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OPEN Network‑targeted transcranial

direct current stimulation
of the hypothalamus
appetite‑control network:
a feasibility study
Theresa Ester‑Nacke 1,2,3,8*, Katharina Berti 1,2,3,8, Ralf Veit 1,2,3, Corinna Dannecker 1,2,3,
Ricardo Salvador 7, Giulio Ruffini 7, Martin Heni 1,2,3,5,6, Andreas L. Birkenfeld 1,2,3,
Christian Plewnia 4, Hubert Preissl 1,2,3 & Stephanie Kullmann 1,2,3

The hypothalamus is the key regulator for energy homeostasis and is functionally connected to
striatal and cortical regions vital for the inhibitory control of appetite. Hence, the ability to non-
invasively modulate the hypothalamus network could open new ways for the treatment of metabolic
diseases. Here, we tested a novel method for network-targeted transcranial direct current stimulation
(net-tDCS) to influence the excitability of brain regions involved in the control of appetite. Based
on the resting-state functional connectivity map of the hypothalamus, a 12-channel net-tDCS
protocol was generated (Neuroelectrics Starstim system), which included anodal, cathodal and sham
stimulation. Ten participants with overweight or obesity were enrolled in a sham-controlled, crossover
study. During stimulation or sham control, participants completed a stop-signal task to measure
inhibitory control. Overall, stimulation was well tolerated. Anodal net-tDCS resulted in faster stop
signal reaction time (SSRT) compared to sham (p = 0.039) and cathodal net-tDCS (p = 0.042). Baseline
functional connectivity of the target network correlated with SSRT after anodal compared to sham
stimulation (p = 0.016). These preliminary data indicate that modulating hypothalamus functional
network connectivity via net-tDCS may result in improved inhibitory control. Further studies need to
evaluate the effects on eating behavior and metabolism.

Transcranial direct current stimulation (tDCS) represents a non-invasive brain stimulation (NIBS) method to
modify cortical excitability in the ­brain1. For this purpose, tDCS uses a weak and constant direct current (DC)
of about 1–2 mA, which is applied via electrodes through the scalp to the b ­ rain2 for a duration of commonly
20 ­min3, where it produces a weak electric field (E-field)3. The underlying principle of action is based on a
subthreshold modulation of neuronal membrane potentials, leading to an alteration of the cortical ­excitability4.
These changes in cortical excitability can be amplified or attenuated depending on the target area and current
­flow5. When stimulating the primary motor cortex, it was shown that the excitability is enhanced within the first
120 min after t­ DCS6. Transcranial direct current stimulation has already been applied in the treatment of various
clinical conditions such as depression, anxiety and chronic ­pain7 and was shown to reduce seizure frequency in
­epilepsy8 as well as binge eating e­ pisodes9. Besides treatment and rehabilitation, tDCS can enhance the ability of

1
Institute for Diabetes Research and Metabolic Diseases (IDM) of the Helmholtz Center Munich at the University
of Tübingen, Tübingen, Germany. 2Department of Internal Medicine, Division of Endocrinology, Diabetology
and Nephrology, Eberhard Karls University Tübingen, Tübingen, Germany. 3German Center of Diabetes
Research (DZD), Tübingen, Germany. 4Department of Psychiatry and Psychotherapy, German Center for
Mental Health (DZPG), Neurophysiology and Interventional Neuropsychiatry, University Hospital Tübingen,
Tübingen, Germany. 5Department for Diagnostic Laboratory Medicine, Institute for Clinical Chemistry and
Pathobiochemistry, Eberhard Karls University Tübingen, Tübingen, Germany. 6Division of Endocrinology and
Diabetology, Department of Internal Medicine 1, University Hospital Ulm, Ulm, Germany. 7Neuroelectrics
Barcelona, Barcelona, Spain. 8These authors contributed equally: Theresa Ester-Nacke and Katharina Berti. *email:
Theresa.ester@med.uni-tuebingen.de

