted state,
tive subtype showed increased D2/D3 binding in suggesting that there may be a distinct patho-
the anterior ventral striatum compared to healthy physiology behind each eating disorder sub-
controls (Table 32.1). Amphetamine-induced type. Similar binding patterns (i.e., increased
dopamine release led to increased anxiety in 5-HT1A and reduced 5-HT2A binding) have
remitted AN patients, which positively corre- also been found in other brain areas – such
lated with dopamine release in the dorsal cau- as temporal, cingulate, and parietal regions
date, while healthy controls responded with the – indicating a distribution beyond the limbic
expected euphoria, which correlated with the system.
Table 32.1  Receptor and transporter binding potential in anorexia nervosa and bulimia nervosa in remission com-
pared to healthy controls. (Mod. after Kaye 2008, with kind permission of Elsevier Publishing)
AN AN-BN BN
Examined region Medial orbitofrontal cortex, subgenual cingulum, medial temporal cortex
5-HT1A-BP – ↑ ↑
5-HT2A-BP ↓ ↓ –
Examined region Anterior ventral striatum
5-HTT-BP ↑ ↓ –
D2/D3-BP ↑ – –
BP Receptor and transporter binding potential, 5-HT1A Serotonin1A receptor, 5-HT2A Serotonin2A receptor, 5-HTT
Serotonin transporter, D2 /D3 Dopamine-D2/D3 receptor, AN restrictive type of anorexia nervosa, AN-BN binge/purge
type of anorexia nervosa, BN Bulimia nervosa
↑ increased; ↓ reduced, – unchanged
244 U. Bailer
32.3 Bulimia nervosa 32.3.3.2 With Activation

Before a test meal, patients with BN showed
32.3.1 Computed Tomography greater right (inferior) frontal and left temporal
and Magnetic Resonance blood flow compared to healthy controls, but
Imaging similar activation after the meal.
A few studies have found pituitary changes,

brain atrophy, and enlargement of the cerebro- 32.3.4 Functional Magnetic Resonance
spinal fluid spaces. However, it is hardly pos- Imaging
sible to draw conclusions about the etiology or
impact of these changes, as they are largely sub- Stimulation with disorder-specific food stimuli
ject to short-term fluctuations in food intake. leads to reduced activation in the lateral prefron-
tal cortex in patients with BN, a region crucial
for inhibitory control. Altered activities can be
32.3.2 Magnetic Resonance found in both the reward network and the ante-
Spectroscopy rior cingulate and insular regions (compared
to healthy controls), although the direction of
In a mixed group of patients with AN and BN, changes in the studies is still inconsistent and
a prefrontal reduction of myo-inositol and lipid- requires further clarification.
containing substances was observed. Whether fMRI studies with a taste stimulus in patients
these changes were specific to BN, however, with BN compared to healthy controls showed
remains unclear. reduced activation in the reward network, includ-
ing the ventral striatum, orbitofrontal cortex,
anterior cingulate, insular region, and ventral pre-
32.3.3 Positron Emission Tomography frontal cortex. Since these regions play a role in
(Single-Photon Emission the anticipation of potential reward, the reduced
Computed Tomography) activation could be a sign of reduced reward
anticipation in patients with BN, making them
vulnerable to so-called overeating. Furthermore,
32.3.3.1 Without Activation a catecholamine depletion study found that the
In the disordered state, a globally reduced dopamine-associated reward network in patients
blood flow could be found using PET, with a with BN appears to be desensitized, leading to a
significant difference to healthy controls in the decoupling between neurotransmitter function
parietal cortex. and behavioral response.
Depressive symptoms correlated in another
study with regional blood flow in the left ante-
rolateral prefrontal cortex. Two studies showed 32.3.5 Neurotransmitter Studies using
that regional cerebral blood flow normalized SPECT and PET
again after remission of the disorder.
While 5-HT2A binding does not differ from
healthy controls in both remitted and disordered
states, it has been shown that 5-HT1A binding References

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The Gut Microbiome
in Anorexia Nervosa 33
Jochen Seitz
Contents
33.1 Weight development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248
33.2 Immunology and Inflammation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
33.3 Gut-Brain Axis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
In the case of AN, as well as depression, anxi- 500 different bacterial species, which outnumber
ety disorders, and stress reactions—and a long the total number of human genes by a factor of
list of somatic diseases—a change in the gut about 150 (Sender et al. 2016).
microbiome is now well documented, and a Therefore, it is not surprising that these intes-
causal involvement in the respective pathophysi- tinal bacteria, more than previously assumed,
ology has been at least suggested by animal perform a variety of useful functions for the
experiments. human organism and have entered into a symbi-
“Gut microbiota” includes all bacteria, fungi, otic relationship with it.
viruses, and archaea found in the intestine,
with bacteria making up the main component.
In the human intestine, there are about 500 dif- Overview
ferent bacterial species, which are individually • Intestinal bacteria can break down and
composed of about 2,000 possible candidates metabolize food components such as
(Almeida et al. 2019). Many of them are still dietary fiber that would otherwise be
largely unknown and have never been cultivated lost to the body. This provides impor-
and characterized. There are about as many bac- tant building blocks such as short-
teria in the intestine as eukaryotic cells in the chain fatty acids and vitamins, as well
entire rest of the body, and their total weight is as an additional energy source. This
estimated at 1–2 kg. The term “gut microbiome” has a significant influence on weight
usually refers to the entirety of all genes of these development.
• Furthermore, intestinal bacteria con-
J. Seitz (*) tinuously interact with our immune
Clinic for Child and Adolescent Psychiatry, system. In “quiet times,” they help
Psychosomatics and Psychotherapy, LVR University “train” it, and when potentially invading
Hospital Essen, Essen, Germany
https://doi.org/10.1007/978-3-662-67662-2_33
248 J. Seitz
Since all three areas are relevant for eating dis-

pathological bacteria are present, they orders, it is important to take a closer look at
serve as an “advanced early warning the role of gut microbiota in AN (unfortunately,
system” for the immune cells of the there are hardly any findings on bulimia nervosa
intestinal wall and can activate them or binge eating) (Fig. 33.1).
through cytokines. An intact microbi-
ota cell lawn on the intestinal wall also
has a placeholder function and makes it 33.1 Weight development
more difficult for pathobionts to settle.
• Meanwhile, more and more is known The gut microbiome has a decisive influence
about a direct interaction between on the regulation of body weight through the
intestinal bacteria and the brain and energy made available per amount of food for
our behavior, the gut-brain axis. The the human body. In 2005, an altered gut micro-
enteric nervous system and direct con- biome was detected for the first time in patients
nections to the brain, such as the vagus with overweight, which seems to extract more
nerve, seem to play a role in this regard. energy from the same amount of food (Ley
In addition, metabolites, hormones, and et al. 2005). Transplantation studies in so-called
cell wall components of bacterial origin germ-free mice, which have grown up com-
constantly pass through the intestinal pletely sterile without intestinal bacteria (germ-
wall into the bloodstream. These can free, GF mice), provided evidence for a causal
either have direct effects in the brain role of these bacteria: The transplantation of
or indirectly through immune activa- feces from overweight mice led to an increase in
tion and inflammatory processes (Cryan body weight of the recipient mouse compared to
et al. 2019). the transplantation of feces from normal-weight
Brain/Behavior:
• Microbiome interacts with the brain ("gut-brain axis")
• Microbiome influences learning, anxiety and mood
• Microbiome modulates cell neogenesis in the brain
Intestinal tract:
• Microbes break down nutrients and influence
energy intake and weight regulation
• Increased intestinal permeability in the AN
animal model.
Immunology:
• Bacterial antigens cross the intestinal wall
• Low-grade inflammatory processes in AN
• Autoantibodies against hunger/satiety hormones
Intestinal microbiome:
• Dysbiosis: altered microbiome diversity and
composition
• More protein fermenting taxa could degrade mucin
degrade and thus increase intestinal permeability
Fig. 33.1  Overview of the interactions between the microbiome and the body relevant for AN
33 The Gut Microbiome in Anorexia Nervosa 249
mice—with the same diet. Conversely, the trans- crypt depths, and decreased tight junction pro-
plantation of feces from underweight children teins (which regulate cell-cell tightness) (Trinh
with kwashiorkor led to weight loss (Smith et al. et al. 2021). The intestinal microbiome con-
2013). Feces from patients with bariatric gastric tinuously interacts with the enterocytes of the
reduction also led to a weight increase before intestinal mucosa and also has a major influence
surgery—after the surgery, however, this effect on permeability (e.g., in chronic inflammatory
disappeared (Tremaroli et al. 2015). In 2019, bowel diseases). In AN, during semi-starvation,
a similar finding was made for the first time an increase in mucus-degrading Firmicutes and
in patients with AN: Feces from patients with Verrucomicrobia has been observed, with a
AN were transplanted into GF mouse moth- simultaneous decrease in carbohydrate-degrad-
ers, whose offspring gained weight only half ing Bacteroidetes. The former have a selective
as fast as offspring of GF mouse mothers with advantage because they can use the mucins of
the transplant of normal-weight control subjects the protective mucus layer as a food source—
(Hata et al. 2019). This demonstrated a causal but this could also contribute to a further shift
relationship between the gut microbiome and towards even greater permeability. As a result,
weight development for the animal model in bacterial metabolites or bacterial components
AN as well. Possibly, the different gut microbi- such as lipopolysaccharides in the intestinal
ome compositions found in patients with restric- wall and blood could lead to inflammatory reac-
tive versus binge-purge AN (Mack et al. 2016) tions and immune responses. In fact, low-grade
may even help to explain the different amounts chronic inflammation with increased inflam-
of energy needed for weight gain (significantly matory markers such as IL-6 and TNF-alpha
more in restrictive AN), but further research is is known from meta-analyses in AN (Dalton
needed in this regard. et al. 2018), which could possibly be related.
Fetissov’s research group was also able to dem-
 Intestinal bacteria play an important role onstrate that patients with AN produce increased
in energy extraction from food, which antibodies, e.g., against certain E. Coli bacte-
appears to be reduced in AN. rial components (Tennoune et al. 2014). These
antibodies show cross-reactivity with hunger
and satiety hormones such as ghrelin and alpha
33.2 Immunology and Inflammation MSH and seem to influence their receptor bind-
ings. In animal experiments, E. Coli admin-
Increased stress and cortisol levels, as often istration not only specifically induced these
found in AN, can increase the permeability of antibodies but also influenced eating behavior,
the intestinal wall and thus the possibility of so this may also be relevant for the pathophysi-
bacterial strain products entering the organ- ology in humans. In addition, patients with AN
ism as described above. However, increased generally have an increased occurrence of auto-
intestinal permeability has not yet been clearly immune diseases, which could also be related.
demonstrated in AN. While there is evidence of For example, endocrine autoimmune diseases
even decreased permeability in the small intes- are 2.4 times more common and gastrointesti-
tine in patients, several studies in the activ- nal diseases 1.8 times more common—Crohn’s
ity-based anorexia animal model have shown disease even 3.9 times more common than in
increased permeability in the large intestine. control subjects (Raevuori et al. 2014). A case
Our own studies with this animal model, in study describes a patient with Crohn’s disease
which rodents receive less food and paradoxi- who also suffered from AN and both diseases
cally show increased wheel running activity, improved significantly under immunosuppres-
also point towards an increase. Here, we were sive anti-TNF-alpha therapy (Solmi et al. 2013).
able to detect thinner intestinal walls, reduced
250 J. Seitz
 Inflammation and (auto-)antibodies could of the number of different bacteria in the gut
thus represent important mechanisms in of an individual patient (Seitz et al. 2019).
the pathophysiology of AN and the inter- Unfortunately, the findings are overall very het-
action with the intestinal microbiome. erogeneous, which is probably due to additional
influencing factors on the microbiome, such
as diet, previous development including mode
33.3 Gut-Brain Axis of birth and breastfeeding, as well as exercise,
other diseases, and medication use. A reduc-
The (initially maternal) gut microbiome inter- tion in alpha diversity is usually associated with
acts from the very beginning with the normal negative consequences, as the microbial commu-
(brain) development of humans and animals. nity may no longer be able to respond as flex-
For example, altered transmitter and growth hor- ibly to disturbances. Reduced alpha diversity is
mone concentrations in the brains of germ-free also found in patients with obesity, depression,
(GF) mice and altered anxiety reactions have and chronic inflammatory bowel diseases, and
been detected. This is the reason why the detour in patients with AN was found to partly corre-
via germ-free mouse mothers was chosen in late with their eating disorder symptoms as well
the above-mentioned transplantation study with as their depression and anxiety (Kleiman et al.
stool from patients with AN—so that the mouse 2015). The so-called beta diversity, a measure of
offspring would no longer grow up without, the heterogeneity of the microbiota composition
but only with an AN-typically altered microbi- of a group, also differs significantly in almost
ome. Interestingly, in addition to poorer weight all studies in AN. However, which individual
gain, these mice also showed increased anxiety bacterial species are increased or decreased var-
and compulsiveness, two typical comorbidities ies greatly from study to study, meaning that
of AN (Hata et al. 2019). Since the control ani- no uniform picture has yet emerged. It seems
mals did not show these effects, this behavior relevant, however, that these changes do not
also seems to be causally induced by the stool of completely regress with weight rehabilitation
patients with AN. This is consistent with trans- (Schulz et al. 2020).
plantation studies with stool from depressed
patients, in which a depressive phenotype was 
This means that these microbiome
also demonstrated in the rat model (Kelly et al. changes in patients with AN are more than
2016). A quasi-complete secondary reduction just a mere epiphenomenon of malnutri-
of gut bacteria by various antibiotics in mice tion or weight loss, but could represent
led in another series of experiments to a restric- a relevant part of the maintaining patho-
tion of learning ability, which was associated physiology. This would also be consist-
with reduced neurogenesis in the hippocampus. ent with the causal findings of the animal
Probiotic supplementation of lacto- and bifido- experiments described above.
bacteria was able to restore both learning ability
and neurogenesis (Möhle et al. 2016). The brain This increases the chances that microbiome-
volume reduction known in patients with AN centered therapies will one day complement
and the possible underlying loss of astrocytes the current AN treatment. These could be in
in the brain could also be related to the microbi- the form of nutritional interventions, supple-
ome. Our own studies demonstrated a possible ments, and prebiotics that stimulate the growth
connection between the loss of gray matter and of specific gut bacteria. For example, omega-3
the diversity of the microbiome in the animal fatty acids influence inflammation and weight
model (Trinh et al. 2021). through the gut microbiome (Costantini et al.
Most studies in patients with AN show a 2017). Interventions can also involve the direct
reduction in so-called alpha diversity, a measure administration of probiotics, i.e., living bacteria
33 The Gut Microbiome in Anorexia Nervosa 251
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disorder. Initial results show a reduction in MAA, Breen G … Himmerich H (2018) A meta-anal-
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teria in anxiety and depression (Pirbaglou et al. Van Hul M, Vieira-Silva S … Cani PD (2019)
Supplementation with Akkermansia muciniphila in
2016). Fecal transplantations could then also overweight and obese human volunteers: a proof-
be performed in patients, as they have shown of-concept exploratory study. Nat Med 25(7):1096–
excellent results in Clostridium difficile infec- 1103. https://doi.org/10.1038/s41591-019-0495-2
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Kimura-Todani T … Sudo N (2019) The gut micro-
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thus represent promising approaches for intestinal microbiota in acute anorexia nervosa
the exploration of future additions to con- and during renourishment: relationship to depres-
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Psychosomat Med 77(9):969
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sometimes relatively easy-to-implement inter- anorexia nervosa does not ameliorate the faecal
vention options, there is hope that this knowl- microbiota, branched chain fatty acid profiles, and
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Möhle L, Mattei D, Heimesaat MM, Bereswill S, Fischer
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Part V
Medical Complications and Somatic
Comorbidity
253
Medical Complications
and Bulimia Nervosa
Hans-Christoph Friederich, Valentin Terhoeven and

Christoph Nikendei
Contents
34.1 Physical Complaints and Laboratory Chemical Changes . . . . . . . . . . . . . . 255
34.2 Organ Manifestations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260
In an observation period of 21 years after the 34.1 Physical Complaints

initial inpatient treatment for severely ill patients and Laboratory Chemical
with AN, the mortality rate was 16% (Zipfel Changes
et al. 2000). In this long-term study the most
common causes of death resulting from somatic Characteristic of patients with eating disorders
complications were infections (pneumonia, sep- in the initial phase of their illness is a lack of
sis) and cardiovascular complications due to or even absent illness insight. The first contacts
dehydration and electrolyte imbalances. with healthcare providers therefore often occur
due to physical sequelae rather than eating dis-
 Important AN is one of the most com- order symptoms. Physicians play an important
mon causes of death among young girls and role in the early detection and planning of fur-
women aged between 15 and 25 years. ther treatment processes for patients with eating
disorders. The spectrum of reported physical
complaints is very diverse. Table 34.1 summa-
rizes the most frequently mentioned symptoms
and complaints of AN and BN patients.
H.-C. Friederich (*) · V. Terhoeven · C. Nikendei  Important Patients with eating disorders usually
Centre for Psychosocial Medicine, Department for seek general practitioners, internists, gynecologists,
General Internal Medicine and Psychosomatics,
orthopedists, and dentists first due to physical com-
University Hospital Heidelberg, Heidelberg,
Germany plaints; in doing so, patients often try to conceal the
e-mail: [email protected] eating disorder.
V. Terhoeven
e-mail: [email protected] In patients with anorexia, numerous changes in
C. Nikendei laboratory chemistry can be observed. These
e-mail: [email protected] include, among others
https://doi.org/10.1007/978-3-662-67662-2_34
256 H.-C. Friederich et al.
Table 34.1  Common physical complaints in AN and complicate hypokalemia due to potassium

BN losses via the kidney and intestine. Furthermore,
Anorexia Bulimia patients with AN have an increased risk of
nervosa nervosa developing hypomagnesemia. The mentioned
Vertigo, collapse tendency, + – electrolyte changes can lead to serious compli-
acrocyanosis
cations, such as cardiac arrhythmias, reduced
Cold sensitivity, hypothermia + – intestinal motility, renal insufficiency, and cer-
Abdominal complaints, consti- + + ebral seizures. Patients with eating disorders
pation often substitute electrolytes and vitamins with-
Heartburn, pain in the throat area +* + out medical consultation. Therefore the absence
Parotid swelling +* + of electrolyte changes does not rule out labora-
Amenorrhea, fertility disorder + (+) tory-effective purging behavior. Another labora-
Apathy, concentration disorder + + tory chemical indication of frequent vomiting is
Muscle weakness, muscle cramps + (+)
hyperamylasemia (elevation of salivary amylase)
or bilateral parotid swelling. If hypokalemia
Skeletal pain under strain + –
does not respond to potassium substitution, the
Teeth damage, tooth hypersen- +* +
magnesium level should be checked, as a mag-
sitivity
nesium deficiency can prevent the increase of
Dry skin, hyperpigmentation + (+)
potassium despite therapeutic substitution.
Lanugo hair, hair loss + –
Sleep disturbance with early + –  Important There is a particularly high risk
waking
for the occurrence of severe hypokalemia
+ common; (+)rare; * only with vomiting when vomiting and simultaneous abuse of
diuretics and/or laxatives occur.
• Disorders of blood formation in the bone Infections and inflammations are often detected
marrow (e.g., anemia, leukopenia with rela- very late in underweight patients with eating dis-
tive lymphocytosis), orders. The reason for this is that patients with
• Enzyme increase in various organs (e.g., AN mostly do not develop the expected signs of
transaminases, salivary amylase), infection, such as febrile temperatures, tachycar-
• Shifts in electrolytes (e.g., hypokalemia, dia, and increased inflammation parameters. In
hypophosphatemia), the assessment of infection signs and parameters,
• Multiple hormonal changes (e.g., hypogon- it should therefore be noted that AN patients often
adotropic hypogonadism), show a reduced increase in the mentioned param-
• Hypercholesterolemia. eters on the one hand, and on the other hand, an
increase in the same parameters due to lower ini-
The laboratory chemical changes are nonspe- tial values (Cuntz et al. 2015; Zeeck et al. 2019).
cific but provide information about the sever-
ity and medical risk of the starvation process or
purging behavior. Patients with eating disorders 34.2 Organ Manifestations
are particularly at risk due to rapidly occur-
ring electrolyte changes. Purging behavior with The following section will discuss medical com-
self-induced vomiting leads to a loss of potas- plications in individual organ systems in more
sium and chloride. The abusive use of diuretics detail. Starvation-related changes can generally
and laxatives for weight regulation can further occur in all organs.
34 Medical Complications in Anorexia Nervosa … 257
34.2.1 Cardiovascular System monitoring. Furthermore, in the presence of

an extended (frequency-corrected) QT time,
Weight loss, regardless of an eating disorder, regular monitoring of electrolytes (potassium,
leads to sinus bradycardia, a decrease in the calcium, magnesium) should be ensured.
stroke volume of the heart, and a drop in systolic
and diastolic blood pressure as an expression of When measured echocardiographically and aus-
a physiological adaptation process to reduced cultatorily, a mitral valve prolapse can be detected
energy supply. Due to the resulting hypovolemia, in approximately 60% of AN patients. This usu-
rapid position changes from lying to standing ally does not result in a manifest mitral valve
can lead to orthostatic hypotension and even cir- insufficiency and therefore has no clinical signifi-
culatory collapse. In addition to these functional cance (Cuntz et al. 2016; Sachs et al. 2016).
changes, the most serious cardiovascular com-
plications with possible death are primarily the
occurrence of cardiac arrhythmias and myocardial 34.2.2 Skeletal System
atrophy. In patients with bulimia nervosa (BN)
and normal body weight, cardiovascular compli- Significant, irreversible medical complica-
cations occur less frequently than in patients with tions in chronic cases for AN and underweight
AN but can also be observed as a consequence of BN patients range from reduced bone density to
self-induced vomiting and hypokalemia. osteoporosis. Puberty is a sensitive phase of bone
The decrease in muscle mass of the heart’s development, during which the maximum bone
ventricles is disproportionately greater than the mass (so-called “peak bone mass”) is achieved.
decrease in body weight. This may be related Due to the typical onset of the eating disorder
to a reduced left ventricular afterload (arterial and underweight being around puberty, there is
hypotension) and reduced heart rate. The cells a reduced bone formation and a lower maximum
of the conduction system are also affected by bone mass. More than half of adolescents with
the atrophy of the heart muscle. This leads to a AN show a reduction in bone density in the sense
ventricular repolarization disorder, which can of osteopenia, and a quarter show osteoporosis
be measured in the electrocardiogram (ECG) as as the most severe form of reduced bone density.
an extended (frequency-corrected) QT time and In chronic cases of the disorder, 44% of those
increased QT dispersion (difference between the affected show osteoporotic bones after a disorder
minimum and maximum QT time in a 12-lead duration of eleven years. Trabecular bone struc-
ECG). Furthermore, chronically ill patients tures in the area of the thigh and lumbar spine are
with AN show altered autonomic cardiac func- particularly affected. In competitive athletes (e.g.,
tion with reduced heart rate variability. Both an ballet dancers), the disease, in combination with
extended QT time and reduced heart rate vari- significant physical stress, can lead to pathologi-
ability are considered risk factors for the occur- cal fractures and stress fractures at a young age.
rence of cardiac arrhythmias and sudden cardiac Moreover, those affected with long-lasting AN
death. In addition, electrolyte changes, which are have up to a 4-fold increased fracture risk.
frequently observed in patients with eating disor- The mechanisms leading to reduced bone
ders (e.g., hypokalemia), can increase the risk of mass in patients with AN are complex. In con-
lethal cardiac arrhythmias. trast to postmenopausal osteoporosis, in which
both bone resorption and bone formation are
 Important In patients with AN, medica- simultaneously increased (high-turnover osteo-
tions that prolong the QT time of the heart porosis), patients with AN show a so-called
(e.g., tricyclic antidepressants) should not low-turnover situation with reduced bone for-
be administered or only under close ECG mation and increased resorption. Thus, estrogen
deficiency, which is considered to be the cause and constipation. Gastrointestinal complaints

of postmenopausal osteoporosis, cannot ade- typically occur with a temporal delay after the
quately explain the bone metabolism situation onset of the eating disorder. Studies of gastro-
in patients with AN. It is currently assumed that intestinal motility confirm delayed gastric emp-
it is an interaction of numerous factors. Here, tying for solid food as well as slowed colonic
underweight, hormonal factors such as reduced transit time and defecation disorders for patients
levels of estrogen, “insulin-like growth fac- with AN. Previous studies on intestinal motil-
tor” (IGF-1), leptin, thyroxine (free T3), and ity suggest that regular food intake and weight
oxytocin, as well as increased levels of cortisol restoration can lead to normalization of motil-
and the satiety hormone (PYY), malnutrition ity function in remitted AN patients. In addition
(calcium, vitamin D), and metabolic acidosis to food restriction, the motility disorder can be
(resulting from fasting) play significant roles. exacerbated by electrolyte shifts and the abuse
The most effective treatment measure for of laxatives. In individual cases, this can lead
preventing osteoporosis is early weight gain in to severe constipation or even paralytic ileus. In
the normal weight range, accompanied by the severely cachectic patients, autophagy of liver
normalization of eating behavior (S3 guide- cells is often observed, and accompanied by an
line). The substitution of calcium, vitamin D, increase in transaminases and sinusoidal fibro-
and vitamin K2 (menaquinone) can be sup- sis, which can lead to liver insufficiency or even
portive, especially in the early refeeding phase. liver failure.
The oral administration of estrogen-progestin Furthermore, in bulimic patients, regularly
preparations has not shown efficacy in previ- self-induced vomiting often leads to acid-related
ous intervention studies. In a recent review, inflammation and injuries to the esophagus.
there was evidence that transdermal applica- During vomiting, the increased pressure in the
tion of 17-ß-estradiol with cyclic progesterone esophagus can cause tears in the mucosa in the
application can at least prevent the progression area of the gastroesophageal junction in the
of osteopenia (Robinson et al. 2017). Treatment sense of a Mallory-Weiss lesion, and continuous
should be reserved for patients who have amen- exposure of the esophagus to acid can develop
orrhea for more than one year or for those whose cylindrical epithelial metaplasias, which can
menstruation does not resume after weight res- lead to Barrett’s carcinoma after some years. A
toration. However, it should be considered with rare but life-threatening complication in patients
caution before the completion of longitudinal with binge eating and vomiting is gastric dila-
growth, as it can lead to premature closure of the tion with tissue necrosis or gastric rupture (Sato
epiphyseal plates. Other promising preparations and Fukudo 2015).
such as IGF-1, dihydroepiandrosterone (DHEA),
parathyroid hormone analogs (teriparatide), and
bisphosphonates have only been administered 34.2.4 Skin and Teeth
and tested in the context of studies, but so far
without data on long-term efficacy and safety In patients with eating disorders, a num-
(Fazeli and Klibanski 2018). In addition, the cur- ber of skin changes can be observed. As a
rent S3 guideline recommends avoiding sports result of starvation and malnutrition, Xerosis
with increased vertical impact (e.g., ballet) or cutis (dry skin due to reduced sebum produc-
increased risk of falls (Cuntz et al. 2019). tion), often associated with hyperpigmenta-
tion and pruritus, lanugo hair (reduced activity
of the 5-α-reductase enzyme system), hair loss
34.2.3 Gastrointestinal Tract (increased telogen hair), acne, acrocyanosis,
purpura (thrombocytopenia), stomatitis (vitamin
Patients with eating disorders regularly report deficiency), decubitus ulcers, and nail dystrophy
abdominal pain, nausea, feelings of fullness, are regularly observed. Furthermore, patients
with AN show a significantly delayed wound testes. Therefore, amenorrhea is common in AN.
healing, which is attributed to hypothyroidism Patients with BN particularly show irregulari-
and zinc deficiency. Patients with BN also often ties or absence of menstruation when they have
show dry skin (xerosis cutis) and an increased a low weight. For this reason, weight normali-
tendency to develop acne (Strumia 2005). zation should be aimed for in cases of amen-
A characteristic skin lesion as a result of self- orrhea or menstrual irregularities (Chap. 28).
induced vomiting is the Russell’s sign. This is a Furthermore, anorectic patients typically show
callus formation over the finger joints (mainly a low-T3 syndrome with low triiodothyronine
on the index finger), which develops due to (T3), but normal thyroxine (T4) and thyrotropin
repeated lesions when inserting the fingers (TSH). In this laboratory constellation, there is
into the throat at the sharp-edged, acid-eroded no treatment-requiring hypothyroidism, and sub-
incisors. stitution of thyroid hormones (e.g., L-thyroxine)
Furthermore, patients with regular vomit- is contraindicated due to an increase in basal
ing report hypersensitivity of the teeth to hot, metabolic rate and energy consumption.
cold, and acidic foods. This is due to exposed Only in cases of clinically confirmed hypo-
dentin in advanced erosions of the tooth hard thyroidism should thyroxine be substituted, but
substance. The repeated exposure to acid leads with a cautiously titrated dosage (S3 guideline).
to permanent damage to the enamel and dentin,
resulting in a reduction of bite height. Moreover,
patients with BN show an increased preva- 34.2.6 Kidney, Water, and Electrolyte
lence of caries due to excessive consumption of Balance
sweets with pre-damaged teeth.
Patients should be thoroughly informed about Disturbances of water and electrolyte balance
the causes, development, and prevention of tooth can lead to serious complications. A subgroup
damage. After vomiting, the best possible neu- of patients with eating disorders significantly
tralization of the acidic stomach contents should restricts not only food but also the amount of
be pursued. Furthermore, erosive and acidic fluid they drink. Consuming fluid causes an
foods should be avoided. unpleasant feeling of fullness in these patients
and is therefore avoided. The risk of dehydration
 Important Within the first hour after self- is further increased by the excretion of osmoti-
induced vomiting, no mechanical oral cally active ketone bodies (mainly in patients
hygiene (tooth brushing) should be per- with AN), self-induced vomiting, or the abuse
formed, as this promotes the progression of of diuretics. In addition to fluid restriction,
acid-related tooth erosions. some patients with eating disorders also show
polydipsia to suppress hunger or increased fluid
intake before weighing to manipulate their body
weight.
34.2.5 Endocrine System Electrolyte changes, such as hypokalemia
with metabolic alkalosis, are indicative of vom-
Anorexia nervosa is associated with numerous iting or abuse of diuretics, whereas hypokalemia
hormonal changes (Chap. 28). The changes are with metabolic acidosis indicates abuse of laxa-
weight-dependent and show complete revers- tives. Patients with purging behavior are often
ibility in the majority of cases after weight well adapted to significantly reduced potas-
restoration. With regard to gonadotropic hor- sium levels. The risk of cardiac arrhythmias is
mones, underweight leads to a reduced release less pronounced with chronic potassium losses
of gonadotropin-releasing hormone (GnRH) than with acute potassium losses. Other elec-
from the hypothalamus and thus to a reduced trolyte changes that can often be observed are
production of sex hormones in the ovaries or hyponatremia, hypocalcemia, hypomagnesemia
and hypophosphatemia (especially during the in all but a few exceptions. Furthermore, latent
refeeding phase). A serious complication of nutrient deficiencies can become clinically sig-
these electrolyte changes and dehydration is the nificant in this build-up or regeneration phase
development of hypokalemic nephropathy up to due to the increased demand.
terminal renal insufficiency. Furthermore, the In rare cases, severe starvation-induced
disturbed water and electrolyte balance leads myocardial atrophy can lead to the occur-
to an increased occurrence of kidney stones rence of heart failure with pulmonary edema in
(Forney et al. 2016). the early phase of refeeding due to the altered
The therapeutic compensation of electro- hemodynamics.
lytes should be undertaken cautiously and not For this reason, food intake in extremely
too quickly. In particular, the increase in sodium underweight patients with AN should be car-
levels in hyponatremia should be slow, as rapid ried out under close laboratory-chemical moni-
changes can lead to the dreaded complication toring of electrolytes, blood pressure, and heart
of central pontine myelinolysis due to osmotic rate. Adequate phosphate intake through food is
effects. particularly important during this phase. So far,
there is no empirical consensus on an optimal
 Important The creatinine level in patients concept for refeeding in AN. However, studies
with AN is reduced due to decreased muscle suggest that in mildly to moderately underweight
mass. Therefore, advanced renal insufficiency patients with AN, refeeding with higher calories
may be present without detectable elevated compared to lower calorie intake (“underfeeding
creatinine levels. To assess kidney function, syndrome”) seems to be advantageous, as long
creatinine clearance should be determined. as electrolytes, fluid balance, and cardiovascular
parameters are monitored (Garber et al. 2016).
34.2.7 The Refeeding Syndrome Conclusion

The presented medical complications under-
This syndrome refers to symptoms and changes
line the urgent need for regular somatic fol-
that can occur in extremely underweight patients
low-up examinations of patients with eating
(BMI < 14 kg/m2) when regular nutrition is
disorders to assess the medical risk.
resumed. The symptoms can be very variable
and range from heart failure to neurological
symptoms to the occurrence of severe infec-
tions. Most commonly, patients with refeeding
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Gynecological Aspects
and Bulimia Nervosa
Markus Anton Glass, Christiane Gerwing and

Anette Kersting
Contents
35.1 Hormonal Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263
35.2 Fertility and Reproduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
35.3 Pregnancy and Birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266
35.4 Conclusion and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
35.1 Hormonal Disorders endocrine disorder of the hypothalamic-pitu-

itary-gonadal axis as a symptom of AN was
35.1.1 Occurrence of Menstrual included in the diagnostic criteria according
Cycle Disorders to ICD-10 and DSM-IV, but is no longer men-
tioned in both current classification systems
According to current knowledge, menstrual (ICD-11, DSM-5). In women, this often mani-
cycle disorders are a consequence of malnutri- fests as primary or secondary amenorrhea.
tion and deficiency in anorexia nervosa (AN) Although body weight in patients with BN is
and bulimia nervosa (BN). They can also occur usually within the normal range, menstrual
independently of significant weight loss and per- cycle disorders are found in about 50% of those
sist even after weight gain. The comprehensive affected. Amenorrhea is present in about 5%.
Forms of Amenorrhea
M. A. Glass (*) • Primary amenorrhea refers to the
Department of Psychosomatic Medicine, University absence of the first menstrual period
Leipzig, Leipzig, Germany
e-mail: [email protected] after reaching the age of menarche.
• If menstruation is absent for more than
C. Gerwing
Gynecological Practice, Münster, Germany three months in a woman who has
e-mail: [email protected] already menstruated, it is called second-
A. Kersting ary amenorrhea.
Department of Psychiatry and Psychotherapy, • If a disturbance of the hypothalamic-
University of Münster, Münster, Germany pituitary regulatory circuit is primarily
https://doi.org/10.1007/978-3-662-67662-2_35
264 M. A. Glass et al.
of pulsations of LHRH (luteinizing hormone-

responsible for the absence of menstru- releasing hormone) secretion and a qualitative
ation, this is referred to as central amen- disturbance of the gonadotropins FSH (folli-
orrhea, which can be further subdivided cle-stimulating hormone) and LH (luteinizing
into hypothalamic and pituitary genesis. hormone).
35.1.2 Primary Amenorrhea The ovarian feedback loop

With the onset of puberty, the hypothala-
Menarche can be disrupted by physical, nutri- mus begins to regulate the adenohypophy-
tional, and psychological factors. A weight loss sis (anterior pituitary) via gonadoliberin
of 10-15% of normal body weight delays puber- (luteinizing hormone-releasing hormone,
tal development and menarche. Growth in height LHRH). The release of LHRH is not con-
and breast development can also be disturbed. In tinuous, but pulsatile with a frequency of
general, these developmental delays are revers- about 90 minutes. LHRH thus stimulates
ible, but in severe cases, they can persist. the formation and release of gonadotro-
pins, FSH (follicle-stimulating hormone)
and LH (luteinizing hormone), in the
35.1.3 Secondary Amenorrhea pituitary gland. These cause follicle matu-
ration, ovulation, and corpus luteum for-
In secondary amenorrhea, a weight loss of mation in the ovary.
10-15% of normal weight is usually the cause,
but in 20% of patients with AN, amenorrhea
Studies show that even short-term fasting can
precedes underweight. It is suspected that this
lead to a prepubertal secretion pattern of gon-
phenomenon is due to a combination of psycho-
adotropins, especially LH. The frequency of
logical stress, excessive physical activity, and
gonadotropin pulsations is then too low to ensure
weight control measures. According to another
follicle maturation and selection up to ovula-
hypothesis, an individual “set weight,” which
tion in the ovary. In women with hypothalamic
may already be below normal weight in some
amenorrhea caused by extreme physical stress or
patients, is necessary for maintaining menstrua-
underweight, reduced levels of LH, estradiol, and
tion. In addition to the absence of menstrual
leptin werehave been found. When leptin was
bleeding, other menstrual disorders, such as an
raised to normal levels through injections, this
extended follicular phase and a disturbed luteal
led to an increase in the frequency of LH pulsa-
phase, are observed in AN. From a biological
tions. The hormone leptin, discovered in 1994
perspective, it makes sense that reproductive
and secreted by adipocytes, plays an important
functions are reduced or stopped when there is
role in regulating the hypothalamic-pituitary-
insufficient food intake, as successful reproduc-
gonadal axis in the starvation state. In highly
tion requires energy reserves.
symptomatic AN, it is reduced due to weight
loss, but can increase rapidly with weight gain.
Current studies on the role of leptin in the female
35.1.4 Endocrine Pathomechanism
cycle suggest that this protein has a signaling
character for the initiation of puberty. In addi-
The endocrine pathomechanism of amenor-
tion, leptin appears to have a connecting function
rhea in AN and BN appears to be primarily due
between nutritional status and the female cycle.
to hypothalamic dysfunction with inhibition
35 Gynecological Aspects in Anorexia Nervosa and Bulimia Nervosa 265
and 1-3% (BN). These are therefore women in

Endocrine disturbances in anorexia the midst of their reproductive age. However, the
nervosa described hormonal disturbances significantly
• Decreased pulsatile secretion of LHRH reduce fertility. Disturbances of the follicular
• Weak response of LH to LHRH and luteal phases lead to a reduced conception
• Reduced concentration of gonadotro- rate and an increased rate of spontaneous abor-
pins and estradiol as well as testosterone tions. In acute AN, there is usually an ovarian
• Decreased feedback effect of estrogen dysfunction with anovulation and infertility.
on the pituitary gland Most patients with restrictive AN are also not
• Lack of follicle maturation and selec- sexually active during this phase of the disorder.
tion in the ovary This can be attributed to a lack of acceptance
• Anovulation or (partly hateful) rejection of one’s own body,
• Reduced leptin levels reduced self-esteem, insufficient sexual identi-
fication, inadequate detachment from primary
caregivers, and loss of libido due to decreased
35.1.5 Oral Hormonal levels of sexual hormones. The resumption of
Contraceptives and Bone menstruation depends on the normalization
Metabolism of the function of the hypothalamic-pituitary-
gonadal axis, which in turn is significantly influ-
The reduction of bone density and osteoporosis enced by the level of leptin. For normalization,
as important, usually irreversible complications a reconstruction of appropriate eating behavior
for patients with AN and underweight patients and weight restitution is required. Numerous
with BN were discussed in detail in the previ- studies have shown that in the majority of
ous chapter. In addition to rapid weight gain and patients with AN, menstruation resumes after
normalization of eating behavior, the resump- weight gain. The likelihood of menstruation
tion of menstruation is a strong predictor for resuming is crucially dependent on the extent
the rehabilitation of bone density. Patients who of weight gain, the body mass index (BMI), and
gained weight within a year and whose menstru- the absolute body fat percentage. In one study,
ation resumed within this year had the greatest an absolute body fat percentage of over 21.2%
increase in bone mass. In patients with persis- was the most reliable predictor for the resump-
tently low body weight and persistent amenor- tion of menstruation. There may be a delay of
rhea, the reduction in bone density persisted. several months between the increase in body
Although some studies (Maïmoun 2019) sug- weight and the resumption of menstruation, so
gest that the administration of an oral hormonal it seems advisable to inform patients about this
contraceptive may limit the extent of bone den- and wait at least six months before conduct-
sity loss in young patients with AN, the applica- ing further examinations. In about 15-30% of
tion of estrogen-progestin preparations does not patients, however, menstruation does not resume
appear to be indicated in this case due to insuf- despite weight gain. Reasons for this can be
ficient or absent effects on bone metabolism persistent abnormal eating habits or underlying
(Legroux 2019). psychological problems. The duration of the eat-
ing disorder is also important for the absence of
menstruation: the longer the disorder persists,
the higher the risk of persistent amenorrhea. In
35.2 Fertility and Reproduction
chronic AN with persistent amenorrhea, infer-
tility is present; at the same time, most affected
The disorders AN and BN particularly affect the
individuals have no intention of becoming preg-
age group of 15-35-year-old women, in whom
nant. The majority of women with AN whose
they occur with a point prevalence of 1% (AN)
menstruation has resumed after overcoming the after fertility treatment, this proportion was
disorder and who have achieved normal body only 4.5% in healthy women. Freizinger et al.
weight and eating behavior can fulfill an exist- (2010) also found evidence of increased use of
ing desire to have children naturally. A long- reproductive medical treatment by women with
term study over 10-15 years in 173 patients a current or past eating disorder. A longitudinal
with BN (Crow et al.2006) showed no increased birth cohort study with pregnant women in the
infertility rate compared to the general popula- Netherlands showed more frequent reproductive
tion. However, the literature also indicates lower medical treatment in women with BN compared
birth rates and more frequent use of reproduc- to healthy individuals (Micali et al. 2015).
tive medical treatment by women with current
or past eating disorders. A study of 66 Canadian  Important In general, women with AN or
women who visited a reproductive medicine BN can become pregnant naturally after
clinic due to unfulfilled desire for children found successful treatment. However, there is
that 8% had a diagnosis of AN or BN (Stewart evidence of lower birth rates and more
et al. 1990). When atypical eating disorders frequent use of reproductive medical treat-
according to DSM-IV (eating disorders not oth- ment in women with current or past eating
erwise specified, EDNOS) were included, 17% disorders.
of the women had an eating disorder. Among
involuntarily childless women with oligomen-
orrhea or amenorrhea, this proportion was even 35.3 Pregnancy and Birth
58%. None of the affected women reported an
eating disorder on their own intiative. The obser- About 1% of all pregnant women have a history
vation that eating behavior disorders are not of AN or BN. Even if eating disorders are pre-
addressed volunatarily by patients in fertility sent, uncomplicated pregnancies and deliveries
treatment has been confirmed in other studies. are possible, but the rate of pregnancy complica-
It is therefore recommended to conduct a sur- tions is increased.
vey on weight development and eating behavior
as well as a weight measurement as part of the
reproductive medical examinations for involun- 35.3.1 Anorexia nervosa
tary childlessness. A retrospective study of over
2000 women who were treated for an eating The incidence of AN during pregnancy is about
disorder (AN, atypical AN, BN, atypical BN, or 19%. A pregnancy rarely occurs under the full
binge-eating disorder) in Helsinki from 1995 to picture of AN, but conception can occur during
2010 showed more frequent childlessness and the first ovulatory cycles of treatment, which
lower pregnancy and birth rates in the patient is accompanied by a normalization of body
group than in healthy controls (Linna et al. weight. The effects of pregnancy on the eating
2013). The lowest pregnancy rate was found in disorder are diverse, and it can lead to both an
women with AN. The frequency of pregnancy intensification and a mitigation of symptoms. If
terminations was significantly increased in BN the symptoms of AN persist or worsen during
compared to healthy individuals. While 7.2% pregnancy, physical and psychological compli-
of women with eating disorders gave birth cations are more frequent.
or – in relation to their gestational age – under-

Pregnancy complications in anorexia weight. The internationally used medical term
nervosa for this is “small for gestational age (SGA).”
• Insufficient weight gain of the woman An association between insufficient weight gain
during pregnancy of the mother and low birth weight of the baby
• More frequent anemia in pregnant is considered proven. SGA children can show
women developmental difficulties over a long period of
• Increased occurrence of hyperemesis time. Mantel et al. (2020) showed that patients
gravidarum with active AN had a twofold increased risk of
• Intrauterine growth retardation in the preterm birth and SGA and a threefold increased
fetus (small for gestational age) risk for the development of microcephaly.
• Increased risk of microcephaly Studies have shown that the perinatal mor-
• Increased abortion and malformation tality rate of children of mothers with AN is 6
rate times higher compared to the rate in the gen-
• Increased risk of preterm birth eral population. Regarding preterm birth and
• Increase in the frequency of surgical miscarriage risk, a twofold increased risk was
deliveries observed. In a Swedish study of 49 women with
• Poorer condition of the newborn (lower a history of anorexic and bulimic eating disor-
APGAR score) ders who were followed during their first preg-
• Increased risk of peripartum bleeding nancy, these women were significantly more
• Increased risk of premature placental likely to develop hyperemesis gravidarum than
detachment healthy pregnant women (Kouba et al. 2005).
• Higher perinatal morbidity and The pregnant women with eating disorders often
mortality suffered from anemia and frequently did not
• Higher risk of postpartum depression in achieve the recommended weight gain of 11.5–
the mother 16 kg during pregnancy, especially in cases of
• More frequent breastfeeding problems previous or current AN. The babies of mothers
with AN had a significantly lower birth weight
 Hyperemesis Gravidarum is defined as per- than the children of healthy mothers. Both in
sistent, non-self-induced vomiting occurring AN and BN, the newborns had a smaller head
more than 5 times per day during preg- circumference.
nancy, which endangers the fluid and food
intake of the affected person and leads to  Important Pregnant patients with AN
a weight loss of more than 5%. The inci- should be treated in an inpatient psycho-
dence is 0.5–2%. The etiology is still largely therapeutic setting following any treat-
unclear; physical adaptation processes to ment for somatic complications during
pregnancy and psychological factors are the therapy phase for weight restoration
discussed. The disease can be associated and the reestablishment of appropriate
with metabolic disorders, dehydration, and eating behavior. Facilities close to home
electrolyte imbalance and can be life-threat- with proven experience in treating eating
ening. Early detection and treatment, which disorders should be preferred. For weight
must be inpatient in severe cases, are there- rehabilitation, a therapy contract should be
fore of particular importance. concluded with the stipulation of a mini-
mum weekly weight gain. The required
If the mother’s malnutrition leads to a nutritional additional weight gain during pregnancy
deficit in the fetus, the newborns are too small must be taken into account.
35.3.2 Bulimia nervosa 35.4 Conclusion

and Recommendations
The incidence rate of pregnancy in women with
BN is over 1%. Underweight and amenorrhea If a patient with a known eating disorder vomits
are less common in this group of patients; thus, frequently during pregnancy, this can sometimes
fertility disorders occur less frequently. 80-90% make it difficult to differentiate diagnostically
of women with BN regularly induce vomiting, whether it is a case of hyperemesis gravidarum
which can lead to frequent, rapid, and severe (pregnancy vomiting), an increase in eating dis-
fluctuations in blood glucose levels. Glucose order symptoms, or a mixed picture. Although
metabolism disorders, in turn, can have a det- nausea and vomiting in the context of hyperem-
rimental effect on fetal development. Pregnant esis gravidarum can persist until birth, the maxi-
women with a history of AN or BN were found mum severity of symptoms usually occurs in
to be more likely to have gestational diabetes the 8th-12th week of pregnancy, which may
mellitus (GDM). GDM is associated with an be related to the ß-hCG level in the blood.
increased rate of preterm birth, an increased risk Insufficient or excessive weight gain, especially
of the mother developing postpartum depres- in the 2nd trimester, hyperemesis gravidarum,
sion, and postnatal adjustment disorders in the and a history of eating disorders can be signs of
child in cases of diabetic fetopathy. Studies also AN or BN. Hyperemesis gravidarum is about 10
showed an increased rate of fetal malforma- times more frequent in women with eating dis-
tions in cases of BN. This is attributed, on the orders compared to healthy women. A Swedish
one hand, to the frequent abuse of laxatives and study (Mantel et al. 2020) also showed higher
diuretics and, on the other hand, to the increased blood pressure values in patients with active eat-
occurrence of alcohol and drug abuse in this ing disorders compared to healthy patients or
group of patients. Weight development during patients with remitted eating disorders. During
pregnancy in BN showed greater fluctuations regular prenatal check-ups, signs of eating disor-
and ranged from excessive to normal to insuf- ders should be asked about and considered. Due
ficient weight gain. In many patients, bulimic to the negative effects of malnutrition and defi-
symptoms decreased during pregnancy and ciency on pregnancy, women with eating disor-
in the first period after birth, as those affected ders are advised to plan their pregnancy in such
paid attention to a healthy diet for the baby’s a way that remission or at least partial remission
sake. However, the physical and psychological of the disorder is present, especially since preg-
stresses of pregnancy can also lead to a worsen- nancy and the associated changes in body image,
ing of the disorder. Changes in appetite and sati- family, and everyday structures can further desta-
ety, as well as the body due to weight gain and bilize psychologically vulnerable patients. In
the growth of the abdomen and breasts, can be general, pregnancies in women with eating disor-
particularly burdensome for women with eating ders should be considered high-risk pregnancies.
disorders. In addition, during pregnancy, first-
time mothers often experience an emotional  Important Patients must be closely moni-
confrontation with the upcoming assumption of tored both during and after pregnancy in
the maternal role. After giving birth, a relapse terms of gynecological and psychoso-
into bulimic symptoms often occurs. Studies matic-psychotherapeutic care to ensure the
show increased rates of spontaneous abortions, physical and emotional well-being of both
lower birth weights of newborns, and more fre- mother and child. The postnatal midwife
quent cesarean section deliveries in women should definitely be informed about the
with BN compared to healthy women. The risk mother’s eating disorder and be involved
of postpartum depression is also significantly in the care.
increased.
References Further Reading
Crow SJ, Thuras P, Keel PK, Capri Workshop Group AWMF online. Leitlinien. S3-Leitlinie „Diagnostik und
(2006) Nutrition and reproduction in women. Hum Therapie von Essstörungen“. https://www.awmf.org/
Reprod Update 12:193–207 leitlinien/detail/ll/051-026.html. Accessed 28 Aug 2019
Freizinger M, Franko DL, Dacey M (2010) The preva- Cardwell MS (2013) Eating disorders during pregnancy.
lence of eating disorders in infertile women. Fertil Obstet Gynecol Surv 68:312–323
Steril 93:72–78 Franko DL, Blais MA, Becker AE et al (2001) Pregnancy
Kouba S, Hällström T, Lindholm C, Linden Hirschberg A complications and neonatal outcomes in women with
(2005) Pregnancy and neonatal outcomes in women eating disorders. Am J Psychiatry 158:1461–1466
with eating disorders. Obstet Gynecol 105:255–260 Franko DL, Latzer IT MD, ISRAEL (2019) Predicting
Legroux (2019) Factors influencing bone loss in anorexia menstrual recovery in adolescents with buimn ner-
nervosa: assessment and therapeutic options. RMD. vosa using body fat percent estimated by bioimped-
https://doi.org/10.1136/rmdopen-2019-001009 ance analysis. J Adolesc Health 64(4):454–460.
Linna MS, Raevuori A, Haukka J (2013) Reproductive https://doi.org/10.1016/j.jadohealth.2018.10.008
health outcomes in eating disorders. Int J Eat Disord Katz MG, Vollenhoven B (2000) The reproductive endo-
46:826–833 crine consequences of anorexia nervosa. Br J Obstet
Maïmoun (2019) Oral contraceptives partially protect Gynaecol 107:707–713
from bone loss in young women with anorexia ner- Micali N, Treasure J (2009) Biological effects of a
vosa. Fertil Steril 111(5). https://doi.org/10.1016/j. maternal ED on pregnancy and foetal development: a
fertnstert.2019.01.008 review. Eur Eat Disord Rev 17:448–454
Mantel Ä MD, PhD, Hirschberg AL MD, PhD, Mitchell JE (2002) Long-term menstrual and reproduc-
Stephansson O MD, PhD (2020) Association of tive function in patients with bulimia nervosa. Am J
maternal eating disorders with pregnancy and neo- Psychiatry 159:1048–1050. ESHRE
natal outcomes. JAMA Psychiatry. https://doi. Spurrell EB (2000) Detection and management of eat-
org/10.1001/jamapsychiatry.2019.3664 ing disorders during pregnancy. Obstet Gynecol
Micali N, Dos-Santos-Silva L, De Stavola B et al (2015) 95:942–946
Fertility treatment, twin births, and unplanned preg- Uhl B (2018) Gynäkologie und Geburtshilfe com-
nancies in women with eating disorders. BJOG pact. Georg Thieme Verlag, Stuttgart. ISBN:
122(6):892. https://doi.org/10.1111/1471-0528.13422 978-3-131-07346-4
Stewart DE, Robinson E, Goldbloom DS, Wright C Wolfe BE (2005) Reproductive health in women with eating
(1990) Infertility and eating disorders. Am J Obstet disorders. J Obstet Gynecol Neonatal Nurs 34:255–263
Gynecol 163:1196–1199
Eating Disorders
and Diabetes Mellitus 36
Stephan Herpertz
Contents
36.1 Eating disorders and type 1 diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272
36.2 iabetes Mellitus and Eating Disorders, a Coincidental Coincidence? . . .
D 272
36.3 Insulin Dose and Weight Regulation (“Insulin Purging”) . . . . . . . . . . . . . . 273
36.4 Course of Eating Disorders in People with Diabetes Mellitus . . . . . . . . . . . 274
36.5 Diagnosis and Treatment of Patients with Diabetes Mellitus
and Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
According to the current Diabetes Atlas of the While type 1 DM, characterized by the
International Diabetes Federation (IDF) from destruction of the ß-cells of the pancreas and
2017, Germany ranks second in Europe and the consequent absolute insulin deficiency,
ninth internationally, with 7.5 million people shows a peak manifestation mainly in puberty
suffering from diabetes mellitus (DM). 95% of and early adolescence, type 2 DM as a result of
those affected suffer from type 2 DM, which insulin resistance, primarily in overweight and
mainly occurs in the second half of life and is obese individuals, represents a disease of mid-
associated with overweight or obesity. DM often dle age or the second half of life. Due to the sig-
reduces the quality of life of those affected and nificantly increasing number of obese children,
shortens life expectancy by about ten years. The insulin resistance is also increasingly observed
development of microvascular, but especially in this age group.
macrovascular sequelae, such as heart attack The course of the disease is significantly influ-
and stroke, are responsible for the significantly enced by the lifestyle and disease behavior of the
shortened life expectancy. patients. Treatment management requires lifelong
planning and control not only of food intake but
also of lifestyle. The treatment requires a high
degree of motivation and self-management on
the part of those affected, who have to integrate
a very complex therapy into their lives and accept
S. Herpertz (*) many restrictions in everyday life. In addition,
Psychotherapy, LWL-University Clinic, Ruhr-University
there is the need for multiple daily blood glucose
Bochum, Bochum, Germany self-checks, at least for patients with type 1 DM
e-mail: [email protected] (intensified insulin therapy).
https://doi.org/10.1007/978-3-662-67662-2_36
272 S. Herpertz
36.1 Eating disorders and type 1 terminology of the disorders is inconsistent, and
diabetes on the other hand, and more significantly, differ-
ent measurement instruments and classification
Compared to metabolically healthy people, systems are used. It is important to distinguish
problematic eating behavior and eating disorders between diabetes-specific and generic screening
are more common in young women with type 1 instruments to detect disturbed eating behavior
DM (Young et al. 2013), although, considering or an eating disorder. Generic instruments have
the significantly lower prevalence of anorexia the advantage of comparability with the general
nervosa (AN), more profound statements can population, but they do not take into account,
only be made about bulimic eating disorders. for example, insulin purging (see below)—with
With regard to the peak of the disease, the coin- the risk of underestimating prevalence. Not least
cidence of AN and bulimia nervosa (BN) with due to the avoidance of hyper- or hypoglycemic
type 1 DM is striking. states, the thoughts and feelings of people with
Patients with DM usually carry out their ther- DM often revolve around topics such as nutri-
apy independently in everyday life. Thus, the tion, physical activity, and weight, without being
lifelong confrontation with food, weight regula- an expression of problematic eating behav-
tion, and physical activity, which is necessary to ior or an eating disorder, which carries the risk
achieve near-normal metabolic control, can ulti- of overly high prevalence estimates. Thus, a sys-
mately pave the way for the development of an tematic review and meta-analysis by Young et al.
eating disorder. (2013), also taking into account the diagnostic
In almost all patients with type 1 DM, the peculiarities, concluded that problematic eating
eating disorder begins after the manifestation behavior or an eating disorder is more frequently
of DM (Herpertz et al. 1998). After diagnosis, observed in adolescents with DM than in meta-
many patients regain weight due to rehydration bolically healthy individuals. In a longitudinal
and anabolic metabolism, sometimes reaching study, Colton et al. (2015) examined 126 girls
a higher weight than before the manifestation with type 1 DM aged around 12 years over a
of DM. A study of 32 young patients immedi- period of 14 years. At the end of the study, more
ately after the diagnosis of DM and again one than 32% of the patients met all criteria for an
year later showed an increase in eating disorder eating disorder (2 AN, 1 BN, 20 unspecified eat-
symptoms. The weight gain averaged almost 7 ing disorders), and an additional 8.5% showed
kg. The weight of all patients was above their disturbed eating behavior. 27% of the study par-
desired weight. Interestingly, most patients had ticipants reported insulin purging as a means of
developed a disturbed body schema, which is weight control.
considered one of the core symptoms of eating
disorders (Steel et al. 1990).  Important A higher prevalence of eating
disorders and disturbed eating behavior is
observed in girls and young women with
36.2 Diabetes Mellitus and Eating DM compared to metabolically healthy
Disorders, a Coincidental women, with the majority being unspeci-
Coincidence? fied eating disorders.
Estimating the prevalence of type 1 DM and More than 80% of all people with type 2 DM
comorbid eating disorders is particularly dif- are overweight or obese. To overcome insulin
ficult for two reasons. On the one hand, the resistance in type 2 DM, weight reduction and
36 Eating Disorders and Diabetes Mellitus 273
appropriate dietary behavior are recommended. 36.3 Insulin Dose and Weight
The observation that long-lasting dietary behav- Regulation (“Insulin Purging”)
ior in the sense of restrained eating can lead to
loss of control in food intake (“binge eating”) “Vomiting through the kidney” (“insulin purg-
and ultimately to BN or binge eating disorder ing”) refers to the deliberate reduction of insulin
(BED), and the fact that only about 15% of all dose, particularly in the evening, for the purpose
people are able to maintain their reduced weight of weight reduction.
permanently, suggests a possible connection The prevalence of deliberate insulin reduction
between type 2 DM and eating disorders, espe- seems to increase with age. “Insulin purging” was
cially BED. observed in only 2% of children and adolescents
aged 9-14 years, while the prevalence increased
 Important In contrast to type 1 DM, to 14% in female teenagers and to 34% in adult
which usually precedes the eating disor- women (Colton et al. 2015). Interestingly, among
der, in half of patients with type 2 DM, girls and young women with DM, “insulin purg-
the onset of the eating disorder is observed ing” can be observed not only in those with eating
before the diagnosis of DM. disorders but also in those without (De Paoli and
Rogers 2018). Possible causes might be disease
In the absence of controlled studies, the question denial, which is not uncommon at this age, fear of
of an incidental prevalence of eating disorders in hypoglycemia, or injection (needle) phobias.
people with type 2 DM, particularly BED, can-
not be answered. Prevalence estimates of BED  Important In particular, in young women
in the general population are 1.6% for women with type 1 DM, “insulin purging” is less
and 0.8% for men (12-month prevalence) an expression of inadequate compliance
(Fichter 2019). In contrast, in a small sample of than of an eating disorder or other psy-
45 patients with type 2 DM, Crow et al. (2001) chological problems or disorders with
observed BED in eleven patients (25.6%). In far-reaching consequences for adequate
a larger multicenter study of 845 patients with treatment.
type 2 DM, Allison et al. (2007) found a signifi-
cantly lower prevalence of 1.4%. Interestingly, In regard to the pathogenesis of comorbid eat-
3.8% met the preliminary criteria for night-eating disorders in type 1 and type 2 DM, the fol-
ing syndrome (consumption of >75% of daily lowing relationships can be discussed:
calories after dinner, at least three nocturnal
awakening phases with imperative food intake). • The eating disorder or a disturbed eating
Even though the monocausal thinking that behavior represents the individual response to
BED is the cause of overweight and obesity the stress of a chronic illness with inappropri-
has had to be revised, obese people with BED ate coping strategies. In particular, depressive
still have a higher weight compared to obese symptoms and feelings of inadequacy have
people without eating disorders. Therefore, been described in young women with eating
a diagnosis of BED in people with type 2 DM disorders.
aggravates the course of weight and insulin • The eating disorder represents the final stage
resistance. In a systematic review/meta-analysis, of a psychological stress situation or disor-
Nieto-Martinez et al. (2017) demonstrated an der that could be compensated for before the
increased risk for the development of type 2 DM diagnosis of DM but is exacerbated by the
in cross-sectional studies, while the relationship burden of the disease.
was less clear in cohort studies.
274 S. Herpertz
• The significant weight gain after the diagno- metabolic control and more frequently lead to
sis (rehydration, anabolic metabolism) aggra- diabetic complications. Even disturbed eating
vates the age-inherent unstable self-esteem behavior that does not meet all the criteria of an
and reinforces restrictive eating behavior. eating disorder, such as insulin purging, mas-
• By deliberately reducing the insulin dose and sive dieting behavior, or self-induced vomiting
subsequent glucosuria, a drastic weight loss is often associated with inadequate metabolic
can be induced (“insulin purging”). control and a high risk for the development of a
• Especially in view of the age of onset of diabetic complication. In an 11-year follow-up
juvenile DM and the eating disorders AN and study, it was shown that insulin purging in peo-
BN, the importance of familial factors must ple with type 1 DM was associated with a signif-
be emphasized. It is likely that the diagnosis icantly increased mortality (Goebel-Fabbri et al.
of DM in a child or adolescent changes the 2008; Goebel-Fabbri 2020).
family structure (dynamics) and, for exam-
ple, strengthens control mechanisms within
a family and contributes to a lack of auton- 36.5 Diagnosis and Treatment
omy development and dependence, which is of Patients with Diabetes
characteristic of many patients with an eating Mellitus and Eating
disorder. Disorders
• People with insulin-dependent type 2 DM
generally have a higher weight than metaboli- In view of the significant health risk associated
cally healthy individuals, to which the ana- with comorbidity of eating disorders and DM,
bolic effect of insulin contributes. Flexible routine screening for eating disorders or dis-
eating behavior for weight stabilization, as turbed eating behavior in adolescent girls and
in healthy individuals, can never completely young women with DM as a designated risk
rule out the risk of hypoglycemia even with population is currently recommended. The clari-
variable handling of the insulin dose. fication of an eating disorder also seems useful
• From psychobiological research, the regu- in patients with insufficient metabolic control
latory significance of certain neurotrans- without evidence of a somatic cause, e.g., auto-
mitters for eating behavior is known. For nomic neuropathy.
example, serotonin has a satiating function. In a systematic review/meta-analysis, Clery
Tryptophan as a serotonin precursor is sub- et al. (2017) examined the efficacy of therapeu-
ject to a competitive transport mechanism at tic interventions in patients with type 1 DM and
the blood-brain barrier with branched-chain comorbid eating disorder with regard to eating
amino acids, whose serum concentration disorder symptoms and metabolic control. Based
depends on insulin secretion. Insulin defi- on six studies that met the inclusion criteria of
ciency thus leads to a reduction in centrally the review and three studies that met the crite-
available tryptophan and serotonin, which ria of the meta-analysis, the authors calculated a
in turn can result in a decreased satiety small effect size (0.21). A significant improve-
behavior. ment in the metabolic control of the intervention
group compared to the control group could not
be observed. Some, but not all studies showed
36.4 Course of Eating Disorders an improvement in eating disorder symptoms.
in People with Diabetes Only a multimodal inpatient treatment, consist-
Mellitus ing of cognitive behavioral therapy, psychoe-
ducation, and family therapy, proved to be the
Numerous cross-sectional studies have shown most effective treatment method (Takii et al.
that both disturbed eating behavior and eating 2003). Psychoeducational treatment approaches
disorders result in a significant deterioration of were found to be insufficient (Olmsted et al.
36 Eating Disorders and Diabetes Mellitus 275
2002; Petrak and Herpertz 2019). In addition to Colton PA, Olmsted MP, Daneman D, Farquhar JC,
an inpatient treatment setting, a higher therapy Wong H, Muskat S, Rodin GM (2015) Eating disor-
ders in girls and women with type 1 diabetes: a lon-
dose also seems to be necessary (Pinhas-Hamiel gitudinal study of prevalence, onset, remission, and
et al. 2015). There is now sufficient evidence for recurrence. Diabetes Care 38(7):1212–1217
involving the family in the treatment of patients Crow S, Kendall D, Praus B, Thuras P (2001) Binge eat-
with eating disorders (AWMF 2019; https:// ing and other psychopathology in patients with type
II diabetes mellitus. Int J Eat Disord 30(2):222–226
www.awmf.org/leitlinien/detail/ll/051-026. De Paoli T, Rogers PJ (2018) Disordered eating and insu-
html). lin restriction in type 1 diabetes: a systematic review
and testable model. Eat Disord 26(4):343–360
 Important For the success of psychother- Fichter M (2019) Epidemiologie der Essstörungen. In:
Herpertz S, Fichter M, Herpertz-Dahlmann B, Hilbert
apy, understanding the patient’s life situ- A, Tuschen-Caffier VS, Zeeck A (Hrsg) S3-Leitlinie
ation in general and the patient with DM Diagnostik und Behandlung der Essstörungen, 2. Ed.
in particular is necessary. This includes Springer, Berlin, Heidelberg, New York, pp 1–18
knowledge about diabetes, its therapy man- Goebel-Fabbri AE (2020) Eating disorders in type 1 and
type 2 diabetes. In: Delamater AM, Marrero D (Hrsg)
agement, and its possible connections with Behavioral diabetes. Springer Nautre, Cham, pp 353–
the eating behavior/eating disorder (e.g., 363. https://doi.org/10.1007/978-3-030-33286-0
hypoglycemia, physical activity, etc.). Goebel-Fabbri AE, Fikkan J, Franko DL, Pearson K,
Anderson BJ, Weinger K (2008) Insulin restriction
and associated morbidity and mortality in women
Patients with eating disorders and type 2 DM with type 1 diabetes. Diabetes Care 31(3):415–419
are predominantly overweight or obese and usu- Herpertz S, Albus C, Wagener R et al (1998)
ally suffer from BED, so considerations for all Comorbidity of diabetes mellitus and eating disor-
three disease entities must be incorporated into ders: does diabetes control reflect disturbed eating
behavior? Diabetes Care 21:1110–1116
the treatment. Therefore, a multimodal treat- Nieto-Martínez R, González-Rivas JP, Medina-Inojosa
ment concept is useful, the integral components JR, Florez H (2017) Are eating disorders risk factors
of which are psychotherapy and weight manage- for type 2 diabetes? A systematic review and meta-
ment. In patients with BED, the initial priority is analysis. Curr Diab Rep 17(12):138
Olmsted MP, Daneman D, Rydall AC, Lawson ML,
the normalization of eating behavior over a more Rodin G (2002) The effects of psychoeducation on
restrictive diet to counteract the vicious cycle disturbed eating attitudes and behavior in young
of diets (control behavior) and loss of control women with type 1 diabetes mellitus. Int J Eat Disord
(“binge eating”). 32(2):230–239
Petrak F, Herpertz S (2019) Psychodiabetologie.
Psychotherapeut 64:489–508. https://doi.org/10.1007/
s0027-019-00391-z
References Pinhas-Hamiel O, Hamiel U, Levy-Shraga Y (2015)
Eating disorders in adolescents with type 1 diabe-
Allison KC, Crow SJ, Reeves RR, West DS, Foreyt JP, tes: challenges in diagnosis and treatment. World J
Dilillo VG, Wadden TA, Jeffery RW, Van Dorsten Diabetes 6(3):517–526
B, Stunkard AJ (2007) Binge eating disorder and Steel JM, Lloyd GG, Young RJ, Macintyre CCA (1990)
night eating syndrome in adults with type 2 diabetes. Changes in eating attitudes during the first year of
Obesity (Silver Spring) 15(5):1287–1293 treatment for diabetes. J Psychosom Res 34:313–318
Arbeitsgemeinschaft Wissenschaftlicher Medizinischer Takii M, Uchigata Y, Komaki G et al (2003) An inte-
Fachgesellschaften (AWMF) (2019) S3-Leitlinie grated inpatient therapy for type 1 diabetic females
„Diagnostik und Therapie der Essstörungen“. https:// with bulimia nervosa: a 3-year follow-up study. J
www.awmf.org/leitlinien/detail/ll/051-026.html Psychosom Res 55(4):349–356
Clery P, Stahl D, Ismail K, Treasure J, Kan C (2017) Young V, Eiser C, Johnnson B, Brierley S, Epton T,
Systematic review and meta-analysis of the effi- Elliot J, Heller S (2013) Eating problems in adoles-
cacy of interventions for people with Type 1 dia- cents with type 1 diabetes: a systematic review with
betes mellitus and disordered eating. Diabet Med meta-analysis. Diabet Med 30(2):189–198
34(12):1667–1675
Part VI
Treatment of Eating Disorders
277
Prevention of Eating
Disorders 37
Andreas Karwautz, Gudrun Wagner and Michael Zeiler
Contents
37.1 Types of Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279
37.2 The “Diet Culture” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279
37.3 Target Areas for Primary Prevention of Eating Disorders . . . . . . . . . . . . . 280
37.4 Efficacy of Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286
37.1 Types of Prevention risk factors and aim to reduce them. Tertiary
prevention aims to prevent the deterioration of a
The common classification of prevention differ- full-syndrome disorder. It includes measures for
entiates between primary, secondary, and tertiary rehabilitation and relapse prevention. Another
prevention. Primary prevention aims to prevent type of classification distinguishes between the
the development of eating disorders and new terms universal, selective, and indicated preven-
cases, to prevent risk factors, and to promote tion. While the term universal prevention refers
protective factors. Primary prevention measures to measures for the entire population, selective
are directed at healthy individuals without eat- prevention programs focus on asymptomatic
ing disorder symptoms. The goal of secondary risk populations. Indicated prevention programs
prevention is early detection and intervention target high-risk groups that exhibit subclinical
to prevent the progression of the disorder and symptoms or clear risk factors.
the development of a full syndrome disorder.
Secondary prevention measures target existing
37.2 The “Diet Culture”
A. Karwautz (*) · G. Wagner · M. Zeiler Being thin, especially for girls and women, is
Department of Child and Adolescent Psychiatry, a significant component of attractiveness in
Eating Disorders Care & Research Unit, Medical today’s society. This fact is reflected in dieting
University of Vienna, Vienna, Austria among girls and young women: before puberty,
about 50% of adolescents show a preference for
G. Wagner a thinner body ideal , and despite normal weight,
almost 30% wish to be thinner. Depending
M. Zeiler on the study, it is reported that 25–63% of
https://doi.org/10.1007/978-3-662-67662-2_37
280 A. Karwautz et al.
adolescents aged 13 and older have experience the societal level. Further guidelines, especially
with dieting. The BELLA study in Germany and regarding the dissemination of eating disorder-
the MHAT study in Austria report that about promoting content via social media channels,
one-third of girls and 15% of boys show an would be desirable. A second, reactive approach
increased risk of developing an eating disor- aims at critically examining messages dis-
der. As body fat increases during puberty, disseminated through fashion magazines or social
satisfaction with one’s weight and shape and media. These can be addressed, for example, by
the risk of disturbed eating behavior tend to health promotion programs in schools. Reviews
rise. It must also be assumed that the exchange on the prevention of eating disorders have criti-
of images promoting a thin body ideal, exces- cized the exclusive focus of existing prevention
sive and unhealthy fitness and nutrition tips via programs on the individual level, as it represents
social media channels (Instagram, Snapchat, adaptive behavior to harmful environmental
Facebook, Tumblr) promotes the development of conditions.
eating disorder symptoms. A recently published
study demonstrated a relationship between the  Important Interaction with media as
frequency of social media use and pathological an external influencing factor and per-
eating behavior, maladaptive cognitions, and sonal vulnerability as an internal fac-
body image problems (Wilksch et al. 2020). tor are important target areas for primary
prevention.
37.3 Target Areas for Primary The salutogenic model of primary prevention
Prevention of Eating focuses on general health promotion, which
Disorders should be anchored in educational policy and
the school system. Primary prevention in this
Strategies to convey preventive sociocultural sense includes strengthening personal resources,
messages through media consist of promot- such as self-esteem, assertiveness, coping strate-
ing the acceptance of a wider range of different gies, stress management, puberty, and develop-
body shapes. The main message should not be ment-related stressors.
that “thinness” is generally bad, but that a wider
range of body shapes is desirable. Individuality  Important Instead of conducting one-day
and self-acceptance—as opposed to conform- information events on eating disorders
ity to a thin ideal—should be emphasized. Such in schools, it is recommended to offer
goals were partially addressedin 2006 through longer-term intervention programs for
the development of guidelines by the “Academy parents, teachers, and students that aim
for Eating Disorders” for modeling agencies to strengthen personal resources and thus
and the fashion industry (https://www.aedweb. reduce the risk of eating disorders and
org/aedold/getinvolved/advocacy/position-state- other mental illnesses.
ments/fashion-industry-guidelines). Initiatives
such as the increasing use of “curvy models” Behavioral change is usually based on a cumula-
and the legally mandated requirement to label tive effect of increased awareness, better under-
Photoshop-altered representations of models standing, beliefs, attitudes, and self-efficacy.
in some countries are examples of how eat- Health-promoting measures should include the
ing disorder prevention can also be advanced at points summarized in the following overview.
37 Prevention of Eating Disorders 281
programs. Larger effects were also observed in

Health-promoting measures older adolescents compared to younger ones and
• Increase access to one’s own feelings in interactive vs. didactic programs conducted
• Promote healthy stress management and by external eating disorder experts compared
coping strategies to teachers. Universal prevention programs
• Increase self-esteem and self-confidence were particularly effective when they aimed
• Create a balance between autonomy and to increase media literacy. In selective preven-
dependence on family members and the tion studies, the largest effects were found in
peer group programs based on cognitive-behavioral ther-
• Express one’s own needs and feelings apy and the theory of cognitive dissonance.
• Reduce ambition and perfectionism Pickhardt et al. (2019) provide a good overview
• Increase positive body experience of a total of 22 German-language prevention
• Build self-esteem through factors other programs for eating disorders, with only half
than weight and physical appearance of these programs being scientifically evalu-
• Convey a critical view of superficial ated. Most of these programs were implemented
sociocultural ideals either in the school context or as pure online
• Teach balanced nutrition and exercise programs and mainly focused on psychoeduca-
behavior tional approaches, increasing media literacy, and
promoting a healthy body image.
Physical changes during puberty, which are also

associated with an increase in body fat in girls, 37.4.1 Efficacy of Primary Prevention
can lead to body dissatisfaction and conse-
quently to dieting behavior. Therefore, convey- Most primary prevention measures take place
ing information about the normality of these for children and younger adolescents in primary
physical changes should be another target area and middle school age up to 14 years, with the
in the primary prevention of eating disorders. school setting playing a major role in the imple-
Providing information on “healthy eating” by mentation of such prevention programs. To a
experts is problematic because it can lead to an large extent, the content of universal prevention
excessive preoccupation with food, which is a programs aims to counteract an overvaluation
known risk factor for eating disorders. Instead, of appearance and thinness ideals and negative
the importance of a balanced diet should be body evaluation, as well as to strengthen posi-
emphasized, which also allows for flexibility tive self-esteem and general coping strategies.
and excludes a “ban” on unhealthy foods. In Another goal is the critical examination of media
secondary prevention, information about eating messages and information about how individu-
disorders for teachers and health professionals is als are influenced by advertising and culture. In
a prerequisite for recognizing risk behaviors in a the review by Le et al. (2017), only programs
timely manner and enabling early interventions. that aimed to increase media literacy proved
to be effective in reducing weight and shape
concerns and internalizing the thinness ideal,
37.4 Efficacy of Prevention with effect sizesin the low to moderate range.
Minimal effects of universal prevention pro-
Stice et al. (2007) and Le et al. (2017) summa- grams on increasing self-esteem and body satis-
rized the results of 51 and 112 prevention pro- faction were also reported by Chua et al. (2019),
grams, respectively, in meta-analyses. It was with higher effects for girls than for boys.
found that selective programs for risk groups Piran (2005) also points out that primary
yielded larger intervention effects than universal prevention programs often achieve changes in
knowledge about healthy nutrition and exercise, Conclusion

but these often do not result in a change in atti- For primary prevention in children and
tude and behavior. younger adolescents, only minor successes
have been achieved so far. Results of previ-
 Important The mode of interven- ous research emphasize the importance of
tion delivery seems to play a cru- interventions at both the individual and set-
cial role: Interactive formats have ting levels, taking into account the interactive
more positive effects on attitude and delivery of content. In particular, studies on
behavior changes than purely didac- the sustainability of these interventions are
tic formats. also lacking.
It must be noted that long-term effects of pre-

vention programs have hardly been studied so 37.4.2 Efficacy of Secondary
far. An exception is the study by Adametz et al. Prevention
(2017), which examined the sustainability of the
German-language universal eating disorder pre- The target group of most existing studies on
vention program “PriMa”. 7–8 years after par- secondary preventive programs is older ado-
ticipating in this program, no sustainable effects lescents and young adults, particularly college
on disturbed eating behavior could be detected, students with weight and body image concerns,
but body-related self-esteem was still signifi- individual symptoms of eating disorders, and
cantly higher than in the control group. overweight. Target areas for these programs are
It is critical to note that most programs focus the reduction of body image problems, drive for
exclusively on promoting individual skills of thinness, binge-eating behavior, restrictive eat-
children, and only a few programs (addition- ing behavior, and negative affect.
ally) include the social environment such as peer The conducted prevention programs are
norms, parents, and teachers. based on different theoretical approaches such
From the public health perspective, coordi- as cognitive-behavioral therapy, cognitive disso-
nated preventive interventions at the macro level nance theory, psychoeducational elements, and
in social policy, the meso level, e.g., in schools, mindfulness.
and at the individual level are necessary. In general, significantly higher effects can
McVey et al. (2009) developed a psychoe- be observed for selective and indicated preven-
ducational intervention for elementary school tion programs than for universal prevention
teachers that aimed to increase knowledge programs. Various review articles in this field
about the development of eating disorders and suggest that the short-term effect of such pro-
provided a practical guidance on promoting a grams is at least in the low to moderate range.
healthy body image in the classroom context. Some studies also indicate that the effectiveness
Participation in this program increased both lasts at least up to a 1-year follow-up. Effects
knowledge about unhealthy dieting and eating were found particularly in terms of improving
disorders and teachers’ confidence in counteract- body image, reducing drive for thinness, and
ing an unhealthy body image in the classroom. bulimic symptoms. The greatestevidence cur-
rently exists for programs based on cognitive-
 Important Programs that include systemic behavioral therapy and cognitive dissonance
interventions, such as changes in peer theory.
norms regarding, e.g., weight-related teas- The reasons for the better results of second-
ing or educational work with teachers in ary compared to primary prevention may lie
the field of eating disorders, have proven in the higher motivation and burden of indi-
to be effective. viduals who are interested in such programs. In
addition, the recruitment of study participants 37.4.3 The Use of New Technologies
for selective and indicated programs is usually in Primary, Secondary,
more targeted, while universal programs, which and Tertiary Prevention
are often implemented in schools, involve all
children and adolescents—regardless of their The advantages of new technologies in preven-
risk level and motivation. Other reasons could tion lie in the broader accessibility to individu-
lie in the fact that the individual approach of als with an increased risk for a specific disorder
secondary prevention is more effective for older . Interactive content can be flexibly targeted to
adolescents and young adults, who have bet- the users’ needs and utilized independently of
ter critical thinking skills, compared to younger time and location. Thus, online programs ena-
individuals, who are more attached to their ble the combination of universal and indicated
social environment. approaches, which is particularly relevant for
In addition to the effects that seem promising use in the school setting. Based on the results of
for secondary prevention programs, other factors a preliminary screening, students can, for exam-
are crucial for the success of an intervention at ple, receive those program elements that are use-
the public health level, which have not been suf- ful based on their individual risk status.
ficiently considered in previous research (Zeiler In the German-speaking area, two internet-
et al. 2021). According to the RE-AIM model based prevention programs for eating disorders
(Glasgow et al. 2019), the following points have been primarily offered and evaluated in
should be considered when evaluating preven- recent years. Student BodiesTM is a cognitive-
tion programs. behavioral prevention program for eating disor-
ders developed in the USA and translated and
adapted for German-speaking countries. Various
RE-AIM factors for the evaluation of versions of this program have been developed
prevention programs for use in universal, selective, and indicated pre-
1. Reach: How well can the target group vention in female adolescents and young adults.
be reached? Previous studies have shown small to moderate
2. Adoption: How willing are organiza- improvements regarding negative body image
tions (e.g., schools, universities) to offer and drive for thinness. The development of a
prevention programs? full-syndrome disorder was prevented in groups
3. Efficacy: How effective are prevention with an increased risk for eating disorders.
programs? How well are such programs Another Internet-based program aimed at reduc-
accepted by the target group (adhering eating problems and improving body image,
ence, satisfaction)? designed for adolescents and young adults in
4. Implementation: How well can preven- Germany, is called “ProYouth”. Previous stud-
tion programs be implemented in the ies have shown that participation in the program
respective setting as intended? To what can reduce the incidence of eating disorders and
extent are adaptations needed? increase the use of further professional support.
5. Maintenance: How sustainable are This program has been further adpated and inte-
preventions at both the individual and grated into the ProHead platform (www.pro-
organizational levels? head.de).
In the USA, an integrative model for the symptoms and social insecurities after nine
identification, prevention, and treatment of stu- months. Participation in the entire program (nine
dents with eating problems was developed in modules) was identified as an important success
the higher education sector (Fitzsimmons-Craft factor. Internet-based programs have also been
et al. 2019). Using an online screening algo- used for aftercare and relapse prevention in former
rithm, each individual receives the appropriate inpatient s with bulimia nervosa to further reduce
intervention program. Students with a low risk binge eating and compensatory behaviors. In a
for an eating disorder and those with overweight randomized controlled trial, moderate effects of
receive the “StayingFitTM” program, those the online program were found in terms of reduc-
with high risk receive the “Student Bodies- ing self-induced vomiting (Jacobi et al. 2017).
TargetedTM” program, and those with subclini- However, possible disadvantages and chal-
cal and clinical eating disorders receive the lenges of Internet-based programs must also be
therapist-supported self-help program “Student considered. First and foremost, the high dropout
Bodies-Eating DisordersTM”. Patients for whom rate or low adherence, especially for unguided
these programs do not lead to sufficient success, programs, should be mentioned. Increasingly,
as well as patients with AN, receive evidence- data protection aspects have also come into
based face-to-face psychotherapy. In this way, focus, which are demanded by users of such
all individuals receive the care that is needed in interventions, not least due to the EU General
a resource-optimized manner. Accompanying Data Protection Regulation. There are currently
political measures to promote a positive body no mandatory quality criteria for e-health inter-
image and healthy lifestyle, as well as the des- ventions. Initial approaches and suggestions can
tigmatization of eating disorders and obesity, are be found in Klein et al. (2018). Furthermore,
intended to lead to better health and quality of challenges in implementation, e.g., in the school
life for students in general. A similar approach setting, must also be considered.
is pursued in Germany through the “Everybody”
program (Nacke et al. 2019), which represents
Conclusion
an adaptation of “StudentBodiesTM” and is being
evaluated within the framework of the EU pro- For the future, systemic changes are required
ject “ICARE” (www.icare-online.eu). in the field of primary prevention in addition
In addition to computer-based programs, the to individual approaches, which necessitate
first smartphone applications for the preven- longer follow-up periods. In view of general
tion of eating disorders have also been devel- health promotion in adolescence, programs
oped in recent years. Such apps primarily serve should be developed on a broader level that
to monitor eating habits, emotions, behaviors, target universal protective and risk factors in
and thoughts. Other apps focus on promoting a adolescence and thus also cover other areas
healthy body image. An example is the app-based such as emotional problems, stress coping,
intervention BodiMojo (Rogers et al. 2018). The and obesity. The use of new technologies in
goals of this app are to increase self-esteem, the prevention of eating disorders has gained
mindfulness, healthy eating and exercise behav- significant importance, and largely compa-
iors, as well as to improve emotion regulation. rable effects with conventional face-to-face
In the field of tertiary prevention, Fichter et al. programs have been observed, although these
(2012) evaluated a virtual intervention program are in the low to moderate range. Resource-
for patients with AN (VIA) in a randomized con- optimizing integrative models for the identi-
trolled trial, which was used for relapse prevention fication, prevention, and treatment of risk and
after inpatient treatment. Compared to conven- patient groups are promising. A comprehen-
tional follow-up treatment, patients who had sive dissemination of such approaches, espe-
been treated with VIA achieved greater weight cially in German-speaking countries, has yet
gain as well as a greater reduction of bulimic to take place.
37.4.4 Joint Prevention Programs personal, and behavioral factors of nutrition and
for Eating Disorders weight-related issues in adolescents:
and Obesity
• Educate adolescents about the dangers of
An integrated prevention approach for obesity diets and unhealthy weight control measures.
and eating disorders is indicated considering Alternative behaviors should be promoted.
that overweight and unhealthy compensatory This includes, for example, regular consump-
weight-reducing measures (such as fasting, skip- tion of fruits and vegetables, paying attention
ping meals, smoking, vomiting, laxative or diu- to portion sizes as well as hunger and satiety,
retic abuse, taking appetite suppressants or food and engaging in more physical activity.
substitutes) often occur simultaneously, and • Promote a positive body image and avoid dis-
considering symptom shifts from e.g., obesity satisfaction with one’s own body as motiva-
to bulimia nervosa (40% of women with BN tion for change.
were overweight in childhood) (Fairburn et al. • Encourage more frequent, and more enjoy-
1997). In addition, practical considerations in able, family meals.
the implementation of intervention programs • Avoid comments on weight and shape within
and time constraints in schools also point to the the family: This includes comments on one’s
usefulness of health-related integrated preven- own weight and diets, discussions about the
tion programs for obesity and eating disorders. weight of others, encouraging children to diet
Nevertheless, the aims of prevention pro- or lose weight, or teasing them because of
grams targeting obesity and eating dis- their weight.
orders appear to be partly contradictory: • Address negative experiences that overweight
behaviors that are an integral part of weight adolescents have had due to their overweight:
reduction programs, such as tracking of nutri- e.g., weight-related bullying or exclusion
tional intake, , reduction of caloric intake, from certain activities due to weight.
and increase in physical activity, are considered
pathological in the eating disorder field. Despite A recently published study also suggests that
the apparent contradictions in treatment, there prevention approaches for both overweight and
are a number of common goals, such as the underweight adolescents focusing on improv-
intake of regular meals (to avoid binge eating), ing mood, reducing stress, and building posi-
paying attention to body signals such as hunger tive coping strategies for dealing with negative
and satiety, avoiding overeating due to “emo- emotions are promising (Zeiler et al. 2021). The
tional hunger” or external cues, enjoying physi- combined eating disorder and obesity prevention
cal activity (preventing too much and too little program “Healthy Teens @ School” is currently
exercise), and promoting general coping strate- being implemented in schools in Austria and
gies for stress and negative emotions. It should Spain, targeting 14- to 19-year-old students and
be considered whether the importance of paying designed as an online program (Jones Bell et al.
attention to body signals, such as hunger and 2019). It represents a further development of
satiety, should be emphasized (as is the case in the StayingFitTM program developed at Stanford
the eating disorder field) or rather portion sizes University in the USA and pursues a comprehen-
(as in the obesity field). sive prevention approach: promoting balanced
Neumark-Sztainer (2009) recommends nutrition and exercise behavior is just as much in
considering the following five points in joint focus as building a healthy body image and pro-
prevention programs for obesity and eating moting healthy coping strategies for dealing with
disorders in adolescents. These are based on stress and negative emotions. Different program
various research studies that examined societal, elements for overweight and normal-weight
students allow for simultaneous use as a univer- Selbstmanagementinterventionen. Nervenarzt 89:

sal and selective prevention program. 1277–1286
Le LK-D, Barendregt JJ, Hay P, Mihalopoulos C (2017)
Prevention of eating disorders: a systematic review
and meta-analysis. Clin Psychol Rev 53:46–58
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Treatment of Eating
Disorders in Childhood 38
and Adolescence
Contents
38.1 Somatic rehabilitation and nutritional therapy . . . . . . . . . . . . . . . . . . . . . . . 288
38.2 Individual Psychotherapeutic Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
38.3 Involvement of the Family . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290
38.4 Treatment of Comorbidity and Medication . . . . . . . . . . . . . . . . . . . . . . . . . . . 292
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
The number of controlled studies investigating for treatment during the first weeks, this is less
the treatment of childhood and adolescent ano- common in adolescents (Guarda et al. 2007).
rexia nervosa (AN) and bulimia nervosa (BN) A preliminary explanation is therefore recom-
has increased in recent years. The improvement mended before inpatient admission, in which
of treatment—especially that of weight rehabili- the patient is informed about the necessity and
tation—has led to a reduction in morbidity and conditions of inpatient treatment. In many cases,
mortality in adolescent AN, although the out- a “viewing appointment” of the ward or day
come of childhood AN seems to be worse than patient department is also helpful. The treat-
that of adolescent AN (Dobrescu et al. 2019; ment facility should be suitable for children or
Eddy et al. 2017; Herpertz-Dahlmann et al. adolescents and include staff trained for this age
2018). Transparency and honesty are of great group as well as the possibility of schooling.
importance in the treatment of patients with In case of a life-threatening condition due to a
AN. In the case of inpatient treatment, these lack of insight, involuntary treatment taking into
young patients often experience external pres- account the legal requirements must be consid-
sure, particularly from family members, and ered for adolescents; if involuntary treatment
deny the need for hospitalization. While adult is necessary beyond the 18th birthday, a guard-
patients often develop insight into the need ian appointment according to the German civil
code may be useful (Herpertz-Dahlmann and de
B. Herpertz-Dahlmann (*) · B. Dahmen
Zwaan 2015). However, with good preparation
Department of Child and Adolescent Psychiatry, and clarification, involuntary treatment is rarely
Psychosomatics and Psychotherapy, RWTH Aachen required in adolescence.
University, Aachen, Germany The treatment of eating disorders in child-
hood and adolescence is multimodal and essen-
B. Dahmen tially consists of four components.
https://doi.org/10.1007/978-3-662-67662-2_38
288 B. Herpertz-Dahlmann and B. Dahmen
Almost all guidelines define the target weight

Treatment of eating disorders in child- as the weight at which menstruation resumes.
hood and adolescence This recommendation cannot be implemented
• Somatic rehabilitation and nutritional for premenarchal patients. In postmenarchal
therapy patients, there is often a longer period between
• Individual psychotherapeutic treatment weight stabilization and the return of menstrua-
• Involvement of the family tion. Patients with premenarchal onset of the
• Treatment of comorbidity and, if neces- disorder, with discharge before achieving the
sary, medication (primarily for BN) target weight, as well as those with a higher pre-
morbid BMI and longer inpatient treatment have
a higher risk of prolonged amenorrhea (Dempfle
et al. 2013).
38.1 Somatic rehabilitation
and nutritional therapy  Important: The German S3 guideline
(Herpertz et al. 2019) recommends the
At the beginning of treatment of AN and 25th age-specific BMI percentile as the
BN, the nutritional history and documenta- target weight, as menstruation resumes in
tion of weight loss are important, with the rate many adolescent patients when this weight
of weight loss (how many kg in which time?) is achieved (Dempfle et al. 2013); the
also being important. The faster and higher the 10th age percentile is considered the mini-
weight loss, the more severe are the somatic mum weight.
consequences. The nutritionist (or therapist)
documents the daily food intake and eating Our experience has shown that it is not always
habits on the ward. In contrast to BN, patients useful to discuss the target weight with the
with AN should not keep a food diary, as this patient at the beginning of treatment, as achiev-
can support the compulsive-perfectionistic traits ing this weight may seem like an insurmount-
of the patient and encourage calorie counting. able obstacle to the patient. Instead, the patient
Outpatients with BN should keep a food diary and therapist set initial weight stages on a
in which they record the food and quantities “weight ladder”, in which certain weight marks
consumed over a period of 1-2 weeks, possibly or an improvement in eating behavior are linked
also the time and situational characteristics of to “reinforcers”, e.g., participation in outdoor
binge eating and self-induced vomiting. Based activities, sports, attending the clinic school,
on the nutrition protocol and/or observation, weekend visits at home, etc. In this age group,
a meal plan is created that includes 5–6 meals the weight curve must be adjusted to the age
(the lower the body weight, the more frequent curve. Sometimes, radiological determination of
the meals). While diet products have no place bone age is useful to detect a starvation-induced
in the meal plan, so-called forbidden (e.g., high- growth retardation.
calorie or sweet) foods should be integrated in The guidelines provide for a weekly weight
order to reduce the likelihood of binge eating, gain of 500–1000 g in an inpatient setting and
especially in patients with BN. In an inpatient about 300 g per week for outpatients. In cases
setting, a so-called “model meal” in sometimes of severe eating problems, temporary nasogas-
recommended, in which the patient eats the tric tube feeding may be useful. In child and
meal with an experienced supervisor to relearn adolescent patients, attention should be paid
normal eating behavior. In the case of BN, the to the possible occurrence of refeeding syn-
link between restrictive eating and binge eat- drome (Chap. 27). However, recent studies have
ing, as well as the necessity of snacks to pre- shown that the risk of refeeding syndrome in
vent feelings of hunger, must be explained to the non-severely starved patients is extremely low
patient. (Garber et al. 2016) and a higher weight gain at
38 Treatment of Eating Disorders in Childhood and Adolescence 289
the beginning of treatment is rather prognosti- likes about herself and which others find appeal-
cally favorable (Nazar et al. 2017). Furthermore, ing. A group therapeutic setting is helpful here,
the patient should have sufficient time to come in which the other participants can provide feed-
to terms with her changed body shape. back on what they appreciate about the patient.
The nutritional counseling is provided indi- When she feels better, friends of the patient are
vidually and in groups. It has been shown that sometimes invited to joint discussions to enable
adolescent patients are well informed about a confrontation with reality. In the context of
the calorie content of individual foods, but not such group discussions, the patient learns that
about the composition of a healthy diet. For critical statements from her or other participants
this reason, we educate our patients about both do not lead to the feared breakdown of a rela-
necessary food components (quantitative and tionship she fears. In a further step, the adoles-
qualitative) and physical and psychological con- cent considers how she can express her need
sequences of starvation. for attention and affection, which is often dif-
ficult in anorexia nervosa. In younger patients,
there is often a pronounced sibling rivalry and
38.2 Individual a desire for parental attention, combined with
Psychotherapeutic the concern that normal weight will also result
Treatment in a loss of parental attention. Here, the patient
must learn to assert her concerns by formulating
Individual psychotherapy for adolescent AN and her own ideas, persisting in enforcing her own
BN is usually based on a cognitive-behavioral wishes, and approaching others.
disorder model. In addition to cognitive-behavioral strategies,
As a first step, following the idea of U. supportive elements play a particularly impor-
Schmidt and J. Treasure (Schmidt et al. 2002), tant role in the treatment of adolescents and
we encourage the patient to write two letters to children. In line with a study by McIntosh et al.
the eating disorder. (2005) on “specialist supportive clinical man-
agement”, which also included 17-year-olds, the
• In the first letter, the patient can list the patient is encouraged to not give up prematurely
advantages she/he sees in the eating disorder; and to stick to her goal of overcoming the dis-
it begins with: “Dearest Anorexia/Bulimia, ease. This aspect becomes more prominent the
you are my best friend because …” younger the patient is, but also with the onset
• In the second letter, the disadvantages of the of chronicity of the disorder. Children with
disorder are listed; it has the salutation: “Bad AN often experience their illness as an “evil
Anorexia/Bulimia, you are my worst enemy power” to which they are helplessly exposed.
because …” They have poor introspective ability and are
unable to develop an individual concept for the
This approach helps to establish an initial con- development and management of their disorder.
nection with the patient, as the eating disorder Here, externalizing the disease (“witch”, “evil
is not only sanctioned, as the patient already power”, see above) helps. Moreover, many of
experienced from her family, but the positives hospitalized young patients suffer from severe
important to her are also heard. In further ther- homesickness. New treatment settings such as
apeutic steps, the patient learns to examine her day patient treatment or home treatment are
fixed thought patterns regarding body shape often helpful for these patients. Here, the ther-
and weight (being competent, “being interest- apist should take on an empathetic role and
ing” is equated with “being thin” etc.). Deeply strengthen the patient in her willingess and abil-
rooted are ideas of one’s own inability (“I am ity to recover. Sometimes, daily conversations
worthless”). It often takes many sessions for the are necessary to encourage the often very bur-
patient to consider which of her qualities she dened and depressed patient.
38.3 Involvement of the Family ward or therapists should be made transparent to

the family. In 5–6 sessions, the necessary knowl-
In the following, both psychoeducational groups edge is imparted to 5–6 sets of parents. Among
for parents and family based interventions in the other things, they receive information sheets
narrower sense are presented. Therapists should summarizing the contents of the individual treat-
be aware that many parents feel guilty for their ment components.
daughter’s illness, invest a large proportion
of their own time in caring for their daughter,
and are often completely exhausted as a result Group Psychoeducation for Parental
(Raenker et al. 2013). Education on Eating Disorders—
Program of Sessions
• 1st session
38.3.1 Group Psychoeducation – Definitions and epidemiology of eat-
for Parents ing disorders
– Symptoms/current state of research
Participation in a group for parents of patients • Key symptoms and behaviors
with eating disorders (e.g., Holtkamp et al. • Mental and physical conse-
2005; Nicholls and Yi 2012) is experienced as quences of semi-starvation
helpful by many caregivers in all treatment set- • Acute and long-term medical
tings (outpatient, day-care and inpatient). complications
• Effects on the environment
 Important The development of psychoe- – Causes/current state of research
ducational projects was prompted by the • 2nd session
realization that many parents, especially
mothers, experience their daughters’ eating – Pathways to treatment (why—
disorders as their fault. A “rationalization” when—what?)—the Aachen model
of the clinical picture, e.g., by understand- – Presentation of the four pillars of
ing the medical consequences of the starva- eating disorder-specific therapy and
tion process, can alleviate feelings of failure their components
and resignation among family members. – Treatment settings (outpatient/inpa-
tient/day patient/home treatment)
The everyday life of a family, including that of – Prerequisites for a treatment alliance
siblings, is significantly affected by a child’s • 3rd session
eating disorder. Shared meals are disrupted by – Nutritional therapy
intense conflicts, parents develop “detective” • Rationale behind and forms of
strategies to find evidence of their daughter’s refeeding and nutritional therapy
vomiting or abusing laxatives, and siblings no components
longer receive the necessary attention from their • Why does the patient need to
parents. A high level of critical comments from practice eating again?
family members (the concept of expressed emo- • Why can’t the patient decide on
tions) is associated with a worse outcome of the her own food choices once she
eating disorder. has achieved the target weight?
As part of the psychoeducational group, par- • What constitutes a healthy diet?
ents should learn to detach themselves from (Yes, sweets, too…)
their “causative role,” better understand their • What do meal plans look like?
daughter’s behavior, and take on co-therapeutic • What are the parents’
tasks. Furthermore, the treatment concept of the responsibilities?
healthy weight and the increasing autonomy

• 4th session of the daughter is at the center of the therapy
– Treatment steps to prepare for (Cooper et al. 2019). FBT can be conducted in
discharge separate sessions for the adolescent and the par-
• Relapse prevention ents as well as in the form of joint conversations.
• Readmission agreement The duration of the treatment also seems to have
– Actors and their tasks in outpatient no significant influence on the recovery success.
follow-up treatment Recently, “multi-family therapy” has been car-
• Doctor (child and adoles- ried out in comparison to single-family therapy
cent psychiatrist, pediatrician, with good results (Eisler et al. 2016). However,
gynecologist) there are hardly any comparisons between FBT
• Psychotherapist and other forms of therapy, and such compari-
• Youth welfare sons are urgently needed to determine whether
• Parents/legal guardians FBT is superior to other psychotherapeutic inter-
– Clarification of open questions ventions and which patient benefits most from
which method.
 Important Children under 14 years of age

