Objective. To examine whether cognitive behavioral therapy (CBT) alleviates dysfunctional eating (DE) patterns and symptoms of anxiety and depression in morbidly obese patients planned for bariatric surgery. Design and Methods. A total of 98  patients with a mean (SD) age of 43 (10) years and BMI 43.5 (4.9) kg/m2 were randomly assigned to a CBT-group or a control group receiving usual care . The CBT-group received ten weekly intervention sessions. DE, anxiety, and depression were assessed by the TFEQ R-21 and HADS, respectively. Results. Compared with controls, the CBT-patients showed significantly less DE, affective symptoms, and a larger weight loss at follow-up. The effect sizes were large , moderate , and low . Conclusion. This study supports the use of CBT in helping patients preparing for bariatric surgery to reduce DE and to improve mental health. This clinical trial is registered with NCT01403558. Bariatric surgery may result in significant weight loss, however with large individual differences , 2. In pDE is associated with overconsumption of energy dense food –15, whicIn addition to DE, patients with morbid obesity may suffer from symptoms of anxiety and depression. The prevalence of any mood disorder is about 16% and 24%, respectively . TheoretTo our knowledge, no previous controlled studies have tested the efficacy of a CBT-intervention aimed at reducing DE in obese patients selected to BS. However, several sources of knowledge indicate that such an intervention could be feasible. The convincing body of knowledge from controlled trials has established CBT as the treatment of choice for the spectrum of eating disorders according to diagnoses and clinical severity  includinUsing a randomized controlled design, the purpose of this study was to examine the efficacy of a CBT-intervention in improving DE as well as affective symptoms. We hypothesized that the intervention would be superior to usual care, particularly with respect to reducing emotional and uncontrolled eating and increasing cognitive restraint of eating.A total of 102 eligible  consecutive morbidly obese patients admitted for bariatric surgery agreed to participate. All patients participated based on informed consent.http://clinicaltrials.gov/ct2/show/NCT01403558) used a mixed design: one between-group factor  and one within-group factor (pre- and postmeasures). The time-interval between pre- and postmeasurements was 10 weeks.This randomized controlled trial (http://www.randomizer.org) was employed (with blocks of 4) to ensure balance between the groups. Two research assistants at the treatment center, with no affiliation to the study, had access to the key to the randomization file. After having read and signed the informed consent letter and completed the baseline measurements, the patients as well as the first author were informed about the allocated treatment arm. The allocation ratio was 1 : 1.A block randomization procedure , “uncontrolled eating” , and “cognitive restraint of eating” . According to the manual, the three subscales were transformed to a 0–100 scale to become comparable [The primary outcome measures were changes in DE as measured by the Three-Factor Eating Questionnaire (TFEQ R-21) which has been validated for use in obese individuals , 27. It mparable . Higher mparable .Secondary outcome measures were symptoms of anxiety and depression, measured by the Hospital Anxiety and Depression Scale (HADS) . HADS isThe procedures were initiated after the study had been approved by the Regional Committee for Medical and Health Research Ethics (2010/2071a).Based on clinical experience, reductions in the emotional and uncontrolled eating scores of 15% or more were considered to be clinically meaningful. A conservative estimate was that no patients in the control group, and at least 30% in the intervention group, would achieve this treatment goal. Given this difference in treatment effect, a 90% statistical power, a significance level of 5%, and a dropout rate of 40%, a minimum sample size of 80 patients was required. To allow for a 20% withdrawal rate, we included 102 patients in the current study. The statistical power was excellent for all analyses (>.99).Data were analyzed by the Statistical Package of the Social Science (SPSS) for Windows, version 17 .g indicating the differences between the groups in number of standard deviations. Effect sizes of 0.20, 0.50, and 0.8 were regarded as small, moderate, and large [The intervention effects were examined by analysis of covariance (ANCOVA), comparing the two posttest group mean scores adjusted for baseline scores. Effect sizes were reported as Hedges' nd large .Hundred and two patients agreed to participate; four patients were lost to follow-up, leaving data from 98 patients for analysis . A complClinical baseline data are presented in The prevalences of clinically relevant symptoms of anxiety and depression (HADS ≥ 8) were 41% and 25%, respectively.The patients in the CBT-group had significant improvements in DE, anxiety, and depression compared with the control group patients. A significant reduction in BMI was also observed.g = − .90, P ≤ .001), cognitive restraint ) to moderate , anxiety , depression ) and low ).The intervention effects are presented in Figures P ≤ .001. For anxiety and depression the adjusted between-group differences were −2.5  and −2.8 , respectively, both P ≤ .001. Concerning BMI and body weight, the adjusted