Binge eating disorder is the most common eating disorder in obese people. Early detection and treatment is critical to the progression and prognosis of sustained weight loss. Multimodal combination therapy aimed at lifestyle modification is a cornerstone of treatment. For psychological comorbidities such as depression or anxiety disorders, the use of behavioral therapy techniques has been shown to be effective. In patients with a BMI >35 kg/m² or greater, surgical intervention should be considered after conservative treatment options have been exhausted.
Eating disorders are often associated with being underweight and vomiting, however, a large number of overweight people also exhibit an eating disorder. In Switzerland, the prevalence of overweight is 42% of adults, 11% of whom are obese [1]. Because of the lower awareness of an eating disorder in overweight people, the disorders are often underdiagnosed. However, the diagnosis is of great relevance, since an eating disorder, if left untreated, can impede or prevent sustained weight loss and sufferers are exposed to an increased mortality with a SMR (“Standardized Mortality Rate”) of 1.50 [2]. The most common eating disorder here is binge eating disorder, which has an incidence of over 50% in obese people. This once again highlights that in addition to excluding somatic causes of obesity, somatic comorbidities and sequelae, a structured history of the weight history should always be taken with a review of the eating disorder “red flags”. A general history guide and screening questions for eating disordered behavior can be found in Figure 1.
Diagnosis of somatic factors
If obesity is present, the standardized underwear body weight survey should be performed at the beginning of each diagnostic procedure, as well as the body height survey to calculate the present BMI. Furthermore, current guidelines recommend measurement of waist circumference from a BMI of >25 kg/m² in conjunction with risk factors. Determining the distribution of fat on the body also allows conclusions to be drawn about cardiovascular risk. For this purpose, the circumferences of the hips and waist are determined and considered in relation to each other. This is in contrast to bioelectrical impedance analysis of body composition practical and possible without much effort [3,4].
If comorbidities are present, such as type 2 diabetes mellitus, cardiovascular disease, or metabolic syndrome, a detailed physical and neurologic examination and laboratory diagnostics are recommended. Cardiovascular risk factors, such as nicotine use or a family history of cardiovascular disease, should also be inquired about [4]. Furthermore, medication intake, consumption of alcohol and drugs, and daily physical activity levels should be collected in the initial history.
Eating disorder diagnostics
In general, it is recommended to consider an eating disorder in cases of overweight and obesity, but also in cases of fluctuating weight trajectories. In addition to the BMI, the weight history of the last years should be collected. In the further history, it is crucial to query certain key topics such as binge eating, cravings, satisfaction with weight, or even loss of control when eating. Those affected often show great shame, which is why, for example, eating attacks are hardly ever addressed by themselves. The screening questions listed in overview 1 are suitable for this purpose. A detailed picture of the patient’s eating behavior should be obtained, including meal structure, size, and composition. A family history of obesity or eating disorders should be taken, as well as questions about dieting behavior and counter-regulatory measures after, for example, binge eating (vomiting, laxatives, etc.).
If the suspicion of an eating disorder is confirmed, a diagnosis using the current classification systems (DSM or ICD) is recommended. A structured anamnesis accompanied by questionnaire diagnostics and/or validated diagnostic interviews is suitable for this purpose. The questionnaires are objective, reliable and valid constructs, some of which are also available free of charge. The DIPS (Diagnostic Interview for Psychological Disorders) is a validated diagnostic interview that provides a good overview of a possible eating disorder and at the same time also asks about comorbidities. It maps well to the relevant DSM-5-oriented diagnostic criteria, but captures less of the subclinical courses. The DIPS is easy to use in clinical practice and can also be used in its short form, the Mini-DIPS. Free access can be found at the following links: http://dips.rub.de; http://mini-dips.rub.de [4,5].
As a specific validated interview, it is recommended to use the Eating Disorder Examination (EDE), which looks at four scales: 1. restrained eating behavior (Restraint Scale); 2. eating-related worries (Eating Concern Scale); 3. figure concern (Shape Concern Scale) and 4. weight concerns (Weight Concern Scale). With the help of the EDE, it is not only possible to map the current psychopathology of eating behavior, but also to depict the effects of psychotherapeutic treatment in the sense of a progression diagnosis.
As a specific validated questionnaire instrument, the Eating Disorder Examination Questionaire (EDE-Q) is recommended as a suitable initial screening tool. This is a self-report questionnaire that is indicated especially when an expert interview (EDE) is not feasible, e.g., for economic reasons, and provides reliable information about the presence of any eating disorder symptoms [4].