38.3.2 Family-Based Intervention seem to benefit from family based meas-
ures in a similar way as adolescents.
Family-based therapy is the only form of psy-
chotherapy for adolescent AN or BN for which
controlled studies are available. Most are based 38.3.2.1 Conclusion
on the concept of the Maudsley Hospital in Family-based intervention is superior to indi-
London (FBT, family-based treatment). The vidual therapy in adolescent AN. Which form of
starting point was the study by Russell et al. family-oriented intervention is applied seems to
(1987), including a 5-year follow-up, which play only a secondary role. However, it must be
showed that family-oriented treatment for noted that almost all of the patients in the afore-
young, non-chronically ill patients with AN mentioned Anglo-American studies with outpa-
was more effective in terms of body weight, tient settings had a significantly higher weight at
resumption of menstruation, and psychosexual the beginning of treatment than those treated in
functions than individual therapy. This form Germany in an inpatient setting (Lock et al. 2010).
of therapy was further developed mainly in the For adolescent BN, there are also more recent
USA and is now carried out in various modifi- controlled studies on the inclusion of the fam-
cations and settings. Its main goals are weight ily. In a study by Le Grange et al. (2015), FBT
rehabilitation and the reintegration of adoles- was compared with cognitive behavioral therapy
cents into age-appropriate development and adapted for adolescents (CBT-A). At the end of
“participation” in social life. It consists of three therapy and after six months, a greater symptom
consecutive phases: In the first phase, parents reduction was observed in the FBT group, which
take responsibility for food intake and weight was no longer detectable after twelve months.
gain. In the second phase, with a lower ses- However, the study had a high dropout rate.
sion frequency, parents learn to delegate more In another study, two family-based treat-
responsibility to the adolescent and to make the ments, FBT and systemic therapy, were com-
AN-centered actions (regulation of food intake, pared in adolescents with BN. Neither was
sports activities, etc.) more flexible. The third superior to the other, but FBT was more cost-
phase begins when the adolescent has achieved a effective (Agras et al. 2014).
 Important Interventions involving the is recommended to first achieve a “healthier”

family also show high efficiency in ado- body weight, e.g., the 10th BMI age percentile.
lescent BN; however, further studies com- The method of choice is exposure with response
paring different therapy types are needed prevention, possibly also metacognitive ther-
before definitive statements can be made. apy, and in more severe cases, the use of selec-
tive serotonin reuptake inhibitors (SSRI) after
weight rehabilitation. SSRIs are not effective in
the stage of starvation. This also applies to the
38.4 Treatment of Comorbidity treatment of depression.
and Medication
38.4.4 Pharmacological Treatment

 Important Due to the high risk of anxiety
disorders in patients with eating disorders,
38.4.4.1 Anorexia Nervosa
social competence training as part of inpa-
Currently, no medication is approved in Europe
tient treatment has proven helpful.
or the USA for the treatment of adolescent AN
(Couturier et al. 2019).
38.4.1 Anxiety Disorders
Antidepressants Neither tricyclic antidepres-
sants nor lithium showed an effect in adolescent
Since the risk of anxiety disorders in adolescent
patients with AN. More recent studies, which
eating disorders is high cross-sectionally and
also included adolescent patients, did not find a
longitudinally, we conduct social competence
relapse prevention effect. SSRIs also showed no
training for patients who show symptoms of a
significant effect on eating disorder symptoms,
social phobia, but only after achieving the 10th
but may be indicated for the treatment of persis-
BMI age percentile in patients with AN.
tent depression after weight rehabilitation.
Antipsychotics Conventional antipsychot-

38.4.2 Social Phobia
ics show no significant effect in the treatment
of AN. Recent meta-analyses in adolescent
The social competence training for the treat-
patients with AN found no superior effect of
ment of comorbid social phobia in AN and BN
atypical antipsychotics as an adjunct to psycho-
refers to both food-dependent and food-inde-
therapy compared to placebo. In a retrospective
pendent situations, i.e., both restaurant and caf-
study with the partial D2 agonist aripiprazole
eteria visits and eating with peers as well as bus
based on medical records, a higher weight
travel, opening a bank account, etc. We con-
gain was observed in treated adolescents com-
sider the treatment of social phobia to be very
pared to untreated adolescents with AN (Frank
important, as a lack of autonomy of the patient
et al. 2017). This study requires replication
may promote a relapse into the sickrole.
with a randomized controlled design. In adults,
a slightly higher but significant weight gain
was found with olanzapine without serious
38.4.3 Obsessive-Compulsive
side effects (Attia et al. 2019). A correspond-
Disorder and Depression
ing study for adolescent patients is not avail-
able. However, the sedative effect of olanzapine
A comorbid obsessive-compulsive disorder
may sometimes be helpful in the treatment of
also requires treatment. In the case of AN, it
pronounced physical hyperactivity at the begin- Conclusion

ning of treatment.
There is an urgent need for further efforts to
 Important So far, there is insufficient find effective treatment methods and more
evidence for the effectiveness of pharma- progressive settings for child and adolescent
cological treatment in children and adoles- eating disorders. The high rate of rehospitali-
cents with AN. zations hinders the personal, social, and pro-
fessional development of adolescents and, in
Osteoporosis Prevention Due to the high prevalence of turn, increases the likelihood of relapse in a
osteoporosis in acutely ill and weight-rehabilitated AN vicious circle.
patients, a transdermal administration of 17ß-estradiol,
supplemented by cyclic administration of progesterone,
was successfully tested in a randomized controlled trial
in adolescent patients. The bone density of the spine
and hip increased significantly compared to the placebo References
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treatment with adolescent-focused individual therapy https://doi.org/10.1002/erv.465
Alternatives to Inpatient
Treatment of Anorexia Nervosa 39
in Childhood and Adolescence—
Day Patient Treatment and Home
Treatment
Contents
39.1 Disadvantages of inpatient treatment for children and adolescents . . . . . . 295
39.2 Day Patient Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296
39.3 Home Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301
39.1 Disadvantages of inpatient were readmitted within one year, regardless of the
treatment for children duration of the first inpatient stay (Madden et al.
and adolescents 2015). In addition, many adolescents and espe-
cially children experience inpatient admission as
In Germany and other European countries, inpa- coercive and suffer from severe homesickness.
tient treatment for children and adolescents, as For numerous young people with AN, their
well as adults with anorexia nervosa (AN), has history provides indications of social phobia or
continuously increased (Stat. Bundesamt 2019; anxious-avoidant personality traits (Chap. 2; Cardi
e.g., Cruz et al. 2018), although there are signifi- et al. 2018). With this in mind, there is a risk that
cant doubts that inpatient therapy is superior to the age-appropriate socio-emotional development
other forms of treatment. In a European follow-up of these adolescents will be impaired by long inpa-
study spanning more than six years with adoles- tient stays. The cost of inpatient treatment is very
cent patients, 50% had to receive inpatient treat- high. A calculation of the direct and indirect treat-
ment a second time (Steinhausen et al. 2009); in ment costs for AN over three months showed that
a more recent Australian study, more than a third approximately 60% of these costs were caused by
inpatient therapy (Stuhldreher et al. 2015).
In contrast to earlier views that considered
separation from parents and children as an
B. Herpertz-Dahlmann (*) · B. Dahmen essential treatment element for AN, it is now
Department of Child and Adolescent Psychiatry, believed that involving parents (or caregivers)
Psychosomatics and Psychotherapy, RWTH Aachen
University, Aachen, Germany makes an important contribution to the success
e-mail: [email protected] of treatment. The family-based therapy (FBT)
B. Dahmen developed primarily at the Maudsley Hospital
e-mail: [email protected] in London has contributed significantly to this.
https://doi.org/10.1007/978-3-662-67662-2_39
All known European guidelines, including the meals”) as well as weekend visits with overnight
German S3 guideline, recommend intensive stays. The weekly weight gain in the DC should
integration of parents into the treatment of AN be at least 300 g (compared to 500 g for inpa-
(Herpertz et al. 2019; NICE Guidelines 2017). tient treatment) (see also Herpertz et al. 2019).
Nevertheless, parents and patients complain that
the transition from inpatient treatment to home
is too difficult and that they feel insufficiently Requirements for day patient treatment
supported. • Somatic stability of the patient
It was therefore our goal to develop alterna- • No severe psychological comorbidity or
tive treatment strategies that allow for greater suicidality
involvement of the patient’s social environment. • Independent nutrition possible (no
In a first step, a day clinic program for children nasogastric tube feeding required,
and adolescents was developed; the second step exceptions possible)
involves an intensive home-based treatment pro- • Sufficient family resources
gram in the patient’s home environment (Home • Distance between clinic and place of
treatment, HoT). residence ≤1 h
• Motivation of patient and family
39.2 Day Patient Treatment

To improve communication between staff and
39.2.1 Practical Implementation caregivers, a report book or daily (data-pro-
tected) email contacts are recommended, in
In the majority of day clinics (DC), the treat- which parents explain their observations or prob-
ment of AN is carried out five days a week from lems with their child with an eating disorder.
morning (8:00 or 9:00 am) until afternoon (4:00 The patient is encouraged to renew their pre-
or 5:00 pm). In some DCs, the day patient treat- inpatient contacts with peers and (sports) clubs.
ment is only conducted in the mornings, after- School attendance is resumed with an increas-
noons, or on individual days. We have found that ingly growing number of hours; this is a very
patients with an eating disorder do not benefit important step, as many patients fear the “con-
sufficiently from a general DC for mental dis- frontation” with teachers and classmates and
orders, but rather should remain in the ward for dread the demands and questions associated
eating disorders, preferably under the care of the with long school absences (“Where have you
same therapist, following inpatient treatment. been for so long? Have you gained weight? You
This also motivates other inpatients, who learn look good.”). In addition, they find it difficult
from the example of their fellow patients and to have a meal with others at school. If the par-
benefit from the “everyday contacts” with the ents agree, a phone call or personal conversation
day patient treatment patients. between the therapist and the class teacher or
Certain prerequisites must be met for admis- head of year is recommended before returning
sion to the DC (overview). This primarily to school. The necessary meals at school can be
includes the patient no longer being physi- discussed with the nutritionist in advance.
cally endangered by their behavior, i.e., no pro- In general, however, the patient participates
nounced laxative abuse or frequent vomiting is in the entire therapy program of the ward, as
present. In addition to the patient themselves, described in Chap. xx, and in addition, parent
their family must also be motivated for DC treat- or family meetings take place very regularly.
ment, as the latter must ensure adequate care Similar to inpatient treatment, the patient is dis-
(and nutrition) in the evenings and on week- charged to outpatient treatment after maintain-
ends. It is advisable to prepare for discharge to ing their target weight for a defined period and
the DC through joint meals in the clinic (“family normalizing their eating behavior.
39 Alternatives to Inpatient Treatment of Anorexia Nervosa … 297
39.2.2 Efficacy of Day Patient 15 days. The authors of a study on this therapy
Treatment believe that parents gain more confidence in car-
ing for their child, and patients realize the better
Several uncontrolled studies concluded, based understanding of their parents. Both contribute
on a comparison of findings before and after day to the efficacy of this treatment, according to a
patient treatment, that adolescent patients with German pilot study (Steinberg et al. 2019). In the
AN benefit from day patient treatment (Serrano- study by Eisler et al. (2016), single-family ther-
Troncoso et al. 2020; Simic et al. 2018). In a apy based on FBT was compared with multi-fam-
review on day patient treatment and therapeutic ily therapy. In this case, the families are together
residential groups (“residential treatment”), it for four consecutive days and then again for six
was shown that the majority of studies describe days over a period of nine weeks. At discharge,
an improvement in eating disorders at discharge 60% in single-family therapy had achieved an
and possibly at a later follow-up examination improvement in symptoms, compared to 75% in
(Friedman et al. 2016). the multi-family group. After 18 months, the dif-
In our own randomized controlled trial, we ference between the two groups was no longer
conducted a comparison between inpatient treat- significant; 78% of the multi-family group still
ment (n = 85) and day patient treatment (n = showed good recovery. However, by this time,
87). After three weeks of inpatient treatment, more than a quarter of the participants had
patients were randomized either to continue inpa- already left the study (Eisler et al. 2016).
tient treatment or to receive day patient treat-
ment. At the one-year follow-up examination, no
significant difference in body mass index (BMI) 39.3 Home Treatment
was found between the two treatment settings.
However, after day patient treatment, patients 39.3.1 Advantages of Home
showed better mental health and better psycho- Treatment (HoT)
sexual development with lower treatment costs
(Herpertz-Dahlmann et al. 2014). In the follow- Although the above-described day patient treat-
up examination two and a half years after admis- ment was associated with better recovery than
sion, in which 80% of the inpatient and 86% of inpatient treatment, almost a third of patients
the day clinic patients participated, the BMI in in day patient treatment had to be readmitted
the day patient group was significantly higher to inpatient care within a 2.5-year observation
and the number of inpatient readmissions signifi- period (Herpertz-Dahlmann and Dempfle 2016).
cantly lower (Herpertz-Dahlmann and Dempfle Even with the outpatient FBT recommended in
2016). This suggests that day patient treatment many guidelines for children and adolescents,
is an effective and safe form of treatment, likely relapse rates are high. In a randomized study
associated with lower costs and lower relapse comparing FBT with individual therapy (adoles-
rates than inpatient treatment. cent-focused therapy, AFT), only 40% of patients
had achieved a stable weight after four years (Le
Grange et al. 2014). As mentioned above, the
39.2.3 Multi-Family Therapy transition from inpatient or day patient treatment,
with a structured nutrition and therapy regime, to
In addition to day patient treatment for the indi- everyday home life is experienced as very diffi-
vidual, in which the caregivers are involved in the cult. Patients and parents desire more support for
form of parent or family sessions, there is also a the family itself, but also for peers and other car-
day patient treatment that takes place over a year egivers (Mitrofan et al. 2019).
on various dates, in which several families with The so-called home treatment (HoT) is a treat-
a daughter/son with AN are treated as a closed ment setting that has already been applied to other
group after an initial appointment for a total of mental disorders and was recommended by the
WHO in 2005 as an advanced treatment method years after the onset of the disorder (Treasure
(WHO 2005, p. 87). Experiences so far are posi- et al. 2015), early intensive intervention, e.g.,
tive in all age groups regarding rehospitalization in the form of HoT, makes sense as secondary
rates and treatment costs, but there are hardly prevention.
any studies comparing HoT with other settings
or including the perspective of the person being
treated (Sjølie et al. 2010). For most patients, it is 39.3.2 Framework and Funding
used for crisis intervention, but not for prevention. of HoT
Moreover, there are hardly any studies that have
investigated the feasibility of HoT for AN. In the Unfortunately, HoT has not yet been estab-
works of Boege et al. (2015, 2020), patients with lished everywhere as a service covered by statu-
eating disorders were only sporadically part of tory health insurance. The law on the “Further
the treatment clientele; an eating disorder-specific development of care and remuneration for psy-
HoT setting was not described. chiatric and psychosomatic services” enables
The British eating disorder researchers hospital providers to offer treatment at home
Schmidt and Treasure (2006) developed a mul- equivalent to inpatient treatment (StäB) as an
tifactorial etiological model for AN, in which, alternative to inpatient treatment (Boege et al.
in addition to disposition, cognitive and socio- 2020). Unfortunately, apart from the studies by
emotional factors, interpersonal factors play a Boege et al., there are hardly any comparisons
significant role. This includes that caregivers of the effects of inpatient treatment and home
unintentionally support the development and treatment. In particular, disorder-specific com-
maintenance of AN (e.g., by purchasing low-cal- parisons between different settings are lack-
orie foods to avoid conflicts, increased attention ing. At the University Hospital Aachen (UKA)
to the child when reducing food intake, support- and the LVR University Hospital Essen, special
ing social withdrawal through greater parental agreements were made with statutory and pri-
affection, etc.). Furthermore, a not insignificant vate health insurance companies for HoT. HoT
proportion of family members themselves have proved to be more cost-effective for health insur-
mental disorders, including eating disorders, ance companies, which participated jointly and
which require special support. Especially in uniformly in funding. A comparison of the pure
early stages of the disorder, HoT can modify treatment costs between inpatient treatment
disorder-enhancing behaviors in caregivers and standard and HoT at our department resulted in
provide security (Fig. 39.1). a saving of about one third per patient. The nec-
More recent studies, especially imaging stud- essary prerequisites are shown in the overview.
ies, show that habituation processes (habits) also
play a major role in maintaining AN. Eating,
exercise, and behavioral rituals, which are pri- Requirements for participation in HoT
marily established at home, become independ- • The presence of a typical or atypical
ent of a primary associated reinforcement (e.g., AN based on ICD-11 or DSM-5
praise for supposedly more attractive appearance • Minimum age 12 years, maximum age
or healthy eating) and become self-perpetuating 18 years
(Uniacke et al. 2018). After an individually vary- • First or second admission due to AN
ing period, the rituals become part of everyday (uncertain whether HoT is suitable for
life, and it takes great strength for patients to chronically ill patients)
break these habits. • Patient lives with at least one parent/
An early interruption of rituals by a trained caregiver
team can break this “vicious circle.” Since it is • Place of residence no more than 1 hour
suspected that chronic symptoms, including irre- away from the clinic
versible neuronal changes, occur as early as three • Consent of caregivers and patient
Precipitating factors
↑ insecure attachment
↑ stress sensitivity/ negative emotions
↑ detail-focused, ↓ set shifting
Triggering factors
Anorexia nervosa
HoT
Fear
Frustration
↓ Warmth
↑ AN ↑ Criticism
Behaviors ↑ Overprotection
Accommodating the pathological
behaviors
Fig. 39.1  Etiological model of anorexia nervosa according to Schmidt and Treasure (2006) and the effects of home
treatment
Patients with severe comorbid disorders such as in the psychoeducational group for parents of
severe self-harming behavior or other primary eating disorder patients (Chap. 14). In addition,
mental illnesses such as psychoses, organic regular individual parent or family meetings take
brain diseases or addiction disorders, severe place. Before admission to HoT, patients must be
somatic diseases, low intelligence or insufficient somatically and psychologically stabilized to the
knowledge of the German language must be extent that they can eat independently, show no
excluded from HoT. pronounced vomiting or laxative abuse, and have
The offer to participate in HoT is made at the satisfactory weight gain (but no defined mini-
time of inpatient admission; inpatient treatment mum weight). Of course, lack of adherence and
is carried out over 4-8 weeks for physical stabi- suicidality are also exclusion criteria.
lization and restoration of independent nutrition.
At the end of the eighth treatment week, the lat-
est hospital discharge and the start of HoT take 39.3.3 Practical Implementation
place. Parents and patients are prepared for HoT of HoT
from the beginning of inpatient treatment, i.e.,
family meals are quickly held, and somewhat Before the treatment at home begins, the target
later, weekend visits and overnight stays at home weight (generally around the 25th–30th BMI
take place. Even nutrition through nasogastric percentile or the weight at which menstruation
tube feeding during the maximum eight-week ceased) is determined. During the HoT treat-
inpatient period is not a contraindication for ment, the patient is weighed at least once a week
HoT. However, parents are required to participate by the HoT team on calibrated scales.
The multidisciplinary team consists of an discharge, two patients (9.5%) were readmitted to
experienced nurse, a nutritionist, an occupa- the hospital (Herpertz-Dahlmann et al. 2021).
tional therapist, a physician, and the psycho- No serious “side effects” were observed. The
therapist who has already treated the patient weight after one year was still somewhat higher
on the ward (psychologist or physician). In the than in the study on day patient treatment (see
first month, the patient/family is visited three above). Eating disorder symptoms and general
to four times a week, in the second month psychopathology decreased significantly. We
three times, in the third month twice, and in the assessed the burden and involvement of car-
fourth (and final) month once. In addition, the egivers using questionnaires, which decreased
patient must attend a group therapy session for over time until the follow-up examination. This
adolescents with eating disorders once a week. change was most evident between inpatient
Appointments are scheduled in advance for one admission and the end of HoT. Quality of life
week at a time. A member of the multidiscipli- and treatment satisfaction were also rated highly
nary team can be reached during working hours at the end of treatment and after one year. The
via a special mobile phone (“hotline”). In urgent total treatment costs of the initial inpatient treat-
cases, the on-call physician can be contacted ment and later HoT were significantly lower
after working hours. than the (mostly inpatient) treatment of anorexia
The frequency with which each profession nervosa on a national average (Jaite et al. 2019).
visits the family depends on individual needs. The members of the multidisciplinary team
The parents must agree before the treatment that were highly motivated in this new treatment
they will be present for at least at one session approach; however, they had also actively sought
per week. Team visits led by a child and adoles- to participate in this project. After an initial train-
cent psychiatrist experienced in the therapy of ing period, they experienced the contacts with
eating disorders take place twice a week. the patient and the family as more intense and
During the first two months, the focus of satisfying than in the inpatient or day patient
treatment is on educating and supporting the treatment setting (Herpertz-Dahlmann et al.
parents, as well as providing direct support to 2021).
the patient; in the 3rd and 4th months, more
emphasis is placed on rebuilding social rela-
Conclusion
tionships (e.g., participation in sports or other
clubs, activities with friends) and promoting the There is no clear evidence as to which treat-
patient’s independence. ment setting has the highest effect for ado-
lescent AN (Hay et al. 2019). Both DC and
HoT represent promising alternatives to
39.3.4 Initial Results of HoT inpatient treatment, and in previous research
were associated with high treatment satisfac-
In a pilot study of 22 patients with a follow-up tion among patients and caregivers. Possibly,
examination one year after admission, we were these offers will make it easier for future
able to demonstrate that most patients reached adolescents with AN to seek treatment ear-
their target weight, which remained stable at lier and for a sufficient length of time. The
follow-up. Three patients had to be readmit- costs are lower than for inpatient treatment.
ted for a few days during the intervention due to Of course, DC and HoT are not suitable for
family conflicts or insufficient weight gain. In all patients with AN. In any case, larger ran-
one patient, the treatment was terminated prema- domized trials are needed to compare the
turely and inpatient treatment had to be resumed. effects and the course of recovery over a
During the one-year observation period after longer period of time in different settings.
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Family-Based Therapy
40
Silke Naab
Contents
40.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303
40.2 Description of Family-Based Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 304
40.3 Efficacy of Family-Based Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 304
40.4 Current Developments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
40.5 Limitations of the Application of Family-Based Therapy . . . . . . . . . . . . . . 307
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308
40.1 Introduction Le Grange et al. 1992, 2016), and the treatment

form of home treatment (Herpertz-Dahlmann
Family therapy for eating disorders, particularly et al. 2014). The family therapy approach sees
anorexia nervosa (AN), has been conducted for parents as a central influencing factor, which is
almost half a century. The interventions were why they should be involved in the treatment
embedded in various family therapy schools. (Murray and Le Grange 2014).
Notable are Minuchin’s structural approach Various international guidelines for the
(Minuchin et al. 1975), strategic family therapy treatment of eating disorders, including the S3
(Madanes 1981), the systemic approach of the guideline for “Diagnosis and Therapy of Eating
Milan School (Palazzoli 1974) and more recent Disorders,” recommend specialized family ther-
narrative applications (Epston et al. 1995), fam- apy for eating disorders as a first-line treatment
ily therapy for anorexia nervosa (FT-AN) (Eisler for adolescent patients with AN and BN (Hilbert
et al. 2016a), systemic family therapy (SFT) et al. 2017; Herpertz et al. 2011).
(Agras et al. 2014), multi-family group therapy The best-studied family therapy is “family-
(Eisler 2005, 2016b) and parent-focused family based treatment” (FBT). FBT is a further devel-
therapy (e.g., separate family therapy and par- opment of the so-called Maudsley method,
ent-focused therapy [PFT]) (Eisler et al. 2000; which was developed in the 1980s as an integra-
tion of a variety of family therapy methods at
the Maudsley Hospital in London (Dare 1985).
It was systematically elaborated and adapted by
S. Naab (*)
Clinic of Psychosomatics and Psychotherapy, Schön James Lock and colleagues and manualized as
Klinik Roseneck, Prien am Chiemsee, Germany family-based treatment (FBT) in 2001 (2nd edi-
e-mail: [email protected] tion: 2013).
https://doi.org/10.1007/978-3-662-67662-2_40
304 S. Naab
40.2 Description of Family-Based

Treatment – Phase I (sessions 1–10): Weight
restoration
 Important Family-based treatment (FBT) – Phase II (sessions 11–16): Returning
for adolescent patients with eating dis- responsibility for eating behavior to
orders (Lock et al. 2001; Lock and Le the adolescents
Grange 2013) is a manualized outpatient – Phase III (sessions 17–20): Building
procedure that initially aims at restor- a healthy adolescent identity and end-
ing weight under parental guidance at ing therapy
home (focus in Phase 1 of the 3-phase • Therapy sessions take place weekly
treatment). during Phase 1, twice a week during
Phase 2, and monthly during Phase 3.
FBT also aims to promote the healthy devel-
opment of adolescents, without dysfunctional
thoughts and behaviors disrupting and interrupt-
ing these healthy processes. In this sense, the 40.3 Efficacy of Family-Based
entire course of treatment takes into account the Therapy
ongoing effects of hunger, cognitions, emotions,
and behaviors on adolescent development. These The efficacy of family-based therapy has been
are integrated into the treatment as potential dis- investigated in five randomized controlled trials.
order-maintaining factors. Essential aspects also It is thus the best-studied therapeutic approach
include considering adolescence in the context for adolescents with AN and currently has the
of family and community and the importance highest level of evidence. The studies to date
of learning in the home environment (Lock and report remission rates between 21.2% and 49%
Nicholls 2020). One of the goals of FBT is also (Agras et al. 2014; Le Grange et al. 2016; Lock
to prevent the need for inpatient admission. et al. 2005, 2010; Madden et al. 2015; Stefini
FBT has also been adapted and manual- et al. 2017).
ized for patients with bulimia nervosa (BN) For adolescents with BN, only two rand-
(Le Grange and Lock 2007). In comparison to omized controlled trials are available, with
FBT for AN, the primary goal to be achieved remission rates of 29–49%. These suggest the
by involving parents is not the restoration of efficacy of FBT for this patient group as well
weight, but the establishment of a stable eating (Le Grange et al. 2007, 2015).
structure. An assessment of the remission rates of FBT
The following presents the therapy concept in patients with AN compared to the guideline
(overview) and treatment phases of FBT (Table procedures cognitive behavioral therapy (CBT)
40.1) for patients with AN. and psychodynamic therapy (PT) is currently
not possible, as there is no worldwide evaluation
of the efficacy of outpatient CBT or PT in ado-
Therapeutic concept of family-based lescents with anorexia nervosa within the frame-
therapy (FBT) for anorexia nervosa work of a randomized controlled study (RCT).
according toLock and Le Grange (2013)
Outpatient Setting  Important Overall, it can be assumed that
FBT is at least as effective as other thera-
• 10-20 treatment sessions (1 hour each) in peutic approaches. However, no statement
6–12 months (on average about 9 months can be made as to whether FBT is supe-
and 15 sessions [Lock et al. 2005]) rior to guideline procedures and also in the
• Parents as a central resource in therapy long term, as there are currently no or too
• Three treatment phases: few studies available.
40
Table 40.1  Treatment phases, goals, and interventions of family-based therapy for anorexia nervosa (Lock and Le Grange 2013)
Treatment phases Main goals Interventions
Phase 1, Session 1 • Involvement of the family in therapy 1. Weighing the patient
Restoration of weight • History-taking: Influence of AN on the family 2. Greeting the family
• Information about the family (coalitions, 3. History-taking of each family member
authority structure, conflicts) 4. Separation of the disorder from the patient
5. Emphasizing the severity of the disorder and the difficulties in recovery
6. Assigning parents the task of increasing weight
Family-Based Therapy
7. Preparation of the family meal for the next session and ending the session
Phase 1, Session 2 • Analyze family structure and possible impact 1. Weighing the patient
on the ability of parents to help their child gain 2. History-taking, observation of family patterns during preparation and serving of food, discussi-
weight and eat healthily ons about food, especially regarding the patient
• Parents should be given the opportunity to 3. Support parents in convincing their child to eat more than they are willing to, or find out how
experience that they can successfully help their they can best contribute to normalizing eating behavior and promoting weight gain
child eat normally and gain weight 4. Engage siblings for support outside of meal times
• Observe strengths and weaknesses of the 5. Ending the session
family, especially during meals
Phase 1, Sessions • Focus family on the eating disorder 1. Weighing the patient at the beginning of each session
3–10 • Support parents in managing their daughter’s 2. Focusing the therapeutic conversation on the design of nutrition and eating behavior as well as
eating habits reducing concerns
• Mobilize siblings to support the patient 3. Discussion and support of parental efforts to promote weight rehabilitation
4. Discussion and support of the family in evaluating the efforts of siblings to help their affected
sister
5. Modifying criticism from parents and siblings
6. Distinguishing between the adolescent patient, her interests, and AN
Phase 2 • Maintaining parental management of eating 1. Weighing the patient
Returning responsibi- disorder symptoms until the patient can 2. Supporting parents in coping with eating disorder symptoms until the adolescent is able to eat
lity for eating behavior demonstrate that she is able to eat well and well independently
to the adolescent gain weight independently 3. Supporting parents and patient in negotiating the return of control over eating disorder symp-
• Returning control of food and weight to the toms to the patient
adolescent 4. Encouraging the family to discuss the connection between problems and the development of AN
• Analyzing the relationship between the 5. Continuing to modify parental and sibling criticism of the patient, returning control over eating
patient’s developmental issues and anorexia to the patient
nervosa 6. Supporting siblings in assisting their ill sister
7. Distinguishing between the adolescent patient and her interests and the interests of AN
8. Reflecting on progress with the family
(continued)
305
306 S. Naab
According to expert opinion, it can be assumed

that various approaches are effective and that
1. Reviewing the adolescent’s issues with her family and developing problem-solving strategies
there is no evidence yet as to whether one
approach is superior to another (Herpertz-
Dahlmann 2017; Zeeck et al. 2018).
40.3.1 FBT in the German Guidelines

for Diagnosis and Treatment
of Eating Disorders
The evidence for family-based therapies in

general is rated in the German guidelines for
the diagnosis and treatment of eating disorders
2. Involving the family in the “review” of the issues
3. Reviewing how much the parents do as a couple
with evidence level Ib (for children and ado-

lescents) for AN and evidence level IIb for BN
(AWMF 2019).
5. Preparing for future problems
40.3.2 Who benefits most from FBT?

4. Exploring adolescent issues
6. Summarizing the session
Various studies on the application of family-

7. Ending the treatment
based therapy examined moderators that have

an influence on therapy outcomes. In Table 40.2,
Interventions
positive moderators for the enrollment of FBT in

patients with AN and BN are listed.
Despite the evidence for the effectiveness
of FBT in adolescents with eating disorders,
there are currently no data on the application of
• Establishing that the relationship between the
Adolescent issues and adolescent and her parents no longer requires
family and developing problem-solving stra-

termination of therapy the symptoms as a form of communication
this therapy approach in adolescents with eat-

• Reviewing the adolescent’s issues with the
ing disorders in Germany (Schlegl et al. 2020).

However, it can be assumed that this method
is rarely used in Germany, as there is a lack of
certified FBT therapists. This may be due to the
fact that family therapies are generally not or
• Termination of therapy
only rarely covered by health insurance compa-

nies. Another reason could be the lack of avail-
ability of training and supervision opportunities
Main goals
regarding this therapy approach.

tegies
40.4 Current Developments

Treatment phases
An adaptation of FBT for patients with AN

aged 16–25 years (FBT-TAY) was carried out
by Le Grange’s working group in a pilot study
Phase 3
(Dimitropoulos et al. 2018). Feasibility and

40 Family-Based Therapy 307
Table 40.2  Positive moderators of FBT in patients with AN and BN (according to Schlegl et al. 2020)
Anorexia nervosa Bulimia nervosa
Higher eating disorder-related compulsivity Younger age
(Le Grange et al. 2016; Le Grange et al. 2012) (Ciao et al. 2015)
Shorter duration of illness More pronounced purging behavior
(Le Grange et al. 2016) (Ciao et al. 2015)
Higher severity of eating disorder symptoms Lower severity of eating disorder symptoms
(Le Grange et al. 2012) (Le Grange et al. 2008)
Bulimic subtype Lower scores on the Conflict subscale of the Family Environ-
(Le Grange et al. 2012) ment Scale
(Le Grange et al. 2015)
Less general compulsive symptomatology
(Agras et al. 2014)
Mothers with no or low depressive symptoms
(Forsberg et al. 2017)
acceptance among patients and therapists were 40.5 Limitations of the

demonstrated, as well as an improvement in Application of Family-Based
symptoms and weight through the application of Therapy
FBT in young adults with AN.
So far, there are only a few studies on the Treatment with FBT involves a number of chal-
application of FBT in an inpatient setting. lenges. There are no direct comparisons of FBT
According to Spettigue and colleagues (2019), with other psychotherapeutic treatment forms
a specialized inpatient therapy program for ado- for patients with eating disorders in combina-
lescents with AN using an adapted form of FBT tion with nutritional management and the goal
also leads to a positive short-term improvement of weight rehabilitation.
in the medical and psychological condition of Current research findings indicate that FBT
the patients (weight gain and reduction of anxi- works well for about two thirds of parents and
ety, depression, eating disorder symptoms). adolescents who accept the treatment, with less
In view of the ongoing COVID-19 pandemic than 40% of patients achieving full remission.
with correspondingly difficult access to stand- FBT cannot be used for adolescents whose
ard psychotherapy, the working group of James parents are not available or do not accept a fam-
Lock (Matheson et al. 2020) points to the neces- ily-based treatment model.
sity of using video-based therapy methods for For patients and parents who participate in
the treatment of patients with eating disorders. the treatment, there may still be difficulties in
So far, these therapy forms have not been suf- implementing the treatment, as FBT is intended
ficiently researched in adolescents with eating to actively involve all family members. Parents
disorders, and there is only one case series on may need to take time off work, siblings need to
video-based FBT (Anderson et al. 2017), but no adapt to the therapy plan, and the family must
RCTs in children and adolescents. It is there- travel to the respective therapy center.
fore largely unknown whether the results of In cases where FBT cannot be well applied
psychotherapy for eating disorders in children in adolescents, is contraindicated, or is not
and adolescents are comparable to the results of accepted, cognitive behavioral therapy for eat-
standard face-to-face treatment. ing disorders (CBT-E) is recommended (NICE
308 S. Naab
guidelines 2017). Results of a study by Dalle References

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of 2 family therapies for adolescent anorexia ner-
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71:1279–1286
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(2017) Utilizing telehealth to deliver family-based
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27.05.2019
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Psychodynamic Therapy
41
Wolfgang Herzog, Hans-Christoph Friederich, Beate Wild,
Henning Schauenburg and Stephan Zipfel
Contents
41.1 Foundations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
41.2 Focal Psychodynamic Psychotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312
41.3 Disorder-Specific Modifications of Psychodynamic Therapy . . . . . . . . . . . 313
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315
41.1 Foundations theory of illness. As outlined in Chap. 11, the

psychodynamic theoretical approach thus goes
Psychodynamic diagnostics and therapy are beyond the purely phenomenological description
based on a psychodynamic personality theory, of mental disorders on which current classifica-
including personality development and a related tion systems of mental illnesses are based.
The perspective of personality, and an essen-
tial consideration of this perspective in the
definition of treatment goals and intervention
techniques, are of central importance in psycho-
dynamic therapy. Especially in the therapy of
W. Herzog (*) · H.-C. Friederich · B. Wild ·
H. Schauenburg eating disorders, this view is consequential and
Department of General Internal Medicine and not at all self-evident: For example, how should
Psychosomatics, Medical Hospital, University of the “severity” of an eating disorder and then,
Heidelberg, Heidelberg, Germany subsequently, the treatment success be deter-
mined: Is a patient with BN who vomits more
H.-C Friederich frequently “sicker” than a patient with a lower
frequency of vomiting?
B. Wild From a psychodynamic perspective, in addi-
tion to symptomatic improvement, the aim is
H. Schauenburg always to work on personality-inherent intrapsy-
chic conflicts, including conflictual relationship
S. Zipfel issues resulting from them. Symptom behav-
Psychotherapy, Medical University Hospital Tübingen, ior can vary considerably in the short term and
Tübingen, Germany is not suitable for sole assessment. Conversely,
e-mail: [email protected] there is a justifiable critical objection that
https://doi.org/10.1007/978-3-662-67662-2_41
312 W. Herzog et al.
emphasizing the importance of working on per- the consideration of other relevant perspectives:
sonality must not lead to ignoring the eating Somatic starvation consequences, maladaptive
symptoms - as could happen in the past - since it family patterns, or symptom loops that arise from
makes the primary contact with the patient more eating disorder-specific symptoms or self-harm-
difficult and is associated with less successful ing behavior and maintain themselves (addic-
therapy outcomes. tively) are examples of such perspectives that may
The elaboration of the subjective, biographi- and must sometimes be in the foreground and
cal “meaning” of symptoms is thus a central require a disorder-specific supplement to general
concern of psychodynamic therapy. The indica- psychodynamic techniques (Dare et al. 2001).
tive character of the symptom, the (mostly
unconscious) psychological, biographical, and
social contexts that make the symptom intra- 41.2 Focal Psychodynamic
psychically the “better alternative” in all of its Psychotherapy
contradictory, absurd and self-harming aspects
compared to the unpleasant feelings that would For pragmatic reasons, evaluations of psycho-
occur without the symptom behavior, point the dynamic psychotherapies for eating disorders
way to therapeutic treatment options. have predominantly taken place in focal therapy
Psychodynamic therapy is therefore about concepts. The Operationalized Psychodynamic
working out an individually valid “hermeneu- Diagnosis (OPD) in its manualized form OPD-2
tics” of the symptomatology, and this becomes (Working Group OPD 2006) serves as a basis
possible in the relational space between patient for focus formation with its axes
and therapist. Here, old, hurtful relationship
traces can be deciphered, and new, corrective • Experience of illness and treatment prereq-
emotional experiences can be made. The lively uisites,
therapeutic relationship becomes the conditio • Relationship,
sine qua non, the developmental space for the • Conflict,
therapeutic process. • Structure.
 Important Psychodynamic therapy always To form a focus, a detailed diagnostic OPD

aims for both symptomatic improvement interview is required. Foci are those features
and the processing of personality-inherent of the OPD findings that contribute to causing
intrapsychic conflicts. and maintaining the disorder and therefore play
a determining role in the psychodynamics of
Even though certain developmental issues, such the clinical picture. This is associated with the
as autonomy development, occupy a large space assumption that something must change with
in psychodynamic therapies for patients with regard to these foci if substantial therapeutic
eating disorders, there is no convincing evidence progress is to be achieved.
of the specificity of personality constellations Particular attention should be paid to foci of
that necessarily lead to the development of eat- the relationship and structure axes. The goal is
ing disorders. In this respect, eating disorders do to identify unfavorable relationship patterns
not differ from other psychosomatic disorders and impairments of the structural level and
(Herzog et al. 1997). to take them into account in therapy planning
It should also be emphasized that the needs (Friederich et al. 2014, 2019). Rudolf (2006)
of psychosomatic patients rarely align with the elaborated on the need to consider a typology of
possibilities and limitations of therapy schools structural disorders in psychodynamic therapy
(Friederich et al. 2007). If the importance of the planning. This approach is valid for all eating
personality perspective has been highlighted for disorders. The structural level is classified into
psychodynamic treatment, this does not exclude six stages.
41 Psychodynamic Therapy 313
largest outpatient psychotherapy study for AN to

Typology of Structural Disorders date (ANTOP), psychodynamic psychotherapy
• Stage 1: well integrated, neurotic did not differ from cognitive behavioral therapy
conflict and the control group in the primary outcome
• Stage 2: well to moderately integrated, (BMI). However, in the secondary outcome
neurotic conflict with structural failures, (remission rate), psychodynamic psychotherapy
e.g., somatoform disorders was superior to the other two groups (Zipfel
• Stage 3: moderately integrated, coping et al. 2014).
with structural disorder through charac- In the ANTOP study, a therapy manual for
ter defense, e.g., narcissistic personality outpatient focal psychodynamic psychotherapy
disorder was used, which was designed for the outpatient
• Stage 4: moderately to poorly inte- treatment of adult AN patients with a BMI of 15
grated, coping with structural disorder kg/m2 or higher (Friederich et al. 2014).
through symptomatic behavior, e.g., In the treatment of AN, the need for a clearly
gambling addiction defined framework for outpatient therapies has
• Stage 5: poorly integrated, e.g., border- been repeatedly emphasized: Medical moni-
line personality disorder toring and setting aspects such as session fre-
• Stage 6: disintegrated, e.g., dissocial quency, weight control, weight limits, and
personality disorder orienting family discussions require explicit
agreement (Friederich et al. 2014).
Schors and Huber (2003) formulated point-
For the disorders and subsequently for therapy edly, andfrom a psychodynamic perspec-
planning, this means that structural disorders tive unusually symptom-oriented, that: “The
become increasingly important as the stages pro- normalization of eating behavior is not every-
gress, and classical neurotic conflicts become thing, but without it, everything is nothing.”
less important. For example, patients with The generally moderately integrated struc-
restrictive-type AN would often be classified at tural level also requires disorder-specific addi-
stage 3, patients with BN and personality disor- tions to standard psychodynamic therapy
der at stages 4-5. Therapy planning takes into (Leichsenring et al. 2004; Herzog et al. 2003).
account the structural disorder component. If the control of eating behavior and the abil-
ity to starve are the “solution” to intrapsychic
problems caused by early childhood experiences
41.3 Disorder-Specific of helplessness reactivated in puberty, then the
Modifications denial characteristic of the disorder in patients
of Psychodynamic Therapy is only logical. A pronounced passive-abstinent
intervention style quickly leads to therapy dis-
41.3.1 Anorexia Nervosa continuation: The patient must first be won
over for therapy. It is advisable, at least in the
The empirical evidence for the effectiveness of initial phase of therapy, to “court” the patient
psychotherapy for AN has grown significantly by repeatedly and concretely naming the cur-
in recent years. Several high-quality outpatient rent relational-dynamic consequences of the
studies are available (Brockmeyer et al. 2018; anorectic behavior related to food intake, thus
Zeeck et al. 2019). making the “mafia-like” closedness of the “sys-
Initial evidence for the effectiveness of psy- tem of anorexia” palpable. The “anorectic life-
chodynamic therapy approaches can be found in style” leads to the avoidance of age-appropriate
older randomized controlled trials with initially activities and isolation. Schneider (2003) took
small case numbers (Zeeck et al. 2019). In the up Boris’s concept of the “desirelessness” of
patients with AN (Boris 1984) and derived from tension between an ideal self, which strives for
it the necessity of a two-phase therapy. In this activity, slimness, an attractive external appear-
approach, the classic conflict-oriented procedure ance, and self-control, and a flawed self, char-
becomes possible only after an initial approach acterized by greed, binge eating, and vomiting.
phase in which the patient establishes a relation- The central affect of BN—shame—arises when
ship with the therapist. the patient does not achieve the ideal state they
While earlier etiological psychodynamic are striving for. Affected individuals typically
concepts were predominantly drive-theoretical report self-related feelings of shame such as
positions, today object-theoretical hypotheses self-hatred and self-disgust. The confrontation
are in the foreground: Against the background with the incompatible self-parts and the asso-
of early experiences of perceived lack of reli- ciated experience of shame are shifted onto
ability of important attachment figures and the the body or individual body parts. Through the
resulting helplessness, a central focus is often displacement onto the body, the conflict and
seen in the struggle for autonomy. Age-specific shame become more controllable and limited.
developmental steps in detaching from the fam- The binge-purge symptoms represent a dysfunc-
ily of origin trigger high levels of insecurity. tional regulation to ward off these inner tensions
To avoid new overwhelming experiences, the (Reich et al. 2014).
control of hunger and weight successfully prac- The treatment focus lies on clarifying the
ticed in AN can become a “safe” mechanism of covert or insufficiently conscious emotions that
self-assertion. trigger the binge eating, which are related to
Through the anorectic and socially distant dysfunctional relationship, transference, con-
relationship formation, patients with AN avoid flict, and defense patterns as well as structural
coming into contact with emotions and affect problems. Due to the addictive nature of the
(Ward et al. 2000). Furthermore, the perception symptomatology and the initial denial of the ill-
of feelings and affect is limited by the under- ness, the first phase of therapy aims to win the
weight (“anorexia as an anesthetic”). Against patient over for treatment. The further treatment
this background, working on affective-emo- focus lies on relationship dynamic aspects of the
tional experiences in the middle therapy phase symptomatology and the associated life-deter-
is of central importance. Initial studies confirm mining conflicts and structural impairments.
that working on affective-emotional experi- The group of patients with BN is very hetero-
ences is associated with better therapy outcomes geneous in terms of their psychodiagnostic clas-
(Friederich et al. 2019). sification (e.g., structural level): The spectrum
ranges from mild, transient disorders with low
psychopathology, to overregulated impulse con-
41.3.2 Bulimia Nervosa trol with occasional impulse breakthroughs, to
the most severe personality disorders with sig-
Outpatient psychodynamic treatments have nificantly impaired impulse control, in which the
proven to be effective in the therapy of BN bulimic symptomatology is only one symptom
(Zeeck et al. 2019). Also in BN, there are indica- among many others (e.g., substance abuse, self-
tions that a focus on eating disorder symptoms harm, post-traumatic stress disorder).
and a more active therapeutic stance are associ- Even though the full picture of a border-
ated with a more favorable treatment outcome. line personality (low integrated structural level
The constant refocusing on the symptoms is according to OPD - level 5) is present in less
necessary throughout the entire therapy and is than 20% of patients, the structural level in
inevitable in a time-limited therapy. patients with BN is often to be assessed as mod-
Patients with BN typically suffer from an erate to low. Rudolf (2006) spoke in this con-
identity conflict, characterized by a conflictual text of coping with structural disorders through
41 Psychodynamic Therapy 315
symptomatic behavior. In treatment, the focus is References

on a therapeutic stance that promotes the devel-
opment of structural abilities (e.g., interactive Arbeitskreis OPD (2006) Operationalisierte
abilities, impulse control, etc.). Psychodynamische Diagnostik OPD-2—Das Manual
für Diagnostik und Therapieplanung. Huber, Bern
If the eating symptomatology has become Boris HN (1984) The problem of anorexia nervosa. Int J
self-perpetuating in an addictive manner, “con- Psychoanal 65:315–322
tracts” can help regain control over eating Brockmeyer T, Friederich HC, Schmidt U (2018)
behavior. Multimodal therapy approaches - out- Advances in the treatment of anorexia nervosa: a
review of established and emerging interventions.
patient, e.g., as a psychodynamic group with Psychol Med 48:1228–1256
upstream individual symptom control or as part Dare C, Eisler I, Russell G et al (2001) Psychological
of inpatient psychotherapy - represent further therapies for adults with anorexia nervosa: ran-
alternatives here. domised controlled trial of outpatient treatments. Br J
Friederich HC, Schild S, Wild B et al (2007) Treatment out-
come in people with subthreshold compared with full-
41.4 Binge Eating Disorder syndrome binge eating disorder. Obesity 15:283–287
Friederich HC, Herzog W, Wild B et al (2014) Anorexia
nervosa. Fokale Psychodynamische Psychotherapie,
For the psychodynamic psychotherapy of binge 1st ed. Hogrefe, Göttingen
eating disorder, currently only clinical stud- Friederich HC, Wild B, Zipfel S, Schauenburg H, Herzog
ies for a psychodynamic-interpersonal oriented W (2019) Anorexia nervosa. Focal Psychodynamic
treatment in group format are available (Zeeck Psychotherapy. Hogrefe, Göttingen
et al. 2019). The treatment program by Tasca A, Tuschen-Caffier B, Vocks S, Zeeck A (Eds)
(Tasca et al. 2006) proved to be effective com- (2019) S3-Leitlinie Diagnostik und Behandlung der
pared to an untreated waitlist group. The treat- Essstörungen. Springer, Berlin
ment approach assumes that primarily negative Herzog W, Schellberg D, Deter HC (1997) First recovery
in anorexia nervosa patients in the long-term course:
feelings, which arise in the context of conflictual a discrete-time survival analysis. J Consult Clin
relationship constellations, trigger the recurring Psychol 65:169–177
binge-eating episodes. In the context of group Herzog W, Munz D, Kächele H (Hrsg) (2003)
therapy sessions, the maladaptive relationship Essstörungen. Therapieführer und psychodynamische
Behandlungskonzepte. Schattauer, Stuttgart
patterns are reactivated and processed. Further Leichsenring F, Rabung S, Leibing E (2004) The effi-
psychodynamic psychotherapy studies are cacy of short-term psychodynamic psychotherapy in
urgently needed to improve the evidence base. specific psychiatric disorders. Arch Gen Psychiatry
The indication for psychodynamic therapy is 61:1208–1216
Reich G, Horn H, Winkelmann K, Kronmüller KT,
given if self-help measures or symptom-oriented Stefini A (2014) Psychoanalytisch-orientierte
short-term therapies are not effective. Fokaltherapie der Bulimia nervosa bei weiblichen
Psychotherapeutic measures generally have Jugendlichen und jungen Erwachsenen. Ein Manual.
only a limited effect on weight reduction. This is Prax Kinderpsychol Kinderpsychiatr 63:2–20
Rudolf G (2006) Strukturbezogene Psychotherapie.
particularly true in the long term (Herpertz et al. Schattauer, Stuttgart
2019). Schneider G (2003) Die psychoanalytisch fundierte
A combined therapy based on the “pillars” Behandlung anorektischer Patientinnen. In: Herzog
of nutrition, exercise and psychotherapy is W, Munz D, Kächele H (Hrsg) Essstörungen.
Schattauer, Stuttgart, pp 94–106
recommended. Here, a group therapy with psy- Schors R, Huber D (2003) Psychoanalytisch denken,
chodynamic elements can be used as the psy- verhaltenstherapeutisch handeln? In: Herzog W,
chotherapeutic pillar (Friederich et al. 2007). Munz D, Kächele H (Eds) Essstörungen. Schattauer,
Stuttgart, pp 60–81
Tasca GA, Kowal J, Balfour L, Ritchie K, Virley B, nervosa. In: Herpertz S, Fichter M, Herpertz-Dahlmann
Bissada H (2006) An attachment insecurity model of B, Hilbert A, Tuschen-Caffier B, Vocks S, Zeeck A
negative affect among women seeking treatment for (Eds) S3-Leitlinie Diagnostik und Behandlung der
an eating disorder. Eat Behav 7:252–257 Essstörungen. Springer, Berlin, pp 67–216
Ward A, Ramsay R, Treasure J (2000) Attachment research Zipfel S, Wild B, Groß G et al (2014) Focal psychody-
in eating disorders. Br J Med Psychol 73:35–51 namic therapy, cognitive behaviour therapy, and opti-
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Cognitive Behavioral
Therapy 42
Tanja Legenbauer
Contents
42.1 eneral Approach and Standard Elements in the Treatment of
G
Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318
42.2 Normalization of Eating Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319
42.3 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325
In the last decade, research findings on the treat- Guidelines are now available from almost
ment of eating disorders have increased sig- all European countries, as well as the USA,
nificantly. The clinical effectiveness of various Australia, Canada, and New Zealand. Since the
psychotherapeutic methods has been examined so-called NICE guidelines (NICE: National
in several meta-analyses. The results show that Institute for Clinical Excellence 2020) were
cognitive behavioral therapy (CBT) continues to developed by British experts in 2004, the
be the treatment of choice for eating disorders American guidelines (American Psychiatric
in adulthood; in addition to its successful use Association 2006) followed in 2006, and the
in treating bulimia nervosa (BN) and binge eat- German S3 guidelines for the diagnosis and
ing disorder (BED), studies also show success treatment of eating disorders in 2010 (Herpertz
in treating anorexia nervosa (AN). Furthermore, et al. 2011). In 2017, a total of 33 guidelines
there is increasing evidence that CBT can also were identified in a review (Hilbert and col-
be successfully used to treat adolescents with leagues 2017). The guidelines are continuously
eating disorders. These empirical findings form updated. Currently, there is a revised version of
the basis of the guideline recommendations for the NICE guidelines from 2017. The German
the treatment of eating disorders. AWMF-S3 guideline was updated in 2018 and
its English translation was published. Canadian
guidelines for the treatment of children and ado-
lescents with eating disorders have also been
available since 2020. The German S3 guideline
is also available in a patient version.
T. Legenbauer (*)
LWL-University Hospital for Child and Adolescent Although it is very encouraging that treat-
Psychiatry, Ruhr University Bochum, Hamm, Germany ment guidelines are being developed to stand-
e-mail: [email protected] ardize and improve treatment quality, it is
https://doi.org/10.1007/978-3-662-67662-2_42
318 T. Legenbauer
critical to note that not all guidelines are evi- • the short-term improvement of eating behav-
dence-based. In addition, there are significant ior or the achievement of weight restoration,
differences in clinical consensus recommenda- and
tions across all guidelines. Cross-country coor- • the long-term treatment of problem areas
dination and standardization could help further associated with the disturbed eating behavior,
improve quality standards. for example through cognitive techniques or
skills training, to increase social competence
 Important Cognitive behavioral therapy and emotion regulation.
remains the method of choice in the treat-
ment of eating disorders, particularly This equally addresses both physiological and
bulimia nervosa and binge eating disorder. psychological problems associated with the
It also appears to be effective in treating eating disorder. The basis of most cognitive-
anorexia nervosa and eating disorders in behavioral treatment programs is the transdiag-
children and adolescents. nostic view of eating disorders, first introduced
by Fairburn et al. 2003 and since then used as a
fundamental model for modifying existing treat-
42.1 General Approach ments. The transdiagnostic model assumes that
and Standard Elements all forms of eating disorders have a common
in the Treatment of Eating core pathology in the form of an excessive pre-
Disorders occupation with food, shape , and weight. This
is where cognitive-behavioral interventions
Regardless of the type of eating disorder and the come in, focusing on symptoms depending on
specific approach, the following general ther- the disorder, such as underweight, binge eating
apy guidelines apply: and/or vomiting. The individual treatment com-
ponents are derived from this disorder model.
• Individuals with eating disorders should The treatment of eating disorders can take
receive therapy as early as possible from place in both individual and group settings,
facilities and professionals specializing in eat- with empirical data showing no clear superior-
ing disorders. The treatment should include ity of one of these methods. Patients with eating
disorder-specific elements. disorders do not necessarily have to be treated
• Healthcare professionals should recognize that as inpatients. Recent studies suggest that at least
those affected by eating disorders are often in adolescence, day care treatment for AN is
ambivalent about therapy (shoulder-to-shoulder, not inferior to inpatient treatment in terms of
not head-to-head) and that the recovery process weight gain (Herpertz-Dahlmann et al. 2014).
usually takes many months, if not years. For BN, there are no significant differences
• Psychoeducational measures should be between the settings, regardless of age (Zeeck
offered. et al. 2009).
Inpatient treatment is mainly recommended if
Cognitive-behavioral therapy in the treatment of any of the following is present:
eating disorders includes analyses of individual
behavior and conditions. Based on these, particu- • severe physical impairment (e.g., in AN BMI
larly problematic areas are identified and a con- < 15 kg/m2or in children and adolescents with
crete therapy plan is created. Therapeutic work AN a weight below the 3rd BMI age percen-
is done in small steps and through behavioral tile) or very chaotic eating behavior in BN
experiments, which help to transfer the devel- • very rapid or persistent weight loss (e.g.,
oped solutions into everyday life. In general, the >20% over 6 months)
most important principle in the treatment of eat- • lack of success in outpatient treatment
ing disorders is the focus on two goals, namely
42 Cognitive Behavioral Therapy 319
Moreover, the presence of pronounced somatic In contrast to the treatment goals mentioned
and psychiatric comorbidity as well as the above for AN, the treatment of BN includes,
lack of social support or intact social networks as the first goal, the reduction of binge eating
should be taken into account when considering and compensatory behaviors. According to the
inpatient treatment. German guideline, addressing the importance
In addition to information on diagnostics of body weight for self-evaluation and thus the
and choice of settings, the guidelines of vari- treatment of body image disturbances in BN is
ous countries usually contain treatment goals also an important treatment goal. The remain-
for individual eating disorder diagnostic groups. ing goals are identical to the treatment of AN,
Specifically, in reference to the core symptoms although there are differences in content, e.g.
of eating disorders, the American Psychiatric in the teaching of information on eating behav-
Association Eating Disorder Workgroup (2006) ior and in relapse prevention. Explicitly, the
lists eight goals for the treatment of AN. German guideline also mentions the treatment
of self-esteem problems, perfectionism, impul-
sivity, and problems in emotion regulation as
Goals for the treatment of AN (APA essential in the treatment of BN. In the case of
2006) BED, the treatment goals largely correspond to
1. Weight restoration the aims outlined above. It should be noted that
2. Treatment of physical sequelae in BED with comorbid obesity, unlike in AN
3. Enhancement of treatment motivation and BN, the goal of weight reduction can also
4. Psychoeducation regarding nutrition be supported, and the interventions on eating
and eating behavior behavior must be adjusted accordingly. In the
5. Modification of dysfunctional thoughts, following, the components of cognitive-behavio-
feelings, and attitudes related to the eat- ral therapy for AN, BN, and BED to achieve the
ing disorder therapy goals are described in more detail.
6. Treatment of associated comorbid psy-
chiatric problems such as depressive
moods, impulse control disorders, low 42.2 Normalization of Eating
self-esteem, etc. Behavior
7. Support for the family or, if necessary,
family therapy Both for weight gain and for the reduction of
8. Relapse prevention binge eating and vomiting, a normalization of
eating behavior is essential and therefore impor-
tant for both AN and binge eating-related eating
In addition to the points mentioned above, the disorders such as BN and BED. The normali-
German guideline emphasises that social inte- zation of eating behavior is intended to amend
gration is of great importance in the treatment of the physiological and psychological conse-
AN, as often, missed developmental steps have quences of severe underweight and the strongly
to be made up for. Also not explicitly mentioned restrained eating behavior between binge epi-
is the treatment of body image. A negative body sodes, primarily occurring in patients with BN,
image contributes to the development and main- and to establish a biological-physiological bal-
tenance of eating disorders and is considered a ance. By using therapeutic strategies to nor-
negative predictor if it persists despite treatment. malize eating behavior, a balanced and regular
In recent years, the treatment of body image dis- nutrition in everyday life should be established.
turbance has become a central component of AN This includes not only an adequate calorie
treatment. intake but also an adequate nutrient composition
320 T. Legenbauer
of the selected foods and a sensible temporal Biased Information Processing A third aspect
distribution of meals throughout the day. With of cognitive work concerns biased information
regard to BED, it should be noted that the estab- processing, such as schema-consistent process-
lishment of a healthy, balanced, and pleasure- ing of threatening stimuli or selective attention
oriented eating behavior should prevent the control.
occurrence of binge eating and maintain the cur- All three areas of cognitive disturbances
rent weight. should be addressed and worked on in treat-
The normalization of eating behavior is ment. Cognitive bias modification methods can
achieved through various therapeutic means: be used to change automated selective or dys-
functional attention control. However, it should
• Self-observation, for example using food be noted that the evidence for these methods in
diaries, eating disorders is still limited.
• Psychoeducation on topics such as physi-
ological and psychological consequences of  Important The various cognitive aspects
malnutrition/diets, in patients with eating disorders are
• Introduction of structured eating days to addressed using Socratic dialogue, pro-
practice normal eating behaviour. and-con exercises, cost-benefit analyses,
and other general cognitive techniques.
Overall, the various interventions aim to reduce
cognitive control over food intake and establish
a natural sense of hunger and satiety. In addi- 42.2.2 Specific Aspects in the
tion to the mentioned therapy techniques, food Treatment of Anorexia
or stress exposures with response prevention Nervosa
are also carried out. In the case of BED, stimu-
lus exposure with response prevention is also 42.2.2.1 Weight Restoration
used, among other things, to practice the abil- Due to the often medically alarming under-
ity to discriminate between hunger and satiety. weight, weight restoration is the most important
Additionally, pleasure- and mindfulness-ori- short-term goal in the treatment of AN, whereas
ented exercises can be carried out to increase the this is not mandatory in the treatment of BN,
patients’ enjoyment. as the body weight of patients with BN is usu-
ally within the normal range. In cases of severe
underweight or serious medical complications,
42.2.1 Cognitive Treatment weight restoration should be done in an inpa-
Elements tient setting. Rarely, invasive methods such as
tube feeding are used in cases where there is a
Automatic Thoughts A core element of CBT particular risk.
for eating disorders is the identification and Depending on the setting, the weekly weight
modification of automatic thoughts regarding gain to be achieved varies: While weight gains
food, weight, and shape.
of 500 g to 1000 g/week can be achieved in an
inpatient treatment, according to the German
Core Beliefs There is evidence from research
guideline, only a weight gain of 200–500 g/
that, in addition to automatic thoughts, endur-
week should be aimed for in outpatient treat-
ing and action-guiding core beliefs are impor-
tant, although these do not necessarily have to ment. However, this seems difficult in reality.
be associated with eating disorder-specific areas. As shown in a recent meta-analysis, the average
On the contrary, these seem to encompass rather weight gains achieved in outpatient settings are
general principles and rules that develop from 105 g/week for adults and 192 g/week for ado-
learning experiences throughout life. lescents (Zeeck et al. 2018).
To gain 100 g/day in weight, approximately Clear agreements on the approach in treatment
800–1200 kcal must be consumed in addition are useful to ensure treatment adherence.
to the energy expenditure. In practice, a calorie
intake of 1000–1600 kcal/day is often started  Important The autonomy needs of the
and the daily calorie intake is increased in sev- patients must be taken into account in
eral intervals, for example by 250 kcal/day, dur- order to achieve lasting treatment success.
ing the course of treatment, depending on the
achieved weight gain. The administration of Implementing such operant programs is often
high-calorie liquid nutrition in addition to regu- easier in the inpatient setting, as there are fewer
lar meals seems to lead to faster weight gain in direct opportunities for the therapist to influence
the inpatient setting, particularly in severely treatment in an outpatient setting. Nevertheless,
underweight patients. Overall, the current data weight gain contracts or the administration of
show that treatments with initially higher energy high-calorie supplementary nutrition can also be
intake lead to overall better treatment courses useful in the outpatient setting. Enhanced cogni-
and do not—as previously assumed—result in tive-behavioral therapy (E-CBT) for AN in the
complications, such as refeeding syndrome, outpatient setting, on the other hand, focuses on
more frequently than by chance. intrinsic motivation for weight gain. It aims to
motivate patients to gain weight solely through
 Important Adjusting calorie intake to per- education and cautious discussion of weight
formance output and activity level of the without a contract. If sufficient weight gain is
patients is essential to ensure the desired not achieved within 4–5 months (approx. 20 ses-
weight gain. sions), a therapy contract may also be consid-
ered in E-CBT. Regardless of whether a contract
Cognitive-behavioral programs use specific is concluded, the purpose of the interventions
reinforcement programs to achieve weight res- should be transparent to the patient in order to
toration. In the inpatient setting, various individ- ensure compliance.
ually agreed reinforcements for weight gain and
normalization of eating behavior are system-  Important Weight loss or stagnation is
atically used in addition to nursing support and usually an indication of a lack of motiva-
high-calorie food. The operant programs usu- tion or ambivalence and should always be
ally include an initial phase of self-responsibil- addressed with the patient, regardless of
ity, in which the patient should achieve weight the setting.
gain independently after admission. If this is not
successful, external control programs are intro-
duced. These often include specific rules on eat- 42.2.2.2 Motivation
ing behavior, participation in therapy offerings Above all, the mostly ambivalent therapy moti-
and leisure activities, and receiving visitors, in vation poses a major challenge in the treatment
addition to signing a weight gain contract and of AN. Many patients do not enter therapy on
agreeing on a target weight to be achieved. For their own initiative, but are urged to do so by
adults, the target weight should correspond to a family members. Even in patients who come
BMI of at least 18.5 kg/m2, while for children to treatment out of their own motivation, the
and adolescents, a target weight around the 25th low weight is rarely the primary treatment
BMI age percentile is recommended. concern, but rather the emotional and physi-
More modern programs keep the degree of cal problems caused by the eating disorder,
external control as low as possible to meet the such as reduced performance or the narrowing
autonomy needs of the patients and reduce the of thinking to food, figure, and weight. Newer
risk of possible relapse after the program ends. programs therefore usually include a module
322 T. Legenbauer
to increase motivation at the beginning of treat- modifying them. In addition to direct interven-
ment, although it should be noted that motivations to improve emotion regulation, improving
tion also plays an important role in the further stress management, increasing stress tolerance,
course of treatment. The motivational strategies and building interpersonal skills are also pursued.
should include, in addition to psychoeducational Mindfulness-based techniques are often taught in
elements, for instance on the consequences of this context (Sipos and Schweiger 2016).
the eating disorder, the confrontation with the To improve impulse control, computer-based
short- and long-term positive and negative con- training interventions have been developed,
sequences of the eating disorder (Legenbauer through which patients with binge eating can
and Vocks 2014). practice improving food-related inhibitory con-
trol. Initial results seem promising, but trans-
 Important Due to the ambivalence towards ferring them to everyday care has hardly been
the primary therapy goal—weight gain— achieved so far. It makes sense to address the
motivational strategies seem to be of par- different components simultaneously, i.e., treat-
ticular importance in the treatment of AN. ment should strengthen emotion regulation
while improving inhibitory control and teaching
techniques for delayed gratification (e.g., Preuss
42.2.3 SpecificAspects in the et al. 2018).
Treatment of Binge Eating- Food exposure is a possible therapeutic
Related Eating Disorders tool to integrate the various components and
strengthen patients’ self-efficacy regarding eat-
42.2.3.1 Emotion Regulation ing. The rationale of food exposure is based on
and Impulsivity extinguishing conditioned stimulus-response
Many studies show an association between neg- associations. The craving-triggering food is
ative affect and the occurrence of binge eating. examined, touched, etc., under the guidance of
Furthermore, patients with binge eating-related the therapist. Ratings are given for the extent of
disorders (BN, BED, binge-eating/purging type the craving, and the exposure is only terminated
of AN) seem to have a rather increased reward when habituation has been achieved and the
sensitivity and often show decreased inhibitory craving has significantly decreased (e.g., by 50%
control at the same time. In combination, these of the initial value). Newer methods of food
processes support the establishment of an auto- exposure involve the violation of expectations in
mated unfavorable eating behavior (Legenbauer the exposure (e.g., Schyns et al. 2018). The stud-
and Preuss 2019). Accordingly, factors such as ies have primarily been conducted in adults with
stress and negative events play a significant role BED and obesity. However, a transfer to classi-
in the development and maintenance of binge cal eating disorders seems possible.
eating. Developing the ability to regulate emo-
tions and postpone or suppress urgent impulses,  Important In particular, modules such as
such as the urge to eat, is thus a central thera- perception of feelings and building stress
peutic goal in the treatment of binge eating- tolerance, as well as learning mindfulness,
related eating disorders. have proven promising for improving
There are nowadays various manuals that emotion regulation in binge eating-related
focus on building emotion regulation skills in disorders. Additionally, underlying com-
eating disorders. Therapeutic elements include ponents of inhibitory control and reward
sensitization to emotional states, such as per- sensitivity should be addressed. This can
ceiving, recognizing, classifying, and differ- be done through computer-supported
entiating feelings, as well as coping with or training or food exposure, if necessary.
42.2.4 Third-Wave Cognitive • Acceptance

Behavioral Therapy Methods • Cognitive Defusion
in the Treatment of Eating • Mindfulness
Disorders • Self-as-Context
• Formulating Personal Values
Within the framework of the third wave of • Committed Action
behavior therapy, cognitive behavioral therapy
has integrated elements such as mindfulness Eating disorder-specific modifications exist for
and acceptance towards inner experiences, and both children and adolescents as well as adults.
contextual and experiential aspects have been Initial studies in inpatient settings with adult
emphasized more strongly (Heidenreich et al. patients with BN and AN, as well as in outpa-
2007). Among the methods that have developed tient settings with children and adolescents,
eating disorder-specific interventions within the show greater improvements in eating disorder
third wave of behavior therapy or have been pathology, the occurrence of binge eating, etc.,
studied in the context of eating disorder treat- when ACT elements are integrated into standard
ment are, for example, dialectical behavior ther- treatment. However, ACT alone is not superior
apy (DBT), acceptance and commitment therapy to CBT treatment and is currently considered
(ACT), schema therapy, mindfulness-based more as an alternative or complementary treat-
interventions, and compassion-focused therapy ment element.
(CFT).
42.2.4.3 Schema Therapy
42.2.4.1 DBT Schema therapy was developed especially for
DBT was originally developed for the treatment patients with therapy-resistant mental disorders.
of borderline personality disorders, but in recent It combines methods of cognitive behavioral
years has increasingly been used in the treat- therapy with experiential and action-oriented
ment of BN and BED. In particular, the skills approaches such as imagery and chair work. In
training has been adapted for the treatment of addition, the conscious design of the therapeu-
BN and BED to achieve improvements in the tic relationship (e.g., through “reparenting”) is a
regulation of stress and emotion. Mindfulness central element. The goal of schema therapy is
exercises, sensitization to emotional states, and to identify unfavorable experiential and behav-
building stress tolerance are the main focus. ioral patterns that have developed historically,
DBT is probably the best-studied therapy form to relate them to symptoms, and to change them
of the third wave and is considered a promising in such a way that better behavior regulation
add-on therapy module for reducing binge eat- and satisfaction of needs are achieved. There
ing and eating disorder pathology. In the pre- are now manuals available that describe the inte-
vention area, DBT modules seem to show the gration of schema therapeutic work in patients
greatest effects in selective prevention measures with eating disorders (e.g., Archonti et al. 2016).
for reducing conspicuous eating behavior com- However, the empirical evidence for the effec-
pared to other third-wave methods. So far, high- tiveness of schema therapy for eating disorders
quality, randomized controlled trials regarding is still quite limited.
the treatment of AN are lacking.
42.2.4.4 Mindfulness-Based Therapy
42.2.4.2 ACT Mindfulness-based psychotherapy was primar-
ACT includes six treatment steps aimed at ily developed for the treatment of depressive
achieving greater psychological flexibility and disorders (mindfulness-based cognitive therapy
contextual control. These are: for depression, MBCT). The focus is not on
324 T. Legenbauer
changing cognitive content, but on developing  Important Third-wave behavioral therapy

an accepting and open attitude towards dysfunc- approaches are considered promising.
tional beliefs. Mindfulness is conveyed in various Currently, the empirical evidence is not
ways, on the one hand through so-called formal sufficient for clear recommendations. The
mindfulness exercises such as meditations, body best studied is the use of DBT modules
scans, yoga, etc., and on the other hand through such as skills training for binge eating-
informal exercises to transfer a mindful attitude related disorders like BN and BED.
into everyday life (Heidenreich et al. 2007).
Meanwhile, there are many disorder-specific
modifications, including for patients with eat- 42.2.5 Effectiveness of Cognitive
ing disorders. Overall, the results are promising Behavioral Therapy in the
here as well, but the mechanisms are unclear, and Treatment of Eating Disorders
the superiority of mindfulness-based approaches
over CBT has not yet been demonstrated. Although studies on the treatment of AN have
However, it seems that patients who meditate been conducted continuously in recent years,
more frequently also show stronger reductions there is still a lack of high-quality randomized
in the frequency of binge eating and loss of con- controlled trials and replications of existing
trol over eating. Only a few studies have applied results by independent working groups. Based
mindfulness-based approaches to the treatment of on the current empirical data, it can be con-
AN. cluded that there is no superiority of CBT com-
pared to other therapeutic approaches for AN
42.2.4.5 CFT in adulthood. In childhood and adolescence,
CFT is certainly one of the most recent devel- family-based therapy seems to be particularly
opments of the third wave. It was developed successful, but in the long term, individual
by Paul Gilbert in 2006 together with col- therapeutic measures also appear to be similarly
leagues and is based on neurophysiological, successful. With regard to weight gain, CBT for
evolutionary biological, and social-cognitive AN is superior to non-specific treatment strate-
models, and integrates Christian and Buddhist gies, such as nutritional counseling alone. A
values and attitudes into psychotherapeutic major challenge for clinicians is the high drop-
work. Compassion has emerged as a therapeu- out rates of sometimes over 40%, which still
tic factor in various studies and is associated limit the ability to make definitive statements on
with anxiety, depression, and stress. Overall, the effectiveness of CBT.
the stronger the compassion and self-compas- In contrast, the short- and long-term suc-
sion are, the less pronounced the psychopathol- cesses of modified CBT treatment offers for BN
ogy. It is assumed that compassion strengthens and BED can be considered good. In particular,
an accepting attitude towards painful experi- the core features of BN can be reduced in the
ences and facilitates the adequate regulation of long term. This applies especially to the reduc-
negative experiences. CFT therefore focuses on tion of binge eating and vomiting as well as
building self-compassion and compassion and changes in diet behavior. After treatment, binge
uses methods such as mentalizing, mindful- eating symptom scores can be achieved that cor-
ness, exposure, imagery, and guided discovery respond to a healthy comparison population.
(Gilbert and Plata 2013). There are initial stud- Effects for other eating disorder symptoms, on
ies that used CFT for BED, in which CFT suc- the other hand, are rather small to medium and
cessfully led to a reduction in eating disorder therefore clinically less significant. This applies,
symptoms, but was not superior to the active for example, to cognitive aspects such as dys-
control condition. The improvement in eating functional beliefs or self-esteem. Similar to AN,
disorder symptoms was significantly associated the major problems are the dropout rate and
with an increase in compassion, a reduction in the still improvable proportion of patients who
fear of compassion, and a reduction in shame. show full remission at the end of treatment. For
BED, a meta-analysis showed that the reduc- restoration for anorexia nervosa (AN) or reduc-
tion of binge eating and associated dysfunction of binge eating and purging for BN, as well
tional beliefs (e.g., preoccupation with food and as cognitive interventions to reduce dysfunc-
weight) could be achieved through CBT-based tional core beliefs and automatic thoughts, and
psychotherapies with large clinical effects, techniques for emotion regulation and reduction
whereas BED-specific treatment showed barely of impulsivity. Newer methods such as cogni-
any positive influence on comorbid symptoms tive Bias modification, modified forms of food
and weight. However, it should be noted that exposure focusing on expectancy violation, and
even with CBT for BED, there are high dropout third-wave approaches represent complementary
rates and many patients still report eating disor- measures that still require further empirical vali-
der symptoms at the end of treatment. Relapse dation. It remains unclear which patient groups
rates after CBT treatment seem to be around could benefit from which additional/new therapy
30%. methods.
Several reviews and meta-analyses examined
the effectiveness of third-wave approaches in
the treatment of eating disorders. Initial results References
are described as encouraging, but the study find-
ings are very mixed, and only a few randomized APA (American Psychiatric Association) (2006) Practice
controlled trials are available (Pisetsky et al. guidelines for the treatment of patients with eating
disorders, 3rd edn. Am J Psychiatry 163(Suppl):1–54
2019). A meta-analysis showed that third-wave (review). https://psychiatryonline.org/guidelines.
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tion, achieve good results in reducing abnor- Archonti C, Roediger E, De Zwaan M (Eds) (2016)
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und Arbeitsmaterial. Beltz
image (g = 0.35; Lindardon and colleagues Fairburn CG, Cooper Z, Shafran R (2003) Cognitive-
2019). With regard to the treatment of clinically behavioral therapy for eating disorders: a “trans-
relevant eating disorders, the evidence does not diagnostic theory and treatment”. Behav Res Ther
yet seem to be sufficient. 41(5):509–528
Gilbert P, Plata G (2013) Compassion focused therapy.
Junfermann
 Important It must be concluded that fur- Heidenreich T, Michalak J, Eifert G (2007) Balance von
ther optimization of existing approaches Veränderung und achtsamer Akzeptanz: die dritte
and investigation of the mechanisms of Welle der Verhaltenstherapie. PPmP-Psychother
Psychosom Med Psychol 57(12):475–486
action of existing therapy components are Herpertz S, Herpertz-Dahlmann B, Fichter M et al
still necessary. (2011) S3-Leitlinie Diagnostik und Behandlung der
Essstörungen. Springer, Heidelberg
Herpertz-Dahlmann B, Schwarte R, Krei M et al (2014)
Day-patient treatment after short inpatient care ver-
42.3 Conclusions sus continued inpatient treatment in adolescents
with anorexia nervosa (ANDI): a multicentre, ran-
Cognitive behavioral therapy (CBT) is the domised, open-label, non-inferiority trial. Lancet
treatment of choice for bulimia nervosa (BN), 383(9924):1222–1229
Hilbert A, Hoek HW, Schmidt R (2017) Evidence-based
with both individual and group therapy set- clinical guidelines for eating disorders: international
tings proving effective. Group therapy strate- comparison. Curr Opin Psychiatry 30(6):423
gies are particularly attractive in terms of better Legenbauer T, Preuss H (2019) Verbesserung der Impuls-
cost-effectiveness and provide additional ben- und Emotionsregulation bei Binge-Eating-Störungen.
Kindheit Entwicklung 28:210–219
efits for patients through the interactive aspect Legenbauer T, Vocks S (2014) Manual der kognitiven
of the group setting. Important components of Verhaltenstherapie bei Anorexie und Bulimie, 2nd
any CBT for eating disorders should include edn. Springer, Berlin
normalization of eating behavior and weight Linardon J, Gleeson J, Yap K et al (2019) Meta-analysis
of the effects of third-wave behavioural interventions
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on disordered eating and body image concerns: impli- Schyns G, van den Akker K, Roefs A, Hilberath R,
cations for eating disorder prevention. Cogn Behav Jansen A (2018) What works better? Food cue expo-
Ther 48(1):15–38 sure aiming at the habituation of eating desires or
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Guidelines for eating disorders. http://www.nice.org. ing expectancies? Behav Res Ther 102:1–7
uk/nicemedia/pdf/cg009niceguidance.pdf. Accessed: Sipos V, Schweiger U (2016) Therapie der Essstörung
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peutisches Behandlungsprogramm. Hogrefe vosa: a systematic review and network meta-analysis.
Front Psychiatry 9:158
Interpersonal
Psychotherapy 43
Anja Hilbert
Contents
43.1 Basics of Interpersonal Psychotherapy for Eating Disorders . . . . . . . . . . . 327
43.2 Eating Disorder Treatment through IPT . . . . . . . . . . . . . . . . . . . . . . . . . . . . 328
43.3 Scientific Foundation of IPT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329
43.4 Summary and Outlook . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 330
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
43.1 Basics of Interpersonal suggest that mental disorders are caused and
Psychotherapy for Eating maintained by interpersonal problems.
Disorders
Interpersonal psychotherapy (IPT) was developed 43.1.1 Theoretical and Empirical

by Klerman et al. (1984) for outpatient short-term Foundations of IPT
therapy of unipolar depression. After evidence of
its efficacy, IPT was adapted for the treatment of Theoretically, the interpersonal approach is
other mental disorders, including eating disorders based on the “interpersonal school.” Influential
such as bulimia nervosa (BN) and binge-eating were the psychobiological concept of psychia-
disorder (BED). Initial adaptation results are try by psychiatrist Meyer and the interpersonal
available for anorexia nervosa (AN). theory of psychiatry by neo-Freudian Sullivan,
The concept of IPT is based on disorder who considered interpersonal problems central
theories and empirical research findings, which to the development and treatment of mental dis-
orders. Beyond the theoretical foundation, IPT
was guided by empirical findings on psychoso-
cial risk factors of mental disorders, including
A. Hilbert (*) critical life events, such as
Integrated Research and Treatment Center
Adiposity Diseases, Research Unit Behavioral • loss experiences,
Medicine, Department of Psychosomatic Medicine
and Psychotherapy, University of Leipzig Medical • interpersonal conflicts,
Center, Leipzig, Germany • changes in living conditions,
e-mail: [email protected] • lack of social support.
https://doi.org/10.1007/978-3-662-67662-2_43
328 A. Hilbert
The theoretical and empirical foundations can emotional expression, communication analysis,
be condensed into two clinically relevant basic and behavior modification are particularly used.
assumptions of IPT for eating disorders. The therapeutic relationship is collaborative, and
the therapist acts as the patient’s “advocate.” The
therapist adopts an appreciative, supportive, and
Basic Assumptions of IPT for Eating optimistic attitude towards the patient. The treat-
Disorders ment by IPT includes the following three treat-
• Interpersonal problems are significantly ment phases (Table 43.1).
involved in the development and main-
tenance of eating disorders.
• A resolution of the interpersonal prob- 43.2.1 Initial Phase
lems that are currently relevant to the
disorder leads to an improvement in eat- The initial phase of IPT serves to identify inter-
ing disorder symptoms. personal problems and symptom management.
Against the background of clinical-psychological
and medical diagnostics, the therapist explains
the eating disorder diagnosis to the patient. They
43.2 Eating Disorder Treatment convey disorder and treatment knowledge and
through IPT describe the therapy concept and approach of
IPT. In addition, the therapist assigns the patient
IPT for eating disorders is an outpatient short- the sick role. The latter is intended to relieve the
term therapy with approximately 16–20 ses- patient and signal the importance of working
sions. It focuses on the treatment of currently on the disorder. A central element of the initial
relevant interpersonal problems. An updated phase is the relationship analysis (“interpersonal
treatment manual by Weissman et al. (2000, inventory”). The goal of this unstructured inter-
2009) is available. The essential modification view-based relationship analysis is to identify the
in the adaptation of IPT for eating disorders by problem areas associated with the development
Fairburn involves considering the eating dis- and maintenance of the disorder. Both past and
order symptoms (rather than depressive symp- present relationships are considered in terms of
toms) in the interpersonal context in which they their influence on the symptoms. In addition to
have developed and are maintained. exploring the expectations of the patient and the
Initially, IPT was developed as individual other person/partner regarding their relationship,
therapy, but it is also available in a group for- the evaluation of the relationship and possible
mat. In all phases of IPT, the therapeutic tech- desires for change on the part of the patient are
niques of exploration, clarification, promotion of also taken into account.
Table 43.1  Overview of interpersonal psychotherapy for eating disorders

Phase Duration Therapeutic Goals
Initial Phase 3–5 sessions Identification of the problem
Symptom management
Middle Phase 10–12 sessions Work on the currently relevant interpersonal problem area(s)
Final Phase 3–5 sessions Consolidation of achievements
Preparation for further independent work on interpersonal problems
43 Interpersonal Psychotherapy 329
In IPT, four core areas of interpersonal prob- of therapy, the patient is guided to identify early
lems are distinguished: signs of relapse and derive coping measures in
case of a recurrence of symptoms. A specific
• Grief in the sense of complicated grief, due to plan for further work after the end of treatment
the loss of a person is developed.
• Interpersonal role conflicts, resulting from
different expectations of a relationship
• Role changes, leading to difficulties with a 43.3 Scientific Foundation of IPT
changed life status
• Interpersonal deficits, leading to social isola- 43.3.1 IPT for Bulimia nervosa
tion or chronically unsatisfying relationships
According to randomized clinical trials, IPT
Subsequently, in collaboration with the patient, is substantially and sustainably efficacious
one or more problem area(s) are selected that pri- in patients with BN. Compared to cognitive-
marily determine(s) the current symptomatology. behavioral therapy (CBT), it is less effective
The therapist and patient agree on specific treat- at the end of treatment, while there are no dif-
ment goals. The agreements for further work dur- ferences in long-term efficacy between the two
ing therapy are recorded in a treatment contract. therapy forms. In the long term, about 40%
of patients are fully remitted. Compared to a
reduced behavioral therapy treatment, IPT is
43.2.2 Middle Phase superior in both short and long term. IPT leads
to significant improvements in eating disorder-
The core of IPT is the middle phase. In this phase, specific psychopathology, including binge eat-
strategies for solving the identified interpersonal ing, purging behavior, restrained eating, and
problem(s) are developed and implemented. shape and weight concerns, as well as general
Important strategies for treating all problem areas psychopathology and interpersonal problems,
include summarizing the symptomatology and with low dropout rates. Analyses of therapy
placing it in an interpersonal context, developing course suggest that IPT and CBT work through
and establishing specific behavioral strategies for different mechanisms of action. Crucial for
the identified problem area(s) with the patient, the greater efficacy of CBT at the end of treat-
encouraging work on treatment goals, and pro- ment is that CBT achieves a stronger reduction
moting the expression of negative emotions in the of restrained eating than IPT in the first four
identified problem area(s). weeks of treatment. Consistent with this result,
a combination with a symptom-oriented, cog-
nitive-behavioral approach seems to lead to an
43.2.3 Final Phase increase in IPT effectiveness. Predictors of bet-
ter therapy response are a stronger reduction of
The final phase aims to consolidate the progress purging behavior within the first four treatment
achieved and identify areas for further work on weeks and – before treatment begins – a higher
interpersonal problems. The end of treatment is body mass index and less severe eating disorder
addressed and processed as a farewell or grief and general psychopathological symptoms.
process. The patient is encouraged to perceive
and verbalize their feelings about the end of Evidence-based guideline for IPT of BN In
therapy. In addition, the progress made is con- the German evidence-based S3 guideline “Diag
sidered and acknowledged to promote a sense of nosis and therapy of eating disorders” for the
competence and self-efficacy. Towards the end treatment of BN, IPT is recommended as an
330 A. Hilbert
alternative treatment to CBT if it is not avail- normalizing eating behavior and body weight
able, proves ineffective, or is not desired (B). is more effective in the short term than IPT,
However, it should be noted that IPT is not which does not directly address these symptoms,
yet approved as a guideline psychotherapy in while no differences are shown in the long term.
Germany. IPT does not appear to differ in efficacy from
CBT. With high dropout rates, a total of 30%
of patients showed good or very good improve-
43.3.2 IPT for Binge-Eating Disorder ments after completing therapy. For the remain-
ing patients, no or minor improvements were
Randomized clinical trials show that IPTalso observed. These preliminary results indicate
leads to substantial and long-lasting improve- that a symptom-oriented approach is of central
ments in symptoms for patients with BED. importance in the treatment of AN.
Compared to CBT, IPT is equally effective in
the short and long term as CBT and more effec-
tive than behavioral, i.e. multimodal weight 43.4 Summary and Outlook
loss treatment. In the long term, about 60% of
patients are fully remitted. IPT leads to a reduc- IPT offers a psychotherapeutic approach with
tion in eating disorder-specific and associated many advantages. These include an empirically
general psychopathological symptoms with low based theory formation, a disorder model based
dropout rates: binge eating, shape and weight on this, a focused therapeutic approach that con-
concerns, general psychopathological symp- centrates on the treatment of current problems,
toms, and interpersonal problems are signifi- and a pragmatic combination of proven thera-
cantly reduced. As with CBT, it has been shown peutic strategies from various therapy directions.
for IPT that successful treatment leads to a sig- Despite the eclectic therapy concept, the
nificant, albeit small, weight reduction. Less acceptance of IPT among patients with BN and
severe binge-eating symptoms before treatment, BED and their therapists is high. The evidence
fewer interpersonal problems, or lower shape of IPT’s efficacy in these eating disorders is
and weight concerns are predictors of better convincing, as IPT represents the main alterna-
treatment success. IPT also shows increased effi- tive treatment to CBT for BN and BED. Patients
cacy compared to guided, CBT-based self-help who do not benefit from CBT, however, also
treatment and behavioral weight loss treatment seem not to benefit from a subsequent IPT. With
for patients with more severe eating disorder regard to patients who achieve no or only minor
psychopathology and greater self-esteem prob- improvements through IPT, the central ques-
lems. However, guided CBT self-help treat- tion is how further increases in efficacy can be
ment proves to be most effective for those with achieved in the psychotherapy of BN and BED.
more severe binge eating symptoms. This question can be empirically explored by
identifying treatment-specific predictors. The
Evidence-based guideline for IPT of BED In differential indication for IPT is still unclear.
the German evidence-based S3 guideline “Diag It is also unclear how IPT works, i.e., whether
nosis and Therapy of Eating Disorders” for the it actually reduces interpersonal problems
treatment of BED, IPT is recommended as an or affects eating disorder symptoms through
alternative treatment to CBT (B). other process characteristics. Clarification of
this question also requires a reliable and valid
assessment of interpersonal problems.
43.3.3 IPT for Anorexia nervosa Evidence of IPT’s efficacy in AN is still
pending. Despite the initially less promising
Initial results for IPT in patients with AN sug- results, an interpersonal treatment focus in AN is
gest that supportive clinical management for plausible due to the empirically proven disorder
43 Interpersonal Psychotherapy 331
relevance of interpersonal problems. However, Arbeitsgemeinschaft der Wissenschaftlichen Medizinis

a symptom-oriented approach seems indispen- chen Fachgesellschaften (2020) S3-Leitlinie Diag
nostik und Therapie der Essstörungen. http://www.
sable for the treatment of this particular eating awmf.org/uploads/tx_szleitlinien/051-26l_S3_
disorder. In general, it should be noted that in Diagnostik_Therapie_Essstoerungen.pdf. Accessed:
previous efficacy studies in the eating disor- 12. Jan 2022
ders field, a symptom-oriented approach within Carter FA, Jordan J, McIntosh VV et al (2011) The long-
term efficacy of three psychotherapies for anorexia
IPT was not allowed in order to avoid over- nervosa: a randomized, controlled trial. Int J Eat
lap with comparison conditions such as CBT, Disord 44:647–654
although the IPT treatment manual explicitly Hilbert A (2006) Interpersonelle Psychotherapie. In:
permits a symptom-oriented approach. A com- Rief W, Exner C, Martin A (Eds) Psychotherapie. Ein
Lehrbuch. Kohlhammer, Stuttgart, pp 404–416
bination with a cognitive-behavioral approach Hilbert A, Brähler E (2012) Interpersonelle Psycho
seems to lead to an overall increase in IPT’s therapie bei Essstörungen: Eine systematische und
effectiveness. Clarification of for whom, how, praxisorientierte Übersicht. Verhaltenstherapie
and under what conditions IPT works is not least 22:149–157
Hilbert A, Bishop ME, Stein RI et al (2012) Long-term
a prerequisite for further promoting IPT applica- efficacy of psychological treatments for binge eating
tions in clinical practice. Already at this point in disorder. Br J Psychiatry 200:232–237
time, the evidence of IPT’s efficacy provides the McIntosh VV, Jordan J, Carter FA et al (2005) Three
basis for recognition as a guideline psychother- psychotherapies for anorexia nervosa: a randomized,
controlled trial. Am J Psychiatry 162:741–747
apy, at least for BN and BED. Good trainability Murphy R, Straebler S, Basden S et al (2012)
of IPT has been demonstrated. Interpersonal psychotherapy for eating disorders. Clin
Psychol Psychother 12:150–158
Schramm E (Ed) (2010) Interpersonelle Psychotherapie,
3rd edn. Schattauer, Stuttgart
References Wilfley DE, MacKenzie KR, Welch RR et al (2000)
Interpersonal psychotherapy for group. Basic Books,
Klerman GL, Weissman MM, Rounsaville BJ, Chevron New York
E (1984) Interpersonal psychotherapy of depression. Wilfley DE, Welch RR, Stein RI et al (2002) A rand-
Basic Books, New York omized comparison of group cognitive-behavioral
Weissman MM, Markowitz JC, Klerman GL (2000) therapy and group interpersonal psychotherapy for
Comprehensive guide to interpersonal psychotherapy. the treatment of overweight individuals with binge-
Basic Books, New York eating disorder. Arch Gen Psychiatry 59:713–721
Weissman MM, Markowitz JC, Klerman GL (2009) Wilson GT, Wilfley DE, Agras WS (2010) Psychological
Interpersonelle Psychotherapie: Ein Behand treatments of binge eating disorder. Arch Gen
lungsleitfaden. Hogrefe, Göttingen Psychiatry 67:94–101
Weiterführende Literatur
Agras WS, Crow SJ, Halmi KA et al (2000) Outcome

predictors for the cognitive behavior treatment of
bulimia nervosa: data from a multisite study. Am J
Cognitive Remediation
Therapy 44
Timo Brockmeyer
Contents
44.1 Cognitive Inflexibility and Anorexia Nervosa . . . . . . . . . . . . . . . . . . . . . . . . 333
44.2 Set-shifting and Central Coherence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333
44.3 Translating Research Findings into a Targeted Intervention . . . . . . . . . . . 334
44.4 Overview of the Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334
44.5 Modules of the Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334
44.6 Metacognitive Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335
44.7 Example Presentation of the Exercises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 336
44.8 Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 338
44.1 Cognitive Inflexibility embedded in obsessive-compulsive personal-

and Anorexia Nervosa ity traits (excessive preoccupation with details
and order, perfectionism, rigidity, exagger-
In patients with anorexia nervosa (AN), an ated conscientiousness) (Lilenfeld et al. 2006),
obsessive preoccupation with nutrition, body which are considered a risk factor for AN
shape, and weight, as well as highly ritualized (Holliday et al. 2005) and have been associ-
behavior (e.g., extensive chopping of food, calo- ated with a worse prognosis (Crane et al. 2007).
rie counting, measuring body circumference, Neuropsychological tests also reveal, at least on
weighing, compulsive exercising) can often be average, reduced cognitive flexibility (set-shift-
observed. In other everyday routines, patients ing) and excessive detail focus in patients with
with AN are often very rigid and react to changes AN (Lang et al. 2014; Wu et al. 2014).
with anxiety and discomfort (Brockmeyer and
Friederich 2015). Such behaviors are often
44.2 Set-shifting and Central
Coherence
T. Brockmeyer (*) Set-shifting describes the ability to adapt quickly
Department of Clinical Psychology and
Psychotherapy, Institute of Psychology, University of to changing environmental demands by flexibly
Münster, Münster, Germany switching between different rules, tasks, and
e-mail: [email protected] actions (Monsell 2003). Cognitive inflexibility,
https://doi.org/10.1007/978-3-662-67662-2_44
334 T. Brockmeyer
on the other hand, is characterized by rigid and

perseverative behavior despite changing envi- processing, behavioral routines, and
ronmental conditions. Central coherence refers habits
to the ability to overview and integrate com- • focuses more on “how” a person thinks
plex information, essentially seeing the “bigger and less on “what” they think
picture.” Weak central coherence, by contrast, • is based on a variety of exercises, usu-
manifests in a compulsive focus on details, i.e., ally performed in individual or group
essentially the problem of “not seeing the forest therapy under the guidance of a thera-
for the trees” (Happé and Frith 2006). pist, sometimes also on a computer
• is highly structured, playful, and time-
limited (usually 8–10 sessions)
44.3 Translating Research
Findings into a Targeted
Intervention
44.4 Overview of the Intervention
Tchanturia and colleagues translated the findings
on weak set-shifting and central coherence in The intervention usually consists of 8–10 ses-
AN into a specific clinical intervention by adapt- sions, with individual therapy sessions typically
ing the so-called cognitive remediation therapy lasting about 30–50 minutes and group therapy
(CRT) for AN (Davies and Tchanturia 2005). sessions lasting 90–100 minutes. Sessions usu-
Originally, CRT was designed for patients with ally take place weekly, in an inpatient setting
brain lesions (Goldberg 2002) and subsequently sometimes several times per week. The patient
successfully applied as an add-on intervention to and therapist work together on relatively sim-
improve cognitive and social functions in schizo- ple, material-based exercises. The patient should
phrenia (Wykes et al. 2011). have the opportunity to playfully discover poten-
CRT can be counted among the so-called tial weaknesses in set-shifting and central coher-
neurobehavioral therapy approaches (Siegle ence and then reflect on their impact on her
et al. 2007) and largely corresponds to the idea everyday life. Through continuous practice dur-
of a “brain gym” in which certain brain func- ing treatment, she should improve her abilities in
tions are to be trained using cognitive-behavioral these areas and transfer them to her everyday life
exercises. This is intended to alleviate specific through behavioral experiments. Typical eating
symptoms and accompanying manifestations of disorder-specific topics such as nutrition, weight,
the disorder directly and to create a neurocogni- and body shape are deliberately excluded, which
tive basis for a better response to psychothera- usually contributes to high treatment acceptance.
peutic interventions. The modified CRT for AN
specifically aims to favorably influence the two  Important Cognitive remediation ther-
cognitive control functions of set-shifting and apy is not a standalone treatment option
central coherence mentioned above. for AN. It can only be used as an add-on
treatment component to promote flexible
thinking and action.
Cognitive Remediation Therapy for AN
…
• is focused on personality traits and 44.5 Modules of the Intervention
basic cognitive functions, not acute
symptoms At the beginning of the intervention, a brief
• aims to reflect on and lend greater flexi- introduction is given (for an example of phras-
bility to rigid thinking styles, information ing see Example phrasing for introducing the
44 Cognitive Remediation Therapy 335
intervention). Subsequently, the individual ses- and individual behaviors. These thinking
sions largely follow the same structure, with styles have nothing to do with education or
increasing levels of difficulty in the exercises. A intelligence, but rather with how certain net-
CRT session typically begins with a detailed dis- works of our brain process incoming infor-
cussion of the therapeutic homework carried out mation. Such thinking styles usually have
by the patient since the last session. This is fol- both advantages and disadvantages, almost
lowed by 2–3 new exercises with multiple rep- never are they purely negative or hinder-
etitions. These are often paper- and pencil-based ing or completely positive and helpful. It
(examples are given below). The observations can be imagined that each thinking style is
made during these exercises (e.g., discomfort, useful in some situations and more of a hin-
tension and restlessness, or difficulties in forced drance in others. For example, some people
switching between different tasks/rules/require- find it very easy to switch between differ-
ments and “sticking” to existing rules or require- ent ideas, rules, or tasks. Such people can
ments) are discussed, reflected upon, and related often manage multiple tasks simultaneously
to difficulties in everyday life (e.g., in a situation (multitasking) and adapt quickly and eas-
where a previously agreed meeting with friends ily to changing conditions in everyday life.
is spontaneously discarded by them in favor of However, they may not be as strong in con-
another plan). This is followed by a selection of scientiously and carefully working on a spe-
new therapeutic homework assignments and a cific task and sometimes overlook details.
corresponding preliminary discussion. In some Other people are more inclined to focus
cases, sessions are also interspersed in which the strongly on a single topic. These people are
patients independently (possibly at home or on probably very good at doing things very con-
mobile devices) or under minimal supervision scientiously, accurately, and carefully, and
work on computer tasks designed to promote they often discover small things that others
cognitive flexibility and central coherence. overlook. They often find it disturbing when
they are interrupted in something, when
they have to switch quickly between differ-
General Recommendations for Imple ent tasks, or when plans or routines change.
menting the Intervention In this training, we will think together about
• The therapeutic stance should be char- our own thinking. The goal of this training
acterized by cooperation, guided dis- is for you to become aware of the strengths
covery, resource orientation, and and weaknesses of your own thinking style
empathy and to expand your repertoire of thinking
• The activation of intense emotions and action strategies so that, ideally, you
should be avoided can choose a suitable strategy for different
• Exercises should be presented as situations.”
opportunities to gain specific experi-
ences, not as performance tests
• Tasks and exercises should be tailored to 44.6 Metacognitive Level
the individual patient as much as possible
An important component of the intervention
is to reflect on one’s own thinking (and behav-
ior). This is very similar to a related treat-
Example Phrasing for Introducing the
ment approach, metacognitive training, which
Intervention
is often used as an add-on intervention in the
“We all have different styles of thinking, treatment of schizophrenia (van Oosterhout
which shape our own unique personalities et al. 2016).
336 T. Brockmeyer
processing conflict that can occur, for example,