between-group differences were −1.1 kg/m2  and −3 kg .Adjusted between-group differences at follow-up for EE, UE, and CR were −19 , −19 , and 20 , respectively, all This study contributes to the literature as being the first randomized controlled trial of a CBT-intervention to treat dysfunctional eating behaviors among severely obese patients scheduled for bariatric surgery. It demonstrated that patients in the CBT-group showed a strong reduction in DE and a moderate alleviation of anxiety and depression following the 10-week intervention compared to the control group. In addition, the CBT-group lost about 3 kg body weight.To our knowledge, no previous controlled study has assessed a CBT program in the treatment of DE. Nevertheless, DE is closely linked to BED both cognitively and behaviorally in terms of eating patterns and the use of food to regulate negative mood. Although BED was not assessed in the present study, a comparison with previous BED-studies may be warranted. Hence, previous BED-studies , 24 suppAs DE often includes overeating in relation to negative mood states or a tendency to lose control over eating, it includes cognitive, emotional, and behavioral elements. It is plausible that a targeted CBT-program could have beneficially affected all these elements. As repeated measures following each session were not taken, it was impossible to discern which of the specific parts of the intervention produced the improvements. In addition, a nonspecific, independent effect of the therapist and the therapeutic alliance cannot be excluded.The reduction of affective symptoms might be considered an adjuvant effect of the CBT-intervention. Although the intervention did not address symptoms of poor mental health specifically, it addressed how to detect and improve the tolerance of negative emotions triggering DE behaviors and associated dysfunctional cognitions. Moreover, as the intervention included home-sessions with practical tasks that were possible to accomplish for all patients, feelings of coping and mastery might partly explain the apparent antidepressive and anxiety reducing effect.Strengths of the study are the randomized controlled treatment design and the low attrition rate. In addition, the recruitment of consecutive treatment seeking white morbidly obese patients preparing for bariatric surgery in a large tertiary care center suggests that our results may be generalizable to similar populations.As the first trial addresses DE and the effect of CBT before bariatric surgery, our results need replication trials. Indeed, such replications will need to take this pioneer study's limitations into account. Notably, one needs to sort out common versus specific effects by including more than one therapist as well as possible treatment component effects. In addition, further studies should develop a control treatment condition in more detail and with a number of sessions equal to the CBT-condition. Furthermore, future studies should also collect additional data such as binge eating symptoms, which was not done in the current study.This study shows the success of a 10-week CBT-intervention program in improving DE behaviors and affective symptoms in morbidly obese patients admitted for bariatric surgery. Future research should investigate whether these proximal effects are sustained and whether presurgical improvement in DE behaviors and affective symptoms do provide an additive benefit to bariatric surgery in terms of a stabilization of weight loss.


Previous research indicated that women are more vulnerable than men to adverse psychological consequences of weight gain. Other research has suggested that weight gain experienced during antipsychotic therapy may also psychologically impact women more negatively. This study assessed the impact of acute treatment-emergent weight gain on clinical and functional outcomes of patients with schizophrenia by patient gender and antipsychotic treatment .Data were drawn from the acute phase (first 6-weeks) of a double-blind randomized clinical trial of olanzapine versus haloperidol in the treatment of 1296 men and 700 women with schizophrenia-spectrum disorders. The associations between weight change and change in core schizophrenia symptoms, depressive symptoms, and functional status were examined post-hoc for men and women and for each medication group. Core schizophrenia symptoms (positive and negative) were measured with the Brief Psychiatric Rating Scale (BPRS), depressive symptoms with the BPRS Anxiety/Depression Scale and the Montgomery-Asberg Depression Rating Scale, and functional status with the mental and physical component scores on the Medical Outcome Survey-Short Form 36. Statistical analysis included methods that controlled for treatment duration.Weight gain during 6-week treatment with olanzapine and haloperidol was significantly associated with improvements in core schizophrenia symptoms, depressive symptoms, mental functioning, and physical functioning for men and women alike. The conditional probability of clinical response (20% reduction in core schizophrenia symptom), given a clinically significant weight gain (at least 7% of baseline weight), showed that about half of the patients who lost weight responded to treatment, whereas three-quarters of the patients who had a clinically significant weight gain responded to treatment. The positive associations between therapeutic response and weight gain