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working ­memory10 and cognitive ­control11. Although tDCS shows promising effects, meaningful clinical impact
still needs to be confirmed for most ­conditions12.
So far, most of the tDCS studies targeted specific brain areas by bipolar tDCS, which usually includes two
large sponge electrodes (one anode, one cathode)2. Thereby, the stimulating electrode is placed over the target
region, while the reference electrode is located ­remotely13. More recently, it is possible to target brain regions
more focally using high-definition (HD)-tDCS by applying multiple smaller electrodes. This has been reported
to improve target intensity and f­ ocality14. By using multiple electrodes, it is also possible to stimulate brain net-
works, which is referred to as network-targeted tDCS (net-tDCS) stimulation.
Information on variation in network organization is primarily captured by resting-state functional con-
nectivity (FC) using functional magnetic resonance imaging (fMRI)15. For instance, Fischer et al.16 showed
that excitability of the left primary motor cortex (M1) and its associated resting-state network was more than
twofold increased when using net-tDCS compared to bipolar tDCS targeting solely the M1. This is in line with
a recent study where net-tDCS was able to induce greater FC during and after stimulation compared to bipolar
tDCS when stimulating the sensorimotor ­network17. Results indicate the possibility of using a network-specific
stimulation approach to activate numerous regions of a specified network, which could potentially lead to an
overall more prominent modulatory ­effect18.
To influence eating behavior, previous tDCS studies have primarily focused on stimulating parts of the lateral
prefrontal cortex, due to its fundamental role in inhibitory ­control19. Poor inhibitory control is thought to be
involved in the development and maintenance of ­obesity20 and neuroimaging studies indicate that a diminished
prefrontal cortex activity affects response i­ nhibition21. Previous studies have therefore used predominantly bipolar
tDCS to stimulate parts of the lateral prefrontal cortex, with the goal to increase inhibitory c­ ontrol22, reduce food
intake and food craving (for review ­see23). Results are however not conclusive, with small moderating effects
of tDCS on inhibitory control in single-session d ­ esigns24. This could be because brain regions are continuously
interacting and do not act in ­isolation16,25. Indeed, synchronized activation of the dlPFC and vmPFC has been
shown to be necessary for successful dietary self-control26,27. Hence, it could be beneficial to stimulate an entire
brain network vital for the inhibitory control of eating, rather than a single brain area.
The hypothalamus is crucial for whole body energy homeostasis and communicates with other regions in the
brain and peripheral organs to control a wide range of neuroendocrine, metabolic and behavioral p ­ rocesses28.
Resting-state FC studies revealed FC between the hypothalamus and regions important for motivation, reward
and emotions as well as cognitive c­ ontrol28–30, particularly FC to striatal and bilateral medial and lateral prefrontal
­regions31. Obesity is associated with hyperactivity and higher FC in reward-related regions, as the striatum, and
hypoactivity and lower FC in regions involved in cognitive c­ ontrol32. Moreover, hypothalamus resting-state FC
to prefrontal and striatal regions is particular responsive to changes in satiety levels and hormonal modulations,
an effect that is diminished in persons with obesity and insulin r­ esistance28,33. Hence the hypothalamus network
could be an ideal target to influence eating behavior and inhibitory control through its functional connections
to striatal and prefrontal regions.
In the current pilot study, we aim to explore the effects of anodal and cathodal net-tDCS targeting the hypo-
thalamus (i.e. appetite) network on inhibitory control in persons with overweight or obesity. We hypothesized
that A) net-tDCS would be well tolerated and B) anodal stimulation would enhance inhibitory control during
a Stop-Signal-Task (SST).

Materials and methods

Study population
In total, ten individuals with overweight or obesity (5 males and 5 females, age 45.70 ± 14.64 years, body mass
index (BMI) 30.11 ± 3.39 kg/m2 reported as mean ± SD) were recruited via mail. Recruitment process is pro-
vided in Suppl. Figure 1. Exclusion criteria included severe pre-existing conditions, neurological or psychiatric
disorders, frequent severe headaches and type 2 diabetes (T2D). Suppl. Table 1 provides information about the
baseline characteristics of the participants.

Experimental design and procedure

The study was conducted as a double-blind, crossover, sham-controlled study comparing anodal and cathodal
net-tDCS versus sham stimulation. The experimental design is shown in Fig. 1 (reporting checklist for tDCS
studies see Suppl. Table 2). A block randomization procedure was used for the allocation of the participants.
Participants underwent three identical sessions of anodal, cathodal, or sham net-tDCS, with a wash-out period of
five to eight days following each session. On the tDCS visits, subjects arrived at 08:00 am after an overnight fast.
To ensure a distraction-free environment, the stimulation took place in a separate quiet test room. Participants
then underwent net-tDCS for 25 min and completed a 20 min SST to measure response inhibition. The inves-
tigator was in the same room but without being able to observe the task performance of the participant. At the
end of each stimulation, a questionnaire evaluating possible adverse effects of the stimulation was administered.
Prior to the tDCS-sessions, participants underwent a screening visit with resting-state fMRI, to assess resting-
state FC of the hypothalamus network, and an initial medical examination to assess BMI, fasting glucose levels
and peripheral insulin resistance.