Metacognitive Approach in Cognitive when words that denote colors (e.g., “yellow”)
Remediation Therapy: Examples of do not match the color (e.g., blue) in which they
possible effects of weak cognitive flex- are printed. The patients are asked to name vari-
ibility and central coherence ous stimuli in turn and, following the therapist’s
• Interpersonal problems due to: strong instructions, to repeatedly change the applicable
adherence to plans and agreements, rule (naming the content meaning of the word
rapid frustration with deviations from ↔ naming the print color).
plans, lack of spontaneity, monotony,
“hair-splitting,” unwillingness to del- Geometric Figures Patients can be asked to
egate tasks to others, rejection or reser- describe complex geometric figures as simply as
vation towards new things possible so that the therapist or another patient
• Emotional problems due to: “getting can draw them (without seeing the figure).
stuck” in or not being able to detach In doing so, patients sometimes tend to over-
well from negative feelings/moods, emphasize individual details of the figures or
not being able to “switch off” well, not describe them too precisely, instead of convey-
being able to evaluate situations well ing the rough features of the figure to their coun-
from another perspective terpart in a simple and understandable way. In
this task, feedback from the counterpart should
be included as much as possible, which should
illustrate to the patient that it is difficult or stren-
44.7 Example Presentation of the uous to follow an overly detailed or fragmented
Exercises description and is of little help in imagining the
figure.
In the following, some of the exercises will be
presented briefly as examples. Summarizing Texts and Images This exer-
cise to promote global information processing
Optical Illusions These are optical illusions involves asking the patient to briefly summarize
or hidden picture puzzles that contain a figure (differently) long and complex texts (e.g., let-
that is usually not recognizable at first glance, ters or newspaper articles), give them headlines
or images that convey different image contents or subtitles, summarize a text in one sentence or
from different perspectives due to their special even one word. Similarly, patients can be asked
construction. The patients are first asked what to identify the essential elements, messages, or
they can recognize in the picture. If they only atmosphere of very complex images (e.g., hid-
recognize one of the possible images or figures den object pictures, paintings by Brueghel or
in the overall picture, they are asked if they can Bosch).
see anything else. If necessary, they receive help
in recognizing the other image or figure. They Behavioral experiments in everyday life
are then asked, for example, to point with their Exercises for transfer to everyday life repre-
finger at individual features or different images sent another important component of the inter-
or figures (in the relatively well-known face/ vention. For this purpose, simple, individually
vase illusion, for example, at the nose and chin tailored behavioral experiments should be
of the face and then at the bottom and neck of developed together with the patient, with which
the vase) and to quickly switch back and forth the patient can challenge her (possibly not yet
between the different perspectives. always conscious) routines and habits in every-
day life. To minimize the risk of frustration and
Stroop Tasks In this type of task, the so-called failure, it is advisable to start with easy, rela-
Stroop effect is used. This is based on a mental tively tolerable routine changes for the patient.
At least initially, it can be helpful for some 44.8 Evidence

patients if some examples are provided (see
below). These tasks may seem extremely trivial, A series of case series and uncontrolled fea-
but they actually represent a challenge for many sibility studies with positive results regarding
patients that is large enough to discover and improvements in cognitive and clinical param-
question cognitive inflexibility in everyday life. eters after the application of CRT in adult and
The aim is not to discover that deviating from adolescent patients with AN led to the interven-
a routine or changing a habit is always better tion being considered a promising new option
than doing something as usual. There are often in the treatment of AN (Tchanturia et al. 2013,
good reasons why certain routines have become 2017). Meanwhile, there are six published ran-
established. Rather, it is about patients playfully domized controlled trials on the effectiveness
trying out what it feels like to do something dif- of CRT in AN. In these studies, CRT was com-
ferently than habit dictates. This is intended pared with standard treatment (treatment as
to train a certain flexibility in terms of action usual), with cognitive behavioral therapy alone
options and, on the other hand, to help patients (without CRT as add-on), or with a nonspecific
learn to deal with aversive emotions triggered cognitive training (which was not focused on
by deviation from the familiar (such as inse- set-shifting and central coherence). The evi-
curity, discomfort, nervousness), to tolerate or dence for the effectiveness of CRT in improv-
accept and process them, in order to be better ing cognitive functions (primarily set-shifting
“equipped” for changes and surprises that inevi- and central coherence) is heterogeneous. In
tably arise in life. two smaller pilot studies (Brockmeyer et al.
2014; Lock et al. 2013), some effects (at least
with regard to some of the measures used)
Suggestions for Behavioral Experiments were found, with one of these studies using an
• Choose a different ringtone or back- adapted, intensified, and computer-supported
ground image for your phone version of CRT. In four other studies, three of
• Wear your wristwatch on the other which had larger sample sizes, no effects were
hand or upside down (12 pointing found (Dingemans et al. 2014; Herbrich et al.
downwards) 2017; Sproch et al. 2019; van Passel et al. 2016).
• Sit somewhere different than usual In four of the six randomized controlled tri-
• Multitasking during housework or als, potential effects of CRT on clinical param-
gardening eters (e.g., body mass index) were investigated.
• Try a new route to work/school/university/ In one of these studies, superiority of CRT was
home found in terms of self-assessed eating disor-
• Change something small in the room der symptoms and health-related quality of life,
• Change the order of brushing your teeth but not in terms of weight gain (Dingemans
(e.g., first top, then bottom) et al. 2014), whereas in the three other trials,
• Change a product brand (e.g., buy a dif- no greater improvements in clinical param-
ferent toothpaste) eters were found when patients received CRT
• Leave the room/house untidy when (Herbrich et al. 2017; Lock et al. 2013; Sproch
going out et al. 2019). It should also be considered that the
• Watch a new series or movie that you only study to find superiority of CRT in terms
wouldn’t normally watch of clinical parameters examined a mixed sample
• Listen to different music than usual of patients with very different eating disorders,
338 T. Brockmeyer
and there was no equivalence between the treat- Brockmeyer T, Ingenerf K, Walther S, Wild B, Hartmann
ment arms in terms of treatment dose, as a sin- M, Herzog W, Bents H, Friederich HC (2014)
Training cognitive flexibility in patients with anorexia
gle standard treatment was compared with a nervosa: a pilot randomized controlled trial of cogni-
standard treatment plus CRT (Dingemans et al. tive remediation therapy. Int J Eat Disord 47:24–31.
2014). In a recently published study with 167 https://doi.org/10.1002/eat.22206
adolescent and adult patients with AN, in which Brockmeyer T, Schmidt H, Leiteritz-Rausch A,
Zimmermann J, Wünsch-Leiteritz W, Leiteritz A,
we compared CRT with a variant of art therapy Friederich H-C (2021) Cognitive remediation therapy
(both as group therapy and as an add-on to inpa- in anorexia nervosa—A randomized clinical trial. J
tient standard treatment), we found no superi- Consult Clin Psychol 89(10):805–815
ority of CRT in terms of changes in body mass Crane AM, Roberts ME, Treasure J (2007) Are obses-
sive-compulsive personality traits associated with
index, self-assessed severity of eating disorder a poor outcome in anorexia nervosa? A systematic
symptoms, and health-related quality of life review of randomized controlled trials and natural-
(Brockmeyer et al. 2021). Likewise, the groups istic outcome studies. Int J Eat Disord 40:581–588.
did not differ in terms of changes in set-shifting https://doi.org/10.1002/eat.20419
Davies H, Tchanturia K (2005) Cognitive remediation
and central coherence, except for a short-term therapy as an intervention for acute anorexia ner-
superiority of CRT regarding set-shifting. In vosa: a case report. Eur Eat Disord Rev 13:311–316.
light of this evidence, CRT can only be recom- https://doi.org/10.1002/erv.655
mended to a very limited extent as an additional Dingemans AE, Danner UN, Donker JM, Aardoom JJ, van
Meer F, Tobias K, van Elburg AA, van Furth EF (2014)
treatment component for AN. The effectiveness of cognitive remediation therapy in
patients with a severe or enduring eating disorder: a
randomized controlled trial. Psychother Psychosom
83:29–36. https://doi.org/10.1159/000355240
44.9 Conclusion for Practice Goldberg E (2002) The executive brain: frontal lobes and
the civilized mind, 1. issued Oxford University Press
Cognitive remediation, as a neuroscience- paperback. Oxford University Press, Oxford [u. a.]
informed treatment module, represents a prac- Happé F, Frith U (2006) The weak coherence account:
detail-focused cognitive style in autism spectrum
ticable addition to other psychotherapeutic
disorders. J Autism Dev Disord 36:5–25. https://doi.
interventions for AN. The intervention is gener- org/10.1007/s10803-005-0039-0
ally well-received by patients due to its playful, Herbrich L, van Noort B, Pfeiffer E, Lehmkuhl U,
non-confrontational approach and because eat- Winter S, Kappel V (2017) Follow-up assessment of
cognitive remediation therapy in adolescent anorexia
ing disorder-related topics such as weight and
nervosa: a pilot study. Eur Eat Disord Rev 25:104–
shape are broadly excluded. However, the evi- 113. https://doi.org/10.1002/erv.2501
dence for the specific effectiveness of CRT in Holliday J, Tchanturia K, Landau S, Collier D, Treasure
improving cognitive functions, eating disorder J (2005) Is impaired set-shifting an endophenotype of
anorexia nervosa? Am J Psychiatr 162:2269–2275.
symptoms, and quality of life must be consid-
https://doi.org/10.1176/appi.ajp.162.12.2269
ered low. Patients with pronounced difficulties Lang K, Lopez C, Stahl D, Tchanturia K, Treasure J
in the areas of set-shifting and central coher- (2014) Central coherence in eating disorders: an
ence may benefit more from the intervention. updated systematic review and meta-analysis. World
J Biol Psychiatry 15:586–598. https://doi.org/10.3109
However, empirical evidence for this hypothesis
/15622975.2014.909606
is still lacking. Lilenfeld LRR, Wonderlich S, Riso LP, Crosby R,
Mitchell J (2006) Eating disorders and personal-
ity: a methodological and empirical review. Clin
Psychol Rev 26:299–320. https://doi.org/10.1016/j.
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and fostering cognitive-behavioural flexibility in tion therapy feasible to use in randomized clinical tri-
anorexia nervosa. In: Tchanturia K (Ed) Cognitive als for anorexia nervosa? Int J Eat Disorder. https://
remediation therapy (CRT) for eating and weight dis- doi.org/10.1002/eat.22134
orders. Routledge/Taylor & Francis Group, London/ Monsell S (2003) Task switching. Trends Cogn Sci 7:134–
New York, pp 92–108 140. https://doi.org/10.1016/s1364-6613(03)00028-7
van Oosterhout B, Smit F, Krabbendam L, Castelein S, Tchanturia K, Lloyd S, Lang K (2013) Cognitive reme-
Staring ABP, van der Gaag M (2016) Metacognitive diation therapy for anorexia nervosa: current evidence
training for schizophrenia spectrum patients: a meta- and future research directions. Int J Eat Disorder
analysis on outcome studies. Psychol Med 46:47–57 46:492–495. https://doi.org/10.1002/eat.22106
van Passel B, Danner U, Dingemans A, van Furth E, Tchanturia K, Giombini L, Leppanen J, Kinnaird E (2017)
Sternheim L, van Elburg A, van Minnen A, van den Evidence for cognitive remediation therapy in young
Hout M, Hendriks GJ, Cath D (2016) Cognitive people with anorexia nervosa: systematic review and
remediation therapy (CRT) as a treatment enhancer meta-analysis of the literature. Eur Eat Disord Rev
of eating disorders and obsessive compulsive dis- 25:227–236. https://doi.org/10.1002/erv.2522
orders: study protocol for a randomized controlled Wu M, Brockmeyer T, Hartmann M, Skunde M, Herzog
trial. BMC Psychiatry 16. https://doi.org/10.1186/ W, Friederich HC (2014) Set-shifting ability across
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https://doi.org/10.1002/eat.23143
Treatment of Body
Image Disorders 45
Silja Vocks and Anika Bauer
Contents
45.1 Development of a Disturbance Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342
45.2 odification of Dysfunctional Body-Related Cognitions . . . . . . . . . . . . . . .
M 342
45.3 Body Exposure via Mirror and Video . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343
45.4 Exposure Exercises for Reducing Body-Related Avoidance
and Checking Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 344
45.5 Building Positive Body-Related Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . 345
45.6 Findings on the Effectiveness of Cognitive-Behavioral Interventions
for Improving Body Image . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347
In several prospective studies, the high relevance findings suggest integrating interventions for
of a disturbed body image for the development targeted improvement of body image into eating
and maintenance of eating disorders has been disorder treatment, such treatment measures are
demonstrated. Furthermore, additional longi- often not considered or only unsystematically
tudinal studies showed that patients who were and insufficiently implemented in the therapy
able to normalize their eating behavior through of anorexia nervosa (AN) and bulimia nervosa
therapy but still maintained a negative attitude (BN). The following presents various mod-
towards their own physical appearance had a ules for cognitive-behavioral treatment of body
higher risk of relapse. Although these research image disorders, which were developed based
on existing research findings and address the
four components of the disturbed body image.
Components of the disturbed body

S. Vocks (*) · A. Bauer image
Institute of Psychology, Department of Clinical • Perception
Psychology and Psychotherapy, University of • Cognition
Osnabrück, Osnabrück, Germany
e-mail: [email protected] • Emotion
• Behavior
A. Bauer
https://doi.org/10.1007/978-3-662-67662-2_45
342 S. Vocks and A. Bauer
achievements) and negative experiences (e.g.,

Modules of body image therapy bullying) in the various phases of their lives
• Development of an individual disorder have contributed to the development of their
model own body image. In this context, the influence
• Modification of dysfunctional body- of the ideal of extreme slimness, which is omni-
related cognitions present in Western society and disseminated
• Body exposure using mirror and video by the media—especially social media such
• Exposure exercises to reduce body- as Facebook or Instagram—is also reflected.
related avoidance and checking behavior Likewise, the specific body image problem
• Establishment of positive body-related regarding the four components (i.e., perception,
activities cognition, emotion, and behavior) is worked out
for each patient. In addition, the factors main-
taining the negative body image and thus also
Finally, current research findings on the effec- the eating disorder (e.g., body-related avoidance
tiveness of cognitive-behavioral interventions behavior) are identified with each patient. It is
for improving body image are summarized. agreed with the patients that the therapy should
Body image therapy can be conducted in both focus on these maintaining factors in order to
individual and group settings and represents a break existing vicious cycles.
supplementary component to regular eating dis-
order treatment. Due to the body exposure exer-
cises, which are usually performed wearing only 45.2 Modification
underwear or a bikini, it is recommended that of Dysfunctional Body-
body image therapy be conducted by same-sex Related Cognitions
therapists for the patients.
Numerous studies have shown that patients
 Interventions for improving body image with eating disorders have a greater dissatisfac-
represent a complementary component in tion with their own body than healthy women,
the cognitive-behavioral treatment of eat- with patients with BN appearing to evaluate
ing disorders. They address the distorted their body even more negatively than women
perception of one’s own body, negative with AN. Moreover, it is known that the areas
body-related emotions and cognitions, as of “shape” and “weight” have a high signifi-
well as dysfunctional body-related avoid- cance for patients with AN and BN in terms of
ance and checking behavior. self-esteem. Therefore, treatment of body image
disturbances should actively address the body-
related cognitions of the patients. Both negative
45.1 Development of a automatic thoughts that are activated in body
Disturbance Model image-relevant situations (e.g., “Everyone is
looking at me now because I have such a big
In order to convey the treatment rationale to butt”) and basic assumptions (e.g., “My worth as
the patients and thereby increase therapy moti- a person depends on my weight”) are identified
vation, an individual disturbance model using various cognitive-behavioral techniques.
regarding the development and maintenance of Based on this, these cognitions are critically
body image disturbance should be developed examined for their functionality and reality
together with each patient in a first step, from appropriateness using the method of Socratic
which the individual treatment components can Dialogue, which can also be used in the group
then be derived. The focus is on the individual setting in the form of role plays, and gradu-
body image history, i.e., it should be compiled ally changed, for example, through the use of
for each patient which positive (e.g., athletic self-instruction exercises and documentation
45 Treatment of Body Image Disorders 343
techniques. The patients are instructed to sys- and reduced through processes such as habitua-
tematically integrate the learned techniques into tion during a sufficiently long exposure.
their everyday lives in order to gradually replace
the established—mostly negatively distorted Body-Related Avoidance Behavior To pre-
or dysfunctional—thinking patterns with more vent the occurrence of the negative emotions
reality-appropriate and functional cognitions. described above, which can arise from dealing
with one’s own body, many women with eat-
ing disorders exhibit pronounced body-related
45.3 Body Exposure via Mirror avoidance behavior(Sect. 45.4). In extreme
and Video cases, this manifests itself in consistently avoid-
ing one’s own physical appearance (e.g., by cov-
Body exposure exercises are a central compo- ering mirrors) or, as far as possible, not touching
nent of body image therapy. Under therapeutic one’s own body. Overcoming this avoidance
guidance, patients systematically deal with their behavior is therefore the second goal of body
own body. exposure exercises.
Distorted Mental Representation of One’s

45.3.1 Goals Own Body The third goal of body exposure is
to correct the distorted mental representation
Body exposure exercises are intended to achieve of one’s own body. According to the results of
various goals, which are listed below and subse- numerous studies, women with both AN and
quently justified by various research findings. BN overestimate their body dimensions. This
overestimation is not limited to their own body
size but also extends to their movement patterns
Objectives of Body Exposure concerning their own bodies. The overestimation
1. Reduction of negative body-related of one’s own body dimensions does not seem
emotions to be based on a sensory deficit of the patients
2. Overcoming body-related avoidance but is rather to be understood as a cognitive phe-
behavior nomenon that can be explained by information
3. Correction of the distorted mental rep- processing theories. Through systematic feed-
resentation of one’s own body back during body exposure exercises, a correc-
4. Reduction of the deficit-oriented view tion of the overestimation of one’s own body
of one’s own body dimensions and movement patterns and thus the
establishment of a more realistic mental repre-
sentation of one’s own body should occur.
Negative Body-Related Emotions The first
objective of body exposure is to reduce negative Deficit-Oriented View of One’s Own Body
body-related emotions. The basis for this lies in The reduction of the deficit-oriented view of
the results of several studies that indicate that one’s own body represents the fourth goal of
patients with eating disorders show pronounced body exposure exercises. Studies conducted
negative affective reactions regarding their own using eye tracking suggest that women and girls
bodies. For example, women with eating disor- with eating disorders particularly focus on the
ders experience emotions such as fear, anger, negatively evaluated areas of their own bod-
sadness, and disgust to a greater extent when ies and, conversely, pay less attention to more
looking at their own bodies than individuals positively evaluated aspects. One consequence
without eating disorders. In the context of body of these findings is that patients should be sup-
exposure, these negative emotions are activated ported in specifically confronting their own
bodies to increasingly pay attention to the more in negative emotions is recorded. Furthermore,
positively evaluated body regions, thus leading the exercises should be repeated regularly to
to a more balanced view and a more realistic allow habituation processes. Accordingly, it is
mental representation of their own bodies. recommended that the body exposure exercises
be continued independently by the patients as
part of homework assignments.
45.3.2 Procedure
The four mentioned objectives of body expo- 45.4 Exposure Exercises

sure require different approaches. For example, for Reducing Body-Related
overcoming the negative affective reaction to the Avoidance and Checking
sight of one’s own body and reducing the asso- Behavior
ciated body-related avoidance behavior initially
requires the activation of negative emotions. In The transfer of exposure rationale to everyday
the context of body exposure exercises, this is life should be carried out within the framework
achieved by focusing on negatively evaluated or of interventions to overcome body-related avoid-
previously avoided body areas. In contrast, the anceand checking behavior. This area of behav-
objective of a balanced view of one’s own body ioral manifestation of a disturbed body image
requires an increased focus on (potentially) posi- has only recently received attention in both
tive, but previously less noticed body areas. For research and therapy contexts. Various stud-
this reason, it is recommended to perform these ies show that women with AN and BN exhibit
two variants of body exposure—focusing on a higher degree of body-related avoidance and
negative or avoided and focusing on positive, checking behavior than healthy control sub-
but previously less noticed body areas—one jects. The extent of these behaviors positively
after the other. It has proven useful to start with correlates with the severity of shape and weight
the focus on negatively evaluated or avoided concerns. Body-related avoidance behavior
body areas. Before performing the exercises, the manifests itself in the avoidance of situations
therapist should therefore determine which body and contexts in which the patient’s own attention
areas are rated more positively and which more or that of others is directed towards the patient’s
negatively by the respective patient. body. Body-related checking behavior includes
In both variants of the body exposure exer- strategies such as weighing oneself after every
cises, the patients systematically look at their meal or measuring specific body areas with a
body in a full-length mirror, ideally wearing tape measure. Although these behaviors differ
only a bikini. To keep the patient’s attention on phenomenologically, they are similar in terms
her own body and prevent (even hidden) avoid- of their functionality. Both strategies serve the
ance behavior during the exposure exercises, the short-term avoidance or reduction of negative
therapist asks targeted questions (e.g., “Can you body-related emotions. However, studies have
describe the shape of your stomach to me?”). also provided initial evidence that body-related
These exercises can be supplemented by the checking behavior may temporarily intensify
instruction to not only look at certain body areas negative emotions. These findings, as well as
but also to touch them. In addition to mirror initial experimental investigations suggesting
exposure, video exposure exercises are also used, that these behaviors may contribute to the long-
allowing patients to deal not only with their body term maintenance of a body image disturbance,
shapes but also with their own movement patterns. suggest that their reduction should be another
In general, it should be noted that body expo- goal of body image therapy. Specifically, expo-
sure sessions should be sufficiently long, i.e., sure exercises are carried out in the listed
not be terminated before a significant decrease contexts.
positive body-related activities should be car-

Exercise Areas for Reducing Body- ried out, based on the exercises to reduce body-
Related Avoidance and Checking related avoidance behavior. The patients should
Behavior learn to get to know their own body as an instru-
• Activities (e.g., undergoing a previously ment with which they can have positive experi-
avoided medical examination) ences, and not primarily perceive it as a burden.
• Locations (e.g., going to the swimming Corresponding exercises can be assigned to
pool) three content areas.
• Social activities (e.g., dancing)
• Clothing (e.g., wearing tight pants)
• Body care (e.g., applying lotion) Areas for building positive body-related
• Body positions (e.g., sitting down with- activities
out crossing legs) • Health/Fitness (e.g., practicing yoga)
• Shape and weight control (e.g., refrain- • Sensory experiences (e.g., smelling a
ing from weighing oneself after every perfume)
meal) • Body care/Appearance (e.g., taking a
• Reassurance (e.g., not seeking feedback bath with essential oils)
on one’s own figure)
• Social comparisons (e.g., not comparing
oneself to slim friends) However, many patients with AN and BN
exhibit excessive physical activities that can
contribute to the maintenance of the eating dis-
First, it is necessary to identify the situations order. Therefore, when planning the reinforcing
and locations in which a person’s body-related activities, it is important to ensure that sports
checking behavior is exhibited. Based on this, activities are only established in a functional
the cognitions underlying avoidance and check- (moderate) form for the treatment goals and are
ing behavior should be highlighted and their not carried out by the patients out of the motiva-
appropriateness to reality should be exam- tion to burn calories.
ined. In the next step, specific exercise areas
are worked out and the exposure exercises are
planned in more detail. To prevent the exercises 45.6 Findings on the
from being discontinued, potential problems Effectiveness of Cognitive-
that may arise during the exposure exercise are Behavioral Interventions
discussed in anticipation. It may be helpful for for Improving Body Image
the therapist to accompany the patient during
the first exposure exercises; however, the patient Various studies have demonstrated the effec-
should later continue these exercises indepen- tiveness of comprehensive cognitive-behavioral
dently to facilitate the transfer to everyday life. interventions for body image in patients with
AN and BN. In the evaluation study of the body
image therapy program presented above, the
45.5 Building Positive Body- most significant therapy effects were found in
Related Activities terms of a reduction in body dissatisfaction and
concerns about shape and weight, followed by
There is now initial research evidence for the improvements in body-related avoidance and
observation that patients with AN and BN per- checking behavior. While the assessment of
form fewer positive body-related activities in one’s own body dimensions did not change sig-
everyday life than women without eating dis- nificantly towards a more realistic mental rep-
orders. For this reason, interventions to build resentation, the patients’ desired “ideal figure”
was no longer considered to be as slim as at the smaller reduction in negative emotions during
beginning of therapy. Improvements were also the course of the body exposure session. With
observed in the number of binge eating epi- regard to the cognitive component of body
sodes and the extent of striving for thinness, as image, numerous studies on women suffering
well as in eating disorder-related measures such from body dissatisfaction or eating disorders
as depression and self-esteem. Initial evidence have shown that performing body exposure
that these intervention effects also manifest in a exercises leads to a reduction in negative body-
more ecologically valid context was provided by related thoughts, shape and weight concerns, as
another study. The emotional and cognitive reac- well as a general improvement in body satisfac-
tion to looking at one’s own body in the mirror tion. Also, regarding the behavioral component
after body image therapy was less pronounced of body image disturbance, initial studies pro-
than before treatment. Another study compared vide evidence of positive effects of body expo-
two variants of body image therapy and showed sure in the form of a reduction in body-related
that the variant in which mirror exposure was checking and avoidance behavior, although most
performed was superior to a variant without of these findings are based on the investigation
this intervention. Initial indications for neural of non-clinical samples.
correlates of the effects of cognitive-behavioral A general limitation is that there are only a
body image therapy are provided by an fMRI few randomized controlled studies on body
study, which demonstrated increased activation exposure in patient groups so far, so the reported
of specific brain areas relevant for visual body effects should be interpreted with caution.
processing after conducting a manualized body Moreover, there is a lack of studies on the effec-
image therapy in patients with eating disorders. tiveness of other specific treatment components
In addition to these studies, which focus on of body image therapy in relation to the four
more comprehensive body image treatment manifestation levels of disturbed body image.
programs, several studies have been conducted
examining only one treatment component—
Conclusion
mostly body exposure—in terms of its effective-
The presented studies suggest the effective-
ness on the four described levels of body image
ness of cognitive-behavioral interventions for
disturbance. In research on the perceptual com-
body image in patients with eating disorders.
ponent of a negative body image, some stud-
However, many aspects have not yet been
ies have shown a more realistic assessment of
adequately researched, such as the question
one’s own body dimensions through body image
of the mechanisms of action of individual
therapy, while other studies have not described
therapeutic modules. It is also unclear what
any related effects. Studies on the change in
factors are responsible for the interindivid-
the affective component provide promising
ual differences in response to body image
results and showed that the implementation of
therapy. Since body exposure, in particular,
body exposure exercises in patients with eat-
is often perceived as temporarily stressful
ing disorders leads to a reduction in negative
by patients, identifying predictors of success
body-related feelings both during the exposure
and failure in body image therapy is impor-
exercises themselves and between therapy ses-
tant. This would contribute to adapting the
sions. Furthermore, it was found that there are
therapeutic approach to the needs of differ-
interindividual differences in the extent of this
ent patient groups and further improving the
reduction. For example, a pronounced habitual
cost-benefit ratio of the interventions.
body-related checking behavior predicted a
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Pharmacotherapy
of Eating Disorders 46
Martina de Zwaan and Jana Svitek
Contents
46.2 Bulimia Nervosa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355
46.1 Anorexia Nervosa under pharmacotherapy. The available con-

trolled trials on the use of tricyclic antidepres-
46.1.1 Weight Restoration sants (TCA) showed no significant efficacy on
weight gain and depressive mood compared to
The evidence for pharmacotherapy of anorexia placebo. Selective serotonin reuptake inhibi-
nervosa (AN) is overall unsatisfactory for both tors (SSRIs) have also proven to be ineffective
antidepressants and antipsychotics (AWMF and are not likely to support weight gain (de Vos
2018). Primary outcome criteria were primarily et al. 2014). Retrospective studies confirm this
weight criteria: extent of weight gain, speed of negative result for adolescents as well. SSRIs
weight gain, duration of treatment until weight are often used in clinical practice in combina-
restoration, and number of patients who achieved tion with psychotherapy for patients with AN, as
sufficient weight gain. Only a few studies had an effect on comorbid disorders such as depres-
longer follow-up periods, which are necessary to sion, anxiety, obsessive-compulsive symptoms,
assess the clinical significance of weight effects or bulimic symptoms is expected. However, it
has been reported that antidepressants have lit-
tle to no effect on comorbid symptoms in many
patients in the underweight state. A low efficacy
M. de Zwaan (*) of antidepressants in the state of starvation can
Psychotherapy, Hannover Medical School, be assumed (Jordan et al. 2008). Comorbid dis-
Hannover, Germany orders can improve solely through weight gain
e-mail: [email protected] without additional specific therapy, so decisions
J. Svitek about adjuvant pharmacotherapy should be made
Department of Psychiatry, Socialpsychiatry and after weight gain. If depressive symptoms persist
Psychotherapy, Hannover Medical School (MHH), after sufficient weight rehabilitation, additional
Hannover, Germany
e-mail: [email protected]; [email protected] treatment with SSRIs should be considered.
https://doi.org/10.1007/978-3-662-67662-2_46
350 M. de Zwaan and J. Svitek
Furthermore, the risk of side effects in anti- Despite these not very encouraging results, a
depressant pharmacotherapy for AN is increased study from the USA shows that the prescription
due to some specific conditions: of atypical antipsychotics has increased in recent
years (Fazeli et al. 2012). This is critical consid-
• Body weight is lower; distribution volumes ering the numerous side effects, including a neg-
are smaller. ative impact on bone density. Attention should
• Considering the unregulated eating behav- also be paid to the development of extrapyrami-
ior and recurrent vomiting, oral intake is dal-motor side effects in atypical antipsychotics,
difficult. especially since it is not known whether patients
• Cardiac side effects are more threatening due with AN may show a higher risk. Possible car-
to the already existing cardiac risks. diac side effects of atypical antipsychotics (QTc
• Electrolyte disturbances are more common. time prolongation) should be particularly con-
The risk of overlooking an induced syndrome sidered in patients with AN of the binge-purge
of inappropriate ADH secretion (SIADH) is type and require monitoring. Fat and glucose
therefore higher. metabolism disorders (insulin resistance) can
also occur in underweight patients.
 Important There is no evidence for the The AWMF-S3 guidelines recommend the
specific efficacy of antidepressants in AN. use of low-dose neuroleptics in individual cases
If antidepressants are used in the therapy for severely weight-anxious and food-restricted
of AN (e.g., for the treatment of depres- thinking, pronounced stress states, and uncon-
sion), attention should be paid to side trollable urge to move. Drugs with low extrapy-
effects (e.g., cardiac side effects, SIADH). ramidal impairment should be preferred. The
treatment indication is limited to the duration
In recent years, several small controlled trials of the aforementioned symptoms (no long-term
(RCTs) on the effectiveness of atypical antip- therapy) and applies only within the framework
sychotics in AN have been published, leading of an overall treatment plan.
to initial meta-analyses (Kishi et al. 2012; Dold
et al. 2015). The average effect size for weight  Important Atypical antipsychotics are not
gain comparing verum and placebo was only suitable for achieving weight gain in AN.
0.27 and 0.13, respectively. The extent of weight There is limited evidence that compulsive
gain is thus surprisingly low. It is discussed symptoms and ruminations can be favora-
whether physiological changes or a “resistance” bly influenced by olanzapine.
at the behavioral level could be responsible for
this low weight gain. Since the revision of the A number of other substances have been tested
AWMF guideline (2018), a larger controlled in controlled and uncontrolled trials (cyprohep-
trial with olanzapine has been published (Attia tadine, clonidine, naltrexone, THC, dronabinol,
et al. 2019). Olanzapine was compared with lithium, D-cycloserine, benzodiazepines, oxy-
placebo in the dose range of 2.5–10 mg over tocin, growth hormone, and most recently met-
16 weeks at five centers in the USA. A total of releptin), but a satisfactory effect on weight gain
152 patients were randomized, but only 83 com- could not be demonstrated. In addition, the use
pleted the outpatient therapy phase. This high of these substances was accompanied by some-
dropout rate was comparable in both groups. times significant side effects (THC). Only the
The BMI increase was 0.26 kg/m2 in the olan- substitution of zinc proved to be effective in
zapine group and 0.1 kg/m2in the placebo group. some patients (Birmingham and Gritzner 2006),
Other psychological symptoms (e.g., compul- but has not become established in clinical rou-
sion) did not improve in this study. tine to date. Determination of zinc (and possibly
46 Pharmacotherapy of Eating Disorders 351
substitution) may be useful in the presence of on the pharmacological treatment of BN (Svaldi

typical skin changes as an indication of zinc et al. 2019).
deficiency. Meaningful data are primarily available
for substances from the group of antidepres-
 Important So far, no psychotropic drug has sants, with the greatest evidence and low side
been approved for the indication of AN, so effect rates for SSRIs (Davis and Attia 2017).
the use always represents an “off-label use.” Antidepressants not only have a positive effect
on binge eating and compensatory behavior, but
 Important Neuroleptics and antidepres- also reduce eating disorder-specific psychopath-
sants should not be used to achieve weight ological features such as dysfunctional attitudes
gain in AN. towards body and weight. In most studies, a
decrease in depressive and anxiety symptoms is
also observed. Some studies explicitly excluded
46.1.2 Relapse Prevention patients with depressive symptoms, and it
appears that the response to antidepressants
Initial controlled results showed a superiority is independent of mood. A direct anti-bulimic
of fluoxetine over placebo as relapse preven- effect of antidepressant substances is therefore
tion one year after successful inpatient weight assumed. The onset of action of antidepressant
restoration. However, in a later larger study medication is often observed after the first week.
in which fluoxetine or placebo was combined However, an increase in restrictive eating behav-
with cognitive behavioral therapy (CBT) after ior has also been observed under fluoxetine.
weight restoration, the positive results could not This could prove countertherapeutic, as a crucial
be confirmed (Walsh et al. 2006). Overall, anti- first step in the therapy of BN is the establish-
depressants cannot be recommended for relapse ment of regular eating habits and a reduction in
prevention in AN. fear of weight gain. Restrictive eating behavior,
on the other hand, can increase the risk of fur-
ther binge-eating episodes in a vicious circle
46.2 Bulimia Nervosa (AWMF 2018).
Fluoxetine is the only SSRI approved for the
46.2.1 Acute Therapy treatment of BN in Germany and many other
countries, after two multicenter outpatient stud-
In contrast to AN, a variety of different medica- ies with large numbers of participants, but only
tions have been tested in controlled trials for the in combination with psychotherapeutic meas-
pharmacological treatment of bulimia nervosa ures. In the treatment of BN, a higher fluoxetine
(BN) (Mitchell et al. 2013): TCAs (amitriptyline, dose of 60 mg/day appears to be more effective
imipramine, desipramine, nomifensine), non- than the dose of 20 mg/day recommended for
tricyclic antidepressants (mianserin, trazodone, the treatment of depression. It is generally rec-
bupropion), monoamine oxidase-inhibitors ommended to increase the dose gradually, but
(MAOIs) (phenelzine, isocarboxazid, tranylcy- there is also good experience with the imme-
promine, brofaromine, moclobemide), SSRIs diate administration of the full dose of 60 mg/
(fluoxetine, sertraline, fluvoxamine, citalopram), once, in the morning. The results of an open
appetite suppressants (d-fenfluramine), trypto- study suggest the efficacy of fluoxetine 60 mg/
phan, antiepileptics (carbamazepine, phenytoin, day in adolescents with BN, but no medication
topiramate), lithium, ondansetron, and opioid is approved for children and adolescents in this
antagonists (naloxone, naltrexone). There are indication, and its use is only possible within the
numerous reviews, meta-analyses, and guidelines framework of an “individual treatment attempt”
according to § 41 of the Medicines Act. Smaller for extreme caution in suicidal patients.
controlled trials are available for sertraline, cital- With the administration of MAOIs, the
opram, and fluvoxamine, but it must be critically risk of hypertensive crises is not negligible
noted that there is likely a bias in the publication in cases of very chaotic eating behavior.
of drug studies for BN. There are at least two Bupropion is contraindicated in BN (and
unpublished studies of negative, multicenter, and also in AN) due to an increased risk of
multinational placebo-controlled trials with flu- seizures.
voxamine that could not demonstrate the superi-
ority of the drug. In the large multicenter studies with fluoxetine,
In drug therapy, dropout rates can be con- sexual side effects (e.g., reduced libido) were
siderable. Moreover, even with statistically common, and with a dose of 60 mg/day, sleep
significant superiority, the clinical effect is not disturbances, nausea, and asthenia occurred in
substantial for many patients (AWMF 2018). 25-33% of patients.
Thus, remission rates after short-term therapy To achieve an optimal effect, it may be nec-
range from 0 to 68%, averaging about 24%. If essary to use different antidepressants sequen-
no qualified psychotherapy is available, fluox- tially. If there is an inadequate response to drug
etine can be recommended as initial therapy. therapy, it should be checked whether the medi-
Antidepressants may prove helpful for patients cation intake is closely related to self-induced
with pronounced comorbid symptoms such vomiting. If serum levels are available for a
as depression, anxiety, compulsiveness, and drug, it can be checked whether an effective
impulse control disorders or for patients who level has been reached at all.
have not or only suboptimally responded to ade- In smaller controlled trials, the efficiency
quate psychotherapy. of the antiepileptic topiramate was demon-
strated. Due to the numerous side effects (cogni-
 Important Psychotherapeutic treatments tive disturbances, paresthesias), the medication
are more effective for patients with BN should only be used for BN if other drug ther-
than pharmacotherapy alone. CBT and apy attempts have proven ineffective. The dose
interpersonal psychotherapy (IPT) not increase must be carried out slowly. The weight-
only lead to better short-term results reducing effect of topiramate further limits its
(reduction of binge eating by 85% with use in normal and underweight patients.
remission rates around 50%), but also to Special mention should be made of bupro-
more stable long-term successes and are pion. Although it achieved significantly better
therefore considered the first-choice ther- results than placebo, it is contraindicated in BN
apy for patients with BN. because it led to generalized seizures more fre-
quently than expected.
More recently, an association between BN and Lithium is ineffective in the treatment of BN
ADHD in childhood and adolescence has been and carries the risk of overdosing due to fluid
reported. In cases of confirmed comorbidity, shifts. In patients with BN and bipolar disorder,
treatment with stimulants (methylphenidate) or the risk of toxicity is increased under lithium
atomoxetine should be considered. Since appe- therapy. Both lithium and valproic acid can lead
tite reduction occurs especially under methyl- to significant weight gain, reducing the accept-
phenidate, the risk of potential abuse must be ance of these medications. An alternative “mood
monitored (Svedlund et al. 2017). stabilizer” should be considered for comorbid
bipolar disorder.
 Important TCAs and MAOIs have rarely
been used in patients with BN and cannot  Important Pharmacotherapy should not be
be recommended. The toxicity and poten- offered as the sole treatment for BN.
tial lethality in the case of overdose call
46.2.2 Maintenance Therapy initially recommended, especially when a quali-

fied CBT is offered simultaneously.
The evidence for the use of fluoxetine as a
relapse prevention is low, with loss of effi-
cacy during long-term administration and 46.2.4 Sequential Therapy
high relapse rates after discontinuation of anti-
depressants being reported. Although corre- Sequential therapy studies investigate the
sponding data are lacking, a therapy duration effectiveness of a second-line therapy in non-
of 9-12 months is generally recommended if responders to a first-line therapy. If CBT alone
the response is satisfactory. Increasing the dose does not lead to a significant symptom reduction
or administering a second medication may be after ten sessions, the additional administration
useful in cases of relapse during maintenance of fluoxetine is recommended. Another possible
therapy. However, only open studies supporting indication may be relapse prevention after the
this are available so far. completion of psychotherapy.
Conclusion Conclusion
In summary, it can be stated that SSRIs, In summary, the use of antidepressant medi-
especially fluoxetine, must be considered cations must be considered as a second-line
the first-choice antidepressants due to their therapy in the treatment of patients with
acceptance by patients, their favorable side BN according to current knowledge. It can
effect profile, and symptom reduction. The be recommended to use antidepressants, if
effective dose of fluoxetine for BN is in a necessary, as a component, especially at the
higher range (60 mg). An effect often occurs beginning of therapy.
quickly, but little is known about the long-
term effect. A treatment attempt should be
undertaken with a minimum duration of four 46.3 Binge Eating Disorder
weeks. If the therapy is successful, a longer
treatment duration can be considered. Other
medications cannot be recommended for rou- Overview
tine use in the treatment of BN at this time.
In the therapy of binge eating disorder
(BED), several goals can be defined:
46.2.3 Combination of Psychotherapy • Reduction of the frequency of
and Medication binge eating episodes
• Reduction of eating disorder-specific
Pharmacotherapy does not necessarily have an psychopathology (e.g., overvaluation of
additive effect to a psychotherapeutic approach weight and shape)
in BN (ceiling effect). In some studies, the com- • Weight loss or prevention of further
bination of cognitive-behavioral therapy (CBT) weight gain
and an antidepressant showed the highest remis- • Improvement of general psychopathol-
sion rates. In other studies, the additional admin- ogy (e.g., depression)
istration of antidepressant medication to CBT • Improvement of physical health
showed only moderate or no additional effects
on the reduction of bulimic symptoms. However,
a superiority of combination therapy for the The therapeutic work on one of the goals should
reduction of depression and anxiety has been not negatively affect the other areas if possible.
reported. Combination therapy can therefore be It is particularly important to clarify whether
eating behavior and weight should be treated in binge eating episodes. However, we know from
parallel or consecutively. psychotherapy studies that complete remission
of binge eating episodes is associated with a
higher weight reduction.
46.3.1 Reduction of Binge Eating Topiramate has also shown a positive effect
Episodes on binge eating episodes and weight, but due to
its problematic side effects (see BN), its clinical
SSRIs and SNRIs are effective in treating usefulness is limited.
BED; however, no medication is currently In the United States, the amphetamine
approved for the treatment of BED in Europe. derivative lisdexamfetamine was approved for
Medications that have proven effective in the the treatment of BED (moderate to severe) in
therapy of BN have been consistently used. In January 2015, after several studies with positive
particular, SSRIs and SNRIs can effectively results had been published (McElroy et al. 2015;
reduce binge eating episodes and comorbid Hudson et al. 2017). The amphetamine derivative
depressive symptoms in short-term therapy. lisdexamfetamine is approved in Germany for
Remission rates are significantly higher than the treatment of ADHD in children and adults.
in studies of BN, with the average reduction of Meanwhile, a meta-analysis of four stud-
binge eating episodes in most studies being well ies is available, showing that lisdexamfetamine
over 60%. The dosages are again at the upper (50–70 mg) is superior to placebo in terms of
limit of the dosage recommended for the treat- reduction and remission of binge eating episodes
ment of depression. It should be critically noted as well as weight reduction. However, side effect
that response rates to placebo in the therapy of rates and dropout rates are higher. The risk of
BED can also be very high and that, although cardiovascular side effects and addiction poten-
pharmacotherapy proved more effective than tial must be considered (Fornaro et al. 2016).
placebo, the efficacy in relation to the core
symptoms of BED was only slightly above that  Important Currently, no medication is
of a placebo medication (Hilbert et al. 2019). approved for the treatment of BED in
Results of open studies must therefore be evalu- Europe. Psychopharmacotherapy using
ated with great caution, especially in the case centrally acting stimulants (especially
of BED. Furthermore, the problem of relapses lisdexamfetamine), second-generation
after the end of therapy is also encountered here. antidepressants, and anticonvulsants is
Long-term effects of psychotropic drugs in BED effective but also leads to side effects.
are not sufficiently researched; therefore, long- Therefore, it should only be considered
term use of psychotropic drugs for the treatment for patients with BED if psychotherapy is
of BED cannot be recommended. As a rule, the rejected or unsuccessful.
decrease in binge-eating episodes is not accom-
panied by a significant weight loss, even though
most studies find a higher weight reduction with
verum than with placebo. 46.3.2 Combination of Psychotherapy
and Medication
 Important It is a clinical reality that
weight reduction usually remains the most The administration of antidepressant medica-
important goal for these patients. tion in addition to behavioral weight reduction
programs or to eating disorder-oriented CBT
It is therefore assumed that patients will resume does not appear to have any additional effect
dieting after the end of therapy despite remis- on reducing binge eating episodes, but in some
sion of binge eating episodes, thereby increas- cases, it may increase the extent of weight
ing their vulnerability to the recurrence of reduction or the extent of reducing depressive
symptoms. In the combination studies presented, Fornaro M, Solmi M, Perna G, De Berardis D, Veronese
psychotherapeutic interventions were generally N, Orsolini L, Ganança L, Stubbs B (2016)
Lisdexamfetamine in the treatment of moderate-to-
superior to medication alone, so for BED, psy- severe binge eating disorder in adults: systematic
chotherapy (CBT) must also be considered the review and exploratory meta-analysis of publicly
first-choice therapy for reducing eating disor- available placebo-controlled, randomized clinical tri-
der-specific symptoms. Surprisingly, in the two als. Neuropsychiatr Dis Treat 12:1827–1836
Hilbert A, Petroff D, Herpertz S, Pietrowsky R, Tuschen-
combination studies with fluoxetine, no superi- Caffier B, Vocks S, Schmidt R (2019) Meta-analysis
ority of the medication over placebo regarding of the efficacy of psychological and medical treat-
the reduction of binge eating episodes could be ments for binge-eating disorder. J Consult Clin
determined. Psychol 87(1):91–105
Hudson JI, McElroy SL, Ferreira-Cornwell MC,
Radewonuk J, Gasior M (2017) Efficacy of lisdexa-
mfetamine in adults with moderate to severe binge-
Conclusion eating disorder: a randomized clinical trial. JAMA
In summary, based on current knowledge, it Psychiatry 74(9):903–910
Jordan J, Joyce PR, Carter FA, Horn J, McIntosh VV,
can be stated that only fluoxetine in combina- Luty SE, McKenzie JM, Frampton CM, Mulder RT,
tion with psychotherapy is approved for the Bulik CM (2008) Specific and nonspecific comorbid-
treatment of BN. No medication is approved ity in anorexia nervosa. Int J Eat Disord 41(1):47–56
for the treatment of AN and BED in Europe. Kishi T, Kafantaris V, Sunday S, Sheridan EM, Correll
CU (2012) Are antipsychotics effective for the treat-
For AN, no medication has proven effective ment of anorexia nervosa? Results from a system-
in supporting weight reduction. atic review and meta-analysis. J Clin Psychiatry
73:e757–e766
McElroy SL, Hudson JI, Mitchell JE, Wilfley D,
Ferreira-Cornwell MC, Gao J, Wang J, Whitaker T,
Jonas J, Gasior M (2015) Efficacy and safety of lis-
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Neuromodulation
in Eating Disorders 47
Kathrin Schag
Contents
47.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357
47.2 Assumed Mechanisms of Action in the Treatment of Eating
Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357
47.3 Introduction to Neuromodulation Methods . . . . . . . . . . . . . . . . . . . . . . . . . 358
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 362
47.1 Introduction neuromodulation represents an innovative treat-

ment approach, but by no means an evidence-
In this chapter, a brief introduction to various based intervention for eating disorders. This
neuromodulation methods and their potential chapter is based on a recently published narra-
effectiveness in the treatment of eating disorders tive overview by Schag and colleagues on the
will be provided, as a significant proportion of topic of non-invasive brain stimulation in eating
patients with eating disorders still cannot suffi- disorders (Schag et al. 2020).
ciently benefit from existing treatment methods.
Neuromodulation methods represent an innova-
tive treatment approach. Currently, promising 47.2 Assumed Mechanisms
studies have been published in this regard. It of Action in the Treatment
is assumed that in various forms of eating dis- of Eating Disorders
orders, certain dysregulations in the brain play
a role in the development and maintenance of Regarding neuromodulation, it is generally
the disorder, which can potentially be posi- assumed that central nervous activity can be
tively influenced by neuromodulation. Overall, altered by specific stimulation and thus con-
however, the empirical basis is still thin, so tribute to changes in a person’s experience and
behavior. An overview of the individual methods
can be found in Fig. 47.1.
K. Schag (*) In eating disorders, it is assumed that various
Department of Psychosomatic Medicine and dysregulations in the brain likely contribute to
Psychotherapy, Medical University Hospital
Tübingen, Tübingen, Germany
the development and/or maintenance of eating
e-mail: [email protected] disorder pathology. It is assumed that patients
https://doi.org/10.1007/978-3-662-67662-2_47
358 K. Schag
neuromodulation
Invasive Non-invasive
procedures procedures
Transcranial Transcranial
Deep brain Vagus nerve
magnetic direct current
stimulation stimulation
stimulation stimulation
Fig. 47.1  Overview of common neuromodulation techniques
with anorexia nervosa (AN) show increased self- studied in mental disorders so far are deep brain
control, i.e., increased prefrontal activity, while stimulation and vagus nerve stimulation as inva-
patients with binge eating disorder (BED) and sive procedures, as well as transcranial magnetic
bulimia nervosa (BN) show reduced self-control stimulation (TMS) and transcranial direct cur-
(Schag et al. 2020; Schaumberg et al. 2017). rent stimulation (tDCS) as non-invasive pro-
Therefore, in various studies on eating disor- cedures (Schag et al. 2020). The decision as to
ders, the prefrontal cortex is specifically stimu- which neuromodulation technique should be
lated, as it is understood as the center of so-called applied depends on the disorder, the location or
cognitive control functions and can be directly size of the target, and the desired effect. Despite
addressed by neuromodulation (Plewnia et al. the possibility of reaching subcortical brain
2015; Schag et al. 2020). areas using invasive techniques, their use in eat-
ing disorders is rather rare due to the invasive
nature and possible side effects such as pain in
47.3 Introduction the surgical area and wound infections (Tracy
to Neuromodulation and David 2015). Therefore, non-invasive neuro-
Methods modulation methods have been primarily used in
studies in patients with eating disorders (Schag
et al. 2020). A more detailed description of non-
 Important Neuromodulation includes vari invasive neuromodulation techniques can be
ous treatment techniques that can spe- found in the infobox.
cifically modulate neuronal activity. To
influence the brain, either a very weak
electrical current or rapidly changing mag- Infobox: Non-invasive Neuromodul
netic fields are used (Jauregui-Lobera and ation Techniques (Schag et al. 2020)
Martinez-Quinones 2018; Schag et al.
2020). Transcranial Magnetic Stimulation
(TMS)
In principle, a distinction is made between inva- Transcranial magnetic stimulation
sive procedures, which require surgery, and (TMS) can alter brain activity by attach-
non-invasive procedures, in which the brain is ing a plastic-coated coil with rapidly
accessed via the skull surface (Schag et al. 2020; changing magnetic fields to the skull
Val-Laillet et al. 2015) (see Fig. 47.1). The surface. Repetitive TMS (rTMS), which
neuromodulation techniques most frequently sends multiple pulses over a short period,
47 Neuromodulation in Eating Disorders 359
47.3.1 Evidence regarding

is intended to support sustained changes the effectivity of Non-invasive
in dysfunctional activation patterns Neuromodulation in Eating
(McClelland et al. 2013). A distinction Disorders
is made between low-frequency (<5 Hz)
and high-frequency (>5 Hz) rTMS. Low- So far, only very few studies in patients with
frequency rTMS inhibits cortical activ- eating disorders have investigated the effectiv-
ity, while high-frequency TMS increases ity of neuromodulation, as neuromodulation
cortical activity. In terms of patient safety, is a very young field of research overall. Most
TMS is considered safe and has few side studies on eating behavior have examined the
effects, although seizures have occurred in influence of eating behavior in healthy or sub-
individual cases (Val-Laillet et al. 2015). clinically conspicuous samples (e.g., Hall et al.
There is strong evidence for the efficacy 2018). The study situation is also very het-
of TMS in treating depression and mod- erogeneous, as very different stimulation tech-
erate evidence for treating hallucinations. niques and protocols have been used in the study
Current studies are investigating, among implementation, e.g., regarding the number of
other things, eating disorders, addiction, sessions, intensity and location of neuromodu-
pain, and self-harming behavior (Tracy lation, and duration of individual modulation
and David 2015). sessions. In patients with eating disorders, non-
Transcranial Direct Current invasive methods have mostly been used, which
Stimulation (tDCS) will be the focus in the following. Surprisingly,
In tDCS, cortical activity is modulated many review articles have been written on the
by a weak direct current (1–2 mA) flowing subject. However, Schag and colleagues (2020)
from an anode electrode to a cathode elec- identified only nine original studies regard-
trode. Activation usually occurs below the ing the effectiveness of non-invasive neuro-
anode, while inhibition of cortical activ- modulation in patients with eating disorders.
ity occurs below the cathode. Different Another study has recently been published (Max
effects can be achieved in specific regions et al. 2020). These ten studies can be categorized
and between hemispheres through vari- according to the disorder profile of the sample,
ous montages (McClelland et al. 2013). the type of stimulation, or the stimulation site.
tDCS is considered a safe procedure. Only The studies are described below based on the
a few mild and short-term side effects, treatment goals pursued. An overview is pro-
such as itching at the electrodes and tem- vided in Table 47.1.
porary headaches, are known (Tracy and
David 2015). tDCS is still less researched 47.3.1.1 Treatment Goal Enhancement
than TMS (McClelland et al. 2013); how- of Self-Control
ever, it offers promising initial treatment As mentioned at the beginning, most studies
results for depression, stroke, and spe- on the effectivity of neuromodulation meth-
cific symptoms of schizophrenia (Tracy ods in patients with eating disorders aim to
and David 2015). Of particular interest in increase self-control abilities, for example, to
tDCS is that stimulation can be combined reduce the desire to eat and ultimately also food
with disorder-specific training tasks, and intake (Schag et al. 2020). This treatment goal
brain regions that are active during task is particularly important for patients with BN
processing can be specifically modulated or BED, i.e., those affected by binge eating. To
(Plewnia et al. 2015). increase self-control abilities, the dorsolateral
prefrontal cortex (DLPFC) was stimulated in all
360 K. Schag
Table 47.1  Studies on the effectiveness of neurostimulation methods in patients with eating disorders, sorted by
treatment goals
Study Diagnosis of Neuromodula- Stimulation site
the sample tion method Main results
Treatment goal: enhancement of self-control
Van den Eynde BN high-frequency left DLPFC Desire to eat and binge eating reduced
et al. (2010) rTMS in rTMS compared to SS
Gay et al. (2016) BN high-frequency left DLPFC No reduction in binge eating and
rTMS vomiting
Guillaume et al. BN high-frequency left DLPFC Impulsivity improved in rTMS condi-
(2018) rTMS tion, no differences compared to SS
Burgess et al. BED tDCS (2 mA) DLPFC (anodal right, Desire to eat and food intake reduced
(2016) cathodal left) in tDCS compared to SS, especially
in men
Kekic et al. BN tDCS (2 mA) DLPFC (anodal left, Desire for binge eating reduced with
(2017)† cathodal right or anodal tDCS compared to SS
right, cathodal left)
Max et al. (2020) BED tDCS (1 mA DLPFC (anodal right) Improvement in inhibitory control and
or 2 mA) reduction of binge eating with 2 mA
tDCS
Treatment goal: reduction of self-control
Van den Eynde AN high-frequency left DLPFC No decrease in desire to eat restricti-
et al. (2013)† rTMS vely or exercise
McClelland et al. AN high-frequency left DLPFC Reduction of AN symptoms with both
(2016) rTMS rTMS and SS, with rTMS tending to
be stronger
Costanzo et al. AN tDCS (1 mA) DLPFC (anodal left, BMI increase in tDCS arm compared
(2018) cathodal right) to family-based therapy
Treatment goal: reduction of eating disorder-related cognitions
Van den Eynde AN high-frequency left DLPFC Feeling of being fat, fullness, and
et al. (2013)† rTMS anxiety were reduced
Kekic et al. BN tDCS (2 mA) DLPFC (anodal left, Eating disorder-related cognitions
(2017)† cathodal right or anodal are reduced with tDCS (anodal right,
right, cathodal left) cathodal left) compared to other
conditions
Mattavelli et al. Various tDCS (1 mA) medial prefrontal cortex With tDCS, especially when stimula-
(2019) eating disor- (anodal), ting the right extrastriate body area,
ders right extrastriate body women with EDs change their attitude
area (anodal) towards food more than healthy women
† Listed twice due to thematically double assignment; DLPFC: dorsolateral prefrontal cortex; SS: sham stimulation
available studies (see Table 47.1). For example, that the stimulation device would be turned off
in the study by van den Eynde and colleagues after a short time. Compared to SS, the desire
(2010), 38 patients with BN were stimulated for food was reduced when evaluating a stand-
with high-frequency rTMS on the left DLPFC. ardized buffet in the stimulation condition, and
A so-called sham stimulation (SS) was used the number of binge eating episodes within the
as a control condition. In SS, patients were next 24 hours also decreased. However, a simi-
told they would be receiving stimulation but lar study with 47 women with BN showed no
reduction in the number of binge eating episodes overregulation of eating behavior to a normal
and vomiting after ten stimulation sessions with level and thus promote weight gain.
rTMS (Gay et al. 2016). In a subgroup analysis For example, Van den Eynde et al. (2013)
of this study by Gay et al. (2016), improvements stimulated ten AN patients with high-frequency
in self-control abilities, so-called inhibitory con- rTMS in a pilot study. However, there was no
trol, were found in the stimulation condition, reduction in the desire for self-control abilities,
although these did not differ significantly from restrictive eating, or exercise. A more recent
SS (Guillaume et al. 2018). The empirical evi- study with a larger sample and a SS as a control
dence for rTMS on the left DLPFC is therefore condition, however, showed that a session with
heterogeneous. high-frequency rTMS at least tended to reduce
Considering the studies using tDCS, a more AN symptoms and also improved performance
consistent picture emerges: A study by Burgess in a decision-making task, which is an indicator
and colleagues (2016) in patients with BED of increased cognitive flexibility (McClelland
investigated the effectivity of tDCS on the et al. 2016). Costanzo and colleagues (2018)
DLPFC, with the anode placed on the right hem- were ultimately able to demonstrate in a current
isphere and the cathode on the left hemisphere. neuromodulation study that regularly performed
The desire for specific foods and the amount of tDCS in adolescents with AN, in addition to
food intake in a sham taste test at a standardized standard treatment, led to a significant increase
buffet decreased compared to the SS condition. in body mass index (BMI) compared to standard
Another study with tDCS in patients with BN treatment with additional family therapy. This is
by Kekic and colleagues (2017) yielded simi- a promising result, which, among other things,
lar results. In the randomized controlled trial, a suggests that the number of stimulation sessions
reduced desire for binge eating and an increase may also play an important role. In this study,
in self-control abilities were also observed. This 18 sessions were conducted, while in the two
effect was independent of whether the left hemi- previously mentioned studies, only one session
sphere was stimulated anodally and the right was conducted. Overall, the studies indicate that
cathodally or vice versa. A recently published neuromodulation methods also have potential in
pilot study with tDCS in patients with BED by the treatment of AN.
Max and colleagues (Max et al. 2020) suggests
that the intensity of the stimulation plays a role: 47.3.1.3 Treatment Goal Reduction
Improvements in self-control abilities seem to of Eating Disorder-Related
occur primarily with 2 mA stimulation, but not Cognitions
with 1 mA. Overall, these studies suggest that Eating disorder-related thoughts and feelings
self-control can be enhanced and the desire for about food, body shape, and weight represent
food reduced through neuromodulation. both a risk factor and a consequence of eating
disorders. Therefore, there are also efforts in
47.3.1.2 Treatment Goal Reduction of this direction to reduce eating disorder-related
Self-Control cognitions by neuromodulation. Two already
Another, so far less comprehensively investi- described studies, in which the DLPFC was
gated approach is the reduction of self-control stimulated, also addressed this issue (Kekic
abilities through neuromodulation methods. et al. 2017; Van den Eynde et al. 2013). Van den
The available studies on this subject focus Eynde and colleagues (2013) found, in their
on the reduction of restrictive eating behav- rTMS study with AN patients, that there was
ior in patients with AN, as this represents the no change in self-control abilities. However, the
main symptom of the patients (Table 47.1). In feeling of being fat, the feeling of fullness, and
these studies, the DLPFC was also targeted the associated anxiety were reduced after rTMS.
to reduce the often-present strictly controlled Kekic and colleagues (2017) also observed an
362 K. Schag
improvement in eating disorder-related cog- However, the current state of research does
nitions in their tDCS study with BN patients. not yet provide a sufficient basis for the imple-
This improvement was only seen with anodal mentation of neuromodulation methods in clini-
stimulation of the right hemisphere and cathodal cal practice. Further studies are needed to clarify
stimulation of the left hemisphere, and not in the which specific type of neuromodulation, with
reverse condition. which specific parameters, can help with which
Another study, by Mattavelli and colleagues eating disorder symptoms. The effect of neuro-
(2019), pursued an interesting approach in modulation on body schema disturbance and
which they attempted to change so-called related body and weight concerns has also been
implicit attitudes, i.e., internalized and uncon- scarcely investigated. A promising approach
scious attitudes, towards food and body image. would be to combine training programs with
In this study, not the DLPFC, but the medial neuromodulation to directly target the prob-
prefrontal cortex or the extrastriate body area lem behavior (Plewnia et al. 2015). Ultimately,
were stimulated compared to a SS in women nothing is known about the sustainability of the
with various eating disorder diagnoses and com- effects found so far. For these points, further
pared to healthy women. In an implicit associa- basic research and randomized controlled tri-
tion test, which checks implicit attitudes, it was als with larger samples and control conditions,
found that after stimulation of the extrastriate as well as standardized treatment protocols, are
body area, patients rated tasty foods more posi- necessary.
tively and their preferences aligned with those of
healthy women. However, body image remained
unaffected by both stimulation conditions. References
Overall, these three studies suggest that neuro-
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Inpatient and Day
Hospital Treatment for 48
Eating Disorders
Almut Zeeck
Contents
48.1 Significance of Inpatient and Day Hospital Treatment . . . . . . . . . . . . . . . . 365
48.3 Bulimia Nervosa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 370
48.5 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
48.1 Significance of Inpatient nervosa (AN), inpatient treatment is most often

and Day Hospital Treatment indicated due to the physical risk and pro-
nounced fear of weight gain, and in some cases,
Eating disorders are often chronic diseases, it may be the primary entry point into a longer-
which require long-term treatment plan- term therapy process (Zeeck 2018).
ning. In general, outpatient treatment meas- There are hardly any studies comparing
ures are sufficient (Herpertz et al. 2019). This treatment settings for patients with compara-
applies especially to the treatment of bulimia ble symptom severity (Herpertz et al. 2019).
nervosa (BN) and binge eating disorder (BED). In addition, the conditions under which eating
However, if outpatient treatment is not sufficient disorders are treated in an inpatient setting vary
due to the severity, chronicity, or complexity greatly. Concepts and treatment duration are
of the symptoms (e.g., in cases of comorbid- determined less by patient characteristics (e.g.,
ity requiring treatment, suicidality, or medical disorder severity) than by organizational, eco-
complications), day hospital or inpatient ther- nomic, and tradition-related conditions of dif-
apy may be necessary. In the case of anorexia ferent countries or hospitals (see, for example,
Kordy 2005; Föcker et al. 2017). There are only
a few studies on inpatient treatment of BN and
BED (Herpertz et al. 2019).
The current situation of inpatient treatment
A. Zeeck (*) is characterized by increasing economic pres-
Department of Psychosomatic Medicine und
Psychotherapy, Center for Mental Health, Faculty of sure, which has led to a shortening of treatment
Medicine, University of Freiburg, Freiburg, Germany durations. However, especially for first-time
e-mail: [email protected] hospitalizations for AN, it should be ensured
https://doi.org/10.1007/978-3-662-67662-2_48
366 A. Zeeck
that patients have sufficient time to reach an important in cases of long-term illness and fre-
adequate weight. This reduces the risk of chro- quent hospital admissions.
nicity and rehospitalizations. Inpatient treat- Special attention should also be paid to the
ment should not be seen as a “last resort” but admission and discharge situations. Prior to
rather also as a treatment option that offers spe- admission, the focus is primarily on clarify-
cific therapeutic opportunities. ing treatment motivation, discussing the frame-
work conditions and, if necessary, a treatment
 Important Eating disorders are often chr agreement, and clarifying the objectives for the
onic diseases. Inpatient treatment phases upcoming treatment phase. Discharge is associ-
may be necessary, especially for anorexia ated with a risk of relapse, so anticipating this
nervosa. is important, including targeted preparation for
the situation outside the hospital. It should be
considered that patients are responsible for all
48.1.1 Overall Treatment Planning meals after discharge and therapeutic support
is reduced from several hours per week to 1–2
The course of an eating disorder usually spans hours. Good arrangements with the psychothera-
several years, during which there may be mul- pist providing continuing treatment and the pri-
tiple therapy episodes (e.g., outpatient, inpa- mary care physician, as well as clear rules for
tient, day hosp). The diversity of problem areas the possibility of readmission, help ensure the
(psychological, familial, medical, social) also continuity of treatment—as does targeted prep-
requires collaboration among various prac- aration for the subsequent outpatient situation
titioners. In clinical practice, the sequence of with practice elements (e.g., regarding grocery
treatment phases and the number of people shopping and meal preparation) and conversa-
involved are often unclear and poorly coordi- tions with primary caregivers for children and
nated. This contrasts with the recommendations adolescents (Herpertz et al. 2019; Herpertz-
of the S3 guideline, which states that the treat- Dahlmann et al. 2015).
ment providers involved (psychotherapists, spe- All involved practitioners should have experi-
cialist physicians, hospitals, outpatient clinics, ence in the therapy of eating disorders.
nutritionists, counseling centers) should ensure
close cooperation and coordination (Herpertz  Important Coordination among the
et al. 2019). involved practitioners and targeted, long-
The term “overall treatment planning” also term therapy planning are necessary
implies that the patient’s previous course of ill- to enable continuous and coordinated
ness should be kept in mind and previous ther- treatment.
apy experiences should be taken into account
when deciding on further action. For example,
for a patient with chronic BN and borderline 48.1.2 Differences Between
personality disorder, a day hospital stay instead Inpatient and Day Hospital
of an inpatient stay may be useful, despite Programs
severe symptoms, if she was able to reduce
her bulimic symptoms well in an inpatient set- The establishment of day hospital programs
ting multiple times but relapsed shortly after for patients with eating disorders is a relatively
discharge. Day hospital treatment may lead to recent development in Germany. Day hospi-
a slower symptom reduction, but one that has tals can take the form of independent units or
been “tested” in everyday situations. Day hopsi- integrated concepts that allow for a gradual
tal treatment would also allow a patient to main- approach: patients are initially admitted as inpa-
tain her social contacts, which is particularly tients and switch to a “patial hospitalization
48 Inpatient and Day Hospital Treatment for Eating Disorders 367
status” some time before discharge (they spend 48.1.3 Goals

evenings and weekends at home). While inpa-
tient therapy involves removal from the every- Physical stabilization A primary goal of inpa-
day life context, day hospital treatment involves tient and day hospital treatment is initially
the daily alternation between intensive treatment physical stabilization, which includes adequate
in the hospital and return to everyday life (Zeeck weight gain for patients with AN and a reduc-
et al. 2020). tion of self-induced vomiting or laxative abuse
When comparing inpatient and day hospital for patients with BN. To achieve this goal,
settings, each has specific advantages and disad- structured work on normalizing eating behavior
vantages. The advantages of inpatient treatment and food composition, as well as accompany-
include the constant availability of people to pro- ing physical monitoring is required. If severe
vide help, the ongoing provision of a daily and comorbid disorders are present, a hierarchy of
mealtime structure, all-day monitoring in case of therapy goals may be necessary—and in individ-
physical endangerment, and distance from poten- ual cases, even a postponement of work on eat-
tially stressful or recovery-hindering relationship ing disorder symptoms (for example, in cases of
contexts at home. The disadvantage of inpatient acute suicidality or severe self-harm).
therapy lies in the artificial situation of the inpa-
tient milieu, which emphasizes caring and protec- Motivation An important prerequisite for treat-
tive aspects. Some patients find it difficult to cope ment and at the same time a goal to be pursued
with the demands of everyday life after a longer is sufficient motivation for a change process.
treatment. Especially for young patients, it should If this is very limited or not present, the treat-
be considered that they are removed from school ment should initially focus on the ambivalence
and their circle of friends for several months, thus of the patients with regard to a change. This can
missing important age-appropriate experiences. take place within the framework of a motiva-
Therapy in a day hospital program empha- tion phase preceding the inpatient therapy or in
sizes independence and personal responsibility. the form of an initial motivation period. Fellow
Patients are challenged to spend and structure patients who already have therapy experience
evenings and weekends outside the hospital, can play an important supportive role here.
which can lead to feelings of overwhelm on
the one hand, but also strengthen the percep- Providing support Weight gain or giving up
tion of having achieved changes on their own. bulimic behavior can be associated with such
Proximity and distance to others are easier to strong fears and feelings of insecurity that an
regulate in a day hospital, which can be par- outpatient setting is not sufficient. In this case,
ticularly beneficial in the treatment of patients inpatient or day hospital treatment has the
with comorbid personality disorders. In the day function of providing a supportive and secure
hospital context, aspects of therapy can be tried framework in which the emerging fears can be
out at home on a daily basis. On the other hand, addressed promptly.
difficulties from everyday situations outside the
hospital continuously flow into the therapy (e.g., Conflict resolution During inpatient or day
difficulties with eating, but also problems with hopsital treatment, an attempt should be made to
family or partner). This can be particularly ther- create the prerequisites for outpatient follow-up
apeutically useful when it comes to preparing psychotherapy treatment. In addition to physi-
for the time after the clinic. The disadvantage cal stabilization and sufficient motivation, this
of day hospital treatment is that patients who includes identifying central psychological prob-
tend to be secretive and hide their difficulties lems and conflicts that play a significant role in
can more easily maintain pathological behaviors the development and maintenance of the dis-
unnoticed. order (e.g., fears of maturation, problems with
368 A. Zeeck
affect regulation, self-esteem conflicts, dysfunc- • medical treatment and, for AN, regular dis-
tional interaction patterns, dysfunctional coping cussion of the weight curve
strategies in the family). • components targeting the psychological dif-
ficulties of patients (disorder-oriented indi-
Structuring daily life after discharge For vidual and group therapy, body therapy,
chronically ill and socially very isolated specialized therapies such as art or music
patients, inpatient or day hospital treatment may therapy)
aim to achieve a higher quality of life by struc- • sessions with family members (especially for
turing the daily routine and rebuilding social children and adolescents)
contacts and activities outside the clinic.
In the design of treatment programs, there is a
trend away from rigid behavior modification
Goals of Inpatient or Day Hospital programs towards more flexible approaches
Treatment for Eating Disorders that take into account the individual develop-
• Physical stabilization ment of each patient. However, the specification
• Normalization of eating behavior (meal of a daily and meal structure and supervision of
structure, meal composition) eating behavior are necessary prerequisites for
• Development of sufficient motivation changing disturbed eating behavior.
• Identification of central psychological Inpatient and day hospital programs for
problem areas eating disorders in Germany have many simi-
• Improvement of concomitant psycho- larities, although a distinction must be made
logical symptoms (e.g., depression, between hospital treatment and rehabilitation.
anxiety, self-harm) Hospital treatment focuses on intensive treat-
• Working on central dysfunctional rela- ment of symptoms, while rehabilitative treat-
tionship patterns ment focuses on restoring the capacity to work
• Support with problems in the social after a longer illness process. The concepts are
environment based on either cognitive-behavioral or psycho-
dynamic orientation. Stand-alone day hospitals
for eating disorders are still rare but are gain-
ing importance. On the other hand, “stepped-
48.1.4 Elements of Inpatient and Day care” approaches, which allow for a gradual
Hospital Treatment reduction in treatment intensity (inpatient—day
clinic—outpatient), have increased significantly.
Inpatient therapy programs are generally mul-
When transitioning from inpatient to day hos-
timodal, allowing for a combination of therapy
pital treatment, the treatment team and patient
elements that cannot be offered simultaneously
group should ideally not have to change. This is
in an outpatient setting. Programs for eating dis-
possible if an inpatient treatment unit has “inte-
orders should include the following elements
grated” places for partial hospitalization(see
(Herpertz et al. 2019):
also Zeeck et al. 2020).
Inpatient or day hospital treatment always
• structured, symptom-oriented components
involves treatment in a group of patients.
(concrete work on eating and, if necessary,
Patients with eating disorders benefit from the
exercise behavior, e.g., using food diaries,
exchange with other affected individuals, and
accompanied eating and cooking [“eating
the therapeutic “milieu” of a hospital also allows
support”]; for AN, the agreement on a target
for important relationship experiences and work
weight and weekly targets for weight gain,
on dysfunctional interaction patterns, which are
regular weighing, graded exercise programs)
not possible in this form in an outpatient setting.
For young patients with AN who still live in 48.2.2 Treatment Agreements
their family of origin, it is essential to involve
the family in the therapy in the form of family Treatment should initially focus strongly on
sessions, unless there are valid reasons against it. improving the symptoms of disordered eating
behavior. Clear agreements between the treat-
48.2 Anorexia Nervosa ment team and patients have proven effective
and are more likely to lead to sufficient weight
48.2.1 Indication gain. They should include a target weight and
arrangements for weekly weight gains and
weighing appointments. Empirical studies sug-
The indication criteria for inpatient therapy for
gest that in AN, achieving the highest possible
AN are shown in Table 48.1. The weight (BMI)
weight (BMI ≥ 18.5 kg/m2; for children 25th
should not be the sole criterion for indication,
BMI age percentile, but at least the 10th BMI
but the overall physical condition, social situa-
age percentile) and resuming/starting menstrua-
tion, history, and severity of mental impairment
tion should be aimed for to reduce the risk of
should also be taken into account. Furthermore,
relapse.
inpatient treatment should not only be consid-
The guidelines recommend weight gain tar-
ered as a last step in cases of severe physical
gets of 500–1500 g per week.
instability, as a more complicated treatment
If patients can experience maintaining the
course and increased risks during weight gain
achieved weight for a certain period of time
can be expected in such a situation.
while still in an inpatient setting (“stabilization
In most cases of AN, an initial inpatient
phase”), this seems to be associated with a lower
treatment phase is preferable to a day hospital
risk of later relapses and rehospitalizations
treatment. The question of differential indica-
(Gross et al. 2000).
tion—i.e., when inpatient therapy is indicated
and when day hospital treatnent is indicated—
has so far been insufficiently investigated empir-
ically. In most cases where outpatient therapy is
48.2.3 Characteristic Difficulties
not sufficient, inpatient therapy initially seems
The inpatient treatment of patients with AN
indicated, providing all-day structure and sup-
leads to characteristic difficulties in the treat-
port—even if only for a few weeks. To prepare
ment teams. Feelings of frustration, worry, pow-
for discharge or to shorten inpatient treatment,
erlessness, and anger may predominate, leading
a subsequent day hospital phase may be use-
to the impulse to control a patient and enforce
ful (see above). Day hospital treatment is rec-
changes. Disagreement within the team about
ommended when patients are not extremely
the most appropriate approach can make con-
underweight (BMI ≥ 15 kg/m2 or > 3rd BMI
structive work more difficult. In this context, the
age percentile), show good motivation, or when
framework of a therapy agreement can provide
it is possible for children and adolescents to
orientation and relief. Characteristic are regular
continue therapy with the same treatment team
disputes with patients about eating and weight
after a short inpatient stabilization phase and to
gain. Regular exchange within the team and
involve parents intensively (Herpertz-Dahlmann
supervision are helpful in ensuring a construc-
et al. 2014). Chronically ill patients, for whom
tive treatment process.
the focus is less on weight gain and more on
Patients with AN tend to manipulate their
improving social integration and quality of life,
weight (drinking fluids, etc.) and to undermine
can also benefit from a day hospital episode that
treatment in order to maintain a sense of control
continuously incorporates their everyday life
into therapy.
370 A. Zeeck
and autonomy. This behavior should ideally not 48.3 Bulimia Nervosa
lead to the termination of treatment, but should
be examined with the patient in terms of its 48.3.1 Indication
function. The therapeutic stance should be clear
and consistent with regard to therapy goals and Most patients with BN can be treated on an out-
overall rules of conduct, but also empathetic and patient basis. However, more intensive therapy
flexible. may be appropriate under certain conditions (see
Due to the ambivalence of patients regard- Table 48.1). Individual studies have shown the
ing treatment, there is a risk of premature treat- effectiveness of day hospital treatment. A smaller
ment terminations and relapses after discharge. randomized controlled trial comparing inpatient
Factors associated with an increased risk of with day hospital treatment showed that both
dropout include the binge-eating/purging sub- settings were equally effective in the short term.
type of AN, a pronounced fear of growing up, However, patients with BN may benefit more in
more severe psychopathology, a personality the long term from a day clinic setting, which
disorder, greater weight concerns, and a low better prepares them for the time after discharge
desired weight (Herpertz et al. 2019). Patients due to the daily “practice situation” (Zeeck et al.
admitted with a BMI < 13 kg/m2 have a particu- 2009).
larly high risk of chronicity and increased mor-
tality rates. Even among patients who achieved
remission during inpatient treatment, relapse 48.3.2 Treatment Agreements
rates of approximately 40% are found in the first
year after discharge. Here too, the binge-eating/ Similar to the treatment of AN, it has
purging subtype has a higher risk (Carter et al. proven effective to combine structured
2012).
Table 48.1  Indication criteria (see AWMF-S3 guideline; Herpertz et al. 2019)

Anorexia nervosa—inpatient treatment Bulimia nervosa—(partial) inpatient treatment
• Rapid or persistent weight loss (>20% over 6 months) • I nsufficient effectiveness or lack of possibility
• Severe underweight (BMI < 15 kg/m2, in children and adole- for outpatient psychotherapy
scents below the 3rd age percentile) •S evere mental comorbidity (e.g., suicidality,
•P ersistent weight loss or a stagnant (under)weight for 3 months severe self-harm, poorly controlled diabetes
despite outpatient or day clinic therapy (in children and adole- mellitus, drug or alcohol dependence)
scents, even earlier) • A strong physical endangerment, eating dis-
•S ocial or familial factors that strongly hinder the recovery pro- order-related complications of pregnancy, or
cess (social isolation, problematic family situation, in children other severe medical complications
and adolescents also: insufficient social support) •M assive laxative or diuretic abuse
•S evere mental comorbidity/suicidality •S evere, uncontrolled bulimic symptoms that
• Insufficient outpatient treatment options require closely structured guidelines for
•S evere bulimic symptoms, massive laxative or diuretic abuse, or change
excessive exercise that cannot be controlled on an outpatient basis •C ircumstances in the patient´s environment
• Physical endangerment or medical complications that hinder a successful psychotherapeutic
• Especially in children and adolescents: low illness insight process
•O verwhelmed in the outpatient setting, if it provides too few
structured guidelines (meal structure, amount of food, feedback
on eating behavior); in children and adolescents: breakdown of
family resources
symptom-oriented elements with elements • Inpatient treatment phases are primarily

that address patients’ psychological difficulties needed for anorexia nervosa.
(self-esteem issues, perfectionism, difficulties • For bulimia nervosa and binge eating dis-
in affect regulation, interpersonal problems). order, specialized day hospital or inpatient
Patients with BN also have a negative body treatment is only required for severe eating
experience and a pronounced fear of weight disorder pathology and comorbidity, or if
gain, especially when normalizing their eating outpatient therapy did not lead to sufficient
behavior and giving up compensatory behaviors symptom reduction.
such as vomiting and laxative abuse. A support- • Day hospital and inpatient treatment pro-
ive body therapy offer is therefore useful. As grams for patients with eating disorders
part of a multimodal treatment, it is also indi- should include both structured, symptom-
cated to identify social difficulties (isolation, oriented treatment elements and those that
indebtedness, difficulties in professional and address further psychological difficulties of
educational situations) and to offer appropriate the patients.
support to patients.
48.4 Binge Eating Disorder References

Carter JC, Kimberley B, Mercer-Lynn KB, Norwood
48.4.1 Indication SJ, Bewell-Weiss CV, Crosby RD, Woodside DB,
Olmsted MP (2012) A prospectice study of predic-
In the case of BED, clinical treatment is rarely tors of relapse in anorexia nervosa: implications for
relapse prevention. Psychiatry Res 200:518–523
indicated. Exceptions are patients with comor- Föcker M, Heidemann-Eggert E, Antony G, Becker K,
bidity requiring treatment, in which a combi- Egberts K, Ehrlich S, Fleischhaker C, Hahn F, Jaite
nation of different therapy options is necessary C, Kaess M, Schulze UME, Sinzig J, Wagner C,
(individual and group therapy, body therapy, Legenbauer T, Renner T, Wessing I, Herpertz-Dahlmann
B, Hebebrand J, Bühren K (2017) The inpatient treat-
medical care) or the symptomatology with binge ment of patients with anorexia nervosa in German clin-
eating is so severe that external control and ics. Z Kinder Jugendpsychiatr Psychother 45(5):381–390
structuring are required. Gross G, Russell JD, Beumont PJ, Touyz SW, Roach P,
Aslani A, Hansen RD, Allen BJ (2000) Longitudinal
study of patients with anorexia nervosa 6 to 10 years
after treatment: impact of adequate weight restoration
48.4.2 Goals on outcome. Ann N Y Acad Sci 904:614–616
In the case of BED, the objective of a day hos- A, Tuschen-Caffier B, Vocks S, Zeeck A (2019)
S3-Leitinie Diagnostik und Behandlung der
pital or inpatient treatment is to reduce psycho- Essstörungen. Springer, Berlin
logical impairment, normalize eating behavior, Herpertz-Dahlmann B, Schwarte R, Krei M, Egberts K,
identify central problem areas (and thus the Warnke A, Wewetzer C et al (2014) Day-patient treat-
function of the eating disorder), and address ment after short inpatient care versus continued inpa-
tient treatment in adolescents with anorexia nervosa
social difficulties. In addition, the goal is a slow (ANDI): a multicentre, randomised, open-label, non-
but continuous weight reduction. Planning for inferiority trial. Lancet 383:1222–1229
outpatient follow-up treatment is of great impor- Herpertz-Dahlmann B, van Elburg A, Castro-Fornieles J,
tance to ensure long-term stabilization. Schmidt U (2015) ESCAP Expert Paper: new devel-
opments in the diagnosis and treatment of adolescent
anorexia nervosa- a European perspective. Eur Child
Adolesc Psychiatry 24(10):1153–1167
48.5 Conclusion Kordy H (2005) Counting the COST: a European collab-
oration on the efficiency of psychotherapeutic treat-
ment of patients with eating disorders. Eur Eat Disord
• Patients with eating disorders should be Rev 13(3):153–158
treated in clinics that offer specialized pro- Zeeck A (2018) Anorexia nervosa: Diagnostik und
grams for eating disorders. Behandlung. PSYCH up2date 12(1):59–73
372 A. Zeeck
Zeeck A, Weber S, Sandholz A, Wetzler-Burmeister Zeeck A, Lau I, Flösser K (2020) CME Fortbildung:
E, Wirsching M, Scheidt CE, Hartmann A (2009) Behandlung in psychosomatisch-psychotherapeutis
Inpatient versus day treatment for Bulimia ner- chen Tageskliniken. Psychotherapeut 65:211–222
vosa: results of a one-year follow-up. Psychother
Psychosom 78:317–319
Self-Help in Eating
Disorders 49
Cornelia Thiels and Martina de Zwaan
Contents
49.1 Why Self-Help? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373
49.2 What is Self-Help? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374
49.3 Self-Help Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374
49.4 For Whom Is Self-Help Suitable? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375
49.6 Bulimia Nervosa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377
49.1 Why Self-Help? disorders has been advocated in recent years,

not least for economic reasons. The first step
Self-treatment approaches have been discussed consists of “low-threshold” therapy approaches.
for some time as an alternative to existing psy- In the literature, terms such as self-help (SH),
chotherapeutic and pharmacological treat- self-treatment, self-change, or bibliotherapy are
ment approaches, including in the context of used. In the revised S3 guideline (AWMF 2018),
“stepped-care models” (Mitchell et al. 2011; “self-management” is used instead of self-help,
Ramklint et al. 2012). The majority are based as the studies included in the meta-analyses are
on therapy manuals that contain essential ele- approaches based on structured evaluated pro-
ments of CBT approaches. In therapy research, a grams and thus differ from traditional self-help
stepped-care approach to the treatment of mental groups. Self-help manuals have been developed
that follow the guidelines of cognitive-behav-
ioral therapy approaches (CBT approaches)
C. Thiels (*) and can be carried out independently by those
University of Applied Sciences Bielefeld, Bielefeld, affected with minimal therapeutic guidance
Germany (guided, GSH) or without (pure, PSH). Such
e-mail: [email protected] self-management programs for patients with eat-
M. de Zwaan ing disorders are available in online and offline
Department of Psychosomatic Medicine and versions and range from pure self-help using
Hannover, Germany a book (bibliotherapy), an app, or a computer
e-mail: [email protected] program to programs with occasional therapist
https://doi.org/10.1007/978-3-662-67662-2_49
374 C. Thiels and M. de Zwaan
contact and guided self-help programs. In addi-

tion to personal contact, these therapist contacts Disadvantages of Self-Help
can take place in an audio and video chat pro- • Motivation problems
gram or in writing in a chat or by email, with the • High rejection rates
latter allowing asynchronous communication. • High dropout rates
The supportive brief contacts take less time than • Adherence not optimal
psychotherapy sessions, and their content is not • Minimal therapeutic support
psychotherapeutic in the strict sense. • Overwhelmed patient, feeling left alone
The number of people with eating disorders far • Self-efficacy decreases due to lack of
exceeds the number of available therapy places. success
SH can be used to shorten the wait for special- • Appropriate responses in crisis situations
ized treatment. The majority of those affected by (e.g., suicidality) only possible to a lim-
bulimia nervosa (BN) and binge eating disorder ited extent
(BED) do not seek professional help but could be • No funding in standard care
reached through SH offers. Another advantage of
SH is its availability at any time and in (almost)
any place, depending on the SH materials
(Beintner and Jacobi 2017). Patients who do not 49.2 What is Self-Help?
speak the local language well can use SH materi-
als in other languages. It is also worth examining Self-help can be pure (PSH) or guided (GSH).
whether SH might be suitable for replacing spe- PSH is independent of additional appointments
cific and expensive psychotherapeutic treatments. with professional or lay helpers (coach), as
Possible advantages and disadvantages of offered in GSH.
self-help approaches are presented below (Yim In the following, the focus is not on SH
and Schmidt 2019). groups and internet portals that only provide
information about eating disorders and the
opportunity for affected individuals to exchange
Advantages of Self-Help with one another, but on SH treatments that are
• Therapy without waiting time, possibly based on a clear disorder and treatment model.
bridging treatment during waiting time This is offered in the form of books, videos,
• Optimization of treatment access for CD-ROMs, or via the internet. Affected indi-
patients who are underserved for vari- viduals receive information about their illness
ous reasons (e.g., due to local condi- and are taught specific skills for solving and
tions, lack of therapy places, etc.) dealing with health problems. Participants in SH
• Constant quality of self-help programs treatments follow the advice in the SH material,
that can be easily copied or disseminated carry out tasks, and evaluate the success of their
• High acceptance among many patients, efforts.
respects privacy, less threatening (e.g.,
shame)
• Reduced stigmatization 49.3 Self-Help Guide
• Cost-effective (Lynch et al. 2010)
• Usage independent of time and place The self-help (SH) guide typically includes:
(patients can work on material at a con-
venient learning time and pace) • explanations of the SH material,
• Materials can be processed repeatedly • answering questions,
• Self-efficacy is increased • promoting motivation,
• Guidance by non-specialists possible • support and adaptation of the SH program to
individual needs.
49 Self-Help in Eating Disorders 375
Furthermore, there is the possibility for perspective for crisis situations, combined with
the question of whom the patient can turn to if
• diagnosis, she cannot continue with SH or if questions
• ongoing risk assessment, arise.
• if necessary, referral to other, usually more So far, it is not known whether PSH as a
intensive treatments. first therapy step can also have negative conse-
quences, such as discouragement in the absence
Not only has personal guidance in SH proven of improvement. However, if the indication for
effective, but also guidance via telephone or SH is made as support during an unavoidable
email. Worksheets can be helpful in providing waiting period for GSH or conventional psycho-
guidance. It may be sufficient to involve rela- therapy, this risk is probably lower than if SH
tively inexperienced individuals in the treatment is offered as the sole treatment. Other patients
of eating disorders for guidance, as long as they experienced GSH as an opportunity to more eas-
are trained, provided with training and self- ily find their way into more intensive treatment.
evaluation materials, and closely supervised. GSH can help shorten and/or focus conventional
It has been shown that this “train-the-trainer” psychotherapy more on comorbid disorders such
implementation strategy can be successful in as depression. The chance that patients with BN
the therapy of recurrent binge eating (Zandberg or BED will participate in GSH decreases with
and Wilson 2013). There is evidence of an asso- increasing waiting time. In a Swedish study,
ciation between the quality of the relationship the dropout rate was significantly reduced after
between the trained coaches and the patients and reducing the waiting time.
the success of GSH. Patients generally report
positive experiences with their coaches and feel  Important For those with high treatment
supported by their respect, interest, flexibility, motivation and rather mild symptoms,
and responsiveness to their needs. GSH may be sufficient.
49.4 For Whom Is Self-Help 49.5 Anorexia Nervosa

Suitable?
SH for patients with AN has been scarcely inves-
The more motivated and ready for change the tigated (Zeeck et al. 2018). In a German study,
patient, the milder the eating disorder, the less an SH manual, combined with weekly telephone
comorbidity (including personality disorders), and guidance over a period of six weeks while wait-
the more supportive the social environment, the ing for an inpatient therapy place, was well
less therapeutic attention is likely to be required. accepted by many patients with the binge-eating/
However, even multi-impulsive bulimic patients purging subtype of AN. The duration of the sub-
can benefit significantly from GSH, although sequent hospital stay was significantly shortened
they seem to fare worse compared to non-multi- compared to control subjects without an SH
impulsive and less depressed control subjects. manual (Fichter et al. 2008). However, GSH is
Other studies were unable to confirm that different probably not sufficient as the sole or only ther-
degrees of depression influence the success of PSH apy for patients with AN, also due to the existing
or GSH. Realistic expectations, sufficient time for risk of medical complications.
working through self-help materials, and personal
appointments with the coach have been shown to
be prognostically favorable (Jones et al. 2012). 49.6 Bulimia Nervosa
A prerequisite for the indication of SH is the
examination of whether the patient has previous The effectiveness of SH manuals has so far
experience with SH treatments and how suc- only been empirically verified in isolated cases,
cessful they were. It is important to discuss a such as the manuals by Schmidt et al. (2016)
376 C. Thiels and M. de Zwaan
and Fairburn (2004), which are also avail- in book form), in which information on BED
able in German. The German S3 guidelines for and the individual therapeutic steps for over-
the diagnosis and therapy of eating disorders coming binge eating are manualized. It should
(AWMF 2018) highlighted the effects of self- be noted that the self-help interventions included
help methods, although they are less pronounced in the analysis are based on scientifically tested
compared to classical psychotherapeutic meth- psychotherapeutic treatment measures and have
ods. At the end of the self-help treatment, an been professionally transferred to this treatment
average of 17% of patients were symptom- format.
free, with respect to binge eating and vomiting.
In comparison to conventional individual and  Important For structured, manualized
group therapy, symptom reduction occurs more self-help, particularly with treatment ele-
slowly, sometimes even only during the follow- ments of CBT, there is evidence of effi-
up period. The question of whether non-psycho- cacy, so it should be recommended for
therapists, such as general practitioners, can lead patients with BED. However, compared
GSH is controversial, and further studies are to psychotherapy, structured, manualized
needed to make valid statements. Qualitatively self-help is less effective (de Zwaan et al.
and quantitatively adequate guidance, i.e., good 2017).
training or supervision, improves the success of
therapy.
49.8 Conclusion and Outlook
 Important For some patients with BN,
participation in an evidence-based self- A classical psychotherapy, usually in individual
management program can be recom- therapy and less often in group therapy settings,
mended, which is carried out under is not reliably available. The current state of
therapeutic guidance (“guided self-help”) research indicates a superiority of self-help (SH)
and is based on elements of cognitive over waiting groups in terms of eating disorder
behavioral therapy (Svaldi et al. 2019). symptoms and other psychological symptoms.
Especially guided self-help (GSH) can be a sen-
sible first therapy option for bulimia nervosa
49.7 Binge Eating Disorder (BN) and binge eating disorder (BED) (Traviss-
Turner et al. 2017). If necessary, a more inten-
In a recent meta-analysis (Hilbert et al. 2019) sive conventional psychotherapy can follow.
on the efficacy of structured, manualized self- Self-help offers can contribute to the treat-
help, 15 study conditions with 453 participants ment of eating disorders, both as a standalone
were included, of which eight were guided treatment option and as part of an overall treat-
structured self-help treatments, and seven were ment plan. In some cases, the efficacy of manu-
unguided but structured self-help treatments. alized self-help programs may be comparable
In five treatment conditions, group treatments to that of conventional treatment options. The
were conducted, and in ten conditions, indi- indication for self-management must be indi-
vidual treatments were carried out. The major- vidually assessed for each patient. If the effect
ity of the structured self-help programs were is not achieved, more intensive treatment options
cognitive-behavioral therapy-oriented (seven of should be offered early on. Adherence and treat-
eight guided and five of seven unguided treatment progress should therefore be regularly
ments). In terms of study quality, the self-help monitored.
studies predominantly showed a low or unclear For mental disorders such as anorexia ner-
risk of bias. The content of structured self-help vosa (AN) and bulimia nervosa (BN), which
largely corresponded to that of CBT. Patients predominantly affect young people, books are
usually receive appropriate work materials (e.g., increasingly being replaced by electronic media.
49 Self-Help in Eating Disorders 377
Therefore, the use of these new media is also Cost-effectiveness of guided self-help treatment
suitable for psychotherapeutic purposes, and for recurrent binge eating. J Consult Clin Psychol
78:322–333
they are increasingly being used in the context Mitchell JE, Agras S, Crow S, Halmi K, Fairburn CG,
of SH treatments. The use of modern media in Bryson S, Kraemer H (2011) Stepped care and cog-
the treatment of eating disorders is reported in nitive-behavioural therapy for bulimia nervosa: ran-
Chapter 50. domised trial. Brit J Psychiatry 198:391–397
Ramklint M, Jeansson M, Holmgren S, Ghaderi A (2012)
Guided self-help as the first step for bulimic symp-
 Important Even if it is not certain whether toms: implementation of a stepped-care model within
GSH is sufficient as a treatment, it is at specialized psychiatry. Int J Eat Disord 45:70–78
least suitable as a first treatment option Schmidt U, Treasure J, Alexander J (2016) Die Bulimie
besiegen. Ein Selbsthilfe-Programm. Beltz, Weinheim
that can be supplemented if necessary. Svaldi J, Schmitz F, Baur J, Hartmann AS, Legenbauer T,
This can provide more people with access Thaler C, von Wietersheim J, de Zwaan M, Tuschen-
to evidence-based treatments. Caffier B (2019) Efficacy of psychotherapies and
pharmacotherapies for bulimia nervosa. Psychol Med
49(6):898–910
Traviss-Turner GD, West RM, Hill AJ (2017) Guided
References self-help for eating disorders: a systematic review and
metaregression. Eur Eat Disord Rev 25:148–164
AWMF-Leitlinie (2018) Diagnostik und Therapie der Yim SH, Schmidt U (2019) Experiences of computer-
Essstörungen. Register-Nr. 051/026 Klasse p 3 based and conventional self-help interventions for
Beintner I, Jacobi C (2017) Selbsthilfe in der eating disorders: a systematic review and meta-
Behandlung von Essstörungen. Psychotherapeut synthesis of qualitative research. Int J Eat Disord
62:183–193 52:1108–1124
Fairburn CG (2004) Ess-Attacken stoppen: Ein Zandberg LJ, Wilson GT (2013) Train-the-trainer: imple-
Selbsthilfeprogramm. Huber, Bern mentation of cognitive behavioural guided self-help
Fichter M, Cebulla M, Quadflieg N, Naab S (2008) for recurrent binge eating in a naturalistic setting. Eur
Guided self-help for binge eating/purging anorexia Eat Disord Rev 21:230–237
nervosa before inpatient treatment. Psychother Res Zeeck A, Herpertz-Dahlmann B, Friederich HC,
18(5):594–603 Brockmeyer T, Resmark G, Hagenah U, Ehrlich
Hilbert A, Petroff D, Herpertz S, Pietrowsky R, Tuschen- S, Cuntz U, Zipfel S, Hartmann A (2018)
Caffier B, Vocks S, Schmidt R (2019) Meta-analysis Psychotherapeutic treatment for anorexia nervosa: a
of the efficacy of psychological and medical treat- systematic review and network meta-analysis. Front
ments for binge-eating disorder. J Consult Clin Psychiatry 9:158
Psychol 87(1):91–105 de Zwaan M, Herpertz S, Zipfel S, Svaldi J, Friederich
Jones C, Bryant-Waugh R, Turner HM, Gamble C, HC, Schmidt F, Mayr A, Lam T, Schade-Brittinger C,
Melhuish L, Jenkins PE (2012) Who benefits most Hilbert A (2017) Effect of internet-based guided self-
from guided self-help for binge eating? An investiga- help vs individual face-to-face treatment on full or
tion into the clinical features of completers and non- subsyndromal binge eating disorder in overweight or
completers. Eat Behav 13:146–149 obese patients: the INTERBED randomized clinical
Lynch FL, Striegel-Moore RH, Dickerson JF, Perrin trial. JAMA Psychiatry 74(10):987–995
N, Debar L, Wilson GT, Kraemer HC (2010)
Use of Modern
Media in Prevention 50
and Treatment
Stephanie Bauer
Contents
50.1 Forms of Digital Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 379
50.2 Areas of Application for Digital Interventions . . . . . . . . . . . . . . . . . . . . . . . 380
50.3 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 382
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383
50.1 Forms of Digital Interventions in the intensity of contact between participants

and providers. Programs range from pure infor-
In recent years, there has been an increase in mation offers and fully automated and unguided
proposals for the use of information and com- interventions, which participants work through
munication technologies (“E-mental health”) in without any contact with a counselor or thera-
the prevention and treatment of eating disorders. pist, to interventions that provide therapeutic
These technology-supported interventions are contact via video conferencing and are compa-
expected to improve the reach, accessibility, and rable in therapy dose to conventional treatments.
availability of support services. Furthermore, Another distinguishing feature is the extent
it is assumed that programs that provide low- to which technology-supported interventions
threshold access to information and support via enable individualized, i.e., participant-tailored
the internet are less susceptible to barriers such support. While some programs are completed in
as uncertainty, shame, and stigmatization, which the same form by all participants, others involve
can hinder the use of professional help, com- an exchange between participants and/or regular
pared to conventional (face-to-face) offers. feedback from a therapist or counselor, enabling
Available programs vary significantly in a more individualized program use. Monitoring
terms of the underlying concepts and the tech- systems can contribute to flexibility and indi-
nology used. There are considerable differences vidualization to a particular extent, provided
that the collected progress information (e.g., on
symptoms and behaviors) is used to adapt the
intervention over the course of participation.
The majority of interventions presented
S. Bauer (*)
so far are based on behavioral therapy con-
Center for Psychotherapy Research, University
Hospital Heidelberg, Heidelberg, Germany cepts and manuals. The structured programs
e-mail: [email protected] are worked through session by session by the
https://doi.org/10.1007/978-3-662-67662-2_50
380 S. Bauer
participants independently or with accompany- However, so far, there are only a few empirical
ing professional guidance. Table 50.1 provides findings on the potential of such “blended care”
an overview of some modules that are frequently approaches to improve the treatment of eating
integrated into E-Mental-Health interventions to disorders.
promote exchange between participants and ena-
ble individualized support.
In addition to the aforementioned aspects, 50.2 Areas of Application
from a supply perspective, it is particularly for Digital Interventions
important whether and, if applicable, how a digi-
tal intervention is combined with conventional 50.2.1 Prevention and Early
prevention, counseling, and therapy services. Intervention
While technology-based interventions are often
used independently of conventional care (i.e., In the field of prevention, the use of internet-
“stand-alone”), combined approaches involve based interventions is advantageous, as large
parallel use (“blended Ccre”) or sequential use target populations can be reached from a central
(“stepped care”) of the two settings. So-called location with relatively little effort. This can be
“blended care” approaches can aim to improve achieved, in particular, through a combination of
the effectiveness of conventional therapeutic automated components (e.g., psychoeducational
measures by using a digital intervention as an materials, exercises, screening and monitoring
add-on treatment, thereby optimizing therapy. procedures) on the one hand and personalized
Alternatively, an increase in efficiency can be components (e.g., moderated discussion forums,
sought by offering certain therapy content digi- therapist-led chat groups) on the other hand.
tally, for example, and thus reducing therapy Promising empirical findings, with small
time in the face-to-face setting and associated to medium effect sizes, have been reported
costs without compromising therapy outcomes.
Table 50.1  Examples of E-mental health modules