were similar for the olanzapine and haloperidol treatment groups. Improved outcomes were, however, more pronounced for the olanzapine-treated patients, and more olanzapine-treated patients gained weight.The findings of significant relationships between treatment-emergent weight gain and improvements in clinical and functional status at 6-weeks suggest that patients who have greater treatment-emergent weight gain are more likely to benefit from treatment with olanzapine or haloperidol regardless of gender. Because antipsychotic drugs are considered the core treatment modality for schizophrenia  the diffAlthough most of the literature on treatment-emergent weight gain tends to focus on this event as adverse, a growing body of research has demonstrated a significant link between beneficial therapeutic response and treatment-emergent weight gain. With the exception of a few studies that failed to find an association between weight gain and better clinical outcome -9, most The study of gender differences in the relationship between treatment-emergent weight gain and therapeutic response has gained limited attention and provided conflicting results. A brief report on weight gain during clozapine therapy indicated that greater weight gain was associated with clinical improvement among women, but not among men . In contWomen in the general population appear to be vulnerable to the adverse emotional and psychosocial consequences of weight gain. For women, obesity has been linked to lower life satisfaction, increased social isolation , and lowThe primary objective of this study was to expand on prior research and investigate whether the relations between acute weight gain during antipsychotic therapy and treatment outcomes differ based on patient gender and the specific antipsychotic used in the treatment regimen, olanzapine or haloperidol. This study also aimed to broaden the definition of therapeutic response by extending beyond positive and negative symptoms of schizophrenia to depressive symptoms and levels of mental and physical functioning, because these domains tend to deteriorate with weight gain among women in the general population.We used data of 1296 men and 700 women who participated in a randomized, double-blind, multi-center, clinical trial comparing olanzapine to haloperidol . ParticiParticipants were randomly assigned in 2:1 ratio . Although randomization was not stratified on gender or any other patient characteristics, it resulted in a 2:1 ratio for males (870/426) and for females (426/233). The olanzapine group (N = 1337) included 467 women and 870 men, and the haloperidol group (N = 659) was comprised of 233 women and 426 men.Participants were randomly assigned to olanzapine, 5 to 20 mg/day, or haloperidol, 5 to 20 mg/day. The type of antipsychotic medication used prior to enrollment was not assessed in the current study, but the likelihood of previous treatment with an atypical antipsychotic drug was very low, because the study was initiated in 1994 when only clozapine was available in some of the sites. Further, randomization worked for patient and illness characteristics , and theWe used data from the acute phase, the first 6 weeks of the study, for several reasons. First and foremost, this study was a 6-week randomized double blind clinical trial with a 46-week "responder maintenance period", in which only patients who responded to the acute 6-week treatment per predetermined response criteria were eligible to continue. Consequently, the study design did not permit a longer-term analysis on the link between weight gain and improvement because only patients who improved during the first 6-weeks phase were followed-up for a longer time period. Second, the 6-week period represents a relevant time frame often used in clinical practice to determine treatment outcome and decide on treatment discontinuation . For manDuring the 6-week acute phase, the mean modal dose was 13.2 mg/day (SD = 5.8) for olanzapine and 11.8 mg/day (SD = 5.6) for haloperidol. There were no discontinuations due to weight gain as an adverse event for any treatment group during the 6-week study period, and the rate of discontinuation for any cause was similar for women (62.7%) and men (60.8%), with a significantly smaller proportion of the patients in the olanzapine group (33.5%) than in the haloperidol group . In addition, the percentage of patients who discontinued treatment because of an adverse event or a lack of efficacy was significantly higher in the haloperidol group than in the olanzapine group. Further details on the parent study design and primary findings are available elsewhere .2).This investigation used measures of positive and negative symptoms ("core schizophrenia symptoms"), depressive symptoms, functional status, and body weight. Core symptoms of schizophrenia were assessed by the Positive Symptom and the Negative Symptom subscales on the BPRS  extracted from the Positive and Negative Syndrome Scale (PANSS) . Levels To enhance comparability of findings on different measures, the clinical measures were all standardized to z-scores. For the BPRS Core Symptoms, MADRS, and BPRS Anxiety and Depressive Subscale, this was done by subtracting the measure's overall mean and dividing by the measure's standard deviation at baseline. A single measure of depressive symptoms was calculated as the average of the standardized MADRS and BPRS Anxiety and Depressive Subscale. If