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Kenkre JS, Gesell S, Keller A, Milani RM, Scholtz S, Barley EA. Alcohol Misuse post Metabolic and Bariatric Surgery: A Systematic Review of Longer-term Studies with Focus on new Onset Alcohol use Disorder and Differences Between Surgery Types. Curr Obes Rep 2024:10.1007/s13679-024-00577-w. [PMID: 38850501 DOI: 10.1007/s13679-024-00577-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/29/2024] [Indexed: 06/10/2024]
Abstract
BACKGROUND Evidence suggests an increased risk of alcohol problems post-surgery where no problematic alcohol use was present prior to surgery which may be different across types of surgery. OBJECTIVE To characterise the risk of new onset alcohol misuse post bariatric surgery, differences between surgeries and the impact over time. METHODS All published studies on new and relapsing alcohol use were reviewed. Data were classed as 'subjective' (clinical interview, self-report questionnaires) and 'objective' (hospital admissions, substance misuse programmes) and further categorised by follow up time - 'shorter-term' (one year), 'medium-term' (one year to two years) and 'long-term' (> two years). RESULTS Twenty-three of the forty-two studies included in the review reported new onset data. Nine studies reported on differences between surgery types. In those reporting objective measures, all of which were long term, RYGB carried a higher risk than SG, followed by LAGB. All but one study using subjective measures reported a small but significant number of new onset concerning alcohol use, and comparisons between surgery types had more varied results than the objective measures. Studies of substance abuse programmes found high rates of new onset cases (17-60%). CONCLUSION This systematic review provides support for the consensus guidance suggesting patients should be informed of a small but significant risk of new onset alcohol use following bariatric surgery, with the strongest evidence in the medium- to long-term and in those who have had RYGB followed by SG.
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Affiliation(s)
- Julia S Kenkre
- Section of Endocrinology and Investigative Medicine, Imperial College, London, UK
| | - Sutapa Gesell
- Central and North West London NHS Foundation Trust, London, UK
| | - Annalise Keller
- School of Human and Social Sciences, University of West London, London, UK
| | - Raffaella M Milani
- School of Human and Social Sciences, University of West London, London, UK
| | - Samantha Scholtz
- Section of Endocrinology and Investigative Medicine, Imperial College, London, UK.
- West London NHS Trust, London, UK.
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2
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Cooper KM, Colletta A, Hebda N, Devuni D. Alcohol associated liver disease and bariatric surgery: Current perspectives and future directions. World J Gastrointest Surg 2024; 16:650-657. [PMID: 38577096 PMCID: PMC10989338 DOI: 10.4240/wjgs.v16.i3.650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 01/27/2024] [Accepted: 02/26/2024] [Indexed: 03/22/2024] Open
Abstract
Bariatric surgery is a routinely performed procedure and is associated with a reduction in all-cause mortality in patients with obesity. However, bariatric surgery has also been linked to increased alcohol use with up to 30% of these patients developing alcohol use disorder (AUD). The mechanism of AUD after bariatric surgery is multifactorial and includes anatomic, metabolic, and neurohumoral changes associated with post-surgical anatomy. These patients are at increased risk of alcohol associated liver disease and, in some cases, require liver transplantation. In this article, we provide a scoping review of epidemiology, pathophysiology, and clinical outcomes of alcohol-related health conditions after bariatric surgery.
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Affiliation(s)
- Katherine M Cooper
- Department of Medicine, UMass Chan Medical School, Worcester, MA 01655, United States
| | - Alessandro Colletta
- Department of Medicine, UMass Chan Medical School, Worcester, MA 01655, United States
| | - Nicholas Hebda
- Department of Medicine, UMass Chan Medical School, Worcester, MA 01655, United States
| | - Deepika Devuni
- Department of Medicine, UMass Chan Medical School, Worcester, MA 01655, United States
- Division of Gastroenterology, UMass Chan Medical School, Worcester, MA 01655, United States
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3
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Capelo Vides M, Campello de Oliveira M, Lassi DLS, Malbergier A, Florio L, de Azevedo-Marques Périco C, Abrantes do Amaral R, Torales J, Ventriglio A, Negrão AB, Castaldelli-Maia JM. Bariatric surgery and its influence on alcohol consumption: Differences before and after surgery - A systematic review and meta-analysis. Int Rev Psychiatry 2023; 35:367-376. [PMID: 38299644 DOI: 10.1080/09540261.2023.2223317] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 06/06/2023] [Indexed: 02/02/2024]
Abstract
BACKGROUND Through new publications on the subject, the main goal of this article is to seek a change in the pattern of alcohol use before and after bariatric surgery. METHODS We searched the National Library of Medicine, CINAHL, and PsycINFO databases. We included original articles regarding alcohol consumption before and after bariatric surgery to conduct the systematic review. RESULTS Our systematic review, which included 18 articles, yielded mixed results. Meta-analysis of six articles did not reveal statistically significant differences in alcohol use behaviours before and one year after bariatric surgery. However, throughout the perspective of follow-up after bariatric surgery, nine out of the twelve articles showed improvement in the pattern of alcohol consumption when evaluated up to two years after the end of the surgical period, and four out of the five articles with monitoring beyond two years showed worsening in consumption, compared to pre-surgery alcohol use behaviours. CONCLUSIONS Conclusions about the relationship between alcohol consumption and bariatric surgery are challenging primarily because of the variety of the methods used and the alcohol consumption measures. Despite that, our research pointed to an increased risk of alcohol use disorders two years after bariatric surgery.