Binge Eating Disorder (BES)
Binge-eating disorder (BES) is not listed as a separate diagnosis until the new U.S. classification system, DSM-5. Previously, the disorder was grouped under the diagnosis F50.8 other eating disorders (ICD-10). DSM-5 diagnostic criteria include recurrent binge eating (bouts of ravenous hunger) (info box) accompanied by a sense of loss of control. There is a high level of suffering, which is usually accompanied by a feeling of shame and/or guilt after the binge eating episodes. Large amounts of food are eaten in a defined period of time, usually 2 hours, often without feeling hungry. Because of shame, binge eating is often done in secret. This can lead to social withdrawal, which at the same time can be perpetuating for the disorder, as possible triggers for an eating episode can be feelings of loneliness. Unlike bulimic binge eating, inappropriate countermeasures, such as vomiting, do not regularly follow, leading to long-term weight gain when larger amounts of food are ingested [6]. Seizure frequency may reflect severity. For example, 1-3 binge eating episodes per week are considered mild, 4-7 are considered moderate, 8-13 are considered severe, and more than 14 binge eating episodes are considered extremely severe. The detailed diagnostic criteria are summarized again in Table 1.
BES often begins in adolescence and occurs with a lifetime prevalence of 1.6% [7]. It was shown that 57% of girls and 35% of boys with extreme obesity who had participated in a weight loss intervention had BES [8]. The proportion of individuals suffering from BES in Switzerland is 2.4% of women and 0.7% of men [9].
Various theories are discussed as the cause of the disorder. On the one hand, an affect regulation disorder is suspected. Here, binge eating represents dysfunctional coping strategies for feelings such as anxiety, anger, or loneliness. However, studies show that binge eating does not objectively reduce unpleasant feelings [10]. Another explanation is the escape theory. Preoccupation with food serves as a distraction from one’s own thoughts and feelings, away from self-awareness and examination of oneself [10].
Other eating disorders
Night Eating Syndrome (NES): Night eating syndrome (NES) involves recurrent food intake after awakening from sleep or excessive food intake after dinner, usually associated with food restriction throughout the day [11]. Important to delineate are changes in individual sleep-night rhythms, such as night duties or sociocultural influences. Overview 2 summarizes the criteria. Patients usually suffer from obesity and exhibit sleep disturbances. Studies have also shown that NES is often associated with (usually severe) depression [11]. Patients scheduled for bariatric surgery in particular have a high prevalence of 2-20% [12]. Testing of disordered eating behavior is performed using the Night Eating Questionnaire (NEC). In a population sample from the NEC, the prevalence of night eating syndrome for Germany was 1.1% [12].
Emotional eating: Emotional eating involves eating when experiencing unpleasant as well as pleasant feelings. Usually, no negative consequences, such as eating disorder-specific cognitions or poor psychological well-being, occur after eating due to positive feelings, such as pleasure, in contrast to eating due to negative feelings (sadness, boredom, etc.) [13].
A distinction must be made between the urge to eat and the actual act of eating. It is possible that due to the actual act, sufferers may slip into an emotional eating attack [14], again allowing a transition into the diagnostic criteria of a binge eating disorder. Over time, sufferers lose the ability to distinguish between emotional and psychological hunger and the satisfaction of the feeling of hunger. Neurobiological influences of leptin and cortisol are suspected [12].
Grazing/picking behaviors: These are isolated behaviors, but also occur in conjunction with other eating disorders. One is grazing, or picking, eating small snacks throughout the day without feeling hungry. Grazing can be divided into loss-of-control, compulsive, and non-loss-of-control types. In patient groups with an eating disorder, the prevalence is up to 60% [15]. If binge eating occurred before bariatric surgery, patients were more likely to exhibit grazing behavior postoperatively [12].
Loss of Control Eating (LOC): Loss of Control (LOC) Eating can be compared to binge eating, but is characterized by the person’s primarily subjective experience of having consumed an excessive amount of food. In addition, LOC Eating is usually accompanied by a high level of suffering. Similar to the other eating disorders, LOC eating is also associated with emotional dysregulation [16].
