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Clinical Neuropsychiatry logoLink to Clinical Neuropsychiatry
. 2025 Feb;22(1):40–52. doi: 10.36131/cnfioritieditore20250104

Effectiveness of Non-Invasive Brain Stimulation (NIBS) in Overeating and Increased Body Mass Index (BMI): An Umbrella Review

Nikolaos Liaskopoulos 1, Andreas S Lappas 2, Myrto T Samara 3, Nikolaos Christodoulou 4
PMCID: PMC11956884  PMID: 40171118

Abstract

This review of reviews aims to investigate the effectiveness of non-invasive brain stimulation (NIBS) methods, i.e., transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS), in reducing elevated body mass index (BMI) and overeating behavior (food cravings, binge eating, increased food consumption). Systematic reviews and meta-analyses in the English language were included. A search was conducted in PubMed and EMBASE until January 2024. The quality of all included reviews was assessed using the “A Measurement Tool to Assess Systematic Reviews” (AMSTAR-2). Quality assessment and data extraction were conducted by two independent reviewers, while all reviewers participated equally in article synthesis. Twenty-four systematic reviews were included, most of which show promising results regarding the effectiveness of NIBS on overeating and increased BMI . For weight reduction, rTMS is more effective, and tDCS can improve food cravings and food consumption. However, the critically low quality of most included studies and the heterogeneity of the intervention parameters are strong limitations against drawing any safe conclusions. More studies are needed with stable NIBS parameters.

Keywords: transcranial magnetic stimulation, transcranial direct current stimulation, BMI, body weight, overeating, binge-eating

Introduction

Overeating can be described as a situation in which the calorie intake exceeds calorie expenditure. It can be a pathological food behavior associated with a multitude of conditions. Food cravings occur in the healthy population regardless of the individual's BMI (Roefs et al., 2019) and can lead to increased body weight (Adams et al., 2019). They are also present in the binge-eating episodes that are characteristic of bulimia (Argyrou et al., 2023) and binge-eating disorder (Hilbert, 2019). Obesity and overweight are considered by the WHO to be a public health problem at the level of an epidemic (Roefs et al., 2019).

More specifically, in 2016, 39% of adults were overweight, while 13% were obese (WHO, 2016). The economic burden of obesity is estimated at $275 billion annually in the USA (Spieker & Pyzocha, 2016), while in the UK, by 2025, there will be a total burden of £37.2 billion (Adams et al., 2019). Overweight is defined as a BMI greater than or equal to 25 kg/m2, while a BMI greater than or equal to 30 kg/m2indicates obesity. These conditions can lead to cardiovascular problems, diabetes mellitus, orthopedic issues, and even carcinogenesis, thus reducing life expectancy, quality of life, and burdening the public health system (WHO, 2016).

Increased food consumption is not only observed in pathological conditions and psychiatric disorders but also in the daily lives of the healthy population. In these cases, people consume food to satisfy a behavioral form of food addiction. These food cravings typically involve foods high in carbohydrates and low in nutritional value. The intensity of these cravings increases in relation to BMI (Roefs et al., 2019).

Overeating is also a symptom of bulimia nervosa and binge eating disorder. Both eating disorders involve episodes of binge eating, but what distinguishes bulimia nervosa from BED is the presence of unhelpful compensatory behaviors, such as self-induced vomiting, misuse of some kinds of medication, fasting and excessive exercise (Erzegovesi & Bellodi, 2016). The prevalence of BED ranges from 0.9% to 5.6% (Hilbert, 2019), while in bulimia, the rate is around 4.4% (Arcelus et al., 2013). The inclusion of BED as a separate eating disorder in the DSM-5 manual was a necessary addition due to the frequency and severity of the disorder, as well as its psychiatric and pathological comorbidities (Hilbert, 2019). The foundation of the treatment for this disorder, as with bulimia nervosa (Argyrou et al., 2023), is psychotherapy, while pharmacotherapy and other methods can be used as adjuncts (Hilbert, 2019). Regarding bulimia nervosa, even with available treatments, it is often challenging to treat due to various factors (Argyrou et al., 2023).

The pathophysiology of eating disorders is also multifactorial. In bulimia nervosa, higher binding to the 1A serotonin receptor, as well as lower striatal dopamine release (which correlates with an increased frequency of binge eating episodes), have been found, and in obesity, cytokine levels are increased (Frank et al., 2019). At a functional level, a stronger connection between the dorsal anterior cingulate cortex and medial orbitofrontal cortex, right precuneus, and the dorsolateral prefrontal cortex (DLPFC) has been found in BN (Lee et al., 2014). There is limited data on BED regarding neurophysiological dysfunction (Frank et al., 2019).

The methods of non-invasive brain stimulation include transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS). TMS is applied through a coil placed on the skull, which administers magnetic pulses, creating an electric field in the brain tissue (Rawji et al., 2020). When magnetic pulses are administered repeatedly (rTMS), the effects of brain stimulation are longer-lasting. Thus, rTMS treatment can induce excitation or inhibition of neural circuits (Lefaucheur, 2019) and changes in neurotransmitter secretion (Dubin, 2017). Similar findings have been observed using tDCS, a NIBS method that uses direct currents moving through two electrodes, usually placed on opposite brain hemispheres (Lefaucheur, 2019). In the literature, which includes clinical trials and reviews, the most common protocol is the administration of an excitatory NIBS protocol to the DLPFC, a region of the cerebral cortex responsible, among other things, for the conscious control of behavior, including food cravings, binge-eating, and overeating (Val-Laillet et al., 2015).

So, there are few options beyond lifestyle change for managing obesity and overeating. Even if this change brings results -5-10% weight loss for the most intensive programs (Papamargaritis et al., 2024), there is a high likelihood of relapse (Kim, 2024). Regarding the administration of pharmaceutical treatment for elevated ΒΜΙ, while it appears to be effective, there isn't sufficient data on maintaining the results after discontinuation of the treatment and on the action of the medications in patients with diabetes. In a review concerning the pediatric population, a frequency of serious side effects of 1% is reported (Torbahn et al., 2024). Bariatric surgery appears to be effective with results that persist over time, but it constitutes an invasive method with the potential for complications, and many patients may not be suitable candidates for the procedure (Papamargaritis et al., 2022).