Tolerability of tDCS
Common side effects, based on previous ­literature34 (tingling, itching, pain and exhaustion), were assessed using
a 100 mm Visual Analogue Scale (VAS) subsequently after stimulation. In addition, participants were asked on
a 100 mm VAS, [“Overall, how uncomfortable was the stimulation for you?”]. Moreover, one line was left blank
for additional side effects not listed above.

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Figure 1.  Experimental design. Screening was conducted prior net-tDCS visits. On the day of the screening
visits, participants received an initial medical examination and a whole-brain resting-state fMRI was obtained
on a separate day. On three separate visits (separated by 5–8 days), net-tDCS using three different protocols
(anodal, cathodal, sham) took place in a pseudorandomized order. During net-tDCS, participants performed
a 20 min SST. Subsequently after stimulation, participants filled out a questionnaire regarding side-effects.
Abbreviations: fMRI, functional magnetic resonance imaging; SST, Stop-signal task.

Stop signal task

Response inhibition (i.e. inhibitory control) was assessed during net-tDCS, using the SST by CANTAB (Cam-
bridge Neuropsychological Test Automated Battery)35. The primary outcome parameter is the stop signal reaction
time (SSRT), which represents the duration of the inhibition process estimated from a mathematical m ­ odel36.
For the task, participants touched a button on the left or right edge of a tablet computer screen using their
left or right index finger as quickly as possible, every time an arrow in the center of the screen pointed in the
corresponding direction. In 25% of the trials, an additional auditory signal (a beep) was presented, indicating
the participant to withhold the response (response inhibition). In total, the task consists of a 16-item trial and
five test blocks, each block consisting of 64 trials. The task uses a staircase design to adapt to the participants
performance, achieving a 50% success rate for inhibition. The SSRT is calculated by a stochastic model that
incorporates the average reaction time in runs without a stop signal, as well as the time interval between visual
and auditory signal in which the subject is still able to withhold the reaction in 50% of ­cases37. This concept is
considered adequate to measure inhibitory control, as the SSRT is assumed to equal the time before the action
becomes ballistic and therefore one is no longer able to suppress i­ t38.

Network‑targeted tDCS montage

Stimulation was delivered by a network-targeted multichannel tDCS device ­(Starstim® 32, Neuroelectrics Barce-
lona S.L.U., Barcelona, Spain) with the corresponding NIC 2.0 software (NIC2 v2.0.11, https://​www.​neuro​elect​
rics.​com/​resou​rces/​softw​are). Twelve circular Ag/AgCl gelled electrodes were inserted into a neoprene cap with
predefined positions (Headcap R, Neuroelectics Barcelona S.L.U., Barcelona, Spain) according to the 10–20 EEG
international system (Fig. 2A–C and see Table 1 for electrode placement, current intensities and current density).
To enhance current conductivity, the scalp at the electrode positions was gently rubbed with a cotton swab and
an alcohol solution before stimulation. Active net-tDCS (anodal, cathodal) was delivered for 25 min, including
a ramp-up of 15 s and a ramp-down of 60 s at the beginning and end of the stimulation. For sham tDCS, current
was only delivered during ramp-up and ramp-down of the session. Impedance was kept below 10 kΩ during
stimulation in order to minimize cutaneous sensations. Blinding was activated and maintained by using the
NIC 2.0 Software (Neuroelectris Barcelona S.L.U., Barcelona, Spain). The anodal, cathodal and sham protocol
was given a generic name from a third party, who then also activated the “double-blind” mode with a password
requirement. Both the investigator and the participant were blind to the applied protocols.
Stimulation montage aimed to modulate the hypothalamus FC network. For this, the electrode positions and
current per electrode were determined based on a computer algorithm (­ Stimweaver™ ­see39), resulting in a 12
channel optimization. The optimization was constrained to a total injected current of 4.0 mA and a maximum
current at any given electrode of ± 2.0 mA. The E ­ n-field calculations during the optimization was conducted on
a template head model (Colin head ­model40). The target E ­ n-field weights were defined based on the correlation
strength obtained from the resting-state FC pattern of the hypothalamus from the Neurosynth website (https://​
neuro​synth.​org/​locat​ions/6_​2_-​10_6/). Stronger weights were given to areas with positive FC, as those had the
stronger correlation coefficients (these are primarily frontal regions). Hence FC above 0.225 was assigned a
weight of 10, everything below a FC of − 0.09 a weight of 4. For the range of the FC between − 0.09 and 0.225, the
weights were scaled linearly. The resulting montage consisted of twelve π-cm2 size Ag/AgCl electrodes (Pistim,
Neuroelectrics Barcelona S.L.U., Barcelona, Spain). In this optimization we focused on the ­En-component of the
E-field because it is thought to be the most relevant E-field orientation to excite/inhibit the pyramidal cells in
the cortex: positive/negative E-field values (E-field directed into/out-off the cortical surface) lead to increases/
decreases in the excitability. The optimization algorithm minimizes the least squares difference between the
weighted target ­En-field and the one induced by the montage.
The rationale for anodal net-tDCS followed the criteria presented in a previous s­ tudy16, aiming to increase
excitability in areas showing positive functional connectivity to the hypothalamus (i.e. regions showing positive
correlation coefficients with hypothalamus) and inhibit excitability in those showing a negative functional con-
nectivity. The cathodal net-tDCS aimed to inhibit excitability in areas showing positive functional connectivity
and increase excitability in those showing a negative functional connectivity.