a score was missing on either depression measure, the score on the available measure was used. The two depression measures were pooled because each is an independent and valid estimate of patients' level of depressive symptoms, and aggregating them should provide the best and most comprehensive estimate of depressive symptoms. Additionally, the pooling helped minimize loss of data, which are assumed not to be missing at random. The SF-36 Physical and Mental Component scores were converted from T-Scores to z-scores.Baseline comparisons used independent samples t-tests for continuous variables and chi-square tests for categorical variables. Effects of treatment and gender on independent variables were assessed using ANCOVA, with the baseline score as well as the number of weeks in the study as covariates. The relationship between change in weight and change in each outcome variable was assessed using separate multiple linear regression analyses, each with corresponding clinical change score as a dependent variable, the corresponding baseline score and number of weeks in the study as covariates, and the following independent variables: weight change, treatment group assignment, and gender. In an additional analysis, the interactions of these three independent variables were added to the regression models.The analyses included measures from baseline and the 6-week visit. Missing data were handled by carrying forward the last observation for all patients with at least one post-baseline assessment. All analyses were performed using the Statistical Package for the Social Sciences (SPSS) version 11.0.Relative to men, women were older, more likely to be Caucasians, were more likely to be overweight or obese, had less severe positive symptoms, lower levels of physical functioning, and had higher levels of depressive symptoms Table . Women w2 = 51.8, p < 0.001).In order to illustrate the differences in weight gain by treatment group and gender, the patients were grouped into thirds based on their percentage of change in weight from baseline. Approximately one third of all patients (29.8%) lost weight (any decrease), one third (36.6%) had relatively stable weight (0% to <3% increase), and one-third (33.6%) gained weight (≥ 3% increase). The corresponding mean weight changes in kilograms were -2.1 kg, 0.9 kg, and 4.6 kg, for lost, stable, and increased weight groups, respectively. Figure 2. Within the olanzapine treatment group, but not the haloperidol treatment group, significantly more men than women experienced a potentially clinically meaningful weight gain  = 4.0, p = 0.045 for women and men in the olanzapine treatment group, and 2.3% vs. 3.5%; χ2 = 0.7, p = 0.40, for women and men in the haloperidol treatment group).Compared to women, men experienced greater increases in absolute weight  = 17.3, p < 0.001), were more likely to experience greater increases in BMI  = 5.8, p = 0.016), and were more likely to have an increase of at least 7% from baseline body weight . The results indicated that gender was not a significant variable . Therefore, gender was dropped from subsequent analyses.B = -0.038, t(1899) = 5.6, p < 0.001), in depressive symptoms  = 5.3, p < 0.001), in mental functioning  = 2.0, p = 0.047), and in physical functioning  = 2.3, p = 0.021). Because level of depressive symptoms was based on two depression measures, the MADRS and the BPRS depression/anxiety subscale, we repeated the analysis using each of these measure separately. Results were unchanged.Since men and women were not found to significantly differ on any of the clinical outcome measures and had a similar pattern of weight gain within each treatment group, we examined the association between weight change and change in treatment outcomes for all patients within each treatment group. Regression analyses demonstrated that for both olanzapine and haloperidol-treated patients, increases in weight were significantly associated with improvements in core schizophrenia symptoms, (B's) indicated that every one- kilogram increase in weight at 6-weeks was associated with approximately 0.03 standard deviations improvement in each clinical outcome parameter, when controlling for the effects of treatment group, gender, treatment group-gender interaction, baseline weight, the corresponding baseline outcome measure, and the number of weeks in the study.The regression coefficients  was about a third of 6.26 kg mean weight gain found at 39 weeks, when weight gain tends to plateau on olanzapine . SimilarAlthough weight gain appears to be greatest and most rapid during the first 6 weeks of treatment with clozapine , and durIt is of interest to note, however, that despite rapid weight gain during the 6-week period in our study, when weight gain is more likely to be noticed by the patients and their clinicians and thus may elicit a negative emotional response, the weight gain in this study was not only linked to improved clinical and functional status but also to reduced emotional distress as measured by the depression scales.Another limitation of the study is its lack of assessment of patients' adherence with medication. It is possible that weight gain and improvement occurred together because improvements occur mostly in patients who are medication adherent. Although this was not assessed in the present study, this possibility was previously studied by Meltzer et al. , who fouAnother study limitation is the