Regarding eating disorders, there are many challenges. Half of the patients exhibit atypical eating disorders that do not meet diagnostic criteria, while at the same time, comorbidities are often present (Tomba et al., 2024). The treatment of any eating disorder is equally challenging, as many patients drop out or resist psychotherapy (Tomba et al., 2024).

Therefore, the investigation of non-invasive brain stimulation (NIBS) as an adjunctive or alternative therapy for obesity and overeating is necessary. This review aims to investigate the NIBS on overeating and obesity, assessing and analyzing the primary findings from reviews conducted on the topic.

Methods

The methods of this umbrella review were preregistered in the PROSPERO international database prior to the review (PROSPERO ID CRD42022331029; Liaskopoulos & Christodoulou, 2022). Two authors, working independently and blinded to each other, conducted the study search, quality assessment, and data extraction. In case of any disagreements at the end of each stage, a third author was consulted for resolution.

Studies were retrieved from the PUBMED and EMBASE databases, covering publications up to January 2024. The key search terms employed by the reviewers were ((TMS) OR (transcranial magnetic stimulation) OR (direct current stimulation)) AND ((obesity) OR (bulimia) OR (eating) OR (overeating) OR (hyperphagia) OR (overweight)). Inclusion criteria required that the study design be a systematic review, with or without meta-analysis, published in English, investigating the efficacy of TMS or tDCS to participants with overeating or increased BMI with available data for outcomes relevant to BMI or eating behavior, such as body weight, food consumption and food craving. In the figure below (figure 1), a flow diagram is presented.

Figure 1.

Figure 1.

Flow diagram of included studies

The two reviewers independently created tables to evaluate the quality of the studies and extract data. The quality assessment table listed the studies determined to be included in its vertical column and the various items of the AMSTAR-2 questionnaire (Shea et al., 2017) in its horizontal column. The data extraction table (full in the supplementary materials) encompassed the following information: 1) Author name and Year of Publication, 2) Number of included studies (related to overeating or increased BMI), 3) Year of the most recent study, 4) Total number of participants, 5) Databases used, 6) Inclusion criteria, 7) Outcomes related to eating, 8) Conclusions, and 9) AMSTAR-2 Quality. All researchers collaborated in crafting the final text and, based on the data summarized in the tables, authored the results and discussion sections.

Results

Results of the search

We identified 157 records and included 24 systematic reviews and/or meta-analyses (table 2, full table in online data supplement table S1) that included 60 original trials (tables S2 & S3 – online data supplement) with a total of 1840 participants (673 TMS; 1167 tDCS). The PRISMA flow diagram of the search and screening process is presented in figure 1; detailed characteristics of included systematic reviews are summarized in table S1 in the online data supplement.

Table 2.

Included studies (reviews and metanalyses) and main conclusions. AL/CR: anode left/cathode right; AN: anorexia nervosa; AR/CL: anode right/ cathode left; BED: binge-eating disorder; BMI: body mass index; BN: bulimia nervosa; cTBS: Continuous theta burst stimulation; DLPFC: dorsolateral prefrontal cortex; DMPFC: dorsomedial prefrontal cortex; dTMS: deep transcranial magnetic stimulation; ED: eating disorder; HF: high frequency; IFG: inferior frontal gyrus; MT: motor threshold; NIBS: non-invasive brain stimulation; PFC: prefrontal cortex; RCT: randomized controlled trial; rTMS: repetitive transcranial magnetic stimulation; tDCS: transcranial direct current stimulation