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Figure 2.  (a) Electrostatic potential of the anodal and cathodal net-tDCS. (b) Electrode montage for anodal
and cathodal net-tDCS. Red dots indicate electrodes where current is conducted into the cortex, while blue
dots show electrodes where current is dissipated. (c) Normal electric field (V/m) induced by a 12-electrode
multichannel montage. Figures from Neuroelectrics Barcelona S.L.U.

Functional magnetic resonance imaging data acquisition

Whole brain functional fMRI data was obtained by using a 3.0 T scanner (Magnetom Prisma, Siemens Healthcare
GmbH, Erlangen, Germany). Functional resting-state data were collected by using simultaneous multi–slice
(SMS) sequence. The following sequence parameters were used: Acceleration factor = 4; TR = 1.18 s; TE = 34 ms;
FOV = 205 mm2; flip angle 65°; voxel size 2.5 × 2.5 × 2.5 ­mm3; slice thickness 2.5 mm; images were acquired in an
interleaved order. Each brain volume comprised 60 slices and each functional run contained 200 image volumes,
resulting in a total scan time of 5 min. In addition, high-resolution T1 weighted anatomical images (MP2RAGE:
192 slices, matrix: 256 × 240, 1 × 1 × 1 ­mm3) of the brain were obtained.

Resting‑state fMRI Data processing

We used the Data Processing Assistant for Resting-State fMRI (DPARSF) (http://​www.​restf​mri.​net)41 to analyze
the resting-state fMRI data. DPARSF is based on Statistical Parametric Mapping 12 (SPM12) (http://w ​ ww.​fil.i​ on.​
ucl.​ac.​uk/​spm) and Resting-State fMRI Data Analysis Toolkit (REST, http://​www.​restf​mri.​net)42. The functional
images were realigned and co-registered to the T1 structural image. The anatomical image was normalized to the
Montreal Neurological Institute (MNI) template using DARTEL, and the resulting parameter file was used to
normalize the functional images (voxel size: 2 × 2 × 2 ­mm3). Finally the normalized images were smoothed with
a three-dimensional isotropic Gaussian kernel (FWHM: 4 mm). A temporal filter (0.01–0.08 Hz) was applied to
reduce low frequency drifts and high frequency physiological noise. Nuisance regression was performed using

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Anodal stimulation Applied current Anodal stimulation Current density Cathodal stimulation Applied Cathodal stimulation Current
Electrode placement [μA] [mA/cm2] current [μA] density [mA/cm2]
P8 251 0.08 − 251 − 0.08
F4 − 524 − 0.17 524 0.17
C4 − 353 − 0.11 353 0.11
FP2 345 0.11 − 345 − 0.11
FPZ 2000 0.64 − 2000 − 0.64
Fp1 342 0.11 − 342 − 0.11
AF3 − 1548 − 0.49 1548 0.49
Fz 357 0.11 − 357 − 0.11
AF4 − 1038 − 0.33 1038 0.33
O1 246 0.08 − 246 − 0.08
F7 459 0.15 − 459 − 0.15
FC5 − 537 − 0.17 537 0.17

Table 1.  Electrode montage, applied current and current density of the net-tDCS for anodal and cathodal
stimulation of the hypothalamus network. The table shows the distribution of the applied current in μA.
A max. total of 4 mA among the twelve electrodes was applied. Positive values indicate that the current is
conducted into the cortex, negative values mean that the current is dissipated at this electrode. The electrode
placement is based on the 10–20 international EEG system. For cathodal net-tDCS it should be noted that by
inverting the current polarity of the electrodes, the effects of stimulation are inverted: areas that were inhibited
before are now excited and vice-versa. This served as the rational for a montage to inhibit the excitability of the
target network (cathodal net-tDCS).

white matter, CSF, and the six head motion parameters as covariates. No participant had head motion with more
than 2.0 mm maximum displacement or 2.0° of any angular motion.