In patients who have undergone bariatric surgery, the reduced size of the stomach means that only a small amount of food can be consumed, which is why “regular” binge eating is not possible from a purely physiological point of view. If patients experience a loss of control over food intake postoperatively, this group of patients is referred to as LOC eating. If LOC eating and/or grazing occurs postoperatively, weight loss is usually less and is associated with more perceived psychological distress [12].
Therapy for eating disorders – Overweight and obesity
Not every person who is overweight necessarily requires treatment. Therefore, diagnosis and indication before starting therapy for people with obesity and overweight requires a complex interdisciplinary approach.
The indication for initiating therapy in people with overweight or obesity results from various factors ascertained in the diagnostic process. A BMI ≥30 kg/m² or obesity with a BMI between 25 and <30 kg/m² in the presence of concomitant obesity-related comorbidities (eg, arterial hypertension, type 2 diabetes mellitus), abdominal obesity, or diseases exacerbated by obesity or high psychosocial distress [17] are indicative of treatment. Contraindications to therapy are consumptive diseases and pregnancy [17]. Obesity should always be viewed as a disease that requires interdisciplinary, multimodal treatment. The three pillars of obesity therapy here are: diet, exercise and behavioral intervention. [17,18] (Tab.2).
Treatment goals
The individual treatment that is appropriate depends on the severity of the obesity, the existing personal risk factors and concomitant diseases, and the psychological comorbidities of the patient. In addition, the age and individual wishes of the patients play an important role in the therapy decision.
Since obesity can be classified as a chronic disease with a high recurrence rate, the overriding goal of treatment should be to permanently reduce body weight, maintain the ability of those affected to work if possible, and improve their quality of life. It should be taken into account that most people who seek treatment for their weight problems have already undertaken various weight-reducing measures and diet attempts in their previous history without any long-lasting effect. This also means that therapy goals should be realistic and adapted to the individual conditions and needs of patients in order to counteract renewed frustration. It is helpful for practitioners to consider the patient’s individual comorbidities as well as risks, expectations, and resources more than weight loss alone.
Long-term and sustained weight loss decreases the risk of physical comorbidities, such as type 2 diabetes mellitus, cardiovascular disease, and a higher risk of malignancy [17,18]. According to the expert consensus of the interdisciplinary S3 guideline of “Prevention and Therapy of Obesity” from 2014, which is currently under revision, a weight loss of >5% of the initial weight should be targeted within six to twelve months for a BMI 25 to 35 kg/m² and of >10% of the initial weight for a BMI >35 kg/m² [17]. The 2016 Swiss Obesity Consensus states a weight loss of 5 to 15% over at least 6 months as a realistic goal. If a BMI >35 kg/m² is present, a weight loss of more than 20% should be aimed for, whereby the goals should be discussed individually and realistically with the patients and assessed by the practitioner [18].
Therapy
Treatment options and the need for medical therapy monitoring depend on the severity of obesity and concomitant comorbidities. Up to a BMI of 35 kg/m² without significant concomitant diseases, medical therapy monitoring is not necessarily required. This means that a therapy program in these cases can also take place under the direction of a commercial provider. In the case of a higher BMI and/or the presence of concomitant medical conditions, medical monitoring is advisable or necessary [17].
At the beginning of any therapy for people with overweight or obesity, a combination of dietary changes, integration of increased physical activity, and psychotherapeutic treatment in the form of behavioral therapy often form the basis of treatment. The interlinking of the above-mentioned therapy components has been shown to be clearly superior to a stepwise approach and is therefore also state of the art of guideline-based treatment [17,18]. Thus, combining the different therapy elements, an additional weight reduction of 6.3 kg was achieved after 12-18 months compared to exercise therapy alone [19].
After successful weight loss, the goal should always be long-term weight stabilization. This represents a therapy component that should not be neglected and should be addressed and planned with high priority at an early stage, since weight stabilization is often the greatest difficulty for overweight and obese people.
Nutrition therapy for obesity
Recommendations for dietary changes in people with obesity should be individually adapted to the therapy goals as well as the respective risk profile and should take into account the existing resources of those affected. Nutritional counseling is available in both individual contact and group therapy settings, and both result in significant weight loss, with the effects of group therapy being superior to those of individual treatment [19]. In order to promote short- and long-term compliance and to improve the results of weight loss programs, it is also helpful to involve the patient’s home environment [20,21]. To reduce body weight, it is recommended to take an energy-reduced mixed diet with a daily energy deficit of >500 kcal/d, in individual cases even higher, or a low-calorie formula diet (also as a meal replacement) [17].