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Affiliation(s)
- Mariana Capelo Vides
- Department and Institute of Psychiatry, University of São Paulo, São Paulo, Brazil
| | | | | | - André Malbergier
- Department and Institute of Psychiatry, University of São Paulo, São Paulo, Brazil
| | - Ligia Florio
- Department of Neuroscience, Medical School, FMABC University Center, Santo André, Brazil
| | | | | | - Julio Torales
- Department of Psychological Medicine, School of Medical Sciences, National University of Asuncion, San Lorenzo, Paraguay
| | - Antonio Ventriglio
- Department of Experimental Medicine, Medical School, University of Foggia, Foggia, Italy
| | | | - João Mauricio Castaldelli-Maia
- Department and Institute of Psychiatry, University of São Paulo, São Paulo, Brazil
- Department of Neuroscience, Medical School, FMABC University Center, Santo André, Brazil
- Department of Psychological Medicine, School of Medical Sciences, National University of Asuncion, San Lorenzo, Paraguay
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4
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Wong E, Fleishman A, Brem A, Jones DB, Wee CC. High-Risk Alcohol Use and Disordered Eating Behavior Before and 1 Year After Sleeve Gastrectomy. Obes Surg 2022; 32:593-598. [PMID: 35088252 PMCID: PMC8794632 DOI: 10.1007/s11695-021-05847-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 12/03/2021] [Accepted: 12/13/2021] [Indexed: 12/25/2022]
Abstract
Background Evidence suggests a rise in alcohol misuse after some bariatric procedures. Whether undergoing sleeve gastrectomy raises the risk of high-risk alcohol use is unclear. Objective To characterize the risk of high-risk alcohol use 1 year after sleeve gastrectomy and collect preliminary data on potential associations between disordered eating and high-risk drinking post-surgery. Methods We interviewed 97 patients before and 1 year after sleeve gastrectomy and assessed for high-risk alcohol use via a modified version of the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C). Eating behavior was assessed using the Three Factor Eating Questionnaire Revised-18 (TFEQ-R18). Results The prevalence of high-risk drinking increased from 13.4% prior to surgery to 22.7% 1 year after sleeve gastrectomy; 16.5% of our sample reported new high-risk drinking equivalent to an incidence of 19.0%. New high-risk drinkers appeared more likely to report lower cognitive restraint scores and higher scores for emotional and uncontrolled eating at baseline and had larger improvements in disordered eating scores post-surgery although these differences approached, but did not reach, statistical significance. Conclusion One in five non-high-risk drinkers developed new high-risk alcohol intake 1 year after sleeve gastrectomy. New high-risk drinkers appear to have greater disordered eating at baseline and reported greater improvement in eating behavior than those who did not develop new high-risk drinking. These results are consistent with the addiction transfer hypothesis postulating that some patients may replace disordered eating with alcohol misuse after sleeve gastrectomy. Graphical abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1007/s11695-021-05847-3.
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Affiliation(s)
- Emily Wong
- Touro University, Nevada College of Osteopathic Medicine, 874 American Pacific Dr, Henderson, NV, 89014, USA
| | - Aaron Fleishman
- Division of Bariatric and Minimally Invasive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Amanda Brem
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Daniel B Jones
- Division of Bariatric and Minimally Invasive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA.,Harvard Medical School, Boston, MA, USA
| | - Christina C Wee
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA. .,Harvard Medical School, Boston, MA, USA.