Module Communication and Interaction Possible Functions within Technology-Supported
Interventions
Discussion forums Asynchronous communication, i.e., • Exchange between participants
requests and comments (“posts”) are • Active engagement with specific discussion topics
expressed with a time delay. • Peer-to-peer support
• Questions answered by moderators or therapists
Chat Synchronous communication, i.e., Group chat:
communication partners are simulta- • Peer-to-peer support
neously in a chat room and exchange • Professional support and advice in a group setting (by
information in real time. counselors or therapists)
Individual chat:
• Professional support and advice in an individual set-
ting (by counselors or therapists)
Self-monitoring Participants are regularly (e.g., daily • Self-observation and self-management
or weekly) prompted to report rele- • Automatically informs counselor or therapist about
vant factors. The query is automated the condition and course of the recorded parameters
(e.g., via smartphone) using a short
questionnaire.
Supportive self- Participants receive supportive • Self-observation and self-management
monitoring feedback tailored to their entries in • Continuous low-intensity support
self-monitoring • Informs counselor or therapist about the condition
and course of the recorded parameters
50 Use of Modern Media in Prevention and Treatment 381
regarding the efficacy of behavioral therapy make an important contribution in this regard.
interventions (e.g., for the program “Student The majority of interventions presented so far
Bodies”) and dissonance-based approaches, as consist of a combination of structured self-help
well as programs aimed at improving media lit- materials based on behavioral therapy concepts
eracy (for an overview, see Wade and Wilksch and professional support from a therapist, coun-
2018). The majority of interventions can be selor, or coach. This person accompanies the
categorized as indicated prevention and target participation, regularly provides feedback on
young women at increased risk of developing progress and homework, answers questions, etc.
an eating disorder. In contrast, other approaches, In the literature, these digital interventions are
such as the “ProYouth” program, aim to address often referred to as “iCBT” programs. The time
broader target groups and tailor the intervention expenditure associated with these usually stand-
to the participants’ needs. For example, partici- alone solutions, on the part of the provider and
pants who report risk factors or initial symptoms therapist, varies depending on the program, but
of an eating disorder in a self-test at the begin- is generally significantly lower than that of con-
ning of the program are specifically recom- ventional psychotherapy. Recent studies have
mended more intensive support and counseling demonstrated the potential of various guided
modules than those who do not report such fac- internet and smartphone-based self-management
tors or symptoms. Likewise, the intervention can programs for reducing eating disorder-related
be flexibly adapted during the course of the pro- impairment compared to untreated control
gram, depending on the participants' individual groups (e.g., Hildebrandt et al. 2020; Linardon
development. This promises, among other things, et al. 2020; Wagner et al. 2016). Only two stud-
advantages regarding the transition from preven- ies, however, have addressed the question of
tion to early intervention, as participants who whether digital interventions are comparable
report manifest symptoms of an eating disorder in efficacy to conventional psychotherapeutic
can receive more intensive online support in a offers for individuals with eating disorders: In
timely manner and, if necessary, be referred to Germany, de Zwaan et al. (2017) compared the
routine care early on (Kindermann et al. 2017). efficacy of therapist-guided iCBT with outpa-
In addition to the question of efficacy, the tient psychotherapy (CBT) for individuals with
implementation and dissemination of internet- BED, and in the USA, Zerwas et al. (2017) com-
based prevention programs have proven to be pared a CBT-oriented group therapy for BN in
major challenges, such that current research is an internet chat with the conventional imple-
increasingly concerned with the question of how mentation of group therapy in a face-to-face set-
to best reach and motivate the target group to ting. In both studies, the conventional therapy
participate, as well as with the impact of differ- was superior at the end of treatment, but not at
ent recruitment methods on willingness to par- follow-up. Due to the faster improvement,
ticipate and program utilization (Moessner et al. face-to-face therapy should therefore remain
2016; Vollert et al. 2020). the method of choice. If this is not available or
accessible to those affected, digital interventions
can obviously be considered as a—slower-act-
50.2.2 Self-help and Treatment ing—therapy option for BN and BED.
One difficulty in providing care for individu-

als with eating disorders is that only a com- 50.2.3 Aftercare and Relapse
paratively small proportion seek professional Prevention
help. In order to expand the reach of evi-
dence-based interventions, the use of guided Particularly in the first months after the end of
self-management offers for BN and BED is treatment, there is a significant risk of relapse,
recommended. Internet-based approaches can but aftercare or maintenance therapy often
382 S. Bauer
cannot be implemented promptly in every- predominantly from relatively small projects,

day care. Digital interventions can improve the and comparatively few multicenter randomized
continuity of care at this point by, for example, controlled trials have confirmed the evidence on
being offered immediately after inpatient treat- digital interventions for the treatment of eating
ment and thus supporting patients in the transi- disorders (Ahmadiankalati et al. 2020).
tion from hospital stay to everyday life. Research projects should address a number of
Various technology-supported approaches other aspects in addition to the question of the
have been evaluated in the field of aftercare and efficacy of technology-supported interventions.
relapse prevention. In this context, a mobile These include, above all, care-related questions
minimal intervention based on the principle of regarding their reach (e.g., can a larger number
supportive monitoring and SMS proved to be of affected individuals be reached through digi-
effective in the post-inpatient care of patients tal offerings? Are these offerings used by peo-
with BN (Bauer et al. 2012). The internet-based ple who would otherwise not have access to or
program“EDINA” contains additional mod- seek care?) and their interaction with routine
ules (e.g., therapist-led group chat, moderated care (e.g., how can we reach those affected as
forum) beyond this monitoring to enable more early as possible and facilitate access to regular
intensive support for those affected (Gulec et al. care?). In addition, questions regarding differ-
2014). The CBT-based program “In@” also ential effectiveness need to be clarified (e.g.,
allows online aftercare for BN through struc- who benefits [or does not benefit] from these
tured sessions, exchange in a discussion forum, offerings?) as well as the necessary and suffi-
and email/chat contacts with an online advi- cient use of therapeutic resources (e.g., what
sor. However, the efficacy of the intervention qualifications are required on the part of the pro-
compared to a control group could not be con- vider? How intensive must the technology-medi-
firmed in a large-scale evaluation study (Jacobi ated contact be?).
et al. 2017). In the area of AN aftercare, on the In conclusion, it should be pointed out that
other hand, significant effects were shown for appropriate offerings should always be designed
the behavior therapy-oriented relapse prevention depending on the care context, or their develop-
program “VIA”, which, in addition to manual- ment should respond to specific challenges in
ized sessions, also contains interactive compo- the respective health system. For example, the
nents such as forums and therapist-led chat aforementioned post-inpatient offerings have
groups (Fichter et al. 2012). Promising results particular relevance for the German system,
were also reported for the use of a smartphone where inpatient treatments are more common
app (“Recovery Record”) in the context of post- than in many other countries and the inadequate
inpatient support for patients with AN. However, continuity of care following hospitalization due
evidence of efficacy is still pending (Neumayr to the traditional separation of inpatient and out-
et al. 2019). patient sectors represents a specific challenge.
Parallel to the increasing use of media in
most areas of everyday life, digital interventions
50.3 Conclusion or intervention components will undoubtedly
increasingly find their way into psychosocial
Research on digital interventions in the field and psychotherapeutic care. A crucial prereq-
of prevention and treatment of eating disor- uisite for this was created in Germany in 2020
ders is a comparatively young, albeit rapidly with the Digital Care Act (DVG). The DVG
growing field. Several reviews conclude that allows doctors and psychotherapists to prescribe
the results obtained so far are promising and certain digital health applications (DiGAs) to
clearly indicate the potential of such interven- their patients, for which evidence of benefit has
tions to improve the care of affected individuals. been provided. It is still unclear whether and
However, it should be noted that the findings are how this option will influence care in the field of
50 Use of Modern Media in Prevention and Treatment 383
eating disorders in the long term, but it is impor- Internet-based prevention and early intervention pro-
tant to scientifically accompany this develop- gram. Int J Eat Disord 50:1215–1221
Linardon J, Shatte A, Rosato J, Fuller-Tyszkiewicz
ment in order to make the best possible use of M (2020) Efficacy of a transdiagnostic cognitive-
the potential of such offerings for the benefit of behavioral intervention for eating disorder psycho-
those affected. pathology delivered through a smartphone app: a
randomized controlled trial. Psychol Med:1–12.
https://pubmed.ncbi.nlm.nih.gov/32972467/
Moessner M, Minarik C, Ozer F, Bauer S (2016)
References Effectiveness and cost-effectiveness of school-based
dissemination strategies of an internet-based program
Ahmadiankalati M, Steins-Loeber S, Paslakis G (2020) for the prevention and early intervention in eating
Review of randomized controlled trials using e-health disorders: a randomized trial. Prev Sci 17:306–313
interventions for patients with eating disorders. Front Neumayr C, Voderholzer U, Tregarthen J, Schlegl S
Psychiatry 11:568 (2019) Improving aftercare with technology for
Bauer S, Okon E, Meermann R, Kordy, H (2012) anorexia nervosa after intensive inpatient treat-
Technology-enhanced maintenance of treatment ment: a pilot randomized controlled trial with a
gains in eating disorders: Efficacy of an intervention therapist-guided smartphone app. Int J Eat Disord
delivered via text messaging. J Consult Clin Psychol 52:1191–1201
80:700–706 Vollert B, von Bloh P, Eiterich N et al (2020) Recruiting
Fichter MM, Quadflieg N, Nisslmüller K et al (2012) participants to an Internet-based eating disorder pre-
Does internet-based prevention reduce the risk vention trial: impact of the recruitment strategy on
of relapse for anorexia nervosa? Behav Res Ther symptom severity and program utilization. Int J Eat
50:180–190 Disord 53:746–754
Gulec H, Moessner M, Túry F, Fiedler P et al (2014) Wade TD, Wilksch SM (2018) Internet eating disorder
A randomized controlled trial of an internet-based prevention. Curr Opin Psychiatry 31:456–461
posttreatment care for patients with eating disorders. Wagner B, Nagl M, Dölemeyer R et al (2016)
Telemed J E Health 20:916–922 Randomized controlled trial of an internet-based cog-
Hildebrandt T, Michaeledes A, Mayhew M et al (2020) nitive-behavioral treatment program for binge-eating
Randomized controlled trial comparing health coach- disorder. Behav Ther 47:500–514
delivered smartphone-guided self-help with standard Zerwas SC, Watson HJ, Hofmeier SM et al (2017)
care for adults with binge eating. Am J Psychiatry CBT4BN: a randomized controlled trial of online
177:134–142 chat and face-to-face group therapy for bulimia ner-
Jacobi C, Beintner I, Fittig E et al (2017) Web-based vosa. Psychother Psychosom 86:47–53
aftercare for women with bulimia nervosa following de Zwaan M, Herpertz S, Zipfel S et al (2017) Effect of
inpatient treatment: randomized controlled efficacy internet-based guided self-help vs individual face-
trial. J Med Internet Res 19:e321 to-face treatment on full or Subsyndromal binge
Kindermann S, Moessner M, Ozer F, Bauer S (2017) eating disorder in overweight or obese patients:
Associations between eating disorder related symp- the INTERBED randomized clinical trial. JAMA
toms and participants’ utilization of an individualized Psychiatry 74:987–995
Involuntary Treatment
Andreas Thiel and Thomas Paul
Contents
51.1 Forced Treatment Under Guardianship Law . . . . . . . . . . . . . . . . . . . . . . . . 386
51.2 Coercive psychotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 386
51.3 Procedure for Coercive Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 387
51.4 Treatment With Respect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 388
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 389
Anorexia nervosa (AN) is a serious and often condition in combination with pneumonia, elec-
chronic mental illness that significantly impairs trolyte imbalances, cardiac arrhythmias, blood
the quality of life of those affected. Core symp- formation disorders, gastrointestinal bleed-
toms of this disorder include, among other ing, and hepatic or renal dysfunction can lead
symptoms, the fear of weight gain. In severe to serious, and possibly life-threatening, com-
cases, this fear can impair the patient’s ability plications. The mortality and risk of suicide in
to make rational decisions. A possible decision patients with AN are significantly higher com-
to reject treatment or to refuse urgently needed pared to the general population.
weight gain is therefore not always the result of The voluntariness as a prerequisite for ther-
rational decision-making, but may be a symptom apy is anchored in the constitution through the
of the eating disorder and thus an expression two basic human rights to freedom and physi-
of the mental illness. In addition to the psycho- cal integrity. It is also ethically required and
pathological symptoms, the clinical picture is therapeutically sensible. However, if the reject-
marked by somatic complaints. Depending on ing attitude of a patient with AN poses a direct
the degree of underweight, the reduced general and immediate danger to their life, the question
arises as to a possible involuntary treatment in
order to enforce weight gain – despite a lack of
insight into the illness and motivation for ther-
A. Thiel (*)
Department of Psychiatry, Psychotherapy apy. Therapists are ethically responsible not only
and Psychosomatic Medicine, Agaplesion for their actions but also for their omissions.
Diakonieklinikum Rotenburg, Rotenburg (Wümme), Involuntary treatment against the will of the
Germany
patients may be medically and ethically justified
in cases of severe underweight and poor general
T. Paul condition if the patients are unable to adequately
Psychotherapy Practice, Hamburg, Germany
https://doi.org/10.1007/978-3-662-67662-2_51
386 A. Thiel and T. Paul
care for themselves due to their illness and are or if a medical examination or treatment is
no longer capable of giving consent. For these required. Within the framework of such inpatient
situations, German law provides exceptions that treatment, the legal guardian can then consent to
legitimize the forced placement and treatment of an involuntary medical treatment with the appro-
patients and the associated interventions in their priate judicial approval under § 1906a BGB.
basic rights. The appointment of a legal guardian or the
The current German guideline of the application for approval of placement and invol-
Association of the Scientific Medical Societies untary treatment under guardianship law should
for the treatment of eating disorders (AWMF be carefully considered and calmly discussed
2018) explicitly mentions the possibility or and prepared with patients and family members.
necessity of involuntary treatment under special, The legal guardianship should be established for
life-threatening circumstances. The guideline a period of at least 3-6 months, as significant
of the American Psychiatric Association (APA and stable improvement can hardly be expected
2006, 2012) and that of the National Institute for before that. In many cases, maintaining guardi-
Clinical Excellence (NICE 2017) also contain anship for a longer period and beyond the end of
corresponding references, and even the patient involuntary treatment will be useful. Involuntary
guideline of the AWMF (2015) mentions the treatments under guardianship law are not only
possibility of involuntary treatment. possible in psychiatric clinics but could also
be carried out in other clinics and institutions,
 Important In the case of anorexia nervosa, provided that these institutions are willing to
involuntary treatment against the patient’s assume the corresponding responsibility.
will may be medically and ethically nec-
essary under certain circumstances, such  Important In Germany, involuntary treat-
as severe underweight, life-threatening ment under inpatient conditions can be
somatic complications, or suicidality, and approved upon the request of the legal
if the patient is unable to give consent due guardian under guardianship law (§ 1906
to the illness. and § 1906a BGB). Information on the
practical procedure can be obtained from
the responsible guardianship court at the
local court, as well as the health depart-
51.1 Forced Treatment Under ment and the social psychiatric service.
Guardianship Law
If an adult is unable to manage his or her affairs

wholly or partially due to a mental illness or a 51.2 Coercive psychotherapy
physical or mental disability, it is possible to
appoint a legal guardian for him or her. The Involuntary treatment does not replace psy-
corresponding legal regulations are also referred chotherapy, but it does not exclude it either.
to as guardianship law and are part of the Responsible involuntary treatment is the begin-
German Civil Code (BGB). The appointment of ning or continuation of psychotherapy under
a guardian is made upon the request of the per- particularly difficult conditions. Coercive ther-
son concerned or by official order. The guardian apy is also possible. The widespread view that
is appointed only for the specific tasks defined psychotherapy is only possible under absolutely
in each individual case. The legal guardian with voluntary conditions is incorrect. For example, it
the appropriate scope of duties can apply to the is known from the treatment of acutely suicidal
guardianship court for the placement of a non- patients in life crises or patients with borderline
consenting ward under § 1906 BGB if there is a disorders that, after placing a person against
risk of self-endangerment due to a mental illness their will, a meaningful psychotherapeutic
51 Involuntary Treatment in Anorexia Nervosa 387
collaboration can be achieved in many, but compelling reason. A motivated and qualified
not all cases. This also applies to forced treat- nursing team can often avoid the use of direct
ments of patients with anorexia nervosa (AN). force in force-feeding.
Prerequisites for this are committed staff with
in-depth knowledge of the disorder and particu-  Important Not physical violence, but the
larly high psychotherapeutic qualifications. interpersonal relationship and the psycho-
therapeutic climate are the relevant factors
 Important Psychotherapy is also possible for the course of treatment.
and indicated under involuntary treatment.
The principle of carefully dosing coercion also
The lower weight limit for initiating involun- applies to ensuring food intake. Any necessary
tary treatment for AN cannot be precisely deter- force in force-feeding must be increased very
mined. The indication should be considered at cautiously and reduced as quickly as possible;
a BMI ≤ 13 kg/m2. This value is based on the the following steps are conceivable.
experience that mortality increases significantly
when weight decreases below a BMI of 13 kg/
m2. However, even at a higher weight, suicidal- Possibilities of force-feeding in AN
ity, electrolyte imbalances, cardiac arrhythmias, • Eating normal food in the presence of
and other acute psychological or physical prob- and with encouragement from staff
lems may render involuntary treatment neces- • Drinking special nutritional drinks in
sary in some cases. the presence of and with encouragement
from staff
• Combination of tube feeding and nor-
51.3 Procedure for Coercive mal food
Measures • Feeding by staff
• Feeding via gastric tube without
Coercive measures must be applied carefully restraint, during the day or at night
and dosed appropriately. Patients who are forci- • Feeding via PEG without restraint, dur-
bly treated against their will do not always have ing the day or at night
to be force-fed through a gastric tube, PEG (per- • Combination of several options
cutaneous endoscopic gastrostomy with inserted • Feeding via gastric tube or PEG with
feeding tube), or venous catheter, and restrain- restraint, during the day or at night
ing or confining them to a closed ward without • Parenteral nutrition through infusions
exit is not always necessary. The unreflective,
excessive, and insufficiently dosed use of coer-
cive measures is a medical error that unnecessar- From the outset, the goal of psychotherapy is
ily traumatizes patients. In many cases, the clear to motivate patients for increasingly independ-
statement of the therapist and the legal guardian ent and balanced food intake even during forced
about the necessity and enforcement of the treat- treatment. If this is not successful, various
ment is sufficient to motivate patients to cooper- alternatives for food intake can be considered,
ate adequately, so that the further application of which can be discussed and tried step by step.
direct force can be avoided or at least severely Force-feeding via tube, PEG, or venous catheter
restricted. The coercive character present in often leads to patients manipulating the system,
this situation is less injurious than direct use of which must not be responded to using increased
force. Restraints must be reduced to the absolute force without due reflection, as this risks an
minimum necessary and suspended as early as escalation of violence with lasting damage to
possible; under no circumstances should patients any trustful cooperation. Patients should be
be restrained for extended periods without involved in the decision about the form of food
388 A. Thiel and T. Paul
intake in order to avoid unnecessarily restricting an increase in coercion and violence or a restric-
their autonomy in an already difficult situation. tion of their freedom through clear agreements.
Any coercion used to ensure nutrition must also Conversations with family members are also
be terminated. By the time of discharge, patients useful during involuntary treatment in many
must be able to take responsibility for adequate cases.
nutrition again.
The topics of food, body shape, and weight  Important The goal of involuntary treat-
often play a dominant role for these patients. ment is not a defined weight, but the con-
However, in psychotherapy, other relevant topics tinuation of treatment without coercion.
and conflicts must not be forgotten, such as self-
esteem issues and achievement orientation, psy- Involuntary treatment must not destroy any
chosexual fears, or family conflicts. Even during further therapy motivation. On the contrary: it
forced treatment, these topics must be given should support the patients in gaining courage
appropriate space in therapy. Patients and staff for further therapy without coercion. The time of
must always know that achieving a target weight involuntary treatment aims to help the patients
is not an end in itself, but must serve to improve find a new perspective for themselves and to get
the quality of life. The therapy should follow the closer to the distant goal of a largely complete
motto: “Weight gain is not everything, but with- recovery from the eating disorder.
out weight gain, everything is nothing.” Respect for the patient also requires the staff
Medications are of secondary importance to accept the limits of therapeutic possibilities.
for the treatment of AN. Therefore, no general Involuntary treatments are only justified if there
psychopharmacological therapy recommenda- is a prospect of sufficient improvement in health
tion can be given for involuntary treatment. and quality of life. There are severe and chronic
Regardless of this, the indication for an anxio- courses of AN in which those affected obviously
lytic treatment with benzodiazepines or for an do not benefit sufficiently from any therapy or
antidepressant therapy or an antipsychotic treat- involuntary treatment. In such a palliative situa-
ment attempt must be checked depending on the tion, the initiation or continuation of involuntary
current psychopathological findings. treatment should be waived.
Conclusion
51.4 Treatment With Respect Severe courses of AN with a risk to the
patient’s life may require involuntary treat-
The unstable self-esteem regulation and the ment in individual cases. The decision for
conflicts regarding dependency and autonomy involuntary treatment can then be a relief
are of central importance for these patients. It for the affected patients and their family if
is particularly difficult not to further damage they can temporarily place responsibility in
patients’ lack of security and autonomy, but professional hands. The practical implemen-
to strengthen it under the unfavorable condi- tation of involuntary treatment and forced
tions of involuntary treatment. An absolute pre- feeding places high demands on the compe-
requisite for this is respectful treatment of the tence and care of the therapists in order not
patients. The respect and friendly commitment to disproportionately burden the often inad-
of the staff protect the dignity and self-esteem of equately developed motivation of the patients
the patients. Treatment with respect also means for the necessary psychotherapeutic work.
discussing all essential details of the therapy The goal of involuntary treatment is not to
openly and precisely with the patients, involv- achieve a defined weight, but to continue
ing them as much as possible in decisions, and therapy without coercion.
opening up opportunities for them to counteract
51 Involuntary Treatment in Anorexia Nervosa 389
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tion and treatment. May 2017. https://www.nice.org.
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Treatment of Chronically
Ill Patients 52
Thomas Paul and Andreas Thiel
Contents
52.1 Definition of Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391
52.2 Initial Situation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 392
52.3 Helpful Basic Principles in the Treatment of Chronically Ill Patients . . . . 392
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 396
52.1 Definition of Terms the literature (Broomfield et al. 2017; Hay and
Touyz 2018):
The term chronification is generally used to
describe diseases with long-lasting, mostly • Illness duration over several years, for exam-
incurable conditions. Despite the general knowl- ple at least 3–7 years
edge and significance of the high chronifica- • Several therapy attempts without sufficient
tion rates in AN and BN, this term is used very clinically relevant improvement
differently. Due to the high mortality and the • A persistent underweight
massive negative impact on quality of life, the
severe and enduring courses of AN (SEAN) Thus, statements about chronified patients usu-
are particularly relevant. The term “severe and ally describe a subset of a relatively large, very
enduring” seems more appropriate for describ- heterogeneous overall group for which univer-
ing these courses than the adjective “chronic,” sally valid treatment guidelines—similar to the
as improvements are generally possible even Practice Guideline for the Treatment of Patients
after many years (Eddy et al. 2017). A gener- with Eating Disorders of the APA (2006)—are
ally accepted definition of SEAN is still lacking; lacking and which have long been neglected
the following criteria are usually suggested in in the literature and research. This is particu-
larly surprising given the fact that this group
includes the majority of patients with eating dis-
T. Paul (*) orders who die from the symptoms in the long
Psychotherapy Practice, Hamburg, Germany term (in the case of AN, 15–20% or 0.5–0.75%
A. Thiel per year), experience increased suffering with
Centre of Psychosocial Medicine, Agaplesion reduced quality of life, and place a considerable
Diakonieklinikum Rotenburg, Rotenburg (Wümme), emotional burden on the people involved and
Germany
e-mail: [email protected] on the entire health system, usually financially.
https://doi.org/10.1007/978-3-662-67662-2_52
392 T. Paul and A. Thiel
The average annual treatment costs in German with their illness in the long term and not sim-
clinics for patients with AN are estimated at ply dismiss them as “incurable” or “unmotivated
around 12,800 euros, with it being noted that cases.” These principles apply to patients with
about 10–20% of patients with AN are treated chronic eating disorders who voluntarily enter
in hospitals each year and the average length of treatment. Treatment guidelines for patients who
stay in clinics is 50 days (Krauth et al. 2002). must be treated against their will are outlined in
The German guidelines of the Association of the Chap. 51of this book.
Scientific Medical Societies for the treatment of
eating disorders (AWMF 2018) speak of gaps
in care in Germany regarding specific offers for Helpful Basic Principles in Treatment
patients with SEAN. The current discussion on 1. Check if the patient has chosen the
SEAN also addresses the question of whether right time for her therapy.
and, if so, how the methods and goals of ther- 2. Create a trusting framework in which the
apy for these special patients need to be adapted therapeutic measures, conditions, and
(Kotilahti et al. 2020). therapy goals to be pursued are made
transparent before the therapy begins.
3. Do not set therapy goals unilaterally,
52.2 Initial Situation but together with the patient.
4. Make yourself an ally of the patient to
While there are more or less clear disease try to overcome the illness together.
courses with corresponding classification 5. Give the patient a large part of the
according to disease stages for chronic dis- responsibility for the progress of the
eases such as diabetes mellitus, hypertension, or treatment.
degenerative joint diseases, and specific thera- 6. Accept that the treatment can be
peutic measures can be derived for each of these lengthy and that it can be assumed that
stages, such descriptions for temporally succes- the patient will have great difficulty
sive chronic stages for patients with ANand BN allowing changes in her symptoms.
are not available. The chronic course of the dis- 7. Note that treatment cannot be carried
order varies greatly from patient to patient, and out against the patient’s will.
general guidelines cannot be established due 8. Ensure that the patient is integrated
to individual differences. Thus, practitioners into an appropriate care chain.
are repeatedly confronted with the question of 9. Observe the patient’s right to involun-
which treatment measures to take in individual tary admission.
cases. Although there are general criteria for the 10. Do not give up hope.
indication of various treatment settings (APA
2006), these do not correspond to the sever-
ity of the chronicity but are based solely on the
practitioner’s assessment of the patient’s symp- 52.3 Helpful Basic Principles
toms at the time of examination. Despite nearly in the Treatment
identical symptoms and the same duration of of Chronically Ill Patients
illness, the same therapeutic measures in the
same therapeutic setting can lead to very differ- 52.3.1 Timing of Therapy
ent outcomes. Unsatisfactory therapy courses Initiation
can lead to feelings of helplessness, frustration,
or anger among therapists. In our opinion, it Patients who voluntarily enter therapy can be
is very helpful to refer to general basic princi- described as “therapy-motivated.” However,
ples in treatment, which we describe below, in this does not mean that they are sufficiently
order to help even the “difficult patients” cope “change-motivated” from the outset or that they
52 Treatment of Chronically Ill Patients 393
have consciously dealt with the fact that they should be able to make a free and well-founded
will have to undergo a difficult process as part of decision for or against the treatment. Written
the therapy, which will demand a lot from them. information in the form of patient brochures has
It is therefore important to check early on with also proven helpful in this regard. In our experi-
the patient whether they are actually willing and ence, however, such written information should
able to cope with this task at the present time. only supplement, not replace, a preliminary
The mere desire to give up symptoms is usually discussion.
not enough to mobilize the necessary forces and
to endure the difficult therapeutic process in the
long term. For example, a patient with chronic 52.3.3 Establishing Joint Therapy
AN may be motivated to accept help, but at Goals
the same time still refuse the necessary weight
gain. Also, patients often do not see the fac- In order to achieve changes, patients must
tors maintaining the symptoms as being within expend a lot of energy. This can only be done
themselves, but rather attribute them externally at the expense of other resources, and at least in
to other people or specific circumstances. If the the short term, it may be necessary to temporar-
patient is still in a very ambivalent phase of their ily neglect other important and satisfying areas
illness (Prochaska and DiClemente 1992), the of life. It is therefore all the more important that
question arises as to the meaning of an inter- the patient and therapist agree on
vention at this point in time. It is known that
patients who failed at a first treatment attempt • which therapy goals are to be pursued within
are able to benefit very well at a later point in which time frame,
time within the same setting and justify this in • which measures should be used to achieve
retrospect by the fact that there was no suffi- • these goals, and
cient motivation or insight into the necessity of • what consequences this will have for other
change at the first attempt. areas of the patient’s life.
This process of agreement takes time, and it

52.3.2 Transparency of Framework is necessary to agree on realistic goals that the
Conditions patient can identify with. If unrealistic goals
are pursued, they will soon lead to frustration
Especially for patients with chronic disor- on both sides, jeopardizing long-term therapy
der courses who have often already undergone success. Just as the therapist should not unilat-
therapy and have not been able to achieve last- erally formulate the goals, it is also important
ing improvement of their symptoms, it is par- that therapists are not persuaded to agree to
ticularly important to discuss the corresponding therapy goals of which they themselves are not
framework conditions, therapeutic approach, convinced. As a rule, setting therapy goals is
and expectations of the patient very transpar- therefore a joint, sometimes tough process, at
ently before the start of therapy. For this purpose, the end of which both parties must be convinced
detailed preliminary discussions on site are suit- of the sense of the intended goals. “Lazy” com-
able, in which the patients are informed com- promises or seemingly consenting without con-
prehensively and in detail about the treatment viction will not hold up in the long term. Once
setting and have ample opportunity to ask ques- the therapy goals have been jointly developed
tions. Therapists should not conceal any distress- and established—perhaps even in writing—
ing elements of the treatment just to motivate a the patient should be committed to giving their
patient to start treatment. Based on the informa- “best” within the treatment without overburden-
tion received during this conversation, the patient ing themselves (commitment).
52.3.4 The Therapist as an Ally ultimately only be “a tool” for success, but not
responsible for progress. The patient should
When a patient enters therapy, she needs help. already check at the beginning whether she
Her mental or physical condition is causing her is willing to start therapy under the given cir-
to suffer, and she does not feel capable of giving cumstances—even if some conditions do not
up the distressing symptoms on her own. She seem “optimal” to her. It is helpful to initially
relies on a therapist who first tries to understand agree on a “trial therapy” with the patient for a
the patient with her illness in order to then work clearly defined period (in the context of inpa-
out a way to cope with the illness together. In tient therapy, this is often 14 days). During this
order to muster the necessary strength and con- time, it is the patient’s task to show the therapist
fidence, the therapist should stand by her side as or the therapeutic team that she can make pro-
an ally, patiently work out her path with her, and gress under the given conditions. If this does
above all, be present even when it becomes diffi- not succeed, the indication for continuing treat-
cult and the patient may even threaten to discon- ment must be reviewed. The main responsibil-
tinue therapy. It is precisely in such situations ity for therapy progress is thus transferred to the
that the resilience of the therapeutic alliance patient. This is intended to prevent the patient
becomes apparent. This requires particularly from complaining unilaterally and dispropor-
trained therapists who can maintain an overview tionately about supposed inadequacies of the
of the dynamics of the therapeutic process even therapy or the therapists, while losing sight of
in the face of personal attacks, reflect on the her own responsibility for therapy progress.
situation, and act deliberately. In this way, it is
possible to identify the specific barriers in the
currently difficult situation with the patient and 52.3.6 Acceptance of the Protracted
to develop joint, goal-oriented measures to solve Length of Treatment
the problem. This can also help to avoid unnec-
essary and destructive disputes, which often lead Patients with chronic disorder courses have usu-
to lasting discord on both sides or even to ther- ally become accustomed to their symptoms
apy terminations. over many years and have come to terms with
their illness. The factors that ultimately led to
the onset of the disorder are often still virulent;
52.3.5 Appeal to Personal however, further conditions that maintain the dis-
Responsibility ease have been added, which hinder the improve-
ment of the disorder. In some cases, an “eating
Every type of treatment requires the patient’s disorder identity” has even emerged as a result
willingness to actively engage with her prob- of the illness (“we anorexics”). The patients are
lems and to try out solutions without having the also afraid of change because they are looking
guarantee that they will be successful (“try first, into an uncertain future and fear that they will
criticize later”). It has proven helpful to make it not be able to cope adequately with the demands
clear to the patient from the outset that there is they anticipate upon recovery. The symptoms,
probably no treatment concept that will allow therefore, offer protection in addition to various
her to improve her symptoms without great impairments, which the patient certainly can-
effort, and that during therapy she may reach a not give up in just a few weeks or months. The
point where she questions the treatment setting, various resistances to change within the therapy
the specific therapeutic approach, or even the largely reflect the patient’s fear of failure in the
therapist himself. Overcoming these phases in face of demands. In this situation, it should be
therapy is more likely to succeed if the patient examined which steps of change are currently
is aware from the outset that the therapist can realistic for the patient. It is often more favorable
52 Treatment of Chronically Ill Patients 395
to formulate and achieve smaller partial goals extends from outpatient self-help groups, out-
than to set too large goals and then fail at them. patient psychotherapy, outpatient psychiatric
This approach also counteracts the frequent care and treatment, involvement of the social
“black-and-white thinking” of patients, who psychiatric service, day clinic treatment, to inpa-
often have a perfectionist drive and usually place tient psychiatric, internal medicine, or psychoso-
high demands on themselves. matic treatment, accommodation in residential
groups, or even involuntary treatment as a last
resort. The transitions between the different set-
52.3.7 Voluntariness of Treatment tings should be planned and discussed with the
patients early on. The better the communica-
Resorting to therapy against the patient’s will tion between the individual institutions about
should generally only be used as a last resort in the treatment process and the coordination of
the treatment process (see Chap. 51). As thera- the next treatment section, the easier it will be
pists, we should strive in each individual case to for the patient to engage in the proposed meas-
understand the patient in their symptomatology ures and benefit from them in the long term. If
with their specific fears and, if possible, create the institutions involved see themselves only
conditions that also enable them to make pro- as an important link in the chain of necessary
gress within the treatment. It makes no sense therapeutic measures, they can succeed in not
to confront the patient with a setting and meas- overburdening the patients during the therapeu-
ures and persuade her to consent, which she is tic sub-process and setting up realistic therapy
unable to accept and which she sees as having a goals with them, which, when achieved, can
coerceive character. Patients will quickly (have lead to an increased self-efficacy expectation
to) drop out of such treatment and the chronic- and motivation.
ity will be further reinforced. On the other hand,
we should not agree to conditions that we know
will further support the patient in her avoidance 52.3.9 “Right to Involuntary
behavior. We must learn to accept that our treat- Admission”
ment offer is not accepted by patients in need
of treatment and that they do not consent to the Considering the alarmingly high mortality and
proposed therapy. We should respect this right chronicity rates among patients with AN, the
of choice of the patients without fundamentally question arises whether, in individual cases and
questioning our therapeutic basic conditions under special circumstances, the option of
and/or reacting with a negative attitude towards involuntary admission should be used more fre-
the patient. On the contrary, we should encour- quently (Chap. 51). In exceptional situations,
age and support the patient in seeking helpful patients may also have a right to involuntary
alternatives to our treatment. treatment. The frequently expressed concern
in this context that psychotherapeutic follow-
up treatment would be impossible after such an
52.3.8 Integration into the Care intervention is incorrect. Responsible involun-
Chain tary treatment is the beginning or continuation
of psychotherapy under particularly difficult
It can be assumed that the treatment process for conditions. The goal of involuntary treatment is
chronically ill patients is generally more diffi- not to achieve a defined weight, but to continue
cult and that a single therapeutic setting will not therapy without coercion. In all measures carried
be sufficient. The treatment, therefore, requires out against the will of the patient, it is always
careful, flexible coordination between differ- important to ensure that the patient is treated
ent settings, which can be used as needed for a with respect and her dignity is not unnecessarily
certain period. The range of therapeutic options violated.
52.3.10 Don't Give Up Hope References
Therapy courses for patients with chronic eat- APA (American Psychiatric Association) (2006) Practice
guideline for the treatment of patients with eating dis-
ing disorders are hardly predictable. Experienced
orders. Am J Psychiatry 163(Suppl):1–54
practitioners rightly point out that even formerly AWMF (Arbeitsgemeinschaft der Wissenschaftlichen
very difficult, seemingly hopeless cases can take a Medizinischen Fachgesellschaften) (2018)
positive course after many years. Therefore, even S3-Leitlinie Diagnostik und Behandlung der
Essstörungen, 2nd edn. Registernummer 051–026.
in the most difficult courses, it seems justified to
https://www.awmf.org/uploads/tx_szleitlinien/051-
face patients and their relatives with hope and to 026l_S3_Essstoerung-Diagnostik-Therapie_2020-03.
assure them that improvements in symptoms up to pdf. Accessed: 14. Oct 2020
recovery from the eating disorder are fundamen- Broomfield C, Stedal K, Touyz S, Rhodes P (2017)
Labeling and defining severe and enduring anorexia
tally possible. In light of the greater knowledge
nervosa: a systematic review and critical analysis. Int
and better therapeutic options for eating disor- J Eat Disord 50:611–623
ders, William Gull’s statement from 1873 remains Eddy K, Tabri N, Thomas J, Murray H, Keshaviah A,
valid: “None of these cases, however exhausted, Hastings E, Edkins K, Krishna M, Herzog D, Keel
PK, Franko DL (2017) Recovery from anorexia ner-
are really hopeless as long as life exists”.
vosa and bulimia nervosa at 22-year follow-up. J Clin
Hay P, Touyz S (2018) Classification challenges in the
Conclusion field of eating disorders: can severe and enduring
The treatment of patients with chronic eat- anorexia nervosa be better defined? J Eat Disord 6:41
Keel PK, Brown TA (2010) Update on course and out-
ing disorders poses a special challenge for come in eating disorders. Int J Eat Disord 43:195–204
every therapist and treatment team. It is not Kotilahti E, West M, Isomaa R, Karhunen L, Rocks
possible to establish universally valid criteria T, Ruusunen A (2020) Treatment interventions for
for the application of specific interventions severe and enduring eating disorders: systematic
review. Int J Eat Disord 53:1280–1302
depending on certain stages of the disor- Krauth C, Buser K, Vogel H (2002) How high are the
der. However, regardless of specific condi- costs of eating disorders—anorexia nervosa and
tions and settings, helpful basic principles bulimia nervosa—for German society? Eur J Health
can be formulated as guidelines for thera- Econ 3:244–250
Prochaska JO, DiClemente CC (1992) Stages of change
peutic action, with the help of which power in the modification of problem behaviors. Prog Behav
struggles and the “iatrogenic” chronicity of Modif 28:183–218
patients can be more easily avoided.
Working with Family
Members 53
Ulrike Schmidt
Contents
53.1 Definitions and Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 397
53.2 Why Work with Family Members? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 398
53.3 Burden on Family Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 398
53.4 Needs of Family Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 398
53.5 Goals and Contents of Working with Family Members . . . . . . . . . . . . . . . . 399
53.6 Interventions for Family Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 399
53.7 Summary and Outlook . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 400
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 400
53.1 Definitions and Context environment of the person concerned.” (http://

de.wikipedia.org/wiki)
The term family member can be defined as fol- The widely used expression in Anglo-Saxon
lows: “a person who is in a special legal or soci- literature, “carer,” describes a person of any age
ological relationship with another person or a who provides unpaid support or care to a relative
group of persons, when one wants to emphasize or friend who would not be able to cope with-
this special relationship. Most often, people who out this help. The support is necessary because
are in close familial or personal relationships the person concerned is either sick, frail, or disa-
with each other are meant. The term is broader bled, or suffers from a mental disorder (http://
than that of a nuclear family. It includes, in par- www.carers.org/what-carer).
ticular, spouses or life partners and in-laws. In In the broadest sense, work with family
addition, the term in the sense of ‘belonging’ membersis understood here as all theory- and
can also include people who belong to the life evidence-based interventions that attempt to pro-
vide family members with new information—
including new research findings—and practical
skills to help them to cope better with an eating
disorder. Such work with the family goes far
U. Schmidt (*) beyond mere information provision and emo-
Centre for Research in Eating and Weight tional support (e.g., through self-help groups).
Disorders, Institute of Psychiatry, Psychology and It is also distinct from family therapy and simi-
Neuroscience, King’s College London, London,
Great Britain
lar methods (multi-family groups) that are dealt
e-mail: [email protected] with elsewhere in this book.
https://doi.org/10.1007/978-3-662-67662-2_53
398 U. Schmidt
In research on work with family members, or alcoholism), families of patients with AN

the main focus is on approaches that involve tar- spend about twice as much time in direct contact
geted processing of maintaining interpersonal with the patient (Ränker et al. 2013; Viana et al.
factors. 2013), i.e., they are exposed to a high objective
burden. A study of family members, mainly par-
ents (n = 224) and partners (n = 28) of inpa-
53.2 Why Work with Family tients with AN (n = 178, mainly adults), found
Members? that family members spent most of their time
providing emotional support and assistance
Since the widespread introduction of community- with food intake. Mothers and partners of indi-
based psychiatric care, the responsibility for the viduals with AN were similar in terms of the
daily care, nursing, and support of mentally ill extent of support offered, whereas fathers spent
patients often lies with their family. It is known less time caring for their daughters with AN.
that the families of people with severe mental Approximately 30% of the sample suffered from
illnesses, such as psychoses or dementia, are stress and clinically relevant anxiety symptoms.
heavily challenged and often carry a large objec- A high degree of objective burden was associ-
tive and subjective burden (Graap et al. 2008a; ated with a high level of stress in the family. In
Kyriacou et al. 2008). In the field of eating disor- particular, partners of individuals with AN had
ders, the involvement of family in the treatment of little support from others, and the severity of
children and adolescents has long been common, their anxiety and stress symptoms was compara-
e.g., through psychoeducational parent groups ble to that of mothers (Ränker et al. 2013).
(Geist et al. 2000). In contrast, this development
has been much more hesitant in the treatment of
adults, although most people with anorexia ner- 53.4 Needs of Family Members
vosa (AN) still live with their family of origin or
at least have close contact with the family and Studies in which families of eating disorder
receive support from home in adulthood. patients were asked about their needs have
shown that they often identify large gaps in
knowledge and skills in themselves and also feel
53.3 Burden on Family Members inadequately supported and advised by profes-
sionals (Haigh and Treasure 2003; Graap et al.
Studies on mental health issues among fam- 2008b). It is important to note that the various
ily members of inpatients or outpatients with groups of family members (e.g., mothers, fathers,
AN or bulimia nervosa (BN) indicate a high partners/spouses, siblings) differ significantly in
prevalence of anxiety and depressive symptoms terms of their burden and thus also their needs.
(Anastasiadou et al. 2014). These symptoms
seem to correlate with the extent of objective “Interpersonal Vicious Cycle”
and subjective burden on the family members. Recent research suggests that family members
Both the subjectively perceived burden and the may contribute to the development of dysfunc-
number of problems caused by the illness are at tional interpersonal vicious cycles (Fig. 53.1)
least as high in family members of patients with through certain behaviors and thus unintention-
AN as in the family of patients with depression ally contribute to the maintenance of eating dis-
or schizophrenia (Graap et al. 2008a; Martin order symptoms (Treasure et al. 2020). Factors
et al. 2015; Treasure et al. 2001). Relatives of that play a role in this regard, based on empiri-
patients with BN also feel significantly burdened cal studies, are high levels of “expressed emo-
(Anastasiadou et al. 2014). Compared to families tions”, which refers to either overprotective or
of adults with severe physical (e.g., cancer) or excessively critical or even hostile attitudes of
mental illnesses (such as psychoses, dementia, family members towards the patient. In addition,
53 Working with Family Members 399
AN mode: Starved
AN impacts on
relaonships
Family very concerned & make

AN becomes stronger
excepons and accommodates AN or:
They become crical & hosle
AN symptoms increase &

paent becomes less
flexible
or: self-cricism &
withdrawal from others
increase
Fig. 53.1  The vicious cycle of dysfunctional interpersonal behavior
the family may adapt to the symptoms or even • empowering them in the broadest sense by
reinforce them (“accommodation and enabling training them to become “experts” in the
of symptoms”) (Anastasiadou et al. 2014). This eating disorders of their loved one, learning
vicious cycle can be somewhat simplified in its to cope better with the eating disorder, and
representation. thereby building self-confidence.
 Important Family members can unintention- Furthermore, the goal is to indirectly have a posi-
ally reinforce the eating disorder symptoms tive effect on the patient’s eating disorder symp-
of patients. toms in this way. An empirical model of the
family, societal, and disorder factors that affect
the subjective experience and coping strategies of
53.5 Goals and Contents of Working family members has been developed (Treasure and
with Family Members Nazar 2016). The model identifies potential inter-
vention targets and associated assessment scales.
International guidelines (e.g., NICE 2017) rec-
ommend early involvement of family mem-
bers in the treatment of patients with eating 53.6 Interventions for Family
disorders. Goals of working with family mem- Members
bers include (Treasure and Nazar 2016):
A meta-analytical study examined all interven-
• providing family members with specific tions for caregivers aimed at either reducing the
knowledge about symptoms, risks, treatment, subjective burden and any anxiety and depres-
and prognosis of eating disorders; sive symptoms of family members, or helping
• teaching them skills to recognize and spe- them to support the person with AN more effec-
cifically change dysfunctional interpersonal tively. Both uncontrolled and randomized tri-
vicious cycles that maintain the disorder als were included. Interventions included both
(e.g., through improved communication with training workshops and self-help procedures
the person with the eating disorder); for family members. The self-help procedures
• helping them recognize the negative effects of were mostly guided and either manualized or
the eating disorder on their own mental health, internet-based. In most interventions, there was
seek support, and conserve their own resources; a reduction in anxiety and depressive symptoms
400 U. Schmidt
in family members with a medium effect size References

and a decrease in relative burden and expressed
emotion with a small to medium effect size. Anastasiadou D, Medina-Pradas C, Sepulveda AR,
These improvements remained stable during the Treasure J (2014) A systematic review of family car-
egiving in eating disorders. Eat Behav 15(3):464–477
follow-up period (Hibbs et al. 2015a). Since the Cardi V, Ambwani S, Robinson E, Albano G, MacDonald
publication of this meta-analysis, two more large P, Aya V, Rowlands K, Todd G, Schmidt U, Landau
randomized trials on manual-based supported S, Arcelus J, Beecham J, Treasure J (2017) Transition
family self-help with accompanying DVDs as a care in anorexia nervosa through guidance online
from peer and carer expertise (TRIANGLE): study
supplement to inpatient treatment (Hibbs et al. protocol for a randomised controlled trial. Eur Eat
2015b; Magill et al. 2016) or outpatient treat- Disord Rev 25(6):512–523
ment of AN (Hodsoll et al. 2017) have been Dimitropoulos G, Landers A, Freeman V, Novick J,
published. These studies replicate the results of Schmidt U, Olmsted M (2019) A feasibility study
comparing a web-based intervention to a workshop
the meta-analysis, i.e., long-term improvements intervention for caregivers of adults with eating disor-
were found in various family variables. In addi- ders. Eur Eat Disord Rev 27(6):641–654
tion, effects on patient outcomes and health- Geist R, Heinmaa M, Stephens D et al (2000)
care utilization (e.g., fewer inpatient days) were Comparison of family therapy and family group psy-
choeducation in adolescents with anorexia nervosa.
observed. Another smaller pilot study evaluated Can J Psychiatr 45(2):173–178
an internet-based cognitive-systemic intervention Graap H, Bleich S, Herbst F et al (2008a) The needs of
for caregivers compared to training workshops. carers: a comparison between eating disorders and
Although there were few differences in improve- schizophrenia. Soc Psychiatry Psychiatr Epidemiol
43(10):800–807
ments in family variables, the workshops were Graap H, Bleich S, Herbst F et al (2008b) The needs of
perceived as significantly more acceptable by carers of patients with anorexia and bulimia nervosa.
participants (Dimitropoulos et al. 2019). Eur Eat Disord Rev 16(1):21–29
Haigh R, Treasure J (2003) Investigating the needs of
carers in the area of eating disorders: development of
the Carers’ Needs Assessment Measure (CaNAM).
53.7 Summary and Outlook Eur Eat Disord Rev 11(2):125–141
Hibbs R, Rhind C, Leppanen J, Treasure J (2015a)
Currently, several large studies on work with Interventions for caregivers of someone with an
eating disorder: a meta-analysis. Int J Eat Disord
family members as a supplement to AN treat- 48(4):349–361
ment are being completed (e.g., Cardi et al. Hibbs R, Magill N, Goddard E, Rhind C, Raenker S,
2017; Spencer et al. 2018). Based on the cur- Macdonald P, Todd G, Arcelus J, Morgan J, Beecham
rent state of knowledge, we can say that this J, Schmidt U, Landau S, Treasure J (2015b) Clinical
effectiveness of a skills training intervention for car-
treatment approach is perceived as very help- egivers in improving patient and caregiver health
ful and positive by family members (Treasure following in-patient treatment for severe anorexia
et al. 2021). However, several important ques- nervosa: pragmatic randomised controlled trial.
tions remain largely unresolved, e.g., the relative BJPsych Open 1(1):56–66
Hodsoll J, Rhind C, Micali N, Hibbs R, Goddard E,
merits of different intervention goals/contents Nazar BP, Schmidt U, Gowers S, Macdonald P, Todd
and different types of support for self-help pro- G, Landau S, Treasure J (2017) A pilot, multicen-
cedures. In addition, it is also unclear what the tre pragmatic randomised trial to explore the impact
relative costs and benefits of training workshops of carer skills training on carer and patient behav-
iours: testing the cognitive interpersonal model in
compared to self-help procedures are, both for adolescent anorexia nervosa. Eur Eat Disord Rev
the family members themselves and for the 25(6):551–561
patients and the healthcare system. Kyriacou O, Treasure J, Schmidt U (2008)
Understanding how parents cope with living with
someone with anorexia nervosa: modelling the fac-
 Important Family members should also be tors that are associated with carer distress. Int J Eat
involved in the treatment of adult patients Disord 41(3):233–242
with AN and BN.
53 Working with Family Members 401
Magill N, Rhind C, Hibbs R, Goddard E, Macdonald P, Treasure J, Nazar BP (2016) Interventions for the carers
Arcelus J, Morgan J, Beecham J, Schmidt U, Landau of patients with eating disorders. Curr Psychiatry Rep
S, Treasure J (2016) Two-year follow-up of a prag- 18(2):16
matic randomised controlled trial examining the Treasure J, Murphy T, Szmukler G et al (2001) The expe-
effect of adding a carer’s skill training intervention in rience of caregiving for severe mental illness: a com-
inpatients with anorexia nervosa. Eur Eat Disord Rev parison between anorexia nervosa and psychosis. Soc
24(2):122–130 Psychiatry Psychiatr Epidemiol 36(7):343–347
Martín J, Padierna A, van Wijngaarden B, Aguirre U, Treasure J, Parker S, Oyeleye O, Harrison A (2020)
Anton A, Muñoz P, Quintana JM (2015) Caregivers The value of including families in the treatment of
consequences of care among patients with eating dis- anorexia nervosa. Eur Eat Disord Rev. https://doi.
orders, depression or schizophrenia. BMC Psychiatry org/10.1002/erv.2816. Epub ahead of print. PMID:
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(NICE) (2017) Eating disorders: recognition and value of including families in the treatment of ano-
treatment. https://www.nice.org.uk/guidance/ng69 rexia nervosa. Eur Eat Disord Rev 29(3):393–401
Ränker S, Hibbs R, Goddard E et al (2013) Caregiving Viana MC, Gruber MJ, Shahly V, Alhamzawi A,
and coping in carers of people with anorexia nervosa Alonso J, Andrade LH, Angermeyer MC, Benjet C,
admitted for intensive hospital care. Int J Eat Disord Bruffaerts R, Caldas-de-Almeida JM, Girolamo G,
46(4):346–354 Jonge P, Ferry F, Florescu S, Gureje O, Haro JM,
Spencer L, Schmidt-Hantke J, Allen K, Gordon G, Hinkov H, Hu C, Karam EG, Lépine JP, Levinson
Potterton R, Musiat P, Hagner F, Beintner I, Vollert B, D, Posada-Villa J, Sampson NA, Kessler RC (2013)
Nacke B, Görlich D, Beecham J, Bonin EM, Jacobi Family burden related to mental and physical dis-
C, Schmidt U (2018) A web-based intervention for orders in the world: results from the WHO World
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trial protocol of a randomised controlled trial investi- 35(2):115–125
gating the effectiveness of different levels of support.
Internet Interv 16:76–85
Relapse Prevention
Katrin Giel and Ulrike Schmidt
Contents
54.1 Relapses in Anorexia Nervosa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 403
54.2 Specifics of Relapse Prevention in AnorexiaNervosa . . . . . . . . . . . . . . . . . . 404
54.3 Therapy and Care Concepts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 405
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 406
54.1 Relapses in Anorexia Nervosa therapy having already proven critical (Khalsa
et al. 2017; Berends et al. 2018). In a majority of
Many patients with anorexia nervosa (AN) who patients who have received inpatient treatment
undergo therapy benefit from acute treatment, for an eating disorder, there is at least one hos-
achieve weight gain, and experience an improve- pital readmission during the course of the illness
ment in eating disorder symptoms. However, (Rigaud et al. 2011).
AN is characterized by a high risk of relapse.
Between a third and about half of treated Definition of a Relapse
patients suffer a relapse, with the risk of relapse So far, no uniform criteria for a relapse in AN
being greatest in the first year after therapy have been defined (Khalsa et al. 2017; Berends
and the very early point of three months after et al. 2018). Clinically, a relapse is generally
understood as a significant deterioration in core
symptoms of the eating disorder (e.g., a sig-
nificant weight loss). In this respect, the assess-
ment of a relapse is primarily based on the
individual course of the patient’s illness and the
K. Giel (*)
Department of Psychosomatic Medicine and clinical impression of the treating professionals.
Psychotherapy, Medical University Hospital Currently discussed stage models of AN include
Tübingen, Tübingen, Deutschland both objective criteria (BMI) and subjective
e-mail: [email protected] symptoms (e.g., fear of weight gain) in a pro-
U. Schmidt posed definition of a relapse, recommend a fixed
Centre for Research in Eating and Weight time criterion, and suggest using standardized
Disorders, Institute of Psychiatry, Psychology and measurement instruments to describe the eating
Neuroscience, King’s College London, London,
Great Britain
disorder pathology (Khalsa et al. 2017).
https://doi.org/10.1007/978-3-662-67662-2_54
404 K. Giel and U. Schmidt
54.1.1 Protective and Risk Factors 54.1.2 Care Situation and Risk
regarding Relapse of Relapse
Not all patients with AN are equally at risk of The often lengthy and severe course of AN
relapse – some subgroups manage to overcome poses particular challenges to the care of
the eating disorder in the long term, whereas patients and necessitates the frequent utilization
others experience repeated relapses. Empirically, of different intensive therapy settings and vari-
a number of risk and protective factors regarding ous therapists. Thus, after completion of acute
relapse in AN have been identified (Carter et al. treatment for the eating disorder, the initiation
2012; Khalsa et al. 2017; Berends et al. 2018; of follow-up treatment is often sought to con-
Stockford et al. 2019). These provide important solidate achieved therapy successes. Especially
starting points for therapeutic content and priori- in healthcare systems with sectoral separation
ties for relapse prevention. between (partial) inpatient and outpatient care,
there may be a lack of networking and long
waiting times at these transitions between treat-
Factors promoting relapse ment settings (Giel et al. 2011), which promote
• Low weight at discharge from inpatient relapses into the illness (Herpertz et al., 2019).
therapy
• Hyperactivity
• Binge/purging subtype of AN and pro- 54.2 Specifics of Relapse Prevention
nounced binge eating in AnorexiaNervosa
• Pronounced body dissatisfaction and
pronounced fear of weight gain 54.2.1 Importance
• Psychiatric comorbidity
• Low level of psychosocial functioning Dealing with relapse risks and setbacks should
• Long duration of illness already be addressed in the later therapy phases
of acute treatment ( Herpertz et al., 2019). In
particular, psychoeducationregarding the course
Factors promoting recovery or protect- of recovery as well as the course and signifi-
ing against relapse cance of relapses is also useful in early phases
• Full remission at the end of therapy of acute treatment, as the patients’ attitude
• Age < 18 years towards possible relapses seems to be an impor-
• Low weight- and body-related concerns tant predictor for the success of eating disorder
• Absence of depressive comorbidity therapy. After completing acute treatment, fol-
• Social support low-up treatment should generally be provided,
• Strong motivation for change especially for subgroups of patients with par-
• Strong therapeutic alliance ticularly high relapse risk.
• Development of an eating disorder-
independent identity
• Perception of recovery as a process 54.2.2 Treatment Goals
• Self-acceptance
Relapse prevention aims to prevent relapses
after acute treatment (usually inpatient or day-
patient therapy). Since there is no uniform
54 Relapse Prevention in Anorexia Nervosa 405
definition of relapse in AN, this goal is very therapy and care concepts that can contribute to
individually tailored, i.e., it is primarily about maintaining the achieved therapy successes and
maintaining and ideally further stabilizing and preventing relapses following acute treatment.
improving the individual condition of a patient
upon discharge from acute therapy.
Secondary treatment goals include 54.3.1 Guided Self-Help
• achieving the longest possible relapse-free Offers for guided self-help include therapy pro-
phase, grams in which patients independently work
• improving eating disorder symptoms, on therapy content using specific materials and
• improving general psychopathology, media (e.g., a manual, a homepage, or a smart-
• improving quality of life, phone app). Depending on the format, they can
• if necessary, motivating for and transitioning be therapist-supported or in contact with other
to further follow-up treatment or the use of patients, e.g., via email or chat. Such self-help
other support services. programs represent relatively low-threshold
offers, in which patients can independently
access therapeutic help irrespective of location
54.2.3 Treatment Elements and time, while avoiding long waiting times for
alternative care options (Section 54.1.2). The
Clinical guidelines have identified a number of efficacy of an internet-based self-help program
therapeutic contents that are central to psycho- specifically designed for relapse prevention in
therapeutic interventions for relapse prevention AN after discharge from inpatient therapy has
(Marlatt et al. 2002): been demonstrated (Fichter et al. 2012). There
is also initial evidence that specific smartphone
• Recording the previous course of the disor- apps are highly accepted by patients, but their
der, including previous relapses, efficacy has yet to be proven (Neumayr et al.
• Psychoeducation regarding the course of 2019).
recovery and relapses,
• Reviewing and strengthening therapy
motivation, 54.3.2 Pharmacotherapy
• Formulating individual treatment goals,
• Identification of possible relapse triggers, Although there is no evidence for the efficacy of
• Identification of strategies for dealing with pharmacological agents in the acute treatment
possible relapse triggers and for dealing with of AN (Davis and Attia 2017; Herpertz et al.,
setbacks and relapses, 2019), the potential benefit of pharmacother-
• Strengthening self-efficacy and individual apy in relapse prevention has been discussed,
resources. as medications may not work or not work suf-
ficiently in acutely ill patients due to starvation
effects, but could have effects in weight-reha-
54.3 Therapy and Care Concepts bilitated patients during the relapse prevention
phase (Walsh et al. 2006). However, there is no
So far, few interventions have been devel- evidence to date that pharmacotherapy alone or
oped specifically for relapse prevention in AN. in combination with psychotherapy can prevent
However, there are a number of structured relapses in AN (Walsh et al. 2006).
406 K. Giel and U. Schmidt
54.3.3 Psychotherapy therapeutic services, including psychotherapy,

nutritional therapy, and medical support. This
After completing inpatient or day care acute care concept is particularly recommended for
treatment for AN, outpatient psychotherapy is adolescent patients if chronicity is imminent or
usually sought to prevent relapses and, if nec- has occurred, in cases of social isolation and
essary, continue working on symptom improve- problems in coping with everyday life, and in
ment (for central elements of psychotherapeutic cases where the patient’s home situation is not
interventions for relapse prevention, see sec- sufficiently supportive or health-promoting
tion 54.2.3). There is evidence that outpatient (Herpertz et al., 2019).
psychotherapy methods specifically aimed at
relapse prevention effectively prevent or at least
delay relapses. Relapses occurred less frequently Conclusion
and later in patients who participated in outpa- Anorexia nervosa is characterized by a high
tient cognitive-behavioral relapse prevention risk of relapse. Treatment and care concepts
in the first year after discharge than in patients specifically aimed at preventing relapses
in the respective control groups who received following acute treatment of anorexia can
either standard aftercare (Carter et al. 2009) or improve the course of the disorder. These
nutritional counseling (Pike et al. 2003). The include guided self-help, psychotherapy, and
psychotherapeutic treatment concept “Maudsley – for specific indications – therapeutic resi-
Model of Anorexia Nervosa Treatment in dential groups.
Adults” (MANTRA) (Schmidt et al. 2012)
includes a separate therapy program for relapse
prevention in AN, which was developed based References
on the disorder model of anorexia and empiri-
Berends T, Boonstra N, van Elburg A (2018) Relapse in
cal risk and protective factors regarding relapse
anorexia nervosa: a systematic review and meta-anal-
(Sect. 54.1.1) (Giel et al. 2013, 2015). ysis. Curr Opin Psychiatry 31(6):445–455
Carter JC, McFarlane TL, Bewell C et al (2009)
Maintenance treatment for anorexia nervosa: a com-
parison of cognitive behavior therapy and treatment
54.3.4 Therapeutic residential groups
as usual. Int J Eat Disord 42(3):202–207
Carter JC, Mercer-Lynn KB, Norwood SJ et al (2012)
While behavioral change with psychothera- A prospective study of predictors of relapse in ano-
peutic support within a protected framework, rexia nervosa: implications for relapse prevention.
such as inpatient treatment, may be successful,
Davis H, Attia E (2017) Pharmacotherapy of eating dis-
it can be difficult to implement this at home orders. Curr Opin Psychiatry 30(6):452–457
in everyday life after discharge, leading to a Fichter MM, Quadflieg N, Nisslmuller K et al (2012)
threat of relapses into old patterns of behavior. Does internet-based prevention reduce the risk
of relapse for anorexia nervosa? Behav Res Ther
Therefore, a limited stay in a therapeutic resi-
50(3):180–190
dential group can be helpful, providing an envi- Giel KE, Groß G, Zipfel S (2011) Neue S3-Leitlinie
ronment both outside a clinic and outside one’s zur Behandlung von Essstörungen. Verweis auf alte
own social environment, where lessons learned Lücken im deutschen Gesundheitssystem. Psychother
Psychosom Med Psychol 61:293–294
from the acute treatment of AN can be trans-
Giel KE, Leehr E, Becker S et al (2013)
ferred to everyday life and further developed. Rückfallprophylaxe bei Anorexia nervosa. Psychother
There are therapeutic residential groups spe- Psychosom Med Psychol 63(7):290–295
cifically for patients with eating disorders: Here, Giel KE, Leehr EJ, Becker S, Herzog W, Junne F,
Schmidt U, Zipfel S (2015) Relapse prevention via
those affected live together for a certain period
videoconference for anorexia nervosa ─ findings
of time, continue attending school, vocational from the RESTART pilot study. Psychotherapy &
training, or studying, and receive comprehensive Psychosomatics 84:381–383
54 Relapse Prevention in Anorexia Nervosa 407
Herpertz S, Fichter M, Herpertz-Dahlmann B, Hilbert treatment: a pilot randomized controlled trial with
A, Tuschen-Caffier B, Vocks S, Zeeck A (Eds) a therapist-guided smartphone app. Int J Eat Disord
(2019) S3-Leitlinie Diagnostik und Behandlung der 52(10):1191–1201
Essstörungen. Springer, Berlin Pike KM, Walsh BT, Vitousek K et al (2003) Cognitive
Jacqueline C, Carter Kimberley B, Mercer-Lynn Sarah behavior therapy in the posthospitalization treat-
Jane, Norwood Carmen V, Bewell-Weiss Ross D, ment of anorexia nervosa. Am J Psychiatry
Crosby D. Blake, Woodside Marion P, Olmsted 160(11):2046–2049
(2012) A prospective study of predictors of relapse in Rigaud D, Pennacchio H, Bizeul C et al (2011) Outcome
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org/10.1016/j.psychres.2012.04.037 Schmidt U, Oldershaw A, Jichi F et al (2012) Out-patient
Khalsa SS, Portnoff LC, McCurdy-McKinnon D, psychological therapies for adults with anorexia ner-
Feusner JD (2017) What happens after treatment? A vosa: randomised controlled trial. Br J Psychiatry
systematic review of relapse, remission, and recovery 201:392–399
in anorexia nervosa. J Eat Disord 5:20 Stockford C, Stenfert Kroese B, Beesley A, Leung N
Marlatt A, Parks G, Witkiewitz K (2002) Clinical guide- (2019) Women’s recovery from anorexia nervosa: a
lines for implementing relapse prevention therapy. systematic review and meta-synthesis of qualitative
Author: http://www.sygdoms.com/pdf/relapse/4.pdf. research. Eat Disord 27(4):343–368
Accessed: 5. Dec 2014 Walsh BT, Kaplan AS, Attia E et al (2006) Fluoxetine
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ogy for anorexia nervosa after intensive inpatient
Part VII
Definition, Classification, and
Epidemiology of Obesity
409
Diagnosis and Etiology
of Obesity 55
Alfred Wirth
Contents
55.1 Diagnosis of Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411
55.2 Causes of Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 413
55.3 Recording of Physical Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 418
55.4 Low Socioeconomic Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 419
55.5 Sleep Deprivation—Disturbed Sleep . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 419
55.6 Diseases Associated With Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 419
55.7 Drugs and Weight Gain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 420
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 422
55.1 Diagnosis of Obesity BMI =

Body weight (kg)
Body length h2 (m)
The diagnosis for defining obesity is simple. For Obesity is defined based on the BMI
the care of people with overweight and obesity, (Table 55.1); the BMI is a measure of body fat
anthropometric measurements are sufficient. mass.
For several years, the term overweight has
been used synonymously with the term pre-obe-
55.1.1 Anthropometry sity in publications. Bariatric surgeons occasion-
and Definition of Obesity ally refer to patients with a BMI > 50 kg/m2 or
60 kg/m2 as “superobese.”
The body mass index (BMI) is determined using Equally important and even more significant
weight-height indices. It is calculated from the for the metabolic consequences of obesity than
quotient of body weight and body height: the BMI is the waist circumference , which is
a rough measure of intra-abdominal (visceral)
fat. The waist circumference is measured in the
standing patient at mid-breath between the lower
edge of the ribs and the upper iliac crest. If the
A. Wirth (*)
Bad Rothenfelde, Germany hip circumference is also measured, the waist-
e-mail: [email protected] to-hip ratio can be determined, a value with
A. Wirth similar significance to the waist circumference
Melle, Germany (Table 55.2).
https://doi.org/10.1007/978-3-662-67662-2_55
412 A. Wirth
Table 55.1  Classification of obesity in adults according at various body sites. The sum of the skin-
to BMI. This classification applies to Europeans; lower fold thickness can be used to estimate body fat
thresholds apply to other ethnicities (e.g., Asians) (WHO
2000) mass using regression formulas. In children
and adolescents, the results are relatively valid,
Category BMI (kg/m2) Risk of comorbi-
dities and there are reference values for Germany. In
adults, especially in people with obesity, the
Underweight < 18.5 low Low
method is less precise, with deviations of up to
Normal weight 18.5–24.9 Average
20% compared to reference methods.
Overweight >25.0 Slightly increased
Pre-obesity 25.0–29.9 Slightly increased Bioelectric impedance analysis (BIA) In the
Obesity class I 30.0–34.9 Increased BIA method, the electrical alternating current
Obesity class II 35.0–39.9 High conductivity in body fluid is measured. Four
electrodes are attached to the hand and foot,
with the current frequency usually being 50
Table 55.2  Waist/hip circumference and risk for obe- kHz. The impedance is determined, which is
sity-associated complications (according to Lean et al. the resistance to alternating current, composed
1995) of the resistive resistance (water and electro-
Risk for metabolic Waist circum- Waist-to-hip lyte content) and the capacitive resistance (cell
and cardiovascular ference (cm) ratio membranes). Using algorithms and reference
complications
Men Women Men Women methods, parameters of body composition (total
Increased ≥ 94 ≥ 80 ≥ 1.0 ≥ 0.85 body water, extracellular body water, body cell
Significantly ≥ 102 ≥ 88 mass, fat-free mass) can be calculated. The body
increased fat mass is obtained from body weight—body
cell mass. The phase angle is an indicator of
hydration and cell membrane integrity. The BIA
55.1.2 Methods for Measuring Body method is now also frequently used in clinical
Composition practice. It is better suited for estimating body
composition than for monitoring progress, as
Body composition is of great importance for a small changes in body weight do not adequately
differentiated view of obesity. Body fat mass is reflect changes in body compartments. So-called
distributed differently in individuals, which is fat scales with impedance measurement are not
relevant for morbidity, quality of life, and mor- very precise, as the current is only conducted
tality. Some people in the overweight range have through the legs and lower abdomen.
no increased fat mass but a strongly developed
musculature, and some have very little muscle Dual X-ray absorptiometry (DXA) In this
but a relatively large proportion of fat (sarco- X-ray method, two different photons are emit-
penic obesity). Nowadays, there are numerous ted, attenuated differently in the body by dif-
methods, some of which are easy to handle, ferent compartments, and reabsorbed. The
while others are very complex and complicated, radiation exposure is low, but not tolerable for
so they are only used for scientific purposes pregnant women and children. DXA was pri-
(Bosy-Westphal and Müller 2013; Okorodudu marily developed for bone density measurement.
et al. 2019). The method can also quantitatively capture soft
tissues such as body fat and muscles. To capture
Skinfold thickness measurement With a regional body fat in the visceral or gluteal-femo-
measuring clamp (e.g., caliper), the subcu- ral region, special software is required. Patients
taneous fat layer thickness can be measured weighing >150 kg cannot be examined by many
devices.
55 Diagnosis and Etiology of Obesity 413
Density measurement (densitometry) In sagittal (intra-abdominal) diameter correlates

hydrodensitometry (underwater weighing), with the visceral fat mass.
the body volume is measured according to the
Archimedean principle (water displacement) and Dilution methods Dilution methods are suit-
the body density is calculated from body mass able for measuring body water. Isotopes such
and body volume. It is a classical method with as deuterium (D2O), oxygen (H218O), or tritium
precise results. However, the equipment, person- (3H2O) are commonly used. The isotopes dis-
nel, and time required are considerable, so the tribute in all fluids, and body water is measured.
method is only used for special scientific inves- Isotopes can be measured accurately, with the
tigations, but increasingly less so. precision for total body water being about 2%.
The water content of the body in a 70 kg man is
Air-displacement plethysmography This 63%, and in an obese person, it is significantly
method can also be used to determine body den- less depending on the extent. However, the mus-
sity, with a precision of 2–3%. The measuring cular water content is quite constant at 73%. The
principle is based on the Poisson gas law. Body measurement parameters provide good results
surface and thoracic gas volume, determined regarding total body water, extracellular water,
in the body plethysmograph, as well as other fat mass, and fat-free mass (muscle mass). The
parameters, are included in the calculation. The method is used only for scientific purposes.
measurement can be performed in a few min-
utes. It is much less labor-intensive than hydro-  Important
densitometry and much more comfortable for • Obesity is defined by weight-height indi-
the patient. Children can be examined with spe- ces (BMI).
cial devices. • Measuring waist circumference provides
further indications for morbidity and mor-
Computed tomography (CT) and mag- tality risk.
netic resonance imaging (MRI) These meth- • Some methods have proven effective in
ods allow for a differentiated and quantitative clinical practice depending on the ques-
assessment of body organs that are of interest tion: skinfold thickness measurement,
in the diagnosis of obesity: total body fat, vis- bioelectrical impedance analysis (BIA),
ceral fat, subcutaneous fat tissue, gluteo-femoral dual X-ray absorptiometry (DXA).
fat tissue. Depending on the target size, several • In scientific research, other methods are
scans are required, with visceral fat being meas- used: air-displacement plethysmography,
ured at the level of L4. Differences in organ den- magnetic resonance and computed tomog-
sity are shown in grayscale scans. Quantitative raphy, as well as dilution methods and
evaluation is carried out using planimetric meth- ultrasound.
ods. A CT involves significant radiation expo-
sure, while an MRI does not and can therefore
also be used for pregnant women and children. 55.2 Causes of Obesity
Ultrasound The widespread availability of 55.2.1 Genetic Predisposition

these devices in practices and clinics is one rea-
son to also perform measurements in people Genetic research has generated many insights
with obesity. More than half of those affected in recent years, as a number of new techniques
have fatty liver. Using certain scores, the liver have been applied that can also be used in large
fat content can be determined. The subcutane- population groups. Inheritance can affect energy
ous fat layer thickness can be easily measured intake (hunger and satiety regulation), energy
at many body sites. The determination of the expenditure, and energy storage.
414 A. Wirth
Significant findings come from twin the genetic causes, a small part of what has been
research. Twins were either observed over sev- shown in formal genetic studies (50–80%).
eral years or were experimentally under- or
overfed. In adoption studies, genetic effects can
be convincingly investigated, as the adoptees 55.2.2 Disturbance of Energy Intake
share the genetic material with their biological
parents and the environment with their adoptive The energy balance is controlled in the hypothal-
parents. An evaluation of the Danish adoption amus by biological mechanisms that are partly
register with 3,580 individuals revealed the fol- determined by genetics and/or the environment.
lowing (Stunkard et al. 1986): The weight of the The consumed food is important in terms of
adoptees did not correlate with that of the adop- type and quantity, as it is not only relevant for
tive parents, but only with that of the biological its energy content but also affects biological and
parents. psychological mechanisms. If the energy bal-
If a genetic variant, a mutation in a single ance is positive, mainly body fat is stored; if
gene, exists, it is referred to as a monogenic it is negative, fat is broken down. This system,
form of obesity. Affected are individuals who maintaining a constant body weight, works for
are not only obese but also exhibit additional many people throughout their lives. Often, the
characteristics, in which case a syndromal regulation is disturbed by caloric overconsump-
obesity exists. These individuals can be diag- tion, as there were many phases of malnutrition
nosed through careful clinical examination and and famine in evolutionary history. This “expe-
by taking a medical history. These syndromes rience” also explains why counter-regulatory
are rare but are of great clinical interest due to mechanisms are activated during weight loss.
high morbidity. More than 50 such syndromes
are known worldwide, some of which are men-
tioned here: Prader-Willi syndrome, Ahlström 55.2.3 Regulation of Hunger
syndrome, Cohen syndrome, Carpenter syn- and Satiety
drome, Albright’s hereditary osteodystrophy,
Rubinstein-Taybi syndrome, etc. The regulation of hunger and satiety is often
In some monogenic forms, only obesity represented in analogy to the “satiety cascade”
is present, with a so-called major gene effect. developed by Blundell (2010): Appetite and
This has been demonstrated for the hormone hunger initiate the eating process. This is ter-
leptin and leptin receptors. Leptin reduces the minated by a feedback mechanism through the
expression of proopiomelanocortin (POMC) in consumed food and sensory influences (“satia-
the hypothalamus, which activates the release tion”). The resulting “fullness” causes no more
of melanocortin-4 receptor (MC4R) over sev- eating and the meal is finished for an extended
eral stages. A mutation in the MC4R is found in period, satiety (“satiety”) sets in. The satiety
2–6% of children with extreme obesity (Hinney between meals (“inter-meal satiety”) and the
et al. 2010). length of breaks between meals depend on the
More common than monogenic forms are type and amount of food and its chemical prop-
polygenic forms of obesity. Genome-wide asso- erties (macro- and micronutrients). For example,
ciation studies (GWAS) can identify gene vari- tasty food stimulates hunger and shortens the
ants. In a meta-analysis, 941 BMI-associated time between meals.
polymorphisms were described, explaining 6% Biological signals for the regulation of hun-
of the variance in BMI (Yengo et al. 2018). Of ger and satiety mainly come from the gastro-
great importance is the FTO gene, the presence intestinal tract. Ghrelin and cholecystokinin
of which increases the risk of obesity by 1.5 greatly stimulate hunger and food intake. They
times. GWAS can so far only describe 6% of are produced in the gastric fundus and in the
proximal small intestine (duodenum and jeju- of 17,000–84,000 kcal was determined and a
num), respectively. Glucagon-like peptide and weight gain of 1.4–8.9 kg occurred (Bray and
peptide YY reduce appetite and food intake. In Bouchard 2020).
addition to these substances, there are a num-
ber of other substances that play a role outside
the gastrointestinal tract. Orexigenic substances 55.2.5 Significance
stimulate hunger and appetite: neuropeptide Y, of Macronutrients
melanin-concentrating hormone, agouti-related
protein, cannabinoids, etc. Anorectic substances
have the opposite effect: leptin, amylin, seroto- Fat Fat in the diet promotes weight gain. Fat
nin, norepinephrine, endocannabinoid receptor contains twice as much energy as carbohydrates
inhibitors, corticotropin-releasing hormone, etc. or protein. Individuals with obesity consume
more fat than those with normal weight. The fol-
lowing questions arise: Is more fat consumed
55.2.4 Malnutrition not only for reasons of taste, but also due to lack
of satiety? Do people with obesity behave dif-
For many years, Western society has been in an ferently than those with normal weight? Many
environment with an abundance of food. The studies on this topic show that fat has little sati-
general availability, tastiness, and low prices ating effect and meals with high fat content and
encourage overconsumption. Fig. 55.1 shows thus high energy content do not cause increased
the results of 19 studies in which overnutrition or longer-lasting satiety. Since high-fat foods
9.00
8.00
7.00
6.00
Weight gain (kg)
5.00
4.00
3.00
2.00
1.00
0.00
0 10000 20000 30000 40000 50000 60000 70000 80000 90000
Overeating (Kcal)
Fig. 55.1  Weight gain with overnutrition in 19 studies with different observation periods. (Modified after Bray and
Bouchard 2020)
416 A. Wirth
taste good and provide little satiety, they are and fruit juices increased by about half (Nielsen
often eaten in excessive amounts, referred to as and Popkin 2003). The same applies to snacks,
“passive overconsumption”. french fries, hamburgers, and cheeseburgers.
Fatty foods often lead to overnutrition: Experimental studies show that large packaging
sizes and large portions also lead to increased
• tastiness energy intake. Those who have a lot on their
• high energy density plate usually eat a lot (Mesas et al. 2012).
• low volume
• low satiety Distribution of meals—eating frequency Most
studies, including meta-analyses, found a weak
Carbohydrates Carbohydrates consist of association between the frequency of meals and
sugars with different chemical composi- their distribution throughout the day. It has been
tions. Sugary drinks have a particularly nega- proven that one should not snack between meals
tive impact on weight, especially in children unless hungry. There is also no recommendation
and adolescents. Complex carbohydrates (e.g., on how often one should eat per day; eating 2, 3,
fiber, whole grains) are evaluated differently, or 4 times a day is of no importance. However,
as they have a low energy density and provide those who consume larger amounts of food
significant satiety. According to the German in the evening or at night are at risk for weight
Society for Nutrition (DGE 2017): “An increase gain. More important than the “eating pattern”
in whole grain product intake is associated are energy content, energy density, and portion
with preventive benefits.” Consuming carbo- sizes (Mesas et al. 2012).
hydrates with a lower glycemic index may be
advantageous, but the evidence for this is weak. Fast food and convenience prod-
Sweeteners (e.g., saccharin, cyclamate, aspar- ucts Predominantly younger individuals fre-
tate, acesulfame-K, etc.) contain almost no quently consume fast food, a product that often
energy, and foods with sweeteners (“diet” prod- contains a lot of fat, refined sugars, and little
ucts) contain less than those with sugar. In mod- dietary fiber. Fast food is often characterized by
eration, sweeteners do not increase food intake. large portions, tastiness, high energy density,
and a high glycemic index. According to the
German Frozen Food Institute, per capita con-
55.2.6 Alcohol sumption of convenience products has doubled
in the last 20 years.
Although low and moderate alcohol consump-
tion can have positive effects on health, alcohol Energy density The energy density of foods,
has a negative impact on body weight. Alcoholic i.e., the quotient of energy content (calories)
beverages with high calorie content (e.g., beer) and quantity (g), is of great importance for the
were found to be positively correlated with body development of obesity (Bes-Rastrollo et al.
weight in many studies. 2008). Those who consume foods with high
energy density (e.g., animal fats, sweets) have
little on their plate but still many calories. Foods
55.2.7 Portion Sizes with low energy density are water- and fiber-
rich foods such as vegetables, fruits, soups, and
Many people consume little fat and sugar and water.
still become overweight. Reasons for this
include increasing packaging sizes in recent Diagnosis of energy intake Table 55.3 pro-
years. Observations from the USA over 20 vides an overview of nutritional assessment
years show that packaging sizes for soft drinks methods.
Table 55.3  Overview of nutritional assessment methods; the use for research and/or practice depends on the respec-
tive question; pro=prospective; retro=retrospective. (Mod. after Holzapfel and Wirth 2013)
Method Prospective/ Practice/
Retrospective Research Evaluation
Weighing Pro Practice/Research Very accurate, time-consuming
Nutrition diary Pro/Retro Practice/Research “Gold standard” in combination with weighing
Food frequency ques- Retro Practice/Research No quantity information, fast, suitable for large cohort
tionnaire
Nutritional history Retro Practice Dependent on memory, “obsolete”
24-hour recall Retro Practice/Research Dependent on memory
“New technologies” Pro/Retro Research Promising, not yet established, benefits still unclear
Weighing Weighing in combination with a indicate the consumption frequency of certain

nutrition diary is considered the gold stand- foods in a table (in writing or electronically),
ard. In experimental situations, the amount of which are sorted by groups (e.g., cereal prod-
food on the plate and the leftovers are usually ucts, dairy products, vegetables, and fruits). The
weighed. The energy content can be calculated frequency classification ranges from “daily”
from the difference and the food composition to “three to four times per week” to “never”.
with an accuracy of about 2%. If the plate is In the therapeutic area, an evaluation can be
continuously weighed during eating, it is called made based on a rating using traffic light colors
a “Universal Eating Monitor” (UEM). The so- (e.g., commendable [green], questionable [yel-
called “Food Dispenser” has become estab- low], not recommended [red]). Compared to
lished in science; here, even solid foods can be the food record, food frequency questionnaires
administered. have the advantage of placing fewer demands
Diet History This is a structured interview on the patient in terms of time and intelli-
in which retrospective data on nutrition is col- gence. The questionnaire can also be evaluated
lected. Using a standardized questionnaire, semi-quantitatively.
a dietary survey (sequence and frequency of
meals), quantity (in household measures) of Accuracy of interviews, questionnaires, and
individual foods, dietary habits, seasonal peculi- records
arities, and social circumstances are conducted. The main advantage of all these methods lies in
The dietary history can be supplemented by a the simple, fast, and cost-effective collection.
so-called “24-hour recall”. In this case, the food Both the interviewer and the patient may have
intake of the past three days is usually asked biases. People with obesity significantly under-
by a nutritionist; the result can be recorded on estimate the quantity of food compared to those
standardized forms. with normal weight (“under-reporting”). In a
valid study, people with obesity under-reported
Food record In a food record, the consumed their food intake by 34-47% (Lichtman et al.
foods are recorded in writing or electronically. 1992).
For example, 100 common foods and beverages
are provided in tabular form for selection. The
patient/participant enters the number of individ- 55.2.8 Physical Inactivity, Immobility
ual foods (e.g., two teaspoons of sugar, one slice
of whole grain bread). A low energy expenditure due to physical inac-
tivity contributes to the development of obesity,
Food frequency questionnaire In food fre- as does an increased energy intake. While basal
quency questionnaires, patients/participants metabolic rate and thermogenesis, the other
418 A. Wirth
components of energy expenditure, can only be no significant effect (Rosenberg et al. 2013).
influenced to a small extent, there are naturally Other studies have shown that younger individu-
large variations in physical activity. A distinc- als benefit more from increased physical activ-
tion is made between spontaneous and inten- ity than older ones, with no gender differences.
tional activity, the former being unconscious/ Guidelines recommend engaging in moderate to
genetically predetermined (e.g., fidgeting), the intense physical activity for >150 minutes per
latter being deliberately initiated. The rest- week.
ing energy expenditure (basal metabolic rate)
is essentially determined by age, sex, fat-free
body mass (muscle mass), ethnicity, and genetic 55.3 Recording of Physical
predispositions. Activity
Almost all studies (observational and experi-
mental) show that high physical activity reduces Resting energy expenditure and thermogenesis
or prevents weight gain; in industrialized soci- are measured using indirect calorimetry (gas
eties, adults gain 0.5–0.8 kg in weight per year. exchange). In the respiration chamber, spontane-
In a large study with 20,259 normal-weight ous activity can also be determined by motion
women under 40 years of age, physical activ- sensors. Total energy expenditure can be accu-
ity was recorded, among other things. After 14 rately recorded under everyday situations using
years of observation, obesity was especially less doubly labeled water.
likely to develop in women who engaged in mod- Physical activity is usually recorded using
erate to high-intensity activity (jogging, swim- two different measurement variables, the meta-
ming, aerobics, basketball) (Fig. 55.2). However, bolic equivalent (MET) and the physical activity
walking, strolling, and exercising at home had level (PAL).
BMI <25 kg/m2 BMI >25 kg/m2

1
0.9
Relative risk for obesity
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
No Exercise 1-2 3-4 5-6 >7
Physical activity (hours/week)
Fig. 55.2  Prevention of obesity through physical activity (medium to strong activity) (Modified from Rosenberg
et al. 2013)
MET (metabolic equivalent) 1 MET cor- low status were two to three times more likely
responds to the resting energy expenditure of to be obese across all age groups than women
3.5 ml O2/kg/Min or 1.2 kcal/kg/Min. METs with a high social status. In men, the trend was
are always given as multiples of resting energy much less pronounced, with a low social status
expenditure. MET is an absolute measure of increasing the prevalence of obesity by about
energy consumption: 10% (younger) to about 50% (older).
MET for physical activities:
• light activity: >3 METs (e.g., slow walking) 55.5 Sleep Deprivation—
• moderate activity: 3–6 METs (e.g., walking Disturbed Sleep
at 4–7 km/h)
• intense activity: >6 METs (e.g., jogging) In children, there is a close relationship between
sleep duration and body weight. This relation-
PAL (physical activity level) PAL is primar- ship is also present in adults, as shown by a
ily used to determine total energy expenditure. 1 meta-analysis of twelve studies (Zhou et al.
PAL corresponds to resting energy expenditure. 2019). As with previous studies, it was found
PAL classification for physical activities: that a sleep duration of seven hours per night has
the lowest risk of developing obesity (Fig. 55.3).
• sedentary: >1 to 1.4 A reduction in sleep duration significantly
• lightly active: >1.4 to <1.6 increases the risk, while an extension hardly
• active: >1.6 to <1.9 does.
• very active: >1.9 to <2.5 Individuals with shortened sleep duration eat
irregularly, often at night, and are more hungry
Example: Total energy expenditure for a during the day. The background for this may be
45-year-old assembly line worker with a BMI of increased ghrelin and cortisol levels as well as
29.3 kg/m2: decreased leptin concentrations. A short sleep
duration also increases fatigue and leads to less
physical activity.
• Resting energy turnover 1908 Kcal/d
(measured)
• 8 hours of work as an assembly line worker
55.6 Diseases Associated With
with 1.6 PAL
Obesity
• 8 hours of leisure time 1.4 PAL
• 8 hours of sleep with 0.95 PAL
Hypothyroidism Hypothyroidism is present in
The total energy expenditure is calculated: (8 ×
about 3% of cases of obesity. Due to the simple
1.6) + (8 × 1.4) + (8 × 0.95)/24 × basal meta-
diagnosis and good therapeutic success, this dis-
bolic rate = 2518 Kcal/d
ease should always be ruled out. Determining
the basal TSH in plasma is sufficient for this
purpose.
55.4 Low Socioeconomic Status
Cushing’s disease Cushing’s disease should
In the study on adult health (DEGS1), a repre- only be verified or ruled out in cases of clini-
sentative survey of 8152 women and men aged cal suspicion (frequency <1%). Red striae
18–80 years in Germany from 2008 to 2011, a and trunk-centered fat distribution are hardly
clear relationship between BMI and socioeco- pathognomonic for this disease and often occur
nomic status was found regarding the preva- in obese individuals without elevated cortisol
lence of obesity (Kurth 2012). Women with a levels.
420 A. Wirth
1.8
Relative risk of obesity
1.6
1.4
1.2
0.8
4 5 6 7 8 9 10
Sleep duration (hours per night)
Fig. 55.3  Sleep duration and risk of obesity. Mean values (solid line, standard deviation dashed line) (Mod. after
Zhou et al. 2019)
Polycystic ovary syndrome (PCOS) This syn- kg), cortisone (2.0 kg), beta-blockers (0.5–2.3
drome is associated with obesity (50%), hir- kg). In a more recent meta-analysis of 307 arti-
sutism (70%), amenorrhea (50%), infertility cles, some substances are mentioned that cause
(70%), and large, sclerotic, cystic ovaries. The a weight gain of >5 kg with long-term use (Bak
cystic ovaries are diagnosed sonographically. et al. 2014).
Hypothalamic symptom complex There is Antidepressants Antidepressants are often

a disturbance in the hypothalamus, the center prescribed, especially for patients with obesity,
for hunger and satiety, with various underlying as they are more likely to experience depres-
causes. Tumors, inflammatory processes, leu- sion and anxiety compared to people with nor-
kemic infiltrates, traumas, and aneurysms can mal weight. Many patients find themselves in a
cause damage at different locations with varying vicious cycle:
symptomatology. weight gain → depression → antidepressants
→ further weight gain → increased depression
The highest weight gains are observed with
55.7 Drugs and Weight Gain amitriptyline, mirtazapine, and paroxetine,
which amount to 2–3 kg in chronic treatment, as
Drugs with weight gain as a side effect are shown by a meta-analysis (Serretti and Mandelli
mainly found in psychiatric disorders/diseases, 2010; Fig. 55.4). Some antidepressants ini-
but also in diabetes mellitus, inflammatory dis- tially reduce weight and increase it in the long
eases, and hypertension. A systematic review of term (e.g., duloxetine, paroxetine, citalopram).
43 randomized trials found the following results Bupropion significantly reduces weight not only
regarding weight gain (Himmerich et al. 2005): in the short term but also in chronic therapy.
antipsychotics (2.1–7.1 kg), mood stabilizers
(2.5–5.8 kg), insulin (1.8–6.6 kg), sulfonylureas Mood stabilizers These “mood enhancers” are
(1.4–5.0 kg), tricyclic antidepressants (1.7–3.7 also often prescribed for patients with obesity,
2.5
1.5
1
Weight change (kg)
0.5
-0.5
-1
-1.5
-2
line
n
ne
ine
line
ne
e
bo
line
ne
pin
pio
pra
eti
eti
eti
ce
am
rtra
pty
pty
za
pro
ox
lox
rox
Pla
alo
ipr
rtri
itri
rta
Se
Flu
Bu
Du
Pa
Cit
Im
Am
No
Mi
Fig. 55.4  Antidepressants and weight change, meta-analysis. (Modified from Serretti et al. 2012)
but often for other indications (e.g., epilepsy). quetiapine, amisulpride, aripiprazole, ziprasi-
Lithium leads to weight gain in about 25% of done and haloperidol.
patients, often in the range of 4–12 kg. Weight
gain to a similar extent has also been proven for Insulin and oral antidiabetics Insulin, a
gabapentin. Carbamazepine increases weight growth hormone, increases body weight by 5–10
less, mainly due to fluid retention. Lamotrigine kg through various mechanisms. Sulfonylureas
appears to be weight-neutral (Torrent et al. and glinides also cause weight gain.
2008).
Corticosteroids Cortisol increases body
Neuroleptics Some representatives of this sub- weight, typically in the form of abdominal obe-
stance class lead to significant weight gains. For sity with a round face, striae rubrae, muscle
decades, this has been described for olanzapine weakness, and osteoporosis. Cortisol stimulates
and clozapine with average weight gains of 8–12 appetite and fat formation.
kg. It is reported that more than half of individu-
als taking clozapine gain more than 10% and Estrogens/contraceptives Estrogens in the
one in five gains more than 20% (Torrent et al. context of hormone replacement therapy do not
2008). Less pronounced weight gains occur increase body weight, whereas contraceptives
with molindol, loxapine, pimozide, risperidone, promote body fat accumulation by inhibiting fat
oxidation.
422 A. Wirth
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Epidemiology of Obesity
56
Katharina Nimptsch and Tobias Pischon
Contents
56.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 425
56.2 Definition of Obesity in Epidemiological Studies . . . . . . . . . . . . . . . . . . . . . 425
56.3 Global and Temporal Trends in Obesity Prevalence . . . . . . . . . . . . . . . . . . 427
56.4 Development of Individual BMI Over the Life Course . . . . . . . . . . . . . . . . 428
56.5 Determinants of the Rising Prevalence of Obesity . . . . . . . . . . . . . . . . . . . . 428
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 429
56.1 Introduction it can be considered as a chronic entity, as the

individual BMI in adulthood is a relatively sta-
The prevalence of obesity has substantially ble characteristic in the short term and tends to
increased in almost all countries of the world, increase rather than decrease over the course of
and a further increase is also expected for the life. Long-term weight loss, on the other hand,
future (N. C. D. Risk Factor Collaboration is less common, as intervention measures for
2016). Obesity is a risk factor for a number of weight reduction in overweight or obese people
chronic diseases, especially type 2 diabetes mel- usually only show short-term effects. This chap-
litus, coronary heart disease, and certain cancers ter provides an overview of the epidemiology of
(Haslam and James 2005; Nimptsch and Pischon obesity.
2015). Consequently, obesity is also associ-
ated with a lower life expectancy (Whitlock
et al. 2009). Even though obesity is not yet 56.2 Definition of Obesity
referred to as a chronic disease in all countries, in Epidemiological Studies
Since the 1980s, the body mass index (BMI,

calculated from the quotient of body weight
K. Nimptsch (*) · T. Pischon in kilograms and the square of body height in
Molecular Epidemiology Research Group,
Max Delbrück Center for Molecular Medicine in the meters) has been the globally accepted meas-
Helmholtz Association (MDC), Berlin, Germany ure for the definition of overweight and obe-
e-mail: [email protected] sity in adults, with a BMI greater or equal to
T. Pischon 25.0 kg/m2 being considered overweight and
e-mail: [email protected] a BMI greater or equal to 30.0 kg/m2 being
https://doi.org/10.1007/978-3-662-67662-2_56
426 K. Nimptsch and T. Nimptsch
considered obese. Normal weight is defined as a and chronic inflammatory processes (Galic
BMI between 18.5 and 24.9 kg/m2, and a BMI et al. 2010).
below 18.5 kg/m2 is considered underweight.
The obesity threshold, also supported by the Simple measures for assessing body fat distri-
World Health Organization (WHO), is based bution are waist circumference and waist-to-hip
on the observation in epidemiological studies ratio. These measures have the advantage of
that a BMI of 30.0 kg/m2 or higher is associated correlating more strongly with visceral adipose
with a higher mortality risk (Expert Panel on the tissue than BMI. The WHO recommends addi-
Identification 1998; World Health Organization tional measurements for body fat distribution in
2000). The mentioned thresholds for overweight individuals with a BMI between 25.0 and 34.9
and obesity apply particularly to Western popu- kg/m2; with a waist circumference greater than
lations. Lower thresholds for the definition of or equal to 102 cm for men or 88 cm for women,
overweight and obesity have been proposed for or a waist-to-hip ratio greater than or equal to
Asian populations, as it has been observed that 0.95 for men or 0.80 for women as a criterion
Asians, compared to non-Asians with the same for abdominal obesity (Expert Panel on the
BMI, have a higher body fat percentage and a Identification 1998; World Health Organization
higher metabolic risk (insulin resistance, dia- 2000). However, recent studies show that waist
betes, dyslipidemia) (Pan and Yeh 2008). For circumference measurement is also important for
children and adolescents, there is no univer- morbidity and mortality risk in individuals with
sally valid BMI-based definition of obesity due lower BMI (below 25.0 kg/m2) (Pischon et al.
to the rapid changes in proportions and body 2008; Feller et al. 2010). Newer techniques for
composition during growth. Instead, the WHO refined diagnosis of obesity, such as imaging
recommends the use of age-specific BMI refer- methods like magnetic resonance imaging (MRI)
ence curves (WHO Growth Standards) for the to distinguish between fat mass and fat-free
definition of obesity in children and adolescents, mass or subcutaneous and visceral fat, are prom-
which were constructed from data of a multi- ising but currently have limited clinical signifi-
center, population-based study from 1997–2003 cance, as established thresholds are still lacking.
(WHO Multicentre Growth Reference Study In addition to the described “eutopic” fat
Group 2006; de Onis et al. 2007). accumulation, ectopic fat deposition likely plays
In both clinical and scientific-epidemiological a special role in disease risk (Shulman 2014).
contexts, the BMI has proven its worth, as it is This involves (presumably due to a capacity
easy to measure and is associated with both mor- overload of adipose tissue) abnormal fat deposi-
bidity and mortality. The BMI correlates with fat tion in organs (mainly in the liver and muscles),
mass; however, it is not a perfect measure, as it leading to insulin resistance and its associated
cannot distinguish between fat mass and fat-free consequences (Shulman 2014). Ectopic fat dep-
mass and does not take into account body fat osition can be quantified primarily with mag-
distribution. Visceral fat is particularly important netic resonance spectroscopy; however, the liver
for the metabolic changes associated with obe- enlargement associated with fatty liver also con-
sity and the resulting increased disease risk. tributes to waist circumference.
To assess the prevalence of obesity epide-
 Important While the largest proportion of fat miologically, reliable data sources are needed.
mass is found subcutaneously, the adipose In epidemiological studies and national and
tissue in the abdominal cavity, i.e., the adi- regional health surveys, the collection of body
pose tissue surrounding the organs (visceral weight and height has become standard, with dif-
fat), has the highest metabolic activity: Vis- ferences in whether the measurements are taken
ceral adipose tissue produces relatively more using standardized methods or self-reported by
hormones and cytokines, which promote study participants. Measures of body fat distribu-
metabolic disorders such as insulin resistance tion, such as waist circumference or waist-to-hip
56 Epidemiology of Obesity 427
ratio, are often, but not always, measured in a The highest obesity prevalences in 2014 were
standardized manner in studies. observed for men and women in Polynesia and
Micronesia (50% of women and 38% of men
were affected by obesity). Prevalences of over
56.3 Global and Temporal Trends 30% were observed in 2014 for men and women
in Obesity Prevalence in English-speaking high-income countries
(Australia, New Zealand, Canada, USA, Ireland,
 Important National, regional, and multi- UK) as well as for women in southern Africa,
center studies have shown that the prevalence the Middle East, and North Africa.
of obesity has increased dramatically over A global increase in mean BMI was also
the past 50 years, not only in industrialized observed between 1975 and 2016 for children
countries but also in emerging and develop- and adolescents aged 5-19 years, with strong
ing countries. regional differences. The smallest increase was
recorded for boys and girls in Eastern Europe,
The global and temporal trends of BMI and while the highest increase was observed for
obesity prevalence at the population level are boys and girls in Polynesia and Micronesia
currently being systematically investigated and for girls in Latin America. Interestingly,
using a variety of population-based studies and the BMI increase curve for girls and boys has
surveys with measured BMI data from two pri- flattened since 2000 in Northwest Europe,
vately funded initiatives: on the one hand, by English-speaking high-income countries, and
the Non-Communicable Disease Risk Factor the Asia-Pacific region, while the increase in
Collaboration (NCD-RisC) (N. C. D. Risk East, Southeast, and South Asia continues una-
Factor Collaboration 2016, 2017), and on the bated. The age-standardized obesity prevalence
other hand, by the Global Burden of Metabolic (defined as BMI > 2 standard deviations from
Risk Factors of Chronic Diseases Collaborating the median of the WHO reference curve for chil-
Group (Finucane et al. 2011) dren and adolescents) has increased in the last
The most comprehensive data on the devel- four decades, from 0.7% to 5.6% in girls and
opment of measured BMI and obesity preva- from 0.9% to 7.8% in boys. Despite the strong
lence were provided by NCD-RisC. For adult increase in obesity prevalence, more girls and
trends, data were evaluated from 1,698 popu- boys worldwide are still moderately to severely
lation-based studies with BMI measurements underweight (2016: 8.4% for girls, 12.4%
for 19.2 million participants in 200 countries for boys) than affected by obesity, with only a
for the years 1975–2014 (N. C. D. Risk Factor slight decrease in the prevalence of underweight
Collaboration 2016). For trends in children, ado- in the last four decades. The highest preva-
lescents, and adults, data were evaluated from lences of underweight in 2016 were observed
2,416 population-based studies with a total in South Asia, particularly in India (22.7% for
of 128.9 million participants in 200 countries girls, 30.7% for boys). An increase in obesity
for the years 1975–2016 (N. C. D. Risk Factor prevalence among children and adolescents was
Collaboration 2017). observed worldwide in all regions, with the
The data collected by NCD-RisC show that increase being less pronounced in high-income
the mean BMI and obesity prevalence in adults regions, but particularly pronounced in south-
worldwide have increased over the past four ern Africa. The highest obesity prevalence in
decades. 2016 was observed in Polynesia and Micronesia
for both sexes (25% for girls, 22% for boys),
 Important Between 1975 and 2014, the age- followed by English-speaking high-income
standardized global obesity prevalence in- countries.
creased from 3.2% to 10.8% in men and from The figures on obesity prevalence and global
6.4% to 14.9% in women. temporal trends compiled by the Global Burden
of Metabolic Risk Factors Collaboration are childhood and adolescence plays a key role in
overall comparable to those of the NCD-RisC, the epidemiology of obesity, as overweight chil-
although methodological differences can be dren have a high risk of being affected by obe-
found in the data sources used, the number sity in adulthood (Baird et al. 2005).
of countries included, and the age definitions
(children and adolescents aged 2–19 years)
(Finuncane 2011; Stevens 2012). 56.5 Determinants of the Rising
Prevalence of Obesity
56.4 Development of Individual BMI The cause of obesity at the individual level is
Over the Life Course still considered to be a long-term positive energy
balance, i.e., a higher energy intake from food
In order to understand the epidemiology of obe- than energy consumed through basal metabo-
sity, it is important to note that the figures shown lism, the thermal effect of food, and physical
for the prevalence of obesity always refer only activity. Determinants of obesity include a wide
to a snapshot of the current weight status of range of complex biological and social factors as
the study participants. On an individual level, well as environmental conditions that influence
however, body weight and BMI change over energy balance. These determinants include
the course of life. While the individual BMI in physiological and psychological susceptibility
middle age is a relatively stable characteristic factors at the individual level, physical activity
in the short term, there is a tendency for weight and dietary factors, as well as food production,
gain in the long term in adulthood, despite that supply, and marketing, socioeconomic factors,
fact that the negative consequences of obesity and environmental conditions that influence
for health are widely known. Exceptions to this physical activity and dietary behavior at the
are only seen in very old age or in the last years societal level.
before death. An analysis of three long-term
studies from Sweden showed that there are two  Important Although primarily behavioral and
turning points in BMI development in adult- environmental factors influence individual
hood (Dahl et al. 2014): BMI initially increases energy balance, genetic factors also play a
steadily between the ages of 25 and 65, with role.
this increase stopping after the age of 65. At the
age of 80, there is finally a decrease in BMI. The heritability of BMI has been estimated at
The influence of known lifestyle factors such as 40–70% in twin studies. On the other hand,
physical activity, alcohol intake, and smoking genome-wide association studies have found
on BMI varies in strength over the life course. that only a limited proportion of up to 6–11%
However, it must be taken into account that with of BMI variability can be explained by genetic
increasing age, the ratio of fat mass to mus- variants (Speliotes et al. 2010). The globally
cle mass changes, i.e., fat mass increases while observed increase in mean BMI and obesity
muscle mass decreases, which is not necessar- prevalence cannot be explained by genetic influ-
ily reflected in the BMI. Longitudinal studies ences alone.
have shown that waist circumference increases Socioeconomic status and country-specific
with age, especially in women, and this occurs differences in wealth, on the other hand, partly
throughout the entire life span. This means that explain some of the observed temporal trends
in older age, waist circumference and fat mass and regional differences in obesity prevalence.
can continue to increase despite a stable or even An increase in obesity prevalence has been
declining BMI, which overall has an unfavora- observed since the mid-1970s, initially in high-
ble effect on the risk of chronic diseases (Kuk income countries, followed by middle-income
et al. 2009). In addition, body weight during countries as wealth increased, and finally in
56 Epidemiology of Obesity 429
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Psychosocial Factors of Obesity
in Childhood and Adolescence 57
Petra Warschburger
Contents
57.1 Definition and Prevalence of Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 431
57.2 Social Stigmatization, Teasing, and Obesity . . . . . . . . . . . . . . . . . . . . . . . . . 432
57.3 Psychological Disorders and Behavioral Problems . . . . . . . . . . . . . . . . . . . . 433
57.4 Quality of Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 434
57.5 Conclusion: Importance of Psychological Factors . . . . . . . . . . . . . . . . . . . . 435
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 435
Obesity in childhood and adolescence has long on reduced self-regulation skills. Psychosocial
been a neglected topic. Meanwhile, it has become factors play an important role in the development
clear that this is by no means a temporary or and maintenance of obesity and should be given
minor phenomenon, but rather a serious health central importance in treatment.
problem, particularly due to its diverse psycho-
logical consequences. Children and adolescents
with obesity experience increased social stigma- 57.1 Definition and Prevalence
tization (e.g., teasing), and this has a negative of Obesity
impact on their psychosocial well-being (e.g.,
self-esteem, body image, quality of life). In addi- Obesity refers to an excessive relative body fat
tion, there are increased rates of clinical disorders percentage, which is associated with increased
in both internalizing (e.g., anxiety, depression) morbidity and mortality. It is estimated using the
and externalizing behaviors (e.g., aggression, BMI. When determining critical BMI values for
ADHD). In general, these burdens are particu- children and adolescents, their growth and puber-
larly pronounced in groups that also seek clinical tal development must be taken into account. This
treatment, but, to a lesser extent, they are found is done using age- and sex-specific BMI per-
in population-based studies as well. In recent centile curves. As a criterion for the presence of
years, there has also been an increase in findings obesity, values above the 97th percentile are rec-
ommended; overweight is defined as BMI values
above the 90th (and below the 97th) percentile
(see Kromeyer-Hauschild et al. 2001).
P. Warschburger (*)
Department of Psychology, Counseling Psychology,
The prevalence of overweight and obesity is
University of Potsdam, Potsdam, Germany very high in our society. According to current
https://doi.org/10.1007/978-3-662-67662-2_57
432 P. Warschburger
data from a representative nationwide study in and ambiguous remarks. In the literature, the
Germany (Schienkiewitz et al. 2018), 9.3% of 3- term “bullying” is also often used, which addi-
to 17-year-old children and adolescents are over- tionally includes physical forms of social exclu-
weight and an additional 5.9% are obese. This sion of a direct (e.g., pushing) or indirect nature
means that approximately 800,000 children and (e.g., denying someone access to a group).
adolescents in Germany are affected by obesity. Studies consistently show that overweight
With the start of school, there is a significant and obesity are associated with increased teas-
increase in prevalence, and no gender-specific ing and/or bullying experiences (Puhl and
prevalence differences are found. Particularly Heuer 2009) and that these negative comments
affected are children and adolescents from lower or exclusion experiences have various psycho-
social classes and with a migration background. social consequences. This is particularly true
While the prevalences in Germany have been for children and adolescents who have inter-
relatively stable since the beginning of the 21st nalized these negative attributes (Zuba and
century, the severity of obesity has increased. Warschburger 2017). The experience of stigma-
tization (and its internalization) contributes to
the emergence of vicious cycles: for example,
57.2 Social Stigmatization, children and adolescents who are teased dur-
Teasing, and Obesity ing sports activities subsequently tend to avoid
physical exercise. As a result, they increasingly
57.2.1 Negative Social Evaluation lack athletic competencies, which in turn pro-
vide further opportunities for teasing. Often,
Obesity cannot be hidden; from the physical in response to these experiences, attempts are
appearance, conclusions are drawn about a per- made to regulate negative mood through eating
son’s personality traits. Even preschool children (eating as a coping strategy), which contributes
rate children with overweight/obesity as “stupid, to further weight gain.
lazy, and unpopular”. This negative evaluation
tendency has not decreased despite the increas-  Important Almost all children experience
ing prevalence of overweight and obesity, but teasing. It occurs more frequently in children
on the contrary, has become even more frequent and adolescents with overweight and often
and pronounced (cf. Puhl and Heuer 2009). centers around the same theme.
These negative attributions are found in all
population groups and are partly internalized by The negative social image of people with obe-
those affected and applied to their own person sity, combined with stigmatization and discrimi-
(internalization of weight stigma). nation in everyday life, is considered the central
source of the development of psychological
stress. The experience of stigmatization also
57.2.2 Teasing contributes substantially to the maintenance, as
well as the development, of obesity (Major et al.
Social stigmatization manifests itself in child- 2018). Moreover, social exclusion experiences
hood and adolescence primarily in the form of can be seen as a breeding ground for the devel-
teasing. Teasing is an integral part of the social opment of psychological disorders and increased
life of almost all children and is defined as a stress perception.
deliberate provocation that refers to a salient
characteristic of the “victim” and is accompa-  Important Appropriate coping strategies for
nied by “playful” hints such as exaggerations dealing with persistent teasing are crucial for
psychosocial well-being.
57 Psychosocial Factors of Obesity in Childhood and Adolescence 433
57.3 Psychological Disorders speak of “unhappiness” and point out that the
and Behavioral Problems criteria for full manifestations of affective dis-
orders are not necessarily met. On the other
Regarding the question of psychological comor- hand, the data in clinical groups, especially in
bidity in obesity during childhood and adoles- girls from adolescence onwards, clearly indicate
cence, numerous studies have been published significantly increased prevalence rates of up
to date, both in clinical and population-based to 40%. There seems to be a bidirectional rela-
samples. Often, rather than investigating the tionship between depression and obesity. From
percentage of children and adolescents who suf- adolescence onwards, there are also indica-
fer from problems requiring treatment, the tions of increased suicidal thoughts, so suicidal-
studies drew comparisons with normal-weight ity should be examined in this age group using
peers at the level of mean values (Warschburger screening  instruments.
2000, 2011). Cross-sectional studies predomi-
nate, which do not allow for conclusions about
the temporal relationship between weight status 57.3.2 Anxiety Disorders
and psychological burden. However, prospective
studies also point to bidirectional relationships The findings regarding anxiety disorders are
and an escalation process between psychologi- relatively inconsistent. Surveys were gener-
cal burden and (further) weight gain. In the lit- ally not conducted using clinical interviews, but
erature, there are indications of an increased rather with general questionnaires for screen-
occurrence of mental disorders and psychosocial ing behavioral problems. Only the clinical
problems, especially within the group in ques- groups were found to be more affected, whereas
tion for treatment offers. Therefore, the possibil- population-based studies showed indications
ity of a mental disorder requiring treatment must of increased anxiety, but not increased rates of
be diagnostically clarified particularly in this manifest anxiety disorders. Compared to chil-
context. dren affected by asthma or neurodermatitis,
children with obesity showed the highest lev-
els of anxiety, and especially social anxieties
Mental disorders and behavioral (Warschburger 2000).
problems
• Affective disorders
• Anxiety disorders 57.3.3 Externalizing Disorders
• Externalizing disorders (such as ADHD,
conduct disorders) A number of studies observed increased atten-
• Eating disorders (binge eating and loss tion problems up to manifest attention deficit
of control eating) and hyperactivity disorders (ADHD) in children
• Low self-esteem and adolescents with obesity. In addition, there
• Negative body image is evidence that comorbidity with ADHD nega-
tively affects the course of therapy and fur-
ther weight development. This relationship is
explained by the limitation of self-regulation
57.3.1 Affective Disorders skills, such as inhibitory control or reward delay
in children and adolescents with obesity (Favieri
In school samples, there was an approximately et al. 2019). In addition to the increased atten-
30% increased occurrence of depression and tion problems, a higher occurrence of physical
depressive symptoms in children with obesity, aggression, especially in boys, was observed
while no increased risk was found for over- (Tso et al. 2018).
weight (Sutaria et al. 2019). Many authors rather
434 P. Warschburger
57.3.4 Loss of Control Eating there are still very few prospective studies
and Binge Eating on the temporal relationship between obe-
sity and psychological disorders in childhood
Maladaptive eating behaviors are widespread in and adolescence, depressive and aggressive
children and adolescents with overweight and behaviors are considered more as a reaction
obesity. Research has focused on the experi- to overweight and especially the experienced
ence of loss of control while eating (LOC) and stigmatization. The relatively frequently
the associated consumption of large amounts found problems suggesting attention deficit
of food (binge eating, BE). The criteria for the and hyperactivity disorders are attributed to
full manifestation of a binge eating disorder the reduced self-regulation skills that play a
(BED) are rare in children and adolescents. prominent role in both disorder patterns.
Disturbed eating behaviors such as LOC and BE
are among the most common comorbid disor-
ders in obesity and are observed in about 25% 57.4 Quality of Life
of children and adolescents with obesity (He
et al. 2017). These pathological eating behaviors Many psychological problems do not have the
should also be addressed in treatment. status of disorders, but still represent a special
burden for children and adolescents and their
families. In the context of chronic illness, the
57.3.5 Self-Esteem and Body Image health-related quality of life of those affected is
increasingly investigated. Quality of life, as a
Data predominantly indicate lower self-esteem, multidimensional construct, represents the sub-
especially from puberty onwards and in girls. jective level of functioning in various areas of
However, the study findings are very heteroge- life (such as psychological and physical well-
neous, and more pronounced impairments were being, social and family life) and thus more
found primarily in the clinical setting (Pinquart sensitively captures psychosocial well-being.
2013a). Increased dissatisfaction with one’s own Reviews and meta-analyses have shown that
appearance or a negative body image are very children and adolescents with overweight/obe-
strongly pronounced and widespread in children sity report a lower quality of life compared to
and adolescents with obesity (Pinquart 2013b). their normal-weight peers of the same age and
This is particularly relevant as increased body gender. This observation is particularly pro-
dissatisfaction is considered a risk factor for the nounced in clinical samples and with increas-
development of an eating disorder. ing age. Parents, compared to their children,
tend to rate the health-related quality of life
lower. Although impairments are often found in
Conclusion
various dimensions of quality of life, they are
Although psychological problems occur rela- particularly pronounced in the areas of social
tively frequently, the majority of children and well-being and physical functioning. Compared
adolescents with obesity are not affected by to other chronic diseases, such as atopic der-
a clinically relevant disorder. Nevertheless, matitis, asthma, and even cancer, lower values
screenings for psychological disorders were found, which further emphasizes the spe-
should be considered, especially in weight cial psychosocial burden associated with obe-
reduction programs. There is no homogene- sity (see Warschburger 2005). Quality of life is
ous psychosocial profile, with the spectrum increasingly considered as a secondary outcome
ranging from internalizing disorders (such as in intervention studies alongside weight. It is
depression or pathological eating behavior) consistently shown that comprehensive multidis-
to externalizing disorder patterns (such as ciplinary treatment programs are not only asso-
attention problems or aggression). Although ciated with weight reduction but also contribute
57 Psychosocial Factors of Obesity in Childhood and Adolescence 435
to an improvement in the quality of life of those functions, increased reward sensitivity for food,
affected (Peirson et al. 2015). and strong attentional focus on (high-calorie)
food becomes the center of interest. Newer
 Important The health-related quality of life interventions specifically aim to reduce these
of children and adolescents with obesity is neurocognitive characteristics and thus contrib-
significantly impaired. ute to successful weight reduction (Jansen et al.
2015).
Weight control programs should not focus
57.5 Conclusion: Importance solely on reducing overweight but should pri-
of Psychological Factors marily aim for a healthy diet and exercise, as
well as placing the mental health of children
The potential of psychosocial burden for those and adolescents at the center of treatment.
affected seems considerable in view of the high Psychological aspects play an important role
visibility of obesity and the high attribution of in the development and maintenance of obe-
responsibility. Predominantly, it is indicated sity and thus also form central starting points in
that mental disorders and psychosocial stress treatment.
are consequences of obesity or the associated
stigmatization. This is also emphasized by stud-
ies that have observed a reduction in psychoso- References
cial impairments following successful weight
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loss. The relationship between experiences of
functions in overweight and obesity: a systematic
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underlines the importance of addressing these gitudinal studies. Front Psychol 10:281
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this also entails the risk of unrealistic expecta-
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Kinderheilkunde 149:807–818
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Socioeconomic Aspects
of Obesity 58
Contents
58.1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 437
58.2 Model Proposal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 439
58.3 Modern Explanatory Approaches—The Life Course Perspective . . . . . . . 441
58.4 Selection Thesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 441
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 442
58.1 Background high SES (Schienkiewitz et al. 2018). These dif-

ferences are even more pronounced when con-
The risk of overweight is unevenly distributed sidering the obesity prevalence included in
within the German population: In this country, the above figures. Girls with low SES have a
there are socioeconomic differences in the prev- prevalence of 8%, which is four times higher
alence of overweight and obesity. These dispari- than in girls from the high SES group (2%).
ties, also referred to as “social” or “stratification A social gradient is also evident among boys,
gradient,” are considerable: where those with low SES have a prevalence
According to data from the nationwide of 11% compared to those with high SES at
“German Health Interview and Examination 3% (Schienkiewitz et al. 2018). Data from the
Survey for Children and Adolescents” (KiGGS; school entry examinations of the federal states
for the years 2014–2017), 27% of girls and 24% suggest that the social differences remained rela-
of boys with low socioeconomic status (SES) in tively constant in the period from 2001 to 2015
the age group of 3 to 17 years are overweight, (Lampert et al. 2017).
compared to only 7% and 9% of their peers with The social gradient continues into young
adulthood and remains more pronounced among
young women than young men: In the age
group of 18 to 29 years, 32% of women in the
S. Schneider (*) · B. Holzwarth low SES group are overweight or obese, com-
Center for Preventive Medicine and Digital Health
(CPD); Division of Public Health, Social and pared to 17% in the high SES group. Even
Preventive Medicine, Medical Faculty Mannheim, in this age group, the gap is wider than among
Heidelberg University, Mannheim, Germany men, where the comparative figures are 33% and
e-mail: [email protected] 25% (for the years 2014–2015; Schienkiewitz
B. Holzwarth et al. 2017). Moreover, such a gradient has
https://doi.org/10.1007/978-3-662-67662-2_58
438 S. Schneider and B. Holzwarth
been observed in higher age groups for many In the following, we present a model to
years (Schienkiewitz et al. 2017). Incidentally, explain these socioeconomic differences in obe-
not only the obesity-specific social gradient per sity prevalence (Fig. 58.1). Our model posits
se but also the more pronounced association an interconnectivity in which individual behav-
between SES and obesity in women compared ior results from various factors at macro and
to men has long been observed in other industri- micro levels, ultimately leading to an imbalance
alized countries (Lampert et al. 2017). between energy intake and energy expenditure
and resulting overweight.
Social gradient
regarding...
Macro level
... obesogenic environments
… material deprivation
… health literacy
... psychosocial stressors and

resources
micro level
… pre and perinatal factors
…nutritional behavior …activity behavior …resting metabolism
…energy intake …energy intake
…overweight
and obesity
Fig. 58.1  Conceptual explanatory model for socioeconomic differences in obesity prevalence