Resting‑state functional connectivity analyses

Resting-state FC maps of the 10 participants were obtained using a seed-based approach by computing resting-
state FC between the hypothalamus and all voxels of the entire brain. We defined the hypothalamic region of
interest using MNI coordinate hypothalamus x = 6, y = 2, z = − 10, including a 4 mm sphere. The resting-state FC
maps were transferred to z values using Fisher’s transformation. Average FC values (z-transformed correlation
coefficients) were extracted of the hypothalamus FC network. The extracted FC values were used to evaluate
whether resting-state FC strength of the hypothalamus network predicted the net-tDCS induced changes in SSRT.
Regions of the hypothalamus FC network were defined based on the resting-state FC pattern of the hypothala-
mus (https://​neuro​synth.​org/​locat​ions/6_​2_-​10_6/) and separated into a map with fisher z-transformed positive
FC coefficient values (threshold r > 0.005) and negative FC coefficients (threshold r < − 0.005). The corresponding
map is depicted in Fig. 3 for illustration purpose. The two maps were further binarized, combined and used as
a mask to extract the FC values of the 10 participants.

Statistical analysis
Data is presented as mean and standard error of the mean (SEM) unless otherwise stated. For non-parametric
data, we reported the median and interquartile range (IQR). Statistical analysis were performed using the pro-
gram R (R version 4.3.3 (2024-02-29 ucrt), https://c​ ran.r-p
​ rojec​ t.o
​ rg/b
​ in/w
​ indow
​ s/b
​ ase/). Statistical significance
was set at p ≤ 0.05. A normal distribution of the parameters used was assessed by Shapiro–Wilk’s test. When data
was not normally distributed, parameters were log-transformed prior analysis or non-parametrical analyses
were conducted.
Net-tDCS effects on inhibitory control were analyzed using the SSRT of the SST by means of a Linear Mixed
Effects Model (LMER) using the lmer function of the lme4 package in R. As random effect we included a random
intercept for each participant in order to account for differences at baseline between individuals. Stimtype (sham,
anodal and cathodal net-tDCS), age and visit (visit 1, visit 2, visit 3) were included as fixed effects. Sham and
visit 1 were defined as reference category in the model. Effect size was evaluated using the effectsize function of
the effectsize package in R which supports lmer objects. Additionally, in an exploratory analysis, we compared
the effects of anodal vs. cathodal net-tDCS using the same lmer function and framework. To associate changes
in SSRT with baseline resting-state FC exploratory partial correlation analysis was used by pcor.test function of
the ppcor package in R. Age was used as a covariate. A Friedman-Test was used to evaluate side effects of the
stimulation.

Ethics approval and consent to participate

The study protocol was approved by the ethics committee of the University Hospital Tübingen prior study start
(project number: 243/2019BO1). Data acquisition was performed at the University Hospital of Tübingen between
November 2019 and March 2020. All participants provided written informed consent prior study enrollment.
All methods were carried out in accordance with relevant guidelines and regulations.

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Figure 3.  Hypothalamus FC map on a standardized T1 image computed using the Neurosynth website (https://​
neuro​synth.​org/​locat​ions/6_​2_-​10_6//) (thresholded at correlation coefficient r = − 0.005 and r = 0.005). Cortical
areas with positive correlations to the hypothalamus were the bilateral ventromedial prefrontal cortex (PFC),
orbital part of the inferior frontal gyrus (IFG), frontal pole, posterior cingulate cortex and hippocampus. Brain
regions with negative correlations to the hypothalamus were the bilateral paracingulate cortex, dorsolateral PFC
(including parts of the IFG), anterior insula, putamen, caudate, thalamus and orbitofrontal cortex. Yellow–red
brain regions indicate positive correlations to the hypothalamus; blue-green brain regions indicate negative
correlations to the hypothalamus.

Results
Tolerability of net‑tDCS
Both, active and sham net-tDCS were well tolerated and no participant discontinued the study due to side
effects. Subsequently after stimulation, participants completed a VAS where the most common side effects were
listed. Table 2 summarizes the mean values of the side effects across all stimulation protocols. There were no
significant difference in experienced levels of discomfort between stimulation protocols (tingling χ2(2) = 0.171,
p = 0.918; itching χ2(2) = 1.152, p = 0.562; pain χ2(2) = 0.703, p = 0.704; exhaustion χ2(2) = 3.813, p = 0.149; overall
impression (“Overall, how uncomfortable was the stimulation for you?”) χ2(2) = 3.211, p = 0.201). In total, four
individuals reported further side effects in addition to those already included on the questionnaire. 1) slight
burning sensation at the beginning (1 × anodal, 1 × sham), feeling of warmth (1 × anodal, 1 × cathodal, 2 × sham)
and a feeling of pressure or tension (1 × cathodal, 1 × sham). No severe adverse events occurred during the study.