Exercise therapy for obesity
Adequate exercise therapy not only has a positive effect with regard to a number of obesity-associated diseases and often improves comorbid depression, but also improves quality of life and leads to a negative energy balance due to increased energy expenditure. To achieve effective weight loss, one should exercise >150 min./week with an energy expenditure of 1200 to 1800 kcal/week. Strength training alone is insufficient for effective weight loss [22]. For people with a BMI >35 kg/m², care should be taken to select a type of sport that is not stressful for the musculoskeletal system, such as swimming [17].
Drug therapy for obesity
In Switzerland and Germany, only the two drugs orlistat and liraglutide are approved for weight reduction. Both reduce weight as well as accompanying risk factors. Results of a study in obese prediabetics showed a weight reduction of 4.4 kg after one year and 2.8 kg after four years under 3x 120 mg orlistat placebo-adjusted [23]. The drug liraglutide lowered body weight by 5.6 kg more than placebo within 56 weeks at a dose of 3.0 mg/d [24]. Overall, drug support with liraglutide is particularly useful if, for example, prediabetes or diabetes mellitus is already present, as it has a positive effect on glucose metabolism [25]. Drug support for weight loss should always be critically considered and should never be the sole therapy, but must always be considered in combination with other therapy components.
Psychotherapy for obesity
If the diagnosis of overweight or obesity reveals the presence of an eating disorder, such as binge-eating disorder (BES), or if there are accompanying psychological comorbidities such as depression or anxiety disorders, it is recommended that more intensive psychotherapeutic treatment be sought here, as they can hinder both the desired weight reduction and weight maintenance regardless of biological and environmental factors. [26]. It is worth mentioning here that, according to the guidelines, behavioral therapy is an equal therapeutic component in the treatment of obesity, along with the components of nutrition and exercise therapy, regardless of whether or not there is an accompanying eating disorder. Thus, cognitive behavioral therapy is the psychotherapeutic method of choice in the treatment of people with overweight or obesity [17,18].
A behavior modification through behavioral therapy interventions. (Tab. 2), such as self-observation, by keeping a food diary, weighing regularly and visualizing the change in a weight curve, stimulus control and cognitive restructuring in combination with training through nutritional counseling, which should include the patients’ personal environment, support a change in diet and exercise in everyday life and improve the results of weight loss programs [27,28]. Furthermore, it is useful to support patients in relearning the physiological sensation of a feeling of hunger and satiety. It is a good idea to document these sensations in a food diary before and after each meal [18].
Therapy for Binge Eating Disorder (BES) and Night Eating Syndrome (NES).
In addition to the elements of obesity treatment listed above, which should complement psychotherapy in accordance with the guidelines, the integration of psychotherapeutic treatment concepts becomes necessary right at the beginning of therapy for this patient group if a comorbid eating disorder such as BES is present. In order to gain a better understanding of the underlying, central psychopathological mechanisms of eating disorders, it is useful to adopt a transdiagnostic perspective (Fig. 1). Only an interplay of understanding the mechanisms of eating disorder pathology and targeted diagnostics will ultimately help to achieve successful therapy. Here, it is important that psychotherapeutic interventions include eating behavior and weight management in addition to the areas of emotion regulation, body image, social skills, and self-esteem, and that expectations that are too high with regard to weight loss are normalized. Thus, the cycle of binge eating, insufficiency experience, depressed mood and frustration with self-sacrifice should be interrupted at an early stage. Treatment of psychopathology should be considered a priority over weight loss [4]. The psychotherapeutic treatment goals of a BES or a NES include, among others, the reduction of eating attacks, the teaching of eating disorder-specific psychopathology as well as relapse prevention in the form of psychoeducation, teaching of skills, but also work on self-esteem conflicts and shame problems as well as affect regulation and strengthening of social skills [4]. If other psychological comorbidities, such as depression or anxiety disorders, accompany the eating disorder, this also requires co-treatment [4]. The most commonly used and best established form of psychotherapy in the treatment of BES is cognitive behavioral therapy. It has been shown to be particularly effective in terms of identifying and modifying unfavorable thought and behavior patterns, a reduction in binge eating, and eating disorder-related symptoms [4]. However, with regard to improvement of concomitant depressive symptomatology by behavioral therapy interventions, the results were inconsistent. In addition, weight stabilization but not significant weight reduction was achieved. An effect duration of up to 4 years after the end of treatment was demonstrated for KVT as well as interpersonal psychotherapy [29].