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Bramming M, Becker U, Jørgensen MB, Neermark S, Bisgaard T, Tolstrup JS. Bariatric surgery and risk of alcohol use disorder: a register-based cohort study. Int J Epidemiol 2021; 49:1826-1835. [PMID: 33085738 DOI: 10.1093/ije/dyaa147] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Bariatric surgery has been associated with altered alcohol metabolism. We examined whether patients undergoing bariatric surgery have a higher risk of developing alcohol use disorder (AUD) compared with individuals with obesity who have not received bariatric surgery. METHODS In this prospective cohort study, we followed 13 430 patients undergoing bariatric surgery (95% gastric bypass) between 2005 and 2013 and a reference group of 21 021 individuals with obesity for a median of 6.9 years (5th-95th percentile: 4.0-9.8). Four different approaches were used to account for baseline differences between the two groups: (i) adjustment; (ii) inverse probability of treatment weighting (IPTW); (iii) 1:1 matching based on propensity scores; and (iv) before-and-after analysis comparing the bariatric surgery group with itself 5 years before and after surgery. Cox proportional hazard modelling was used to estimate hazard ratios of AUD defined from national registers. RESULTS When applying the IPTW approach, the hazard ratio (HR) of AUD for bariatric surgery patients was 7.29 [95% confidence interval (CI): 5.06-9.48] compared with individuals without surgery. When employing different approaches (adjustment for baseline variables, matching on propensity scores, before-and-after analyses), results were of similar magnitude. Analysis stratified by time after surgery revealed a higher risk of AUD already within the first year following surgery [HR: 2.77 (95% CI: 1.39-5.53)]. CONCLUSIONS Patients undergoing bariatric surgery have a higher risk of developing AUD compared with individuals without bariatric surgery. The higher risk observed in this group of patients cannot be explained by differences in baseline characteristics such as socioeconomic factors. Despite the higher risk of AUD, only few individuals developed AUD. Individuals with disabling obesity should therefore not rule out surgery based on these results but rather be aware of negative implications.
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Affiliation(s)
- Maja Bramming
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - Ulrik Becker
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark.,Gastrounit Medical Division, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Maja B Jørgensen
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - Søren Neermark
- Gastrounit Medical Division, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark.,Center of Planning, Danish Board of Health, Copenhagen, Denmark
| | - Thue Bisgaard
- Surgical Department, Zealand University Hospital, Køge, Denmark
| | - Janne S Tolstrup
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
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Koball AM, Ames G, Goetze RE. Addiction Transfer and Other Behavioral Changes Following Bariatric Surgery. Surg Clin North Am 2021; 101:323-333. [PMID: 33743972 DOI: 10.1016/j.suc.2020.12.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Despite its important treatment implications for obesity and related comorbidities, bariatric surgery requires several behavioral changes that warrant comprehensive evaluation and support before and after surgery. This article outlines emerging scientific and anecdotal evidence for addiction transfer after bariatric surgery. Other common behavioral changes that impact adherence, weight loss, and psychiatric risk after surgery are also reviewed. Last, recommendations for presurgical psychological evaluation and postoperative support are provided.
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Affiliation(s)
- Afton M Koball
- Behavioral Medicine, Gundersen Health System, 1900 South Avenue, La Crosse, WI 54601, USA.
| | - Gretchen Ames
- Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA
| | - Rachel E Goetze
- VA Maine Healthcare System-Togus, 1 VA Center, Augusta, ME 04330, USA
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7
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Iossa A, Ciccioriccio MC, Zerbinati C, Guida A, Di Giacomo L, Silecchia G. Alcohol ingestion symptoms after sleeve gastrectomy: intoxication or drunkenness? A prospective study from a Bariatric Centre of Excellence. Eat Weight Disord 2020; 25:1719-1725. [PMID: 31721103 DOI: 10.1007/s40519-019-00813-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 10/30/2019] [Indexed: 01/28/2023] Open
Abstract
PURPOSE The aim of this original research is to evaluate the effect of SG on alcohol intake symptoms, blood alcohol content (BAC), and alcohol metabolite levels. METHODS At 0-6-12 months after SG, BAC of patients was measured at 0, 15, 30, and 60 min, and then every 30 min, and urinary metabolite (ethanol and acetaldehyde) levels were measured 2 h after consuming a standard red wine drink. Symptoms perceived by patients were evaluated using symptom alcoholization post-obesity surgery scores. RESULTS Thirty obese patients (12 men/18 women; mean body mass index, 44 ± 4 kg/m2) who underwent SG were enrolled in this study. At 12 months after SG, no alcohol use disorder was observed and BAC tended to peak after 15 min, with alcohol intoxication symptoms (nausea/vomiting, flushing, and diaphoresis), and return to zero after 90 min of wine intake. Ethanol and acetaldehyde levels were significantly different at 12 months compared with the levels at time 0 (p < 0.05). CONCLUSIONS Following SG, patients exhibit a high BAC at 15 min after moderate alcohol consumption accompanied with increased metabolite excretion and intoxication symptoms. LEVEL OF EVIDENCE Level III obtained from well-designed cohort analytic study.