Response inhibition during SST

The SST evaluates impulse control and response ­inhibition35. The primary outcome measure is the SSRT, which
estimates the time a participant needs to successfully inhibit a planned response. The mean SSRT across the three
stimulation protocols was as follows: anodal tDCS (210.1 ± 25.1 ms); cathodal stimulation (229.7 ± 32.2 ms);
sham tDCS (229.3 ± 32.2 ms). Figure 4 depicts the raw values of the SSRT during all three stimulation conditions.
We found a significant difference between anodal and sham net-tDCS (Estimate− 14.88, CI [− 28.93 –− 0.83],
p = 0.039) with a medium effect size (std. coef. 0.48), indicating shorter SSRT during the anodal compared to
sham. This indicates better inhibitory control during anodal than sham stimulation. There was no difference
in the SSRT during the cathodal stimulation compared to sham (Estimate 0.36, CI [− 13.48–14.19], p = 0.958).
There was a main effect of visit (visit 1 vs. visit 2 (Estimate − 18.14, CI [− 32.19–− 4.09], p = 0.014); visit 1 vs.
visit 3 (Estimate − 25.41, CI [− 39.46–− 11.36], p = 0.001)) with longer SSRT during visit 1. Age was a significant
predictor (Estimate 1.57, CI [1.17–1.98], p < 0.001) with longer SSRT with increasing age. See Fig. 5 for regres-
sion estimates of the model. Moreover, exploratory analysis showed significant higher SSRT during cathodal
compared to anodal stimulation (Estimate 15.97, CI [0.71–31.22], p = 0.042).

Range (Min–
Anodal (n = 10) Range (Min–Max) Cathodal (n = 10) Range (Min–Max) Sham (n = 10) Max)
Tingling 3.1 ± 5.8 0–8.7 5.1 ± 6.9 0–9.7 3.9 ± 5.6 0–7.7
Itching 0.4 ± 4.8 0–8.7 0.9 ± 6.9 0–8.3 0.2 ± 3.4 0–7.5
Pain 0.3 ± 0.9 0–8.8 0.3 ± 1.6 0.1–8.3 0.5 ± 1.0 0–8.5
Exhaustion 0.1 ± 0.8 0–1.5 0.4 ± 0.8 0–4.9 0.4 ± 0.9 0–5.2
Overall impression 4.1 ± 2.3 0–7.3 4.7 ± 2.1 0.3–6.0 4.4 ± 2.8 0.3–5.9

Table 2.  Subjective side effects. Subjective side effect measures of the net-tDCS for all three stimulation
conditions reported by the participants on a 0–100 VAS. Data are Median ± IQR.

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Figure 4.  Raincloud plots of the raw SSRT. Each dot represents one participant in each condition (sham,
anodal, cathodal net-tDCS). Box plots display the median and upper/lower quartiles for each stimulation
condition and the histograms represent the data distribution. N = 10.

Figure 5.  Effect of active net-tDCS on SSRT compared to sham stimulation. Plot shows regression estimates
with 95% CI. Visits 2 and 3 showed shorter SSRT values compared to visit 1. Compared to sham, anodal net-
tDCS resulted in shorter SSRT values. There was no effect of cathodal net-tDCS compared to sham stimulation.
Age is a significant predictor indicating that SSRT values are higher with increasing age. N = 10.

Correlation between resting‑state hypothalamic FC and tDCS‑induced changes in SSRT

We evaluated whether resting-state FC of the hypothalamus network prior to stimulation correlated with net-
tDCS induced changes in SSRT. Hypothalamic resting-state FC significantly correlated with changes in SSRT after
anodal stimulation (compared to sham) (r = − 0.890, p = 0.001 adj. for age) (Fig. 6). No correlation was observed
with SSRT after cathodal stimulation (r = − 0.496, p = 0.174 adj. for age). Hence, participants with higher hypo-
thalamus resting-state FC prior to stimulation showed better cognitive performance (i.e. response inhibition)
during SST in response to anodal compared to sham stimulation.