Author name, Year of Publication Number of included studies (related to overeating or increased BMI) Total number of participants Conclusions
Sampaio et al., 2012 6 174 Four out of six studies found that NIBS (2 studies on tDCS and 2 on rTMS) can reduce the desire for food consumption and food cravings. These effects appear to be more pronounced after DLPFC stimulation in stress response situations and psychiatric conditions. Flowever, two rTMS studies did not find a significant improvement in food cravings. The prefrontal cortex's role as a decision-making and impulse inhibition region of the brain is emphasized. Additionally, the PFC may play a significant role through its connection with the brain's reward system. Limitations of these studies include most of them measuring the effects of a single session and having unclear hypotheses. More neuroimaging studies and investigations using dTMS and high-definition tDCS are needed. Long-lasting results of NIBS should be explored in subsequent studies.
McClelland et al., 2013 11 206 One study on a healthy population without food cravings showed that lFIz rTMS to the right DLPFC ‘decreased the value assigned to food.’ Two studies using lOFIz rTMS to the left DLPFC didn't show an improvement in food cravings in healthy food cravers. Two tDCS studies showed an improvement in food cravings after AR/CL stimulation, and one showed a reduction in the desire to eat after AL/CR stimulation.
Two case reports on BN used rTMS, one on the left DLPFC, and the other on bilateral DMPFC, resulting in full recovery from binging/ purging. Two out of three clinical trials of rTMS on a larger sample showed improvements in the urge to eat and binge-eating episodes after left DLPFC was stimulated with HF protocol.
NIBS seems to be able to reduce food cravings. rTMS, especially FIF-rTMS to the left PFC, shows promise in reducing bulimic symptoms and binge-eating episodes. tDCS, through the inhibition of the left PFC and excitation of the right PFC, reduces food cravings. A variety of parameters can be applied in NIBS therapy, which may explain the variable results in each study.
Sauvaget et al., 2015 6 91 tDCS has been shown to be effective in reducing food cravings, based on findings from six RCTs. Most participants in these trials were women under the age of 30, who reported experiencing frequent food cravings. Five out of the six studies involved a single session of tDCS. It's worth noting that tDCS efficacy in treating eating disorders is the most extensively researched area when it comes to behavioral addictions. Flowever, other outcomes such as impulsivity should also be considered.
The studies demonstrate that stimulating the right DLPFC and inhibiting the left DLPFC result in a statistically significant reduction in food cravings by addressing inter-hemispheric imbalance. More research is needed in this area, particularly studies that combine neuroimaging and electrophysiology techniques.
Dunlop et al., 2016 12 215 Most NIBS studies on food craving target female patients with single-session interventions. One of the two lOFIz rTMS studies on DLPFC in healthy cravers showed an improvement in craving. Four studies on tDCS demonstrated an improvement in craving and food intake after a single session of AR/CL stimulation. For BN, a case report using 10 sessions of 20Flz rTMS over the left DLPFC led to an improvement in binge/purge symptoms. Two out of three other clinical trials on FIF-rTMS on DLPFC showed an improvement in symptoms in BN patients. The two studies applying lOFIz rTMS over DMPFC showed an improvement in binge/purge symptoms in bulimic patients. More RCTs on multi-session tDCS are needed, especially for populations diagnosed with an eating disorder. Also, rTMS to DMPFC for BN must be investigated further. NIBS strategies aimed at improving cognitive control designed for addiction might be helpful.
Lowe et al., 2016 11 235 Over 80% of the participants were female and about 26 years old. Method-specific analysis showed a significant effect of rTMS on food cravings (g, -0.834; p = .008), but not for tDCS (g, -0.252; p = .37). There were no significant differences between the methods (p = .17). BMI (p = .5) and age (p = .11) had no moderating effect. There was no effect of NIBS on food consumption (g, -0.174; p = .28). In one study comparing AL and CL stimulation, it showed that the first technique reduced food consumption the most, especially for soda and fat. Reduced carbohydrate-dense food consumption was observed in another tDCS study. There was a significant improvement in food cravings after single-session TMS studies. The results of NIBS therapies on food consumption were mixed. DLPFC may be involved in reward valuation and cognitive control via glutamatergic projections to the brain's dopaminergic reward system.
Dalton et al., 2017 6 167 A study of a single-session rTMS found an improvement in food craving and hunger but not in BN symptoms. A 10-session rTMS study showed no improvement in BN symptoms. In one study, a single session of tDCS (AR/CL and AL/CR) improved the urge to binge eat and self-regulatory control for less than 24 hours. Two tDCS studies (single session and five sessions) found an improvement in food craving. The single-session study also found a reduction in craving for specific foods and reduced food intake. In another study, AL led to an improvement in food intake and a reduction in weight compared to CL, but not compared to sham. There is potential in NIBS treatment for eating disorders, but this hypothesis needs further investigation. More research is needed on patient selection, intervention protocols, and treatment targets. There is no evidence indicating which NIBS method should be preferred.
Bell and DeWall, 2018 6 326 tDCS at PFC significantly reduced by a small amount overeating (d=-0.29, SDweighted=0.33, p=0.03).
Dalton et al., 2018 19 378 Seven out of eight studies on NIBS in healthy individuals with food cravings showed improvements in food cravings, particularly for sweets, and food valuation. Two out of four studies that assessed food consumption found that NIBS reduced this symptom in healthy participants. In a study that utilized multiple (5) sessions of tDCS (AR/CL), a reduction in food cravings was observed in this population, even lasting for 30 days post-treatment. tDCS also improved cravings for fast food and sweets.