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Affiliation(s)
- Angelo Iossa
- Division of General Surgery and Bariatric Centre of Excellence, Department of Medical-Surgical Sciences and Biotechnologies, University of Rome "La Sapienza", Rome, Italy.
| | - Maria Chiara Ciccioriccio
- Division of General Surgery and Bariatric Centre of Excellence, Department of Medical-Surgical Sciences and Biotechnologies, University of Rome "La Sapienza", Rome, Italy
| | - Chiara Zerbinati
- Biochemistry, Researcher of Department of Medicine and Pharmacy, University of Rome "La Sapienza", Rome, Italy
| | - Anna Guida
- Division of General Surgery and Bariatric Centre of Excellence, Department of Medical-Surgical Sciences and Biotechnologies, University of Rome "La Sapienza", Rome, Italy
| | - Liliana Di Giacomo
- Head of Clinical Pathology Department, Santa Maria Goretti Hospital, Latina, Italy
| | - Gianfranco Silecchia
- Division of General Surgery and Bariatric Centre of Excellence, Department of Medical-Surgical Sciences and Biotechnologies, University of Rome "La Sapienza", Rome, Italy
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Freire CC, Zanella MT, Arasaki CH, Segal A, Carneiro G. Binge eating disorder is not predictive of alcohol abuse disorders in long-term follow-up period after Roux-en-Y gastric bypass surgery. Eat Weight Disord 2020; 25:637-642. [PMID: 30859463 DOI: 10.1007/s40519-019-00663-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 02/26/2019] [Indexed: 01/12/2023] Open
Abstract
INTRODUCTION Some studies have shown an increase in alcohol use disorders (AUD) after Roux-en-Y gastric bypass surgery (RYGB), but its relationship with binge eating disorder (BED) has not been fully explored. The purpose of this study was to determine the prevalence of AUD and BED after RYGB and also to evaluate if BED is predictive of late postoperative occurrence of AUD or BED. METHODS Patients (n = 46) submitted to RYGB, in a tertiary outpatient weight management service at a Federal University of Sao Paulo, Brazil, were tested for BED and AUD using the Questionnaire on Eating and Weight Patterns-Revised (QEWP-R) and AUDIT, respectively. BED was tested before surgery, while both disorders were evaluated with a follow-up period of 12 ± 1.6 years after RYGB. RESULTS No patients reported AUD before RYBP. After a mean period of 12 years from surgery, ten patients (21.7%) were diagnosed with AUD. Before surgery, BED was present in 24 patients (52.2%) and it was detected in seven out of these 24 patients (29.2%) after RYGB. Thirteen new cases of BED (28.2%) were detected after surgery; total of 20 patients (43.5%) with BED. No association was found between pre- and postsurgery BED (p = 0.148). After RYGB, four out of 24 patients (16.6%) with presurgery BED developed AUD, and no association was found between presurgery BED and postsurgery AUD (p = 0.384). Seven out of ten patients (70%) with AUD after RYGB also developed BED, but no statistical significance was found between these two disorders (p = 0.061). CONCLUSION The presence of BED before RYGB did not predict AUD and BED after RYGB. Nevertheless, factors involved in a possible association between BED and AUD after surgery remain to be determined. LEVEL OF EVIDENCE Level III, cohort study.