58 Socioeconomic Aspects of Obesity 439
58.2 Model Proposal areas, studies from Germany also show that
the quality of these central exercise resources
58.2.1 Obesogenic Environment for children is often significantly worse in
disadvantaged residential areas (Buck et al.
The term “obesogenic environment” refers to 2019). The importance of obesogenic environ-
the sum of all influences from the environment, ments for the development of overweight and
opportunity structures, and living conditions on obesity goes far beyond the social gradient
the development of overweight (Swinburn et al. considered here. Therefore, obesogenic envi-
1999). Obesogenic environments particularly ronments are dedicated to a separate chapter in
promote unhealthy eating habits and physi- this book (Chap. 74).
cal inactivity. In the context of the topic of this
chapter, it should be noted that at the level of
social areas, the neighborhood socioeconomic 58.2.2 Material Deprivation
status often correlates negatively with obeso-
genic characteristics. Material deprivation can be partly responsible
This applies, on the one hand, to many for the development of overweight and obe-
aspects of the so-called food environment: sity, as well as for a poorer state of health and a
The supply in the regional, stationary retail shorter life expectancy (Schneider 2002). A low
trade (b2c) and in the food services indus- income reduces access to a comprehensive range
try is relevant for individual eating behavior. of healthier foods and opportunities for physi-
Internationally and now also for Germany, it has cal activity: European studies show that food
been proven that in low-SES residential areas, prices determine purchasing and thus eating
there are regularly more fast-food providers than habits. The relative share of food expenditure
in privileged areas. The supply density of snack in a household’s total expenditure is lowest for
bars, kebab shops, and hamburger restaurants is higher incomes, at less than 10%, significantly
higher in low-SES residential areas, and the dis- higher for low incomes, at around 30%, and
tance to the nearest fast-food provider is shorter highest for households receiving social benefits,
(Schneider et al. 2013). Thus, the food environ- at around 40% (Robertson et al. 2007). Thus,
ment can fundamentally reinforce and contrib- food expenditure becomes a flexible spending
ute to a social gradient in terms of significantly item with savings potential, especially for low-
higher exposure to unhealthy foods. In this con- income households, unlike rent costs, for exam-
text, the term “deprivation amplification” has ple. The most favorable calorie-per-euro ratio,
been established internationally for the conse- according to the authors, can be achieved in the
quences of an unhealthier food environment case of a limited financial budget by purchas-
in deprived residential areas (Schneider et al. ing cheap foods with high energy density and
2019). low nutrient density (Robertson et al. 2007).
On the other hand, in socioeconomically The nutritional quality of dishes in the cater-
disadvantaged residential areas—at least in ing industry also correlates with the price, as a
this country—there is often a higher traffic recent nationwide study in German full-service
density, which restricts non-motorized mobil- restaurants has shown (Rüsing et al. 2020).
ity (children’s cycling, the objective and sub- Likewise, options for physical activity depend
jective safety of pedestrians, etc.). Although on material conditions. Many organized and
the quantitative provision of exercise oppor- unorganized sports cannot be realized with a
tunities (playgrounds, soccer fields, green low budget. In addition to club fees, the costs
spaces, and jogging tracks) is often compara- for sports equipment, joining fees, and fees for
ble or even better in disadvantaged residen- sports and fitness studios should be mentioned
tial areas than in socioeconomically better-off as examples.
58.2.3 Health Literacy disadvantaged individuals (Hapke et al. 2013),

also due to social and economic deprivation.
Health literacy is the individual’s ability to inde- Additionally, there is often a specific stress
pendently find, process, and understand basic exposure in the workplace. Studies based on
information and use services to make appropri- the effort–reward imbalance model developed
ate health-related decisions (Chari et al. 2014). by Siegrist, for example, show a significantly
In relation to the socioeconomic differences higher stress exposure in poorly paid jobs and
in obesity prevalence to be explained, it seems precarious employment relationships (Siegrist
relevant here that the realization of health- 1994). The effects of chronic stress on the cor-
promoting behavior requires the acquisition tisol axis, appetite, food intake, and ultimately
of and access to health-relevant knowledge. overweight and obesity are described in detail
This addresses more direct educational effects, elsewhere in this book. Subjective stress expo-
such as medical knowledge (on basic metabolic sure can be moderated, i.e., buffered, by relief
processes, etc.) and the anticipation of health- resources. Important resources in this context
relevant behavior (for example, relevant knowl- are psychological and emotional support, instru-
edge about the negative consequences of an mental, informational, and financial assistance,
unhealthy diet and the effects of regular exer- as well as the additional effect of social net-
cise). Indirect effects also play a role, such as works through social control.
the ability to research, discuss, act, and self-dis-
cipline acquired through education (Maas et al.
1997; Becker 1998). In addition, there is a more 58.2.5 Pre- and Perinatal Factors
favorable doctor-patient communication for
patients with a high SES (Gerhardt 1991). Pre- and perinatal determinants for over-
Numerous international studies have shown weight and obesity are also unevenly distrib-
that health literacy is positively correlated uted across social groups. Weight is influenced
with educational level and thus with social by the pre- and perinatal behavior of the par-
status (Chari et al. 2014). However, a review ents, and especially the mother (Weschenfelder
prepared for the European Commission con- et al. 2019). Although the complex interactions
cluded that a lack of relevant information on between maternal BMI, maternal weight gain
nutrition and exercise among participants in during pregnancy, fetal programming, breast-
the 2006 Eurobarometer survey was not a sig- feeding behavior, and infant nutrition cannot
nificant reason for an unbalanced energy bal- be discussed in detail here, the known associa-
ance, regardless of SES (Robertson et al. 2007). tion between the mother’s SES, her BMI, and
Consequently, the authors argue that the impor- the child’s birth weight should be mentioned
tance of pure information campaigns in the (Weschenfelder et al. 2019).
sense of classical health education should not be
overestimated (Robertson et al. 2007).
58.2.6 Nutrition, Exercise Behavior,
and Resting Metabolism
58.2.4 Psychosocial Stressors
and Resources According to the social-ecological model, the
factors discussed so far, which are intended to
Socioeconomic differences in obesity prevalence explain socioeconomic differences in obesity
can also be explained by the fact that individuals prevalence, can be assigned either to the macro
with higher SES have fewer stressors and more level or to the micro level. This is illustrated in
resources than other status groups. Stress expo- our model (Fig. 58.1). All these factors interact
sure is often higher among socioeconomically with each other and, at the same time, influence
individual behavior—specifically, nutrition micro-factorial influences (Reeske and Spallek

behavior, exercise behavior, and resting metab- 2011). In this chapter, only the most important
olism (Lehrke and Laessle 2009). In particular, determinants of the mentioned social gradient
the latter has increasingly come into the focus of discussed in the literature could be outlined.
research due to recent findings on the independ- Even in the course of this brief description, it
ent importance of sedentary behavior. became clear that explaining these complex rela-
The state of research on socioeconomic dif- tionships requires a consideration of the entire
ferences regarding these three lifestyle aspects life course. After all, some determinants have
is extensive and clear: The nutrition and exer- a different significance in different life phases.
cise patterns of socioeconomically disadvan- With regard to relevance, the initially important
taged individuals pose a higher risk of a positive breastfeeding, for example, gives way to paren-
energy balance. Their energy intake exceeds tal table and eating culture, which later gives
the energy expenditure according to numerous way to local school catering and finally to occu-
studies, because the purchased, available, and pational stress exposure and the walkability of
ultimately consumed food items have a higher the residential neighborhood.
energy content and a lower content of micro- From social epidemiology and medical
nutrients than is the case with typical shopping sociology, it is known that factors influencing
baskets of socioeconomically better-off individu- health inequalities interact throughout life and
als. Individuals with low SES, for example, eat can accumulate over time. In the mentioned
fewer vegetables and fruits, and they drink more neighboring disciplines, the research branch of
sweetened soft drinks than those with high SES life course research has therefore been estab-
(Robertson et al. 2007). The energy balance on lished in recent decades. Reeske and Spallek
the expenditure side is less clear: On the one therefore call for always taking socioeconomic
hand, it is known for children and adolescents aspects into account in obesity prevention—ide-
that socioeconomically disadvantaged individually within the framework of a life course-based
als engage in less exercise (Krug et al. 2018), approach (Reeske and Spallek 2011).
on the other hand, socioeconomically disad-
vantaged individuals generally perform more
manual physical activities and sit less at work 58.4 Selection Thesis
(Wallmann-Sperlich et al. 2014). Particularly
striking socioeconomic differences are evident Our model also takes into account the reverse
in children and adolescents, such as in the con- direction of effect, i.e., the influence of over-
sumption of soft drinks (Schneider et al. 2020). weight and obesity on SES. The selection the-
In this context, it is also interesting that espe- sis, also referred to as the drift thesis (Schneider
cially socioeconomically disadvantaged girls are 2002), is represented in our illustration in the
physically less active and more sedentary than form of a retrograde arrow. This causal relation-
other adolescents (Robertson et al. 2007). ship is relevant both intrapersonally and inter-
personally: Social psychology has shown that
obese individuals are disadvantaged compared
58.3 Modern Explanatory to slim or athletic individuals in professional
Approaches—The Life and other social contexts. Intrapersonally, it is
Course Perspective also conceivable that the health consequences of
overweight may hinder professional and social
The etiology of obesity and especially its soci- advancement. Interpersonally, the selection
oeconomically unequal distribution have not thesis means that obese parents pass on their
yet been fully deciphered. Scientific consen- risk of overweight to some extent to the next
sus is a multifactorial genesis of macro- and generation.
Lehrke S, Laessle RG (2009) Adipositas im Kindes-und

Conclusion and Outlook Jugendalter. Springer Medizin Verlag, Heidelberg
Health and health inequality are two dif- Maas I, Grundmann M, Edelstein W (1997)
Bildungsvererbung und Gesundheit in einer sich
ferent and highly relevant entities. Even if modernisierenden Gesellschaft. In: Becker R (Ed)
it were possible to curb or even reduce the Generationen und sozialer Wandel. VS Verlag,
spread of obesity in our society in the com- Wiesbaden, pp 91–109
ing years, obesity-specific health inequality Reeske A, Spallek J (2011) Sozioökonomische
Aspekte der Primärprävention von Adipositas bei
could remain unchanged or even increase, Kindern und Jugendlichen. Bundesgesundheitsblatt
namely if, according to the phenomenon of Gesundheitsforschung Gesundheitsschutz 54:272–
“preaching to the converted”, future interven- 280. https://doi.org/10.1007/s00103-010-1221-x
Robertson A, Lobstein T, Knai C (2007) Obesity and
tions primarily reach the high SES groups.
socio-economic groups in Europe: Evidence review
Therefore, we conclude that it will continue and implications for action. European Commission,
to be difficult to curb socioeconomic dif- Brussels, pp 1–41
ferences in obesity prevalence without an Rüsing L, Hilger-Kolb J, Schneider S (2020) Desert on
the menu? What children are served in German full-
interdisciplinary consideration of the multi-
service restaurants. Cent Eur J Publ Heal 28:87–93
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in Deutschland. J Health Monitoring 2:21–28. https://
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Genetic Aspects of Obesity
59
Helge Frieling, Anke Hinney and Stefan Bleich
Contents
59.1 Twin and Adoption Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 446
59.2 Monogenic Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 447
59.3 Association Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 447
59.4 Polygenic Forms of Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 448
59.5 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 449
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 449
The etiology of obesity is multifactorial. Social of time in front of the television, computer, or
environmental factors, such as advertising or gaming console. However, these factors have
consumer pressure, and material environmental different effects on different people; they do not
factors, such as means of transportation, archi- cause an increase in body weight for everyone.
tecture, and the constant availability of high- The predisposition for obesity is largely heredi-
calorie food, have created an “obesogenic” tary. This has been most impressively demon-
environment that promotes obesogenic behav- strated by three experimental twin studies. In
iors. These include consuming large, high-calo- one study, twin pairs were deliberately given an
rie meals, little exercise, and/or spending a lot energy intake that was too high for their body
height, while in two other studies, they were
given an intake that was too low. These stud-
ies consistently showed that there were groups
of participants with very strong weight gains
H. Frieling (*) · S. Bleich or losses, those who hardly reacted in terms of
Department of Psychiatry, Socialpsychiatry and
body weight, and an intermediate group with
Psychotherapy Hannover Medical School (MHH),
Hannover, Germany moderate weight gains or losses. The fact that
e-mail: [email protected] weight changes were very similar within a twin
S. Bleich pair, while there were large differences between
e-mail: [email protected] different twin pairs, suggests a strong hereditary
A. Hinney component.
Department of Child and Adolescent Psychiatry, The attempt to elucidate the molecular basis
Psychosomatics and Psychotherapy, University Hospital for this heritability has made great progress in
Essen, University of Duisburg-Essen, Essen, Germany
recent years. The complex phenotype of obesity
https://doi.org/10.1007/978-3-662-67662-2_59
can be caused by a whole range of monogenic

and, above all, polygenic variants (genotypes). knock-out mice and then confirmed in
Since body weight is also a continuous variable humans. The discovery of leptin and its
that moves along a continuum between normal physiological functions is an illustrative
and pathological values, the investigation of example:
possible genetic influencing factors is addition- The so-called obese mouse, a mouse
ally complicated. Genes with small effects may with a mutation that leads to extreme obe-
be overlooked in an (arbitrary) dichotomization sity, was discovered in 1949 at the Jackson
into normal/obese. Therefore, not only “clas- Laboratories. This strain lacks the product
sical” case-control studies are useful for inves- of the leptin gene (LEP). A second strain,
tigating the genetic basis of body weight, but the so-called diabetes mouse db, lacks the
also population-based studies with body weight, leptin receptor (LEPR). Parabiosis experi-
measured as body mass index (BMI), as the tar- ments, in which animals from both strains
get variable. share a blood circulation, suggested that
one strain has a mutation affecting a sol-
uble factor, while the other strain has a
59.1 Twin and Adoption Studies mutation that destroys the corresponding
receptor. This assumption was confirmed
There is a large number of twin and adoption in 1994/95 by the cloning and identifi-
studies, according to which the heritable propor- cation of the leptin and leptin receptor
tion of body weight and fat mass can be quanti- genes.
fied at about 64-80%. Studies on adopted twins Another example of a spontaneous
who grew up separately showed a close relation- mutation leading to obesity is the so-
ship between the BMI of the children and that of called agouti yellow (Ay) mouse. The yel-
the biological parents, but hardly any relation- lowish Ay mice have been known for about
ship with the BMI of the adoptive parents. The 200 years. The agouti peptide is normally
prevalence of obesity was also only comparable produced in skin cells and blocks the
between biological parents and children. Further action of α-melanocyte-stimulating hor-
twin studies were also able to demonstrate the mone (α-MSH). In Ay mice, the agouti
heritable components of both physical param- peptide is expressed in all cells and thus
eters of energy utilization (e.g., basal metabolic also blocks the anorexigenic α-MSH sig-
rate, thermogenesis, and energy expenditure dur- nals in the brain, which are mediated via
ing light and moderate physical exertion) and the melanocortin-4 receptor (MC4R).
habitual physical activity. Blockade of MC4R accordingly leads
to hyperphagia and obesity. Loss of the
α-MSH activating enzyme, carboxypepti-
Animal Models dase E (CPE), also leads to obesity. A CPE
Almost all findings on genes and meta- spontaneous mutation was detected in
bolic pathways involved in the regulation another obesity strain, the fat mouse.
of appetite, energy balance, and adipose There are now numerous knock-out
tissue were initially obtained in animal strains that exhibit obesity or fat distribu-
models and could then be transferred to tion disorders. A constantly updated over-
humans. Likewise, most monogenic forms view can be found in the Obesity Gene
of obesity were first discovered through Map (http://obesitygene.pbrc.edu/).
spontaneous mutations in rodents or in
59 Genetic Aspects of Obesity 447
59.2 Monogenic Disorders leptin substitution. However, overall, less than

100 cases worldwide have been described for
Severe obesity is a known symptom of complex this mutation.
pleiotropic diseases such as Prader-Willi syn-
drome or Bardet-Biedl syndrome, which also
exhibit dysmorphia, mental retardation, and sin- 59.3 Association Studies
gle organ damage. These syndromes are caused
by disorders of individual genes. In addition, Molecular genetic analyses investigate the asso-
there is a group of diseases in which obesity ciation between genetic variants (genotype) and
is the central symptom. These diseases follow a specific trait expression (phenotype).
a Mendelian inheritance pattern and are usu-
ally associated with very severe obesity, which
typically begins in childhood. The genes iden- 59.3.1 Candidate Gene Approach
tified so far are mostly located in the leptin-
melanocortin metabolic pathway (Table 59.1). Genes for which there are biochemical, physi-
Especially in patients with a mutation of the ological, molecular genetic, or molecular biologi-
leptin gene, obesity can be causally treated with cal indications of relevance for the expression of
body weight (e.g., obesity) are called candidate
genes. Thus, there is an a priori hypothesis about
the influence of the gene (gene product) on the
Table 59.1  Examples of nonogenic forms of obesity in
humans development of obesity (Hebebrand et al. 2013).
The genotyping of genetic variants (alleles) in
Gene Chromosomal OMIM
Locus such a candidate gene is carried out in a large
Corticotropin Releasing Hor- 17q12–q22 122561
number of trait carriers or patients (“cases”) and
mone Receptor 1 (CRHR1) unaffected individuals (“controls”). An associa-
Corticotropin Releasing Hor- 7p14.3 602034 tion is present if there are significant (relevant)
mone Receptor 2 (CRHR2) differences in allele or genotype distribution
G Protein-coupled Receptor 22q13.3 601751 between cases and controls. Since effect sizes of
24 (GPR24) these genetic variants are often very small, a large
Leptin (LEP) 7q31.3 164160 number of both cases and controls is required.
Leptin Receptor (LEPR) 1p31 601007
59.3.1.1 Melanocortin Receptor 4
Melanocortin 3 Receptor 20q13.2–q13.3 601665
(MC3R) A central role in the control of appetite and sati-
Melanocortin 4 Receptor 18q22 155541
ety is played by the feedback loop of α-MSH
(MC4R) and the associated neuronal melanocortin recep-
Neurotrophic Tyrosine Kinase 9q22.1 600456 tor subtype 4 (MC4R) (“animal models”). Over
Receptor Type 2 (NTRK2) 150 different mutations and variants are known
Proopiomelanocortin 2p23.3 176830 in the MC4R, which can lead to (partially)
(POMC) extreme overweight. About 2–5% of extremely
Proprotein Convertase Sub- 5q15–q21 162150 obese individuals carry such MC4R mutations,
tilisin/Kexin Type 1 (PCSK1) which are associated with reduced receptor
Single-minded Homolog 1 6q16.3–q21 603128 function. The quantitative effect of these muta-
(SIM1) tions is 4.5–9 BMI points. This means that carri-
Mutations in the mentioned genes are associated with an ers of the mutations are about 15–30 kg heavier
obese phenotype. Information from Obesity Gene Map. than non-carriers, as determined in a family
OMIM: Online Mendelian Inheritance in Man study (Hinney et al. 2013).
A polymorphism in the MC4R gene, in which DNA methylation. The strongest FTO expres-
valine is replaced by isoleucine at position 103 sion is found in neurons. When the FTO gene
in the protein (Val103Ile), was initially consid- is switched off in mice, it results in reduced fat
ered insignificant after its discovery, as neither mass. Increased FTO production, on the other
a functional effect of the polymorphism nor a hand, leads to obesity. Whether this is due to
direct association with obesity could be dem- altered calorie intake, energy expenditure, or
onstrated. However, in a large family analysis, both is still unclear (Müller et al. 2013). In
a transmission disequilibrium for the isoleucine humans, increased expression of the FTO gene
allele was observed, which was less frequently is associated with increased fat mass, and this
inherited by overweight children. In a meta- effect is due to increased food intake (Müller
analysis of all studies with a total of 7,937 par- et al. 2013). In 2015, a study pointed to another
ticipants, a negative association between the pathway of the FTO locus for regulating adipo-
Ile103 allele and obesity was found. This find- cyte thermogenesis. It was shown that variants
ing was confirmed in a further meta-analysis of in the genes IRX3 and IRX5 neighboring the
more than 10,000 participants and 18,000 con- FTO gene have an obesity effect.
trols. However, there is evidence of an improved
receptor effect, which is consistent with the
weight-reducing effect (Hinney et al. 2013). 59.4.1 Polygenic Risk Scores
In order to better capture the individual genetic

59.4 Polygenic Forms of Obesity risk for the development of obesity, polygenic
risk scores have been increasingly derived from
Many common genetic variants each make a GWAS datasets in recent years. A polygenic
(very) small contribution to the risk of obe- risk score represents the sum of the existing risk
sity in polygenic forms of obesity. In 2018, variants and their effect sizes in an individual.
one of the largest studies on obesity polygenes Across a population of cases versus controls,
was published by the “Genetic Investigation these scores are usually normally distributed,
of Anthropomorphic Traits” (GIANT) con- with the median or mean being higher in cases
sortium. This is a meta-analysis of approxi- than in controls. In the case of obesity, these
mately 700,000 individuals of European origin. scores work a bit differently, as they are usually
In total, 941 nearly independent variants were directly correlated with BMI and can thus poten-
found to be associated with BMI expression. A tially estimate a BMI based on the polygenic
previous study showed that the respective obe- score using various statistical methods. In recent
sity risk variants increase body weight by an studies, interesting associations and interactions
average of about 170 g. The maximum weight between various polygenic BMI scores and envi-
increase is 1.5 kg per risk allele. In addition to ronmentally induced risk factors have been dem-
the genes known from the candidate gene stud- onstrated. For example, the polygenic influence
ies described above, such as MC4R, obesity on BMI is moderated by socioeconomic status
polygenes were identified. in childhood, social perception of body image,
The FTO gene (’fat mass and obesity-associ- and individual educational history. There is also
ated’ gene) is the obesity polygene with the larg- a different influence of genetic risk in different
est effect size. Homozygous carriers of the risk age cohorts. Despite these findings, the propor-
allele of a variant in the first intron (non-cod- tion of body weight that can be explained by
ing region) of the gene are about 3 kg heavier polygenic influences remains relatively small.
than non-carriers. Their risk of becoming obese An increase in the BMI polygenic score by one
is approximately 1.5 times higher (Frayling standard deviation (!) increases BMI by 5.7%.
et al. 2007). The FTO protein plays a role in
59 Genetic Aspects of Obesity 449
59.5 Conclusion Claussnitzer M, Dankel SN, Kim KH, Quon G,

Meuleman W, Haugen C, Glunk V, Sousa IS, Beaudry
JL, Puviindran V, Abdennur NA, Liu J, Svensson
The investigation of genetic contributions to PA, Hsu YH, Drucker DJ, Mellgren G, Hui CC,
BMI and obesity shows on the one hand clear Hauner H, Kellis M (2015) FTO obesity variant cir-
and known genetically determined syndromes cuitry and adipocyte browning in humans. N Engl
J Med 373(10):895–907. https://doi.org/10.1056/
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between genetic risk and obesogenic environ- Jacobson P, Carlsson LM, Kiess W, Vatin V, Lecoeur
C, Delplanque J, Vaillant E, Pattou F, Ruiz J, Weill
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come much more into focus in recent years, S, Le Stunff C, Bougneres P, Kovacs P, Marre M,
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and severe adult obesity. Nat Genet 39:724–726
successful. Fox CS, Heard-Costa N, Cupples LA, Dupuis J, Vasan
RS, Atwood LD (2007) Genome-wide association
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Microbiome
and Inflammation 60
in Obesity
Isabelle Mack
Contents
60.1 Gastrointestinal (GI) Microbiota . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 451
60.2 GI Microbiota in Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 452
60.3 GI Microbiota and Inflammation in Obesity . . . . . . . . . . . . . . . . . . . . . . . . . 453
60.4 Influence of Diet and Lifestyle on the GI Microbiota in Obesity . . . . . . . . 453
60.5 Influence of Pro- and Prebiotics on GI Microbiota in Obesity . . . . . . . . . . 454
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 455
60.1 Gastrointestinal (GI) can affect the host’s brain function and behavior
Microbiota through communication via the gut-brain axis.
Since the characterization of germ-free ani-
The human gut is a complex ecosystem in which mals compared to conventional animals in the
a large variety of microbes live, belonging to the 1960s and 1970s, it has been shown that the
domains of bacteria, archaea, and eukaryotes— GI microbiota plays a physiological role in the
our GI microbiota. The composition and diversity host’s weight regulation. However, only in the
of microbial species not only vary consider- last 15–20 years has researchers’ interest turned
ably along the gut compartments but also differ to the relationship between GI microbiota and
between individuals and are influenced by age, weight regulation in humans (Mack et al. 2018).
genetics, health status, diet, and other factors.
Dysbiosis is associated with inflammatory  Important Gut microbes produce short-
bowel diseases and colon cancer, and also with chain fatty acids (SCFA) such as butyrate,
diabetes and metabolic syndrome, suggesting propionate, and acetate through fermen-
a systemic influence of the GI microbiota on tation of dietary fibers and endogenous
human health. Furthermore, the GI microbiota substrates. It is believed that these fatty
acids contribute 5–10% to human energy
requirements.
Moreover, it has been shown that SCFA
I. Mack (*) interact with specific G-protein-coupled re-
Psychotherapy, Medical University Hospital ceptors expressed by enteroendocrine cells
Tübingen, Tübingen, Germany in the gut, thereby influencing the release
e-mail: [email protected] of satiety hormones such as peptide YY.
https://doi.org/10.1007/978-3-662-67662-2_60
452 I. Mack
In addition, proteins or amino acids that escape microbiota influences body weight depends on
digestion, or endogenous mucins, are fermented the animal species, the age of the animals, and/
by gut microbes to branched-chain fatty acids or the specific strain. However, with Bäckehed
(BCFA) such as isobutyrate and isovalerate and and colleagues’ publication, further researchers’
to toxic compounds such as phenols and indoles attention turned to the GI microbiota and its role
(both co-carcinogens), ammonia (mutagen, in weight regulation. In 2005, Gordon and col-
cytotoxin), amines (neurotransmitter/mutagen leagues reported significantly different ratios of
precursors), HS-and thiols (both cytotoxins). the phyla Bacteriodetes and Firmicutes in the
Several of these toxic compounds have the stool of lean versus obese mice with leptin defi-
potential to negatively affect the host’s gut phys- ciency (ob/ob mice), with more Firmicutes and
iology, motility, and psychology, the latter via fewer Bacteroidetes in the obese mice. A simi-
the gut-brain axis (Mack et al. 2016). lar pattern was found for the diet-induced obe-
sity mouse model. More importantly, Turnbaugh
and colleagues showed that the differences in
60.2 GI Microbiota in Obesity the ratio of the dominant phyla Bacteriodetes
and Firmicutes also had functional effects on
The observation that germ-free pigs have a the host: The gut microbiota was associated with
lower body weight than conventionally raised different capacities for energy extraction from
pigs was described in 1966 and 1972. In a large food. In particular, the gut microbiota of obese
sample of mice derived from Swiss-Webster mice produced larger amounts of SCFA, and the
mice (N = 97), Gordon and colleagues showed excreted feces contained less energy than the
the opposite, and another study with ICR strain feces of normal-weight animals. Finally, Ley
mice showed similar results to those in pigs, but and colleagues were the first to show that differ-
the weight differences were smaller. Fully fed ences in the ratio of Bacterioidetes to Firmicutes
germ-free Lobund-Wistar rats had a lower body exist between normal-weight and obese humans
weight compared to their conventionally raised and that weight loss in the latter led to a shift in
littermates, but the opposite was shown in these this ratio towards a similar ratio to that in nor-
rats when food intake was restricted. No differ- mal-weight individuals.
ences in body weight were observed in germ- Since then, many more articles have been
free chickens compared to conventionally raised published dealing with obesity and gut micro-
chickens, and similar weight loss trends during biota. For example, significant changes in gut
fasting were observed. Interestingly, about 40 microbiota after bariatric surgeries have been
years later, Bäckehed and colleagues showed, described, and the role of gut microbiota in cen-
after a thorough morphological characterization tral nervous system functions has been recently
of germ-free animals, for C57BL/6J (B6) that discussed. However, the contribution of spe-
germ-free mice had a lower body weight and cific microorganisms to the development of
less body fat than conventional animals despite obesity remains controversial, as many subse-
increased food consumption and reduced energy quent studies were unable to confirm the dif-
expenditure. After transferring feces from con- ferences between Bacteroidetes and Firmicutes.
ventional animals to germ-free animals, the lat- Nonetheless, a recently conducted re-analysis
ter gained body weight and body fat, despite of raw data from ten individual human obe-
lower food consumption and increased energy sity studies showed a relationship between the
expenditure similar to that of conventional human microbial gut community and obesity
animals. In view of the literature mentioned status. It is important to note, however, that this
above, it seems that the extent to which the GI association was weak (Mack et al. 2018).
60 Microbiome and Inflammation in Obesity 453
60.3 GI Microbiota Our GI-tract is divided into different com-

and Inflammation in Obesity partments. The utilization of non-absorbed food
components takes place in the colon. Preferred
All inflammation markers are associated with food substrates for the GI-microbiota include
obesity and obesity-related diseases. Examples dietary fibers, which can be classified accord-
include CRP, PAI-1, and inflammatory cytokines. ing to solubility, chemical structure, and phys-
The mechanisms and relationships between icochemical and physiological properties.
inflammation and obesity are not fully under- Well-known examples are polysaccharides
stood, and the GI-microbiota likely plays an such as psyllium (psyllium husks), beta-glu-
important role in this regard. Many review arti- can (endosperm of oats and barley), and inu-
cles have been published on this topic, but most lin, resistant starches, and oligosaccharide and
findings come from preclinical studies, while disaccharide dietary fibers (McRorie 2015).
human studies are few in number with small sam-
ple sizes and often show contradictory results.  Important It should be emphasized that die-
It is currently assumed that dysbiosis of the tary fibers not only provide fermentation sub-
GI-microbiota impairs intestinal permeability, strates for GI microbes in the colon but also
and the resulting activation of the immune system 1) contribute to increased satiety through vol-
may contribute to a low-grade chronic inflam- ume and swelling or water-binding capacity
mation. Modulation of intestinal permeability in the stomach, 2) support the slowed absorp-
by influencing the gut microbiota is therefore an tion of simple sugars into the blood in the
attractive intervention approach (Cox et al. 2015). small intestine, and 3) also act as a mechani-
cal stimulus and form stools in the colon due
to their physicochemical properties.
60.4 Influence of Diet and Lifestyle
on the GI Microbiota in Obesity When the absorption capacities of simple
and double sugars in the small intestine are
The GI-microbiota is largely determined by exhausted, these substrates are rapidly utilized
the host’s immune system. However, exter- by the GI-microbiota. A main product of car-
nal factors strongly influence the habitat of bohydrate fermentation is SCFA, which the
GI-microbes, leading to adaptations. For exam- host uses as an energy source but which also
ple, if the diet changes, this means a change in has various other positive physiological effects.
the food source and possibly also in intestinal As mentioned above, in addition to carbohy-
peristalsis, leading to adjustments in the eco- drates, amino acids, the building blocks of pro-
system of GI microbes in the gut. Similarly, teins, can also be fermented. These come from
changes in activity and sleep habits can affect food as well as from the intestine itself, and
the GI-microbiota, either directly through their fermentation produces a number of unfa-
changes in the GI tract itself or indirectly, e.g., vorable metabolic products for the host. Lipids,
in the case of weakening the immune system. on the other hand, usually reach the colon in
Studies in both humans and other vertebrates smaller amounts and do not play a decisive role
have shown that adaptations to a changed diet in fermentation due to the anaerobic conditions
can occur within a few days, which speaks for prevailing there. However, lipids can have anti-
a high adaptability of the GI microbiota and bacterial effects due to their physicochemical
suggests that it is potentially easily influenced properties and are currently being researched in
(Santos-Marcos et al. 2019). this regard (Oliphant and Allen-Vercoe 2019).
454 I. Mack
 Important For practice in obesity treatment, 60.5 Influence of Pro- and Prebiotics
this means that the GI microbiota can be pos- on GI Microbiota in Obesity
itively influenced by a balanced diet, with an
appropriate proportion of dietary fiber. The According to the expert consensus of the
German Society for Nutrition’s recommenda- International Scientific Association for
tion of 30 g/d of dietary fiber can be used as a Probiotics and Prebiotics (Gibson et al. 2017),
guideline. probiotics are live microorganisms that, when
administered in adequate amounts, confer a
These recommendations are similar in all health benefit to the host. Depending on the
European countries and are based on findings mechanism of action, inactivated bacteria or
related to cardiovascular diseases and intesti- their components can also be just as effective
nal health. The dietary fibers themselves are not and safe. They are referred to as parabiotics or
further specified. However, most people find it postbiotics. Commonly used microbes include
difficult to adhere to these guidelines. In prac- lactobacilli and bifidobacteria. A prebiotic, on
tice, 30 g/d of dietary fiber can be achieved, for the other hand, is a substrate selectively uti-
example, by consuming three slices of whole- lized by the host organism’s microbiota (acti-
grain bread, three potatoes, two handfuls of vating metabolic activity), thereby causing a
fruit, and three handfuls of vegetables (Stephen health-promoting effect. All dietary fibers are
et al. 2017). thus prebiotics, which act both species- and site-
Considering the current situation, where low- specifically. For example, lignin has a probiotic
carbohydrate or carbohydrate-reduced diets are effect in ruminants but not in humans. When
used in obesity therapy, special attention should pro- and prebiotics are combined, they are called
be paid to high-quality carbohydrates, i.e., those synbiotics. Typically used prebiotics are fructo-
with a high fiber content, with regard to GI and galactooligosaccharides, which are classi-
health. Under protein-rich nutrition, the com- cally considered dietary fibers.
munity structure of GI microbes tends to change Study findings regarding pro- and prebiotics
unfavorably, according to current assessment are not only inconsistent in the field of obesity
(Santos-Marcos et al. 2019). A conclusive evalu- but also in areas where probiotics have tradition-
ation of the topic of GI microbiota and health ally been used from the very beginning, such
with long-term protein- and fat-rich nutrition as in GI complaints and diseases, e.g., irritable
and potentially low fiber content is currently not bowel syndrome.
possible. The reason is that studies on probiotics use
different individual microbes or a mixture of
 Important In the context of weight reduc- microbes in different dosages and treatment
tion in obesity, patient compliance with the durations, with different research questions
chosen nutritional strategy is crucial and and study designs. Therefore, summarizing the
can therefore vary individually (Mack and research in the context of meta-analyses is a sig-
Hauner 2007). As long as weight success is nificant challenge and often reaches the limits of
accompanied by a properly functioning GI its informative value. Only a few pro- and para-
tract, regular bowel movements, and normal probiotics are approved as drugs (Mack et al.
metabolic levels, there is primarily no rea- 2021) and are subject to strict testing (Preidis
son to interrupt or reevaluate the nutritional et al. 2020). “Next generation probiotics” give
strategy. hope for better development in the field. The sit-
uation is even more complex for prebiotics, and
In the course of successful therapy, it is then especially symbiotics, because a colorful mix
worthwhile to take a closer look at dietary habits of known and unknown mechanisms and their
and possibly adjust them. interactions come together, ultimately rendering
60 Microbiome and Inflammation in Obesity 455
it unclear why no, positive, or negative effects et al. 2020). It is unclear whether prebiotics
are observed. In addition, the fermentation of can contribute to health if the recommended
prebiotics in the intestine depends on the indi- fiber intake is achieved through diet. It is also
vidual’s GI microbial equipment, which can lead unclear whether the intake of the same amount
to different effects individually. of prebiotics is equivalent to a mixture of fib-
Overall, it is important to note that placebo ers through the diet, which also contains other
effects in probiotic studies tend to be high. A essential components, such as secondary plant
recently published elaborate meta-analysis on substances. However, since the recommended
probiotics and inflammatory markers in healthy daily amount of fiber is usually not achieved, the
and sick individuals showed no superiority of question arises whether prebiotics could make
probiotics for the inflammatory markers TNF- a supplementary contribution to reaching these
alpha, IL-6, IL-1b, IL-4, IL-10, and IFN-gamma guidelines.
in healthy individuals and those with metabolic
diseases. An improvement in CRP values under
probiotics for metabolic diseases (with high Conclusion
heterogeneity between studies) did not with- In summary, no recommendation can cur-
stand subgroup analysis for metabolic syndrome rently be made for a specific pro- or prebiotic
(Kazemi et al. 2020), and in another meta-analy- for the treatment of obesity with inflamma-
sis, CRP values improved under placebo (Lopez- tion. However, it can be assumed that among
Moreno et al. 2020). The influence on body the “next-generation probiotics” there are
weight also seems negligible, but positive effects candidates suitable for use in obesity ther-
were shown for probiotics that influenced the GI apy. Prebiotics may potentially contribute
microbiota compared to those where it remained to achieving the recommended daily fiber
constant (Lopez-Moreno et al. 2020; Suzumura intake.
et al. 2019). Even after bariatric surgery, with
a limited number of studies, no advantage of a
probiotic intervention emerged for physical or References
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positive effects on obesity-associated parame- Cox AJ, West NP, Cripps AW (2015) Obesity, inflam-
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Supplementation with Akkermansia muciniphila in
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levels and insulin concentration, but not for concept exploratory study. Nat Med 25(7):1096–1103
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meta-analysis on prebiotics in obesity showed Kashyap Rebecca L., Morgan (2020) AGA Technical
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clear conclusion can be drawn (Qu et al. 2019). Association for Probiotics and Prebiotics (ISAPP)
Another meta-analysis confirmed the improve- consensus statement on the definition and scope
ment in CRP values in obesity, but also with of prebiotics. Nat Rev Gastroenterol Hepatol
a limited number of studies (da Silva Borges 14(8):491–502
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benefits, part 1&2: what to look for and how to
Risk Factors of Obesity
in Childhood 61
and Adolescence
Wieland Kiess
Contents
61.1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 457
61.2 Risk Factors and Causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 458
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 461
obese than children from privileged families with

61.1 Background a high socioeconomic status. It is important for
approaches to prevention and/or therapy to rec-
The high prevalence of overweight and obesity
ognize and address risk factors for the develop-
in children and adolescents in Germany remains
ment of obesity or weight change. In particular,
persistent. While the frequency and extent of
it is also necessary to explore barriers that make
obesity are fortunately no longer increasing in
it difficult or even impossible for those affected
young children, in adolescence, the trend towards
to participate in prevention or therapy programs.
increased obesity and a higher frequency of
Only when barriers to participation and involve-
obesity continues to rise (Kurth and Schaffrath
ment are identified and their effects understood
Rosario 2010; Blüher et al. 2011). In addition to
can effective prevention and treatment programs
genetic factors, unhealthy and disease-causing
be designed and ultimately implemented. Risks
lifestyles, dietary factors, and lack of exercise
of obesity for the social life, health, and devel-
play a central role in the development of obe-
opment of children and adolescents must also be
sity. Overweight and the underlying behavior-
investigated, and their causes must be recognized
related risk factors are significantly influenced by
and ultimately prevented or treated.
the immediate and broader social environment.
Overweight and obesity in children are distrib-
uted differently within and between social classes
Possible Causes and Risk Factors
and groups. Children from socially disadvantaged
(Worldwide)
families are much more likely to be overweight or
• Genetics
• Ethnicity
• Fetal, early imprinting/programming
W. Kiess (*)
Hospital for Children and Adolescents, Department • Biological factors
of Women and Child Health, Center of Paediatric – Adipocytokines, hormonal signals
Research, University of Leipzig, Leipzig, Germany – Underlying diseases, syndromes
https://doi.org/10.1007/978-3-662-67662-2_61
458 W. Kiess
61.2 Risk Factors and Causes

– Medications
– Disabilities 61.2.1 Social Inheritance
• Psychological factors
– Resilience
In the sense of the social inheritance hypothesis,
– Dependency (Addiction?)
higher prevalence rates of obesity and over-
• Socioeconomic and sociocultural
weight, and a movement and nutrition behavior
conditions
that promotes overweight and obesity, are often
– Poverty
found among the parents and other relatives of
– Income
affected children. However, the immediate circle
– Living conditions
of friends of affected families also generally has
– Food supply: quantity and quality
a high prevalence of obesity (Igel et al. 2013). In
– Sedentary and resting lifestyle
individual studies, the coincidence of obesity in
• Personal factors
the circle of friends is reported to be higher than
– Family structure
in the biological family.
– Neighbors and friends
“Obesogenic” characteristics of the living
– Education, training
environment, such as socioeconomic depriva-
• Globalization
tion of the neighborhood, distance to parks and
• Industrialization
playgrounds, limited access to healthy foods,
• Modernization
and lack of footpaths and bicycle paths, promote
• Urbanization
overweight and obesity even in children. In the
city of Leipzig, for example, the prevalence of
overweight in preschool children is almost twice
as high in socially disadvantaged neighbor-
Influencing Factors and Barriers to the
hoods as in socially privileged neighborhoods.
Success of Therapy and Prevention
Concepts of neighborhood-based health promo-
• Upbringing
tion to reduce the prevalence of obesity in chil-
• Education within the family, of the
dren in the sense of an “intention-to-treat” study
parents
approach have therefore been presented (Igel
• Family structure, single parents
et al. 2013; Gausche et al. 2014).
• Age of the child, siblings, parents
• Parents’ income
• Poverty
• Friends/peers
61.2.2 Genetics
• Sociocultural factors
Genetic disorders associated with obesity are
• Nutrition
common. Many of these obesity syndromes
• Habits
have a characteristic age of presentation, a
• Religious affiliation
unique phenotype, and sometimes overlapping
• Environmental factors
clinical symptomatology. The latter empha-
• Living situation
sizes that in some of these syndromes, com-
• Indoor temperature of apartments; air
mon signal transduction pathways are disturbed
conditioning
and affected, leading to obesity. Once the
• Climate and outdoor temperature
genetic backgrounds of these syndromes are
fully understood, the functional consequences
61 Risk Factors of Obesity in Childhood and Adolescence 459
and causes of obesity development will also be healthy subjects are offered food on large plates
understood. In addition, new specific therapies and/or in large portions, more is consumed.
based on basic scientific findings will become Conversely, small cutlery sizes and smaller
conceivable. plate sizes lead to smaller food portions being
Bardet-Biedl syndrome and Prader-Willi syn- consumed. The general availability of food in
drome, which is the most common obesity syn- many countries and societies also leads to eat-
drome and is caused by a loss of “imprinted” ing outside of meals and an uncontrolled and
genes on chromosome 15q11–13, should be excessive intake of food in terms of quantity
mentioned. In addition, other genetic obesity and calorie content. The consumption of sweet-
syndromes such as Alström syndrome, Cohen ened beverages has also been proven to have a
syndrome, Albright’s hereditary osteodystro- significant effect on weight gain in children: In
phy (pseudohypoparathyroidism), and finally a clinical, randomized experiment, replacing
Carpenter syndrome are described. The MOMO sweetened beverages with sugar-free, unsweet-
syndrome, Rubinstein-Taybi syndrome, and ened, low-calorie beverages led to weight loss
deletions on chromosomes 1, 2, 6, and 9, as well in the participants within half a year of the study
as other genetic syndromes, are associated with duration. Not food itself, but parameters such as
obesity already in early childhood. Monogenic portion sizes, availability of food, and hidden
obesity forms are rare but are increasingly being calories and sweet drinks are thus risk factors
targeted by pharmacological therapies. for the development of obesity in childhood and
Overall, a polygenic inheritance of obesity adolescence.
risk is generally assumed. In many genome-
wide studies, a large number of obesity loci and
so-called copy-number variations associated 61.2.4 Sedentary and Resting
with obesity development have been found. In Lifestyle
most cases, very large cohorts of affected indi-
viduals were studied as part of consortial, mul- The term sedentary and resting lifestyle encom-
ticenter studies. The effect size of individual passes a variety of personal and societal attitudes
“obesity genes” is generally low. In particular, and beliefs. This involves fundamental questions
variants of the FTO gene are characterized by about the organization of everyday life, but also
obesity, “obesogenic” behavior, and a certain content-related descriptions of food preferences,
“resistance” to interventions in affected indi- meal sizes, and frequencies. Additionally, there
viduals. Many other “obesity genes” have been are lifestyle-related differences in terms of phys-
found in the area of the G-protein-coupled ical activity and sports participation, as well as
receptor family and in genes encoding pro- in the consumption of new media and television.
teins in neuronal networks: Considering the While long television viewing times have always
important role of the central nervous system in been associated with obesity, the relationship
the reception and transmission of hunger, sati- between the use of new media and body weight
ety, and hedonic and reward signals, this is not is less clear. Lack of physical exercise and sed-
surprising. entary activities naturally lead to lower calorie
expenditure and, together with increased calorie
intake, are considered mediators of weight gain
61.2.3 Availability of Food and weight control. Insufficient physical exer-
and Portion Sizes cise and poor nutrition should not be seen as
causal factors, but rather as mediators and “facil-
Particularly in England and the USA, it has been itators.” It is important to note that, for example,
found in recent years that both the prevalence membership of sports clubs and activity-focused
of obesity in children and the portion sizeof leisure behavior are stratified. Frequency and
fast food and soft drinks have increased. When intensity of sports participation are linked to
460 W. Kiess
higher educational levels and higher income. glucose intolerance, and lipid metabolism dis-
Moreover, high consumption of fruits and vege- orders, as well as fatty liver, back pain, genu
tables in children is again associated with higher valgum, and flat foot, and dermatoses, e.g., pso-
parental educational levels and higher family riasis, more frequently than lean individuals.
income. A sedentary or resting lifestyle is con- In particular, the fact that cardiovascular risk
sidered one of the most important risk factors for factors and surrogate markers for the develop-
obesity at all ages. It must be emphasized once ment of cardiovascular diseases in adulthood are
again that the effects are neither causal nor nec- already measurable in childhood is alarming. It
essarily direct. is therefore also justified to classify obesity as
a disease and to develop and implement appro-
priate treatment strategies. In summary, obesity
61.2.5 Industrialization in early life is associated with higher utilization
and Globalization of health services, higher disease burden, and
increased mortality. Cancer, cardiovascular dis-
Western lifestyle is associated with the develop- eases such as heart attack and stroke, as well as
ment of obesity, particularly in emerging coun- hypertension and diabetes mellitus occur much
tries. Historically and in an evolutionary context, more frequently in obese people than in lean
industrialization and globalization, along with individuals (Baker and Sørensen 2011).
urbanization and modernization, have also been
recognized as societal risk factors for obesity:
To what extent the accessibility of fast food and 61.2.7 Risk Factors and Barriers
sweetened beverages, as well as advertising strat-
egies of food corporations, play a role has so far By designing living environments, it might
not been sufficiently researched. The influence of be possible to sustainably minimize obeso-
food production processes (“food processing”), genic risk factors in the sense of a public health
plastic packaging, freezing methods, freeze- approach, positively influence the lifestyle of
drying, and preservation on the obesogenity of all residents of a city or municipality, and thus
nutrition has barely been investigated. Moreover, partially overcome the prevention dilemma.
although it is known from animal experiments However, mainly due to methodological weak-
that environmental temperature and light cycles nesses of primary studies, the evidence for
influence weight gain in experimental animals complex neighborhood-based health promotion
such as mice and rats, it has not been conclu- is still insufficient (Baker and Sørensen 2011;
sively clarified whether living environment, light Hayes et al. 2014).
cycles (illuminated rooms), and sleep duration Another research context that has not yet
significantly influence human weight develop- received sufficient attention revolves around the
ment. However, reports on studies showing an question of why it is difficult to introduce obese
inverse relationship between sleep duration and patients to therapy programs and why adherence
body weight and weight gain, even in children, to these programs is low. What barriers exist that
have increased in recent years. The reduction in prevent children and adolescents from following
sleep duration in many countries over the past the recommendation to exercise more, eat health-
100 years coincides with the increase in obesity ier, consume less television, and engage in fewer
prevalence in the same countries. sedentary activities? For example, it is known
that children of single parents, parents with low
educational attainment, and parents with low
61.2.6 Health Risks of Obesity income participate less in obesityprograms and
are less adherent than children from intact fami-
Even in childhood and adolescence, individu- lies with higher social status. Greater distance to
als with obesity have increased blood pressure, therapy facilities and time restrictions may also
61 Risk Factors of Obesity in Childhood and Adolescence 461
be barriers to participation and involvement (Alff Baker JL, Sørensen TI (2011) Obesity research based
et al. 2012). on the Copenhagen School Health Records Register.
Scand J Public Health 39(Suppl):196–200
Blüher S, Meigen C, Gausche R et al (2011) Age-specific
stabilization in obesity prevalence in German chil-
Conclusion dren: a cross-sectional study from 1999 to 2008. Int J
Pediatr Obes 6:e199–e206
Obesity is usually a polygenically inherited Gausche R, Igel U, Sergeyec E et al (2014)
disease caused and maintained by environ- Stadtteilbezogene Gesundheitsförderung zur
mental conditions in the social context. Given Reduktion der Adipositasprävalenz bei Kindern und
Jugendlichen. Adipositas 8:18–124
the multitude of risk factors that promote Hayes A, Lung T, Wen LM, Baur L, Rissel C, Howard K
and drive the development of obesity from (2014) Economic evaluation of „healthy beginnings“
an early age, only fundamental, multi-level, an early childhood intervention to prevent obesity.
and multifactorial prevention and therapy Obesity (Silver Spring). 22:1709–1715. (Epub ahead
of print)
concepts can be successful. Only when the Igel U, Baar J, Benkert I et al (2013) Deprivation im
diversity and complexity of risks and causes Ortsteil und Übergewicht von Vorschulkindern.
are recognized and acknowledged by all Adipositas 7:27–31
stakeholders and those affected will there be Kurth BM, Schaffrath Rosario A (2010) Overweight
and obesity in children and adolescents in
success in the treatment and prevention of Germany. Bundesgesundheitsbl Gesundheitsforsch
unhealthy overweight and obesity. Gesundheitsschutz 53:643–652
References
Alff F, Markert J, Zschaler S et al (2012) Reasons for
(non)participating in a telephone-based intervention
program for families with overweight children. PLoS
One 12:e34580
Part VIII
Comorbidity of Obesity
463
Social and Psychosocial
Consequences of Obesity: 62
Weight-Related Stigmatization
and Discrimination
Anja Hilbert
Contents
62.1 Weight-related Stigmatization and Discrimination in Obesity . . . . . . . . . . 465
62.2 sychosocial Consequences of Weight-Related Stigmatization
P
and Discrimination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 468
62.1 Weight-related Stigmatization of their overweight, this is referred to as

and Discrimination in Obesity weight-related discrimination.
Compared to many other physical and men- Stigmatizing attitudes that characterize people
tal health disorders, obesity is associated with obesity as lazy, weak-willed, undisciplined,
with the most socially accepted stigma. This ugly, and emotionally disturbed are widespread
stigma, including, for example, the blame for in the population. They are related to pervasive
being overweight, can lead to actual discrimina- beliefs of responsibility and a cultural devalua-
tion in a variety of areas of life. tion of obesity. Stigmatizing attitudes towards
people with obesity are particularly common
 Important A social stigma is a characteris- among men, older individuals, and those with
tic that makes a person appear deviant, con- lower levels of education. However, they are
spicuous, or impaired. Stigmatizing attitudes independent of the respondents’ body mass
towards people with obesity include preju- index (BMI, kg/m2).
diced attributions of negative evaluations due
to their overweight. If people with obesity are  Theoretical Classification of Obesity Stigma:
denied the equal treatment they need because Attribution Theory Theoretically, reactions to
stigmas such as obesity are often explained by
referring to the attribution theory. Attribution
A. Hilbert (*) theory states that the more a stigma is attributed
Integrated Research and Treatment Center
Adiposity Diseases, Behavioral Medicine Research
to internal, controllable causes, the stronger the
Unit, Department of Psychosomatic Medicine and negative reactions to it. Ideologies of individual-
Psychotherapy, University of Leipzig Medical ism or political conservatism are the main back-
Center, Leipzig, Germany ground for these attribution patterns.
https://doi.org/10.1007/978-3-662-67662-2_62
466 A. Hilbert
Weight-related discrimination experiences are obesity exist among members of many health-
common in people with obesity in areas such as care professions, including doctors, nurses, die-
the workplace, healthcare, school, and personal titians, and even those professionally involved in
relationships. Discrimination experiences within weight loss treatment. These negative attitudes
close relationships, such as partnerships, fam- include attributions of lack of self-control and
ily, or friendships, which may consist of nega- willpower, poor hygiene, and assumptions of not
tive comments about body shape and weight, following treatment recommendations, some-
are perceived as particularly intrusive. The more times even being dishonest and hostile. Doctors
severe the obesity, the more frequent the weight- and nursing staff report being reluctant to treat
related discrimination. Even after weight loss to patients with obesity. Conversely, patients with
normal weight, formerly obese individuals are obesity report feeling inadequately cared for,
stigmatized. It is not clear whether women with especially regarding their body weight. Indeed,
obesity are overall more affected by weight- there is evidence that patients with obesity
related stigmatization compared to men; how- receive certain examinations less frequently than
ever, there seem to be stronger disadvantages for normal-weight patients due to stigmatizing atti-
women with obesity in specific areas. tudes and also avoid certain, for example, pre-
ventive healthcare services due to shame about
their own weight.
62.1.1 Professional Life
Numerous studies document disadvantages 62.1.3 Childhood

for adults with obesity in professional life.
Experimental investigations have shown that can- Stigmatizing attitudes have been documented
didates with obesity are less frequently selected in children from around the age of 3 years.
for interviews and hiring, particularly for posi- Subsequently, children with obesity are con-
tions with representative functions, than candi- sidered mean, stupid, ugly, and lazy and are
dates with normal weight. Stigmatizing attitudes rejected as playmates. Students with obesity, in
of superiors, colleagues, and employees char- turn, feel excluded, teased, and insulted by their
acterize people with obesity in the professional peers due to their weight. Teachers also show
world as less competent, ambitious, and deserv- stigmatizing attitudes towards students with
ing of promotion, as well as lazier, undisci- severe overweight. Evidence has been found of
plined, emotionally unstable, and less attractive. disadvantages for adolescents with obesity in
Epidemiological data indicate that people with university admissions and financial support for
obesity are less frequently hired compared to education from their own families, regardless of
normal-weight individuals with comparable pro- the family’s educational level and income, and
fessional qualifications, they hold leadership posi- particularly for girls with obesity. Parents seem to
tions in companies less often, and receive lower play a central role in conveying negative weight-
salaries—this particularly affects women with related attitudes and are themselves a source of
obesity. Working individuals with obesity report weight-related criticism towards their children.
weight-related discrimination, such as lower
remuneration or dismissals due to overweight.
62.1.4 Public Social Sphere
62.1.2 Healthcare The obesity stigma is also present in other areas

of life: For example, cases of discrimination
Evidence of weight-related stigmatization and against people with obesity have been reported
discrimination has also been found in health- regarding tight seating in public transportation,
care. Stigmatizing attitudes towards adults with theaters, or airplanes, less customer-oriented
62 Social and Psychosocial Consequences of Obesity: Weight-Related … 467
advice from salespeople in retail, and lower the obesity stigma differs from other stigmatized
chances of renting housing or participating in groups, which exhibit a positive “ingroup prefer-
adoption processes. ence” for their own group. A possible explana-
tion for this self-stigma is that when attributing
internal causes, the assignment to the group of
62.1.5 Media individuals with obesity offers little support.
Psychologically, experiences of weight-related
The obesity stigma also appears to be transmit- discrimination and the internalization of the
ted by a negative media portrayal of people with obesity stigma seem to increase vulnerability to
obesity. While representations of overweight psychopathology.
individuals on television and other media are Population-based data for adults indicate that
underrepresented, obese characters, for exam- experiences of weight-related discrimination are
ple in television shows, are rarely shown as cross-sectionally not associated with self-esteem
attractive, have fewer romantic interactions, and and depressive symptoms. However, among par-
receive less physical affection compared to non- ticipants in weight loss programs, it has been
obese television characters. In contrast, they are found that experiences of discrimination are
more often depicted eating or being ridiculed. indeed associated with low self-esteem, anxiety,
depressive symptoms, and greater dissatisfac-
tion with one’s own body. Clinical samples with
62.1.6 State of Research obesity are generally more psychopathologically
burdened than non-clinical samples. However,
Stigmatizing attitudes towards people with obe- it remains unclear whether experiences of dis-
sity are so widespread in the population that crimination causally impair psychological func-
they can be considered normative. Conversely, tioning in adults or are reported more frequently
weight-related discrimination is an experience due to a psychopathologically altered selective
that people with obesity often encounter in many perception.
different life contexts. While previous research On the other hand, it has been shown for
has primarily focused on these two aspects of the children and adolescents that experiences of
obesity stigma, objective weight-related disad- weight-related discrimination are relevant for
vantages often remain unproven. Because actual the development of psychopathology. Affected
weight-related discrimination in everyday life is children, especially girls, for example, have an
methodologically difficult to assess, many study increased likelihood of being teased or criticized
results are based on experimental case vignettes by other same-aged children or even family
and manipulations of causality, often using stu- members because of their weight. Teasing expe-
dent samples, which limits the generalizability riences predict a lower self-esteem, impaired
of the findings. In addition, potential confound- quality of life, increased dissatisfaction with
ing variables such as age, origin, or gender were one’s own body, binge eating, dieting behav-
not systematically considered. ior, depressive symptoms, and even suicidal
thoughts and attempts in children and adoles-
cents with obesity, even after controlling for
62.2 Psychosocial body weight. In retrospective surveys of adults
Consequences of Weight- with binge eating disorder, weight-related teas-
Related Stigmatization ing and criticism from peers and family were
and Discrimination also identified as risk factors in childhood and
adolescence for the development of the eat-
Various studies have shown that people with ing disorder. Increasingly evident is that expe-
obesity also harbor stigmatizing attitudes riences of weight-related discrimination can
towards their own social group. In this respect, mediate the relationship between obesity and
468 A. Hilbert
psychopathology, stress, and general health are only present in subgroups. Due to the pos-
parameters. Longitudinal studies have shown sible psychopathological relevance of dis-
a clear association between experiences of discrimination experiences, further exploration of
crimination and an increased risk of developing weight-related discrimination and stigmatiza-
or maintaining overweight or obesity, through tion processes represents a significant challenge
associations with obesogenic eating behaviors, for future research, not least to determine start-
such as overeating and low physical activity. ing points for stigma reduction; stigma reduc-
Comparatively little is known about the inter- tion has so far been achieved in only a few
nalization of the obesity stigma or self-stigma. existing studies, mostly not sustainably. In par-
Current research on adults and adolescents ticular, empowering individuals with obesity in
shows that self-stigma explains psychopathol- dealing with weight-related discrimination and
ogy and general health variables to an extent self-stigma seems promising. Legal measures
that goes beyond experiences of discrimination, to protect against weight-related discrimination
stigmatizing attitudes, and body mass index. have so far achieved only moderate public sup-
Vulnerable individuals, for example, those with port, for example, in Germany.
low self-esteem, are particularly affected by the
negative consequences of self-stigma.
References
62.3 Conclusion and Outlook Albano G, Rowlands K, Baciadonna L, Coco GL, Cardi
V (2019) Interpersonal difficulties in obesity: a sys-
tematic review and meta-analysis to inform a rejec-
Obesity not only affects people with a low tion sensitivity-based model. Neurosci Biobehav Rev
socioeconomic status in particular, but also 107:846–861
entails social and psychosocial impairments. Baldofski S, Rudolph A, Tigges W, Herbig B, Jurowich
C, Kaiser S, Dietrich A, Hilbert A (2016) Weight bias
Stigmatizing attitudes towards people with internalization, emotion dysregulation, and non-nor-
obesity are widespread in the population and mative eating behaviors in prebariatric patients. Int J
seem to have increased over the past four dec- Eat Disord 49:180–185
ades, parallel to the pandemic increase of this Emmer C, Bosnjak M, Mata J (2020) The association
between weight stigma and mental health: a meta-
health disorder. These include attributing nega- analysis. Obes Rev 21:e12935
tive characteristics to affected individuals, such Hilbert A (2016) Weight stigma reduction and genetic
as being lazy and weak-willed. Weight-related determinism. PLoS One 11:e0162993
stigmatization can essentially be explained by Hilbert A, Puls HC (2019) Adipositas und
Stigmatisierung [Obesity and stigmatization]. In: de
internal attributions to an alleged individual mis- Zwaan M, Herpertz S, Zipfel S (Eds) Psychosoziale
conduct of those affected. Thus, stigmatizing Aspekte der Adipositas-Chirurgie [Psychosocial
attitudes are also an expression of a reduction- aspects of obesity surgery]. Springer, Berlin, pp
ist understanding of the complex, multifactorial 67–86
Hilbert A, Puls HC (2019) Stigma associated with
etiology of obesity, in which genetic predis- obesity in children and adolescents. In: Herpertz-
positions and external influences of the obeso- Dahlmann B, Hebebrand J (Eds) Eating disorders
genic environment are neglected. In view of the and obesity in children and adolescents. Elsevier,
ubiquitous obesity stigma, it is not surprising Amsterdam, pp 105–110
Hilbert A, Puls HC (in press) Stigmatisierung bei
that people with obesity often face weight- Adipositas [Stigmatization in obesity]. In: Hauner H,
related discrimination in many important areas Wirth A (Eds) Adipositas [Obesity], 5. edn. Springer,
of life. Weight-related discrimination experi- Berlin
ences are particularly relevant for the devel- Hilbert A, Hübner C, Schmutzer G, Danielsdottir S,
Brähler E, Puhl R (2017) Public support for weight-
opment of psychopathology in childhood and related antidiscrimination laws and policies. Obes
adolescence, whereas in adulthood, associations Facts 10:101–111
between such experiences and psychopathology Hilbert A, Braehler E, Schmidt R, Löwe B, Häuser
W, Zenger M Self-compassion as a resource in the
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self-stigma process of overweight and obese individ- Puhl RM, Himmelstein MS, Pearl RL (2020) Weight
uals. Obes Facts 8:293–301 stigma as a psychosocial contributor to obesity. Am
Hübner C, Baldofski S, Zenger M, Tigges W, Herbig B, Psychol 75:274–289
Jurowich C, Kaiser S, Dietrich A, Hilbert A (2015) Rubino F, Puhl RM, Cummings DE, Eckel RH, Ryan
Influences of general self-efficacy and weight bias DH, Mechanick JI et al (2020) Joint international
internalization on physical activity in bariatric sur- consensus statement for ending stigma of obesity. Nat
gery candidates. Surg Obes Relat Dis 11:1371–1376 Med 26:485–497
Hübner C, Baldofski S, Crosby RD, Müller A, de Zwaan Sikorski C, Spahlholz J, Hartlev M, Riedel-Heller SG
M, Hilbert A (2016) Weight-related teasing and non- (2016) Weight-based discrimination: an ubiquitary
normative eating behaviors as predictors of weight phenomenon? Int J Obes 40:333–337
loss maintenance. A longitudinal mediation analysis. Spahlholz J, Baer N, König HH, Riedel-Heller SG,
Appetite 102:25–31 Luck-Sikorski C (2016) Obesity and discrimina-
Pearl RL, Puhl RM (2018) Weight bias internalization and tion—a systematic review and meta-analysis of
health: a systematic review. Obes Rev 19:1141–1163 observational studies. Obes Rev 17:43–55.
Puhl RM, Lessard LM (2020) Weight stigma in youth:
prevalence, consequences, and considerations for
clinical practice. Curr Obes Rep 9:402–411
Obesity and Comorbid
Mental Disorders 63
Stephan Herpertz and Magdalena Pape
Contents
63.1 Mental Stress and Illnesses in Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 471
63.2 Psychosocial Stress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 471
63.3 Psychosomatic Aspects of Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 472
63.4 Obesity and Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 472
63.5 Pathological Hypercaloric Eating Behavior and Binge Eating Disorder . . 473
63.6 Obesity, Personality Traits, and Personality Disorders . . . . . . . . . . . . . . . . 473
63.7 Obesity and Addiction Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 474
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 474
63.1 Mental Stress and Illnesses 63.2 Psychosocial Stress

in Obesity
Regardless of the etiology of obesity, the psy-
In the case of mental stress, it is ideally neces- chosocial stress of a person with obesity is
sary to distinguish between causal factors and unmistakable. It is mainly due to the discrep-
consequential states of obesity, but this is usu- ancy between the increasing average body
ally not possible. While the view that obesity weight of the population and the traditionally
represented a personality disorder was wide- high societal norms of slimness. Even chil-
spread until the 1960s, modern obesity research dren and adolescents with obesity are exposed
predominantly interprets mental aspects as to significant societal prejudices (Hilbert et al.
dependent variables. Thus, follow-up studies 2013). Since social stigmatization is expected
show that weight loss in most people is asso- to have an impact on self-esteem, the self-
ciated with an improvement in psychological esteem regulation of children with obesity com-
symptoms, particularly anxiety and depression. pared to those with normal weight has been
repeatedly investigated. Despite controversial
study results, the self-esteem of younger chil-
S. Herpertz (*) · M. Pape dren with obesity seems to be only slightly or
Department of Psychosomatic Medicine and not at all impaired, whereas adolescents from
Psychotherapy, LWL-University Clinic, Ruhr-
University Bochum, Bochum, Germany
puberty onwards show a clear problem with self-
e-mail: [email protected] esteem (Goodman and Whitaker 2002).
M. Pape
The described discrimination, particularly
e-mail: [email protected] in women, often has negative effects both on
https://doi.org/10.1007/978-3-662-67662-2_63
472 S. Herpertz and M. Pape
relationships and in the workplace. A frequently (BED) are the most common comorbid men-
replicated observation is the inverse relation- tal illnesses of obesity (Baumeister and Härter
ship between socioeconomic status and the 2007; Carey et al. 2014). Certain forms of obe-
prevalence of obesity. Social status, especially in sity show phenotypic behavioral similarities
women, has an impact on weight: the lower the with addiction disorders.
social class, the higher the weight (Gortmaker
et al. 1993).
63.4 Obesity and Depression
63.3 Psychosomatic Aspects Obesity and especially atypical depression show

of Obesity important similarities, such as lack of drive,
lack of physical activity, pathological hyperca-
Although genetic findings suggest a stronger loric eating behavior, e.g., in the form of a BED,
“genetic-biological control” of eating behavior overweight, and finally increased morbidity and
and body weight, approximately 10–40% of the mortality in the context of cardiovascular dis-
variance in body weight at the population level eases and type 2 diabetes mellitus.
can be attributed to environmental factors such
as diet and physical activity (Silventoinen et al.  Important In particular, more recent
2010). Behavior-related factors are to be under- prospective studies identify depres-
stood both in the context of sociocultural condi- sion in childhood and adolescence
tions and against the background of individual as a risk factor for the development
socialization (individual learning history). of obesity in adulthood.
 Important In addition to satisfying The data on the relationship between depression

hunger, eating has important other and obesity in adulthood is more conflicting.
functions to fulfill. For instance, The literature shows both positive and nega-
eating often serves the purpose of tive, as well as no relationships between depres-
affect regulation, e.g., in the sense of sive symptoms and body weight, although more
coupling negative emotional states recent meta-analyses highlight a bidirectional
and food intake (e.g., parents com- relationship between obesity and depression
forting their children by offering (Luppino et al. 2010). Thus, obesity represents
sweets). a risk factor for the development of depression,
and conversely, depression is more often associ-
With regard to obesity, of particular interest ated with obesity.
are habitualized actions related to food intake Psychosomatic and psychobiological factors
which ultimately influence eating behavior both are suggested to explain the apparent association
qualitatively and quantitatively for the purpose between depression and obesity. Depending on
of stress reduction and at least temporary post- the severity of obesity, significant, usually pain-
ponement of dysphoric feelings, and change the ful complaints of the musculoskeletal system can
balance of energy intake and expenditure. Thus, occur, which can be accompanied by a signifi-
within the overall cohort of people with obesity, cant restriction of mobility, in turn resulting in a
a subgroup can be identified in whom mental depressive mood (Hagena and Herpertz 2020).
problems and disorders lead to a change in eat- The described negative stigmatization is
ing and exercise behavior, the consequence of likely to weigh more heavily on women than on
which is a persistent positive energy balance men, against the background of diverging devel-
with overweight and obesity. opments of increasing body weight and socially
In addition to depressive disorders, anxiety, mediated beauty ideals (“thin is in”) in recent
somatoform disorders, and binge eating disorder decades. Moreover, the success of conservative
63 Obesity and Comorbid Mental Disorders 473
weight loss measures is only moderate, which usually time-limited episodes of strict dieting
leads to the repeated experience of not only behavior and subsequent drastic weight loss.
failure but also the paradoxical yo-yo effect in However, a steady weight gain usually resumes
those affected and can contribute to a depres- afterwards, often exceeding the body weight
sive development in the sense of the etiological before the start of the diet (yo-yo effect). Obese
model of “learned helplessness” (Hagena and people with BED have lower self-esteem com-
Herpertz 2020). pared to obese individuals without an eating
Psychobiological factors, in particular, stress disorder. Other comorbid mental disorders, par-
models and – related to this – the activation of ticularly affective disorders and personality dis-
the hypothalamic-pituitary-adrenal (HPA) axis orders (Davis et al. 2008), are more frequently
are discussed in the development of depres- observed. The development of obesity, often
sion. Conversely, increased cortisol levels as associated with early dieting and unsuccessful
an expression of hyperactivity of the HPA axis attempts at weight loss, begins anamnestically
are held responsible for an increase in visceral earlier compared to obese individuals without
fat tissue in depressive patients. The weight- an eating disorder. Further differences exist with
increasing effect of many psychotropic drugs, regard to food or energy intake, which is greater
including many antidepressants, should not be in obese people with BED both globally and on
underestimated in the comorbidity of obesity days without binge eating episodes. There is a
and depression. direct relationship between psychopathology
and the degree of eating disorder, while the psy-
 Important There is a bidirectional chopathological findings seem to be less associ-
relationship between depression and ated with the extent of obesity (de Zwaan and
obesity, with both psychosomatic Friederich 2006; Herpertz 2008).
and psychosocial as well as psycho- In addition to BED, there are numerous
biological factors playing a role. In variants of pathological eating behavior. It is
particular, women with obesity often worth mentioning so-called “grazing”, in which
experience high levels of distress— patients primarily consume sweet foods over
up to depressive symptoms. a long period and not within a short time. Also
noteworthy is night eating syndrome, which was
first described in 1955 and is characterized by
63.5 Pathological Hypercaloric a rather hypocaloric diet during the day, hyper-
Eating Behavior and Binge phagia during the night hours, and sleep distur-
Eating Disorder bances (Müller et al. 2018).
BED was introduced as a new eating disorder

entity in the 5th edition of the Diagnostic and 63.6 Obesity, Personality Traits,
Statistical Manual of Mental Disorders (DSM-5) and Personality Disorders
in 2013. While BED occurs in the general popu-
lation with a prevalence of 1–3%, it is relatively The relationship between personality traits and
common in samples of people with obesity who body weight has been investigated through both
suffer from their overweight and seek medi- cross-sectional and longitudinal studies, with
cal or mental health help for weight loss, with the aim of identifying personality character-
up to 30%. In contrast to anorexia nervosa and istics that are frequently associated with obe-
bulimia nervosa, which primarily affect women, sity (cross-sectional studies), and to assess the
approximately 40% of affected patients are men. possible predictive value of personality traits
Obesity often associated with BED frequently for weight development, e.g., in the context of
motivates patients to engage in regular fasting, conservative and surgical weight loss measures
(longitudinal studies) (Dalle Grave et al. 2008).
474 S. Herpertz and M. Pape
A stronger expression of the traits “neuroti- (Volkow et al. 2013). In particular, the dopa-
cism”, “impulsivity”, and “extraversion” rep- minergic reward system, which is also involved
resents a risk factor for the development of in the development and maintenance of (non-)
overweight and obesity, whereas “conscien- substance-related dependencies, seems to play
tiousness” seems to have a protective function. a role (Chap. 27). In some affected individuals,
Likewise, the relationship between impulsivity and an uncontrolled, excessive eating behavior (food
eating behavior is particularly relevant with regard addiction) develops.
to binge eating symptoms (Gerlach et al. 2015). While nicotine consumption and overweight
Insufficient regulation of affects can be an are often associated, the study findings regard-
expression of a general disturbance of impulsiv- ing the comorbidity of obesity and alcohol
ity in the sense of an impulse control disorder, dependence are heterogeneous (VanBuskirk
as is primarily found in certain personality dis- and Potenza 2010), with different etiologi-
orders such as emotionally unstable personality cal concepts being discussed. Overweight and
disorder (borderline personality disorder (BPD). obesity are discussed as protective factors for
The comorbidity of obesity and BPD has so the development of alcohol dependence, while
far been primarily investigated in clinical sam- on the other hand, excessive alcohol consump-
ples (Frankenburg and Zanarini 2006), with tion can contribute to overweight or obesity due
prevalence rates of 7–40%. In samples of bari- to increased energy intake. In addition, some
atric surgery patients, usually with obesity grade patients develop alcohol dependence after bari-
III, prevalence rates range between 1.0 and 30%. atric surgery, which is interpreted, among other
BPD is of multifactorial origin and the product things, as a shift in addiction (Steffen et al.
of a complex interplay of innate temperament, 2015). With regard to (non-)substance-related
severe childhood stress, and relatively subtle dependencies such as internet-related disorders,
forms of neurological and/or biochemical dys- the association with overweight or obesity is
function. Severe childhood stress includes trau- explained by physical inactivity and unhealthy
matic experiences such as sexual abuse. Indeed, eating habits (Aghasi et al. 2020).
in psychiatric or psychosomatic care, comorbid
patients are found in whom impulse control dis-
order, e.g., in the context of BED, plays a sig- References
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j.1467-789X.2012.01031.x
Metabolic Syndrome
and Depression 64
Bernd Löwe
Contents
64.1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 477
64.2 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 479
64.3 Relationship Between Metabolic Syndrome and Depression . . . . . . . . . . . . 480
64.4 Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 481
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 483
64.1 Background 64.1.1 Prevalence
A series of metabolic risk factors for coronary Due to the increase in the prevalence of obe-
heart disease, heart attack, and cardiovascu- sity, diabetes mellitus, and metabolic syndrome
lar mortality typically co-occur. Various terms in the last 20 years and the occurrence already
have been used in recent decades to describe the in early childhood (Eckel et al. 2005), it is now
combination of these cardiovascular risk fac- referred to as a “global epidemic”; prevention
tors; today, the term “metabolic syndrome” has strategies are urgently called for (Zimmet et al.
largely prevailed. 2001). Parallel to the increase in metabolic syn-
drome, depressive disorders are being diagnosed
 Important The metabolic syndrome, more frequently, and it is expected that they will
formerly also called “Syndrome become the leading global cause of disease bur-
X” or the “deadly quartet” (Kaplan den by 2030.
1989), refers to a symptom complex
of reduced glucose tolerance, obe-
sity, dyslipoproteinemia, and arterial 64.1.2 Definitions
hypertension.
Although the term “metabolic syndrome” is
widely accepted, various definitions have long
been used. In 1998, the WHO developed the
B. Löwe (*)
first internationally recognized definition of
Institute and Outpatients Clinic for Psychosomatic the metabolic syndrome. In response, the Adult
Medicine and Psychotherapy, University Hospital Treatment Panel III (ATP III) developed a new
Hamburg-Eppendorf, Hamburg, Germany definition of the metabolic syndrome, which
https://doi.org/10.1007/978-3-662-67662-2_64
478 B. Löwe
was much simpler to capture compared to the 64.1.3 Criticism of the Concept
WHO definition. In 2005, revised versions of of Metabolic Syndrome
the ATP-III criteria were issued in parallel by
the International Diabetes Federation (IDF) and However, justified criticism of the concept of
the American Heart Association/National Heart, metabolic syndrome has also been expressed:
Lung and Blood Institute (AHA/NHLBI), which The American Diabetes Association (ADA)
correspond to the specified limits for hypertri- and the European Association for the Study of
glyceridemia, reduced HDL cholesterol, arte- Diabetes (EASD) published a provocative call
rial hypertension, and increased fasting glucose. for critical questioning of the concept of meta-
However, the waist circumference thresholds in bolic syndrome (Kahn et al. 2005). In this pub-
the American AHA/NHLBI definition are higher lication, the definition is criticized as imprecise
than in the IDF definition, and the diagnostic and the clinical benefit of summarizing known
algorithm shows slight differences. In 2009, a risk factors into a syndrome is questioned. It is
joint Interim Statement was issued by the IDF, suggested that clinicians, until better research
NHBLI, AHA, and other international asso- results are available, should diagnose and treat
ciations (World Heart Federation, International only the individual risk factors instead of the
Atherosclerosis Society, and International metabolic syndrome. In contrast, the IDF argued
Association for the Study of Obesity), which that, given the worldwide epidemic of diabetes
aimed to standardize the definition of the mellitus and cardiovascular diseases, it makes
metabolic syndrome (Alberti et al. 2009). sense to identify individuals with risk factors for
Table 64.1shows the diagnostic criteria for the these diseases as early as possible and encour-
metabolic syndrome that are listed in this state- age them to change their lifestyle (Alberti et al.
ment, with at least three of the five criteria need- 2005).
ing to be met.
Table 64.1  Definition of the metabolic syndrome. (Data from Alberti et al. 2009)
Diagnostic Criteria
(min. 3 of 5) Thresholds
Central obesity* Waist circumference
≥94 cm (men of European origin)
≥80 cm (women of European origin)
Hypertriglyceridemia Triglycerides > 150 mg/dl
Specific treatment for this lipid disorder
Low HDL cholesterol <40 mg/dl (men)
<50 mg/dl (women)
Specific treatment for this lipid disorder
High blood pressure Systolic ≥ 130 mmHg
Diastolic ≥ 85 mmHg
Treatment of previously diagnosed arterial hypertension
Increased fasting glucose ≥100 mg/dl
Previously diagnosed type 2 diabetes mellitus
* Normal values for waist circumference differ for various ethnic groups. An overview of the norm values can be
found in Alberti et al. (2009)
64 Metabolic Syndrome and Depression 479
64.2 Epidemiology et al. 2004). However, in physically ill patients,

the prevalence of depressive disorders is esti-
64.2.1 Metabolic Syndrome mated to be around 20–35%, with the prevalence
increasing significantly with the severity and
Internationally, the prevalences of metabolic chronicity of the physical illness.
syndrome vary greatly: In various samples of
the American general population, prevalences of  Important Large studies and meta-
20–40% were reported (Ford 2005a), while, for analyses have now shown that a
example, in France, much lower prevalences of depressive disorder is a significant
7% were found (Eckel et al. 2005). Reliable fig- risk factor for cardiovascular mor-
ures on the frequency of metabolic syndrome in bidity and mortality. A depressive
the German general population are not available. disorder increases the risk of dying
The prevalence of metabolic syndrome increases from a myocardial infarction by
significantly with age (Eckel et al. 2005), e.g., about a factor of 2.
in American women from 12% at the age of
20–29 years to 61% at the age of 60–69 years Since depressive disorders and metabolic syn-
(Ford 2005a). The frequency of metabolic syndrome are already associated with consider-
drome increases with increasing body mass able morbidity and mortality on their own, it
index; hypertensive individuals are about twice is to be feared that a combination of the two
as likely to have metabolic syndrome as normo- will have particularly serious consequences.
tensive individuals (Ford 2005a). Similarly, in However, there are only a few studies on this,
patients with coronary heart disease (CHD), the which do not allow for a conclusive quantitative
age-adjusted prevalence of metabolic syndrome assessment.
(Ford 2005a) is doubled compared to patients
without CHD Sedentary lifestyle, smoking,  Important Patients with the indi-
and chronic work stress have been identified as vidual components of the metabolic
additional risk factors for metabolic syndrome syndrome, i.e. diabetes mellitus,
(Adams et al. 2005). In individuals with meta- arterial hypertension, or obesity, suf-
bolic syndrome, the probability of occurrence of fer from depressive disorders sig-
cardiovascular diseases and diabetes mellitus is nificantly more often than persons
significantly increased compared to individuals without these risk factors (Anderson
without metabolic syndrome (Ford 2005b). As et al. 2001).
the INTERHEART study and other studies have
impressively shown, the increased risk of myo-
cardial infarction applies not only to the full pic- 64.2.3 Metabolic Syndrome
ture of metabolic syndrome but also to a similar and Mental Disorders
extent for each of its components, i.e., arterial
hypertension, abdominal obesity, diabetes mel- The metabolic syndrome is of particular rel-
litus, and hyperlipidemia (Yusuf et al. 2004). evance for psychiatry, psychosomatic medicine,
and psychotherapy, as it occurs more frequently
in patients of these disciplines. A recent meta-
64.2.2 Depression analysis based on 198 studies found that about
one in three patients (32.6%) (Vancampfort et al.
According to a study by the WHO, the 12-month 2015) with a severe mental illness suffers from
prevalence of depressive disorders in the gen- a metabolic syndrome. In patients with depres-
eral German population is 3.6% (Demyttenaere sion, the prevalence of metabolic syndrome was
480 B. Löwe
31.3% (Vancampfort et al. 2015). The relation- and atherosclerotic complications (Ramasubbu
ship between mental disorders and metabolic 2002). The cause of hypercortisolism may be an
syndrome is bidirectional: depression increases increase in TNF-α (tumor necrosis factor-α) and
the risk of developing a metabolic syndrome interleukin-6 as part of an imbalance between
(adj. OR approx. 1.5), and the metabolic syn- anti- and pro-inflammatory cytokines, which
drome increases the risk of developing depres- subsequently leads to an increase in diabe-
sion (adj. OR approx. 1.5) (Pan et al. 2012). It togenic hormones (adrenocorticotropic hormone
should be noted that the pharmacological treat- ACTH, corticotropin-releasing hormone CRH,
ment of mental disorders, especially with antip- growth hormone GH) and, through interaction
sychotics and tricyclic antidepressants, can with insulin receptors, modulates the activity of
also contribute to the development of a meta- the pituitary-hypothalamic-adrenal cortex sys-
bolic syndrome: among persons with mental tem. Due to this metabolic constellation, there is
disorders, antipsychotic-naive patients have an increased risk for the development of meta-
the lowest prevalence of metabolic syndrome. bolic syndrome with impaired glucose toler-
Moreover, the risk increases significantly with ance, relative insulin resistance, dyslipidemia,
psychopharmacological combination therapy and an increase in intra-abdominal fat tissue
compared to monotherapy. A particularly high compartments. In this context, intra-abdominal
prevalence of metabolic syndrome was found (visceral) fat tissue plays a particularly impor-
in patients treated with clozapine, at 47.2% tant role. Depressed patients are often obese
(Vancampfort et al. 2015). In addition to psy- and have an increased volume of intra-abdomi-
chopharmacological medication, numerous other nal fat components: This, in turn, represents an
mediating mechanisms have been assumed for increased risk for the development of metabolic
the relationship between depression and meta- syndrome and diabetes as well as cardiovascular
bolic syndrome. diseases. Finally, genetic correlations are likely
significant for the development of metabolic
syndrome in depression, although a monogenic
64.3 Relationship Between etiology is not assumed (Ramasubbu 2002).
Metabolic Syndrome However, there are also contradictory findings
and Depression for the assumption of a genetic component.
The development of metabolic syndrome in
Interactions between metabolic syndrome and depressed individuals can also be iatrogenically
depressive disorders occur at the behavioral, promoted by the intake of antidepressant medi-
metabolic, genetic, and iatrogenic levels. In gen- cation. Weight gain and metabolic deterioration
eral, depressive patients exhibit a less healthy due to antidepressant medication, particularly
lifestyle than non-depressive individuals. The tricyclic antidepressants, have been described.
less healthy lifestyle in depressed individuals, Figure 64.1 illustrates mechanisms and fac-
which promotes the development of metabolic tors that exert an impact in the development of
syndrome, includes increased rates of nicotine metabolic syndrome with depression and clari-
abuse, malnutrition, inadequate sleep hygiene, fies how a metabolic syndrome can cause both a
and lack of exercise (Kahl 2005). worsening of depressive symptoms and a poten-
A significant relationship between depres- tiation of somatic morbidity. Both the affective
sion and metabolic syndrome is also seen in disorder and the progressive somatic morbid-
insulin resistance , which is associated with ity, in turn, lead to a worsening of depressive
hypercortisolism, activation of pro-inflamma- symptoms. Ultimately, a classic vicious cycle
tory cytokines, decreased physical activity, emerges with self-reinforcing mechanisms and
disastrous consequences.
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Fig. 64.1  Interactions between depression and metabolic syndrome; insulin resistance: reduced sensitivity of carbo-
hydrate metabolism to insulin. (From Löwe et al. 2006; with kind permission of Hans Huber Publishers)
64.4 Therapy  Important If a patient suffers from

both metabolic syndrome and a
64.4.1 General Aspects depressive disorder, both disorders
must be considered simultaneously in
the treatment plan.
A prerequisite for successful treatment is com-
prehensive diagnostics of mental and somatic
Since a mutual reinforcement of features of the
disorders. Diagnosing mental disorders in
metabolic syndrome and symptoms of men-
patients with metabolic syndrome can pose
tal disorders can be assumed, the psychosocial
particular challenges for the treating physician:
treatment of this patient group must be multidi-
Typically, the mental disorders are not pre-
mensional and aim to enable the patient to suc-
diagnosed, and the recognition of psychological
cessfully manage their physical and emotional
symptoms can be complicated by the overlay of
stress. Only if the patient’s depression improves
physical and psychological complaints. In many
will they be motivated to actively work on the
cases, the patient is externally motivated and
components of the metabolic syndrome.
sees their problems more in their overweight
and physical complications than in psychosocial
 Important In fact, the two basic ther-
causes. As with other physical illnesses, it can
apeutic principles in the treatment of
be assumed that the frequency of mental dis-
metabolic syndrome, namely physi-
orders increases with the severity and chronic-
cal activity and weight loss, are also
ity of the metabolic syndrome and its sequelae.
effective in treating depression.
However, metabolic syndrome seems to be less
sufficiently treated in patients with severe men-
In some cases, the risk factors of metabolic syn-
tal disorders than in patients without mental dis-
drome, i.e., hypertension, diabetes mellitus,
orders (Kreyenbuhl et al. 2006).
and hyperlipidemia, must also be treated with
482 B. Löwe
medication (Eckel et al. 2005). In the treatment Health behavior To increase physical activity,
process, cooperation between general practi- structured activity plans should be developed.
tioners, internists, physicians for psychosomatic The therapist reinforces the implementation of
medicine and psychotherapy, and physicians physical activity. Additional consultations should
for psychiatry and psychotherapy must ensure be provided regarding lifestyle and nutrition.
that the patient feels sufficiently informed about
diagnosis, treatment options, and prognosis. Explanatory models The patient’s subjec-
Adequate medical treatment of risk factors or tive explanatory and treatment models must be
comorbid physical disorders is also a prerequi- included in the treatment so that the patient and
site for effective therapy. Weight, blood pres- doctor can reach mutual decisions regarding the
sure, fasting blood sugar, HbA1c, and lipids applied treatment methods.
must be monitored frequently enough to pro-
Deriving the focus and therapy planning The
vide feedback to the patient and the physician
treatment mandate, the focus of treatment, and
on the success of the therapy. Accompanying
the therapy goal should be explicitly discussed
addiction withdrawal (smoking!) is necessary in
with the patient. Depending on the therapeutic
many cases. The motivation and compliance of orientation of the therapist, the Operationalized
the patient can often be strengthened by involv- Psychodynamic Diagnostics (OPD-2) or a struc-
ing the family or circle of friends. A key goal of tured problem and behavior analysis are suitable
treatment is to promote health behavior so that as a basis, for example.
the patient can manage their metabolic syndrome
and comorbid diseases in the long term. In treat- Cognitive techniques Patients must learn to
ing a depressed patient with metabolic syn- identify and change dysfunctional negative cog-
drome, it is of great importance not to treat the nitions and evaluations.
patient as “mentally ill” but as a normal person
suffering from unusual stress. Integration of reference persons Interpersonal
problems are the most common subjective cause
 Important Accompanying antidepres- of emotional problems in patients with physical
sant pharmacotherapy is sometimes illnesses. The inclusion of the family or the most
indicated for mild and moderate depres- important reference persons in couple or family
sive episodes, and almost always for sessions serves to solve interpersonal problems
severe depressive episodes. and to learn health-promoting behaviors for the
entire family.
64.4.2 Treatment Principles Problem-solving skills To achieve sustainable

improvements, it makes sense to practice with
the patient to recognize, analyze, and construc-
The psychosomatic treatment of the patient,
tively solve problems early on.
which can be carried out in individual and group
settings, should be resource-oriented and include Motivational interviewing To effectively
the following components. address motivational problems related to behav-
ior changes, motivational interviewing tech-
Psychoeducation The patient and their clos- niques have proven to be effective.
est reference person must be informed about
both the metabolic syndrome and its treatment
as well as depressive disorders so that they have 64.4.3 Efficacy
the necessary basic knowledge to manage their
health problems independently. So far, there are no studies on the efficacy of
psychotherapeutic treatment of patients with
depression and metabolic syndrome. Such stud- Society, International Association for the Study of
ies are urgently needed, as this patient group Obesity (2009) Harmonizing the metabolic syn-
drome: a joint interim statement of the International
represents a numerically rapidly growing high- Diabetes Federation Task Force on Epidemiology
risk group for cardiovascular and other diseases and Prevention; National Heart, Lung, and Blood
or death. The controlled studies on the efficacy Institute; American Heart Association; World Heart
of psychotherapy or antidepressant pharmaco- Federation; International Atherosclerosis Society; and
International Association for the Study of Obesity.
therapy in depressive patients with coronary Circulation 120(16):1640–1645
heart disease or diabetes mellitus (Didjurgeit Anderson RJ, Freedland KE, Clouse RE, Lustman PJ
et al. 2002; Glassman et al. 2002; Katon et al. (2001) The prevalence of comorbid depression in
2004; Lustman et al. 1998) suggest, however, adults with diabetes: a meta-analysis. Diabetes Care
24:1069–1078
that these interventions could also be effective in Demyttenaere K, Bruffaerts R, Posada-Villa J, Gasquet I,
patients with metabolic syndrome. Kovess V, Lepine JP, et al. (2004) Prevalence, sever-
ity, and unmet need for treatment of mental disor-
ders in the World Health Organization World Mental
Health Surveys. JAMA 291(21):2581–2590
Conclusion
Didjurgeit U, Kruse J, Schmitz N et al (2002) A time-
Depression and metabolic syndrome have limited, problem-orientated psychotherapeutic
intervention in type 1 diabetic patients with compli-
become more common in recent decades and cations: a randomized controlled trial. Diabet Med
co-occur more frequently than by chance. 19:814–821
Both are risk factors for cardiovascular mor- Eckel RH, Grundy SM, Zimmet PZ (2005) The meta-
tality, and can mutually reinforce each other bolic syndrome. Lancet 365:1415–1428
Ford ES (2005a) Prevalence of the metabolic syndrome
in a vicious cycle through factors such as defined by the International Diabetes Federation
inactivity, social withdrawal, metabolic among adults in the US. Diabetes Care 28:2745–2749
parameters, and non-compliance. Therefore, Ford ES (2005b) Risks for all-cause mortality, cardiovas-
diagnostic and therapeutic measures must cular disease, and diabetes associated with the meta-
bolic syndrome: a summary of the evidence. Diabetes
simultaneously take into account both meta- Care 28:1769–1778
bolic syndrome and depression. The goal of Glassman AH, O‘Connor CM, Califf RM, Swedberg
treatment is not only to achieve remission of K, Schwartz P, Bigger JT, Krishnan KR, Van Zyl
depression but also to enable the patient to LT, Swenson JR, Finkel MS, Landau C, Shapiro
PA, Pepine CJ, Mardekian J, Harrison WM (2002)
successfully and independently manage the Sertraline treatment of major depression in pari-
health challenges of metabolic syndrome. ents with acute MI or unstable angina. JAMA
288:701–709
Katon WJ, Von Korff M, Lin EH et al (2004) The path-
ways study: a randomized trial of collaborative care
in patients with diabetes and depression. Arch Gen
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Kahl KG (2005) Metabolisches Syndrom und psychis-
Adams RJ, Appleton S, Wilson DH, Taylor AW, Dal che Erkrankungen: Relevanz Risikofaktoren, und
Grande E, Chittleborough C, Gill T, Ruffin R (2005) praktische Konsequenzen. MMW Forschr Med
Population comparison of two clinical approaches 147:32–34,36
to the metabolic syndrome: implications of the new Kahn R, Buse J, Ferrannini E, Stern M (2005) The meta-
International Diabetes Deferation consensus defini- bolic Syndrome: time for a critical appraisal: joint
tion. Diabetes Care 28:2777–2779 statement from the American Diabetes Association
Alberti KG, Zimmet P, Shaw J (2005) The metabolic and the European Association for the Study of
syndrome—A new worldwide definition. Lancet Diabetes. Diabetes Care 28:2289–2304
366:1059–1062 Kaplan NM (1989) The deadly quartet. Upper-body obe-
Alberti KG, Eckel RH, Grundy SM, Zimmet PZ, sity, glucose intolerance, hypertriglyceridemia, and
Cleeman JI, Donato KA, Fruchart JC, James WP, hypertension. Arch Intern Med 149:1514–1520
Loria CM, Smith SC Jr, International Diabetes Kreyenbuhl J, Dickerson FB, Medoff DR, Brown CH,
Federation Task Force on Epidemiology and Goldberg RW, Fang L, Wohlheiter K, Mittal LP,
Prevention, National Heart, Lung, and Blood Dixon LB (2006) Extent and management of car-
Institute, American Heart Association, World diovascular risk factors in patients with type 2
Heart Federation, International Atherosclerosis
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diabetes and serious mental illness. J Nerv Ment Dis Ramasubbu R (2002) Insulin resistance: a metabolic link
194:404–410 between depressive disorder and atherosclerotic vas-
Löwe B, Hochlehnert A, Nikendei C (2006) cular diseases. Med Hypotheses 59:537–551
Metabolisches Syndrom und Depression. Ther Umsch Vancampfort D, Stubbs B, Mitchell AJ et al (2015) Risk
63:521–527 of metabolic syndrome and its components in people
Lustman PJ, Griffith LS, Freedland KE, Kissel SS, with schizophrenia and related psychotic disorders,
Clouse RE (1998) Cognitive behavior therapy for bipolar disorder and major depressive disorder: a sys-
depression in type 2 diabetes mellitus. A randomized, tematic review and meta-analysis. World Psychiatry
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RR, Hu FB (2012) Bidirectional association between tially modifiable risk factors associated with myocardial
depression and metabolic syndrome. A systematic infarction in 52 countries (the INTERHEART study):
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Tobacco Dependence in Eating
Disorders and Obesity 65
Marlen Brachthäuser and Anil Batra
Contents
65.1 Foundations of Tobacco Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 486
65.2 iagnosis of Tobacco Addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D 487
65.3 Tobacco Addiction and Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . 487
65.4 Factors Associated with Increased Smoking Prevalence in Eating
Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 488
65.5 Smoking and Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 490
65.6 Weight Gain Due to Tobacco Abstinence . . . . . . . . . . . . . . . . . . . . . . . . . . . . 491
65.7 Treatment of Tobacco Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 492
65.8 Tobacco Cessation in Patients with Eating Disorders . . . . . . . . . . . . . . . . . 493
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 494
In Germany, 26.4% of men and 18.6% of diseases and premature death in industrialized
women older than 15 years smoked in 2017 countries. Approximately 121,000 smokers die
(Federal Statistical Office 2018). In a study on annually in Germany as a result of tobacco con-
smoking behavior among adolescents and young sumption (German Cancer Research Center
adults aged 15–20 years, the Federal Statistical 2015). The harmful health effects of tobacco
Office determined a smoking prevalence of less consumption are due to numerous toxic or carci-
than 11%. Smoking prevalence and the number nogenic substances—such as carbon monoxide,
of cigarettes smoked daily increase with age. nitrogen dioxide, benzene, nitrosamines, polycy-
Today, smoking is considered the most sig- clic aromatic hydrocarbons, free radicals, heavy
nificant single risk factor for a variety of serious metals, and many others—that are inhaled with
tobacco smoke. The harmful health effects also
exist for non-smokers who are regularly exposed
to tobacco smoke (“passive smokers”). The most
common tobacco-associated diseases include
M. Brachthäuser (*) · A. Batra cardiovascular diseases, carcinomas (especially
Department of Psychiatry and Psychotherapy of the lung, larynx, and esophagus), and chronic
Tübingen, Center for Mental Health (TüCMH), obstructive bronchitis. Several studies have
University Hospital Tüebingen, Tüebingen, Germany
shown that the life expectancy of a regular long-
term smoker is reduced by about 8–10 years
A. Batra
(Doll et al. 2004).
https://doi.org/10.1007/978-3-662-67662-2_65
486 M. Brachthäuser and A. Batra
65.1 Foundations of Tobacco The nicotine withdrawal syndrome (ICD-10,