Obesity surgery
Bariatric surgery interventions have proven their effectiveness through a large number of clinical trials. Depending on the procedure, weight reduction ranges from 21 to 38 kg after one year and 15 to 28 kg after 10 years [30].
In patients with extreme obesity (BMI ≥40 kg/m²) without or BMI of >35 kg/m² with comorbidities who have achieved less than 10% weight reduction with 6 months of conservative weight loss measures, the indication for bariatric surgery should be made and considered on an interdisciplinary basis [17]. Because of the considerable invasiveness of bariatric surgery, it is important to discuss individual counseling and a weighing of the potential benefits against the possibly irreversible harm together with the patient in advance. For the assessment before such an operation, a presentation should also be made to a psychosomatic outpatient clinic for patients undergoing bariatric surgery or to a psychotherapist with experience in bariatric surgery. Here, it is important to elicit unstable psychopathological states in an evaluation, especially the presence of a severe eating disorder with very frequent binge eating or even self-induced vomiting. Regular self-induced vomiting is a contraindication for such an intervention and requires psychotherapeutic treatment before such a measure can be considered [31]. Patients who have undergone bariatric surgery should receive lifelong interdisciplinary follow-up [17].
Summary
Common comorbidities of obesity and overweight are eating disorders, such as BES, NES, or nonspecific eating disorders. These are often neglected or not sufficiently recognized in diagnostics. The reasons for this are unfamiliarity on the part of diagnosticians as well as shame and silence on the part of patients. Therefore, a structured history of the weight history as well as a review of the “red flags” of the eating disorder and initial screening questions on dysfunctional eating behavior should be implemented regularly in the daily work with obese patients.
Guideline-based therapy for overweight and obesity consists of a multimodal treatment concept. This involves a combination of the three elements of diet, exercise and behavior (Tab. 2). The currently available drug treatment approaches play a rather minor role. The goal of the expected weight reduction should be set individually and realistically. Only long-term and permanent weight reduction reduces the risk of physical comorbidities and helps sufferers to achieve a lasting improvement in their quality of life. In the case of comorbid eating disorders, such as BES or affective disorders, cognitive behavioral therapy is the psychotherapeutic treatment method of choice and should be initiated at the very beginning of therapy. If extreme obesity (BMI ≥40 kg/m²) without or a BMI of >35 kg/m² with comorbidities is present and only less than 10% weight reduction has been achieved by 6 months of conservative weight loss measures, the indication for bariatric surgery should be made and considered on an interdisciplinary basis. In the postoperative follow-up of this patient group, it will remain important to closely elicit eating behavior, especially in the case of minor weight loss.
Literature:
- Federal Office of Public Health: www.bag.admin.ch/bag/de/home/gesund-leben/gesundheitsfoerderung-und-praevention/koerpergewicht/uebergewicht-und-adipositas.html.
- Fichter MM, Quadflieg N: Mortality in eating disorders – Results of a large prospective clinical longitudinal study. International Journal of Eating Disorders 2016; 49: 391-401.
- Obesity Consensus 2016, Swiss Society of Endocrinology and Diabetology.
- Herpertz S, et al: Quality S3 Interdisciplinary Guideline on “Diagnosis and Treatment of Eating Disorders” 2018; www.awmf.org/leitlinien/detail/ll/051-026.html.
- Margraf J, Cwik JC: Mini-DIPS open access: diagnostic brief interview in mental disorders. Bochum: Mental Health Research and Treatment Center, Ruhr University 2017; doi: 10.13154/rub.102.91.
- American Psychiatric Association 2013. diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC. (German: Falkai, P. & Wittchen, H.-U. (eds.) (2015). Diagnostic and statistical manual of mental disorders DSM-5. Göttingen: Hogrefe.).
- Swanson SA, et al: Prevalence and correlates of eating disorders in adolescents: results from the national comorbidity survey replication adolescent supplement. Archives of General Psychiatry 2011; 68: 714-723.
- Ackard DM, Fulkerson JA, Neumark-Sztainer D: Prevalence and utility of DSM-IV eating disorder diagnostic criteria among youth. The International Journal of Eating Disorders 2007; 40: 409-417.