Discussion
The present study evaluated the effects of net-tDCS targeting the hypothalamus appetite control network in a
sham-controlled crossover experiment in persons with overweight or obesity. The network included regions
functionally connected to the hypothalamus, including parts of the frontal cortex, posterior cingulate cortex,
striatum, insula and hippocampus. The study focused on response inhibition using a novel approach to stimulate
brain ­networks16,17. Specifically, the trial investigated the safety, feasibility and efficacy of a net-tDCS approach
optimized to stimulate the appetite network, based on hypothalamus resting-state FC. Network-stimulation was
well tolerated. Preliminary results suggest increased inhibitory control during anodal net-tDCS compared to
sham and cathodal stimulation. Moreover, hypothalamic resting-state FC was predictive for the enhanced cogni-
tive performance in the anodal condition. However, due to the small sample size of 10 individuals, results should
be carefully interpreted and this novel approach requires further validation. This limitation must be taken into
account when transmitting these results to larger populations, as the small number of subjects increases the risk
of Type I and Type II errors. Future research should therefore prioritize a larger sample size in order to improve
the reliability of the data and to better support the validity of the observed effects. A recent study evaluating the

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Figure 6.   Partial correlation (corrected for age) between the hypothalamus resting-state FC at baseline and
the changes in the SSRT after anodal stimulation compared to sham. Participants with higher hypothalamus FC
show a stronger reduction in SSRT in response to anodal net-tDCS, which indicates better inhibitory control.

tolerability and blinding of small Ag/AgCl electrodes found the stimulation to be generally well tolerated and
showed no safety-related adverse e­ vents43. Here, we used twelve π-cm2 size Ag/AgCl electrodes in an electrode
placement according to the 10–20 EEG international system. All three stimulation protocols were well tolerated
with only minor side effects and no differences were observed between sham versus anodal or cathodal net-
tDCS. For multichannel stimulation, usually higher current intensities are used compared to bipolar ­tDCS17. The
present study stimulated with a total injected current of 4 mA, whereas most bipolar tDCS studies apply 2 mA. A
study evaluating the tolerability of 2 and 3 mA in a multichannel tDCS setting showed no serious adverse effects
and tolerability did not differ between current ­intensities44. In addition, a recent study compared side effects of
net-tDCS (4 mA) and bipolar tDCS (2 mA) targeted over the M1 and did not find differences between groups
nor between active and sham stimulation regarding subjective ­sensations17.
Higher activity in frontal brain regions are associated with higher levels of dietary ­restraint45 and self-control
in response to ­food46,47. Accordingly, individuals with obesity show diminished prefrontal cortex activity, which
affects inhibitory control and the regulation of body w ­ eight21,24. Modulation of prefrontal cortex activity with
tDCS has been used to enhance inhibitory ­control24,48,49. Individualized electrode montage over the dlPFC has
been discussed to improve neuropsychological o ­ utcomes50, but no study has investigated network based tDCS
and its effects on response inhibition so far. There is, however, first evidence showing increased resting-state FC
within the sensorimotor network after net-tDCS compared to bipolar ­tDCS17. However, there are limited studies
available that examined the outcome of net-tDCS on behavior. Gregoret et al.51 evaluated net-tDCS of the motor
network on pain perception and electro-cortical response to pain. While no differences were observed on pain
perception, net-tDCS was effective in modulating the neural response to p ­ ain51. Moreover, there is evidence that
simultaneous stimulation of multiple brain areas increases inhibitory control. A multitarget HD-tDCS study
concurrently targeted the right IFG and the pre-supplementary motor area (pre-SMA) and stimulated these
brain regions individually for comparison. Results indicate that the combined stimulation of both regions led
to improved inhibitory control, while no such improvement was observed when stimulating one single brain
­region52. Here, we tested the impact of net-tDCS optimized to modulate regions important for appetite control,
which included parts of the dlPFC, vmPFC, IFG as well as limbic regions important for reward processes and
decision making. We showed that anodal net-tDCS was able to enhance response inhibition compared to sham
and cathodal net-tDCS. Further studies using net-tDCS are needed to evaluate whether the possible improve-
ments result in enhanced cognitive control of eating.
A functional network is determined by positive as well as negative functional connections (i.e. correlations).
The hypothalamus network showed positive correlations with parts of the ventromedial PFC, posterior cingulate
cortex, and hippocampus. Negative correlations with the hypothalamus are found with parts of the dlPFC, insula
and striatal regions. These negative correlations are also referred to as anti-correlations, which play a crucial
role in the functional organization of the b­ rain53 and have been found to be influenced by body w ­ eight54. In the
current study, we took positive and negative FC into account in the development of the stimulation protocol.
If and how these FC patterns were influenced by the current net-tDCS protocols still needs to be determined
in future fMRI studies. There is evidence, however, that FC can be influenced by tDCS, which is related to
improved response ­inhibition49,55. While these studies did not evaluate eating behavior, fMRI studies revealed