All case series of rTMS on individuals with BN noted a reduction in the urge to eat, with three of them also showing a reduction in binge/purge episodes. A single-session rTMS RCT found an improvement in binge-eating and the urge to eat in bulimic patients 24 hours after treatment. In one study, 20 sessions of rTMS on the DMPFC improved BN symptoms for one month. However, two multiple-session RCTs using rTMS (10 and 15 sessions) found no improvement in binge/purge symptoms. A single session of tDCS (AL/ CR) led to an improvement in BN symptoms.
Regarding BED, two studies (one using rTMS on the left DLPFC and one using tDCS with AR/CL) showed improvements in BED symptoms. In the tDCS study, the improvement in craving and food consumption was more significant for males than females.
Forcano et al., 2018 10 163 For healthy cravers, whether with normal or excess weight, two studies utilized single-session HF-rTMS over the left DLPFC. However, no significant improvement in food cravings or food intake was observed in these cases. Conversely, in five studies, single-session tDCS demonstrated enhanced food craving reduction, particularly for sweets and carbohydrates. Out of four studies, two exhibited an improvement in food consumption following tDCS. Additionally, in one study, the combination of tDCS with exercise resulted in better hunger control and reduced desire to eat compared to tDCS or exercise alone.
Three multiple-session tDCS studies showcased notable enhancements in food cravings and food intake, particularly with respect to carbohydrates, soda, and fat. TMS, on the other hand, proved to be less effective than tDCS in reducing food cravings and food intake. When it comes to tDCS, multiple sessions have been shown to yield better results in terms of food intake and maintaining reduced food cravings than single sessions. The mean quality score of the included studies was 12.25 (SD 1.48), within a range of 0-13.
Fady Rachid, 2018 12 204 No dTMS studies were found. HF rTMS to the left DLPFC was found to improve binge eating, the urge to eat, and hunger in none out of two multiple-session studies and in two out of four single-session studies in patients with BN. When neuro-navigated HF rTMS was applied to the DMPFC in one study on BN patients, binge eating remained stable. Two case reports of HF rTMS to the left DLPFC and bilateral DMPFC showed a recovery from BN symptoms. In the healthy population with food cravings, one study of a single session of rTMS on the left DLPFC found no improvement in food cravings between the active and sham groups. cTBS on the DLPFC improved food cravings in one study. In a case report, 20 sessions of 10Hz rTMS on the left DLPFC reduced binge eating in a patient with BED but did not affect their BMI. Most studies a good safety profile for rTMS. The number of sessions or the exposure to food stimuli did not appear to affect the effectiveness of the method.
Jauregui- Lobera et al., 2018 12 338 The left DLPFC, a component of the dorsal cognitive frontostriatal circuitry connected to ventral limbic circuitry, may play a role in self- control and reward-seeking behavior. Therefore, interventions focused on the DLPFC may have implications for improving food craving and binge-eating behaviors. All tDCS studies applied the intervention to the DLPFC. Among these, four out of six studies reported a reduction in food intake, BMI, food craving, and the urge to binge eat, particularly following AR/CL stimulation. Regarding TMS, two studies applying multiple sessions at high frequency to the left DLPFC did not show a superior reduction in binge eating among bulimic patients compared to sham stimulation. Flowever, when TMS was applied to the DMPFC, it resulted in a reduction in binge eating. Additionally, three studies using single-session rTMS found an improvement in food craving.
Duriez et al, 2020 16 347 Two studies found no improvement in binge/purge behavior and food craving after rTMS on the DLPFC. In one study, 20 sessions of FIF-rTMS on the DMPFC led to a ‘paradoxical suppression of frontostriatal connectivity.’ Most rTMS studies target the left DLPFC with excitatory stimulation. An excitatory protocol should be applied in future studies on the DMPFC as well, because this region is implicated in self-control and impulsivity.
A single-session tDCS (AR/CL) on the DLPFC was found, in an RCT, to improve cognition in bulimic patients. Two studies found that tDCS applied to the right DLPFC reduced food craving, especially in men.
There is a variety of methodologies among studies and a high risk of errors. Most rTMS studies used manual methods to locate the target, employed a figure-of-8 coil, and involved patients undergoing a limited number of sessions (1-10).
Ester et al., 2021 25 835 Most tDCS studies assessed food craving by enhancing the right DLPFC, which is associated with inhibitory control and reward-based learning. Others used excitation of the left DLPFC or bilateral stimulation (AR/CL). One study targeted the IFG but didn't improve food craving. Six out of sixteen studies showed improvement in food craving. Two studies showed sex effects on tDCS stimulation: one showed much improvement for men, the other for women. Five studies found improvement in craving for specific food categories (especially sweet), independently of BMI. Multisessional tDCS is more effective than single-session tDCS on food craving.
BMI was assessed after stimulating the right (two studies) and left DLPFC (six studies). One study showed that three days of tDCS on the left DLPFC didn't lead to an overall improvement in BMI. Flowever, BMI showed better improvement in obese patients. Two other studies on multiple-session tDCS found no improvement in BMI.