Dependence F17.3) is characterized by the symptoms listed
in the overview.
Tobacco dependence is multifactorial and arises
from the complex interplay of social, psycholog-
ical, and (neuro)biological factors. The interac- Symptoms of Nicotine Withdrawal
tions of physiological and psychological effects Syndrome
lead to a consolidation of smoking behavior and • Intense craving for smoking
promote the development of dependence. • Feeling of illness or weakness
• Anxiety
• Dysphoric mood
65.1.1 Neurobiological Aspects • Irritability
of Tobacco Dependence • Restlessness
• Insomnia
The psychopharmacological effects of nico- • Increased appetite
tine are held responsible for the development • Increased coughing
of physical dependence. The nicotine inhaled • Ulcerations of the oral mucosa
through tobacco smoke unfolds its effects in the • Concentration problems
central nervous system within 7–10 seconds and
has a bivalent spectrum of action, which, depend-
ing on the dose, has both calming and stimulat- 65.1.2 Psychosocial Aspects
ing effects. After inhalation of tobacco smoke, of Tobacco Addiction
nicotine centrally increases the concentration
of various neurotransmitters such as dopamine, In the psychodynamic understanding, smoking
acetylcholine, norepinephrine, and serotonin by represents a neurotic maladjustment; smoking
stimulating presynaptic nicotinic acetylcholine is seen as oral drive satisfaction, as a regulatory
receptors. This is associated with different active mechanism for internal psychological deficits, or
qualities (well-being, mood elevation, activa- as unconscious self-destructive behavior. From
tion, calming, reduction of anxiety, subjectively a learning theory perspective, social modeling,
experienced increase in cognitive performance). classical and operant conditioning processes, as
The dopaminergic activation mediated by nico- well as cognitive learning processes related to
tine in the mesolimbic “reward center” (nucleus the expectation of effects and individual func-
accumbens) seems to be important for the devel- tional significance of smoking, are responsible
opment of dependence. An adaptation following for the development and maintenance of addic-
regular nicotine consumption leads to a reduction tion. At the beginning of the smoker’s career,
of dopamine release in the nucleus accumbens social reinforcement processes and the associa-
below the baseline level during nicotine with- tion of smoking with positive concepts such as
drawal. As a result of repeated and prolonged sociability, but also “being slim,” play a role.
receptor desensitization, the density of central With regular tobacco consumption, the phar-
nicotinic α4β2-acetylcholine receptors increases macological effects of nicotine become increas-
compensatorily. This “up-regulation” depends ingly important. Smokers increasingly use the
on the nicotine dose and only decreases after a pleasant effects of nicotine in a targeted and
longer abstinence period. The increased number functional way for reward, stress reduction, and
of free nicotinic α4β2-acetylcholine receptors relaxation, and eventually, tobacco consumption
is, among other things, held responsible for the is maintained to avoid withdrawal symptoms
development of withdrawal symptoms (Heinz (Batra 2011).
et al. 2012).
65 Tobacco Dependence in Eating Disorders and Obesity 487
65.2 Diagnosis of Tobacco (averaged for both genders) among people with
Addiction depressive and/or anxiety disorders is estimated
at 35%, while prevalence rates of 65–95% are
An important prerequisite for planning an inter- reported for patients with psychotic or other
vention is a comprehensive diagnosis that allows addiction disorders (Batra 2000; Rüther et al.
for the assessment of possible complications in 2014).
tobacco cessation and the risk of relapse (Batra The meta-analysis by Solmi et al. (2016)
et al. 2015; AWMF 2021). This includes the col- summarized results from 31 studies on the prev-
lection of smoking history variables (daily ciga- alence of tobacco dependence in eating disor-
rette consumption, smoking onset, smoking ders (AN, BN, or binge eating disorder (BED))
duration), the functionality of smoking behav- compared to healthy controls. Across all studies,
ior in the social environment, risk factors (preg- a significantly higher proportion of smokers was
nancy, psychiatric and somatic diseases, regular found among people with BN and BED. In the
intake of medications), as well as the assessment presence of AN, the proportion is slightly (but
of dependence criteria according to the ICD- not significantly) lower than in healthy con-
11 (tobacco addiction F17.2) and the strength trol groups. The highest lifetime prevalence for
of dependence with the Fagerström Test for tobacco dependence is found in BED (47.7%),
Cigarette Dependence (FTCD, Fagerström 2012; followed by BN (39.4%). A similar result was
Heatherton et al. 1991; see also AWMF 2021) reported in a study by Anzengruber et al. (2006)
The FTCD allows for an assessment of the in 1,524 women with or without one of the eat-
strength of dependence and, according to current ing disorder diagnoses. Smoking behavior and
treatment guidelines, is a reliable instrument for the intensity of dependence were determined
estimating the occurrence of withdrawal symp- using the Fagerström Test. Women with eating
toms. The higher the total score, the more with- disorders showed higher prevalences of tobacco
drawal symptoms are to be expected, and the dependence, with the highest rates found among
higher the risk of relapse. The strength of depend- the binge-eating/purging subtype of AN. Binge-
ence and the evaluation of individual questions eating/purging behavior appears to be the vari-
provide indications for the necessary pharmaco- able with the strongest association with smoking
logical and psychotherapeutic interventions. behavior (White and Grilo 2006). Insofar as
this was differentiated in the studies, the lowest
smoking rates were found among the patients
65.3 Tobacco Addiction with restrictive-type AN—below the prevalence
and Eating Disorders of healthy control groups.
Brewerton et al. (2014) examined several
The following will first present studies on the relevant variables of tobacco dependence in
prevalence of smoking and tobacco addic- a sample of 850 women and girls with AN or
tion in eating disorders, as well as the relation- BN (AN, restrictive type: n = 306; AN, binge-
ships between smoking and conspicuous eating eating/purging: n = 293; BN: n = 251). There
behavior. was no difference between the individual groups
Some studies analyze smoking behavior regarding the onset of smoking, but significantly
within the diagnostic categories of eating dis- more study participants (59.9%) started smok-
orders, while others compare data between ing only after the onset of their eating disorder.
patients and healthy controls. In the case of already disturbed eating behavior
The prevalence rates of smoking are assumed in childhood, there also seems to be an accumu-
to be between 20 and 30% internationally. In lation of substance abuse. The strength of nico-
Germany, a prevalence of 24.5% is reported. tine dependence, measured with the FTND, as
In comparison, the proportion of smokers well as the daily cigarette consumption, were
significantly higher in the overall group of anorexia are likely to have an increased risk
women with an eating disorder than in the con- of esophageal cancer. The simultaneous pres-
trols. Within the group, those with restrictive ence of risk factors such as smoking, alcohol
AN again showed the lowest nicotine depend- consumption, and malnutrition is more likely
ence and the lowest daily cigarette consump- to contribute to the etiopathogenesis of the car-
tion. Taking into account the strength of tobacco cinoma than self-induced vomiting in an eating
dependence, there were no significant differ- disorder (Brewster et al. 2015).
ences between the groups regarding the num-
ber of abstinence attempts. Ex-smokers had a
significantly higher BMI than non-smokers and 65.4 Factors Associated
smokers. with Increased Smoking
Patients with a self-reported eating disorder Prevalence in Eating
diagnosis reported more frequent use of elec- Disorders
tronic cigarettes containing nicotine for weight
control in a more recent study (Morean and Nicotine suppresses the feeling of hunger. It has
L’Insalata 2018). been widely proven that smokers have a lower
average body weight than non-smokers. There is
 Important In the presence of BED an association between the number of cigarettes
and BN, the prevalence of tobacco smoked daily and weight. In particular, moder-
smoking and the intensity of tobacco ate and older smokers have a more pronounced
dependence are significantly higher “weight control benefit.” Thus, the consump-
than in people without an eating tion of nicotine-containing products—especially
disorder. In the case of AN, the cigarettes—in eating disorders with a conscious
smoking prevalence depends on the desire for slimness and the use of weight con-
presence of a binge-eating/purging trol measures represents a way of appetite and
type versus a restrictive subtype: hunger regulation. This can promote motivation
there is a tendency for increased to start smoking, maintain it, or foster ambiva-
smoking rates in the purging type, lence about quitting smoking. Women with an
while lower smoking rates can be eating disorder showed a significantly higher
expected in restrictive AN. motivation to smoke compared to a control
group with depression. The strongest smoking
So far, there are no studies on the over-additive motives are weight control and stress manage-
health risks of smoking in cases of bulimia/ano- ment. Increased anxiety has been identified as a
rexia. However, bulimia and tobacco addiction comorbid factor (Georg and Waller 2005).
share a number of medical risks in the area of Since a large proportion of patients with eat-
cardiovascular diseases, as well as diseases of ing disorders also have other comorbid psychi-
the mouth and throat, esophagus, and stomach. atric disorders such as anxiety, depression, and
It can be assumed that the risk of esophageal personality disorders, nicotine or smoking may
cancer is significantly higher in cases of comor- also be used additionally as a means of regulat-
bidity than in the presence of only one disorder. ing the comorbid disorder of emotion regulation.
Theoretical research findings are provided The multiple functional significance of smok-
by Ehrlich and colleagues (2012) in a study on ing results in a more intense addiction in these
the epigenetic influence of malnutrition and patients.
smoking on the DNA methylation of a disease- With regard to typical smoking motives in
relevant gene in connection with stress and individuals with eating disorders, for exam-
food control. Smoking, but not malnutrition in ple, in a sample of 102 women with BN, it was
connection with anorexia, influenced the DNA found that they used smoking significantly more
methylation of the risk gene. Patients with often to avoid eating or to control their weight.
Compared to control groups with and without Copeland et al. (2016) conducted a study to
mental illness, they relapsed more frequently investigate the factors “drive for thinness” (DT)
after achieving abstinence because they had con- and “fear of fatness” (FF) and their relationship
cerns about weight gain or worries about their to smoking behavior in eating disorders. They
figure. Comorbid depressive or anxious symp- assumed that these are two different motivations,
toms were more pronounced in this group. In a both playing a role as approach or avoidance
non-clinical study on the relationship between goals. Only DT was positively correlated with
smoking and body image, young female smok- the number of cigarettes smoked daily, while
ers showed more bulimic symptoms and con- this relationship was reversed for FF. This might
cerns about their figure than non-smokers explain the comparatively lower smoking rates
(Kendzor et al. 2009). in the restrictive type of AN, as only avoidance
strategies for weight regulation are used here,
and smoking is less necessary as a compensa-
65.4.1 Weight Control and Weight tory strategy for slimming.
Concerns A therapeutic focus on “weight concerns”
can increase the long-term abstinence rates of
Numerous studies have addressed the con- smoking cessation. In a therapy study, the group
cept of “weight concerns.” Young people with whose treatment was directly aimed at reduc-
weight problems often develop a regular smoking concerns about weight achieved the highest
ing behavior later on (Saules et al. 2007). long-term abstinence rates (21% compared to
Concerns about weight could thus represent a 13% in an intervention group that received addi-
predictor for the onset of smoking, a reason for tional behavior-related elements for weight con-
relapse after achieving abstinence, or an obsta- trol, or a “standard treatment” that achieved only
cle to smoking cessation treatment (Pomerleau 9%). This illustrates the relevance of changing
and Saules 2007). Since different variables dysfunctional beliefs regarding the prevention of
are examined in relation to “weight concerns” weight gain, body shape, and dieting, as well as
depending on the study, the interpretation of reducing restrained eating behavior in smoking
study results and their comparability is difficult. cessation for this patient group (Perkins et al.
Nevertheless, several conclusions can be drawn 2001).
from the literature regarding the dimension of
“weight concerns.” A high dissatisfaction with
one’s own body, pronounced dieting behavior 65.4.2 Emotion Regulation
and diet practices that indicate disturbed eating
behavior, such as the use of laxatives, purging, Patients with eating disorders report that, in
or binge-eating, combined with a rather negative addition to weight control, smoking provides
affect, are considered risk factors for the onset an even higher motivation for stress regula-
of smoking as well as for the development of an tion (Georg and Waller 2005). In overweight
eating disorder (Pomerleau and Saules 2007). individuals with BED, emotion regulation also
Unhealthy eating behavior is correlated with appears to play an important role in maintaining
the use of tobacco products among adolescents BED (Gianini et al. 2013). Since the inclusion
(Sutter et al. 2016). of BED in the DSM-5 for research purposes,
If concerns about weight gain are very several scientific studies have examined the
high, they pose an obstacle to smoking cessa- relationship between binge eating with loss of
tion treatment or lead to a higher likelihood of control as part of BED (or BN) and dependent
terminating smoking cessation. The concern behavior. It is discussed whether a subgroup of
about weight gain seems to be a more signifi- those affected by binge eating could show a kind
cant predictor of relapse than the actual increase of “eating addiction,” such that these individu-
(Meyers et al. 1997). als could have a generally higher vulnerability
to addiction. There is no clinical consensus on on health risks in eating disorders is poorly

such a concept, but there are indications of simi- researched. Since binge eating in the absence
larities in the characteristics of “strong urge or of compensatory behaviors is a risk factor for
compulsion to consume,” loss of control, and overweight and the development of obesity, and
neurobiological reward in the mesolimbic rein- binge eating or uncontrolled eating behavior
forcement system (Schreiber et al. 2013). There is associated with an increased risk of tobacco
is limited evidence for comparable disorder- use, it can also be assumed that the prevalence
maintaining mechanisms in BE D and addiction of tobacco dependence is influenced by obesity.
in terms of impaired reward system and impul- However, people with BED seem to have higher
sivity (Schulte et al. 2016). prevalence rates compared to obese people with-
out binge eating. Smoking and binge eating seem
to have in common that they are used as coping
65.4.3 Genetic Factors strategies for dealing with stress and negative
emotions. At the same time, obese people with
Some twin studies have already pointed to BED have increased lifetime prevalence rates for
the role of genetic factors in the association a number of other psychiatric disorders, such as
between problematic alcohol consumption and, depression, anxiety disorders, and addiction dis-
in particular, BN (Munn-Chernoff et al. 2013). orders (White and Grilo 2006). Some studies do
A more recent twin study by Baker and col- not differentiate between overweight (BMI > 25)
leagues (2018) on the relationship between eat- and obesity, so statements must be generalized to
ing disorder phenotypes (drive for thinness, both groups for the time being. People with over-
bulimia, body dissatisfaction) and substance use weight and obesity use smoking both for appetite
in terms of cigarette consumption or illegal drug control and as a means to prevent or counteract
use only confirmed a significant relationship further weight gain. Another study also showed
between smoking and BN as well as drive for that female smokers with overweight/obesity,
thinness. For illegal drugs, a clearer correlation compared to those with normal weight, had sig-
was also found in further studies, with the influ- nificantly greater fears of gaining weight after
ence of genetic risk factors playing an etiologi- quitting smoking. These smokers reported that
cal role similar to that of problematic alcohol they would be more likely to smoke in the event
consumption (Munn-Chernoff et al. 2020) of weight gain. In the group of smokers with
overweight/obesity, “weight concerns” and the
 Important In AN, BN, and BED, expectation that smoking is an effective means of
smoking is used both as a specific weight control seem to be important motives for
measure for weight control and, smoking.
presumably due to the psychop- A study that examined the mortality risk of
harmacological effects of nicotine, both risk factors in 64,120 women and 18,760
as a coping strategy for dealing men (Freedman et al. 2006) found:
with negative emotions. The fear of
weight gain results in lower motiva- • In men under 65 years of age, the mortality
tion to quit smoking. risk in the group with a BMI between 30 and
34.9 was 3.8 times higher and in the group
with a BMI of 35+ was 5.2 times higher.
65.5 Smoking and Obesity • In women under 65 years of age, the mortal-
ity risk with a BMI between 30 and 34.9 was
Overall, there are still few studies that explicitly 2.2 times higher and with a BMI of 35+ was
investigate mutual influences between smok- 4.2 times higher.
ing and obesity, just as the influence of smoking
Broken down by cancer and cardiovascu- psychological aspects and the associations
lar disease mortality, these figures lay at 2.45 with other psychiatric disorders. In the case
and 10.6 for men with a BMI of 30+; 2.7 and of BED and overweight, smokers show
6 for women with a BMI of 30+. The risks poorer psychosocial and metabolic health.
for ex-smokers with overweight were signifi-
cantly reduced compared to smokers with over-
weight. Therefore, especially in the case of 65.6 Weight Gain Due to Tobacco
obesity, smoking cessation is an essential factor Abstinence
in reducing morbidity and mortality. Another
study, by Udo and colleagues (2016), in obese According to the results of a meta-analysis,
patients with BED showed among other things women seem to gain slightly more weight after
that current smokers had higher psychiatric quitting smoking than men (Farley et al. 2012).
comorbidity, lower physical quality of life, and Heavy smokers tend to approach the body
an increased risk of metabolic syndrome and weight of non-smokers more closely. This rela-
unfavorable cholesterol levels compared to non- tionship has not yet been clearly proven for
smokers and former smokers. In contrast, former smokers up to the age of 19, while older smok-
smokers and non-smokers did not differ in this ers gain more weight (Prod’hom et al. 2013).
regard, which underlines the possible positive Characteristics of eating behavior (binge eat-
consequences of smoking cessation in patients ing) are also associated with weight gain after
with BED and obesity or overweight. In a larger tobacco abstinence (White et al. 2010).
population study in Finland, the interaction A meta-analysis based on 62 studies deter-
between smoking status and BMI and the extent mined the average weight gain in smokers who
of abdominal adipose tissue was investigated. had become abstinent without medication and/or
Among women with overweight, a significant (psycho-)therapeutic support (these were usually
correlation between excessive smoking and the the control groups of randomized clinical tri-
extent of abdominal adipose tissue was demon- als). Twelve months after achieving abstinence,
strated (Tuovinen et al. 2016). 16–21% of participants had lost weight, 37%
In a recent study on an animal model with had gained less than 5 kg, 34% had gained 5–10
obese rats, it was shown for the first time how kg, and 13–14% had gained more than 10 kg.
chronic exposure to cigarette smoke affects Tobacco abstinence is associated with an aver-
various metabolic, pulmonary, intestinal, and age weight gain of 4–5 kg after one year (Aubin
cardiac parameters in the overweight rats et al. 2012).
(Dubois-Deruy et al. 2020). The cigarette The majority of weight gain occurs within
smoke altered the fat distribution in favor of an the first 3–12 months after quitting smoking
increased proportion of visceral adipose tissue. (Prod’hom et al. 2013). The number of ciga-
The respiratory function was further impaired, rettes smoked daily appears to be a significant
inflammation in the lung tissue and emphysema predictor of expected weight gain (Prod’hom
were promoted. In addition, the intestinal flora et al. 2013). The relationship between initial
and cardiac parameters were negatively affected. weight and weight gain is assessed differently;
Lycett et al. (2011) found a strong increase with
high initial consumption, while Prod’hom et al.
Conclusion (2013) found no relationship.
There is still a need for research regarding Various mechanisms are considered to be
the relationships and interactions between responsible for weight gain after achieving
smoking and eating disorders as well as tobacco abstinence. Nicotine affects energy bal-
obesity. This concerns both the somatic ance, accelerating heart rate, increasing blood
consequences resulting from a joint pres- pressure and bowel movements, and thus lead-
ence, as well as the epidemiological and ing to increased energy consumption. The
basal metabolic rate increases by about 5–10% that inhibits the reuptake of dopamine and nor-
(equivalent to about 200 kcal/day). After achiev- epinephrine. In eating disorders (AN or BN),
ing abstinence, a decrease in basal metabolic there is a contraindication for the use of bupro-
rate and thus calorie requirements would be pion due to an increased likelihood of epileptic
expected. Some studies have also observed an seizures observed in these patients. Varenicline
increased calorie intake after quitting smoking, and cytisine are partial agonists at the nicotinic
which was estimated at 200–300 kcal depending α4β2 acetylcholine receptor. The efficacy of
on the study. In addition, changes in the activ- these medications is supported by meta-analy-
ity of adipose tissue lipoprotein lipase (AT-LPL) ses. They increase long-term abstinence pros-
and lipolysis are considered as co-contributors pects by a factor of 1.55 (nicotine replacement)
to weight gain. Food intake can partially replace to 2.24 (varenicline) (Batra et al. 2015; AWMF
the rewarding effects of nicotine in the dopa- 2021).
minergic reinforcement system (Reinholz et al.
2008; Volkow et al. 2008). However, the under-
lying mechanisms have been predominantly 65.7.2 Motivational Interviewing
studied in animal experiments, so their influence and Psychotherapy
on weight gain in humans is not yet fully under-
stood (Filozof et al. 2004). Using brief interventions based on the principle
All mentioned factors are used to explain the of motivational interviewing, smokers willing
observed weight gain. The underlying mecha- to quit can be identified and guided to initiate
nisms are not yet fully understood. smoking cessation. For smokers who are very
Various interventions have been investigated ambivalent about attempting to quit, the focus
that should have a favorable influence on weight of a brief intervention is on clarifying the possi-
development. The use of medication support can ble advantages and disadvantages of abstinence.
mitigate weight gain but not prevent it. Regular Brief interventions have a measurable impact
moderate physical exercise also counteracts on the likelihood of an attempt to quit and can
greater weight gain and has a positive effect on be easily integrated into medical practice or a
long-term abstinence. counseling context. Useful supplements include
information brochures, such as those offered
free of charge by the Federal Center for Health
65.7 Treatment of Tobacco Education or the German Cancer Aid, or—even
Dependence better—self-help guides/manuals.
Smokers who cannot quit on their own or as
Both German (Batra et al. 2015; AWMF 2021) part of brief counseling should be recommended
and US guidelines (Fiore et al. 2008) for the to participate in a behavioral tobacco cessation
treatment of tobacco dependence provide rec- program. Cessation courses take place in groups
ommendations for psychotherapy and pharma- of 6–12 people and comprise 6–10 sessions of
cotherapy, which can only be summarized in 60–120 min each. At the beginning of a behav-
excerpts here. ioral cessation treatment, there is an intensive
examination of motivation, smoking behavior,
and its functionality. Based on this, smoking
65.7.1 Medicinal Treatment Options cessation is prepared, which is usually accompa-
nied by individually adapted medicinal support.
Medicinal treatment options for withdrawal syn- After achieving abstinence, various cognitive-
drome include substitution treatment with nico- behavioral interventions should be used for sta-
tine (patch, gum, tablet, mouth spray, or inhaler) bilization and relapse prevention (Batra et al.
or treatment with bupropion, cytisine or vareni- 2015; AWMF 2021). Adapting these programs
cline. Bupropion is an atypical antidepressant for individual treatment with a shorter duration
is quite possible. However, existing treatment aimed to evaluate a specific intervention for
guidelines do not specify specific therapy rec- dealing with negative emotions, emotional eat-
ommendations for patients with eating disorders. ing, and coping with fear of weight gain in
smoking cessation (“distress tolerance treatment
for weight concern”, DT-W; Bloom et al., 2017,
65.8 Tobacco Cessation 2020). This program is based on acceptance
in Patients with Eating and commitment therapy (ACT) and includes
Disorders mindfulness-based skills to improve stress tol-
erance, mindful eating, and self-perception of
The recommendations for evidence-based appetite. It is designed as a group program for
tobacco cessation treatment, as outlined in the women over nine weeks. However, the first ran-
German guidelines for the treatment of patients domized trial with 69 participants did not show
with mental disorders (Batra et al. 2015; AMWF any advantage of this program. Further research
2021), can also be applied to patients with eat- seems necessary in this area.
ing disorders. In general, the same strategies Behavioral therapy measures, however,
should be used as for smokers without men- showed potential for weight regulation and less
tal comorbidity. Measures with the best evi- weight gain after smoking cessation, as well
dence level and highest abstinence prospects as—related to this—higher effectiveness of
include behaviorally oriented individual or tobacco cessation (Spring et al. 2009; Love et al.
group treatments, which should be combined 2011). The measures can aim to reduce various
with medicinal support in cases of strong physi- problematic excessive behaviors such as binge
cal dependence. Depending on individual psy- eating and substance use in general. Specific
chological stress factors, strategies for mood programs could also be beneficial for patients
regulation, dealing with negative emotions, or with BED, as the presence of binge-eating
strengthening impulse control should be used behavior, but not obesity alone, makes weight
within the framework of behavioral support. gain due to smoking cessation more likely.
This also applies to the treatment of patients In the psychotherapeutic treatment of eating
with severe overweight or obesity. Regardless of disorders, smoking as a means of weight control
this, the health benefit of tobacco abstinence is and emotion regulation should be considered,
much higher for this group than a weight gain and patients with strong tobacco dependence
that may be caused by abstinence. Some authors may be referred to additional counseling ser-
therefore advocate the use of specific interven- vices and support for smoking cessation. As part
tions in the treatment of obesity that take into of the treatment, patients should be informed
account comorbidity with substance abuse that weight gain is possible but usually remains
(VanBuskirk and Potenza 2010). within moderate limits. The positive health
Due to the role of weight concerns in patients aspects supported by tobacco abstinence should
with eating disorders, various studies have been always be emphasized. The pharmacologi-
conducted to investigate the effect of specific cal support of tobacco cessation with nicotine
cognitive-behavioral interventions on tobacco replacement therapies counteracts weight gain at
abstinence in this group. The results suggest least for the duration of the drug treatment and
that the best outcomes in terms of smoking ces- often reduces the fear of it (Perkins et al. 2001;
sation can be achieved if, above all, concern Levine et al. 2010; Farley et al. 2012).
about weight gain can be reduced. In a study The focus of psychoeducation should overall
by Perkins et al. (2001), a cognitive-behavioral be on a healthier lifestyle, balanced nutrition,
program to reduce weight concerns positively regular meals, moderate physical exercise, suf-
influenced smoking abstinence in the 1-year ficient sleep, and learning stress management
follow-up, to a higher degree than weight con- skills (Farley et al. 2012). All the recommenda-
trol or standard counseling. Two pilot studies tions listed are also components of behavioral
tobacco cessation programs and can be adapted Batra A, Hoch E, Mann K, Petersen KU (2015)
to the specific group. In particular, additional S3-Leitlinie Screening, Diagnostik und Behandlung
des schädlichen und abhängigen Tabakkonsums.
cognitive interventions aimed at restructuring Springer, Heidelberg
dysfunctional thoughts and irrational beliefs Bloom EL et al (2017) Distress tolerance treatment for
regarding body shape, body image, effective- weight concern in smoking cessation among women:
ness of weight control measures, and diet behav- the WE QUIT pilot study. Behav Modif 41:468–498
Bloom EL et al (2020) A pilot randomized controlled
ior are conceivable. With regard to binge eating, trial of distress tolerance treatment for weight con-
elements from existing treatment strategies for cern in smoking cessation among women. Nicotine
BED may also be helpful if this behavior should Tob Res 22:1578–1586
increase after smoking cessation. Due to the Brewerton TD, Rance SJ, Dansky BS et al (2014) A
comparison of women with child-adolescent versus
importance of smoking for patients with eating adult onset binge eating: Results from the National
disorders, diagnostic screenings have also been Women’s study. Int J Eat Disord 47:836–843
proposed to specifically address such patients Brewster DH, Nowell SL, Clark DN (2015) Risk of
in smoking cessation programs. The authors of oesophageal cancer among patients previously hos-
pitalised with eating disorder. Cancer Epidemiol
the study conclude that a screening was easy to 39:313–320
perform and effective, but its acceptance among Copeland AL et al (2016) Fear of fatness and drive for
patients was low. thinness in predicting smoking status in college
women. Addict Behav 54:1–6
Deutsches Krebsforschungszentrum (Eds) (2015)
Tabakatlas Deutschland 2015. Deutsches
Conclusion Krebsforschungszentrum, Heidelberg
Tobacco cessation treatment should pay par- Doll R, Peto R, Boreham J, Sutherland I (2004)
Mortality in relation to smoking: 50 years observa-
ticular attention to the importance of smok-
tions on male British doctors. BMJ 328:1519
ing as a means of weight control and emotion Dubois-Deruy E et al (2020) Modelling the impact of
regulation in patients with eating disorders. chronic cigarette smoke exposure in obese mice:
Often, there is great concern about weight metabolic, pulmonary, intestinal, and cardiac issues.
Nutrients 12:827
gain due to tobacco abstinence. If the con-
Ehrlich S et al (2012) Smoking, but not malnutrition,
cern about weight gain can be alleviated, influences promoter-specific DNA methylation of the
higher and more stable abstinence rates can proopiomelanocortin gene in patients with and with-
be achieved. out anorexia nervosa. Can J Psychiatry 57:168–176
Fagerström K (2012) Determinants of tobacco use and
renaming the FTND to the Fagerström Test for
Cigarette Dependence. Nicotine Tob Res 14(1):75–78
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Impulsivity and Obesity
66
Astrid Müller
Contents
66.1 Impulsivity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 497
66.2 Impulsive Disorders and Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 498
66.3 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 499
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 500
66.1 Impulsivity both a high cognitive pace and impaired impulse

control (Dawe and Loxton 2004). In the course
The term impulsivity is usually used when of strong affective reactions, cognitive distor-
impulses cannot be suppressed. This is referred tions, and motor impulse breakthroughs, hasty
to as reduced inhibitory control. As a result, decisions with negative consequences for the
hasty, poorly reflected, inappropriate actions executing person or other people can occur.
occur, the long-term consequences of which are As is well known, many mental disorders are
not sufficiently taken into account. Impulsive characterized by a high level of impulsivity, e.g.,
individuals find it difficult to postpone actions substance-related addictive behaviors, behav-
that are rewarding in the short term but ulti- ioral addictions, or bulimic eating disorders. In
mately negative and harmful in the long term recent years, several studies have also shown
Here, the interplay between reward sensitivity that obesity is associated with increased impul-
and a rash-spontaneous impulsiveness plays a sivity (Gerlach et al. 2016; Giel et al. 2017).
crucial role (Dawe and Loxton 2004).
Impulsivity is not only expressed at the
behavioral level but also impacts affective 66.1.1 Food-Associated Impulsivity
and cognitive processes as well as personality in Obesity
aspects. Impulsive people are characterized by
It is assumed that a constantly available over-
supply of tasty, industrially processed foods
contributes significantly to loss of control when
A. Müller (*)
Department of Psychosomatic Medicine and eating, resulting in increased food consump-
Psychotherapy, Hannover Medical School, tion and thus the development of overweight
Hannover, Germany and obesity. However, this seems to be particu-
e-mail: [email protected] larly true in combination with high individual
https://doi.org/10.1007/978-3-662-67662-2_66
498 A. Müller
impulsivity. This assumption is based, for  Important It is likely that impulsivity is a

example, on studies that have found a positive persistent personality trait in most people
correlation between the consumption of large with obesity.
amounts of food and high total scores in impul-
sivity questionnaires among people with obesity
(Giel et al. 2017). 66.2 Impulsive Disorders
Imaging studies have shown that visual food and Obesity
stimuli trigger higher activity in brain regions
associated with the reward system in individu- 66.2.1 Obesity and Binge Eating
als with obesity as compared to individuals Disorder
with normal weight. Likewise, neurocognitive
tests of individuals with obesity have demon-
Binge eating disorder (BED) is the most com-
strated a strong tendency for spontaneous, rash
mon eating disorder in people with obesity.
affective, cognitive, and motor responses to
Extreme overeating in the form of repeated
images of high-calorie, industrially processed
objective binge episodes and loss of control
foods and difficulties in suppressing these
while eating are typical characteristics of BED.
impulses (Giel et al. 2017; Schag et al. 2013).
Thus, BED is characterized by high food-associ-
ated impulsivity.
 Important Increased reward sensitivity and
In addition, numerous studies have consist-
impairments in specific (i.e. food-related)
ently found that individuals with obesity and
inhibitory control are considered a plausible
BED report higher scores on questionnaires
explanation for recurrent overeating, which
measuring general, food-independent impulsiv-
may result in overweight and obesity.
ity than individuals with obesity but without
BED (Gerlach et al. 2016). Furthermore, indi-
viduals with extreme obesity and BED not only
show increased impulsivity scores in self-report
66.1.2 Food-Independent Impulsivity
instruments, but they also tend to have stronger
in Obesity
affective responses to images of high-calorie,
industrially processed foods and show poorer
In addition to the highly specific impulsivity
performance in computer-assisted neuropsycho-
associated with food, empirical findings also
logical tests measuring inhibitory control and
suggest an increased general impulsivity in
decision-making abilities (Saruco and Pleger
individuals with obesity (Gerlach et al. 2016).
2021). The latter can be interpreted as indicating
The latter is not related to food, but is rather to
that cognitive control of action impulses seems
be understood as a persistent personality trait.
to be weaker in individuals with obesity and
People with obesity seem to have a higher risk
BED.
for impulsive disorders.
It should also be mentioned that individuals
The results of a longitudinal study with
with obesity and BED have higher general psy-
patients before and two years after obesity sur-
chopathology. This not only refers to impulsive
gery, for example, showed that the significant
symptoms but also includes, for example, affec-
postoperative weight loss was not coupled with
tive and anxiety disorders. For these reasons, it
a reduction in impulsivity scores. The patients
is assumed that individuals with obesity do not
reported consistently high impulsivity scores
represent a homogeneous group and that indi-
regardless of their weight loss (Ryden et al.
viduals with obesity and comorbid BED seem to
2004).
represent a distinct phenotype.
66 Impulsivity and Obesity 499
 Important Individuals with obesity and BED Disorders.” In addition, many findings indicate
are at risk for other mental disorders. a relatively high prevalence of manipulations on
one’s own body tissue with the intention of self-
injury in individuals with mainly severe obesity
66.2.2 Obesity and Attention Deficit/ (e.g., damaging the skin by cutting, scratching,
Hyperactivity Disorder(ADHD) hitting/striking, pinching, biting, or burning)
(Müller et al. 2018). In this context, an increase
In addition to attention problems and hyperac- in self-harming behaviors (non-suicidal self-
tivity, high impulsivity is a typical characteristic injury, but also suicide attempts) after obesity
of ADHD. The disorder begins in childhood and surgery is assumed, as several register-based
can persist into adulthood. Empirical data have cohort studies with large case numbers have
shown a close relationship between obesity and found an increase in emergencies and medical
ADHD (de Zwaan et al. 2011). treatments due to self-harming behavior after
obesity surgery (Müller and Lescher 2019; see
 Important ADHD is relatively common in Chap. 26). Attention should also be paid to the
children, adolescents, and adults with obesity. findings on a possible addiction shift after obe-
Conversely, individuals with ADHD seem to sity surgery. This means that patients with pre-
have a higher risk of being overweight and operative addiction-like eating behavior (food
obese. addiction) may experience a postoperative shift
towards harmful alcohol consumption or even
It is assumed that impulsive, disorganized eat- alcohol dependence or other behavioral excesses
ing behavior in individuals with ADHD may (Ivezaj et al. 2019).
contribute to their overweight. Similar biologi-
cal mechanisms of both diseases are discussed,
which could explain the high comorbidity. It is 66.3 Conclusion
assumed that reduced dopamine activity in the
reward system plays a significant role in both In the development and maintenance of obesity,
obesity and ADHD. not only food-associated impulsivity plays an
obviously important role, but also food-inde-
pendent, general impulsivity.
66.2.3 Obesity and Self-Harming
Behaviors  Important Overlooking impulsive personal-
ity traits that underlie both food-associated
The literature reports an increased occur- and food-independent impulsive behaviors
rence of self-harming behaviors in individu- can diminish treatment success or reduce its
als with obesity. These are mostly impulsive in sustainability.
nature but can also be compulsive or addictive.
This includes, for example, dermatillomania This has implications for clinical work, includ-
(synonym: excoriation disorder, skin picking), ing both conservative treatment and bariatric
in which skin injuries on one’s own body are surgery. The latter requires patients to make an
caused by compulsive, recurring plucking or extreme adjustment and abstain from overeat-
squeezing (mainly face, arms, legs, hands) ing for emotion regulation. Impulsive patients
(Gallinat et al. 2019). The skin manipulations may find this behavioral change difficult, which
are compulsive and usually not carried out may foster the emergence or recurrence of other
with the motive of self-harm or punishment. excessive behaviors. Therefore, the present find-
The clinical picture accordingly belongs to the ings should be taken into account in the diagno-
category “Obsessive-Compulsive and Related sis and treatment of individuals with obesity.
500 A. Müller
References Müller A, Lescher M (2019) Selbstschädigung und

Suizidalität vor und nach Adipositaschirurgie. In: de
Zwaan M, Herpertz S, Zipfel S (Eds) Psychosoziale
Dawe S, Loxton NJ (2004) The role of impulsivity in the
Aspekte der Adipositaschirurgie. Springer, Berlin/
development of substance use and eating disorders.
Heidelberg, pp 151–163
Neurosci Biobehav Rev 28:343–351
Müller A, Claes L, Smits D et al (2018) Lifetime self-
Gallinat C, Moessner M, Claes L, Müller A (2019)
harm behaviors are not more prevalent in bariatric
Skin picking in patients with obesity: associations
surgery candidates than in community controls with
with impulsiveness and self-harm. Scand J Psychol
obesity. Obes Facts 11(2):109–115
60(4):361–368
Rydén A, Sullivan M, Torgerson JS et al (2004) A com-
Gerlach G, Loeber S, Herpertz S (2016). https://doi.
parative controlled study of personality in severe obe-
org/10.1111/obr.12415
sity: a 2-year follow-up after intervention. Int J Obes
Giel KE, Teufel M, Junne F et al (2017) Food-related
Relat Metab Disord 28:1485–1493
impulsivity in obesity and binge eating disorder—
Saruco E, Pleger B (2021). https://doi.org/10.3389/
A systematic update of the evidence. Nutrients
fnut.2021.609012
9(11):1170
de Zwaan M, Gruss B, Müller A et al (2011) Association
Ivezaj V, Benoit SC, Davis J et al (2019) Changes in
between obesity and adult attention-deficit/hyperac-
alcohol use after metabolic and bariatric surgery:
tivity disorder in a german community-based sample.
Predictors and mechanisms. Curr Psychiatry Rep
Obes Facts 4:204–211
21(9):85
Obesity and Binge Eating
Disorder 67
Sandra Becker
Contents
67.1 Obesity with Binge Eating Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 501
67.2 tiology of Binge Eating Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
E 502
67.3 Specifics of Obesity with Binge Eating Disorder . . . . . . . . . . . . . . . . . . . . . . 502
67.4 Psychotherapeutic Treatment Approaches for Obesity with Binge
Eating Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 503
67.5 Psychotherapeutic Treatment Approaches for Binge Eating Disorder . . . . 504
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 504
67.1 Obesity with Binge Eating in which—accompanied by a feeling of loss of

Disorder control—above-average amounts of food are
consumed. Affected individuals suffer from the
A subgroup of patients with obesity also have binge eating episodes, accompanied by feelings
an eating disorder. This needs to be detected or of guilt and shame. The diagnostic criteria for
diagnosed early on, as sustainable weight loss BED are described in detail in Chap. 5.
and long-term weight management are usually BED occurs in the general population with
only successful if the comorbid eating disorder a prevalence of approximately 1–4% (Fichter
is taken into account in the treatment. The most 2019). However, it is much more common, at
common eating disorder associated with obesity about 15–30%, in patients with obesity seek-
is the so-called binge eating disorder (BED), ing a weight loss program (Bertoli et al. 2015).
which has now been included as an independ- Dawes et al. (2016) report that the prevalence
ent clinical diagnosis in the current version of of BED among candidates for obesity surgery
the two common diagnostic systems (DSM-5 is 17%. Likewise, the likelihood of having BED
and ICD-11). In BED, on average, at least increases with the level of the BMI (Da Luz
once a week, there are binge eating episodes et al. 2018).
Studies on the prevalence of patients with
BED and comorbid obesity report prevalence
rates of 32–70% (Villarejo et al. 2012; Kessler
S. Becker (*)
et al. 2013). Thus, there seems to be a closer
Psychotherapy, Medical University Hospital association between obesity and BED, although
Tübingen, Tübingen, Germany it is still unclear whether BED is a cause or
https://doi.org/10.1007/978-3-662-67662-2_67
502 S. Becker
rather a consequence of overweight and obesity and few family meals (Tetzlaff and Hilbert
(Tanofsky-Kraff et al. 2013; Da Luz et al. 2018). 2014). Such biographical and interpersonal
stressors are more common in patients with
BED than in individuals with obesity and indi-
67.2 Etiology of Binge Eating viduals with normal weight (Agüera et al. 2020;
Disorder Ansell et al. 2012).
As immediate triggering factors, in addi-
The etiology of BED is not yet sufficiently clari- tion to acute stressful environmental influences
fied, and no definitive findings are available to and social factors (food availability, prevail-
date. Current models of the etiology of BED ing thin ideal), a lack of affect regulation and
are multifactorial and include factors that are personality-related aspects such as low self-
also relevant to the development of other eating esteem and negative body concept play crucial
disorders, such as anorexia nervosa and bulimia roles. Maintaining functions are attributed to
nervosa. Restrictive eating, dissatisfaction with irregular, restrictive, and low-carbohydrate but
body shape and weight, low self-esteem, dys- high-fat eating behavior during binge episodes,
functional emotion regulation strategies, and conditioning effects, and the short-term suc-
pressure to conform to a thin ideal are consid- cessful affect reduction of binge eating (Mathes
ered central pathological mechanisms underly- et al. 2009; Haedt-Matt and Keel 2011).
ing eating disorders, disordered eating behavior,
and thus BED.
Figure 67.1 summarizes this concept in 67.3 Specifics of Obesity
a multifactorial etiological model of BED with Binge Eating Disorder
(adapted from Munsch 2003). It distinguishes
between predisposing, triggering, and maintain- Patients with obesity and BED differ from
ing factors. However, a strict separation between patients with pure obesity. In addition to physi-
these factors is not possible, as various trigger- cal consequences, they also have impairments
ing conditions can also become maintaining var- on the behavioral level (binge eating) and on
iables in the course of BED. the psychological level, such as increased psy-
Specifically, in BED, two groups of predis- chopathology and pronounced concerns about
posing risk factors seem to play a particularly body shape and weight (Sawamoto et al. 2013).
important role: Tanofsky-Kraff et al. (2013) also describe a
more pronounced body dissatisfaction, lower
• on the one hand, factors that generally self-esteem, and overall lower quality of life. A
increase the risk of mental disorders, such as study by Striegel et al. (2012) showed that prob-
a high prevalence of mental disorders in the lems and limitations in the workplace are greater
family, traumatic childhood experiences, and for the group of patients with obesity and BED
other critical and stressful life events, such than for those with obesity but without further
as stress at school, parental separation, or comorbidity.
neglect, Furthermore, study findings describe that
• on the other hand, factors that increase the patients with obesity and BED achieve less
risk of overweight/obesity in childhood long-term weight loss in therapeutically guided
(Hilbert et al. 2014). weight loss programs than patients with obe-
sity but without BED (Wilson et al. 2010).
In addition, patients might have experienced The authors demonstrated that this difference
derogatory remarks and teasing in the family in weight loss is leveled out when the affected
regarding body shape, weight, and appearance, patients are introduced to a therapy program that
67 Obesity and Binge Eating Disorder 503
Predisposing factors
Childhood obesity Increased vulnerability to

– Early onset of obesity other mental disorders
– Mental illness in the family
– Teasing, stigmatization
– Transmission of the eating and nutritional – Traumatic childhood experiences
behavior and the physical activity style
– Repeated dieting with yo-yo effect
Triggering factors
Emotional and cognitive Stressful events Social factors

factors – Abuse – Food supply
– Low self-esteem
– Stress – Sociocultural factors
– Negative body concept (slimness ideal, role
– Trauma stereotypes)
– Dysfunctional handling of
negative feelings – Social stigma
– Depressive symptoms
Manifestation of BED
Sustaining factors
– Eating behavior (restrictive, irregular)

– Dietary style (low carbohydrate, high fat)
– Deficits in emotion regulation
– Socio-cultural factors
Fig. 67.1  Multifactorial etiology model of BED. (Mod. after Munsch 2003; from Becker et al. 2015; © [2015] W.
Kohlhammer GmbH, Stuttgart)
includes specific interventions for the treatment 67.4 Psychotherapeutic

of binge eating and high body dissatisfaction, in Treatment Approaches
addition to the establishment of regular nutrition for Obesity with Binge
and exercise. Eating Disorder
For this reason, in the psychotherapeutic
treatment of patients with obesity who also suf- The treatment of this patient group has proven to
fer from BED, disorder-specific interventions be insufficient in both pure weight loss programs
such as techniques for emotion and stress regu- and BED-specific programs. In the long-term
lation to reduce binge eating are indicated. effect (two years after the end of the program),
504 S. Becker
these patients do not achieve satisfactory reduc- practice-oriented treatment manual that, in addi-
tion of their binge eating in weight loss programs tion to a theoretical part, consists of a therapeu-
and regain more weight over time compared to tic guide and is based on current evidence-based
patients with obesity but without BED (Wilson results of therapy research for BED. The authors
et al. 2010). In BED-specific programs, eating primarily focus on coping with binge eating epi-
disorder-specific symptoms, especially the fre- sodes. Cognitive-behavioral methods such as the
quency of binge eating, improve. However, the development of individual trigger and response
cessation of BED does not necessarily lead to control strategies or the processing of dysfunc-
weight loss in the medium and long term (Agüera tional thoughts related to one’s own body or self
et al. 2020). Therefore, it is important to coun- are used. Optionally, there are also treatment
teract high expectations regarding weight loss contents for weight loss and increased physical
in order to interrupt the cascade of binge eat- activity. The flexible treatment structure of the
ing, feelings of insufficiency, depressive mood, manual can be easily adapted to the individual
and frustration with self-abandonment early on. needs of those affected. In addition to numerous
Therapy concepts for obesity in combination worksheets available for download, case exam-
with BED require the combination of elements ples are also described, in which the implemen-
from various intervention approaches and should tation of therapeutic interventions is illustrated.
include both concepts that address the treat-
ment of the eating disorder or binge eating, as
well as those that aim for weight loss (Hay and References
Mitchison 2019).
Agüera Z, Lozano-Madrid M, Mallorqui-Bague N et al
(2020) A review of binge eating disorder and obe-
67.5 Psychotherapeutic sity. Neuropsychiatrie. https://doi.org/10.1007/
s40211-020-00346-w
Treatment Approaches Ansell EB, Grilo CM, White MS (2012) Examining the
for Binge Eating Disorder interpersonal model of binge eating and loss of con-
trol over eating in women. Int J Eat Disord 45:43–50
The therapy approach that has been stud- Becker S, Zipfel S, Teufel M (2015) Psychotherapie der
Adipositas. Kohlhammer, Stuttgart
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able evidence of efficacy (Hilbert et al. 2019). adults starting a weight loss or maintenance pro-
Therefore, this therapy should be offered to gramme. Public Health Nutr 19(1):71–77
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patients as the first choice. There is also evi- with comorbid eating disorders: associated health
dence for the efficacy of interpersonal therapy risks and treatment approaches. Nutrients 10(7):829
(IPT) and to a lesser extent for psychodynamic Dawes AJ, Maggard-Gibbons M, Maher AR et al (2016)
psychotherapy (Vocks et al. 2011). In addition, Mental health conditions among patients seeking and
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also be recommended. The content of structured S3-Leitlinie Diagnostik und Behandlung der
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für Betroffene mit Binge-Eating-Störung. Beltz, correlates. Eur Eat Disord Rev 20:250–254
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binge eating disorder. Psychother Psychosom 82:98 Arch Gen Psychiatry 67:94–101
Part IX
The Treatment of Obesity
507
Prevention of Obesity
68
Manfred J. Müller, Isabel Gaetjens and Anja Bosy-Westphal
Contents
68.1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 509
68.2 Concepts and Effectiveness of Lifestyle and Living Environment-
related Measures for Primary Prevention of Obesity. . . . . . . . . . . . . . . . . . . 511
68.3 Prevention of Obesity—What’s Next?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 515
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 516
68.1 Background cities in the context of cultural, economic, politi-

cal, and social factors. The population-wide
A profit-oriented economization of lifestyles occurrence of obesity, the so-called “obesity epi-
and living environments is the basis of our pros- demic,” results from these interrelationships.
perity, but it also influences health risks and “Unhealthy” lifestyles are risks for the so-
the occurrence of diseases. Overnutrition, low called non-communicable diseases (NCD) such
physical activity, and inactivity characterize as obesity, type 2 diabetes mellitus, hyper-
“unhealthy” lifestyles, which are promoted by tension, and cardiovascular diseases, cancer
a diverse range of energy-dense and processed fostered by high energy intake, and neurodegen-
foods, their constant availability and low prices, erative diseases. In Germany, NCD are currently
as well as automation in everyday life and work, responsible for about 91% of all deaths (Effertz
digital technologies, motorized individual trans- et al. 2015; NCD Alliance 2017). Worldwide,
port as a common form of mobility, the walk- about 2 billion people are affected by obesity,
ability and structures of residential areas and with the highest prevalence observed in indus-
trialized nations and among the age group of
40- to 65-year-olds (GBD 2017). In wealthy
countries, there is an “inverse” social gradi-
M. J. Müller (*) · I. Gaetjens · A. Bosy-Westphal
Institute for Human Nutrition and Food Science,
ent: people from educationally and economi-
Christian-Albrechts-University Kiel, Kiel, Germany cally disadvantaged groups are most often obese
e-mail: [email protected] (Marmot and Bell 2019). Obesity accounts for
I. Gaetjens approximately 3.4 million premature deaths per
e-mail: [email protected] year and is responsible for 3.8% of the global
A. Bosy-Westphal disease burden (GBD 2017). The loss of “dis-
e-mail: [email protected] ease-free” years of life amounts to 2.7 (obesity
https://doi.org/10.1007/978-3-662-67662-2_68
510 M. J. Müller et al.
grade 1) or 7.3 years (obesity grade 2 and 3; economization of lifestyles and areas of life
Nyberg et al. 2018). However, it is unclear to (e.g., eating and drinking) while simultaneously
what extent a high BMI itself or the behavioral losing a common everyday culture. Against the
patterns leading to a high BMI increase disease background of this fundamental assessment,
risk. Lifestyles also determine mortality for the previous strategies and measures of obe-
cardiovascular diseases independently of BMI sity prevention aimed at individuals or specific
(Foster et al. 2018). population groups are oversimplified and have
therefore not really been successful.
 Important The prevention of obesity Prevention routinely conceives of an “oppo-
is an important strategy for avoiding site”, at which its strategies and measures are
personal and societal disease burdens. directed. Thus, obesity prevention measures,
for example, address inequalities in education,
Nationally and internationally, there are now income, and opportunities for health, the strong
numerous overviews, position papers, proclama- influence of companies on political decision-
tions, action plans, and programs that advocate makers (e.g., lobbying by the food industry and
for the prevention of obesity through “healthy” trade), the prioritization of commerce and con-
lifestyles and the creation of health-promoting sumption for the success of a society, as well as
living conditions to support them (Swinburn the social, political, socioeconomic, and soci-
et al. 2011, 2019; Lobstein et al. 2015; WHO etal “drivers” that explain prosperity, but also
2018a, b). Currently, obesity is a topic on the its negative effects on health, climate, and the
agenda for future development to reduce prema- environment.
ture mortality; a sustainable development goal In recent decades, various strategies and
is to reduce its prevalence by 33% by 2030 (UN measures of obesity prevention have been
2015). These global “promises” have not yet led attempted. While so-called “downstream actions”
to measurable successes. (e.g., measures aimed at individuals for infor-
The “obesity epidemic” is aggregated with mation and education) were initially favored, in
simultaneously and globally observed epidem- view of the “syndemic,” the concern is now with
ics of underweight and the endemic effects of so-called “upstream actions,” i.e., a reorientation
climate change (Swinburn et al. 2019). This of structures and central systems of agriculture
expanded view allows for a new conceptualiza- and nutrition, transport and traffic, urban plan-
tion of “obesity” as part of a so-called “syn- ning and land use, media and digitization, leisure
demic.” Given the interactions between these and tourism. This involves local and regional,
epidemics, the prevention of obesity does not national, and global solutions. In this context, a
appear to be simple. Since the “obesity epi- largely industrialized food system, which pro-
demic” is linked to the other epidemics and duces market-oriented and profit-oriented highly
these epidemics reinforce each other, there can processed, energy-dense, sugar- or salt-con-
be no prevention of obesity on its own. taining foods from cheap and mass-produced
agricultural products and adds taste-enhancing
 Important Obesity is associated, or appetite-stimulating additives, moves to the
as part of a syndemic, with prob- center of a societal and political discussion about
lems of malnutrition, environmental “obesity prevention.”
damage, and climate change. The
problems occur simultaneously and  Important Currently, obesity pre-
promote each other. vention measures address systems of
agriculture and nutrition, transport
From a public health perspective, the popu- and traffic, urban planning and land
lation-wide occurrence of obesity is “collat- use, media and digitization, leisure
eral damage” of an excessive profit-oriented and tourism.
68 Prevention of Obesity 511
Creating a “healthy” society is the result of an The prevention of obesity takes place on
intention and a collective effort, which must be several levels of politics, living environments,
guided taking into account various interests, socioeconomic conditions, and individual sen-
institutions, and ideas. So far, no area of our sitivities; it is pursued through local, regional,
society, no professional group, no interest group, national, and global strategies; obesity preven-
and no municipality, not even any country in the tion is a strategy that accompanies various life
world, has been able to successfully address the stages. Children and adolescents are an impor-
complex and interconnected causes of obesity tant target group to prevent the early manifesta-
in terms of prevention. However, the problem tion of risks and symptoms of NCD. Most of the
does not only concern society, companies, inter- previous experiences in obesity prevention con-
est groups, politics, or experts: it is also about cern this age group.
personal concern, meaning ourselves. Because:
There are no real illusions concerning ourselves
in the face of the quite plausible and desirable 68.2.1 Strategies for Behavioral
idea of a “healthy society”; we would all wish and Contextual Prevention
for the “insight into man’s active-powerless pro-
portionality” (Strauss 2020). The future of obe- Behavioral prevention attempts to increase the
sity prevention is the overcoming of ambivalent “chances” of health by imparting knowledge
attitudes and behavior based on this insight. and improving competencies (Müller 2013;
The success of prevention is therefore not Weihrauch-Blüher et al. 2018). In contrast, con-
solely based on the “opposite”; it is first and textual prevention aims at changes in the politi-
foremost up to us to use our extensive knowl- cally, ecologically, economically, socially, and
edge and change ourselves. This requires a high structurally characterized living environments
degree of willingness to understand and coop- that co-determine lifestyles and the “chances”
erate in the interaction of society (Habermas of health. Contextual prevention concerns the
2019). Only emancipation from the current so-called “obesogenic environment”, addressing
conditioning factors of our actions and regain- all influences of the living environment and the
ing control over living conditions and lifestyles “drivers” present there, which can promote the
promise a better future. development of obesity.
In public health science, a distinction is made
 Important The success of prevention between “universal”, “selective”, and “targeted”
is based on regaining control over prevention (IMO 1997). “Universal prevention”
our living conditions and lifestyles. (also referred to as health promotion or primary
prevention) is aimed at all people, regardless
of their health and nutritional status. “Selective
68.2 Concepts and Efficacy prevention” targets so-called “risk groups” (e.g.,
of Measures for Primary normal-weight children of obese parents who
Prevention of Obesity Relating have a high risk of becoming overweight them-
to Lifestyle and Living selves), whereas “targeted prevention” addresses
Environment individuals with already manifest obesity or
related diseases. It includes secondary or tertiary
The need for prevention arises from the preva- prevention measures.
lence of overweight and obesity, as well as The target variables of obesity prevention are
“unhealthy” lifestyles, the living environments the behavioral patterns and their determinants
that promote them, and the resulting diseases. and causes that determine the risk of becom-
Prevention aims to improve people’s lifestyles ing obese. Primary prevention of obesity should
(behavioral prevention) and to bring about include both behavioral and contextual preven-
changes in living environments that enable tion measures. The latter requires a fundamental
“healthy” lifestyles (contextual prevention).
political orientation of the health system towards framework conditions that promote awareness
the prevention of chronic diseases; decision- of health and consumption and could improve
makers should assign high value to health in all the success of behavior prevention aimed at
policy areas. Prevention measures are carried strengthening individual health competencies
out within society, taking into account unequal in “settings,” e.g., schools, training centers, and
health opportunities, and aim for comprehensive companies (Müller 2017, 2019).
effectiveness. In view of the “syndemic” of epidemics,
The “Global Action Plan on Physical Activity strategies and measures are being sought that
2018–2030” adopted by the WHO in 2014 address both the global occurrence of over-
(WHO 2018b) exemplifies the political guide- weight and underweight as well as climate
lines of a structural prevention. It includes change and environmental damage. For exam-
ple, a reduction in the consumption of meat and
• the implementation of national or regional sausage products by consumers, brought about
campaigns that raise awareness of the health, by taxes, fewer subsidies, appropriate labeling,
social, economic, and environmental benefits and social marketing, could both reduce the
of regular physical activity and less sedentary risks of obesity and NCDs and benefit the envi-
activities, ronment and climate as a result of a correspond-
• new structures in urban and transport plan- ingly changed land use.
ning such as pedestrian and bicycle networks
that create a movement-friendly environment  Important Obesity prevention is not
and thus promote the extent of mobility, and possible in isolation: In view of the
• political commitment to more physical activ- syndemic of obesity, malnutrition,
ity and less sedentary activities through fun- climate, and environmental damage,
damental advocacy and orientation in various measures are necessary that address
policy areas. the causes of the causes, i.e., the
common causes of the simultane-
Similarly, the “European Action Plan on Food ously occurring, interconnected, and
and Nutrition 2015–2020” (WHO 2015) mutually conditioning problems.
addresses recommendations for creating so-
called “healthy food environments” as meas-
ures of consumer health protection. Demands on 68.2.2 How Effective are Measures
politics include restrictions on the marketing of of Behavioral and Structural
energy-dense and highly processed foods, better Prevention of Obesity?
labeling and health assessment, and compliance
with standards of “healthy” nutrition, e.g., for Scientifically reliable data on behavioral preven-
meals served in daycare centers, schools, can- tion of overweight and obesity are currently only
teens, hospitals, and nursing homes. available for children and adolescents. These are
Political strategies for the prevention of obe- presented in detail in a current Cochrane review
sity are initially targeted. These concern adver- (Brown et al. 2019). The interventions addressed
tising bans for “unhealthy” foods, e.g., for nutrition, physical activity (exercise and sports),
so-called “children’s foods” and “junk food” and inactivity (TV and media consumption)
(= energy-dense foods with a high proportion together or separately. In most studies, body
of fat, sugar, or salt), as well as fiscal meas- weight was examined as an “outcome” variable.
ures, e.g., the introduction of so-called “sugar” Based on 153 randomized controlled trials and
or “soft drink” taxes, which affect their pro- follow-up periods of up to more than two years,
duction and sale. These strategies create social the authors draw the following conclusions:
• In the age group of up to 5 years, interven- through social outreach measures. Preventive
tions targeting nutrition and physical activity measures in families with a migration back-
have moderate effects on nutritional status; ground appear to be almost ineffective, but this
on average across all studies, the difference has not yet been systematically investigated.
in BMI between the intervention and control Prevention and treatment of already over-
groups was −0.07 kg/m2. weight and obese children and adolescents have
• For children aged 6–12 years, small but posi- only small and hardly sustainable effects on life-
tive effects were found after increasing physi- style and body weight (Al-Khudairy et al. 2017;
cal activity: The difference in mean BMI Colquitt et al. 2019; Mead et al. 2017).
between the intervention and control groups Municipal initiatives such as the program
was −0.10 kg/m2; in contrast, measures against overweight and obesity carried out in
addressing nutrition or both nutrition and France (“Ensemble, prévenons l’obésité des
physical activity were hardly successful. enfants”, EPODE) follow the so-called “capac-
• Similar results were shown for older children ity-building” approach,1which involves various
and adolescents, with small effects of physi- local stakeholders such as teachers, doctors,
cal activity-focused interventions observed, representatives ofretail, catering, food industry,
while nutritional interventions remained and media. Twelve years after the establishment
largely ineffective. of themeasure, the prevalence of overweight
• Obesity prevention has no adverse side in the model regions had decreased from 11.4
effects. For example, the development of eat- to8.8%, while it had increased in the comparison
ing disorders is not promoted, and preventive regions from 11.0 to 17.8% (Borys et al. 2012).
measures do not increase social inequalities. However, the evaluation of the data and thero-
bustness of the study design were questioned.
Educational measures of behavioral prevention in In the meantime, the program has beenextended
kindergartens and schools had positive effects on to ten additional regions with a total of 167 cit-
nutritional knowledge and health literacy, while ies in France and to 17 otherEuropean and non-
the incidence of overweight remained almost European countries. Scientific monitoring and
unchanged. However, the effects were selec- continuous publication ofthe results of EPODE
tive: Over observation periods of eight years, have not yet taken place.
positive effects were observed in children of Similar results were found in the munici-
normal-weight parents and children from socially pal prevention program “Be Active, Eat Well”
better-off families, while children of overweight in Australia (Sanigorski et al. 2008). Three
parents and children from socially disadvan- years after the intervention, the age-depend-
taged families did not benefit from the measures ent increase in BMI of the children was lower
(Plachta-Danielzik et al. 2007, 2011a, b). compared to a neighboring region, while the
Interventions in families of children with prevalence and incidence of obesity remained
overweight resulted in small improvements in comparable. The municipal initiative “Shape
health-relevant behavior and a lower increase Up Somerville: Eat smart, Play Hard” founded
in BMI compared to controls (Langnäse et al. in the US city of Somerville also involved col-
2004). However, there were significant differ- laboration between parents, schools, city admin-
ences between children from families with low istration, food industry, and advertising industry.
and high socioeconomic status: Children with Three years after the start of the program, the
overweight from educationally and economi-
cally disadvantaged families showed an increase
in BMI despite intervention, while a decrease in 1 The term capacity buildingrefers to a process by which
BMI was observed in children from socially bet- individuals and organizations acquire the skills, knowl-
ter-off families. Apparently, children with a low edge, and equipment they need to competently perform
socioeconomic status cannot be reached even their tasks.
BMI in the intervention group was slightly the consumption of soft drinks by 7% (Afshin
lower compared to a control group (Economos et al. 2017). The impact of this effect on obesity
et al. 2007). In Germany, the Leipzig project and its sequelae, as well as the transferability
Grünau is so far the only scientifically accom- of these results to wealthier countries, has not
panied municipal initiative for the prevention of been systematically investigated. Higher prices
obesity, but its evaluation has not yet been com- particularly affect people from socially disad-
pleted (Gausche et al. 2014). vantaged groups, but given the socially uneven
The joint consideration of these initiatives distribution of disease risks, the benefits of these
suggests that “municipal” prevention of obe- measures are highest in the lower socioeco-
sity is somewhat more effective than measures nomic groups.
of behavioral prevention that focus exclusively “Upstream actions” require mobilization of
on children in daycare centers and schools or civil society to ensure broad support for politi-
on families. All preventive measures encounter cal and systemic change. For example, the intro-
“barriers” in the living environments, and the duction of a “soft drink tax” in Mexico was
accessibility of socially disadvantaged groups is preceded by a multi-year educational campaign,
poor. which was supported by an alliance of numerous
organizations, interest groups, and physicians.
 Important Behavioral prevention Scientific evidence for the efficacy of “upstream
measures have only a small impact actions” is difficult to provide; there is no con-
on the incidence and prevalence of vincing experimental setting for measures aimed
obesity. at “systems.” This fact contributes to restraint,
half-hearted commitment, and ultimately inad-
Political measures for the prevention of over- equate responses to the “obesity epidemic” on
weight include risk group-targeted measures the part of those responsible, experts (including
(“focused policy”; e.g., programs for “over- physicians), and political decision-makers.
weight families” or migrants), measures that Acceptance and implementation of all pre-
facilitate or promote consumer decisions for ventive measures are hindered by the fact that
“healthy” alternatives (“enabler policy”; e.g., there is no “mission” (or vision) for health
campaigns for healthy nutrition and appropri- “before” medicine in politics and society.
ate food labeling), and regulations that reinforce “Universal prevention” affects areas outside
these measures (“amplifier policy”; e.g., taxes of medical care, the importance of which for
on “unhealthy” foods, limitation of price promo- health is not always clearly defined and can also
tion and subsidies). The justification for politi- be assessed differently from one individual to
cal intervention in the market is seen in market another. It should also be taken into account that
failure: External effects of high productivity preventive measures can “compete” with other
and high profits of companies (e.g., in the food societal concerns (e.g., consumption-dependent
sector) have a long-term negative impact on the economic growth and, related to that, jobs and
health of the population, causing high societal prosperity).
costs.
The population-wide effectiveness of “politi-  Important Proportionate prevention
cal” proportionate prevention (such as advertis- measures promise success, but this
ing bans for “children’s food” or a tax on “junk has not yet been proven and, strictly
food” and “soft drinks”) has so far been pre- scientifically speaking, cannot be
dominantly studied in middle-income countries well proven according to the cur-
(such as Mexico and Chile). Observational stud- rent paradigms of obesity research.
ies suggest an influence of higher prices on con- Proportionate prevention requires
sumer behavior: a 10% price increase can reduce alternative research paradigms.
68.2.3 What are Suitable Times  Important Successful prevention of

for Prevention of Obesity obesity requires a societal change
in Children and Adolescents? characterized by a transformation of
health and food systems.
Overweight and obesity can develop at any stage
of life, but childhood and puberty are considered
particularly critical life stages that justify early 68.3 Prevention of Obesity—What’s
and universal prevention (Weihrauch-Blüher Next?
et al. 2018). Longitudinal data show a high
spontaneous remission of overweight in the first In view of the high prevalence of obesity in all
years of life (von Kries et al. 2012). In contrast, population groups today, as well as the lifestyles
the persistence of overweight and obesity from and living environments that foster it, behavioral
the age of 6 is high. This suggests starting pre- and environmental preventive measures are nec-
ventive measures before or at the time of school essary. Since previous strategies and measures
entry. Early-onset obesity has a high persistence for obesity prevention have been only partially
into adulthood. Since the prevention of obesity successful, it seems promising to focus on liv-
is a lifelong task, it should not be limited to chil- ing environments, structures, and systems, i.e.,
dren and adolescents. away from the obvious “causes” of everyday
actions in people’s lives and towards the “causes
of causes,” i.e., the spatial, political, economic,
68.2.4 What are Suitable Settings cultural, and social conditioning factors of over-
for Obesity Prevention? weight (Müller 2017, 2019). A setting-based
approach in municipalities, which in turn is sup-
A target group-specific approach to health pro- ported by a societal, cultural, and political “cli-
motion is possible in the settings of daycare mate” conducive to the health of people and the
centers, schools, medical care facilities, com- environment, is a concrete challenge (Müller
panies and workplaces, retail, adult education 2019).
centers, sports clubs, consumer health protection A future “prevention of obesity” requires the
institutions, and health insurance companies. All acceptance of limits to previous thinking and
settings have a common anchorage in the munic- action and going beyond them:
ipalities, where people can be reached in their
everyday living conditions. Municipal measures – The previous “solutions” are not solutions:
for the prevention of overweight are complex, There is currently no sufficiently effective
and the evaluation of complex measures for and sustainable measure for the prevention
behavior change has no external validity. and treatment of overweight. The possible
The syndemic occurrence of climate change effects of environmental prevention have not
and obesity requires changes in global and been well studied so far, and they are scien-
national agricultural and food systems through tifically not reliably comprehensible.
appropriate policies that go beyond previous – We need an alternative obesity research: A
experiences with prevention measures. A future focus on the “paradigm of energy balance” as
transformation of health and food systems aimed well as possible biological causes of obesity,
at these goals requires extensive regulations and up to the concept of personalized nutrition,
interventions, which, to be successful, must take does not provide a basis for its prevention.
into account the cultural, economic, ecological, Modern progressive thinking has created a
political, and social contexts of society. false consciousness of a new beginning and
future solutions to current medical prob-  Important Emancipation from the

lems. Biomedical research is not the “unify- social, economic, ecological, and
ing” center of a solution-oriented obesity political conditioning factors of our
research; it rather represents a “narrowing.” actions is liberation, which creates
Future investigations of obesity and its seque- possibilities to successfully address
lae should address the “causes of causes” the current problems of health, envi-
(e.g., the social determinants of health) as ronment, and climate.
well as the “causes of the causes of causes”
of obesity, i.e., the effects of cultural, eco-
nomic, ecological, and political coexistence. References
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Treatment of Obesity
in Childhood 69
and Adolescence
Martin Wabitsch
Contents
69.1 Indication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 519
69.2 Treatment Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 521
69.3 Approach and Treatment Components . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 521
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 523
Meta-analyses of published study results on the which were developed on the basis of existing
therapy of overweight and obesity in children study results and the expertise of a multidiscipli-
and adolescents show that there are effective nary working group.
therapy programs (AWMF guidelines/Wabitsch
and Moss 2019). However, practical experience
teaches us that these programs and the underly- 69.1 Indication
ing treatment concepts are only accepted by a
minority of those affected. The indication for the treatment of a child or
The treatment success of effective therapy adolescent with increased body weight depends
programs can vary greatly between individuals. on the existing functional impairments, somatic
In addition, a dependency of treatment success comorbidity, psychosocial impairment, and pos-
on the treatment center offering the therapy is sibly existing psychiatric sequelae.
known (Reinehr et al. 2009). Every child or adolescent with obesity (BMI
It is therefore recommended to further > 97th percentile, Fig. 69.1) should be given
evaluate and gradually improve current thera- the opportunity for treatment. In children and
peutic efforts. The following explanations sum- adolescents with overweight who have a BMI
marize the current state of knowledge and the between the 90th and 97th percentile and a
recommendations of professional societies, present sequelae of overweight requiring treat-
ment, the underlying overweight should also be
treated. If there is another serious illness (e.g., as
part of a hereditary disease), a very specific ther-
M. Wabitsch (*) apy is usually required. Guidelines for the indi-
Division of Pediatric Endocrinology and Diabetes, cation and implementation of obesity treatment
Department of Pediatrics and Adolescent Medicine,
Ulm University Medical Center, Ulm, Germany
in children and adolescents have been published
e-mail: [email protected] by the Working Group on Obesity in Childhood
https://doi.org/10.1007/978-3-662-67662-2_69
520 M. Wabitsch
45
a
40
35
P99.5
30
BMI (kg/m2)
P97
P90
25
P50
20
P10
P3
15
10
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Old (Years)
b 45
40
35 P99.5
30 P97
BMI (kg/m2)
P90
25
P50
20
P10
P3
15
10
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Old (Years)
Fig. 69.1  Percentile curves for BMI for children and adolescents in Germany. a boys and b girls aged 0–18 years.
(Kromeyer-Hauschild et al. 2001, 2015)
and Adolescence (https://adipositas-gesellschaft. Obesity”, published by the Federal Ministry of

de/aga/). In addition, the legal framework condi- Health (https://adipositas-gesellschaft.de/aga/).
tions for the financing of education programs are It is particularly important to assess the
set out in a consensus paper “Patient Education patient and their family's motivation and and
Programs for Children and Adolescents with capability for therapy. This assessment is
69 Treatment of Obesity in Childhood and Adolescence 521
elegantly solved in the obesity education pro-

gram “Obeldicks” (Reinehr et al. 2005). Patients maintenance of achieved behavioral
who are to participate in the therapy must first changes
regularly attend a sports program for several • Avoiding unwanted therapy effects
weeks. Only when they have done this and • Promotion of normal physical, psycho-
the parents show a willingness for behavioral logical, and social development and
change are the affected children included in the performance
education program, which then runs for almost
a year. Accordingly, this education program also
has above-average medium-term success rates.
If sequelae of obesity in children and adoles- 69.3 Approach and Treatment
cents are already present, a significant weight Components
loss is usually required. If this is not success-
ful, the treatment of comorbidity of obesity in The therapeutic approach is based on the treat-
children and adolescents poses a new challenge ment goals. A change in the body’s energy bal-
(hypertension, impaired glucose tolerance, meta- ance should be achieved by reducing energy or
bolic syndrome, fatty liver disease, orthopedic fat intake (dietary change), e.g., based on the
diseases). optimized mixed diet, and by increasing energy
expenditure (increasing physical activity). This
usually requires a long-term therapeutic measure
69.2 Treatment Goals (e.g., behavior therapy, family therapy), involving
the people in the child’s or adolescent’s imme-
In the treatment of obesity, the physiological diate social environment. An interdisciplinary
basis of body weight regulation must be taken approach is necessary, preferably coordinated by
into account. Therefore, the goal of treatment the pediatrician or general practitioner, with the
is not weight loss, but the stabilization of a support of psychologists, nutrition professionals,
reduced body weight at a lower level (in chil- and sports therapists. In addition to the need for
dren and adolescents, the relationship to body knowledge transfer, changes in eating and exer-
height must always be considered) and thus the cise behavior should be achieved in small, man-
stabilization of a new energy balance. Rapid ageable steps for the patient. The aim is to create
weight loss as part of short-term diets is rather problem awareness, increase motivation, con-
disadvantageous (effect of “weight cycling”). solidate learned new behaviors, train self-control,
Obesity in children and adolescents is a chronic and develop relapse prevention strategies. Once
disease that requires long-term therapy. sufficient behavioral changes have been stabi-
lized, the therapist’s supervision of the patient
can be relaxed. However, regular supervision is
Treatment goals for children and ado- necessary for many years to continue monitoring
lescents with obesity the maintenance of new behaviors and to counter-
• Long-term weight loss (i.e., reduction act relapses in a timely manner.
of fat mass) and stabilization
• Improvement of obesity-associated
comorbidity and associated risk factors 69.3.1 Education Programs
• Improvement of the patient’s current
eating and exercise behavior, involving Promising education programs for children and
their family, learning problem-solv- adolescents with obesity include a combination
ing strategies, and ensuring long-term of the following five modules (Fig. 69.2):
522 M. Wabitsch
Long-term therapeutic success

weight checks and self-monitoring of nutri-
tion, eating, and exercise habits are neces-
sary to start treatment. Small, achievable steps
Behavioral therapy (klein)

Parents as a target group
Exercise therapy (klein)

should be aimed for in behavior change to avoid
Long-term and QA
Nutritional therapy frustrations.
Stimulus control techniques, positive rein-
forcement, reinforcement and reward systems,
modeling, and relapse prevention, as well as
avoiding prohibitions, are essential components
Motivation review
of behavioral therapy. Positive requests are supe-
rior to prohibitions.
Self-observation, self-assessment, and vol-
Fig. 69.2  Treatment components of a treatment concept
for children and adolescents with obesity
untarily controlled behavior change require
intellectual abilities and thus show the limits
of behavioral therapy. Young children and chil-
• Nutrition dren with mental disability are not accessible to
• Exercise this form of therapy.
• Behavioral therapy
• Involvement of parents or caregivers, taking 69.3.1.4 Involvement of Parents
into account the age of the child or Caregivers
• Long-term care Parents are role models for their children’s nutri-
tion, eating, and exercise habits. Controlled,
69.3.1.1 Nutritional Therapy randomized trials have consistently shown that
Included are knowledge transfer, counseling, significantly better results can be achieved by
and practical exercises for parents and children involving parents.
on dietary changes, taking into account the Programs that only target children and do not
DGE recommendations. It is recommended to involve parents are less likely to be successful.
reduce daily calorie intake by about 30%. This For younger children, parent education alone is
is best achieved by reducing the fat content and sufficient to modify children’s eating and exer-
increasing complex carbohydrates, and espe- cise habits and achieve weight control.
cially by avoiding high-calorie snacks (“snack- For adolescents, it may be sufficient to treat
ing”) and energy-rich or sugary drinks. only the affected individuals.
69.3.1.2 Exercise Therapy 69.3.1.5 Long-Term Care

A change in behavioral and lifestyle habits with Behavioral changes can only be achieved
increased physical activity in everyday life is through long-term patient care. Education pro-
necessary; structured training and sports ses- grams should be designed for at least six, pref-
sions alone are not sufficient. Increasing physi- erably twelve months. Subsequently, further care
cal activity in everyday life and, above all, of the patient with relapse prevention strategies
reducing television and computer consumption is required.
are important. It is recommended to reduce daily
television time to one hour. 69.3.1.6 Group vs. Individual Therapy
Group therapy can help build a motivational
69.3.1.3 Behavioral Therapy Methods group atmosphere. Participants benefit from
These are based on the assumption that nutri- the interactions. Due to the variable individual
tion, eating, and exercise habits can influence needs of the person and the individual daily rou-
body weight and that the corresponding behav- tines of a family, individual education sessions
iors can be modified in the long term. Regular are additionally required.
69 Treatment of Obesity in Childhood and Adolescence 523
69.3.1.7 Prognostic Factors
for Successful Treatment • Formation of gallstones
The most important influencing factor is the • Decrease in growth rate (this is most
motivation and willingness for behavioral likely a normalization of accelerated
changes of the child and their family. In addi- linear growth)
tion, better results seem to be achievable for • Psychological destabilization (e.g.,
boys, younger children, and children of normal- impairment of self-esteem) due to deal-
weight parents. The weight change of the paring with increased body weight
ents closely correlates with the weight change of • Excessively rapid weight loss can lead
the children. to the yo-yo effect
69.3.2 Other Therapies References

Drug and surgical therapies are indeed success- Kromeyer-Hauschild K, Wabitsch M, Kunze D et al
ful in adolescents, but there are not yet suffi- (2001) Perzentile für den Body Mass Index für das
cient long-term data, so these procedures should Kindes- und Jugendalter unter Heranziehung ver-
schiedener deutscher Stichproben. Monatsschr
only be used by specialists in cases of compel- Kinderheilkd 149:807–818
ling indications (Wabitsch et al. 2012; AWMF- Kromeyer-Hauschild K, Moss A, Wabitsch M (2015)
Guidelines/Wabitsch and Moss 2019). Referenzwerte für den Body-Mass-Index für Kinder,
Jugendliche und Erwachsene in Deutschland –
Anpassung der AGA-BMI-Referenz im Altersbereich
von 15 bis 18 Jahren. Adipositas 9:123–127
69.3.3 Possible Side Effects Reinehr T, Kersting M, Wollenhaupt A et al (2005)
of Treatment Evaluation of the training program „OBELDICKS“
for obese children and adolescents. Klin Pädiatr
217(1):1–8
The treatment can have undesirable side effects, Reinehr T, Hoffmeister U, Mann R (2009) Medical care
as with other treatments, and therefore requires of overweight children under real-life conditions:
medical supervision. The assessment of side the German BZgA observation study. Int J Obes
effects in relation to the continuation of treat- 33(4):418–423
Wabitsch M, Moss A (federführend für die AGA)
ment must lie in the decision of the treating (2019) S3-Leitlinie zur Therapie und Prävention der
physician. Adipositas im Kindes- und Jugendalter. AWMF-
Register-Nummer 050-002. Version August 2019.
http://www.awmf.org/leitlinien/detail/ll/050-002.
html. Accessed 21 Dec 2020
Side Effects of Obesity Treatment in Wabitsch M, Hauner H, Hebebrand J et al (2012)
Children and Adolescents Bariatrisch-chirurgische Maßnahmen bei
• Development of eating disorders Jugendlichen mit extremer Adipositas. Monatsschr
• Development or exacerbation of ortho- Kinderheilkd 160:1123–1126
pedic complications
Family-Based Approaches
to Treatment 70
Susanna Wiegand and Martina Ernst
Contents
70.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 525
70.2 Family-Based Treatment Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 527
70.3 Problem Areas of Family-Based Approaches . . . . . . . . . . . . . . . . . . . . . . . . 530
70.4 Conclusion and Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 532
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 534
70.1 Introduction Therefore, important for building a therapeutic

relationship with the affected child or adolescent
70.1.1 Family Contribution to the and their family is the assessment of the genetic
Development of Obesity contribution to weight development in relation
to the contribution of family lifestyle and envi-
70.1.1.1 Genetic Contribution vs. ronmental conditions. Neither the common
Lifestyle belief in a difficult-to-influence genetic predis-
Since obesity and its associated diseases tend position (“There’s nothing you can do, it runs
to cluster in families, it is reasonable and nec- in our family!”) nor the primary assumption of
essary to primarily use family-based treatment an unfavorable family lifestyle (“Nothing comes
approaches. If one or both parents are obese from nothing—they’re all too fat!”) is helpful in
themselves, the statistical risk for the develop- this context. Reviews on the course of lifelong
ment of obesity in their children is significantly weight development indicate a genetic predis-
increased. This constellation of an “obesity position contribution of about 40–70% to indi-
family” often leads to experiences of stigma. vidual weight development (Golden and Kessler
2020). These overviews are mostly based on
twin and adoption studies as well as longitudinal
epidemiological data from large cohorts, such
as the Framingham cohort. So far, >100 risk
S. Wiegand (*) · M. Ernst
Center for Social-Pediatric Care/Pediatric
genes for the development of obesity have been
Endocrinology and Diabetology, Charité – identified. Therefore, it can be assumed that the
University Medicine, Berlin, Germany regulation of body weight is based on a very
e-mail: [email protected] complex genetic network. Interestingly, stud-
M. Ernst ies in childhood and adolescence show a higher
https://doi.org/10.1007/978-3-662-67662-2_70
526 S. Wiegand and M. Ernst
genetic contribution to weight development than are less well reached by the healthcare system.
studies in adulthood (Silventoinen and Kaprio Families with a migration background seek
2009). This fact is relevant for therapy, as the treatment only when the extent of overweight
comprehensible communication of this informa- and comorbidity is more severe (Dannemann
tion is experienced as relieving by most parents. et al. 2011) and also perceive their ability to
In the key situation of an initial consultation, actively contribute to their children’s health as
this can lead to both a relief of feelings of guilt lower than families without a migration back-
(“Genes do play a role!”) and an assumption of ground (Sect. 70.3.2). Families from education-
responsibility (“You can still do something!”; ally disadvantaged backgrounds exhibit less
Sect. 70.3.3). health-promoting behavior, particularly with
For a long time, human behavior was con- regard to food selection, media use, and active
sidered to be almost exclusively learned. This leisure activities. Therefore, family-based treat-
paradigm has been partially modified in recent ment approaches for obesity in children and
years, as developmental psychological studies in adolescents must absolutely take into account
particular suggest that behavioral and personal- the respective psychosocial conditions.
ity traits in humans are also partly genetically
determined (DiLalla et al. 2012). Especially in
the early phases of child development, however, 70.1.2 Basic Principles of Family
weight-relevant behavioral areas such as nutri- Therapy for Chronic Diseases
tion and physical activity are also influenced by
the example of parents and possibly siblings as When a child or several family members in a
part of early childhood imprinting. Therefore, family are affected by obesity, systemic aspects
in cases of early-onset obesity, parents or other must form the basis of the treatment. The social
legal guardians are the primary target group for system of the family, with its interaction pro-
obesity education. cesses, is at the center of the intervention. The
primary goal is not only to improve the (health)
 Important Obesity in childhood and condition of the affected family member. In
adolescence is determined by the line with the basic assumption of a biopsycho-
interaction of genetics and lifestyle social origin and maintenance of obesity, the
factors. The cause is a long-term relationships, interactions, and interaction pat-
positive energy balance, meaning terns between individual family members in
less energy expenditure than intake. the context of the chronic disease are exam-
ined in particular. Over time, the chronic dis-
70.1.1.2 Influence of Social Status ease may have established itself in the system
and Migration Background like an additional family member, demanding
Obesity in children and adolescents is not the attention of all family members and caus-
equally distributed across all population groups. ing specific interaction disorders. The aim is to
Rather, families with low socioeconomic sta- achieve an improvement in well-being and an
tus and families with a migration background expansion of action competencies for all fam-
represent particular risk groups (Röbl et al. ily members through improved communication,
2013). Children from families with low socio- mutual understanding, insight into typical con-
economic status have an approximately 3-fold flict patterns, and better conflict resolution strat-
increased risk of being obese, while children egies. The therapeutic attention is focused “on
from families with a migration background have the design of a supportive living environment
a 2-fold increased risk. The hypotheses for pos- to create conditions in which children and ado-
sible causes are diverse. Overall, these groups lescents can develop appropriately” (Rotthaus
70 Family-Based Approaches to Treatment 527
2001). The usefulness of this seemingly unusual 70.2 Family-Based Treatment

treatment approach for obesity therapy becomes Approaches
clearer when considering the enormous every-
day disruptive effect of a chronic disease within 70.2.1 Family Imprinting
a family (in this case, a child with obesity and in Infancy and Preschool
possible secondary diseases). This is particularly Age
relevant when therapeutic measures have notice-
able effects on family habits and structures, 70.2.1.1 Nutritional Behavior
e.g., a change in the food and drink offerings or In infancy (2nd/3rd year of life) and early child-
changes in media use and family exercise habits. hood (preschool age; 4th–6th year of life), the
A systemic perspective also benefits sin- essential foundations for later behavior are laid.
gle parents. 19% of children in Germany live This also includes the weight-relevant areas of
with only one parent in the household (Federal nutrition and physical activity. In these early
Statistical Office 2018). The partial or com- developmental phases, parents play a crucial
plete absence of a parent is even more com- role. For infancy, there is a significant negative
mon in families with an obese child (36% in a association between long breastfeeding dura-
clinical cohort; own data), often in combination tion and the risk of being overweight or obese in
with a low socioeconomic status. Especially for primary school age. However, interpreting these
the sustainable implementation of behavioral data is difficult, as long breastfeeding duration
changes in the family environment, which often is itself associated with, for example, higher
become necessary during obesity therapy for socioeconomic status and better health behav-
children and adolescents, this atypical parent- ior (Koletzko et al. 2020). A protective effect
ing situation poses an additional challenge for a of breastfeeding is suggested, for example, by
family-based approach. Differences in everyday the fact that, in contrast to formula feeding, the
life design and parenting style often contribute infant can largely self-regulate food intake, or
to parental separation. For a successful change that breast milk is lower in protein but contains,
in nutrition and/or exercise behavior in fami- among other things, leptin and thus may have a
lies with separated parents, elements of couple direct effect on appetite regulation. In any case,
therapy can be helpful, which also helps these taking a breastfeeding history (and also sleep
parents understand themselves as responsible behavior) is part of the initial conversation, even
parenting couples and enables coordinated work in the treatment of older children with obesity,
on the concrete behavioral level. as this can also provide clues about attachment
A systemic approach in the treatment of behavior.
obese children and adolescents does not only In infancy and pre-school age, children
mean considering the direct family environ- largely follow the example of their parents. In
ment (parents, siblings), but also involving all the following, portion size and food selection
persons who are responsible for the respec- are considered separately: Directive behavior
tive patient (grandparents, other caregivers). regarding the amount of food, both in the sense
Particularly in the grandparent generation, of urging to continue eating (overeating) and
there are often differing views on normal body in the sense of restriction, increases the risk of
weight, healthy nutrition, and educational overweight. In particular, parents with obesity
issues. If grandparents are regularly entrusted and/or eating disorders often have a harder time
with the care of a patient, they are therefore assessing their child’s needs. The lowest risk of
included in the consultation. becoming overweight is found in children who
can freely choose their portion size and meal increasing media consumption starting from
duration—provided there is a diverse healthy early childhood. Media consumption (TV,
food supply and unhealthy snacks are not con- mobile phone, tablet) is generally associated
stantly available in the household. Children's with physical inactivity and has a negative
sense of taste is developing, and differs sub- impact on weight development, as well as on
stantially from that of adults. Children primar- motor, mental, and psychosocial development. If
ily prefer sweet and salty foods and avoid sour developmental milestones (e.g., standing on one
and bitter ones. Over time, sense of taste and leg) are not reached within physiological devel-
food preferences differentiate, also depending opment windows without causal pathological
on the family’s offerings (Rohde et al. 2020). reasons, but due to a lack of movement oppor-
New taste qualities should be offered repeatedly tunities or stimuli, this has lasting effects on fur-
in small amounts and without coercion. If sweet ther developmental progress. Long-term studies
and/or salty snacks are constantly available, this show a correlation between television viewing
not only disrupts self-regulation (risk of “over- duration in early childhood and achieved educa-
eating”) but also prevents the differentiation of tional level in adulthood, even when adjusted for
taste and thus the expansion of the food spec- factors such as socioeconomic status and BMI
trum. The healthiest food choices are made by (Hancox et al. 2005). In a large cross-sectional
children whose parents non-directively provide study (<250,000 children and adolescents, 35
a healthy, diverse range of minimally processed countries), maternal smoking also had a statis-
foods and eat together with their children in a tical effect on weight in addition to media con-
structured environment. sumption (Mitchell et al. 2018).
70.2.1.2 Physical Activity Behavior