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Affiliation(s)
- Cristina Cardoso Freire
- Department of Medicine, Division of Endocrinology and metalolism, Universidade Federal de São Paulo, End: Street Leandro Duprat, 365, São Paulo, 04025-010, Brazil.
| | - Maria Teresa Zanella
- Department of Medicine, Division of Endocrinology and metalolism, Universidade Federal de São Paulo, End: Street Leandro Duprat, 365, São Paulo, 04025-010, Brazil
| | - Carlos Haruo Arasaki
- Department of Surgery, Division of Surgical Gastroenterology, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Adriano Segal
- Adriano Segal, Department of Medicine, Obesity and metabolic syndrome outpatient service, Universidade de São Paulo, São Paulo, Brazil
| | - Gláucia Carneiro
- Department of Medicine, Division of Endocrinology and metalolism, Universidade Federal de São Paulo, End: Street Leandro Duprat, 365, São Paulo, 04025-010, Brazil
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9
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Nance K, Acevedo MB, Pepino MY. Changes in taste function and ingestive behavior following bariatric surgery. Appetite 2019; 146:104423. [PMID: 31473274 DOI: 10.1016/j.appet.2019.104423] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 07/22/2019] [Accepted: 08/23/2019] [Indexed: 02/06/2023]
Abstract
Bariatric surgery is the most effective treatment for severe obesity and its related comorbidities. Roux-en-Y Gastric Bypass (RYGB) and Sleeve Gastrectomy (SG) are currently the most popular weight-loss surgeries used worldwide. Following these surgeries, many patients self-report changes in taste perception and decreased preference for unhealthy foods. These reported changes might account for increased adherence to healthier diets and successful weight loss after surgeries. However, researchers have used a variety of methodologies to assess patients' reported changes andresults are discrepant. The goal of this review is to summarize the literature regarding changes to taste function and ingestive behavior following RYGB and SG to examine differences in findings by methodology (indirect vs. direct measurements). We focused our review around changes in sweets, fats, and alcohol because most of the documented changes in ingestive behavior post-surgery are related to changes in these dietary items. We found that studies using surveys and questionnaires generally find that subjects self-report changes in taste and decrease their preference and cravings for energy-dense foods (particularly, sweets and high-fats). However, studies using validated sensory techniques that include oral sampling or by using direct food intake measurements find little to no change in subjects' ability to perceive taste or their preference for energy-dense foods. Therefore, reported changes in taste and food preferences are unlikely to be explained by alterations in taste intensity and diet selection, and are rather related to changes in the rewarding value of food. Further, that RYGB, and likely SG, is associated with increased alcohol consumption and arisk to develop an alcohol use disorder) supports the notion that these surgeries alter central circuits of reward that are critical in the regulation of ingestive behavior.
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Affiliation(s)
- Katie Nance
- Department of Food Science and Human Nutrition, College of Agricultural, Consumer and Environmental Sciences, University of Illinois, 905 South Goodwin Avenue, Urbana, IL, 61801, USA.
| | - M Belén Acevedo
- Department of Food Science and Human Nutrition, College of Agricultural, Consumer and Environmental Sciences, University of Illinois, 905 South Goodwin Avenue, Urbana, IL, 61801, USA.
| | - M Yanina Pepino
- Department of Food Science and Human Nutrition, College of Agricultural, Consumer and Environmental Sciences, University of Illinois, 905 South Goodwin Avenue, Urbana, IL, 61801, USA; Division of Nutritional Sciences, College of Agricultural, Consumer and Environmental Sciences, University of Illinois, 905 South Goodwin Avenue, Urbana, IL, 61801, USA.
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10
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Müller A, Leukefeld C, Hase C, Gruner-Labitzke K, Mall JW, Köhler H, de Zwaan M. Food addiction and other addictive behaviours in bariatric surgery candidates. EUROPEAN EATING DISORDERS REVIEW 2018; 26:585-596. [DOI: 10.1002/erv.2629] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 07/02/2018] [Accepted: 07/04/2018] [Indexed: 12/18/2022]
Affiliation(s)
- Astrid Müller
- Department of Psychosomatic Medicine and Psychotherapy; Hannover Medical School; Hannover Germany
| | - Crispin Leukefeld
- Department of Psychosomatic Medicine and Psychotherapy; Hannover Medical School; Hannover Germany
| | - Carolin Hase
- Department of Psychosomatic Medicine and Psychotherapy; Hannover Medical School; Hannover Germany
| | | | - Julian W. Mall
- Department of General, Vascular and Bariatric Surgery; KRH Klinikum Nordstadt; Hannover Germany
| | - Hinrich Köhler
- Department of Surgery; Herzogin Elisabeth Hospital; Braunschweig Germany
| | - Martina de Zwaan
- Department of Psychosomatic Medicine and Psychotherapy; Hannover Medical School; Hannover Germany
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