Gouveia et al., 2021 12 343 Four out of five studies applied rTMS to the left DLPFC, and one study applied dTMS to the PFC and insula. Higher frequencies led to a greater reduction in BMI. The dTMS study found improved energy expenditure and a reduction in binge eating after 1Hz and 18Hz stimulation with an FI-shaped coil at 120% MT for 15 sessions. TMS studies applied multiple sessions of lOFIz neurostimulation at 110-120% MT using a figure-of-eight coil. TMS stimulation led to a 1-4% reduction in BMI. As for tDCS, one study targeted the bilateral DLPFC, two studies targeted the right DLPFC, and four studies targeted the left DLPFC using 2mA for 20-40 minutes. Only one out of seven RCTs showed that eight sessions of tDCS stimulation led to a small but significant (2.32%) reduction in body weight, without a follow-up assessment. tDCS was ineffective for losing weight in obesity but reduced cravings and the frequency of snacking. NIBS is considered safe but not very efficient, with unknown long-term effects.
Ince et al., 2021 5 181 One out of two studies applying 10Hz rTMS on left DLPFC found reduction in binge eating. Three tDCS studies that enhanced right DLPFC found a reduction in food craving and binge eating.
Beaumont et al., 2022 28 996 Seventeen studies targeted the right DLPFC, while eight studies focused on the left DLPFC. Studies investigating interventions in regions other than the DLPFC (such as the right inferior frontal gyrus, medial prefrontal cortex, right extrastriate body area, and the primary motor cortex representation of the tongue muscle) showed stable or worsened findings. Stable results, including increased hunger and desire to eat, were observed after left DLPFC stimulation. Following AR/CL stimulation, the reduction of food-related outcomes ranged from g = -0.39 to 0.01. One study found an increased preference for chocolate after AL/CR stimulation, while another study found that AR/CL stimulation led to a greater reduction in food cravings than AL/CR. Reduced right DLPFC activity may contribute to poor dietary control, supporting the right-brain hypothesis of obesity.
Twenty-three out of twenty-eight studies applied a current intensity of 2mA, while the remaining studies used 1-1.5mA. A current density of 0.057 mA/cm2 reduced all food-related measures (g = -0.25 to -0.06).
Twenty out of twenty-eight studies used 20 minutes of stimulation. Only one study applied tDCS for 15 minutes, stimulating the primary motor cortex representation of the tongue muscle at 1mA, without observing improvement. No conclusion can be drawn regarding whether the duration of stimulation impacts symptom progress.
Nine out of twenty-eight studies utilized a multisession protocol (3-16 sessions). Multisession tDCS showed improvement in food cravings (g = -0.29; 95% Cl = -0.60 to 0.03) and food consumption (g= -0.34; 95% Cl = -1.03 to 0.35) compared to single-session interventions.
Cavicchioli et al., 2022 9 272 rTMS reduced BMI in obese patients (dw= -0.85 [-1.14 - -0.56]; p < 0.001), with large (I2 = 91.44%) and significant (Q[2]= 23.35; p < 0.01) heterogeneity of findings. Age, number of sessions, and duration of treatment were not found to be related to the results. There was no observed improvement in binge eating, urge to eat, or severity of ED symptoms.
De Klerk et al., 2022 6 163 Both rTMS studies consistently demonstrated that HF stimulation of the left DLPFC resulted in a reduction of food intake and BMI.
In one of these studies, there was an observed increase in functional connectivity within the right frontoparietal network. It is likely that rTMS enhances inhibitory control ability. Regarding tDCS, one AR/CL study and two out of three studies targeting the left DLPFC reported reduced food craving and consumption, leading to greater weight loss.
Gay et al., 2022 2 85 One out of two studies in bulimic patients reduced food craving and binge-eating by HF rTMS on left DLPFC.
Orru et al., 2022 5 142 Three out of five studies applied multi-session tDCS. Of these, three studies employed 20-minute sessions, while the other two used 40-minute sessions. In one study, tDCS (anode on the left DLPFC) did not show short-term effects, but long-term assessment revealed improvements in appetite (p=0.01) and desire to eat (p=0.05). In one out of two studies, a reduction in food intake was observed after left DLPFC stimulation (anode and cathode). In another study, a single session of AR/CL stimulation did not result in an improvement in food craving. Similar findings were observed after anode stimulation of the left DLPFC and cathode stimulation of the right posterior cerebellar lobe.
Song et al., 2022 4 117 Food craving reduced (g=0.786, Cl=0.287 - 1.284, p=0.002).
Xu et al., 2022 10 340 No significant difference in symptom improvement was found between rTMS and tDCS. tDCS may reduce ED symptoms for both clinical (g = -0.65, Cl: -0.99 - -0.30) and subclinical patients (g = -0.64, Cl: -0.98 - -0.29). Data for rTMS are mixed with data from AN studies. More sessions of NIBS led to greater improvement.
Alhindi et al., 2023 19 601 Most of the studies utilized 4-5 weeks of intervention. The reduction in body weight after TMS was significant (MD = -3.29 kg, 95% CI [-5.32, -1.26]; I2 = 48%; p < 0.001), especially following 30-minute sessions (MD = -2.59 kg, 95% CI [-4.91, -0.27]; I2 = 0%, p < 0.05), compared to 20-minute sessions (MD = -1.68 kg, 95% CI [-3.28, 0.07]; I2 = 0%, p < 0.05). Additionally, 10Hz rTMS resulted in greater weight loss (MD = -4.17 kg, 95% CI [-7.00, -1.33]; I2 = 54%, p < 0.05) than 18Hz dTMS (MD = -1.68 kg, 95% CI [-3.28, -0.07]; I2 = 0%, p < 0.05). The reduction of BMI after TMS was also significant (MD = -0.74, 95% CI [-1.17, -0.31]; I2 = 0%, p = 0.00). TMS induced an improvement in food craving (g = -0.91, 95% CI [-1.68, -0.14]; p = 0.00), especially after 20 minutes of stimulation (g = -0.49, 95% CI [-0.84, -0.15]; p < 0.05).
tDCS was effective in reducing body weight (MD = -0.82 kg, 95% CI [-1.01, -0.62]; I2 = 0.0%, p = 0.00), especially after 20 minutes (MD = -0.83 kg, 95% CI [-1.03, -0.63]; I2 = 0%, p < 0.05) and CR DLPFC stimulation (MD = -0.84 kg, 95% CI [-1.03, -0.62]; I2 = 0.00%, p < 0.05). tDCS also reduced food craving (g = -0.32, 95% CI [-0.62, -0.02]; p = 0.04).
Batista et al., 2023 7 301 The average BMI was 28.1 kg/m2. Older women (45-65 years old) showed improvement in binge-eating, while younger individuals (19-22) showed worsening of food intake and inhibition control. Six out of seven studies applied stimulation to the left DLPFC. NIBS (Non-Invasive Brain Stimulation) reduced food cravings, especially for sweets and fast food, but BMI remained unchanged.