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that FC between the dlPFC and the vmPFC is linked to food-related impulse c­ ontrol56 and persons with obesity
can learn to increase FC between these regions using neurofeedback training (i.e. a cognitive regulation skill)57.
In the current study, we demonstrated that hypothalamus resting-state FC at baseline predicted improved
cognitive performance during anodal net-tDCS stimulation. There is evidence that resting-state FC is predictive
for individual differences in cognitive performance as well as cognitive i­mpairment58,59. Hence, alterations of
brain networks and network-to-network interactions have been proposed as potential biomarkers in neurological
and psychiatric c­ onditions60. In persons with obesity, higher hypothalamic resting-state FC has been identified
with the insula and s­ triatum28,61 and lower FC in regions associated with c­ ognition32. Moreover, hypothalamus
resting-state FC to frontal areas were shown to be sensitive to changes to peripheral h ­ ormones28,62,63 and even
predictive for weight l­oss54. In response to substantial weight-loss after bariatric surgery, hypothalamic FC has
been shown to normalize with comparable FC patterns as in normal weight controls. Furthermore, dysfunctional
hypothalamus FC has been documented in neurological and psychiatric d ­ iseases28. Hence, we postulate that the
hypothalamus network could be an ideal target to influence physiological and psychological processes.
Overall, the present trial contributes to the understanding of initial resting-state FC as a possible predictor
for tDCS related effects. Whether the current net-tDCS protocol in fact modulates hypothalamus FC still needs
to be determined in future studies.

Limitations and further directions

This is a pilot study and further investigations in larger sample sizes are necessary to evaluate the effects of net-
tDCS targeting the hypothalamus network on eating behavior. In addition, it is important to acknowledge that
no fMRI measurements were performed immediately after stimulation. Hence no conclusion can be drawn as
to whether the implemented tDCS protocols resulted in changes in functional activity within the hypothala-
mus network. The present study used a net-tDCS paradigm, based on fixed electrode positions of the 10–20
international EEG system. Due to this standard configuration, individual anatomical differences were not taken
into account, thus for some individuals we may not have targeted the optimal stimulation points. Future studies
should therefore investigate the possibility of personalized electrode arrangements, for instance based on their
unique brain anatomy and fMRI network dynamics.

Conclusion
Overall, the present study adds novel findings to the growing body of research in the field of multifocal tDCS
solutions. Here, we show that anodal net-tDCS based on resting-state fMRI connectivity patterns of the hypo-
thalamus is well tolerated and able to enhance inhibitory control in individuals with overweight or obesity.
Whether anodal net-tDCS of the hypothalamus appetite network can improve inhibitory control of eating behav-
ior, reduce food craving or ultimately facilitate healthier food choices needs to be investigated in future studies.

Data availability
The data that support the findings of this study are available on request from the corresponding author, [TEN].

Received: 31 October 2023; Accepted: 10 May 2024

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Acknowledgements
Funding Agency: The study was supported in parts by a grant (01GI0925) from the Federal Ministry of Education
and Research (BMBF) to the German Center for Diabetes Research (DZD e.V.). Notes: We thank all participants
for their participation in this project. The authors also thank Maike Borutta (University of Tübingen, Tübingen,
Germany) for her excellent technical assistance.

Author contributions
T.E.N. curated, analyzed and interpreted the data and wrote manuscript. K.B. ran experiment, acquired and
curated the data, interpreted the data and wrote manuscript. R.V. did the fMRI data analysis and gave input
for writing manuscript. C.D. acquired and curated the data. G.R. and R.S. created the tDCS protocol and gave
input for writing manuscript. M.H. designed study and gave input for writing manuscript. A.L.B. gave input
for writing manuscript. C.P. gave input for writing manuscript. H.P. designed study, interpreted data and gave
input for writing manuscript. S.K. designed and supervised the study, interpreted the data and gave input for
writing manuscript.

Funding
Open Access funding enabled and organized by Projekt DEAL.

Competing interests
GR is a co-founder and shareholder and works for Neuroelectrics, a company developing medical devices for
NIBS. RS works for Neuroelectrics. Outside of the current work, MH reports research grants from Boehringer
Ingelheim and Sanofi to the University Hospital of Tübingen, participation in advisory board for Boehringer
Ingelheim, Sanofi and Amryt, and lecture fees from Amryt, Bayer, Sanofi, Eli Lilly, Novartis, Novo Nordisk and
Boehringer Ingelheim. TEN, KB, RV, CD, ALB, CP, HP and SK report no conflict of interest.

Additional information
Supplementary Information The online version contains supplementary material available at https://​doi.​org/​
10.​1038/​s41598-​024-​61852-3.
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