Not only nutrition, but also physical activ- 70.2.2 Importance of Parenting Skills
ity behavior is sustainably shaped during early for Treatment
childhood and preschool age. However, it is
methodologically difficult to directly measure Currently, there are no pharmacological treat-
physical activity in this age group, as many sys- ment options available for children and ado-
tems (e.g., accelerometers) are not designed for lescents with obesity (with the exception of
this purpose. Therefore, parameters are usually rare monogenic forms; e.g., leptin receptor
recorded in questionnaires. The data are quite mutations). Long-term reduction of energy
clear: Active parents have active children. For balance during the treatment phase and nor-
example, in the Framingham Children’s Study, malization during the maintenance phase can
the probability of active play and leisure behav- only be achieved through sustainable behav-
ior in children with two active parents was 5 ioral changes. This requires not only a health-
times higher than in children with inactive par- promoting family environment but also parents
ents (Moore et al. 2003). This observation has or guardians who are able to positively support
also been confirmed in more recent studies. children (and adolescents) with obesity dur-
Families living in an environment with good ing the difficult phase of behavioral change.
access to playgrounds or natural areas (forest, The importance of role modeling in the areas of
meadows) are overall more physically active nutrition and physical activity has already been
than families in less favorable living conditions discussed. In addition, the parenting skills of
(James et al. 2020). parents are another basic prerequisite.
Parents of obese children are not only con-
70.2.1.3 Media Consumption cerned about the health consequences but also,
Promoting physical activity in early develop- and especially, about the social consequences
mental stages is also made more difficult by of obesity. However, they perceive their ability
to influence this as rather limited (Schwimmer d) Positive structure regarding healthy eating
et al. 2003). In therapeutic work with families, and exercise behavior,
the following problem areas can be identified. e) Positive attitude towards sports activities and
fruit consumption.
70.2.2.1 Inconsistent parenting style
In families with unsuccessful therapy attempts The “healthy” clusters were associated with
or renewed weight gain after inpatient weight a higher educational level while the unhealthy
loss, problems in the implementation of rules cluster was associated with a lower educational
and prohibitions are frequently observed. The level. Large longitudinal studies have also
rules can be unrealistic (e.g., “No eating after 6 revealed a relationship between an unfavorable
pm!”) or overwhelm the child’s personal respon- BMI course and family context factors, such as
sibility (e.g., “No sweets from pocket money!”). a lack of everyday structure (Dos Santos et al.
Prohibitions are pronounced but not imple- 2020).
mented in one’s own behavior (e.g., “I need
my cola!”). Rigid rules and prohibitions in this 70.2.2.2 Limited Parenting Ability Due
constellation have either only a very short-term, to Mental Illness
sometimes even opposite effect on the family’s When a parent has a somatic illness there is
eating and/or exercise behavior. In addition, par- no doubt about the need for additional sup-
ents may be insecure in their role, up to a “role port. This is less clear for parents with mental
reversal.” For example, there is an expectation health problems and psychiatric disorders. To
from parents that after inpatient weight loss, our knowledge, there are no data specifically on
the child should introduce a healthy diet in the families with children/adolescents with obesity.
family, as learned in the clinic. In the outpatient Preliminary results of our own studies show an
setting, obesity therapy should also lead to the increased risk for an unfavorable therapy course
child subsequently “learning/knowing what is in cases of maternal depression, anxiety or eat-
healthy.” The basis for family-based treatment ing disorder, as well as addiction (also non-
in these constellations is first and foremost gen- substance, such as gambling) of a parent. The
eral parenting counseling in conjunction with systemic effects of a parent’s psychiatric dis-
realistic goal planning regarding the desired order are particularly serious, as they are often
behavior change. In particular, parents with associated with a loss of emotional stability
negative experiences need a positive expectation and everyday structures. It is quite possible that
of change (e.g., “I can do it!”). Therefore, the the child with obesity is noticeable as an index
first therapeutic agreements must be extremely patient, but in a systemic sense, the (previously
small-scale to allow positive experiences to fol- unrecognized) psychiatric disorder of a parent is
low the positive expectation (e.g., “I managed the cause.
not to buy any more iced tea!” or “Drinking only
water works well!”).
Rodenburg et al. describe five parenting style 70.2.3 Effects of Everyday Structure
clusters that affect both nutrition and physical
activity and either lead to rather unhealthy (a) A long-term positive energy balance is also
or rather health-promoting (b–e) family habits the cause of overweight/obesity in children
(Rodenburg et al. 2013): and adolescents. Energy homeostasis is sig-
nificantly influenced by various circadian-
a) High presence of electronic media and regulated processes. Hunger and satiety, as
unhealthy foods, well as the sleep-wake rhythm, play a major
b) Family rules on nutrition and physical role in maintaining a normal body weight. For
activity, example, children who do not eat breakfast but
c) Low accessibility of unhealthy foods, eat more in the second half of the day have an
unfavorable weight course (Vilela et al. 2019). other psychosocial stress situations also impede
A disturbed circadian rhythm (e.g., due to lack successful obesity treatment in children/adoles-
of sleep and/or nighttime media consumption) cents. Long-term unemployment in the affected
is associated with increased energy intake and, families not only leads to direct financial dif-
as a result, an unfavorable weight course. Both ficulties, but also to a loss of social integration
the endocannabinoid system and the leptin- and daily structure. In families with unemployed
melanocortin signaling pathway potentially play parents, less medical care is also utilized (e.g.,
a role in pathophysiology (Broussard and Van vaccinations and check-ups). This can result in
Cauter 2016). In adolescents with obesity, short relevant health disadvantages. In general, con-
sleep duration leads to less melatonin secretion sidering the psychosocial and family overall situ-
and has a negative impact on mood and health ation is a basic prerequisite for realistic therapy
behavior (Simon et al. 2020). planning, especially in family-based obesity
In addition, there seems to be an evening hun- treatment (Wiegand and Kühnen 2020).
ger phase, followed by low morning appetite,
which is not significantly influenced by eating
or sleeping (Scheer et al. 2013). It is conceivable 70.3.2 Specifics in Families
that these effects are additive and that in chil- with Migration Background
dren/adolescents with obesity, lack of sleep or
an unfavorable sleep-wake rhythm and irregular The cultural influences on family life are very
meals contribute to a disproportionate weight diverse and are shaped on the one hand by origin
gain. Especially for adolescents, the situation on and biography and on the other hand by previ-
school days is particularly difficult, as puberty ous experiences in the host country. Therefore,
development leads to a physiological shift in an individual consideration is always necessary.
spontaneous sleep time to later hours, and a reg- In the following, some aspects of the care of
ular school start at 8 a.m. results in a significant traditionally oriented families from the Muslim
sleep deficit with corresponding negative effects cultural area are presented by way of example
on metabolic regulation (Foster et al. 2013). This (Wiegand and Babitsch 2013):
phenomenon is also referred to as social jetlag
In a meta-analysis of structured physi- Family structure The father, as the male
cal activity programs for children and adoles- head of the family, usually represents the fam-
cents with obesity, energy intake was found ily externally, whereas household manage-
to be reduced despite an increase in physical ment falls within the area of competence of the
activity (Schwartz et al. 2017). The exemplary mothers. Treatment measures must therefore be
studies presented underline the importance of approved by the father, but the concrete imple-
regular meals, active leisure activities, and an mentation should be discussed with the mother.
age-appropriate sleep-wake rhythm for the pre- Occasionally, personal role understanding must
vention and treatment of obesity in children and take a back seat in order to establish a construc-
adolescents. tive level of conversation. For a good start to
the conversation, it is also helpful to familiarize
oneself with the respective greeting rituals (e.g.,
70.3 Problem Areas of Family- handshake yes/no).
Based Approaches
Customs and traditions Meal frequency and
70.3.1 Psychosocial Stress daily structure in many families with a migration
Situations background often still follow the customs of the
country of origin. For example, in many southern
In addition to the already described situation of countries, there is no breakfast as a regular meal,
a psychiatric illness of the parents (Sect. 70.2.2), and many families find it difficult to introduce
it. On the other hand, there is often a joint warm areas based on the general recommendations
family meal in the afternoon or evening. If the (for normal-weight children/adolescents) of the
child already receives a warm meal at school, a respective professional societies has proven suc-
positive energy balance can be the result. cessful. The recommendations were transferred
to a “target value worksheet,” which contains
Values A car and electronic devices can have a very simple recommendations and, in the origi-
high social status if they are in strong contrast to nal version, also includes pictograms for bet-
the standard in the country of origin. Therefore, it ter understanding (Fig. 70.1). Together with the
is sometimes difficult to implement sending chil- patient and family, a self-assessment for prob-
dren to school on foot or removing the television/ lem analysis is carried out using a traffic light
computer from the children’s room. Sports activi- system (Fig. 70.2; see also Ernst and Wiegand
ties are more accepted for boys in traditional 2010). This is then the basis for agreeing on ini-
families than for girls. Advice on active leisure tial behavioral changes.
activities must take into account the experiences Especially for families with many failed
and resources of the families. Especially mothers attempts in the past, a very small-step approach
often cannot ride a bike or swim. Occasionally, is necessary to enable them to experience a posi-
there are special courses that have a lasting effect tive change as a (re-)entry into a successful treat-
on the leisure behavior of families. ment process. Therefore, problem analysis and
realistic assessment of the family’s resources
Hospitality “The commandment of full cup- by a multi-professional team are indispensable
boards” states that a family should always be prerequisites for planning family-based obesity
prepared to receive guests. This includes stock- treatment for children and adolescents (for fur-
ing up on special foods and drinks, such as soft ther information, see Ernst and Wiegand 2010).
drinks in families who do not drink alcohol for In cases of insufficient resources and/or unsus-
religious reasons. This offer can have a thera- tainable basic motivation, a classical obesity
peutically unfavorable effect if, for example, therapy with a behavioral therapeutic approach
there is a control problem with soft drinks. is not meaningful and can even make long-term
The examples mentioned are intended to care more difficult due to further negative expe-
illustrate that treatment planning requires both riences. In these cases, the basic conditions for
knowledge of the cultural specifics of the coun- treatment must be created first, e.g., through
try of origin and the ability to provide culturally social counseling, assistance in parenting (family
sensitive advice. assistance and/or social-pedagogical individual
case assistance), or initiation of psychotherapy
for the parents.
70.3.3 Resource-Oriented Treatment
Strategies  Important In cases of difficult fam-
ily constellations and insufficient
In the practical implementation of obesity ther- resources, obesity treatment in
apy for children and adolescents, the long-term childhood and adolescence is often a
implementation of stable behavioral changes lengthy process that requires multi-
can only be achieved if the multi-professional professional teamwork.
treatment concept takes into account the pre-
vious experiences and the resources of the
family. Especially when unsuccessful therapy Examples of Risk Constellations
attempts have already been made in the past, the • Children with special educational needs
joint development of a therapeutic assignment and/or significant school problems
is necessary. After clarifying the basic moti- • Parents with long-term unemployment
vation, a joint analysis of the weight-relevant and/or severe economic difficulties
DRINKS
Water, unsweetened tea
MOODS + FEELINGS
PORTION SIZE
Resolution of individual conflicts, + FOOD QUANTITY
Promotion 1 child/adolescent portion
emotional well-being
MEAL RHYTHM
LEISURE
Regularly, together,
More active than passive, Recommendations without distraction (no TV)
enough sleep
for children and
teenagers (daily)
FOOD SELECTION
SPORT Little sugar + fat,
Lots of fresh vegetables and
2 - 3 x per week
fruit every day, max.
1-2x per month fast food
EVERYDAY ACTIVITY SNACKING

60 to120 minutes per day SWEET or SALTY
(e.g. 12,000 steps) 1 handful per day
©BABELUGA e.V. Version 07/2018
Fig. 70.1  Target construction sheet
• Parents with addiction problems in Germany currently looks different, although

(substance/non-substance) all those involved are aware of the importance
• Parents with mental health problems or of parent education. Outpatient obesity pro-
psychiatric disorders (even if suspected) grams are not available in many regions (often
• Separated parents with differing parent- due to a lack of cost coverage by health insur-
ing ideas and a lack of a central focus ance), so either no treatment or primarily inpa-
for the child tient treatment is chosen. These mostly remote
facilities can only inadequately implement par-
ent education, so the transfer of initiated behav-
ioral changes into the family’s everyday life
70.4 Conclusion and Implications often fails and rapid weight regain follows. This
psychologically and metabolically extremely
All reviews and meta-analyses on the therapy unfavorable effect could be avoided by accom-
of obesity in children and adolescents over the panying, local parent education and subsequent
past 15 years emphasize the need for a multi- outpatient follow-up care for the child/adoles-
professional treatment and especially the need cent. Such a “treatment chain” is a matter of
for family-based concepts (Sung-Chan et al. course for other chronic diseases, but has not yet
2013; Colquitt et al. 2016; Mead et al. 2017; been established for obesity in children, despite
Al-Khudairy et al. 2017). The treatment reality being essential.
70
Name:
Date:
Drinks
Moods + feelings Portion size
Meal rhythm,
Leisure media,
eating in
hobbies, sleep
between meals
Family-Based Approaches to Treatment
Food selection,
Regular sport
fast food
Wish Confidence Self-assessment
I want to I can Snacking

Everyday activity
do it do it sweet or salty
Current construction site theme: _____________________________________________________________________
Explore & try out: _____________________________________________________________________
_____________________________________________________________________
Weight history
_____________________________________________________________________
©BABELUGA e.V. Version 07/2020
Fig. 70.2  Construction site worksheet. (From Ernst and Wiegand 2010; with kind permission of Huber-Verlag)
533
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Nutrition: the relationship between time-of-day
energy and macronutrient intake and children’s body
Fad Diets
and Commercial 71
Programs
Andreas Fritsche
Contents
71.1 Requirements for a Diet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 537
71.2 Classification of Diets for Weight Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 538
71.3 Evaluation of Diet Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 539
71.4 Individualized Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 540
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 540
Nutritional therapy for obesity aims to achieve • People with obesity should receive in-
weight loss. This is to be achieved by ensuring dividualized dietary recommendations
that energy intake (calorie intake) is lower than that are adapted to therapy goals and
energy expenditure. The diet is a central compo- risk profiles.
nent of obesity therapy. • People with obesity should be offered
nutritional counseling (individual coun-
seling or in groups) as part of their
Nutritional therapy for obesity— medical care.
guidelines • The patient should be comprehensively
In the guidelines of the German Obesity and understandably informed about the
Society from 2014, the following basic as- goals, principles, and practical aspects
pects of nutritional therapy for obesity are of the dietary change.
recommended. It is important to note that • The personal and professional environ-
no special diets are recommended here, ment of the person concerned should be
but rather general advice on individualized included in the nutritional counseling
dietary recommendations is given. and dietary change.
71.1 Requirements for a Diet
A. Fritsche (*) The so-called weight loss diet, with the aim of a
Nutritional Medicine and Preventive Medicine, negative energy balance, should only be applied
Internal Medicine IV, University Clinic of Tüebingen, for a limited time according to the recommenda-
Tüebingen, Germany
tions of professional societies. For sustainable
https://doi.org/10.1007/978-3-662-67662-2_71
538 A. Fritsche
obesity treatment, a permanent change in diet

and lifestyle is necessary. Diets for weight loss
It becomes clear that the same requirements • Mixed diet
should apply to diets for the treatment of obesity • Diets that favor certain food components
as for the testing of drugs. These requirements • High-protein diet
are not met by most (fad) diets. • High-carbohydrate diet
• High-fat diet
• High-fiber diet
Quality features of an obesity diet • Low glycemic index diet
• Efficacy in terms of weight loss should • Food combining
be tested in a clinical study (controlled, • Diets that require a specific daily rhythm
randomized prospective design) • Intermittent fasting
• Efficacy should also be proven in the • “Worldview diet”
long term (follow-up after more than • “Regional” diet
one year) • Formula diet
• Efficacy should also be given in terms • Internet diet
of reducing symptoms of obesity-
related sequelae (e.g., diabetes mellitus,
lipid metabolism disorder, cardiovascu- Examples of mixed diets are the “Brigitte Diet”
lar diseases) and the “Ich-nehme-ab-Programm” (I’m los-
• Side effects (physical and psychologi- ing weight program) of the German Society
cal) should be investigated for Nutrition. High-protein diets include the
• Side effects should be low Hollywood, Mayo, or Sears diets, while high-
• Costs should be appropriate carbohydrate diets include the rice or potato
diet and the 7-day grain or bran cure. The most
famous representative of the high-fat diet is
 Important Requirement: Weight loss the Atkins diet. A diet that includes a low gly-
diets should be subject to the same cemic index is the Glyx diet. Food combining
requirements (clinical trials) as drugs. is promoted by Hay or offered in the “Fit-for-
life program”. Diets that observe a specific
The current guideline for obesity therapy recom- daily rhythm include intermittent fasting, which
mends that patients should be advised on dietary usually involves an 8-hour eating period and
forms that lead to an energy deficit over a suf- a 16-hour fasting period. This also includes
ficient period of time and do not lead to health methods such as dinner canceling or the 5:2
damages. diet (5 days of eating, 2 days of fasting). Diets
that require a specific worldview include the
anthroposophic diet, vegetarianism, the blood
71.2 Classification of Diets type diet, or macrobiotics. In the broadest
for Weight Loss sense, religious fasting and Ramadan nutrition
are also included. Regional diets include the
A multitude of diets and weight loss programs Mediterranean diet or the Eskimo diet. Formula
are offered; their number is overwhelming even diets are offered as “Herbalife” or integrated
for experts. The following classification of dif- into programs such as the “Optifast program”.
ferent diet forms is arbitrary, as most diets Increasingly, diets are also offered on the inter-
include several of the listed aspects. net, with weight loss seekers being supported in
internet forums and email services.
71 Fad Diets and Commercial Programs 539
We deliberately refrain from describing the terms of weight loss. Five studies with a dura-
individual diet forms in more detail here. New tion of 6–12 months on this topic were analyzed
diet trends are constantly being created, which (Nordmann et al. 2006). The initial weight loss
are then explained by nutrition docs and nutri- after 6 months was somewhat stronger in high-
tion experts in various media. Certain character- fat diets (derived from the Atkins diet) without
istics of a diet should arouse skepticism and lead calorie restriction (difference of 3 kg). However,
to the diet not being applied. after one year, the weight loss was comparable
The following statements about a “diet” to the weight loss achieved by low-fat, calorie-
should be treated with caution and the product reduced diets. Furthermore, so-called low-fat
should be discouraged. diets show lower LDL cholesterol levels, while
low-carb diets are associated with higher HDL
cholesterol and lower triglyceride levels.
Negative Signs Another question investigated in several
• High costs for the diet high-quality prospective, randomized controlled
• Money back in case of non-success trials is the effect of diets with a low glyce-
• A quick success is promised (10 kg in 3 mic index or low glycemic load. The glycemic
weeks!) index evaluates a food based on its effect on
• You can continue to eat whatever you blood sugar elevation and normalizes this value
want alongside the diet to the blood sugar increase caused by the same
• Before-and-after success pictures of amount of glucose. The glycemic load is cal-
individuals culated from the product of the glycemic index
• Connection with the name of the and carbohydrate content of the food. High-fiber
“inventor” of the diet (“Professor XY diets, as well as high-fat diets, can be included
Diet”) in these diets. A meta-analysis on this topic was
• Connection with religious and ideologi- conducted by Thomas et al. (2007). Six studies
cal messages with a duration of five weeks to six months were
• No scientific evaluation—mysterious found, which compared a low glycemic index
mechanisms of action diet with a control diet. The meta-analysis con-
cluded that diets with a low glycemic index lead
to greater weight loss than control diets (mean
difference 1.1 kg). In addition to the short study
71.3 Evaluation of Diet Programs durations, the low cumulative number of par-
ticipants of 160 when summarizing all studies is
The efficacy of diet programs should be tested noteworthy and limits the meaningfulness of the
in clinical studies with regard to weight loss, meta-analysis.
effects on metabolism, and side effects. There Commercial weight loss programs are some-
are surprisingly few studies on this topic that times associated with considerable costs for the
meet the requirements of evidence-based participant. A review has dealt with examin-
medicine. ing the components, costs, and efficacy of such
A recently published study of meta-analyses commercial programs and also organized self-
and clinical trials found that low-calorie diets help programs in the USA. The works of Tsai
compared to higher-calorie diets result in short- and Wadden (2005) and an update by Gudzune
term weight loss over less than half a year. et al. (2015) also include programs offered in
However, the benefit decreased in the long term Germany, such as “Weight Watchers” or the
(Chao et al. 2021). “Optifast” program. The overview included 45
A meta-analysis examined the question of studies. A disadvantage of some studies is that
whether a high-fat diet (low-carb) is superior they often represent the so-called best-case sce-
to a low-fat, high-carbohydrate diet (low-fat) in nario, as only people who successfully complete
540 A. Fritsche
the program are evaluated. For example, weight such an approach. The research field of nutri-
losses of 15–25% of the initial body weight tional genetics (“nutrigenomics”) is develop-
are achieved with the “Optifast” program. The ing rapidly, and in the future, diet forms could
“Optifast” program, in particular, is associ- be available that are tailored to the individual
ated with high costs. In contrast, the “Weight for optimal weight loss. So far, however, mostly
Watchers” program achieves a weight loss of pilot studies or “proof-of -concept” studies have
2.6% of the initial body weight after one year in been published on this topic. Until there is more
meta-analyses (Gudzune et al. 2015). Good con- evidence, individual nutritional counseling for
trolled studies on commercial programs are rare. weight loss is preferable, taking into account the
possibilities, wishes, and needs of the individual
 Important It is astonishing how few with overweight or obesity. Long-term motiva-
high-quality studies exist on weight tion through self-help groups can support the
loss diets. Most diets are completely effectiveness of nutritional counseling.
untested and cannot be scientifically
evaluated. Commercial programs are
also insufficiently tested. Conclusion
Fad diets and commercial programs for the
In conclusion, the recommendations of the S3 purpose of weight loss are numerous. In con-
guideline of the German Obesity Society from trast to their strong presence in the media
2014 state that the composition of a weight loss and frequent use by the affected individual
diet in terms of the main nutrients fat, carbohy- with overweight/obesity, the efficacy and side
drates, and protein is of secondary importance. effects of these diets are inadequately stud-
It does not matter whether a “low-fat” or “low- ied, with few exceptions.
carb” diet or a protein-focused diet is chosen
for weight loss: ultimately, the achieved energy
deficit (recommendation 500 kcal/day) counts. References
Much more important is that the diet suits the
person. People who want to lose weight should Chao AM, Quigley KM, Wadden TA (2021) Dietary
interventions for obesity: clinical and mechanistic
no longer be forced into strict schemes. findings. J Clin Invest 131:e140065
Gudzune KA, Doshi RS, Mehta AK et al (2015) Efficacy
of commercial weight-loss programs: an updated sys-
71.4 Individualized Nutrition tematic review. Ann Intern Med 162:501–512
Nordmann AJ, Nordmann A, Briel M et al (2006) Effects
of low-carbohydrate vs low-fat diets on weight loss
The optimal diet for a person is an individual and cardiovascular risk factors: a meta-analysis
diet that maintains or restores them to a balanced of randomized controlled trials. Arch Intern Med
and normal weight and optimal health. Such a 166:285–293
S3 Leitlinie Adipositas – Prävention und Therapie
diet takes into account individual genetic condi- (2014). http://www.awmf.org/leitlinien/detail/ll/050-
tions and individual environmental resources. 001.html. Accessed 30 Jan 2021
Furthermore, lifestyle must be changed; Thomas DE, Elliott EJ, Baur L (2007) Low glycae-
an isolated change in diet usually remains mic index or low glycaemic load diets for over-
weight and obesity. Cochrane Database Syst Rev
unsuccessful. 18(3):CD005105
Treating all people with overweight or obe- Tsai AG, Wadden TA (2005) Systematic review: an eval-
sity with a specific diet form is not appropriate. uation of major commercial weight loss programs in
“One size fits all” inevitably fails. Individual the United States. Ann Intern Med 142:56–66
genetic conditions are not taken into account in
Nutritional Therapy for Obesity
72
Hans Hauner
Contents
72.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 541
72.2 Basic considerations for nutrition therapy . . . . . . . . . . . . . . . . . . . . . . . . . . 542
72.3 Possibilities of Nutritional Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 543
72.4 Very Low-Calorie Diet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 545
72.5 Long-Term Weight Stabilization and Relapse Prevention . . . . . . . . . . . . . . 547
72.6 Nutritional Therapy in the German Healthcare System . . . . . . . . . . . . . . . 547
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 547
72.1 Introduction needs of the individual. Therefore, only through

conscious and stable changes in eating behavior
Weight gain and obesity are the result of a long- can a reduction in energy intake be achieved.
term positive energy balance. Among a variety In addition, the body has effective adaptation
of influencing factors, including genetic pre- mechanisms that counteract weight loss and
disposition, excessive nutrition and decreased aim to stabilize body weight (Holzapfel and
physical activity are the two decisive determi- Hauner 2011). This makes it understandable that
nants. Of the conservative therapy components, nutrition therapy is a major challenge and suc-
an energy-reduced mixed diet is considered cess depends crucially on the recommendations
the most effective measure for reducing body being feasible for and accepted by the patient in
weight. If it is possible to successfully reduce everyday life. This requires a therapy concept
energy intake, weight loss can be achieved in a tailored to individual needs. With a rigid plan
simple and safe manner. – as was often the case in the past – success is
A long-term change in eating habits is dif- hardly to be expected.
ficult, as it involves early learned and long- Despite these problems, there is extensive
practiced behaviors that also fulfill the hedonic experience based on a large number of stud-
ies on how nutrition therapy can be designed
in terms of content to prevent or treat obesity.
H. Hauner (*) The most important concepts will be discussed
Institute of Nutritional Medicine, Else Kröner in more detail below. In this context, it should
Fresenius Center for Nutritional Medicine, also be noted that most people who want to
School of Medicine and Health, Technical University
lose weight initially search for diets themselves
of Munich, Munich, Germany
e-mail: [email protected] and usually aim for rapid weight loss, not least
https://doi.org/10.1007/978-3-662-67662-2_72
542 H. Hauner
due to the very limited range of serious therapy the trends in the eating habits of the population,
offers available. which nowadays significantly influence the risk
Research findings on the effects and risks of developing obesity. These are increasingly
of the various forms of nutrition therapy for characterized by terms such as energy density,
people with obesity have increased signifi- portion size, and snacking. These aspects are of
cantly in recent years. This has also led to the high practical relevance and must be included in
evidence-based treatment corridor becoming nutritional counseling. These aspects will there-
wider. Until the turn of the century, the dogma fore be briefly discussed in the following.
of a fat-reduced diet as the most effective die-
tary intervention for lowering body weight
was dominating. There were hardly any data Trends in nutritional behavior that pro-
available for other concepts, and the personal mote weight gain
needs and wishes of the patients received little • High energy density of modern foods
attention. • Inappropriate portion sizes
It remains unchanged that for the vast major- • Constant availability of “convenience”
ity of people with obesity, the combination of and fast food
dietary change, increased physical activity, and • Growing range of fast food options
behavior modification is the most sensible inter- (fast food restaurants, bakeries, butcher
vention. In a recently published meta-analysis, shops, pizza delivery services, snack
this combination proved to be significantly more stands, etc.)
effective than nutrition therapy alone. This chap- • Continuing trend towards “eating out”
ter focuses on the various options for nutrition and take-away/food delivery
therapy for obesity, based on randomized con- • Growing range of energy-rich beverages
trolled trials.
The term energy density refers to the energy con-

72.2 Basic considerations tent of foods and dishes, relative to the amount
for nutrition therapy of food. In the context of obesity, it is significant
that the consumption of foods and dishes with
The goal of nutrition therapy is the long-term high energy density has increased considerably
reduction of energy intake in order to achieve a in recent decades. The energy density of many
negative energy balance and permanently lower modern foods and fast food meals is 200–300
body weight. It should be noted that any weight kcal per 100 g of solid food, which is about twice
loss also leads to a proportional loss of fat-free as high as traditional, mostly plant-based dishes.
body mass (lean mass). With a weight loss of Since stomach filling and stretching generate
10 kg, in addition to the desired reduction in fat important satiety signals, more calories are usu-
mass by about 7 kg, there is a reduction in fat- ally consumed when eating energy-dense foods
free body mass by about 3 kg. In this case, the before food intake is terminated by such satiety
basal metabolic rate decreases by up to 550 kcal/ signals. It is suspected that the human gastro-
day (Leibel et al. 1995). This means that weight intestinal regulatory system cannot adequately
loss can only be maintained in the long term with respond to the high energy density of modern
appropriate energy restriction. If the previous food, resulting in “passive overconsumption”
diet and energy intake are resumed, body weight with the consequence of weight gain and obesity.
will inevitably increase again. This phenomenon The energy density of foods and dishes is closely
is called the “yo-yo” effect and reflects the physi- associated with fat intake and total energy intake
ological adaptation to the energy balance. (Prentice and Jebb 2003).
When considering and evaluating therapy In recent decades, there has been a continu-
options, it is extremely important to be aware of ous increase in portion sizes, especially for fast
72 Nutritional Therapy for Obesity 543
food products, including sugary beverages. The

pricing in retail also contributes to the fact that Evidence-based nutritional medical
more cost-effective large packages are preferred. concepts
It has been repeatedly shown that the effec- • Fat reduction alone
tive energy intake increases with the portion • Energy-reduced mixed diet (energy def-
size and thus the risk of weight gain increases. icit 500–600 kcal/day)
Controlling portion size accordingly leads to a • Low-carbohydrate diet forms
lower energy intake (Rolls et al. 2006). • Significantly energy-reduced diet forms
Another modern phenomenon is described (energy intake of approx. 800 kcal/day)
by the term “snacking”. Food offers are now • Meal replacement strategy with formula
available almost everywhere and at any time products
of the day (“toxic food environment”), so peo-
ple are constantly tempted to consume mostly
energy-dense “convenience products”, making 72.3.1 Fat Reduction Alone
it difficult not only to maintain a balanced but
also an energetically appropriate diet. A recent Older studies have convincingly shown that
American analysis of eating habits found that even with sole fat limitation, a moderate weight
the further increase in energy intake between loss can be expected. With unchanged intake of
1994 and 2006 was mainly due to the increase in carbohydrates and protein, a reduction of daily
eating occasions, while energy density and por- fat intake to about 50-80 g leads to a decrease
tion size had not changed significantly during in energy intake by 200–500 kcal/day. This
this period (Duffey and Popkin 2011). concept has the advantage that it is didactically
These ongoing changes in the food sup- easy to explain and only requires attention to
ply and in the eating behavior of the popula- the amount of fat. A meta-analysis showed an
tion must therefore be taken into account in the average weight loss of 3.2 kg, but the weight
nutritional therapy of obesity. In addition, the loss can be significantly higher with a high BMI
wide range of food and dishes available in retail (Astrup et al. 2000).
and gastronomy leads to a growing heterogene-
ity in individual nutritional behavior. “Eating 72.3.1.1 Moderately Energy-Reduced
out” or take-away/food delivery is also becom- Mixed Diets
ing increasingly important, as many people no The fat-reduced mixed diet with an energy
longer want to prepare their meals themselves deficit of 500–600 kcal/day remains the stand-
and instead make use of the large selection of ard recommendation in most guidelines (SIGN
mostly energy-rich “convenience” and “fast 2010; NICE 2014; DAG 2014). The intake of
food” products. all nutrients is moderately limited. The most
important single component is the reduction of
fat consumption, so it is primarily a fat-reduced
72.3 Possibilities of Nutritional diet. Mathematically, this corresponds to an
Therapy energy saving of about 3500 kcal/week and thus
an average weight loss of about 500 g/week.
In the following, various concepts for nutritional Over a year, a weight loss of an average of 5–6
therapy will be presented, for which there are kg can be expected. This diet has the advantage
good scientific data today. The concern is always that it is practically side effect-free and safe. It
with which therapy is medically appropriate in does not require a large amount of supervision
the individual case and best meets the possibili- and can be recommended as a long-term nutri-
ties and needs of the person concerned. tion concept.
544 H. Hauner
Evaluation of Weight Loss Programs for extreme forms are discouraged due to various
Obesity Weight loss in a program is usually risks (Mack and Hauner 2007). A sufficient
given as the average weight loss of all partici- intake of dietary fiber, especially from vegeta-
pants. In the evaluation, it is also required that bles, should be specifically targeted, and exces-
dropouts be taken into account in the presentation sive intake of saturated fats should be avoided,
of the results, either within the framework of an which is very difficult under German dietary
LCOF (“Last Observation Carried Forward”) or habits.
a BOCF (“Basal Observation Carried Forward”)
analysis, which often makes the average results
look quite modest with a high dropout rate. 72.3.3 Protein-Rich Diets
However, this overlooks the fact that partici-
pants with good compliance (about one third) Particularly noteworthy in connection with low-
lose significantly more weight on average and carb diets is the importance of increasing the
maintain this success better beyond the inter- protein content. A meta-analysis of intervention
vention period (Holzapfel et al. 2013), while studies concluded that protein-rich diets (20–
participants with poor compliance (also about 30% of energy intake) on average allow for
one third) usually do not reduce their body slightly greater weight loss than diets with nor-
weight at all. For this reason, studies often report mal protein amounts (approx. 15% of energy
the proportion of participants with more than 5% intake) (Krieger et al. 2006). This is attributed
or more than 10% weight loss compared to their to the stronger satiating effect of a protein-rich
initial weight. Nutritional therapies are consid- diet. However, this diet also has certain disadvan-
ered successful if more than 50% of participants tages, such as an increase in urea and uric acid,
achieve a weight loss >5% or more than 20% of an increased risk of kidney stones, and generally
participants achieve a weight loss of more than higher kidney stress (Mack and Hauner 2007).
10% over a one-year period (Hauner et al. 2000). Recent cohort studies also suggest that high
consumption of animal protein increases the
risk of type 2 diabetes (De Koning et al. 2011)
72.3.2 Low-Carbohydrate Diets and—possibly due to the increase in LDL cho-
lesterol—cardiovascular diseases (Noto et al.
For 20 years, low-carbohydrate and fat- or pro- 2013).
tein-liberal diet forms(“low-carb”) have been
heavily promoted. The initial reduction in car-
bohydrate intake leads to a substantial energy 72.3.4 Significance of Macronutrient
deficit and thus rapid weight loss. This deficit Composition
is only partially compensated by the allowed
higher consumption of fat and protein, so that a In recent years, several major studies have been
considerable energy deficit remains. Therefore, conducted on the extent to which the macronu-
in most comparative studies, initially, a greater trient composition (carbohydrates, fats, proteins)
weight loss is observed than with conventional of different diets influences weight loss. These
fat-reduced diets. However, by one year, a con- studies unanimously showed that ultimately, the
vergence of weight loss is observed (Mack and energy deficit is crucial and determines weight
Hauner 2007; Johnston et al. 2014). loss. Under hypocaloric diets with different
The term “low-carbohydrate diet” is not yet macronutrient compositions, no relevant differ-
clearly defined, so carbohydrate intake varies ences were found regarding the improvement of
between 20 g per day (in the Atkins diet) and risk factors and the sensation of hunger and sati-
40% energy depending on the concept. While ety. However, weight loss was closely associated
moderate carbohydrate restriction is justifiable, with therapy adherence (Sacks et al. 2009).
These findings make it clear that ultimately, industrially produced, defined nutrient powders,
it always depends on the energy balance. At mostly based on whey. A daily ration with an
the same time, in practice, this means that indi- energy value of usually 800 kcal is provided.
vidual preferences for foods and dishes can be These products contain defined amounts of pro-
taken into account to achieve this energy deficit. tein (“essential protein requirement” of 40–50
By skillful and conscious food selection, lower- g/day), essential fatty acids, carbohydrates,
energy preparation, and increasing the propor- vitamins, and minerals to ensure the minimum
tion of plant-based foods, an energy saving requirement of critical nutrients. In Germany,
of 500–600 kcal/day can be achieved without numerous formula products are distributed
restricting the amount of food. Competent and through pharmacies, supermarkets, and direct
flexible nutritional counseling is required, which sales. These are now used either as part of a
takes into account the patient’s eating habits. meal replacement strategy or a time-limited,
The corridor for the composition of macronu- very low-calorie diet (“formula diet”).
trients is thus relatively large, and a tailor-made
therapy according to the wishes of the affected
person is usually quite feasible. 72.4.1 Meal replacement strategy
Initially, two main meals are replaced by a for-

Principles of Moderately Energy- mula product, and the third, “normal” main meal
Reduced Nutrition Therapy should be balanced and not exceed an energy
• Nutrition information and education, content of 500–600 kcal. After achieving the
including nutrient tables/apps desired weight loss of about 10 kg after 6–12
• Careful planning of buying foods and weeks, only one main meal is replaced by a for-
restaurant visits mula product to maintain the new weight. The
• Reduction of energy intake by 500–600 patients decide for themselves which main meal
kcal/day is replaced and thus manage their own weight.
• Less fat-rich foods and low-fat prepara- With this strategy, a stabile weight loss can also
tion methods be achieved in the long term. In a meta-analysis,
• Plenty of vegetables, salads, fruits, weight loss under meal replacement therapy was
whole grain products even slightly greater compared to usual moder-
• Higher protein intake if desired and ately energy-reduced cost diets (Astbury et al.
with intact kidney function 2019).
• Exclusively calorie-free beverages (low-
caloric sweeteners if desired)
• Distribution over 2–3 meals/day 72.4.2 Very low-calorie diets
• Avoid snacks as much as possible
• Prepare food as much as possible and With formula products, an extreme energy defi-
reduce “fast food” cit can be ensured for a limited time—usually
4–12 weeks—while simultaneously ensuring
the intake of essential nutrients to achieve rapid
and greater weight success. With a daily energy
72.4 Very Low-Calorie Diet intake of 800 kcal, it is important to ensure an
adequate amount of fluid of about 2.5–3 liters/
If a rapid and larger weight loss is desirable day. The expected weight loss is in the range of
for medical reasons, very low-calorie diets can 1.5–2.5 kg/week.
also be used for a limited time, which allow a This diet form is popular among many diet-
drastic energy deficit. For this purpose, “for- ers because of the rapid weight loss and is espe-
mula diet” products are usually used, which are cially suitable for individuals with a BMI of
546 H. Hauner
≥35 kg/m2. The concept is also easy to imple- of weight loss or changes in cardiometabolic
ment because it completely deviates from parameters (Rynders et al. 2019).
the usual eating habits and, as a result of the Thus, intermittent fasting can also be consid-
high production of ketone bodies usually leads ered an evidence-based option for weight loss.
to a rapid dampening of the feeling of hunger. The disadvantage is that these are restrictive
However, this drastic calorie reduction is not concepts and experiences over longer periods
without risk and requires close medical super- are lacking.
vision, especially for patients with comorbidi-
ties. Side effects such as dizziness due to a drop
in blood pressure, nervousness, concentration 72.4.4 Practical Aspects
problems, freezing, and constipation are com-
mon. Formula diets should not be used for preg- The heterogeneity in the eating behavior of
nant and breastfeeding women, children and patients with obesity requires a problem-ori-
adolescents, very elderly people, individuals ented, patient-centered nutritional counseling
with a BMI <30 kg/m2, and those with severe and—depending on the individual case—addi-
acute or severe chronic diseases (Wadden et al. tional support from behavioral therapists. This
1990). is especially true for patients with indications of
Formula diets should always be combined a binge-eating syndrome (Chap. 5). Restrictive
with increased physical activity, especially guidelines, as practiced in conventional nutri-
to reduce the loss of fat-free body mass. It is tional counseling for a long time, are no longer
essential to practice a new eating behavior with justifiable in view of the broad corridor of
normal food and reduced energy content after secured nutritional medical treatment options.
completing the formula diet. Nevertheless, a cer- This gives the therapist and patient greater scope
tain increase in body weight cannot be avoided for action and thus better chances for long-term
in the following months even under optimal con- therapy success, not least because the eating
ditions. Depending on the situation, a formula habits and preferences of the patients can be
diet can be repeated for a defined period. taken into account more strongly.
In view of the rapidly changing eating hab-
its in the population with a growing proportia
72.4.3 Intermittent Fasting of always available “convenience” foods and a
strong trend towards “eating out”, take-away or
In recent years, various forms of intermittent meal delivery, every counseling session should
fasting for weight loss have become popular also aim to show the patient attractive alterna-
and scientifically studied. The two most com- tives that meet their taste preferences and ulti-
mon forms of intermittent fasting are the 2:5 mately their lifestyle and are useful for weight
fasting with 2 fasting days per week with <25% management. Suitable nutrient tables or apps for
of the usual energy intake and 5 days with iso- smartphones can provide valuable support.
caloric nutrition, and the concept of “alternate- Simple rules, such as appropriate portion
day” fasting, in which fasting days with <25% sizes, no snacks between main meals, general
of the usual energy amount and days with any avoidance of sugar-sweetened beverages, and
energy intake alternate consecutively. lower-energy preparation of meals, can make
Another form is time-restricted eating, in significant contributions to maintaining or reduc-
which the time for daily energy intake is usu- ing body weight. By skillfully selecting primar-
ally limited to 8 hours and fasting occurs for the ily lower-fat foods and increasing fiber intake,
remaining 16 hours. Comparative studies with an energy saving of 500–600 kcal/day can be
continuous energy restriction exist for these fast- achieved without restricting food quantities and
ing types. No differences were found in terms thus ensuring good satiety (Sect. 72.3.4).
72.5 Long-Term Weight weight loss resort to questionable and untrust-

Stabilization and Relapse worthy offers outside the healthcare system.
Prevention
The long-term results of any form of dietary References

obesity therapy depend crucially on the long-
term care concept (Chap. 69). Since energy Astbury NM, Piernas C, Hartmann-Boyce J et al (2019)
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Treatment of Obesity—
Sports and Physical 73
Activity
Petra Platen
Contents
73.1 Effects of Sports and Physical Activity in Adults with Obesity . . . . . . . . . . 550
73.2 Gender-Specific Aspects of Sports and Physical Activity in Obesity . . . . . . 552
73.3 Effects of Sports and Physical Activity in Children with Obesity . . . . . . . . 552
73.4 General Recommendations for Physical Activity and Health . . . . . . . . . . . 553
73.5 Concrete Recommendations for Physical Activity . . . . . . . . . . . . . . . . . . . . 554
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 557
Human evolution has always been accompanied a positive energy balance, inevitably leading to
by a physically active lifestyle and a diet consis- obesity if persistently maintained. The extent
ting mainly of vegetables and wild fruits, with to which a reduction in daily physical activities
occasional meat consumption. Since our genes or an increase in daily calorie intake each con-
have not changed significantly in the last 50,000 tribute to the currently rapidly increasing obe-
years, many of today’s chronic diseases, inclu- sity prevalence is not clearly distinguishable.
ding obesity, can be explained by the maladap- However, recent studies clearly show that both
tation of our genetic makeup, adapted to hunting aspects play a significant role.
and gathering, to our current lifestyle characteri-
zed by inactivity and overnutrition.  Important A main reason for obesity
The lifestyle in modern industrialized nations is the contradiction between human
is characterized on the one hand by low calorie genetic makeup on the one hand and
expenditure due to low physical activity, and on today’s lifestyle (inactivity and over-
the other hand by the intake of an inexpensive, nutrition) on the other hand.
highly calorie-dense diet, which often results in
In these contexts, the consideration is that the
primary therapeutic approach to reducing obe-
sity must be to achieve a negative energy ba-
P. Platen (*) lance. This can be achieved in principle either
Department of Sports Medicine und Sports Nutrition, by reducing calorie intake through diet or by in-
Ruhr-University Bochum, Bochum, Germany creasing calorie expenditure through physical
activities, or a combination of both measures.
https://doi.org/10.1007/978-3-662-67662-2_73
550 P. Platen
73.1 Effects of Sports and Physical was achieved by increasing calorie expenditure
Activity in Adults with Obesity by approximately 700 kcal/day while maintai-
ning the same diet. This calorie expenditure was
73.1.1 Effects on Body Weight, achieved with about one hour of intense, super-
BMI, and Body Fat vised physical activity per day.
Percentage The extent of achievable effects through phy-
sical training also depends on genetic factors.
There is strong evidence from epidemiological There are probably “responders” and “non-re-
studies that physical activity—at least in the sponders” here as well. In a large twin training
general population—either alone or in combi- study, the variance for training effects on body
nation with calorie-reduced diets contribute to weight between twin pairs was 7 times higher
a reduction in body weight and BMI. However, than within the pairs.
these measurements are only indirect and not al- In the long term, body weight will only sta-
ways sufficiently accurate indicators of body fat bilize at the lower level achieved after a training
percentage. For example, trained athletes with intervention program if such a training or acti-
a large muscle mass may have body weight and vity program is continuously maintained.
BMI values that are classified as obese, even
though their body fat percentage is very low. Ac-  Important Physical activity must be
curate measurements of body fat percentage are integrated into daily life as a lifestyle
not practically feasible in large epidemiological change.
studies, so assessments are limited to measu-
ring or inquiring about body height and weight. 73.1.1.2 Reduction of Visceral Fat Mass
Since the reduction in body weight under phy- From a health perspective, visceral body fat is
sical training can be achieved predominantly particularly detrimental. Therefore, it is espe-
through a reduction in body fat percentage and cially important in the therapy of obesity to
less through an (undesirable) decrease in fat-free achieve a reduction of this metabolically ac-
(muscle) mass, as is the case with diet alone, ef- tive tissue through lifestyle changes and/or other
fects of physical activity on fat mass are likely measures. In fact, body weight and visceral fat
underestimated compared to pure diet effects. content can be reduced, particularly through the
combination of aerobic exercise with calorie re-
duction in the diet. Aerobic exercise alone can
73.1.1.1 Combination of Diet reduce visceral fat mass, even if no decrease
and Physical Activity in body weight can be demonstrated. No posi-
The greatest reduction in body weight can be tive effects on visceral fat mass can be achie-
achieved through a combination of calorie-re- ved through strength training alone or in combi-
duced diet and increased physical activity, as a nation with endurance training.
recent summary of various reviews has shown.
A sports or activity program alone without fur-
 Important A positive effect on visce-
ther dietary measures leads on average to a re-
ral body fat mass in individuals with
duction in body weight and/or BMI of “only”
obesity is achieved primarily through
about 2–3% in non-closely monitored inter-
the aerobic component of sports the-
vention programs. However, closely monito-
rapy programs. Strength training
red intervention programs can achieve simi-
alone has no or only minor effects
lar weight loss to diet interventions alone. In a
in this context, even when combined
well-controlled study, an average reduction in
with endurance training.
body weight of about 7.5 kg in three months
73 Treatment of Obesity—Sports and Physical Activity 551
73.1.2 Effects on Cardiovascular much higher overall risk of death than active in-
and Metabolic Performance dividuals with overweight. In this study, the risk
of death for active individuals with overweight
 Important Many studies have shown was even lower than that of inactive non-over-
that regular physical activity and weight individuals. The lowest overall risk was
sports lead to an increase in overall found in active, non-overweight men. The “obe-
physical performance. This also ap- sity paradox,” which describes a lower mortality
plies to obese individuals. rate for more obese individuals compared to less
obese individuals in various diseases such as
Performance improvements can also occur when coronary heart disease, can only be detected in
the training program is not simultaneously as- people with low physical fitness according to the
sociated with weight loss. In a differentiated latest findings. This phenomenon does not occur
view, training effects can also be achieved for in individuals with higher fitness levels.
individuals with obesity in various components The more physically active a person is, the
of fitness, such as cardiovascular performance, lower the risk of chronic diseases such as diabe-
muscle strength, and metabolism, with an im- tes mellitus and hyperinsulinemia, arteriosclero-
provement in so-called “aerobic performance” tic cardiovascular diseases, cancer, lipid meta-
having the highest health relevance. Improved bolism disorders, and hypertension. Sports and
performance is also associated with an increase physical activity can positively influence almost
in quality of life through positive influences on all cardiovascular risk factors even without si-
general mood, self-confidence, and coping with multaneous reduction of body weight. It is par-
activities of daily living. ticularly noteworthy that people with higher ae-
In cross-sectional studies, aerobic per- robic fitness have a lower abdominal fat content,
formance is closely associated with the current which is considered particularly metabolically
level of physical activity, although other factors unfavorable, at the same BMI level.
such as age, gender, health status, and genetic
disposition play a role.  Important Regular and sufficiently
Aerobic performance can be assessed as an extensive physical training changes
objectively measurable parameter, for example, the metabolism of people with obe-
in the context of bicycle ergometer stress tests. It sity from a metabolically unhealthy
is a more accurate parameter than the sole sub- state to a metabolically healthy state,
jective assessment of fitness and activity levels regardless of changes in body weight
when associations between a physically inactive or body fat mass.
lifestyle and negative health effects are to be de-
monstrated. The genetic makeup of modern humans, which
developed due to the living conditions of hun-
ter-gatherers in the Stone Age and long before,
73.1.3 Effects onCardiovascular favors the intramuscular storage of triglycerides
and Metabolic Risk Factors and transient insulin resistance with simulta-
and Overall Mortality neously increased plasma fat levels during times
of food shortage. This metabolic situation ensu-
Both physical inactivity and obesity are wide- red both the supply of vital glucose-dependent
spread and each, both individually and inde- organs such as the brain with sufficient blood
pendently of each other, are associated with glucose and the energetic supply of the muscles
an increased risk of chronic diseases, impai- with fatty acids as fuel for physically demanding
red functionality, and mortality. In a large longi- hunting during periods of food shortage. This
tudinal study of men, it was shown that physi- physiological and transient insulin resistance
cally inactive individuals with overweight have a can be normalized by physical activity and the
552 P. Platen
resulting decrease in intramuscular triglycerides 73.3 Effects of Sports and Physical

as well as food intake (with normal body weight Activity in Children
or body fat percentage). In today’s individu- with Obesity
als with obesity, chronically elevated blood fat
levels also lead to an increase in intramuscular Physical activity is a complex multidimensional
triglycerides and insulin resistance, which per- behavior that is particularly difficult to quantify
sists if an adequate level of physical activity is in children and adolescents. The methodologi-
not achieved. These relationships underline the cal problems of recording are mainly in children
importance of endurance exercises with a suffi- under 10 years of age because their everyday
cient level of fatty acid oxidation to reduce intra- life often consists of spontaneous, unstructu-
muscular triglycerides in the therapy of obesity red activities. Young children are not able to ac-
and the importance of sufficient body fat mass curately record everyday activities or assign ac-
reduction to lower blood lipid levels and thus tivities to specific time periods. The data from
subsequently reduce intramuscular triglyceride questionnaires on physical activity are therefore
storage. Both measures thus have a favorable ef- hardly usable. It is therefore not surprising that
fect on a diabetic or prediabetic metabolic situ- there are only a few studies for this age group
ation and lead to a risk reduction of cardiova- that have investigated the relationship between
scular diseases. In the long term, a high level of measurements of physical activity and body fat
physical fitness seems to be more important for percentage.
health in the presence of obesity than a sole re- Studies that have objective measurement met-
duction in body weight. hods of activity levels are mostly designed as
cross-sectional studies and compare the acti-
 Important From a health perspective, vity levels of children with normal weight and
both a physically active lifestyle and children with overweight. However, a causal
a body weight or body fat percentage relationship between physical activity and exis-
within the normal range should be ting obesity cannot be reliably established. The
aimed for, according to current know- few prospective studies conducted focus on pre-
ledge. pubertal children and show inconsistent relation-
ships between the extent of physical activity and
the development of overweight.
73.2 Gender-Specific Aspects It is certain that watching television, play-
of Sports and Physical Activity ing video and computer games, and the associa-
in Obesity ted absolute physical inactivity are the dominant
leisure activities for today’s children and adole-
For at least a century, it has been known that sex scents. In addition to television consumption and
hormones influence metabolism. Nevertheless, inactivity, however, other confounding factors,
there is little detailed, reliable knowledge about such as eating energy-rich snacks in front of the
the specific effects of the menstrual cycle, hor- television and receiving advertising messages
monal contraception, and menopause on many for energy-rich foods, must be added to promote
aspects of energy expenditure and substrate uti- the development of obesity in children and ado-
lization in the context of the development and lescents.
treatment of obesity. One study suggests that a Meta-analyses of the success of diet and
diet/exercise intervention tailored to the pha- exercise intervention programs in the treat-
ses of the menstrual cycle may lead to potenti- ment of obesity in children and adolescents have
ally higher weight loss compared to a non-cycle- shown that the highest effects were achieved
phase-based intervention. through combination programs, consisting of
sports and diet interventions. However, a reduc- a week that lead to an increase or maintenance
tion in body fat percentage can also be achieved of muscle strength and endurance. Specifically,
through exercise intervention alone. 8–10 exercises that include all major muscle
groups should be performed on two non-conse-
 Important The available facts are suf- cutive days of the week. To achieve optimal ef-
ficient to recommend movement, phy- fects, a resistance (weight) should be chosen that
sical activity, and sports, especially in allows for just 8–12 repetitions of each exercise
terms of long-term, long-lasting suc- execution until fatigue. Such muscle-building
cess, as a necessary part of therapy activities include, for example, weight training
and prevention of obesity in child- programs, exercise programs with additional
hood and adolescence. weight load, stair climbing, and similar activities
with high resistance and the use of large muscle
groups.
73.4 General Recommendations Those who regularly practice more activi-
for Physical Activity and Health ties than the described endurance and strength
components in their daily lives benefit additio-
In their basic principles, the general recommen- nally from positive health effects and a further
dations for people with overweight regarding increase in performance.
physical activity do not differ from the general
recommendations for healthy, normal-weight
people. Therefore, these recommendations are 73.4.2 Recommendations for Older
described below. Adults and Adults with Chronic
Illness
73.4.1 Recommendations for Adults For healthy older adults aged 65 and over and
between the Ages of 18 and 65 for adults aged between 50 and 65 years with
chronic diseases and functional limitations af-
All healthy adult individuals between the ages fecting physical mobility, general performance,
of 18 and 65 should engage in at least 30 min or resilience, the following recommendations
of moderate-intensity aerobic exercise or 20 min apply regarding aerobic activities and strength
of higher-intensity aerobic exercise on five days training.
per week. A combination of moderate and hig- To maintain or optimize health, older adults
her-intensity aerobic exercises is also possible. should perform 30 min of moderate exercise 5
For example, this can be achieved by brisk times a week or 20 min of more intense exer-
walking (moderate) for 30 min twice a week, cise 3 times a week. Combinations of these ac-
combined with 20 min of jogging (higher in- tivities are also possible. The intensity is de-
tensity) three times a week. Moderate exer- termined based on the individual’s current per-
cise is characterized by a noticeable increase in formance level. Moderate intensity on a scale of
heart rate. Such exercises can also be accumula- 0 (absolute rest) to 10 (absolute exhaustion) is
ted from various continuous 10-min phases. Hig- about 5–6 and leads to a measurable increase in
her-intensity aerobic exercises, in the sense inten- breathing and heart rate. More intense exercise
ded here, lead to noticeably faster breathing and is in the range of 7–8 and leads to pronounced
a very clear increase in pulse. These aerobic acti- increases in heart rate and breathing. These exer-
vities should be performed in addition to low-in- cises should be performed in addition to other
tensity or shorter than 10-min daily life activities. moderate or somewhat more intense activities of
In order to maintain or achieve good health daily life lasting less than 10 min.
and independence, adults should, in addition In addition to these aerobic exercises, older
to aerobic exercises, perform activities twice adults should perform exercises that maintain
554 P. Platen
or even improve muscle strength and endurance Children need an environment that accommo-
at least two days a week. The same recommen- dates their natural urge to move and brings joy.
dations apply as for younger adults, except that Restriction and avoidance of movement oppor-
the resistance should be somewhat lower, all- tunities inevitably lead to failures due to poorly
owing for about 12–15 repetitions of each exer- developed motor skills, even more so in chil-
cise until fatigue. dren with overweight. Resignation or aggressive
Older adults also benefit from additional phy- defense sets in. The avoidance attitude causes a
sical activities through a further increase in per- permanent change in the energy balance and fur-
formance and additional health effects. In the ther fat accumulation through increased lack of
case of chronic diseases, the exercises should be movement. The greater the body fat percentage,
adapted to the individual’s resilience. the more difficult every movement becomes: a
To maintain the necessary flexibility to per- vicious cycle.
form the described minimal activities and daily
life stresses, older adults should perform flexibi-  Important Current recommendations
lity exercises for at least 10 min at least twice a state that at least 60 min of moderate
week. to strenuous activity per day, charac-
To prevent falls, older adults should also re- terized by enjoyment of movement
gularly perform exercises that train balance. and varying activities, is necessary for
children.
73.4.3 Recommendations for Children The importance of school sports is repeatedly

emphasized, and there is no doubt that physi-
Movement and play are the basis for the cal education can inspire children for sports ac-
development of sensorimotor skills and for he- tivities. In addition, general motor skills can be
althy intellectual, social, and personal develop- taught in physical education. However, the bene-
ment in childhood. Movement is necessary for fit of school sports for daily activity is not clear.
an optimal cognitive development in children. A study of 9-year-old children showed that de-
The stimulation in the first years of life influen- spite large differences in the number of sports
ces the development of neural connections and hours in different schools, the overall activity of
thus the maturation of the brain. A one-sided the children was the same. Children who partici-
focus within the school on educational content pated in few sports hours compensated for this
at the expense of physical activity does not seem with greater activity outside of school.
justified, as studies show that mental and phy-
sical performance are related. Thus, good and
poor students differ not only in their school per- 73.5 Concrete Recommendations
formance but also in their coordination abilities. for Physical Activity
The deterioration of condition as well as we-
aknesses in the area of coordination are reported 73.5.1 Recommendations
by sports teachers, but are also confirmed by the for adult Adults with
results of federal youth games. The motor per- Obesity
formance of children has decreased by 10% in
the last 25 years. Based on movement diaries, In principle, the recommendations given above
an average primary school child today shows the for healthy people of different age groups also
following activity: apply to individuals with obesity. These state-
• 9 h of lying, ments are supplemented below by concrete
• 9 h of sitting, aspects for people with obesity.
• 5 h of standing, Before starting a sports program, a sports me-
• only 1 h of movement. dicine health examination should be carried out
to assess the cardiovascular risk profile and, if ful in terms of weight loss effects as continuous
necessary, adapt the program to the individual’s exercise forms. Nevertheless, intermittent exer-
resilience. cises spread throughout the day can be strategi-
To achieve stabilization or even a reduction cally helpful for sports beginners with obesity to
in body weight, significantly more activities than get used to an increasing duration of training sti-
the above-described minimum program are li- muli.
kely to be necessary in order to achieve a signifi- Also, activities of daily living play a role in
cant negative energy balance. the overall calorie balance and can contribute to
Some studies suggest that a daily duration an increase in performance and improvement of
of between 60 and 90 min of moderate activi- health-relevant factors. Therefore, individuals
ties is required to stabilize the achieved lower with obesity are advised to be as active as pos-
body weight in the long term after a period of sible in their daily lives to achieve at least mo-
weight loss. In a study in women with over- derate intensities. However, an increase in ever-
weight, a weight loss of 13 kg over 18 months yday activities alone is probably not sufficient
was stabilized with an exercise program of more for weight loss and must at least be combined
than 280 min/week (40 min daily, 7 days/week). with a diet program.
People with obesity who manage to implement a Weight-bearing or strength training forms
more extensive sports program are usually also lead to an increase in muscle strength and
more active in their everyday activities and thus muscle mass (fat-free body mass). Since musc-
achieve an additional calorie deficit. les are metabolically active tissue, it has been
assumed that weight training programs are parti-
 Important For individuals with obe- cularly beneficial for individuals with obesity, as
sity, a program that includes 200– they are assumed to reduce or even completely
300 min per week or more than 2000 prevent a diet-related decrease in muscle mass
kcal energy expenditure is recommen- and thus basal metabolic rate. However, current
ded. Previously untrained individu- studies do not provide evidence for these as-
als should be gradually introduced to sumptions. In well-controlled weight reduction
these exercise volumes. intervention studies with individuals with obe-
sity, additional strength training did not result
The exercise intensity for sports programs in an increase or maintenance of muscle mass,
aimed at weight loss should be high enough to stabilization of resting metabolic rate, or an ad-
achieve a significant caloric expenditure. Inten- ditional reduction in body weight.
sities of 55–70% of maximum heart rate are re-
commended. Higher intensities may achieve  Important Strength training programs
better long-term effects. However, the overall are not superior to conventional end-
calorie turnover achieved seems to be most sig- urance programs. However, they can
nificant. In a well-controlled intervention study, lead to an improvement in everyday
weight reductions after 24 weeks in women with performance (getting up from a chair,
overweight were identical if they had achieved climbing stairs, etc.) in very weak in-
the same caloric expenditure in different combi- dividuals.
nations of volumes and intensities.
 Important The less intensively an 73.5.2 Recommendations for Children

exercise is performed, the longer the and Adolescents with Obesity
duration must be.
At the beginning of an exercise program,
Intermittent activities that are accumulated weight-supporting activities such as swimming
throughout the day are probably not as success- and cycling should be included, as well as ac-
556 P. Platen
tivities that can be integrated into the lifestyle, such a way that motivation for physical activity
such as climbing stairs. The intensity is unim- is promoted. The selection of various sports and
portant in the initial phase. exercises should take into account different pre-
The goal should be for children to stay active ferences of the respective age and developmen-
for at least 30–45 min. Endurance exercises are tal stages and gender and be flexible to change.
not very child-friendly; more appealing are al- Considering trendy sports can be motivating.
ternating loads in a playful form. Musical-rhyth-
mic accompaniment can be stimulating.  Important Any regular physical acti-
It must be achieved that movement is associa- vity is more important than a prede-
ted with fun and joy; it should be avoided that termined exercise program that may
children shy away from physical demands due to be discontinued.
their reduced performance and discontinue the
program. It is important to consider the respec- In the long term, physical activity can more ef-
tive age and different preferences of boys and fectively prevent possible weight regain in chil-
girls in the exercise program. Only when these dren and adolescents with obesity than diet.
goals are achieved and the motivation is suffi- Therefore, normalization or stabilization of
cient can the requirements be adapted to increa- body weight is best achieved through a combi-
sed performance, with a wide variety of sports nation of physical activity and diet. Physical ac-
and movement options available. A recommen- tivity is part of every therapy or prevention pro-
dation must take into account what is desirable gram, more in the sense of an everyday increase
and what is feasible and can be: in activity than through sports courses or physi-
• physical activity of moderate intensity and cal education in school.
lasting more than 30 min on 3–5 days a
week;
• in the long run, if possible, be moderately ac- Conclusion
tive daily for 45–60 min;
Many chronic diseases, including obesity, can
• if motivation is strong, a longer program is
be explained by the maladaptation of our ge-
more favorable.
netically predisposed movement-based traits
to our current lifestyle, which is characterized
The exercise program should not be one-si-
by inactivity and overnutrition.
ded but should be diverse and focus on endur-
Regular physical activity and sports lead
ance training, while also considering strength
to an increase in physical performance. This
training. Exercises for general mobility and co-
also applies to individuals with obesity. Mo-
ordination should not be forgotten, especially
reover, they are capable of positively influen-
for individuals with severe obesity. In the long
cing almost all cardiovascular risk factors and
run, a flexible program will prevail.
improving quality of life without simulta-
It is important to make the entire daily rou-
neous weight loss. Therefore, physical acti-
tine more active. Everyday routes, such as the
vities should be integrated into daily life as a
way to school, should be covered on foot or by
lifestyle change.
bicycle. Instead of using elevators or escala-
For adults with obesity, a program that in-
tors, stairs could be used. Reducing television
cludes 200–300 min per week or more than
time and computer games is also essential. It is
2000 kcal energy expenditure is recommen-
often observed that particularly strenuous exer-
ded for weight loss or improvement of their
cises are chosen in an effort to “burn calories.” It
metabolic situation. Previously untrained in-
is disadvantageous if these exercises cause hun-
dividuals should be gradually introduced to
ger, which is then indulged. It should also be
these exercise volumes.
avoided that thirst is quenched with sweetened
Movement and play are necessary for
drinks. It is important to control the program in
healthy intellectual, social, and personal
development in childhood. Children need an fat oxidation: implications for obesity management.
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In children and adolescents with obesity, aerobic vs. resistance exercise training on visceral fat.
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American College of Sports Medicine and the American elevated triglyceride in muscle: more important for
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Sports Exerc 39(8):1423–1434 Summerbell C, Waters E, Edmunds LD (2001, 2005) In-
American College of Sports Medicine Position Stand terventions for preventiong obesity in children. Coch-
(2001) Appropriate intervention strategies for weight rane Database Syst Rev 1:CD001871
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Approaches to Eliminating
Obesogenic Environments 74
Contents
74.1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 559
74.2 Conceptual Definitions: Definition of Obesogenic Environments . . . . . . . . 560
74.3 Systematization of Obesogenic Environments . . . . . . . . . . . . . . . . . . . . . . . . 560
74.4 Empirical Findings on Obesogenic Environments . . . . . . . . . . . . . . . . . . . . 562
74.5 Methodological Challenges in the Study of Obesogenic Environments . . . 563
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 564
genetic factors (Robert Koch Institute 2019).

74.1 Background Unlike genetic makeup, there has been a rapid
development in our living environment regard-
Lack of physical activity and malnutrition are ing tertiarization, automation, mechanization,
spreading endemically worldwide. The result- and food production during this period (Kirk
ing “obesity epidemic” now represents a central et al. 2010; Huybrechts et al. 2011). Therefore,
health problem, especially in Western industrial- it makes sense to take a closer look at the
ized nations (Benecke and Vogel 2013; Devaux importance of environmental factors in obesity-
and Sassi 2013). In this handbook, various specific explanatory models and intervention
chapters point to the influence of genetic pre- planning.
disposition on the development of overweight. Overweight results from an imbalance
Nevertheless, the drastic increase in obesity between energy intake and energy expenditure
prevalence in recent decades suggests an also (Powell et al. 2010). For decades, biomedical
relevant influence of other, specifically external therapies and educational intervention programs
factors, which are likely to interact with said (such as diets and exercise programs) aimed at
individually balancing these two influencing
factors dominated (Lake and Townshend 2006;
S. Schneider (*) · B. Holzwarth Müller and Kurth 2007). The simplified mes-
Center for Preventive Medicine and Digital Health sage “move more, eat less” (Parise 2020) has
Baden-Württemberg (CPD-BW), Medical Faculty
not been able to curb the obesity epidemic at
Mannheim, Heidelberg University,
Mannheim, Germany the population level to date (Muckelbauer et al.
e-mail: [email protected] 2011). Therefore, the biomedical paradigm,
B. Holzwarth which focuses primarily on genetic and biologi-
e-mail: [email protected] cal influences, has increasingly given way to the
https://doi.org/10.1007/978-3-662-67662-2_74
public health paradigm, which places the con- classic primary (family home), secondary (kin-
text of obesity development at the center (Müller dergartens and schools), and tertiary (sports
and Kurth 2007; Igel et al. 2013). clubs, etc.) socialization instances form these
typical settings. For adults, typical settings can
be the apartment, workplace, or local infrastruc-
74.2 Conceptual Definitions: ture with its shops, transportation, and recrea-
Definition of Obesogenic tional facilities (Swinburn et al. 1999; Gauthier
Environments and Krajicek 2013). Settings are largely geo-
graphically limited, comparatively small-scale,
The term “obesogenic environment” ( German- and influenced by the people present there (Kirk
language counterpart “adipogenic environment”) et al. 2010).
was coined in the late 1990s, particularly by The environments operating at the macro
Swinburn and colleagues: It refers to the sum of level are called sectors. These include, for exam-
all influences from the environment, opportunity ple, the economic, educational, and health sys-
structures, and living conditions on the devel- tems, political framework conditions, mobility
opment of overweight (Swinburn et al. 1999). and transport sector, food, media, and sports
Obesogenic environments particularly promote industries, as well as societal norms, values, and
unhealthy eating habits and physical inactivity cultures (Swinburn et al. 1999; Gauthier and
(Hill et al. 2003). They thus encompass geo- Krajicek 2013). The conceptual model presented
graphical, technological, economic, norma- here for the first time in Fig. 74.1 is intended
tive, and attitude-specific aspects (Gauthier and to illustrate that the supra-regional macro level
Krajicek 2013). Obesoogenic environments are influences the local micro level and both, in
significant for children and adolescents as well turn, affect the living conditions of individuals
as adults. However, the relevant characteris- (Fig. 74.1). This model is thus compatible with
tics can have very different effects for each age the social-ecological approach of public health
group: Due to their dependence on third parties, (Sallis et al. 2006).
limited mobility, and restricted decision-mak- Settings and sectors have physical, economic,
ing freedom, children and adolescents can only political, and sociocultural dimensions (Kirk
select, influence, or leave their environments to et al. 2010). Guiding questions for capturing
a limited extent (Gauthier and Krajicek 2013). and systematizing are: What is available? What
In comparison, adults can move better within does it cost? What (formal) rules apply? What
and between different environments (e.g., the (informal) cultures prevail? We have adopted
workplace, the apartment, etc.) and thus avoid this systematization by Swinburn and colleagues
negative, health-relevant influences more easily. (Swinburn et al. 1999) in Fig. 74.1 and dif-
ferentiated it according to specific obesogenic
environments for dietary behavior (food envi-
74.3 Systematization ronment) and physical activity (physical activity
of Obesogenic Environments environment).
At the local level of settings, obesity can
Obesogenic environments are commonly sys- thus be influenced by the physical environment
tematized according to size, dimensions, and on the one hand. The physical environment, in
impact (Kirk et al. 2010). In terms of size, the turn, comprises natural and artificially created
literature predominantly refers to the micro level aspects. Physical activity depends, among other
when local environments are the focus of con- things, on traffic density in the residential area,
sideration. Local environments are also referred the presence of movement opportunities (play-
to as settings. For children and adolescents, the grounds, soccer fields, green spaces, and jogging
74 Approaches to Eliminating Obesogenic Environments 561
Fig. 74.1  Obesogenic
Macro level
environment—Exemplary
systematization of potential Physical environments
influencing factors on
overweight at micro and macro
levels
Micro level
Physical environments Economic environments
Economic environments
Political environments
Political environments
Sociocultural environments
Sociocultural environments
Physical activity
- & dietary behavior
trails), and the walking and cycling path net- hours, and institutional or family regulations
work. Regarding one’s own nutrition, the sup- (e.g., the school’s house rules or family rules on
ply in regional, stationary retail and gastronomy TV consumption, media use, and shared meals)
is relevant. For children and adolescents, cater- are mentioned analogously.
ing in daycare centers and schools (presence of Within the mentioned settings, the sociocul-
a kitchen or cooking facility, a caterer, or a caf- tural environment, i.e., among other things, the
eteria) and for adults, the offer at study, training, implicitly shared values and norms, also plays a
and workplaces (e.g., canteens and gastronomy relevant role. These influencing factors manifest
near the workplace) is significant. themselves, among other things, as the neigh-
At the same time, the economic environment borhood, company, or school climate and as the
also influences movement and nutrition-specific subjective safety in the residential environment.
decision-making processes (e.g., entrance fees to The physical, economic, political, and socio-
parks and swimming pools, prices of local pub- cultural environments at the micro level are
lic transport, parking fees, membership fees for determined, shaped, or at least influenced by
sports clubs, and the price structure in cafeterias the influences at the macro level (Table 74.1). In
and canteens). addition to natural influences, governments and
Furthermore, the political environment also other state institutions, markets (e.g., the food
plays a role in one’s own health behavior. For and sports industry), and the so-called “third
adults, examples include official usage restric- sector” (non-profit organizations, non-govern-
tions for green spaces, access to green spaces mental organizations (Schneider and Holzwarth
and sports facilities for the possibilities of 2020) are distinguished. These sectoral struc-
engaging in sports, and local traffic regulations tures exist by definition at the supra-regional
(access restrictions, pedestrian zones, parking level and can gain different relevance depending
bans) for the choice of means of transporta- on the setting.
tion. For children and adolescents, access to In the area of the physical, in this case the
playgrounds and sports fields, such as opening natural environment, climate has an influence on
Table 74.1  Obesogenic environments—Systematization of potential influencing factors of movement and nutrition

at micro and macro levels
Physical environments Economic environments Political environments Socio-cultural environments
Movement Walkability Pricing models in public Local driving bans Crime
Crossing aids transport membership and Regulations on pedestrian zones Perception of safety
Sidewalk and bike lane network social contributions for sports Restrictions on use of Trust
Traffic density clubs transport playgrounds and sport Social networks
Elevators and stairs Admission fees for swimming fields (e.g., in common
parks and playgrounds pools, indoor playgrounds property)
Micro level (settings)
and parks Sports facility planning

Exercise Connectivity Economic status of Institutional rules School climate
& Infrastructure parents Family rules (e.g., on TV Guiding principles
Nutrition Microclimate, topography and Pocket money availability consumption, media use, Role model function of
vegetation eating together) teachers, parents and peers
Nutrition Quantity, quality, Pricing models in canteens Water dispensers in schools Regional and family food
accessibility and cafeterias Quality standards for catering culture
and opening hours of the Price structure of e.g. kiosks in schools and daycare Preferences and cooking
offers of e.g.: and supermarkets centers skills within the family and
o Gastronomy Informal rules (e.g., on break among peers
o Retail times, content of
o Canteens breakfast boxes)
o Kiosks
o Snack vending machines
Movement Traffic route structure State or institutional Supraregional traffic planning Movement culture
Sunshine hours funding for physical Urban planning law and Trend sports (e.g. inline
Summer and activity programs building regulations skating, e-biking,
Macro level (sectors)
Winter time regulations Supraregional. Road traffic regulations snowboarding and

sport sponsoring skateboarding)
Fuel prices
Exercise Climate vegetation Supraregional prevention Country-specific curricula Child-friendliness
& spectrum programs and interventions (e.g. on physical education Mass media role models
Nutrition Social inequality and home economics) Beauty ideals and body
images
Nutrition Area-wide offers (e.g. Lobbying of the food Taxes (e.g. fat and Food traditions
children's meals in system industry sugar tax) Drinking and table culture
gastronomy) Food production Food labels (e.g. nutritional
conditions labelling system)
Subsidy policy
our movement and eating behavior. For exam-

ple, an increase in extreme heat periods due to
74.4 Empirical Findings
climate change generally limits outdoor sports
on Obesogenic
activities. At the macro level, economic struc-
Environments
tures also form the framework for our local
Within this young research direction, initial
actions. A high gasoline price, for example,
unsystematic and systematic review articles on
favors the switch to alternative mobility options
the state of research, intervention possibilities,
such as cycling or walking. The price level of
and operationalization instruments have now
sustainably and ecologically produced food pro-
been published (Larson et al. 2009; Kirk et al.
motes health-conscious shopping behavior. At
2010; Mackenbach et al. 2014; Fisberg et al.
the political level, structural preventive meas-
2016; Martínez-García et al. 2019). These
ures such as the introduction of a sugar tax, a
show a broad heterogeneity regarding the
nutritional labelling system, or effective stand-
research question, methodology, and findings
ards for species-appropriate husbandry form the
(Larson et al. 2009; Mackenbach et al. 2014).
framework for the quality of locally available
Mackenbach et al. conclude that although it
food offerings. And finally, cultural changes take
seems intuitively plausible that environmental
place at the macro level. This refers, for exam-
conditions contribute to the obesity epidemic,
ple, to the emergence of new and trendy sports
the existing scientific evidence is neither con-
(such as popular running events, inline skating,
sistent nor convincing (2014). The mentioned
or e-bikes) as well as developments in drink-
reviews also show that the vast majority of
ing and eating culture (functional food, organic
products, vegetarianism, and veganism).
previous studies come from the USA (Lake physical activity and higher BMI values than
and Townshend 2006; Lakes and Burkart 2016; residents whose perception was more in line
Martínez-García et al. 2019). This raises the with the objective indicators (Gebel et al. 2011).
question of the generalizability of the findings to Methodologically, such evaluation processes
European countries, as US-American conditions must be considered as mediator effects (Kremers
may only be partially transferable to the local et al. 2006). In addition, moderator effects must
context. For example, historical urban structures be taken into account, as not every environmen-
are typical in Europe and difficult to compare tal influence is likely to have the same effect on
with urban planning in the USA. every individual. We have illustrated these meth-
It appears that this research gap in Germany odological considerations in detail elsewhere
is only slowly being filled with interdisciplinary (Bucksch and Schneider 2014).
empirical studies. The current evidence-based
S3 guideline of numerous professional socie-
ties for the therapy and prevention of obesity in 74.5.2 Distinction
childhood and adolescence exemplifies that the between Compositional
complex influence and the manifold interven- and Contextual Effects
tion opportunities of obesogenic environments
have not yet been sufficiently recognized: In this Most of the previous findings on contextual
extensive and interdisciplinary guideline, the influences on overweight and obesity result from
term “adipogenic environment” does not appear correlational studies and are not to be inter-
even once. Only in a subordinate clause is there preted causally (Parise 2020). After all, regional
a mention of the “adipogenic living environ- or local differences in the prevalence of over-
ment” (Arbeitsgemeinschaft Adipositas 2019). weight and obesity do not always have to result
from influences of obesogenic environments.
Individual characteristics can also simply clus-
74.5 Methodological Challenges ter in certain living environments. In this case,
in the Study of Obesogenic regional or local prevalence differences are not
Environments caused by environmental factors (i.e., contextu-
ally determined), but are merely a consequence
Worldwide, and particularly in Germany, the of the population composition (i.e., composi-
study of obesogenic environments is still in its tionally determined). For example, if segrega-
infancy. Given the multifactorial etiology of tion effects cause some spatial units of a city to
overweight and the complexity of the explana- have a higher proportion of senior citizens than
tory approach presented here, at least the fol- others, lower sports and movement prevalences
lowing methodological challenges arise for there may be based on a compositional effect
analytical studies of contextual determinants and that merely reflects the generally lower physical
for the evaluation of contextual interventions: activity of older people.
74.5.1 Distinction between Objective Conclusion

and Subjective Aspects The rapid change in our living environments
has created an ever-increasing imbalance in
Objective aspects of a living environment can the metabolism of large segments of the pop-
be perceived subjectively differently by the indi- ulation (Huybrechts et al. 2011), although a
viduals living there. Empirical findings show genetic determination of overweight is undis-
that residents who subjectively classified their puted (Wardle et al. 2008). In our everyday
environment as less walkable, even though life, on the one hand, hardly any physical
this was not objectively the case, had lower
activity is required, and on the other hand, Gebel K, Bauman AE, Sugiyama T, Owen N (2011)
food is cheap, energy-rich, and ubiquitously Mismatch between perceived and objectively
assessed neighborhood walkability attributes: pro-
available (Huybrechts et al. 2011). Therefore, spective relationships with walking and weight gain.
the identification of obesogenic environ- Health Place 17:519–524. https://doi.org/10.1016/j.
ments, i.e., contextual causes at the micro healthplace.2010.12.008
and macro levels, appears to be an innova- Hill JO, Wyatt HR, Reed GW, Peters JC (2003) Obesity
and the environment: where do we go from here?
tive approach to explanation and intervention Science 299:853–855
planning. Huybrechts I, De Bourdeaudhuij I, De Henauw S (2011)
Although the relationships identified so Environmental factors: opportunities and barriers for
far between context factors and weight-spe- physical activity, and healthy eating among children
and adolescents. In: Moreno LA, Pigeot I, Ahrens W
cific risk factors may appear weak and their (Eds) Epidemiology of obesity in children and ado-
empirical explanatory contribution may seem lescents. Springer, New York, pp 391–418
small at first glance, their preventive rele- Igel U, Baar J, Benkert I et al (2013) Deprivation im
vance may still be considerable: After all, the Ortsteil und Übergewicht von Vorschulkindern.
Adipositas 1:27–31
environments surrounding us constantly, and Kirk SF, Penney TL, McHugh T-L (2010) Characterizing
and in the long term, affect not only indi- the obesogenic environment: the state of the evi-
viduals but also large population groups (e.g., dence with directions for future research. Obes Rev
cycle paths, sports fields, quality standards; 11:109–117
Kremers SP, De Bruijn G-J, Visscher TL et al (2006)
Baar et al. 2013; Bucksch and Schneider Environmental influences on energy balance-related
2014; Mackenbach et al. 2014). We con- behaviors: a dual-process view. Int J Behav Nutr Phys
clude that curbing the obesity epidemic will Act 3:1–10. https://doi.org/10.1186/1479-5868-3-9
continue to be unsuccessful without interdis- Lake A, Townshend T (2006) Obesogenic environ-
ments: exploring the built and food environments.
ciplinary consideration and concerted inter- J R Soc Promot Health 126:262–267. https://doi.
ventions at the micro and macro levels. org/10.1177/1466424006070487
Lakes T, Burkart K (2016) Childhood overweight in
Berlin: intra-urban differences and underlying influ-
encing factors. Int J Health Geogr 15:12. https://doi.
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Behavioral Therapy
for Obesity 75
Andrea Benecke
Contents
75.1 Historical Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 567
75.2 Essential Components of Behavioral Therapy for Obesity . . . . . . . . . . . . . 568
75.3 Relapse Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 572
75.4 Maintaining the Lost Weight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 572
75.5 Collaboration with Other Relevant Professional Groups . . . . . . . . . . . . . . 572
75.6 Individual or Group Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 572
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 573
“Behavior modification” is one of the central 75.1 Historical Overview

components of overweight and obesity therapy.
In all relevant guidelines, changing behavior, Behavioral therapy strategies have been applied
specifically in terms of nutrition and physical to obesity since the 1960s. The first approaches
activity, is described as a fundamental interven- described at that time were derived directly from
tion. Behavioral therapy strategies, such as stim- learning theory and had a significant weight
ulus control strategies, have also found their way loss as their central goal. Aversion techniques,
into nutrition counseling and advice on increas- token-economy programs, or covert sensitiza-
ing physical activity. To be distinguished from tion for several weeks were used, with signifi-
this is the behavior therapy of obesity as a psy- cant weight losses achieved in some cases, but
chotherapeutic intervention, which is responsi- these were not permanent. With the increase in
bly carried out by a psychotherapist. the prevalence of overweight and obesity, weight
loss programs were increasingly in demand
and new developments from behavioral therapy
research were adopted. Furthermore, the pro-
grams were extended in time; there are now
offers that last for one year.
Another development boost resulted from
the need to incorporate findings from neighbor-
A. Benecke (*) ing disciplines. It was obvious that overweight
Poly-Clinical Ambulance of the Psychological Institute, had something to do with eating behavior, from
University of Mainz, Mainz, Germany which the conclusion was drawn to significantly
restrict eating. However, it emerged that learning
https://doi.org/10.1007/978-3-662-67662-2_75
568 A. Benecke
an eating behavior that is too restrictive has a based on the calculated energy needs of the
rather negative long-term effect, so that today, a body will not be satisfactory, and a failure of
moderate calorie restriction is usually used, with this “sensible” path is preprogrammed. Since a
no restrictions placed on food selection. In addi- cure for obesity (i.e., achieving normal weight)
tion, it has become clear from various research through behavioral therapy is rather unlikely
activities in recent years that the development of (Sect. 75.4), goal clarification is of essential
healthy exercise behavior is essential for avoid- importance. Strategies for increasing social
ing subsequent weight gain. Although recom- competence and self-esteem stabilization for
mendations on how much exercise per week and an improved life with obesity/overweight also
at what intensity are useful keep changing, there appear important for therapy.
is no longer any doubt about the fundamental
finding that exercise must be included in any
long-term successful weight loss concept. In this 75.2 Essential Components
respect, today’s behavioral therapists must have of Behavioral Therapy
more than just basic knowledge in the field of for Obesity
nutrition and exercise therapy in order to carry
out meaningful and successful treatment pro- 75.2.1 Psychoeducation
grams, or they need to work together with spe-
cialists from these areas (Sect. 75.5). As part of At the beginning of therapy, it is important to
the so-called third wave of behavioral therapy, inquire about the patient’s knowledge regarding
elements of acceptance and commitment therapy the development and maintenance of obesity as
as well as mindfulness-based therapy have also well as their ideas and experiences related to the
been integrated into the treatment of overweight desired weight loss. Often, incorrect or unrealis-
and obesity. The efficacy of these interventions tic ideas are discovered that need to be addressed.
in combination with the proven cognitive-behav- Only when the patient has been provided with a
ioral techniques has not yet been systematically solid basic knowledge of the essential relation-
evaluated. However, initial results demonstrate ships between genetics, metabolism, environmen-
the efficacy of the new approaches. tal influences, nutrition, exercise, psychological
well-being, etc., can meaningful goals and strat-
 Important The goal of today’s pro- egies for therapy be derived. The focus is on a
grams is to change behavior in the long-term lifestyle change, not on implement-
long term, as diets that are followed ing a new diet with psychotherapeutic support.
for a few weeks do lead to weight Patients typically find it difficult to let go of the
reduction, but usually result in rapid diet mindset (i.e., “I’ll restrict myself for a while
weight gain as soon as the diet is and can then return to normal”).
stopped.
The reason for weight gain after the end of a 75.2.2 Agreement on Therapy Goals
diet is that most people revert to old behaviors
and resume their old eating habits again. Only The agreement on goals plays a crucial role
a change “until the end of life” can lead to a in obesity therapy. Patients’ goals (and some-
weight loss that is also (more or less) main- times therapists’ goals) can range from a realis-
tained. However, this means that the desired tic improvement of mental and physical health
behavioral changes must be integrated into eve- to unrealistic expectations, such as finding the
ryday life and the basic needs of the patients perfect life partner once the ideal weight is
must be taken into account. A life that is only achieved. Unrealistic goals must be explored in
75 Behavioral Therapy for Obesity 569
a supportive manner, but ultimately redefined so record when and under what circumstances
that they can be agreed upon as fundamentally physical activity took place. This is intended to
achievable in therapy. sensitize patients to their behavioral patterns.
Patient and therapist should try to The records are also used to identify modifi-
able environmental stimuli that contribute to
• define common goals, overeating and reduced physical activity. In
• agree on respective responsibilities, addition, the number of calories consumed can
• agree on realistic expectations regarding ther- be determined more accurately. Some studies
apy success. have shown that patients who regularly moni-
tor themselves and document their behavior
A weight loss of 5–10% of the original weight, achieve better therapy outcomes than those who
maintained over a year, is considered success- do not. Behavioral analysis refers to the preced-
ful by professional societies. However, many ing conditions, the consequences of behaviors,
patients perceive this goal as disappointingly low. and their contingencies. This can identify con-
Nevertheless, the patient must realize that achiev- ditions that facilitate a specific desired behavior
ing this weight loss is by no means easy and or increase the likelihood of undesired behavior
requires a lot of effort and commitment. In addi- (this applies not only to nutritional and physi-
tion to the number on the scales, it is essential to cal activity behavior but also to problem and
consider other expected improvements, such as goal behaviors such as social contacts, leisure
behavior, etc.). Dysfunctional thoughts can
• improvement in metabolic values, also be recognized in this way (for changing
• improved sleep in the case of sleep apnea, these thoughts, see Sect. 75.2.5) as well as emo-
• improved endurance in activities of any kind, tional states that lead to overeating. In addition,
as well as patients are sensitized to perceive positive and
• increased self-confidence, etc. negative consequences, which should be divided
into short-term and long-term consequences.
This can prevent disappointment over a (not Rapidly occurring consequences (e.g., feeling
yet) achieved target weight from overshadow- good immediately after eating chocolate) deter-
ing all other positive changes. Goals should be mine our behavior to a much greater extent than
specific, easily operationalized, and divided do later consequences (e.g., not reaching the
into short-, medium-, and long-term goals. weekly weight goal).
Operationalizability is important so that the
patient and therapist can clearly recognize when
the goal has been achieved, as this must be 75.2.4 Stimulus Control
rewarded (or “reinforced”). Initially, small goals
should be formulated and targeted, which can be The self-monitoring sheets usually provide a
achieved quickly to strengthen motivation. clear picture of the triggers that determine eating
and physical activity behavior. Actions are influ-
enced, among other things, by the time of day,
75.2.3 Self-Monitoring Behavioral the sight of things, smells, places, situations,
Analysis and thoughts. These influences can be used
to increase the chances of changing behavior.
The focus of self-monitoring is on nutritional The application of stimulus control strategies
and physical activity behavior. Patients should increases the likelihood of desired behavior and
document daily what they ate, when, and decreases the likelihood of undesired behavior.
under what conditions. Likewise, they should
570 A. Benecke
emotionally induced eating. Since emotions are

Proven stimulus control strategies linked to cognitions, changing these cognitions
• Eat at fixed times can also change the emotions that lead to eating
• Always eat in the same place (see above).
• Only shop when not hungry
• Have as few food supplies at home as Justification of exercise behavior Here, too,
possible there may be dysfunctional higher-level plans
• Keep sports shoes near the door that make it difficult to increase physical activity
• Arrange to do sports with friends (e.g., “The day was exhausting enough”).
• Do not eat while watching TV or using
the computer Self-image Self-efficacy beliefs regarding long-
term successful weight loss are often weakly
developed in many people with obesity due to
75.2.5 Cognitive Restructuring repeated unsuccessful attempts to lose weight.
These must be slowly rebuilt. Ideas of worthless-
Among the other antecedents of problematic ness and hopelessness are also often prevalent.
eating and exercise behavior are also dysfunc-
tional thoughts (e.g., “I had such a stress- Body image Many people with obesity have a
ful day, I need a balance,” or “I haven’t lost a distorted body image, usually perceiving them-
single gram, I’ll never make it, so I might as selves as fatter and more shapeless than they
well eat like I used to”). The dysfunctional actually are. Many avoid dealing with their body
thoughts must be identified through self-mon- at all, do not look at themselves, do not touch
itoring sheets, their consequences analyzed, themselves, and do not dare to impose them-
and then changed. Techniques such as Socratic selves on other people. Therefore, problems
dialogues, decatastrophizing techniques, the in sexuality are not uncommon. In therapy, it
three-column technique, etc., are available for is often important to deal with one’s own body
this purpose. The restructuring takes place with (lovingly) and learn to accept it (e.g., through
regard to the functional use of helpful thoughts mirror exercises or elements from acceptance
and the development of strategies to help inter- and commitment therapy).
rupt the behavioral chain that leads to unfavora-
ble behavior early on. Behavior of others Since many people with
The identification of distorted cognitions also obesity have experienced demeaning behavior
relates to the following areas. from others, they are usually very sensitive to
the behavior of others. It can happen that they
Areas of identification of distorted cognitions relate the laughter, whispering, etc., of others to
Development of overweight themselves and feel helplessly exposed to it. It
Deep-seated beliefs that could not be is important to check these interpretations and,
changed at the beginning through education in cases where they are actually the target of
must be changed through cognitive restructur- demeaning behavior, establish alternative behav-
ing. One goal can be to establish a functional ioral options to withdrawal, e.g., through social
understanding of “blame” for being overweight. competence training.
Both excessive self-blame and exaggerated trivi-
alization of the reasons for the weight problem Therapy goals As mentioned, the agreement on
are not conducive to therapy. realistic therapy goals is essential. If these can-
not be achieved through psychoeducation, the
Justification of eating behavior As already fundamental dysfunctional attitudes often need
indicated, there are many reasons to eat. to be reviewed and changed (e.g., “Only people
It seems essential to find alternatives to who are slim can be happy”).
75.2.6 Stress Management Inproving self-confidence in this way in

turn reduces times of stress, which facilitates the
Since psychosocial stress is a predictor of maintenance of the new behavior.
relapses into old behavior patterns, methods for
stress and tension reduction are taught in many
behavioral therapy programs. These can be 75.2.9 Problem-solving Training
“classic” relaxation techniques such as progres-
sive muscle relaxation or autogenic training, or Patients need to learn to effectively and reliably
improved time management, teaching problem- solve emerging problems for their ongoing self-
solving skills, or the application of mindfulness management. The problem-solving training is
exercises. intended to clarify the individual necessary steps
and can be learned and practiced during therapy.
It consists of five steps:
75.2.7 Social Support
• Problem formulation
Shopping, cooking, eating, and drinking take • Goal formulation
place to a significant extent in a social context. • Development of alternatives
Therefore, the social contexts of the patient • Decision for one of the alternatives
should also be addressed in therapy. Family, • Review
coworkers, and friends can facilitate, hinder, or
sabotage weight loss, the achievement of other As part of the problem formulation, the prob-
goals, and the maintenance of therapy suc- lematic situation is first described as precisely
cesses. If possible, partners or other important, and comprehensively as possible on the lev-
close reference persons should be involved in els of situation, feelings, and thoughts (as in a
the therapy. Involvement can become relevant if behavioral analysis). This is the prerequisite for
a partner has taken on a controlling function for all considerations on how to solve the problem.
the eating and exercise behavior of the other or In the next step, the goal to be achieved must
even sabotages the changes. Conversely, it may be described as comprehensively and con-
be useful to involve social partners in support- cretely as possible (“What exactly do I want
ing the desired changes, e.g., to establish joint to achieve?”). Then, considerations are made
sports activities. A general recommendation for as to which possibilities exist for achieving the
the inclusion of life partners/social partners can- goal. At this point, as many and diverse alter-
not be given, as the study findings in this regard natives as possible should be collected. The
are conflicting. consequences of these individual alternatives
for achieving the goal are considered (costs
and benefits). Afterward, a decision is made
75.2.8 Social Competence Training as to which alternative is the best, considering
all implications. Once this alternative has been
Perceiving, expressing, and adequately assert- tried, a further step is to check whether the cho-
ing one’s needs is of great importance in obesity sen alternative was goal-oriented, effective, and
therapy, as many patients have great difficulties efficient, and whether the associated costs were
with this. As part of social competence train- acceptable.
ing, it can be practiced how to refuse offered Selected, effective behavioral therapy tech-
food in a socially competent manner, and how to niques and comprehensive relapse prevention
deal with controlling people or with people who also appear to be effective in the long term
express themselves inappropriately negatively. (Greaves et al. 2011).
572 A. Benecke
75.3 Relapse Prevention To maintain these changes, the behavioral thera-

peutic strategies listed above are helpful.
In this context, it should first be examined what In therapist-led weight loss programs, one
constitutes a relapse or setback. For exam- of the most important factors of effectiveness
ple, this could be a weight gain of a certain is continued contact with the therapist (face-to-
extent, a reduction in physical activity, or a face, by phone, or web-based), albeit at much
change towards less favorable eating behav- larger intervals than during the intervention.
ior. All those involved in the therapy process Conservative treatment measures for obesity
should be aware that relapses are highly likely grade I and II show limited long-term effects
to occur. Strategies for coping with them should in most individuals with obesity. The average
be developed (e.g., “If I weigh 110 kg again, I weight gain is 30–35% of the initial weight one
will keep a food diary and analyze it closely”). year after the intervention. After about 5.5 years,
Through such an approach, patients should most people with obesity have regained their old
realize that a relapse is not a catastrophe, but a weight. However, approximately 15–20% of all
reason to observe more closely and change any participants in weight loss measures are able to
“mistakes” that have crept in. This prevents the maintain their weight permanently.
danger of negative evaluations of these normal
developments being generalized and leading
to negative thoughts about oneself (“I knew it 75.5 Collaboration with Other
wouldn’t work this time either, I’m a hopeless Relevant Professional Groups
case”). On the other hand, patients should be
made aware that they must always be on guard As stated above, a behavioral therapist treat-
against relapses into old habits. This can also ing a patient with obesity should have profound
counteract the danger of trivialization (“Even if knowledge of nutritional and physical activity
I’ve gained a few kilos, what does it matter …”). aspects of obesity treatment. It is advantageous
to work in a team consisting of doctors, medical
or psychological psychotherapists, and nutrition
75.4 Maintaining the Lost Weight and exercise therapists, who work in accordance
with evidence-based guidelines. The possibility
Since 1994, the National Weight Control of such teamwork is not only available in inter-
Registry has been collecting data from people disciplinary outpatient clinics or medical care
who have lost at least 13.6 kg and maintained centers, but also the collaboration of individual
this lower weight for over a year. Over 10,000 practices in obesity networks can be effective.
people have been included in the registry and
prospectively studied so far. From the results
of this study, strategies can be derived that are 75.6 Individual or Group Therapy
more likely to serve long-term maintenance
of the lost weight. The self-control of various In principle, both treatment modalities are pos-
behavioral patterns plays a central role in this: sible. However, group therapy offers some
advantages.
• constant control of eating behavior (control
of calorie intake, regular breakfast, consistent
eating behavior), Group Therapy for Obesity
• sustained weight control (at least once a • Especially when the therapy is offered
week), and by a treatment team, the economic argu-
• control of physical activity (on average 1 hour/ ment for group therapy is potentiated.
day with reduced television consumption). • People with obesity often have a great
reluctance to engage in physical activity
Cooper Z, Fairburn CG, Hawker DM (2008) Kognitive

in public. This is much easier in groups. Verhaltenstherapie bei Adipositas. Schattauer,
Stuttgart
The likelihood that this therapy module
Deutsche Adipositas-Gesellschaft (2014). Interdisziplinäre
will be carried out reliably increases in Leitlinie der Qualität S3 zur „Prävention und Therapie
groups. der Adipositas“ (zurzeit in Überarbeitung). www.
• Social competence can be practiced awmf.de. Accessed 19 Dec 2020
Dombrowski SU, Sniehotta FF, Avenell A et al (2012)
much more effectively in groups.
Identifying active ingredients in complex behavioural
• Model learning can be used well. interventions for obese adults with obesityrelated co-
• Small groups can form from the group, morbidities or additional risk factors for co-morbidi-
whose members continue to support each ties: a systematic review. Health Psychol Rev 6:7–32
Glenny AM, O’Meara S, Melville A et al (1997) The
other even after the therapy has ended,
treatment and prevention of obesity: a systematic
e.g., by continuing to exercise together. review of the literature. Int J Obes 21:715–737
Greaves CJ, Sheppard KE, Abraham C et al (2011)
Systematic review of reviews of intervention compo-
However, care should be taken to establish suf- nents associated with increased effectiveness in dietary
and physical activity interventions. BMC Public Health
ficient individual competencies of the group 11:119
members so that the learned content can be Lawlor ER, Islam N, Bates S et al (2020) Third-wave
maintained even without the continued existence cognitive behaviour therapies for weight manage-
of the group. ment: A systematic review and network meta-analy-
sis. Obes Rev 21:e13013
Levy RL, Finch EA, Crowell MD et al (2007) Behavioral
intervention for the treatment of obesity: strategies
Conclusion and effectiveness data. Am J Gastroenterol 102:1–8
According to the current state of research, Michie S, Ashford S, Sniehotta FF et al (2011) A refined
taxonomy of behaviour change techniques to help
behavioral therapy techniques can be consid- people change their physical activity and healthy eat-
ered effective. The more behavioral therapy ing behaviours: the CALO-RE taxonomy. Psychol
strategies are applied, the more frequent the Health 26:1479–1498
therapeutic contact, and the longer the dura- National Institute for Health and Care Excellence (2014)
Obesity: identification, assessment and management.
tion of the intervention, the greater the effec- Clinical guideline. www.nice.org.uk/guidance/cg189.
tiveness of the measure. If the behavioral Accessed 19 Dec 2020
therapy techniques are combined with dietary National weight control registry. www.nwcr.ws.
changes and/or increased physical activity, Accessed 20 Dec 2020
Norris SL, Zhang X, Avenell A et al (2004) Long-term
the results can be significantly improved. effectiveness of lifestyle and behavioral weight loss
interventions in adults with type 2 diabetes: a meta-
analysis. Am J Med 117(10):762–774
Pudel V (2003) Adipositas. Hogrefe, Göttingen
References Shaw K, O’Rourke P, Del Mar C, Kenardy J (2007)
Psychological interventions for overweight or obe-
Benecke A (2003) Adipositas – eine therapeutische sity. Cochrane Database Syst Rev 3:CD003818
Herausforderung. Verhaltensther Psychosoz Praxis Wadden TA, Sarwer DB, Berkowitz RI (1999)
35(4):729–742 Behavioral treatment of the overweight patient.
Baillieres Clin Endocrinol Metab 13:93–107
Medication Therapy
for Obesity 76
Marcus May and Jens Jordan
Contents
76.1 General Therapy Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 576
76.2 Challenges in Drug Development for Obesity . . . . . . . . . . . . . . . . . . . . . . . . 576
76.3 Orlistat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 577
76.4 Liraglutide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 578
76.5 Naltrexone and Bupropion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 579
76.6 Norpseudoephedrine/Cathin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 579
76.7 Potential Future Obesity Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 580
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 581
In Europe, drug therapy for obesity exists in This chapter mainly deals with the mecha-
the shadows, as the costs are often not covered. nisms of action and clinical data on orlistat, li-
Three medications are approved in Germany for raglutide, and the combination of naltrexone
the long-term treatment of obesity, orlistat lirag- and bupropion, the only drugs approved in Ger-
lutide, and the fixed combination of naltrexone many for the long-term treatment of obesity. In
and bupropion. For short-term therapy, amfepra- the USA, two additional medications, the selec-
mon, cathin, and phenylpropanolamine are still tive serotonin-2c receptor agonist (5-HT2c re-
available. However, due to the insufficiently pro- ceptor agonist) lorcaserin (Belviq®) and the low-
ven efficacy and safety in clinical studies, the dose fixed combination of phentermine and topi-
importance of these substances in obesity the- ramate (Qsymia®) are approved by the Food and
rapy is questionable. Only for the sympathomi- Drug Administration (FDA). Furthermore, seve-
metic cathin, or norpseudoephedrine, are there ral other drugs are currently in clinical develop-
newer studies available, which is why it is men- ment.
tioned here.
 Important Nutritional interventions
M. May (*) and physical exercise are the basic
Serum Life Science Europe GmbH, therapy for obesity. As supportive
Hannover, Germany pharmacotherapy for an extended pe-
e-mail: [email protected] riod, orlistat, liraglutide, and a fixed
J. Jordan combination of naltrexone and bupro-
German Aerospace Center (DLR) Cologne, pion are approved in Germany.
Cologne, Germany
https://doi.org/10.1007/978-3-662-67662-2_76
576 M. May and J. Jordan
76.1 General Therapy Principles ven. A moderate weight loss of 5–10% of body
weight is associated with a significant improve-
Pharmacological therapy methods are suitable ment in the risk profile, but without supportive
for patients who do not respond sufficiently to pharmacological therapy, weight gain usually
non-pharmacological methods. The success of occurs again after a short time. A reduction in
a pharmacological therapy depends on the ac- hard clinical endpoints has not yet been demon-
companying therapy. For example, patients who strated for any obesity medication. In particular,
combined therapy with the formerly approved patients with high cardiovascular and metabolic
weight loss drug sibutramine with an intensive risk often require concomitant therapy with li-
lifestyle intervention lost more than 12 kg wit- pid-lowering agents, antihypertensives, and an-
hin a year. In contrast, body weight was redu- tidiabetic drugs.
ced by only 5 kg when sibutramine was combi-
ned with simple counseling in a doctor’s office  Important The medical goal of obe-
within a year. Therefore, pharmacological the- sity therapy is to reduce morbidity
rapy is described by professional societies (Ger- and mortality while simultaneously
man Obesity Society [DAG] and European As- increasing psychological and social
sociation for the Study of Obesity [EASO]) only well-being. Whether pharmacological
as an adjuvant therapy option and should be part therapy for obesity can achieve all of
of a multimodal treatment plan that includes die- these goals has not yet been proven.
tary changes, an exercise program, and behavio-
ral therapy.
Pharmacological therapy may be conside- 76.2 Challenges in Drug
red for a BMI over 30 kg/m2without comorbidi- Development for Obesity
ties, a BMI over 27 kg/m2 with risk factors/co-
morbidities, after a basic therapy for six months A significant obstacle to pharmacological obe-
has achieved only a weight loss of less than sity therapy is the fact that weight loss drugs are
5% compared to the initial weight, or if there not reimbursed by health insurance companies
has been a subsequent weight gain. In addition, (Social Security Code 5, § 34), even though the
the success should be checked four weeks after biological genesis and significance of obesity
the start of pharmacological therapy, and if the as a risk factor are clearly proven. At the same
weight loss is less than 2 kg, the pharmacologi- time, regulatory authorities have raised the bar
cal treatment should be discontinued. for new weight-reducing drugs. For new drugs, a
placebo-adjusted weight loss of at least 5% after
 Important Pharmacological therapy is one year of therapy is required, with a focus
only considered if non-pharmacologi- on reducing fat tissue rather than fat-free mass.
cal therapy fails. The success of phar- New obesity drugs should improve cardiovascu-
macotherapy depends crucially on the lar risk factors but not have central nervous side
accompanying therapy and is there- effects. It is likely that in the future, the cardio-
fore only indicated in combination vascular safety of all obesity drugs will have to
with basic therapy. be demonstrated before approval in the context
of larger outcome studies.
Obesity therapy aims to reduce morbidity and
mortality while simultaneously increasing  Important Drugs for obesity should
psychological and social well-being. Whet- achieve a placebo-adjusted weight
her pharmacological therapy for obesity can loss of at least 5% after one year and
achieve all of these goals has not yet been pro- have no serious side effects.
76 Medication Therapy for Obesity 577
76.3 Orlistat Weight loss with orlistat has been demon-

strated in numerous double-blind and placebo-
76.3.1 Mechanism of Action controlled trials, which have been summarized
in meta-analyses. In all studies, participants re-
Fat consumed with food can contribute to obe- ceived a hypocaloric diet. With a treatment du-
sity due to its high energy density. During fat ration of one year, the placebo-adjusted mean
digestion, triglycerides are broken down by in- weight loss with orlistat was 2.89 kg. The num-
testinal and pancreatic lipases. The resulting ber of patients with obesity achieving a 5–10%
free fatty acids and monoacylglycerol are in- weight loss increased significantly under therapy
corporated into micelles and absorbed through with orlistat. A positive effect of orlistat on body
the brush border of the small intestine. Orlis- weight was also demonstrated after two and four
tat (tetrahydrolipstatin) almost irreversibly in- years.
hibits intestinal lipase through a covalent bond. Total cholesterol and triglyceride levels in
Triglycerides and cholesterol esters are no lon- the blood decrease under treatment with orlistat.
ger broken down in the intestine, and absorption The mean reduction of LDL cholesterol under
decreases. orlistat is 0.26 mmol/l, while the HDL choles-
terol value hardly changes. Reduced choleste-
rol absorption may contribute to the reduction of
76.3.2 Pharmacokinetics LDL cholesterol.
 Important In 22 studies, for which