Quality assessment

The quality of the included systematic reviews was assessed using the AMSTAR-2 tool (Shea et al., 2017), a questionnaire comprising 16 questions, with 7 aimed at identifying critical flaws. Of these, three questions, two of which are particularly important in assessing weaknesses, pertain specifically to studies that involve meta-analyses of data. A review is considered to have critically low quality if it exhibits at least two critical flaws. For the reasons explained below, twenty reviews assessed here were determined to have critically low quality and four reviews low quality (table 1).

Table 1.

Quality assessment of the included studies, using the AMSTAR-2 tool. The highlighted items correspond to the critical questions. NO MA: no meta-analysis conducted; PY: partially yes

Author name, Year of Publication 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Overall items
Sampaio et al., 2012 YES NO YES YES YES YES NO PY NO NO NO MA NO MA NO YES NO MA YES Critically low
McClelland et al., 2013 YES NO YES YES YES YES NO YES NO NO NO MA NO MA NO YES NO MA YES Critically low
Sauvaget et al., 2015 YES NO YES YES YES YES NO YES YES NO NO MA NO MA YES YES NO MA YES Critically low
Dunlop et al., 2016 YES NO YES NO YES YES NO YES NO NO NO MA NO MA NO YES NO MA YES Critically low
Lowe et al., 2016 YES NO YES YES YES YES NO PY YES NO YES YES YES YES YES YES Critically low
Dalton et al., 2017 YES NO YES YES YES YES NO YES NO NO NO MA NO MA NO YES NO MA YES Critically low
Bell and DeWall, 2018 YES NO YES YES YES YES NO NO YES NO YES YES YES YES NO NO Critically low
Dalton et al., 2018 YES NO YES YES YES YES NO YES NO NO NO MA NO MA NO YES NO MA NO Critically low
Fady Rachid, 2018 YES NO YES NO NO NO NO YES NO NO NO MA NO MA NO YES NO MA NO Critically low
Forcano et al., 2018 YES NO YES YES YES YES NO YES NO NO NO MA NO MA NO YES NO MA YES Critically low
Duriez et al, 2020 YES NO YES NO YES YES NO YES NO NO NO MA NO MA NO YES NO MA YES Critically low
Jauregui-Lobera et al., 2020 YES NO YES YES YES YES NO YES YES NO NO MA NO MA NO YES NO MA YES Critically low
Ester et al., 2021 YES NO YES YES YES YES NO YES NO NO NO MA NO MA NO YES NO MA YES Critically low
Gouveia et al., 2021 YES NO YES YES YES YES NO YES PY NO NO MA NO MA YES YES NO MA YES Critically low
Ince et al., 2021 YES NO YES YES YES YES NO YES NO NO NO MA NO MA YES YES NO MA YES Critically low
Beaumont et al., 2022 YES NO YES YES YES YES NO PY YES NO YES YES YES YES YES YES Critically low
Cavicchioli et al., 2022 YES NO YES YES YES YES NO YES YES NO YES YES YES YES YES NO Critically low
De Klerk etal., 2022 YES NO YES YES YES YES NO YES NO NO NO MA NO MA NO YES NO MA YES Critically low
Gay et al., 2022 YES YES YES YES YES YES NO YES YES NO YES YES YES YES YES YES Low
Orru etal., 2022 YES NO YES YES YES YES NO YES YES NO NO MA NO MA YES YES NO MA YES Critically low
Song et al., 2022 YES NO YES YES YES YES NO PY YES NO YES YES YES YES YES YES Critically low
Xu etal., 2022 YES YES YES YES YES YES NO PY YES NO YES YES YES YES YES YES Low
Alhindi et al., 2023 YES YES YES YES YES YES NO YES YES NO YES YES YES YES YES YES Low
Batista et al., 2023 YES YES YES YES YES YES NO YES YES NO NO MA NO MA YES YES NO MA NO Low

While all the reviewed studies incorporated the PICO criteria into their research hypothesis and inclusion criteria (population - intervention - comparison - outcome) (item 1), only four of them indicated that their methods were defined before the review was conducted, preventing the evaluation of deviations from the original protocol (item 2 - critical flaw). All reviews provided explanations for their choice of specific clinical trial designs (item 3), and most employed a comprehensive literature search strategy (item 4 - a critical question). Only three studies exclusively used a single database (Dunlop et al., 2016; Duriez et al., 2020; Fady Rachid, 2018).

Regarding items 5 and 6, most studies within the reviews were identified and analyzed for their data by at least two researchers, with one exception (Fady Rachid, 2018), where the process of study selection and data extraction was performed by a single author. Another critical flaw (item 7) common to all the included reviews was the absence of a list of excluded studies. However, most of the reviews accurately described the parameters of the clinical trials they included (item 8). In addition, a few of the reviews assessed the risk of bias in clinical trials (item 9 – critical flaw), with all but one (Jáuregui-Lobera & Martínez-Quiñones, 2018) referencing this assessment and its potential impact on trial conclusions (item 13 – critical question). Notably, none of the systematic reviews mentioned conflicts of interest or funding sources for clinical trials (item 10), but most did disclose their conflicts of interest and sources of funding (item 16).

All meta-analyses used appropriate methods for the statistical processing of data (item 11 – critical item), assessed the potential impact of the risk of bias on results (item 12), and, with the exception of one (Bell & DeWall, 2018), conducted a thorough investigation of publication bias (small study bias) and discussed its likely impact on the review results (item 15 – critical item). Finally, all reviews comprehensively addressed the heterogeneity of clinical trial data (item 14).

Description of included reviews and trials

Reviews were published between 2012 and 2023. The mean number of included trials was 11 and participants was about 301. 78,48% of participants (1444 participants) were women (87,37% TMS; 73,35% tDCS). Studies used a variety of stimulation methods (tDCS, rTMS, dTMS, cTBS). The median number of sessions was 10 for TMS (interquartile range: 1-15), 2 for tDCS (interquartile range: 1-5) and the median duration of stimulation was 20 minutes for TMS (interquartile range: 15-20 minutes), 20 minutes for tDCS (interquartile range: 20-20 minutes).

Nibs and food craving/food intake/bmi

Population: Most clinical trials (randomized and non-randomized) involve women aged about 26 years old (Lowe et al., 2014). A recent review showed different results between age groups: women between 45-65 years old showed improvement in binge-eating, while younger individuals (19-22 years old) showed worsening of food intake and inhibition control (Da Silva Lira Batista et al., 2022).

Intervention: Most clinical trials include one NIBS session (Dunlop et al., 2016), while RCTs apply 4-5 weeks of intervention (Alhindi et al., 2023).

Outcomes: Most studies highlight the positive effect of NIBS on food cravings and food consumption (Sampaio et al., 2012; Dalton et al., 2018), but the results are mixed (Lowe et al., 2014). One review found a statistically significant reduction in food cravings (Song et al., 2021). However, there are reviews that claim that NIBS do not reduce food consumption (Lowe et al., 2014). The hypothesis behind the importance of stimulating the prefrontal cortex is the contribution of this brain region to decision-making, impulse inhibition and connection to brain regions responsible for reward (Sampaio et al., 2012; Lowe et al., 2014).

The effect of NIBS was more pronounced on the consumption of sweets (Dalton et al., 2018). rTMS and tDCS did not show a significant difference in efficacy when compared to each other (Lowe et al., 2014). However, some reviews support that TMS is less effective than tDCS for food craving and food intake (Forcano et al., 2018). Neither method is superior to the other in reducing eating disorder symptoms (Xu et al., 2022). Efficacy was also unrelated to BMI and age (Lowe et al., 2014), but related to the number of sessions (Xu et al., 2022). The positive effects appear to be more pronounced after stimulation of the DLPFC in stressful situations or in psychiatric conditions (Sampaio et al., 2012), while in the healthy population the effects on food consumption were mixed (Dalton et al., 2018).