- Schnyder U, et al: Prevalence of Eating Disorders in Switzerland. Commissioned by the Federal Office of Public Health (FOPH) 2012.
- McCuen-Wurst C, Ruggieri M, Allison KC: Disordered eating and obesity: associations between binge-eating disorder, night-eating syndrome, and weight-related comorbidities. Ann N Y Acad Sci 2018; 1411: 96-105.
- Guo F, et al: Night-Eating Syndrome and Depressive Symptoms in College Freshmen: Fitness Improvement Tactics in Youths (FITYou) Project. Psychol Res Behav Manag 2020; 13: 185-191.
- Pfeiffer C, Robitzsch A, Teufel M, Skoda EM: Diagnosis of eating disorders in obesity. CardioVasc 2020; 20: 31-34.
- Braden A, et al: Eating when depressed, anxious, bored, or happy: are emotional eating types associated with unique psychological and physical health correlates? Appetite 2018; 125: 410-417.
- Opolski M, Chur-Hansen A, Wittert G: The eating-related behaviours, disorders and expectations of candidates for bariatric surgery. Clin Obes 2015; 5: 165-197.
- Heriseanu AI, et al: Grazing in adults with obesity and eating disorders: a systematic review of associated clinical features and meta-analysis of prevalence. Clinical psychology review 2017; 58: 16-32.
- Kelly NR, et al: Emotion dysregulation and loss-of-control eating in children and adolescents. Health Psychology 2016; 35(10): 1110-1119.
- Hauner H et al: Interdisciplinary Quality S3 Guideline on “Prevention and Therapy of Obesity” [Internet] 2014 [cited 2020 Mar 18].
- Laederach K, et al.: Adipositas-Consensus 2016 der Schweiz. Society for Endocrinology and Diabetology (SGED)/Switzerland. Metabolism and Obesity Working Group (SAMO/ASEMO).
- Paul-Ebhohimhen V, Avenell A.: A systematic review of the effectiveness of group versus individual treatments for adult obesity. Obes Facts 2009; 2(1): 17-24.
- Kumanyika SK, et al: Trial of family and friend support for weight loss in African American adults. Arch Intern Med 2009; 169 (19): 1795-1804.
- Cousins JH, et al: Family versus individually oriented intervention for weight loss in Mexican American women. Public Health Rep 1992; 107(5): 549-555.
- Waller K, Kaprio J, Kujala UM: Associations between long-term physical activity, waist circumference and weight gain: a 30-year longitudinal twin study. Int J Obes (Lond) 2008; 32(2): 353-361.
- Torgerson JS, et al: XENical in the prevention of diabetes in obese subjects (XENDOS) study: a randomized trial of orlistat as an adjunct to lifestyle changes for the prevention of type 2 diabetes in obese patients. Diabetes care 2004; 27(1): 155-161.
- Pi-Sunyer X: A randomized, controlled trial of 3.0 mg of liraglutide in weight management. N Eng J Med 2015; 373(1): 11-22.
- Davies MJ, et al: Efficacy of Liraglutide for Weight Loss Among Patients with Type 2 Diabetes: The SCALE Diabetes Randomized Clinical Trial. JAMA 2015; 314(7): 687-699.
- Legenbauer TM, et al: Do mental disorders and eating patterns affect long-term weight loss maintenance? Gen Hosp Psychiatry 2010; 32: 132-140.
- Palavras MA, et al: “The Efficacy of Psychological Therapies in Reducing Weight and Binge Eating in People with Bulimia Nervosa and Binge Eating Disorder Who Are Overweight or Obese-A Critical Synthesis and Meta-Analyses.” Nutrients 2017; 9(3): 299.
- Johns DJ, et al: Diet or exercise interventions vs combined behavioral weight management programs. A systematic review and meta-analysis of direct comparisons. Journal of the Academy of Nutrition and Dietetics 2014; 114(10): 1557-1568.
- Hilbert A, et al: Long-term efficacy of psychological treatments for binge eating disorder. Br J Psychiat 2012; 200: 232-237.
- Sjostrom L, et al: Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med 2004; 351(26): 2683-2693.
- Dietrich A, et al: 2018 S3 guideline: surgery for obesity and metabolic disease: www.awmf.org/uploads/tx_szleitlinien/088-001l_S3_Chirurgie-Adipositas-metabolische-Erkrankugen_2018-02.pdf.
FAMILY PRACTICE 2020; 15(12): 8-15