Orlistat is poorly absorbed, exerts its effect in
data on body weight with a treatment
the intestinal lumen, and is largely excreted un-
duration of one year were available,
changed in the stool. A smaller portion is proba-
the placebo-adjusted mean weight
bly metabolized in the intestinal wall and then
loss with orlistat was 2.89 kg.
excreted.
On average, blood pressure decreases by 1.5/1.4
mmHg under treatment with orlistat. The ef-
76.3.3 Drug Interactions
fect of orlistat on blood pressure was examined
in a meta-analysis of placebo-controlled clinical
Orlistat can significantly reduce the availability
trials. In patients with isolated systolic hyper-
of ciclosporin. Therefore, patients receiving cic-
tension, systolic blood pressure decreased by 9.4
losporin should not be treated with orlistat. Or-
mmHg under orlistat and by 4.6 mmHg under
listat has no significant influence on the phar-
placebo. A moderate reduction in blood pres-
macokinetics of warfarin. The effect of warfa-
sure was also observed in patients with elevated
rin and probably other vitamin K antagonists,
diastolic blood pressure values. The reduction in
such as phenprocoumon, is enhanced when
blood pressure under orlistat can be explained
given with orlistat. This is due to the reduced ab-
by the additional weight loss. A substance-speci-
sorption of fat-soluble vitamins, including vita-
fic effect is unlikely.
min K. Orlistat reduces the absorption of amio-
The Xendos study investigated whether orlis-
darone with unclear clinical relevance.
tat can prevent the onset of type 2 diabetes mel-
litus. A total of 3305 patients with a BMI ≥ 30
76.3.4 Efficacy kg/m2were randomized to lifestyle intervention
plus orlistat or a lifestyle intervention plus pla-
Orlistat reduces fat excretion in a dose-de- cebo. 52% of patients in the orlistat group and
pendent manner, with a maximum effect when 34% of patients in the placebo group completed
administering 100–120 mg of orlistat with the study. After four years, the cumulative inci-
meals. dence of type 2 diabetes was 9.0% in the pla-
cebo group and 6.2% in the orlistat group, corre- liraglutide have a considerably longer half-life.
sponding to a relative risk reduction of 37%; 37 Liraglutide increases insulin secretion, slows
patients had to be treated for four years to pre- gastric emptying, and reduces appetite. Blood
vent the onset of one case of diabetes. Patients sugar is reduced without increasing the risk of
with impaired glucose tolerance benefited more hypoglycemia, and weight loss occurs. Liraglu-
from treatment. In diabetics, orlistat reduces fas- tide was approved for weight loss in Europe in
ting glucose by 1 mmol/l and HbA1c value by 2015 under the brand name Saxenda®. Liraglu-
0.4%. tide must be administered subcutaneously.
The efficacy of orlistat in patients with non-
alcoholic fatty liver disease (NAFLD) was in-
vestigated in a smaller randomized, double- 76.4.2 Efficacy and Safety
blind, and placebo-controlled trial. All patients
participated in a weight loss program. After six Liraglutide was compared in doses of 1.2, 1.8,
months of therapy, patients treated with orlistat 2.4, and 3 mg against orlistat 120 mg and pla-
showed a greater reduction in liver fat content cebo over 20 weeks. For 3 mg liraglutide per
estimated by ultrasound. day, a weight loss of 7.2 kg was achieved, com-
pared to 2.8 kg in the placebo group and 4.1 kg
in the orlistat group. The occurrence of predia-
76.3.5 Adverse Effects betes was also reduced. In the SCALE Diabetes
study, liraglutide at doses of 1.8 and 3 mg was
Due to the mechanism of action, gastrointestinal compared in patients with overweight or obe-
side effects frequently occur, which decrease sity and type 2 diabetes mellitus against placebo.
with a reduction in the fat content of the diet. With the higher dosage, 54% of patients reduced
Oily stools are very common. Particularly un- their body weight by at least 5%, in the lower
pleasant is flatulence with involuntary bowel dose group 40%, and in the placebo group 21%.
movement. Steatorrhea is associated with in- In the SCALE Obesity and Prediabetes study,
creased oxalate absorption, which increases oxa- the time to onset of diabetes was extended 2.7
late excretion in the urine. Rarely, an acute de- times over 160 weeks with liraglutide 3 mg.
terioration of kidney function has been observed Since nausea and vomiting often occur, espe-
in patients with kidney damage. Since orlistat cially at the beginning of therapy, it is advisable
reduces the absorption of fat-soluble vitamins, to start with a low initial dose and then gradually
supplementation is advisable. increase the dose. A daily dose of 3.0 mg s. c. is
recommended for weight loss. The starting dose
of 0.6 mg daily can be increased weekly by 0.6
mg up to the target or tolerated maximum dose.
76.4 Liraglutide
The suspicion of an increased risk of develo-
ping pancreatitis has not been confirmed in cli-
76.4.1 Mechanism of Action
nical studies so far. However, slight increases in
lipase and amylase without signs of pancreati-
Liraglutide is an analogue of the endogenous tis have been observed. Furthermore, weight loss
glucagon-like peptide 1 (GLP-1) and has been can promote the formation of gallstones. Mo-
used for weight loss and for the treatment of derate reductions in most lipid parameters with a
type 2 diabetes for several years. Endogenous moderate increase in HDL have been observed.
GLP-1 is secreted postprandially by L-cells of Heart rate increases by 4-8 beats per minute,
the stomach, depending on the intestinal glucose systolic blood pressure decreases by 1.2 mmHg,
concentration. Its short half-life of only two mi- and diastolic blood pressure increases on ave-
nutes is due to the rapid enzymatic degradation rage by 0.6 mmHg. In the LEADER study, a re-
by dipeptidyl peptidase 4. GLP-1 analogues like duction in cardiovascular mortality and overall
mortality was demonstrated in patients with type miting, headache, insomnia, and dry mouth are
2 diabetes treated with the lower dosage appro- described. Although no severe psychiatric di-
ved for this indication. Whether there is a risk sorders or seizures occurred in studies, potential
of worsening diabetic retinopathy under liraglu- risks must be assessed using a checklist (www.
tide requires further clarification. The use for the cheplapharm.com/ppc-mysimba.de). Improve-
treatment of obesity is limited due to significant ment in glucose metabolism is mainly seen in
costs that must be borne by the patient. patients who do not have type 2 diabetes melli-
tus. Despite the significant weight loss, no cor-
responding blood pressure reduction was obser-
76.5 Naltrexone and Bupropion ved, and heart rate may increase. A cardiac out-
come study was compromised and discontinued
76.5.1 Mechanism of Action due to the publication of interim results, so the
cardiovascular safety cannot be conclusively as-
Bupropion and naltrexone have been approved sessed.
as monotherapy for other indications for some
time. Bupropion is a dopamine and norepine-
phrine reuptake inhibitor (SDNRI) used as an 76.6 Norpseudoephedrine/Cathin
antidepressant and for smoking cessation. Its
mode of action includes stimulation of anorexi- Various sympathomimetics, including norpseu-
genic proopiomelanocortin hormones (POMC doephedrine or cathin, have been approved in
neurons) in the hypothalamus, alpha-melano- Germany for short-term use (maximum of three
cyte-stimulating hormone release (α-MSH re- months) for many years. Type 2 diabetes melli-
lease), and resulting melanocortin-4 receptor tus is a contraindication for all sympathomime-
stimulation (MC4R stimulation). The μ-opioid tics, which further limits their use. In addition,
receptor antagonist naltrexone enhances the fee- safety data from large randomized control-
ling of satiety through its additional effect on α- led trials with hard endpoints are lacking. For
MSH release. The fixed-dose combination of 8 norpseudoephedrine/cathin, data from a smal-
mg naltrexone + 90 mg bupropion in extended- ler randomized controlled trial are available.
release tablet form was approved in Europe in In this phase 2b dose-finding study, a dose-de-
2015 under the trade name Mysimba®, and was pendent effect was observed with a placebo-ad-
launched in Germany in early 2018. justed weight loss of up to 6.7 kg in the highest
dose group and a weight loss of > 5% of base-
line weight in 78% of patients in this arm. Ho-
76.5.2 Efficacy and Safety wever, the cardiovascular risk profile is concer-
ning, as individual patients showed increases in
The combination drug naltrexone/bupropion blood pressure and heart rate. When conside-
(32 mg/360 mg) showed an average percentage ring only patients with hypertension, a highly
weight loss of 6.1% compared to 1.3% in the variable blood pressure reduction of systolic
placebo group in clinical trials, and even 8.1% 8 ± 12 and diastolic 4 ± 8 mmHg was obser-
compared to 4.9% with placebo in a study with ved alongside weight loss. Adverse events were
more intensive baseline therapy (COR-BMOD). mainly classified as cardiovascular and cen-
Weight loss is somewhat lower in diabetic pa- tral nervous system reactions to therapy and in-
tients, at 3.7% and 1.7% under placebo. Naltre- creased dose-dependently. Blood pressure, heart
xone/bupropion was well tolerated in the appro- rate, and psychological changes should be care-
val studies. Adverse effects such as nausea, vo- fully monitored during therapy.
76.7 Potential Future Obesity nervous glutamate receptors, blocks voltage-de-

Medications pendent sodium channels, and inhibits some car-
bonic anhydrases. The weight-reducing mecha-
76.7.1 Lorcaserin nism is not clarified. By combining both active
substances in relatively low doses, side effects
Serotonin is involved in the hypothalamic regu- should be reduced and additive effects on weight
lation of food intake. Serotonergic medications reduction should be achieved. In studies with
for the treatment of obesity, e.g. fenfluramine a total of over 3500 patients, about 75% achie-
and dexfenfluramine, were withdrawn from the ved a 5% and about 50% a 10% weight loss.
market due to an increased incidence of heart Two dosages of phentermine and topiramate
valve defects and pulmonary hypertension. Sti- were tested against placebo (7.5 mg/46 mg and
mulation of 5-HT2a and 5-HT2b receptors is 15 mg/92 mg). In the EQUIP study, patients lost
considered to be the cause of the cardiac side 12.6 kg with the higher dose, 6 kg with the me-
effects. For this reason, lorcaserin was develo- dium dose, and 1.8 kg with placebo within one
ped, a specific 5-HT2c receptor agonist without year. In the CONQUER study, the weight loss
effect on 5-HT2a and 5-HT2b receptors. Lor- after one year was 10.2 kg with the higher dose,
caserin has been approved in the United States 8.1 kg with the medium dose, and 1.8 kg with
under the trade name Belviq® since June 2012. placebo. The SEQUEL study, a one-year ex-
Due to the increased safety requirements of tension of the CONQUER study, showed a sus-
the EMA, the application for approval in Eu- tained weight loss and a lower side effect rate
rope was withdrawn by the manufacturer in in the second treatment year. In addition to the
May 2013. The weight-reducing effect of lor- weight-reducing effect, the combination prepa-
caserin was demonstrated in the BLOOM and ration also dose-dependently lowers blood pres-
BLOSSOM studies in more than 7000 people sure and metabolic risk markers. Side effects ob-
with overweight and obesity. In the BLOOM served more frequently and dose-dependently
study, participants lost an average of 3.6 kg under phentermine and topiramate included pa-
more weight than in the placebo arm, and in resthesias, headaches, constipation, dry mouth,
the BLOSSOM study, the weight loss was 5.8 upper respiratory tract infections, nasopharyngi-
kg with twice-daily administration and 4.7 kg tis, and headaches.
with once-daily administration compared to Topiramate is teratogenic, therefore it must
2.9 kg under placebo. More patients achieved a not be given to women of childbearing age who
weight loss of ≥5% under lorcaserin, and blood do not use an effective contraceptive method.
pressure decreased slightly. The incidence of In the USA, the low-dose fixed combination of
heart valve changes in echocardiography was phentermine and topiramate has been approved
the same in both groups. Dizziness and gastro- by the FDA under the trade name Qsymia® since
intestinal side effects were reported more fre- 2012 for patients with obesity and at least one
quently under lorcaserin than under placebo. comorbidity as adjunctive therapy. The EMA
initially rejected the application and requested
additional safety studies.
76.7.2 Low-Dose Fixed Combination
 Important Lorcaserin and the combi-
Phentermine/Topiramate
nation preparation topiramate/phen-
termine are now approved in other
Phentermine, which has long been used in the
countries for the therapy of obesity.
USA for obesity therapy, increases the release of
For a possible approval in Europe, sa-
noradrenaline in the brain. Topiramate is appro-
fety studies must be conducted.
ved for the treatment of epilepsy and migraine.
Among other things, topiramate activates central
References Hutton B, Fergusson D (2004) Changes in body weight

and serum lipid profile in obese patients treated with
orlistat in addition to a hypocaloric diet: a systematic
Allison DB, Gadde KM, Garvey WT et al (2012) Con-
review of randomized clinical trials. Am J Clin Nutr
trolled-release phentermine/topiramate in severely
80:1461–1468
obese adults: a randomized controlled trial (EQUIP).
May M, Schindler C, Engeli S (2020) Modern pharmaco-
Obesity (Silver Spring) 20:330–342
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Astrup A, Rossner S, Van Gaal L et al (2009) Effects of
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Nissen SE, Wolski KE, Prcela L, Wadden T et al (2016)
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Effect of naltrexone-bupropion on major adverse car-
374:1606–1616
diovascular events in overweight and obese patients
Donnelly D (2012) The structure and function of the glu-
with cardiovascular risk factors: a randomized clini-
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Pharmacol 166:27–41
Rossner S, Sjostrom L, Noack R et al (2000) Weight
Fidler MC, Sanchez M, Raether B et al (2011) A one-
loss, weight maintenance, and improved cardiova-
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Gadde KM, Allison DB, Ryan DH et al (2011) Effects of
Steinberg WM, Rosenstock J, Wadden TA, Donsmark
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M et al (2017) Impact of liraglutide on amylase, li-
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bidities in overweight and obese adults (CONQUER):
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type 2 diabetes: secondary analyses of pooled data
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and overweight adults (SEQUEL): a randomized, pla-
weight management. N Engl J Med 363:245–256
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Weight Stabilization
77
Martina de Zwaan
Contents
77.1 What Does Weight Stabilization Mean? . . . . . . . . . . . . . . . . . . . . . . . . . . . . 583
77.2 Psychological Factors and Behavioral Aspects . . . . . . . . . . . . . . . . . . . . . . . 584
77.3 Therapeutic Approaches for Weight Stabilization . . . . . . . . . . . . . . . . . . . . 587
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 588
77.1 What Does Weight initial weight that can be maintained for 1–2
Stabilization Mean? years after conservative weight loss treat-
ment, as even a small to moderate weight loss
Obesity is seen as a chronic disease with a means an improvement in health risks and qual-
high tendency for relapse, which is why suit- ity of life (Magkos et al. 2016). Some authors
able measures for long-term weight stabiliza- (Stevens et al. 2006) even consider a long-term
tion (“extended care”) should be recommended weight loss of only 3% of the initial weight to be
beyond the phase of weight loss. sufficient.
In the majority of patients, there is an The difficulty in maintaining weight is usu-
increase in body weight after the end of a ther- ally attributed to the inability of affected indi-
apy program—often up to the initial weight viduals to implement the necessary behavioral
(“yo-yo effect”) or even beyond. Within the first changes permanently. However, weight loss and
year after weight loss, the majority of patients weight maintenance or stabilization are depend-
regain between 30 and 50% of the lost weight, ent on several factors, such as
and more than half reach or exceed their initial
weight again after about 3–5 years. • environmental factors (availability of food),
Successful weight maintenance is often • physiology/neurobiology,
referred to as a weight loss of 5–10% of the • behavior, and
• psychosocial factors.
Today, it is known that genetic factors and the

changed living conditions of modern society
M. de Zwaan (*)
Department of Psychosomatic Medicine and with food abundance and reduced physical activ-
Psychotherapy, Hannover Medical School, ity (“obesogenic environment”) are strong oppo-
Hannover, Germany nents of conscious control of food intake. The
https://doi.org/10.1007/978-3-662-67662-2_77
584 M. de Zwaan
amount of food consumed increases with por-

tion size, regardless of taste. The constant avail- Factors related to weight regain
ability of food promotes consumption. Under • Attribution of obesity to medical
the given conditions of abundance, it is difficult reasons
to maintain permanent conscious behavioral • Medical reasons as motivation for
control. weight loss
Biological causes for weight regain after • External motivation
successful weight loss are not presented in this • Frequent weight fluctuations (“weight
overview. However, there is increasing evi- cycling”)
dence that the body’s adaptations to the weight- • Problematic eating behavior (binge eat-
reduced state favor weight regain. Increasing ing, emotional eating)
feelings of hunger, changes in peripheral appe- • Disinhibition of eating behavior by
tite-regulating hormones, and changes in neu- internal stimuli
ronal responses to food-related stimuli after • Dissatisfaction with body image
weight loss are held responsible for this (Melby • Psychosocial stress, critical life events
et al. 2017). • Lack of social support
• Mental disorders (e.g., depression,
 Important Especially after conserv- ADHD)
ative weight loss approaches, only • Impulsivity
a small proportion of patients are • Dichotomous thinking style
able to maintain their weight loss • Passive coping strategies
over a longer period of time. • Lack of self-confidence
77.2 Psychological Factors 77.2.1 Weight Course

and Behavioral Aspects
A renewed weight gain seems to occur more
It is well known that regular and balanced food quickly the more severe the previous calorie
intake with plenty of fruits and vegetables, restriction was. Frequent weight fluctuations
low-fat foods, and few additional snacks, self- (“weight cycling”) in the medical history rep-
monitoring of eating behavior and weight, and resent a negative predictor for weight main-
continuous physical activity are prerequisites tenance. Individuals with frequent weight
for long-term weight stabilization. However, fluctuations also report more frequent binge
psychosocial factors can pose a barrier to the eating.
behavioral changes necessary for weight stabili- A pronounced weight loss at the beginning
zation. Psychological factors also play a role in of a program is a positive predictor of long-term
long-term weight outcomes after bariatric sur- weight maintenance. A longer successful weight
gery (de Zwaan et al. 2007; Sarwer et al. 2011). stabilization phase appears to be a good predic-
Numerous psychological factors and behavioral tor for further weight maintenance; weight stabi-
aspects have been investigated as moderators lization seems to become easier over time.
and mediators of successful weight stabiliza-
tion and will be presented in detail (Varkevisser
et al. 2019; Ohsiek and Williams 2011; Elfhag 77.2.2 Reasons for Weight Loss
and Rössner 2005; Teixeira et al. 2005, 2012).
These variables overlap significantly and are Individuals who attribute their obesity to medi-
associated with each other. cal reasons and those who lose weight due
to pressure from their environment (external
77 Weight Stabilization 585
motivation) are less successful in the long term for the abandonment of behaviors that would
(Elfhag and Rösser 2005). Further studies deal favor weight maintenance (Byrne et al. 2004).
with the self-determination theory of motivation Modifying rigid thinking styles regarding eat-
(Teixeira et al. 2012) and recommend motiva- ing and weight might increase satisfaction with
tional interviewing to strengthen autonomous, achievements and represent a promising thera-
intrinsic motivation for maintaining the behav- peutic approach for weight maintenance.
ioral changes necessary for weight stabilization.
77.2.6 Eating for Emotion Regulation

77.2.3 Unrealistic Weight
Loss Expectations Eating is an effective method for many peo-
ple to improve their mood, at least in the short
Both patients and practitioners often have unreal- term. All previous studies consistently con-
istic expectations regarding the extent of weight clude that so-called “emotional eating,” when
loss. Expectations of weight loss include not only used frequently as a coping strategy, promotes
achieving a “dream weight,” but also improv- weight regain. In this case, people eat to feel
ing self-confidence and self-assurance, increas- better (“comfort eating”) or to distract them-
ing attractiveness, and improving health. If selves (“avoidance eating”). Common triggers
the often too high expectations are not met, the are loneliness, nervousness, marital or family
resulting dissatisfaction and demoralization can problems, depression, and anxiety (Byrne et al.
lead to self-stigmatization and the abandonment 2004). These triggers are experienced as less
of behaviors that support weight stabilization stressful by people who are able to maintain
(Teixeira et al. 2005; Hall and Kahan 2018). their weight than by those who regain weight.
People who lack adequate active coping strate-
gies tend to respond to stressful situations with
77.2.4 Dissatisfaction increased eating. This is especially relevant to
with Achievements dealing with relapse situations, which are often
inadequately managed by people with more
Patients need to be supported in directing the passive coping strategies (Elfhag and Rössner
focus of treatment towards health improvement 2005).
(“It’s not a diet, it’s a lifestyle”) (Kwasnicka
et al. 2019). Satisfaction with the achieved
weight, whether it corresponds to the target 77.2.7 Disinhibition of Eating
weight or not, promotes weight maintenance Behavior versus Restrained
(Gorin et al. 2007). Satisfaction with possibly Eating
smaller, but essential weight loss for the physi-
cal sequelae, therefore, represents a significant Disinhibition of eating behavior, i.e., loss of
starting point for weight maintenance programs. control of food intake, especially due to inter-
nal triggers such as thoughts, feelings, and emo-
tions, is associated with weight regain, whereas
77.2.5 Dichotomous Thinking Style restrained, controlled eating with regular weigh-
(“Black-and-White Thinking,” ing and monitoring of food intake is associated
“All-or-Nothing Thinking”) with better weight maintenance (Wing et al.
2008; Elfhag and Rössner 2005). In this context,
A dichotomous thinking style is related to the a somewhat more flexible control may be a bet-
extent of satisfaction with achieved weight loss ter predictor of weight maintenance than a very
and has proven to be a strong negative predictor rigid control over eating behavior.
586 M. de Zwaan
77.2.8 Binge Eating 77.2.10 Depression
Binge eating disorder (BED) is found in up to The relationship between depression and obe-
30% of participants in weight loss programs. sity was examined in a meta-analysis of pro-
Although the frequency of binge eating usually spective studies. The results show a reciprocal
decreases during weight loss and does not seem relationship. Individuals with depression have
to have an influence on the extent of weight loss, an increased risk of becoming obese (odds ratio
the recurrence of binge eating in the weight 1.58), and conversely, people with obesity seem
maintenance phase is quite clearly associated to have an increased risk of becoming depressed
with increased weight regain (de Zwaan et al. (odds ratio 1.55) (Luppino et al. 2010). This is
2005). particularly true for people with atypical features
Up to 50% of patients can be expected to of depression (Silva et al. 2020). This mutual
meet criteria for BED before obesity surgery. A influence might be explained by biological
negative influence of preoperatively diagnosed mechanisms. The inflammatory response, insu-
pathological eating behaviors such as “binge lin resistance, or HPA axis dysfunction found
eating,” “grazing,” “night eating,” or higher con- in obesity might promote the development of
sumption of sweets (“sweet eating”) on postop- depression. On the other hand, the intake of psy-
erative weight loss could not be demonstrated. chotropic drugs in patients with depression can
However, a proportion (up to 50%) of patients promote weight gain. Psychosocial factors such
with BED before surgery develop binge eat- as discrimination against people with obesity
ing or “loss of control (LOC) eating” and other or lack of self-care in depression also represent
eating behavior abnormalities after surgery. possible factors that may explain this reciprocal
Postoperative “LOC eating” not only has a nega- relationship between depression and obesity.
tive impact on the extent of weight reduction
but is also associated with increased general and
eating disorder-specific psychopathology (de 77.2.11 Social Support and Critical
Zwaan et al. 2010). Life Events
Social support has proven to be an important

77.2.9 Impulsivity aid for weight maintenance. However, whether
involving family members in treatment improves
Both in adulthood and childhood, it is becoming long-term outcomes is unclear, as the results are
increasingly clear that obesity seems to be asso- conflicting (Elfhag and Rössner 2005).
ciated with increased impulsivity (Chap. 66). Critical life events, such as physical illnesses,
There is growing evidence that increased impul- grief, or family disputes, not unexpectedly, pose
sivity is a significant negative predictor for suc- a risk factor for weight regain.
cessful weight maintenance. This is especially
true for children, adolescents, and adults suffer-  Important After obesity surgery,
ing from attention deficit/hyperactivity disorder there is usually an improvement in
(ADHD) (Cortese et al. 2016; Nigg et al. 2016). depressive symptoms and a signifi-
Impaired attention and strong impulsivity and cant and rapid increase in quality of
restlessness seem to negatively affect the ability life. However, postoperative persis-
to maintain control over eating behavior over a tent mental comorbidity (depression,
longer period. Children and adolescents receiv- “loss of control eating”) negatively
ing appropriate medication are able to maintain affects weight progression, so post-
their weight better. However, this requires accu- operative monitoring of the mental
rate diagnosis and monitoring of potential side situation is indicated.
effects, especially in people with obesity.
77 Weight Stabilization 587
Conclusion that have been used in partially large patient

Behavioral factors and psychological vari- groups. These include web-based programs
ables seem to play a significant role in the (Sorgente et al. 2017). These programs usu-
ability to successfully maintain or stabilize a ally last for several months, and regular par-
reduced body weight. ticipation is an important predictor of success;
this also applies to the regular use of internet
services (e.g., number of logins, participation
77.3 Therapeutic Approaches in chat rooms). However, the optimal contact
for Weight Stabilization frequency has not yet been clearly determined
(e.g., monthly or weekly). Meta-analyses con-
Since obesity is considered a chronic disease clude that longer-lasting treatment can improve
with a high tendency for relapse, patients should weight maintenance (Middleton et al. 2012;
be recommended and offered appropriate treat- Dombrowski et al. 2014; Peirson et al. 2015),
ment for long-term weight stabilization beyond with moderate effect sizes being reported.
the weight loss phase (Hall and Kahan 2018). Components of successful weight stabilization
strategies include:
Therapeutic Attitude and Approaches • Personal contact with the treatment team
to Support Weight Stabilization • Social support to stabilize behavioral changes
• Offer long-term follow-up care in the areas of nutrition and exercise
• Convey realistic expectations • Regular self-monitoring (including regular
• Promote intrinsic motivation weighing)
• Develop cognitive flexibility • Practicing problem-solving strategies
• Strengthen satisfaction with achievements • Strategies for relapse prevention and dealing
• Support beneficial behaviors (“habit with high-risk situations
formation”)
• Consider mental comorbidity  Important The need for weight
• Implement relapse prevention strategies stabilization programs is unques-
• If necessary, escalate therapy tionable, but they must be further
developed to increase efficacy.
The psychosocial aspects can provide clues for

the development of interventions to optimally Conclusion
support patients in the weight stabilization In order to stabilize weight in the long term,
phase. Skills taught in weight loss programs ongoing cognitive control of food intake is
are not necessarily identical to those for weight required. Environment and biology are pow-
stabilization. Motivation for such programs can erful adversaries. Expectations for long-term
be challenging, as a program that does not lead success should become more realistic, and
to weight loss is experienced as less rewarding. satisfaction with even minor long-lasting
This requires a change in attitude not only of the weight loss should be increased if possible.
patients themselves but also of healthcare pro- Pronounced psychological problems such as
fessionals who should place a greater emphasis ADHD, binge eating, and depression should
on the importance of weight stabilization. be specifically treated, as they can impair
In the literature, there is an increasing num- weight maintenance independently of biolog-
ber of evaluated weight stabilization programs ical and environmental factors.
588 M. de Zwaan
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Sarwer DB, Filks RJ, West-Smith L (2011) Dietary
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Dombrowski SU, Knittle K, Avenell A, Araújo-Soares
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V, Sniehotta FF (2014) Long term maintenance of
Silva DA, Coutinho EDSF, Ferriani LO, Viana MC
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Bariatric Surgery
and Metabolic Surgery 78
Arne Dietrich
Contents
78.1 Indication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 589
78.2 Surgical Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 591
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 599
78.1 Indication meet the necessary requirements (AWMF guide-

line). The indication for an bariatric surgery or
When determining the indication for the pro- metabolic intervention should be interdisci-
cedures described below, it must be decided plinary and include the following team mem-
whether it is primarily a bariatric surgery or a bers: surgeon, internist/endocrinologist, mental
metabolic operation, even if the same proce- health professional, and nutrition specialist, all
dures are performed in both cases. Bariatric with experience in obesity surgery. For meta-
surgery refers to a surgical intervention when bolic interventions, a diabetologist should be
weight loss is the primary focus for the patient involved; for adolescents, a pediatrician.
or the treatment team. Weight loss should natu-
rally lead to an improvement in comorbidities
or their prevention and an improvement in qual- 78.1.1 Indication for Bariatric
ity of life. Metabolic surgery includes surgical Surgery
interventions that primarily aim at the remission
or improvement of pre-existing type 2 diabetes Bariatric surgery should be considered when,
mellitus (DM2). even in the presence of coexisting DM2, weight
Bariatric surgery or metabolic interventions loss is the primary focus for the patient and the
should preferably only be performed in (cer- treating medical team, or when there is no DM2.
tified) centers with appropriate expertise that According to the current guideline (AWMF
guideline), the indication for bariatric surgery is
given under the following conditions:
1. For patients with a BMI ≥ 40 kg/m2without

A. Dietrich (*) comorbidities and without contraindications
Clinic and Polyclinic for Visceral, Transplant, after exhaustion of conservative therapy and
Thoracic and Vascular Surgery, Leipzig, Germany
after comprehensive education.
https://doi.org/10.1007/978-3-662-67662-2_78
590 A. Dietrich
2. For patients with a BMI ≥ 35 kg/m2with one The BMI limits for bariatric surgery were histor-
or more obesity-associated comorbidities ically established without evidence for BMI ≥40
when conservative therapy is exhausted. kg/m2 or BMI ≥ 35 kg/m2. However, it is cer-
3. Under certain circumstances, a primary indi- tain that patients who undergo bariatric surgery
cation for bariatric surgery can be made with- within these criteria lose weight more exten-
out prior conservative therapy. The primary sively and sustainably than after conservative
indication can be made if one of the follow- therapy. In terms of improving obesity-associ-
ing conditions is met: ated comorbidities and quality of life, the sur-
• for patients with a BMI ≥ 50 kg/m2, geries are significantly superior to conservative
• for patients in whom a conservative ther- therapy (Boido et al. 2015; Colquitt et al. 2014).
apy attempt has been deemed unsuccessful Advanced age (≥ 65 years) is not a contrain-
or futile by the multidisciplinary team, dication for bariatric or metabolic surgery. Older
• for patients with a particularly severe patients also benefit from the positive effects of
comorbidity and sequelae that do not these surgeries, with the improvement of qual-
allow for a delay in surgical intervention. ity of life being the main focus, especially in the
context of impending immobility and need for
care. Special regulations apply to children and
Obesity-associated comorbidities adolescents; we refer to the relevant guidelines
DM2, coronary heart disease, heart fail- (AWMF guideline).
ure, hyperlipidemia, arterial hyperten- Type 1 diabetes, chronic inflammatory bowel
sion, nephropathy, obstructive sleep apnea diseases such as Crohn’s disease and ulcerative
syndrome (OSAS), obesity hypoventila- colitis, or multiple sclerosis do not constitute
tion syndrome, Pickwick syndrome, non- contraindications for bariatric or metabolic sur-
alcoholic fatty liver disease (NAFLD) or gery per se.
non-alcoholic steatohepatitis (NASH), Obesity can be a cause of infertility in
pseudotumor cerebri, gastroesophageal women of reproductive age, which can also
reflux disease (GERD), bronchial asthma, determine the desire for surgery. A desire for
chronic venous insufficiency, urinary children is not a contraindication for bariatric or
incontinence, immobilizing joint dis- metabolic surgery; however, pregnancy should
ease, fertility limitations, polycystic ovary be consistently avoided during the period of
syndrome. weight loss (approx. 2 years) to prevent the risk
of inadequate supply to the fetus.
For indication according to points 1 and 2, an

exhausted conservative therapy is defined as fol- 78.1.2 Indication for Metabolic
lows (AWMF guideline): Surgery
• if after at least six months of comprehensive Regarding the indication, a metabolic interven-
lifestyle intervention in the last two years, a tion is to be considered when the improvement
reduction of the initial weight of >15% for of the diabetic metabolic situation is the main
a BMI of 35-39.9 kg/m2 and of >20% for a focus for the patient and the treating medical
BMI over 40 kg/m2 has not been achieved, team. The term “metabolic surgery” was intro-
• if the above weight loss could be achieved duced when it was observed that a high per-
through conservative measures and persis- centage of patients experienced remission of
tent obesity-associated diseases can be further pre-existing type 2 diabetes (DM2) after obesity
improved by bariatric or metabolic surgery, surgery. The improvement of the glycemic meta-
• if after successful weight loss, a weight gain bolic status usually occurs within a few days and
of >10% follows. is independent of weight loss.
78 Obesity Surgery and Metabolic Surgery 591
Patients with a BMI ≥ 40 kg/m2 and coexist- of the diabetic metabolic status, independent of
ing DM2 benefit from a metabolic intervention not weight loss.
only in terms of better glycemic control or reduced
antidiabetic medication but also from sustainable
weight loss. The outcome after surgery is superior 78.1.3 Contraindications for Bariatric
to the results of conservative therapy. Surgery and Metabolic
The indication for a metabolic interven- Surgery
tion should be made in collaboration with a
diabetologist. Contraindications include:
According to the current American Diabetes
Guideline and the German AWMF Guideline, • Unstable psychopathological conditions,
the indication for metabolic interventions can be untreated bulimia nervosa, active substance
made as follows: dependence
• Consumptive underlying diseases, malig-
1. From a BMI ≥ 40 kg/m2 and DM2, a meta- nant neoplasms, untreated endocrine causes,
bolic operation should be recommended as a chronic diseases that worsen due to postop-
possible therapy option, regardless of glyce- erative catabolic metabolism
mic control or the complexity of antidiabetic • Existing or immediately planned pregnancy
medication. In addition to the antidiabetic
effect, the patient also benefits from the If the diseases and conditions mentioned as con-
positive effects achieved through sustainable traindications can be successfully treated or if
weight loss. psychopathological conditions can be brought
2. Patients with a BMI ≥ 35 kg/m2 and < 40 kg/ into a stable state, a re-evaluation should be car-
m2 and coexisting DM2 should be recom- ried out.
mended a metabolic operation as a possible
therapy option if it is not possible to achieve
the diabetes-specific individual target values 78.2 Surgical Procedures
according to the National Care Guideline for
the treatment of DM2. 78.2.1 General
3. Metabolic surgery should be considered as a
possible therapy option for adults with a BMI Bariatric surgery and metabolic interventions
≥ 30 kg/m2 and < 35 kg/m2and coexisting are highly elective procedures. This means that
DM2 if it is not possible to achieve the diabe- prior to the intervention, surgical preparation
tes-specific individual target values according is carried out to minimize the surgical risks as
to the National Care Guideline for the treat- much as possible. This includes the best possible
ment of DM2. adjustment of comorbidities or the clarification
4. Metabolic surgery for adults with a BMI < thereof.
30 kg/m2and coexisting DM2 should only be In most centers, a protein-rich hypocaloric
performed within the framework of scientific diet is performed preoperatively. This serves to
studies. reduce liver volume and to get used to liquid
5. For patients of Asian origin, the BMI limit is food, which is required postoperatively. The
2.5 points lower. adherence of the patients to be operated on can
also be tested once again.
In particular, gastric bypasses lead to altered The need for follow-up care must be clear
intestinal hormone release, changes in food pref- to the patients, and they must consent to it. To
erence, bile acid metabolism, and microbiome, prevent a deficiency of vitamins or trace ele-
etc., which ultimately result in a normalization ments, the intake of appropriate supplements is
recommended.
592 A. Dietrich
Hospitals performing such interventions must

have interdisciplinary expertise and equipment
for patients with severe obesity.
The standard is that all procedures, includ-
ing revision and conversion operations, are per-
formed laparoscopically. Compared to the era
of open surgery, this has significantly reduced
perioperative morbidity and mortality, ultimately
helping obesity surgery gain international
acceptance.
78.2.2 Gastric Band
Synonym: Laparoscopic adjustable gastric band-

ing (LAGB)
In Germany, the number of gastric bands has
decreased significantly in recent years. This is
mainly due to the fact that the results are sig-
nificantly worse compared to the following
operations. The LAGB is a purely restrictive
procedure that limits food intake.
Modern gastric bands are adjustable. The Fig. 78.1  Schematic representation of gastric band
band can be tightened or loosened by filling it
through a subcutaneously placed port (LAGB).
The LAGB is placed as a ring just below the car- the diet, supplementation, etc., band adjustment
dia around the stomach, resulting in the forma- is also necessary. Under fluoroscopy, the width
tion of a small gastric pouch. By placing a cuff of the band is shown and, if necessary, adjusted.
around the band, slipping of the band is to be This makes follow-up care particularly more
prevented (Fig. 78.1). complex, especially at the beginning.
78.2.2.1 Results 78.2.2.2 Pros and Cons of the Gastric

The expected results after implantation of a gas- Band
tric band compared to the other standard pro-
cedures are shown in Table 78.1. It is thus the
procedure with the worst results. Patient selec- Advantages
tion is generally described as difficult, as a sig-
• Compared to the following surgical proce-
nificant percentage of those operated on do
dures, shortest operation duration and lowest
not or hardly benefit from the band placement.
perioperative morbidity and mortality
In addition, after 10 years, about 30% of all
• No malabsorption
patients require revision surgery due to band-
specific complications such as slipping or pen-
etration into the stomach. On the other hand,
band placement is the procedure with the lowest Disadvantages
intra- and postoperative morbidity and mortality
(compared to the other procedures). As with any • In terms of expected weight loss and remis-
procedure, lifelong follow-up care is required sion rates of comorbidities, worse results than
after gastric bands. In addition to monitoring the other surgical procedures described here
Table 78.1  Expected results after bariatric surgery or metabolic interventions (AWMF LL)
Procedure Weight loss Diabetes remission*
[%EWL] [%]
≤ 2 years > 2 to < 5 ≥ 5 years ≤ 2 years > 2 to < 5 ≥ 5 years
years years
Gastric band 28.7–481,a 43.5 (95% CI; 34.7 (95% CI; 62 (95% CI; 62.5 (95% CI; 24.8 (95%
52.3 (95% CI; 38.5, 48.5)3 23.5, 49.9)3 46, 79)2 42.2, 79.2)3 CI; 10.9,
48.7, 55.9)4 49.0 (95% CI; 57.2 (95% CI; 68 (95% CI; 78.7 (95% CI; 47.2)3
43.9 (95% CI; 44.0, 54.0)5 47.2, 67.2)4 50, 83)4 e 53.8, 100.0)5 f
40.3, 47.5)5 82.3 (95% CI;
71.4, 93.1)5 f
Sleeve gastrectomy 49–811 b 36.3 (95% CI; 49.5 (95% CI; 53.31 c 64.7 (95% CI; 58.2 (95%
46.7 (95% CI; 33.1, 39.5)3 39.3, 59.7)3 60 (95% CI; 42.2, 82.1)3 CI; 30.8,
42.9, 50.6)4 51–70)2 81.3)3
86 (95% CI;
73–94)4 e
Gastric bypass** 62.1–94.41 b 49.4 (95% CI; 61.3 (95% CI; 831 d 71.6 (95% CI; 75.0 (95%
80.1 (95% CI; 10.8, 88.0)3 55.2, 67.4)3 77 (95% CI; 59.9, 81.0)3 CI; 63.1,
65.7, 94.4)4 63.3 (95% CI; 64.9 (95% CI; 72–82)2 85.3 (95% CI; 84.0)3
58.0 (95% CI; 58.4, 68.1)5 44.3, 85.6)4 93 (95% CI; 70.9, 99.7)5 f
54.3, 61.8)5 85–97)4 e
84.0 (95% CI;
72.9, 95.0)5 f
Biliopancreatic diver- – – – 89 (95 % CI; – –
sion*** 83-94)2
Biliopancreatic diver- 56.0 (95% CI; 73.7 (95% CI; 49.3 (95% CI; 100.0 (95% CI; 98.9 (95% CI; 99.2 (95%
sion with duodenal 47.9, 64.2)5 69.0, 78.4)5 38.7, 59.9)3 93.2, 100.0)5 f 96.6, 100.0)5 f CI; 97.0,
switch 99.8)3
Data from high-quality systematic reviews (rated +/++ according to SIGN) with adult patients with BMI 30–55 kg/m2
and without exclusive study populations with comorbidities or revision procedures and before-after comparisons over
follow-up period.
There are no high-quality data for the mini-bypass because corresponding studies of sufficient quality are lacking.
* High heterogeneity regarding definitions of diabetes remission between primary studies and systematic reviews.
** RYGB, mini-bypass, and not further specified.
*** High-quality evidence at the level of a systematic review/meta-analysis not available for empty fields.
a Average follow-up 1.7 years
b Average follow-up 1.5 years
c Average follow-up 9 months
d Average follow-up 1 year
e 30 days after surgery
f Data endpoint “resolved or improved” used.
1 Trastulli et al. 2013
2 Panunzi et al. 2014
3 Yu et al. 2014
4 Chang et al. 2013: Results of OBS reported, as results were available for each data point and tended to be a more
conservative estimate. Follow-up time points 2 and 5 years used

5 Buchwald et al. 2009
• High reoperation rate, due to unachieved 78.2.3 Sleeve Gastrectomy (SG)

therapy goals or band-specific complications
• Intensive follow-up care due to band Sleeve gastrectomy is still a relatively new oper-
adjustment ation with a lack of long-term data from larger
• Difficult patient selection studies. The sleeve gastrectomy was established
594 A. Dietrich
as a “first step” in biliopancreatic diversion from high-quality studies are still lacking. In the
with duodenal switch (BPD-DS). Meanwhile, first two postoperative years, similar results can
the procedure has established itself as a solitary be expected after SG and proximal Roux-en-Y
intervention and accounts for about 50% of all gastric bypass, but there is a somewhat stronger
primary bariatric surgeries. weight regain after SG in the further course
As a result of the operation, a small curva- (details; Table 78.1).
ture-sided gastric tube is formed, which leads Regarding remission rates of type 2 dia-
to a restriction of food intake (Fig. 78.2). betes and other comorbidities such as
However, hormonal changes also occur (e.g., arterial hypertension, publications show a sig-
decrease in ghrelin due to the resection of the nificant improvement after SG. The remission
gastric fundus). It is common to measure the rate of type 2 diabetes after five years was 58%.
filling volume of the resectate at the end of However, bypass procedures show better results
the operation. If less than 500 ml of volume regarding the remission of pre-existing type 2
has been resected, a lower weight loss can be diabetes.
expected. SG is a safe operation. The data show that
the mortality rate in large centers is well below
78.2.3.1 Results 1%, and in current RCTs it is 0%. The morbid-
The current data on sleeve gastrectomy can be ity after SG is reported to be 7–8% and is thus
considered good, even though long-term data lower than with bypasses. The most common
complications are (post-)bleeding and fistulas of
the staple line or abscesses.
78.2.3.2 Pros and Cons of Sleeve

Gastrectomy
Advantages
• Technically safe even in very high BMI

range, unlike bypasses
• If therapy goals are not reached, there are
many surgical options, from repeated sleeve
gastrectomy to conversion to a bypass.
• Lower perioperative morbidity compared to
bypasses (but same mortality)
• No malabsorption, omitting prophylactic sup-
plementation (which is not recommended) is
probably less problematic in the long term
Disadvantages
• After 2–3 years, stronger weight regain than

with bypasses, often due to dilation of the
gastric sleeve
• Relevant rate of de-novo reflux disease or
worsening of pre-existing reflux disease
• Inferior to bypasses regarding remission rate
Fig. 78.2  Schematic representation of gastric sleeve of pre-existing type 2 diabetes
• Due to the long staple line and increased

pressure in the gastric sleeve, relatively high
rate of staple line fistulas (1–3%), which is
associated with an extension of hospital stay
78.2.4 Proximal Roux-en-Y Gastric

Bypass (pRYGB)
The proximal Roux-en-Y gastric bypass is the

best-studied of all bariatric surgery or metabolic
procedures, with follow-up data up to 20 years.
It was long considered the “gold standard” and
is the most frequently performed procedure to
date. Currently, the SG or pRYGB is the most
common procedure depending on the country.
However, the Omega-Loop gastric bypass is
increasingly being performed as an alternative to
pRYGB, without high-quality scientific data to
support it.
Numerous technical variants exist for the
“gastric bypass.” The procedure widely accepted
as the “gold standard” for obesity or metabolic
surgery in the past is a laparoscopically per-
formed proximal Roux-en-Y gastric bypass
(Fig. 78.3).
78.2.4.1 Results
Fig. 78.3  Schematic representation of proximal Roux-
The pRYGB provides good long-term results en-Y gastric bypass
regarding sustainable weight loss or remission
or improvement of pre-existing obesity-associ-
ated comorbidities. The proximal Roux-en-Y rate of pre-existing T2DM of 77% (compared:
gastric bypass leads to a sustainable weight loss BPD 89%, SG 60%) (Panunzi et al. 2014).
of approximately 13–14 BMI points up to five Regarding the remission rates of other pre-
years after surgery. existing comorbidities, pRYGB was superior
Compared to SG, the meta-analysis by Zhang or comparable to SG, as shown in a meta-anal-
et al. (2014) found a significant advantage for ysis as follows: for DM2 (OR 3.29), arterial
pRYGB regarding %EWL from the second hypertension (OR 1.29), dyslipidemia (OR
postoperative year (mean difference in favor 1.15), sleep apnea (OR 1.46), however, accept-
of RYGB (mean difference after two years = ing more adverse events OR 1.98 (Zhang et al.
5.77% [95% CI; 4.29; 7.25], mean difference 2014).
after four years = 2.68% [95% CI; 0.18; 5.19]) For gastric bypass procedures, a mortality
Regarding the remission rate of pre-existing rate of 0.38% in RCTs and 0.72% in observa-
DM2, a significant advantage for pRYGB was tional studies is reported, for SG it was 0.29 and
also found. 0.34%, respectively. Morbidity is reported at an
Regarding the remission rate or improvement average of 21% in RCTs (Chang et al. 2013).
of T2DM, a meta-analysis showed a remission
596 A. Dietrich
The most common procedure-specific com- 78.2.5 Omega-Loop Gastric Bypass

plications are (post-)bleeding, staple line fistu-
las, anastomotic insufficiencies, or abscesses. Synonym: Mini Gastric Bypass (MGB)
Due to the exclusion of the stomach, duode- The MGB (Fig. 78.4) was first described by
num, and proximal jejunum, deficiencies after Rutledge in 1997. The number of operations is
pRYGB are more common than after SG. increasing, and it is considered a safe procedure.
If the stomach is transected proximally with The principle of this procedure is the formation
a small pouch as propagated, no (or only very of a small curvature-sided long gastric pouch up
small amounts of) acid can be produced in the to the antrum (up to 18 cm long). In advanced
pouch after reconstruction. Thus, pRYGB also age or vegetarians, shorter biliary limb lengths
represents an effective anti-reflux operation. are preferred (180–200 cm), as well as recom-
mended for less obese type 2 diabetics without
78.2.4.2 Pros and Cons of the Proximal massive obesity (150 cm).
Roux-en-Y Gastric Bypass
Procedure 78.2.5.1 Results
Although the MGB is already relatively wide-
Advantages spread, there are almost no outcome data from
high-quality studies.
• Long considered the “gold standard” of obe-
It can be assumed that the results are similar
sity surgery, with very good available data
to those of pRYGB, but if longer small intes-
with long-term results
tine sections (longer biliopancreatic loop) are
• Effective treatment of pre-existing reflux
made, a stronger weight loss can be expected.
disease
• Bypassing the duodenum leads to hormonal
changes, independent of weight loss/restric-
tion, which favorably influence pre-existing
type 2 diabetes
• Weight regain lower than with sleeve gastrec-
tomy (SG)
• Higher remission rates of pre-existing type 2
diabetes than with SG
Disadvantages
• Risk of dumping syndrome, especially with

improper nutrition
• Lifelong supplementation necessary for pre-
vention of deficiency
• No endoscopic access to the remnant stom-
ach or duodenum
• More complex surgical options for conver-
sion if therapy goal is not achieved (com-
pared to SG)
• Internal hernias
• Technically not possible in higher BMI range
and with unfavorable fat distribution (so- Fig. 78.4  
Schematic representation of Omega-Loop
called apple type) Gastric Bypass
However, in the long term, the risks of increased • No endoscopic access to the remnant stom-
malabsorption (deficiency of vitamins or trace ach or duodenum
elements, hypoproteinemia) or, for example, • Uncertain data regarding negative effects of a
fatty stools are accepted. potential bile reflux into the gastric pouch or
The morbidity is lower than with pRYGB, as the esophagus
only one anastomosis is created. Internal hernias • If therapy goals are not achieved, surgical
also seem to be less common. However, there options for conversion are comparatively
are few or no high-quality data from RCTs on more complex (compared to SG)
this.
Whether the MGB should be used in patients
with reflux disease is controversial. Due to the 78.2.6 Biliopancreatic
surgical technique, bile acids from the biliopan- Diversion (BPD)
creatic loop can enter the gastric pouch, which
can lead to bile reflux in predisposed individu- Synonym: Scopinaro operation
als. It is also historically known from ulcer sur- This is a highly malabsorptive procedure that
gery (similar reconstruction in Billroth II gastric has hardly gained any further distribution out-
resection) that bile in the stomach can lead to side of Italy (Fig. 78.5). The procedure is also
ulcerations and even carcinomas. As a result of rarely performed in Germany. Similar to the
these concerns, the MGB is sometimes contro- Omega-Loop gastric bypass, there are few data
versially discussed and is not offered or only from high-quality studies.
offered for older patients in some clinics.
After MGB, a weight loss of 11.3 BMI points 78.2.6.1 Results
(4.1–18.6 kg/m2) or an EWL of 61–69% after Regarding weight loss and remission of pre-
twelve months can be expected. In the medium existing DM2, BPD seems to be superior to the
term, an expected EWL of 64–85% after two bypasses described above. However, there are no
years or 73–77% after five years is reported high-quality data in this regard.
(Georgiadou et al. 2014; Quan et al. 2015). Due to the very short common channel, there
is a pronounced malabsorption, which results
78.2.5.2 Pros and Cons of the Omega- in deficiencies of vitamins, trace elements, or
Loop Gastric Bypass protein occurring more frequently compared to
the above procedures, despite the prophylactic
Advantages intake of multivitamin preparations with trace
elements. This is also a reason why the proce-
• Compared to pRYGB, shorter operation time dure is not performed by various centers. Fat
and lower morbidity, as only one anastomosis stools and diarrhea can also lead to a reduction
• Compared to pRYGB, also possible in higher in quality of life. The perioperative complication
BMI range, as the pouch is very long and the rates are comparable to those of pRYGB.
small intestine loop does not have to be led
so far to the anastomosis 78.2.6.2 Pros and Cons
of Biliopancreatic Diversion
Disadvantages (according to Scopinaro)
Advantages
• With a long biliopancreatic loop, increased
risk of suffering a deficiency despite • Superior due to the pronounced malabsorp-
supplementation tion of the procedure regarding weight loss
• Especially with improper nutrition, there is a and remission of pre-existing DM2
risk of dumping syndrome • Long-term stable surgical outcome
598 A. Dietrich
usually performed in two steps, which combines

restriction (sleeve gastrectomy; 1st step) with
malabsorption (postpyloric bypass with short
common channel; 2nd step) (Fig. 78.6).
Although not as pronounced as with BPD,
the side effects of malabsorption described
above can occur. In addition, due to the surgi-
cal technique, there is a higher perioperative
morbidity and mortality due to the dissection at
the head of the pancreas and the risk of insuf-
ficiency of the duodenal stump. BPD-DS can be
performed in one or two stages, with the two-
stage approach being more common, especially
in the higher BMI range.
78.2.7.1 Results
BPD-DS offers very good long-term results
regarding weight loss and remission of
Fig. 78.5  Schematic representation of biliopancreatic

diversion (according to Scopinaro)
Disadvantages
• Pronounced disadvantages of malabsorption

such as fat stools, diarrhea, and deficiency
states despite supplementation (which is why
the procedure has not gained widespread
acceptance and is not offered in many places)
• High reoperation rate due to excessive
malabsorption
• Rare procedure, only a few centers have
expertise
• Especially with improper nutrition, there is a
risk of dumping syndrome
• No endoscopic access to the remnant stom-
ach or duodenum
78.2.7 Biliopancreatic Diversion

with Duodenal Switch
The biliopancreatic diversion with duode-

Fig. 78.6  Schematic representation of biliopancreatic
nal switch (BPD-DS) is a complex operation, diversion with duodenal switch
pre-existing DM2. After BPD-DS, complete patients with obesity after failure of conserva-
remission of pre-existing T2DM can be expected tive therapy and refusal of surgery or in cases
in 88–99%. of contraindications for surgery as part of an
Although the common channel is not as short appropriate accompanying program. In patients
as with BPD, stronger malabsorptive effects can with severe obesity, where surgery is not possi-
also be expected with BPD-DS than with the ble or borderline, treatment with a gastric balloon
pRYGB or MGB described above, and intensive can be performed prior to surgery to establish
follow-up of patients, including laboratory con- (safe) operability. This is an individual decision.
trols, is required. As already noted above, perio- Scientific studies proving better outcomes do not
perative morbidity and mortality are higher than exist.
with the other procedures described here. For the Endobarrier™, aspiration therapy
techniques, endoscopic suturing procedures, or
78.2.7.2 Pros and Cons mucosal manipulations, etc., there are currently
of Biliopancreatic Diversion no valid data regarding their sustainability and
with Duodenal Switch risk-benefit ratio, so the application of these endo-
scopic procedures (except gastric balloon) should
Advantages only be carried out within scientific studies.
• Due to the restriction (sleeve gastrectomy)

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The long-term effects of bariatric surgery for type 2
Psychosomatic Aspects
of Bariatric Surgery 79
Stephan Herpertz and Martina de Zwaan
Contents
79.1 On the Question of Indication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 601
79.2 Surgical Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 602
79.3 Preoperative Diagnostics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 602
79.4 Mental Well-Being After Bariatric Surgery . . . . . . . . . . . . . . . . . . . . . . . . 603
79.5 Bariatric Surgery and Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . 604
79.6 Increase in Eating Behavior Disorders (e.g., grazing, LOC eating) . . . . . 604
79.7 Self-Harming Behavior, Suicide, and Suicidality . . . . . . . . . . . . . . . . . . . . 604
79.8 Bariatric Surgery and Addiction Behavior . . . . . . . . . . . . . . . . . . . . . . . . . 605
79.9 Psychological Predictors for Weight Development . . . . . . . . . . . . . . . . . . . 605
79.10 Corrective Plastic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 606
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 606
79.1 On the Question of Indication the exception. About a third to a half of the
original therapy responders have regained their
About half of participants in a conservative initial weight within one year after the end of
weight loss program (“lifestyle” interventions) treatment, and even with long-term treatments,
reduce their weight by 5–10%, which repre- on average, only 4–5% of the initial weight loss
sents the minimum weight loss in terms of a can be maintained (Look AHEAD Research
clinically significant reduction in somatic risk Group 2014). In particular, with severe obesity
parameters. In addition to the high rate of non- (class 3; BMI > 40 kg/m2), the success of a con-
responders, weight regain is more the rule than sistent conservative measure is likely to be even
lower. The figures here range between 2 and
6.9% weight loss (Mingrone et al. 2015).
According to the German guideline
S. Herpertz (*)
Department of Psychosomatic Medicine and “Surgery for Obesity and Metabolic Diseases”
Psychotherapy, LWL-University Clinic, Ruhr- (2018), the indication for surgical intervention
University Bochum, Bochum, Germany after failure of conservative therapy exists for
patients with obesity class 3 (BMI> 40 kg) or
M. de Zwaan for patients with obesity class 2 (BMI> 35 kg/
m2) with significant comorbidities (e.g., type 2
Hannover, Germany diabetes mellitus).
https://doi.org/10.1007/978-3-662-67662-2_79
602 S. Herpertz and M. de Zwaan
79.2 Surgical Approach

Mental Status
While purely restrictive procedures (gastric • Mental disorders including eating
band, gastroplasty) have largely been aban- disorders
doned, the gastric sleeve (gastric sleeve resec- • Psychopathological findings
tion), in which 90% of the gastric fundus and • Inpatient psychiatric/psychosomatic
corpus are removed, leaving a tubular remnant treatments
stomach, is now one of the most common sur- • Outpatient treatments, psychotherapy,
gical procedures within bariatric surgery, along psychotropic drugs
with the Roux-en-Y bypass. While gastric band • Currently in treatment?
and gastroplasty are intended to limit food
intake (referred to as restrictive techniques), the
various gastric bypass procedures additionally
have a malabsorptive effect, i.e., a restriction of Eating and Drinking Behavior
the metabolism of the ingested food. The Roux- • Objective and/or subjective binge eating
en-Y bypass is considered primarily restrictive • Loss of control while eating (binge eat-
with a malabsorptive component, while the bili- ing, grazing, night eating)
opancreatic bypass (BPD) with or without duo- • Drinking amounts, preferred beverages
denal switch (DS) derives its main effect from (high-calorie drinks, alcohol)
the malabsorptive effect. • Compensatory measures (vomiting, lax-
All surgical interventions are performed atives, diuretics)
almost exclusively minimally invasively, which • Restrained eating behavior (constant
is gentler and less complicated for patients attempt to diet)
(lower risk of wound healing disorders due to • Attitude towards and evaluations of
smaller scars, faster mobilization). weight and figure
• Portion sizes, food selection
79.3 Preoperative Diagnostics
Up to 50% of patients with severe obesity who Weight History

present for surgical intervention meet the cri- • Self-report on the development of obe-
teria for a current, treatment-requiring, mental sity (“weight autobiography”)
disorder (Dawes et al. 2016). Up to 30–40% • Overweight/obesity as a child
are in mental health treatment and/or take psy- • Family burden (overweight/obesity in
chotropic drugs, especially antidepressants. A the maternal or paternal line)
preoperative psychological evaluation should • Life events related to weight gain
ideally be carried out by a mental health pro- • Previous weight loss attempts and their
fessional experienced in obesity treatment. This successes
refers to colleagues from the fields of psycho-
somatic medicine, psychiatry, and clinical psy-
chology. Often, the question is about state or
trait, i.e., whether mental health factors signifi- Stress, Problem-Solving Ability
cantly influence the development of obesity or (Coping)
whether the mental health symptoms are a con- • Psychosocial stressors
sequence of obesity and, for example, the asso- • Expected life changes in the year after
ciated societal stigmatization. The following surgery
provides an overview of the “diagnostic building
blocks.”
79 Psychosomatic Aspects of Obesity Surgery 603
79.4 Mental Well-Being After

• Eating as the sole stress management Bariatric Surgery
(coping)
• Positive aspects of obesity (e.g., The vast majority of studies show a signifi-
protection) cant improvement in mental health and various
• Sexual or physical abuse experience psychosocial parameters such as interpersonal
• Intelligence level, cognitive functions relationships, sick leave, and employability.
• Neuropsychological testing if needed Mental comorbidity, especially depressive and
anxiety disorders, generally decrease post-
operatively. Self-esteem and social behav-
ior, including partnership and sexuality, also
Social Support improve. The rate of return to work ranges
• Acceptance and help in partnership, between 16 and 36%. It is obvious that these
family, and circle of friends findings also have a positive impact on qual-
• Possible negative consequences (e.g., ity of life. This applies almost without excep-
attractiveness as a problem for the tion for the first years after the operation, with
spouse)? physical quality of life improving significantly
• Practical help compared to the preoperative status, rather
• Moral support than mental quality of life. In longer follow-
• Openness towards others, hiding (e.g., ups, a declining trend in quality of life can be
for fear of discrimination or fear of observed, although the study findings are not
failure) consistent (Herpertz et al. 2019).
Surgical complications such as band disloca-
tion, pouch dilation, etc., are rarely the cause of
an unsatisfactory postoperative course; rather,
Motivation, Compliance in many cases, an adherence problem can be
• Extent of motivation (e.g., from 0 to 10) assumed, which in turn may be due to mental
• Primary reasons for the surgical inter- health problems. An example is a “suboptimal”
vention (health, mobility, appearance, to disturbed affect regulation, which is associ-
etc.) ated with high-calorie eating behavior. Thus, the
• Intrinsic (self-) or extrinsic motivation consumption of large amounts of sweets, fast
(e.g., by relatives) food, etc., often serves as an attempt to at least
• Previous handling of medical temporarily neutralize dysphoric moods. Affect
recommendations regulation disorders can also be an expression of
a general disturbance of impulsivity in the sense
of an impulse control disorder, as is primarily
found in certain personality disorders such as
Expectations emotionally unstable (borderline) personality
• Weight reduction as the sole “problem disorder. Sexual abuse in the medical history can
solver” (quick fix) trigger fear of sexual retraumatization during
• Realistic expectations of the extent of weight loss; an unstable partnership can break
weight loss (normal weight is rarely up due to the partner’s change.
achieved)
 Important Bariatric surgical meas- other foods, the intake of small amounts of food,
ures and weight loss cannot solve and the necessity of intensive chewing than to a
psychosocial problems. conscious attempt at weight loss.
79.5 Bariatric Surgery and Eating Postoperative Outcomes in Binge

Disorders Eating Disorder
1. Decrease in BED, partly due to the
The prevalence of binge eating disorder (BED) changed postoperative anatomical
in patients with obesity before surgery is about conditions
15–30% (Dawes et al. 2016). However, other 2. Decrease in problematic attitudes
forms of non-normative, usually hypercaloric towards eating, weight, and body shape
eating behavior, such as night-eating syndrome, 3. Decline in eating binges
“grazing” in the sense of consuming small 4. Reduced negative attitudes towards
amounts of food throughout the day without weight and body shape, however,
feeling hungry, loss of control eating (LOC), possibly an increase in eating behavior
emotional eating, eating without hunger, or disorders (e.g., grazing, LOC)
addictive eating are also often observed. Eating
disorders decrease in the short term after bariat-
ric surgery but seem to increase again over time.
The amounts of food consumed during an eat- 79.6 Increase in Eating Behavior
ing binge are generally smaller after restrictive Disorders (e.g., grazing, LOC
surgical procedures than before the operation. eating)
Patients with an eating disorder before surgery
have a higher risk of problematic eating behav- After an initial weight loss, the majority of
ior after surgery (Opozda et al. 2016), which in patients experience a weight gain 1–2 years after
turn is associated with less weight loss or greater surgery, which usually leads to a weight pla-
weight gain. teau. The affected individuals often perceive this
Considering the relationship between pre- weight gain with great fears. The consequence
and postoperative eating behavior and their is often a conscious restrictive eating behavior,
predictive function for postoperative weight which, in the case of a respective vulnerability,
development, postoperative eating behavior is can promote the recurrence of binges.
clearly more informative (Opozda et al. 2016).
The question of which patients will develop eat-
ing binges again and in which the eating binges 79.7 Self-Harming Behavior,
will permanently cease is currently difficult to Suicide, and Suicidality
answer preoperatively (Herpertz et al. 2018).
In a minority of patients, LOC eating occurs Numerous studies in recent years suggest an
for the first time after surgery. So far, there are increase in mortality due to accidents, drug
only individual case reports in the literature overdoses, and suicides in patients after bari-
on the postoperative development of anorexia atric surgery compared to the general popula-
or bulimia nervosa. An adequate distinction tion or individuals with obesity who have not
between normal and pathological eating behav- undergone bariatric surgery (Müller et al. 2019),
ior after surgical obesity therapy is generally with the majority of suicides occurring within
difficult. Some patients show frequent vomiting the first three years after surgery (Tindle et al.
or regurgitations, but in most cases, this is more 2010). In a systematic review, Peterhänsel and
likely due to the initially difficult adjustment to co-authors (Peterhänsel et al. 2013) describe a
fourfold increased suicide risk in patients after 79.9 Psychological Predictors

bariatric surgery compared to the general popu- for Weight Development
lation. This risk seems to apply particularly to
younger patients. The risk of self-harm in bariat- A psychiatric, psychosomatic, or psychologi-
ric surgery patients has also been the subject of cal assessment is important, not least because
several larger studies recently, with the majority mental comorbidity, as described above, is gen-
of studies observing a postoperative increase in erally high in this patient group. With regard
self-harm (Lagerros et al. 2017). The majority to the prognosis of both postoperative weight
of these patients had a history of a mental health development and psychological well-being, the
diagnosis. Whether and what etiological rela- question of psychological predictor variables is
tionship exists with the bariatric surgery inter- repeatedly raised. Personality variables and Axis
vention remains unclear (Mitchell et al. 2013). I mental disorders of the DSM-IV do not pro-
However, it is clear that multidisciplinary bariat- vide reliable predictors for postoperative weight
ric surgery teams should always include experts development or psychological well-being after
in mental health disorders if possible. surgery. Rather, the severity of a preoperative
mental illness seems to be of predictive value. In
patients with severe mental disorders and multi-
Conclusion ple inpatient psychiatric treatments in their his-
Despite low absolute suicide numbers, the tory, not only insufficient weight loss but also
incidence of self-harming behavior and sui- insufficient improvement in psychological well-
cides increases postoperatively. being is often observed. It is important to iden-
tify these patients preoperatively and provide
appropriate treatment.
79.8 Bariatric Surgery Binge eating before surgery does not repre-
and Addiction Behavior sent a stable predictor for weight loss, regardless
of the surgical technique. However, patients who
Meta-analyses and large cohort studies (Spadola develop binge eating again after surgery seem to
et al. 2015; Backman et al. 2016; King et al. lose less weight and gain more weight after the
2017; Ibrahim et al. 2019) have shown that prob- “honeymoon phase” of 1–2 years than patients
lematic alcohol consumption can increase after who never had binge eating or did not develop
obesity surgery. While it was originally thought binge eating postoperatively. There is also evi-
that an increase in problematic alcohol con- dence that these patients may have an increased
sumption occurs mainly after bypass procedures rate of medical complications. The greater con-
(alcohol is absorbed much faster, higher maxi- sumption of sweets is often considered a nega-
mum alcohol concentrations are reached, and the tive predictor for a purely restrictive surgical
elimination time is prolonged), the comparable procedure. In contrast to the recurrence of binge
result after sleeve gastrectomy suggests that other eating, the preference for sweet foods postop-
factors, such as a change in reward processing eratively does not seem to be a reliable predic-
in the brain, could play a role in the postopera- tor for weight gain. Little is known about the
tive increase in problematic alcohol consump- postoperative course of patients with full-blown
tion. This would support the model of “addiction bulimia nervosa; however, appropriate therapy
transfers” or the occurrence of “cross addiction.” should be provided preoperatively in this case,
which would be urgently indicated even without
surgical intervention. There is evidence that the
Conclusion extent of weight loss may not be affected, but
Postoperatively, suicidality and problematic the eating disorder may persist unchanged and
alcohol use should be actively inquired about. possibly increase the complication rate.
Patients must be informed about the potential
risk.
different body regions. Only patients who have

Predictors for Weight Development already lost weight and have been able to main-
tain their target weight for at least six months
No reliable predictors are eligible for body tightening operations.
• Personality variables, Axis I mental dis- Possible dysmorphophobia or fundamentally
orders of the DSM-IV unrealistic aesthetic expectations must also be
• Binge eating preoperatively ruled out preoperatively (AWMF 2018).
• Consumption of sweets
Reliable predictors Conclusion
A key goal of the preoperative psychological
• Preoperative severe and unstable mental
evaluation is, in addition to a detailed psy-
disorders
chological and biographical history, to clarify
• Patients with multiple psychiatric or
the patient’s motivation, knowledge about
psychosomatic prior treatments
the planned procedure, and expectations of
the procedure (“problem solver”, quick fix,
There is no evidence for a general exclusion of achieving normal weight). The evaluation
patients with mental illnesses from bariatric should address the expected social support,
surgery. BED and other eating behavior abnor- reduce anxiety about the surgery, and lay the
malities also do not represent a general contrain- foundation for postoperative adherence.
dication for bariatric surgery. Nevertheless, the
German guideline (AWMF 2018) lists unstable
psychopathological conditions (e.g., suicidal-
ity, acute psychotic states), active substance References
dependence, and untreated bulimia nervosa as
contraindications. After mental stabilization or AWMF S3 Leitlinie „Chirurgie der Adipositas und
metabolischer Erkrankungen“. Version 2.3 (Februar
successful treatment, a psychological re-evalua- 2018) AWMF-Register Nr. 088-001
tion is recommended. Backman O, Stockeld D, Rasmussen F, Näslund E,
Marsk R (2016) Alcohol and substance abuse, depres-
sion and suicide attempts after Roux-en-Y gastric
bypass surgery. Br J Surg 103:1336–1342
79.10 Corrective Plastic Surgery Dawes AJ, Maggard-Gibbons M, Maher AR, Booth MJ,
Miake-Lye I, Beroes JM, Shekelle PG (2016) Mental
As a consequence of massive weight loss, large health conditions among patients seeking and under-
aprons of fat, particularly in the abdominal and going bariatric surgery: a meta-analysis. JAMA
315:150–163
chest area as well as on the thighs and upper Herpertz S, Kessler H, Jongen S (2018) Psychosomatic
arms, which can sometimes take on grotesque and Psychosocial Questions Regarding Bariatric
proportions and be experienced as very distress- Surgery: What Do We Know, or What Do We Think
ing by those affected. In addition to aesthetic We Know? Z Psychosom Med Psychother 63(4):344–
369. https://doi.org/10.13109/zptm.2017.63.4.344
problems, bacterial and fungal infections are not Herpertz S, Jongen S, Kessler H (2019)
uncommon due to limited hygiene possibilities. Adipositaschirurgie – ein narratives Review.
Plastic surgery is the only option for remov- Psychotherapeutenjournal 18:380–388
ing these excess skin folds. Not every patient Ibrahim N, Alameddine M, Brennan J, Sessine M,
Holliday C, Ghaferi AA (2019) New onset alcohol
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after massive weight loss that body-tightening King WC, Chen JY, Courcoulas AP, Dakin GF, Engel
operations are necessary in certain areas. Some SG, Flum DR, Hinojosa MW, Kalarchian MA, Mattar
SG, Mitchell JE, Pomp A, Pories WJ, Steffen KJ,
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study. Surg Obes Relat Dis 13:1392–1402 Psychiatry Rep 21:84
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(2015) Bariatric–metabolic surgery versus conventional Spadola CE, Wagner EF, Dillon FR, Trepka MJ, De La
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5 year follow-up of an open-label, single-centre, ran- use among postoperative bariatric patients: a system-
domised controlled trial. Lancet 386:964–973 atic review of the emerging research and its implica-
Mitchell JE, Crosby R, de Zwaan M, Engel S, Roerig tions. Alcohol Clin Exp Res 39:1582–1601
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New Media in Obesity
Treatment 80
Christina Holzapfel
Contents
80.1 Digitalization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 609
80.2 Telemedical Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 610
80.3 Telephone-based Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 611
80.4 Internet-based Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 612
80.5 Use of Smartphones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 614
80.6 Digitale-Versorgung-Gesetz . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 616
80.7 Outlook . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 617
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 618
80.1 Digitalization • Overcoming spatial distance

• Use of information and communication
Digitalization in the healthcare sector is technology
characterized by various terms, e.g., “digi-
tal health,” mobile (m) health, electronic (e) Digitalization can overcome spatial dis-
health, telemedicine, which are not subject to a tances, making therapy access easier and more
uniform definition. In general, it is about vari- cost-effective due to reduced mobility effort.
ous care and treatment modes in the medical Furthermore, digital approaches promise to
field that take place without direct eye con- reduce inefficiency, increase quality, and per-
tact with patients. The following elements are sonalize the offer for patients. On the part of
characteristic: patients and users, digital approaches facilitate
and promote self-observation (“self-monitor-
• Provision of a health service ing”) through data collection and tracking (e.g.,
• Application in prevention, diagnostics, smartphones, activity trackers). Moreover, a cer-
therapy tain degree of anonymity reduces the inhibition
threshold for affected individuals to participate.
Most weight management interventions (e.g.,
programs, training, counseling) are conducted
through face-to-face conversations in individual
C. Holzapfel (*)
Institute for Nutritional Medicine, Technical or group sessions. Due to the high prevalence
University of Munich, School of Medicine and rates of overweight and obesity, as well as the
Health, Munich, Germany wishes of those affected and professionals,
https://doi.org/10.1007/978-3-662-67662-2_80
610 C. Holzapfel
alternative, easily accessible channels are  Important Digital approaches to obesity

needed to enable all treatment seekers to access therapy are diverse and overcome spatial
individual obesity therapy. Adolescents and distance.
young adults with obesity, in particular, rep-
resent a target group that can be reached and
motivated through the use of new information 80.2 Telemedical Intervention
and communication technologies. To offer those
affected an individual treatment strategy— In a telemedical weight loss program, various
as called for in the guidelines of the German transmission strategies (e.g., email, Bluetooth,
Obesity Society (DAG) e. V.—not only various SMS, telephone, mail) are usually combined
therapy contents (e.g., nutrition, exercise, behav- for data transfer and information flow between
ior) but also different communication methods patient and caregiver (Fig. 80.1). Typically, the
(e.g., telephone, video, internet, smartphone) are patient collects and transmits data (e.g., weight
necessary. data, nutritional parameters, exercise log) to a
The dropout rates in clinical trials and espe- supervising institution, from which they receive
cially in weight loss studies are very high, at up prompt feedback. The feedback can be provided
to 90% (Moroshko et al. 2011). In the review by by a person or generated automatically.
Moroshko and colleagues, the following eight In Germany, there are few evaluated tele-
categories of reasons for dropout were pre- medical programs for weight loss. For example,
sented, which, however, are based on inconsist- the “The Active Body Control” (ABC program)
ent data: demographic variables, weight history, uses scales and pedometers for data collection
eating behavior, mental health, physical health, and a home box for data transfer. The program
health behavior, personal factors, logistics. The is based on a lifestyle intervention and also
latter point includes, for example, the distance includes four personal meetings in which the
to the supervising institution (Moroshko et al. program is explained, the telemedical devices
2011). This sometimes very high time expendi- are handed out, initial anthropometric data are
ture (e.g., travel) can be reduced by digital collected, and blood is drawn. Once a week,
approaches. the health care center sends feedback to the
Data transmission
via e.g. Bluetooth, Internet, email, telephone
Supervisor /
Patient Communication Supervising
institution
via e.g. mail, phone, email, SMS
Feedback and
recommendations
Fig. 80.1  Schematic representation of communication between patient and caregiver/supervising institution within a
telemedical intervention
80 New Media in Obesity Treatment 611
patients via email. A scientific evaluation of a represents a good opportunity to establish con-
small patient group (N = 35) with type 2 diabe- tact with patients, address individual needs,
tes mellitus showed a mean weight loss of 11.8 ensure data exchange, and facilitate regular
± 8.0 kg (94% “completers”) after six months weight control.
(Luley et al. 2011). Another evaluation, in which
individuals with (N = 25) and without (N = 24)  Important Telemedical applications for obe-
the ABC program were compared during the sity therapy are limited. They seem to be a
follow-up period, showed that after 24 months, a good alternative to other methods in obesity
weight loss of 8.5 and 9.0% of the initial weight therapy.
was achieved, respectively (Stumm et al. 2016).
The program has not been carried out in practice
since mid-2021. 80.3 Telephone-based
The telemedical lifestyle-based weight Intervention
manage ment program “SMART—Weight
Management for Risk Patients” is offered at the Personal counseling plays a central role in obe-
Institute for Applied Telemedicine of the Heart sity therapy and is preferred by many thera-
and Diabetes Center (HDZ) North Rhine- pists and affected individuals. In recent years,
Westphalia. An evaluation with 200 participants more and more weight management interven-
showed a weight loss of approximately 6 kg (5.8 tions have been offered in the form of telephone
kg ± 6.1 kg) in the group with low carbohydrate interventions. This communication method is a
intake and approximately 4 kg (4.3 kg ± 5.1 good alternative to face-to-face approaches, as
kg) in the group with low fat intake (intention- it is easy to implement, cost-effective, and still
to-treat) after twelve months. In both groups, allows for personal contact.
weekly nutrition counseling was conducted by
telephone during the first six months. Weight  Important Telephone-based weight manage-
data of the participants was sent once a week ment is associated with less time expenditure
to the study center via mobile phones using a for individuals with obesity and still allows
Bluetooth-equipped scale. Visits for further data for personal contact between patient and
collection took place at the beginning and after caregiver.
six and twelve months (Frisch et al. 2009).
Comparing the weight loss data of these two Comparing telephone-based interventions with
telemedical programs with studies in which a personal counseling sessions (face-to-face) or
face-to-face intervention for weight loss was a control group, it is shown that both interven-
conducted, the results regarding weight loss are tions perform better in terms of weight loss
similar. than the control group. After twelve months (N
Although telemedical weight loss programs = 415), a telephone-based intervention, which
seem to be a good alternative to face-to-face also included a website and email correspond-
interventions at first glance, there are relatively ence, resulted in a weight loss of 4.6 ± 0.7 kg.
few offers. Clinical studies with larger case The group with personal counseling sessions
numbers and longer intervention and follow-up on-site lost 5.1 ± 0.8 kg, and the control group
periods are necessary to make reliable state- lost 0.8 ± 0.6 kg (intention-to-treat) (Appel
ments regarding the efficacy of telemedical et al. 2011). In another study (N = 407), the
weight management programs. Nevertheless, telephone-based intervention group lost an aver-
it is probably undisputed that telemedicine age of 6.2 kg (4.9 to 7.6 kg) after 24 months. In
612 C. Holzapfel
comparison, the weight loss in the face-to-face 80.4 Internet-based Intervention

group was an average of 7.4 kg (6.1 to 8.7 kg),
and in the control group, it was 2.0 kg (0.6 to It is known that internet-based weight loss pro-
3.3 kg) (intention-to-treat) (Rock et al. 2010). As grams can reach a very large number of people
with personal counseling sessions, there is also a at low cost and with high flexibility (Wadden
group effect in telephone-based interventions. In et al. 2012).
the “Support, Health Information, Nutrition and In Germany, several weight loss programs
Exercise” (SHINE) study, the weight loss after have been offered online for several years. The
24 months in the group with telephone confer- growing market is quite confusing, making
ences was almost three times as high (6.2 ± 14.3 it difficult for those affected to choose a suit-
kg) compared to the group with individual phone able program, especially since most programs
calls (2.2 ± 14.2 kg) (Weinstock et al. 2013). are hardly scientifically evaluated and promise
The German health insurance company more than they ultimately deliver. The following
Deutsche Krankenversicherung (DKV) offers its describes selected programs in Germany.
policyholders the weight management program The training program “Lean and Healthy”
“Leichter Leben” (Lighter Living). With this for a healthy lifestyle and successful weight
telephone-based program, participants achieved management is offered through the Hamburg
a weight loss of 4.4 kg after twelve months (N University of Applied Sciences. The program
= 232, completers) (Holzapfel et al. 2016). lasts 52 weeks and costs a one-time fee of 50
euros. An evaluation of 633 people who have
 Important Moderate weight loss can be completed all 52 training modules shows that
achieved with telephone-based lifestyle women lost around 6 kg and men around 7 kg
interventions. after one year (www.lean-and-healthy.de). An
older evaluation of the program found that 13.3%
In general, as with almost all weight loss pro- (intention-to-treat) achieved a weight loss of 5%
grams, there is a lack of reliable long-term data or more after one year (Westenhöfer 2005).
for telephone-based lifestyle interventions. HausMed offers the twelve-week online
Furthermore, due to the different program con- course “Gesund Abnehmen (Healthy Weight
tents and heterogeneous statistical analyses, it Loss),” which, for example, conveys a healthy
is difficult to compare the effectiveness of the lifestyle through nutrition information (weekly
weight loss programs. The moderate weight topics), diaries, and food databases. Experts sup-
loss achieved through telephone-based interven- port participants via forums, email, or telephone.
tion is comparable to on-site personal interven- The program costs 69 euros. Health insurance
tions and is clinically relevant, especially when companies reimburse 80–100% of the costs.
face-to-face interventions are not possible (e.g., Scientific evaluations and long-term data are still
due to mobility restrictions). Further health lacking (www.hausmed.de).
economic analyses are needed to determine the “Abnehmen mit Genuss (Losing Weight
cost-effectiveness of telephone-based programs. with Pleasure)” is a 52-week internet-based
weight loss program aimed at lifestyle changes.
 Important Reliable health economic analyses Personal advice is provided in written form
on the cost-effectiveness of telephone-based (e.g., via email) and through forums by an
weight loss programs are still lacking. interdisciplinary advisory team. There is also a
recipe database, an online community, and the of lifestyle therapy for obesity, weight loss in
option to keep nutrition and exercise diaries. The internet-based programs is lower than in face-
program costs 79.90 euros. AOK-insured indi- to-face counseling sessions, but still clinically
viduals usually receive a refund of the partici- relevant. Internet programs also perform well
pation fee after completing the program (www. in terms of weight maintenance, as continuous
abnehmen-mit-genuss.de). contact between patient and supervisor (whether
online or in person) plays an important role in
 Important The range of internet-based maintaining weight (Wadden et al. 2007). In a
weight loss programs is growing in Germany. Cochrane review, the authors concluded that
Since the market is confusing and many pro- after six months, computer-based interven-
grams are not scientifically evaluated, it is tions achieved greater weight loss than minimal
difficult for those affected to choose a suit- intervention (standard treatment), but less than
able program. intensive personal on-site support (face-to-face).
A similar picture emerges regarding weight
A recently published study demonstrated maintenance. Participants in computer-based
the benefits of an online program offered in interventions regain less weight than those with
America through 15 family doctor practices. standard treatment, but more than those who
In a cluster-randomized intervention study, had personal support (Wieland et al. 2012). This
three approaches to weight loss were exam- shows that the comparison intervention is cru-
ined: A) Online program with obesity manager cial for interpreting the results.
(“Population Health Manager”), B) Online pro-
gram alone, and C) Standard care. A total of  Important Compared to face-to-face inter-
840 adults aged between 20 and 70 years with a ventions, internet-based weight loss programs
body mass index (BMI) between 27 and 40 kg/ do not perform as well. However, with online
m2 and hypertension and/or type 2 diabetes mel- weight loss programs—assuming longer par-
litus participated in the study. All three groups ticipation—a moderate weight loss can be
significantly reduced their body weight after one achieved, which is clinically relevant.
year (Group A: 3.1 kg, Group B: 1.9 kg, Group
C: 1.2 kg) (Baer et al. 2020). The fact that the A large-scale evaluation of an internet-based
online program was embedded in routine pri- weight loss program in Australia examined the
mary care makes the offer interesting. Whether prevalence of dropout and non-usage attrition.
the approach carried out in the study can be Of the nearly 10,000 people who signed up for
implemented in Germany is unclear. either the 12- or 52-week program, the median
The result of various review studies is that age was 36 years. As expected, this group is
internet-based weight loss programs have a high somewhat younger than in other offerings. After
potential for effective obesity treatment. In one twelve weeks, only 35% of the remaining 6,705
review, weight loss in internet-based interven- participants could still be considered users. For
tions ranged from no weight loss to 7.6 kg, with the 52-week group (N = 2,051), only 30% were
the intervention timeframe varying between still users after 52 weeks. This evaluation prob-
studies. In general, a high dropout rate was ably reflects everyday life and shows that a large
observed in internet-based interventions (Arem proportion of participants discontinue active use
and Irwin 2011). Comparing different methods of the online tool (Neve et al. 2010).
614 C. Holzapfel
Table 80.1  Advantages and disadvantages of internet-based weight loss programs and the resulting research needs
Advantages Clinically relevant weight loss, positive effects on weight stabilization, practical, location-
and time-independent, self-monitoring possible, social support (e.g. supervision, chat rooms,
forums), widespread
Disadvantages High development costs, high dropout rates, self-reported data from participants not verifiable,
lack of face-to-face effect
Research needs Risk-benefit consideration, data protection, cost-benefit analysis, scientific evaluation, randomi-
zed studies, optimization of participant retention
 Important The dropout rate in internet-based tools positively influence weight loss. In a com-
weight loss programs needs to be improved. mercial weight loss program (Weight Watchers),
interactive online tools and an app were used in
It is undisputed that internet-based weight loss addition to the established meetings. The tools
programs are increasingly being used and such were freely available to participants. It was
programs are indispensable in obesity therapy. found that using all three components led to the
They undoubtedly expand the range of options highest weight loss after six months (Fig. 80.2)
for those affected and enable a flexible ther- (Johnston et al. 2013).
apy choice tailored to individual preferences. A pilot study (N = 127) investigated the
Despite the advantages that using the internet for acceptance of apps (smartphone), online tools
weight loss brings, there are still some questions (internet), and printed media (paper version) for
that remain unanswered, indicating a significant weight loss. In the smartphone group, the drop-
need for research (Table 80.1). out rate was the lowest and adherence was the
highest. After six months, the average weight
loss (intention-to-treat) in the smartphone group
80.5 Use of Smartphones was 4.6 kg, in the paper version group 2.9 kg,
and in the internet group 1.3 kg (Carter et al.
New information and communication tech- 2013).
nologies also include smartphones, which have In a systematic review and meta-analysis
revolutionized communication and information with 41 studies, 6,348 participants, and 373
exchange between individuals and represent a endpoints, it was shown that the use of apps
high potential for effective use in obesity ther- positively affects eating behavior and nutrition-
apy. The advantage of smartphones is that stand- associated endpoints. In the studies included in
ard websites and mobile-optimized websites the evaluation, the intervention lasted an aver-
can be accessed quickly and easily on the go. In age of 21 weeks. In total, 30 different apps
addition, there are application software (apps, were used across all studies. With regard to the
“applications”) for smartphones that promote a short-term improvement of anthropometric data,
health-promoting lifestyle. significant positive effects were demonstrated
Health apps can facilitate a health-promot- (Villinger et al. 2019). Long-term studies show
ing lifestyle and support weight management that app-supported interventions perform simi-
(Holzmann and Holzapfel 2019). More and larly well or worse than comparison interven-
more commercial providers of weight loss pro- tions or the control group in terms of weight loss
grams are using this technology and offer online and thus do not provide additional benefits for
tools and apps in addition to traditional pro- weight management (Table 80.2).
grams. A study has shown that such additional
0 components 1 components 2 components 3 components

0
a
-2
Weight loss [kg] after 6 months
b b
-4
-6
-8 c
a < b (p<.05)
a , b < c (p<.01)
-10
Fig. 80.2  Weight loss depending on the use of the offered components (meetings, online tools, apps). (From
Johnston et al. 2013)
It should be noted that in the studies, apps are (German consumer organization) examined
often used that are outdated and thus do not cor- health-related apps in 2013, of which around
respond to the current apps on the market. For 100,000 are offered for download and about
this reason, study results with a new generation 1000 are added per month. The 24 tested apps
of apps are to be awaited in order to generate ranged from calorie counting, weight control to
reliable evidence. It is evident from the stud- medication management. The conclusion was
ies and practical experience that apps represent that none of the applications performed very
a helpful additional tool for self-observation, well. Above all, a lack of transparency and data
but personal support from a professional cannot security were criticized.
be replaced in weight loss. The use of activity This conclusion was also reached by an
trackers also shows no additional benefit (Table American review article that examined weight
80.2). management apps more closely. 204 apps
could be identified via iTunes, which could be
 Important In long-term studies, apps and assigned to the categories nutrition, exercise,
activity trackers have so far shown no addi- weight course (19%), nutrition recommenda-
tional benefit for weight loss. tions and histories (34%), and weight control
(46%). In terms of content, most apps were
The ethical and legal framework conditions as inadequate (Breton et al. 2011).
well as the safety aspects regarding apps are In order to improve or ensure the quality of
largely unclear (Holzmann et al. 2017). Many health apps, examinations and certifications
apps collect personal data, and it is not clear are necessary. However, usually only medi-
to users to what extent data protection is guar- cal apps (e.g., apps for diagnosis) are checked
anteed. The sources for the content of the apps by approval authorities, while most apps are
are mostly not transparent, i.e., the user cannot medical products and are therefore not sub-
not understand on which expertise, for exam- ject to any examination or approval procedure.
ple, nutrition tips are based. Stiftung Warentest Health apps thus remain largely unregulated for
616 C. Holzapfel
Table 80.2  Selected intervention studies for weight loss with apps and activity trackers
Study participants Intervention Weight loss Effect Reference
365 adults, BMI a) mHealth intervention (interactive smart- After 2 years No significant Svetkey
≥ 25 kg/m2, 70% phone application) a) 0.99 kg difference et al. 2015
women b) Personal coaching plus smartphone b) 2.45 kg
application c) 1.44 kg
c) Control group
471 adults, BMI 25 All: energy-reduced diet, group counseling After 2 years Significant dif- Jakicic et al.
to 40 kg/m2, 77% All: after 6 months additionally phone a) 3.5 kg ference between 2016
women calls, text messages, homepage b) 5.9 kg groups
→ Randomization after 6 months:
a) Intensive intervention: “wearable”, "web
interface”
b) Control group: self-monitoring via
homepage
279 adults, BMI 27 a) WW Online Program (WWO) After 1 year No significant Thomas
to 40 kg/m2, 78% b) WW Online Program with ActiveLi- a) 2.1 kg difference et al. 2017
women nkVR (WWO1AL) b) 1.6 kg
c) Online newsletter (Control group) c) 1.2 kg
276 adults, BMI 25 a) GROUP (group-based therapy face-to- After 18 months No significant Thomas
to 45 kg/m2, 83% face, paper nutrition logs, written feedback) a) 5.9 kg difference et al. 2019
women b) SMART: Smartphone-based therapy, b) 5.5 kg between SMART
online sessions, self-monitoring, feedback, c) 6.4 kg and GROUP
monthly weighing appointments Significant dif-
c) CONTROL: Self-monitoring, paper ference between
nutrition logs, written feedback, monthly SMART and
weighing appointments CONTROL
consumers. To evaluate the quality, various plat-

80.6 Digitale-Versorgung-Gesetz
forms are currently being set up. In addition,
there are checklists for consumers to evaluate
In 2020, the Digital Care Act came into force
apps according to objective criteria (overview).
in Germany. This law allows digital health
applications (DiHAs), which are listed by the
Federal Institute for Drugs and Medical Devices
Selected criteria for evaluating apps
(BfArM), to be prescribed by doctors. The
• Objective product tests
Digital Care Act created a framework for digital
• Qualification of the provider (ISO,
therapy concepts in Germany, the costs of which
DIN)
are covered by health insurance companies. It
• Interests of the provider (commercial)
should be mentioned that prescribable DiHAs
• Data transparency
undergo a certain formal process through the
• Data protection
BfArM, but this does not necessarily represent a
• Data storage and transfer
quality feature.
• Support/service offering
Independently of the Digital Care Act, cer-
• Permanence of market presence
tified nutrition professionals and doctors in
Germany offer personal consultations for weight
 Important The market for health apps is loss via digital media (e.g., telephone, video,
uncontrolled and intransparent. Many apps apps). These consultations are subsidized by
show weaknesses in terms of data protection, most health insurance companies as part of obe-
security, and evidence-based content. Caution sity therapy.
is advised when selecting and using apps.
80.7 Outlook The guideline of the DAG recommends the

most individual therapy possible, i.e., the choice
There is no doubt that new communication and of the respective option depends on the possi-
information technologies significantly expand bilities and personal preferences of the patient
the range of methods for weight management. as well as the availability of the program. It has
This helps to offer affected individuals programs been shown that the various technical approaches
that suit their preferences and can be easily inte- to obesity treatment can be combined very well
grated into everyday life. Although personal and complement each other. The new generation
face-to-face consultations achieve the greatest of weight loss programs will likely combine the
weight loss success, other channels of informa- various options and still let the patient decide
tion and knowledge transfer still seem to be a which tools they prefer to use.
good alternative to personal consultation. Digital Further innovative technological approaches
offers are particularly beneficial for people with such as Artificial Intelligence and Virtual Reality
limited time windows (e.g., working people) will additionally expand the spectrum of digi-
or with mobility restrictions (e.g., people with tal approaches to obesity therapy. Artificial
illnesses). In addition, the younger genera- intelligence applications based on large mul-
tion and tech-savvy individuals are particularly tidimensional datasets will primarily promote
attracted by interactive electronic components. personalized, target group-appropriate, and “just-
Comparing the various methods (Fig. 80.3) in in-time” recommendations. Virtual environments
terms of individual characteristics, it becomes (e.g., virtual supermarket, virtual doctor’s office)
apparent that weight loss is somewhat lower will allow for realistic settings to be depicted in
with new technologies, but significantly more order to use them for digital interventions in obe-
people can be reached and the cost-benefit effec- sity therapy. The creation of an avatar could, for
tiveness is likely to be improved. example, improve body image perception in peo-
ple with obesity and thus support obesity therapy.
Weight reduction
Face-to-Face New media

e.g. Individual / Telephone e.g. smartphone,
group counseling computer
Trend in weight management

Accessibility,
anonymity, time-saving,
Low-cost, low-intensity, little personal
relationship, little standardization
Fig. 80.3  Advantages and disadvantages of digital approaches to weight loss compared to face-to-face interventions
618 C. Holzapfel
management on weight change: a randomized clinical

Conclusion trial. JAMA 324(17):1737–1746
Breton ER, Fuemmeler BF, Abroms LC (2011) Weight
• Telemedical applications and new commu- loss—there is an app for that! But does it adhere to
nication and information technologies are evidence-informed practices? Transl Behav Med
used in obesity therapy. 1(4):523–529
Carter MC, Burley VJ, Nykjaer C, Cade JE (2013)
• The number of telemedical weight loss Adherence to a smartphone application for weight
programs in Germany is limited. The loss compared to website and paper diary: pilot rand-
achieved weight loss is comparable to omized controlled trial. J Med Internet Res 15(4):e32
face-to-face interventions. Frisch S, Zittermann A, Berthold HK, Götting C, Kuhn J,
Kleesiek K (2009) A randomized controlled trial on
• Telephone-based weight loss programs the efficacy of carbohydrate-reduced or fat-reduced
lead to moderate weight loss and repre- diets in patients attending a telemedically guided
sent a good alternative to face-to-face weight loss program. Cardiovasc Diabetol 8:36
interventions. Holzapfel C, Merl M, Stecher L, Hauner H (2016) One-
year weight loss with a telephone-based lifestyle pro-
• Internet-based weight loss programs have gram. Obes Facts 9:230–240
high dropout rates but lead to clinically Holzmann SL, Holzapfel C (2019) A scientific overview
relevant weight loss. of smartphone applications and electronic devices for
• Health apps show no additional benefit in weight management in adults. J Pers Med 9(2):31
Holzmann SL, Pröll K, Hauner H, Holzapfel C (2017)
terms of long-term weight loss but are a Ernährungs-Apps: Qualität und Limitationen. Eine
good option for self-monitoring and data explorative Erhebung anhand ausgewählter Beispiel-
collection. Apps. Ernährungs Umschau 64(5):8089
• New media significantly expand the range Jakicic JM, Davis KK, Rogers RJ, King WC, Marcus
MD, Helsel D, Rickman AD, Wahed AS, Belle SH
of methods for successful weight man- (2016) Effect of wearable technology combined with
agement. This makes it possible to offer a lifestyle intervention on long-term weight loss:
affected individuals programs that corre- the IDEA randomized clinical trial. JAMA
spond to their preferences and can be eas- 316(11):1161–1171
Johnston CA, Rost S, Miller-Kovach K, Moreno JP,
ily integrated into everyday life. Foreyt JP (2013) A randomized controlled trial of a
• The Digital Care Act in Germany creates community-based behavioral counseling program.
framework conditions for prescribing digi- Am J Med 126(12):1143.e19–1143.e24
tal health applications. Luley C, Blaik A, Reschke K, Klose S, Westphal S
(2011) Weight loss in obese patients with type 2
• Innovative technologies such as Artificial diabetes: effects of telemonitoring plus a diet com-
Intelligence and Virtual Reality will bination - the Active Body Control (ABC) Program.
expand the range of methods for weight Diabetes Res Clin Pract 91(3):286–92
loss in the future. Moroshko I, Brennan L, O`Brien P. (2011) Predictors
of dropout in weight loss interventions: a systematic
review of the literature. Obes Rev 12:912–934
Neve MJ, Collins CE, Morgan PJ (2010) Dropout, non-
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Appel LJ, Clark JM, Yeh HC, Wang NY, Coughlin
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JW, Daumit G, Miller ER 3rd, Dalcin A, Jerome
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GJ, Geller S, Noronha G, Pozefsky T, Charleston
and incentivized weight loss program on weight loss
J, Reynolds JB, Durkin N, Rubin RR, Louis TA,
and weight loss maintenance in obese and overweight
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weight-loss interventions in clinical practice. NEJM
Stumm G, Blaik A, Kropf S, Westphal S, Hantke TK,
365(21):1959–1968
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onitoring weight reduction program “Active Body
weight loss interventions in adults. Obes Rev
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Svetkey LP, Batch BC, Lin PH, Intille SS, Corsino
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L, Tyson CC, Bosworth HB, Grambow SC, Voils
agement program integrated with population health
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(2015) Cell phone intervention for you (CITY): modification for the management of obesity.
a randomized, controlled trial of behavio- Gastroenterology 132:2226–2238
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Handbook of Eating Disorders and Obesity

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Handbook

ISBN 978-3-662-67661-5 ISBN 978-3-662-67662-2 (eBook)

In 2006, at a congress of the Eating Disorder Research Society (EDRS), an

Bochum, Hannover, Tübingen Stephan Herpertz

Part I Diagnosis of Eating Disorders

4 Clinical Aspects of Anorexia Nervosa, Bulimia Nervosa, and

9 Diagnosis of Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Part II Epidemiology, Etiology, and Course of Eating Disorders

14 Anorexia Nervosa in Childhood and Adolescence. . . . . . . . . . . . 97

19 Epidemiology, Etiology, and Course of Eating Disorders. . . . . . 135

Part III Psychological Comorbidity

Part IV Biological and Medical Aspects of Eating Disorders

28.3 Hunger and Satiety and the Regulation of Body

Part V Medical Complications and Somatic Comorbidity

Part VI Treatment of Eating Disorders

38.4 Treatment of Comorbidity and Medication. . . . . . . . . . . . . . 292

44 Cognitive Remediation Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . 333

48.4 Binge Eating Disorder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371

54 Relapse Prevention in Anorexia Nervosa . . . . . . . . . . . . . . . . . . . 403

Part VII Definition, Classification, and Epidemiology of Obesity

59.2 Monogenic Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 447

Part VIII Comorbidity of Obesity

64.3 Relationship Between Metabolic Syndrome and

Part IX The Treatment of Obesity

69 Treatment of Obesity in Childhood and Adolescence . . . . . . . . . 519

74.2 Conceptual Definitions: Definition of Obesogenic

79.5 Bariatric Surgery and Eating Disorders. . . . . . . . . . . . . . . . . 604

Extreme obesity has preoccupied medicine 1.3 History of Anorexia Nervosa

Table 1.1 Definition criteria for diagnoses

Romuald Brunner and Franz Resch

 Physical appearance comparisons with  Problematic attitudes and behaviors

References adolescents: a systematic review with meta-analysis.

3.1 Introduction eating disorders. The ICD-11 follows the con-

be derived (Milos et al. 2020). Ultimately, the 3.3 Bulimia Nervosa

as it is difficult to determine the objectively demographic similarities: They are younger

Martin Teufel, Eva-Maria Skoda and Stephan Zipfel

4.1 Classification of Anorexia can be perceived. There is a desire for weight

suggest intentional or arbitrary behavior on the

4.2 Classification of Bulimia

4.2.1 Subtypes of Bulimia Nervosa

4.4.2 Vomiting exercise and include both intentional athletic

The abuse of medications as compensatory

5.1 Diagnostic Criteria yet sufficiently clarified, but it is a complex

all criteria for BED, classification can be made

In total, over 70% of individuals with BED have

Astrid Müller and Andrea Sabrina Hartmann

6.2 Purging Disorder

nocturnal eating of small amounts of food after

and not empirically supported, such as com-

actually have an increased tendency towards

und Evaluation eines Fragebogens zur Erfassung

B. Tuschen-Caffier (*) · J. Werthmann

Cognitive processes of information process-

8.2.3 Behavioral Component 8.3 Body Image Disturbances

9.1 Screening for Eating Disorders  Important Every doctor or psychologist

9.2 Detailed Psychological

If none of these questions are answered in the 9.2.1.1 Underweight or Overweight

Anthropometry in eating disorders Vascular Status

during refeeding. In particular, potassium in Sex Hormones

However, the diseases mentioned in the over-

Extreme obesity has preoccupied medicine 1.3 History of Anorexia Nervosa

Table 1.1  Definition criteria for diagnoses

3.1 Introduction eating disorders. The ICD-11 follows the con-

be derived (Milos et al. 2020). Ultimately, the 3.3 Bulimia Nervosa

4.1 Classification of Anorexia can be perceived. There is a desire for weight

4.2 Classification of Bulimia

4.2.1 Subtypes of Bulimia Nervosa

4.4.2 Vomiting exercise and include both intentional athletic

5.1 Diagnostic Criteria yet sufficiently clarified, but it is a complex

6.2 Purging Disorder

8.2.3 Behavioral Component 8.3 Body Image Disturbances

9.1 Screening for Eating Disorders  Important Every doctor or psychologist

9.2 Detailed Psychological

If none of these questions are answered in the 9.2.1.1 Underweight or Overweight

11.1 Results of the Research on parameters had an influence on the overall

Fig. 11.1  Long-term course 20.8 5 Mortality

11.3 Prognostic Indicators for a social integration were indicators of a good

12.1 Diagnosis from individuals who had not undergone therapy

12.5.3 Comorbidity 12.5.5 Family of Origin Characteristics

13.1 Introduction where at least two binge eating episodes per

13.5 Disorder Duration and eating disorder pathology (Brownley et al.

Table 13.1  Long-term course of BED after psychotherapy