TMS AND FOOD CRAVING/FOOD INTAKE

HF-rTMS: Most TMS studies locate the target manually, use a figure of 8 coil and apply 1-10 sessions (Duriez et al, 2020). While some reviews highlight the significant effectiveness of the method, others show mixed results on food cravings and food intake after TMS sessions (Cavicchioli et al., 2022; Dunlop et al., 2016; Sampaio et al., 2012), especially after HF-rTMS on the left DLPFC (De Klerk et al., 2022). Some reviews estimate that TMS statistically significantly reduces food cravings (Lowe et al., 2014; Alhindi et al., 2023), especially after 20-minutes stimulation (Alhindi et al., 2023) even after single session (Lowe et al., 2014; Jáuregui-Lobera & Martínez-Quiñones, 2018). It is also argued that HF-rTMS to the left DLPFC does not improve food craving and food intake in healthy cravers (Fady Rachid 2018; Forcano et al., 2018; McClelland et al., 2013) and has mixed results on binge-eating (Ince et al., 2021).

TBS: cTBS on DLPFC seems to be a promising intervention for food craving (Fady Rachid, 2018).

LF-rTMS: There are studies showing that LF-rTMS to the right DLPFC reduces the value assigned to food (McClelland et al., 2013), but most published studies use an excitatory (HF) protocol (Duriez et al, 2020)

dTMS: dTMS may improve energy expenditure and binge-eating (Gouveia et al., 2021).

Regarding BN and BED: In some case reports in patients with BN, the application of TMS on the left DLPFC or on bilateral DMPFC led to improvement of symptoms (Dunlop et al., 2016; Rachid, 2018; McClelland et al., 2013). In general, in BN, the application of high-frequency TMS to the left DLPFC seems to be able to lead to a reduction in some BN symptoms, like urge to eat and binge-eating episodes (Dalton et al., 2018; Dunlop et al., 2016; McClelland et al., 2013), but some reviews show mixed results (Gay et al., 2022; Fady Rachid, 2018). DMPFC is a promising target for stimulation with 10 Hz rTMS in BN patients, as supported by clinical trials, which found a reduction in binge eating (Jáuregui-Lobera & Martínez-Quiñones, 2018) and in binge/purge behaviors (Dunlop et al., 2016), lasting for one month (Dalton et al., 2018). Of course, some studies on bulimic patients that investigated the efficacy of rTMS on DMPFC didn’t show improvement of binge-eating (Rachid, 2018). Also, some studies applying single or multiple sessions of TMS didn’t find reduction of BN symptoms (Dalton et al., 2017; Dalton et al., 2018; Duriez et al., 2020; Jáuregui-Lobera & Martínez-Quiñones, 2018), even when food cravings and hunger were decreased (Dalton et al., 2017). Regarding BED, stimulation of left DLPFC improved BED symptoms in some studies (Dalton et al., 2018; Rachid, 2018). According to other reviews, the results of studies on ED patients are mixed (Xu et al., 2022).

tDCS AND FOOD CRAVING/FOOD INTAKE

According to Sauvaget et al in 2015, the population most investigated using tDCS was female food-cravers under 30 years of age. According to this review, most studies investigated the effect of a single session, while among behavioral addictions, food addiction was the most studied area of tDCS application. Some reviews support that tDCS does not significantly reduce food cravings (Lowe et al., 2014). However, more recent studies find that tDCS can decrease overeating (Bell & DeWall, 2018) and food craving (Alhindi et al., 2023). A common finding of many studies is the reduction of cravings and consumption (Duriez et al., 2020; Gouveia et al., 2021) especially of soda, fat and foods with a high carbohydrate content (Lowe et al., 2014; Dalton et al., 2017; Dalton et al., 2018; Forcano et al., 2018; Ester & Kullmann, 2021). However, results for food consumption are mixed in some reviews (Forcano et al., 2018, Ester & Kullmann, 2021). This method can also reduce ED symptoms in clinical and subclinical conditions (Xu et al., 2022). Also, when combined with exercise, tDCS has greater effects on hunger control and desire to eat (Forcano et al., 2018). In some studies, it seems that the effect of stimulation is more pronounced in women, while in others there is a greater improvement in men (Ester & Kullmann, 2021). BMI does not appear to influence the treatment effect on food craving (Ester & Kullmann, 2021). A current density of 0.057 mA/cm2 reduced all food-related measures (Beaumont et al., 2022).

AR/CL: Findings from several RCTs support a statistically significant reduction in food cravings with the use of tDCS, especially AR/CL stimulation (Beaumont et al., 2022; Sauvaget et al., 2015). DLPFC AR/CL stimulation appears to be able to reduce food craving (Dalton et al., 2018; De Klerk et al., 2022; Dunlop et al., 2016; Jáuregui-Lobera & Martínez-Quiñones, 2018; McClelland et al., 2013), food intake (Dunlop et al., 2016; Jáuregui-Lobera & Martínez-Quiñones 2018; De Klerk et al., 2022), urge to binge eat and self-regulatory control (Dalton et al., 2017; Jáuregui-Lobera & Martínez-Quiñones, 2018), even after single-session (Dalton et al., 2017; Dunlop et al., 2016), but there are reviews that don’t support this finding (Orrù et al., 2022). Excitation of right DLPFC (AR or AR/ CL) was the most common tDCS protocol amongst studies (Ester & Kullmann, 2021), with promising results (Ince et al., 2021). Applying multiple sessions of tDCS has resulted in some studies in reduced food cravings for up to a month after the last session (Dalton et al., 2018). Multiple session studies had shown greater reduction and maintenance of decreased food craving and food intake than single session studies (Forcano et al., 2018; Ester & Kullmann, 2021; Beaumont et al., 2022). Patients with BED, after AR/CL stimulation showed improvement of food craving and consumption (Dalton et al., 2018), effect more significant for males (Dalton et al., 2018). Also, in patients with BN, AR/CL stimulation improves cognition (Duriez et al., 2020).

AL/CR: In addition, the opposite placement of the electrodes (AL/CR) reduces the desire to eat, as stated in some studies (Dalton et al., 2017, McClelland et al., 2013). AL/CR stimulation may lead to improvement of BN symptoms (Dalton et al., 2018). Also, AL stimulation seems to reduce food consumption (Lowe et al., 2014; Dalton et al., 2017; De Klerk et al., 2022) more than CL, but not compared to sham stimulation (Dalton et al., 2017). More recent reviews show stable hyperphagic behavior after left DLPFC stimulation (Beaumont et al., 2022), but long-term effects on food intake, appetite and desire to eat (Orrù et al., 2022).

Other brain regions: Inferior frontal gyrus stimulation (Ester & Kullmann, 2021; Beaumont et al., 2022) and stimulation of other regions than DLPFC (Beaumont et al., 2022) doesn’t seem to improve food craving.

TMS AND BMI

The effect of TMS on BMI is supported by many reviews to be not quite significant, even when binge eating is reduced (Fady Rachid, 2018). On the other hand, high-frequency TMS seems to lead to reduction in BMI (De Klerk et al., 2022), about 1-4% (Gouveia et al., 2021). Even most recent reviews find a statistically significant reduction of BMI (Cavicchioli et al., 2022) and body weight (Alhindi et al., 2023) on obese patients, especially after 30-minutes sessions (MD = −2.59 kg, 95% CI [−4.91, −0.27]) of 10Hz rTMS (MD = −4.17 kg, 95% CI [−7.00, −1.33]) (Alhindi et al., 2023).

tDCS AND BMI

The effect of tDCS on BMI appears to be controversial, even after multiple sessions (Ester & Kullmann, 2021; Gouveia et al., 2021;) on both right and left DLPFC (De Klerk et al., 2022). BMI showed better improvement in obese patients (Ester et al., 2021). Body weight was reduced (MD = −0.82 kg, 95% CI [−1.01, −0.62]) especially after 20 minutes (MD = −0.83 kg, 95% CI [−1.03, −0.63]) CR DLPFC stimulation (MD = −0.84 kg, 95% CI [−1.03, −0.62]) (Alhindi et al., 2023).

Discussion

In general, it seems that NIBS have a positive effect on overeating behavior and BMI. In particular, TMS may be more effective in reducing weight, while tDCS in reducing food consumption and food cravings. Although the mechanism of action is not yet understood, stimulation of the DLPFC improves the control of food intake inhibitions and subsequently eating symptoms.

Most studies in the inclusion criteria have included patients with eating disorders or increased BMI, without diagnosed comorbidities. However, it is advisable to conduct studies that evaluate the same outcomes in relation to outcomes concerning the patient's mental health (scales for depression, anxiety, personality disorders). The effectiveness of TMS and tDCS in these disorders is already established. Therefore, the effects of NIBS in patients with comorbidities may be partly due to the improvement of underlying mental health disorders.

For example, in depression with atypical features, patients exhibit increased food intake (Ohayon et al., 2015). Additionally, emotional overeating is a condition that can occur across the entire spectrum of emotional and anxiety disorders (Dakanalis et al., 2023). TMS and tDCS may potentially reduce the intensity of emotional overeating, similarly to how they affect impulsive behaviors in borderline personality disorder (Lisoni et al., 2022).

However, BMI is an understudied outcome. Data are mixed, so subsequent clinical trials with NIBS intervention need to assess BMI change in participants. Even in the reviews that show a reduction in body weight, the amount is relatively small. Of course, even a small change is particularly beneficial for a patient with extreme BMI value. Furthermore, it shows that NIBS could be used as an adjunctive treatment in eating disorders, overweight and obesity. Since body weight is influenced by eating behavior and tends to change slowly, future studies should assess BMI after multiple NIBS sessions and during long-term follow-up.

Although most reviews find the effectiveness of NIBS on increased food consumption and food cravings, more studies are needed in specific participant groups and diagnoses such as: 1) healthy participants, 2) healthy participants with cravings, 3) patients with BN, 4) patients with BED. In these subpopulations, the change in dietary behavior in relation to their baseline BMI and baseline mental health status needs to be studied. Based on findings from published reviews, it is estimated that populations with eating disorders and/ or elevated BMI show more significant improvement, an indication of the balancing role that NIBS have in the brain.

A particularly interesting finding is the effect of NIBS on the consumption of specific types of food. Specifically, several reviews highlighted the reduction in soda, carbohydrate and fat consumption. Given that these dietary substances are the most prevalent in the diet of the western population, this observation reinforces the hypothesis that NIBS act by increasing conscious control over food consumption and resistance to daily food stimuli.

One significant limitation of this study is that it includes a few reviews with heterogenous data. It is anticipated that within the next few years, there will be a need for updated umbrella reviews, ideally incorporating some data meta-analysis. The absence of data meta-analysis is a major limitation of this study, and this limitation persists due to the heterogeneity of the data. Most of the systematic reviews included in this study have identified the heterogeneity of results as a significant limitation.

The research challenges posed by these reviews include the need for more randomized clinical trials following similar NIBS protocols, especially in the context of multiple NIBS sessions, with the specific goal of assessing the methods' effectiveness in addressing binge eating behavior and increased BMI. Additionally, studies should consider integrating neuroimaging and electrophysiology alongside treatment implementation. They should compare single-session and multi-session approaches, conduct more sessions of NIBS, include patients with diagnosed eating disorders, conduct follow-up assessments after NIBS therapy, explore new NIBS techniques like deep TMS or high-definition tDCS, and expand clinical trials to include populations with major psychotic disorders affected by eating disorders and obesity.

Conclusion

Non-invasive brain stimulation (NIBS) methods have shown promise in addressing overeating behavior and reducing body mass index (BMI). Among these methods, repetitive transcranial magnetic stimulation (rTMS) has demonstrated greater effectiveness for weight reduction, while transcranial direct current stimulation (tDCS) is preferred for reducing food cravings and reducing food consumption. However, it is important to note that more studies with homogeneous population selection and stimulation methods are needed to further investigate and validate these findings.

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