correlational nature of the analyses, which precludes cause-effect relationship and allows for the possibility that the observed associations might be due to an unobserved variable or set of variables. Further, the relatively low correlations suggest that the association explains only a small proportion of the variance in treatment outcomes. Response to antipsychotic medications is a complex phenomenon that is associated by numerous relatively independent components  and weigNext, because the study included patients with a moderately severe level of symptomatology, the current findings may not generalize to patients with milder or residual symptoms of schizophrenia. However, the relationships among the severity of patients' baseline symptomatology, treatment-emergent weight gain and therapeutic response is currently unclear. And lastly, this study used the SF-36, a self-report measure of functional status, which was not designed to assess the potential impact of weight gain on patients' functional status or quality of life. Preliminary information on the first measure designed to specifically capture the impact of antipsychotic-emergent weight gain on patients' psychosocial functioning was only recently published . One wouWomen (and men) with schizophrenia who gained weight during treatment with olanzapine or haloperidol did not experience worsening of clinical or functional status. To the contrary, they had significant improvements in core symptoms of schizophrenia, depressive symptoms, and mental and physical level of functioning. Although excessive weight gain, regardless of origin, is of concern due to its association with physical health problems, the current findings suggest that patients who have greater treatment-emergent weight gain are more likely to benefit from treatment with olanzapine or haloperidol. Findings highlight the complexity inherent in medication management of schizophrenia patients and the need to balance treatment risks and benefits for each patient. In addition, further prospective studies will be required to assess the effects of weight gain, in both psychiatric and medical terms, on individuals treated for schizophrenia with various antipsychotic medications.The authors are employees of Eli Lilly and Company, Indianapolis, Indiana• HAS conceived of the study, participated in its design, the analytical plan, the interpretation of the results, and drafted the manuscript• MS participated in the design of the study, the analytical plan, the interpretation of the results, and performed the statistical analysis• ZZ and BK participated in the design of the study, the interpretation of the results, and the drafting of the manuscript.The pre-publication history for this paper can be accessed here:


The incidence of fractures in rural populations is lower than in urban populations, although the reason for this difference is unclear. This cross-sectional study was designed to examine the difference in bone mineral density (BMD), a primary predictor of fracture risk, between urban and rural Thai populations.Femoral neck and lumbar spine BMD was measured by dual-energy X-ray absorptiometry  in 411 urban and 436 rural subjects (340 men and 507 women), aged between 20 and 84 years. Body mass index (BMI) was calculated from weight and height.P < 0.001), but the difference was not observed at the lumbar spine. After stratifying by sex, age group, and BMI category, the urban-rural difference in femoral neck BMD became more pronounced in men and women aged <50 years and with BMI ≥ 25 kg/m2.After adjusting for age and body weight in an analysis of covariance model, femoral neck BMD in rural men and women was significantly higher than those in urban men and women (These data suggest that femoral neck BMD in rural men and women was higher than their counterparts in urban areas. This difference could potentially explain part of the urban-rural difference in fracture incidence. Osteoporosis and its ultimate consequence of low traumatic fracture pose a major public health problem, because it incurs significant costs and increased risk of mortality -3. OsteoMeasurement of bone mineral density (BMD) is considered the primary predictor of fracture risk . TherefoThe pace of urbanization in developing countries is more pronounced than in developed countries. Therefore, developing countries are ideal settings for studying the urban-rural difference in BMD. The aim of this study was to examine the difference in BMD between an urban population and a rural population in Thailand.The present study was designed as a cross-sectional, population-based investigation. The setting was Bangkok city and Khon Kaen province in Thailand. Bangkok is the capital city with a population of 5.7 million and Khon Kaen is a rural province, located 445 km northeast of Bangkok with a population of 1.8 million and is largely an agricultural community. Further details of this study have been described elsewhere The study included 872 Thai men and women, aged between 20 and 84 years, of whom 422 subjects were from Bangkok and 450 subjects from Khon Kaen. In Khon Kaen, subjects were recruited from 2 villages in the Muang district. There were 14 hamlets in the two villages. In each hamlet, a full list of subjects was obtained, from which 40 subjects were randomly selected by the village's administrator. The selected subjects were then sent a letter of invitation to participating in the study. The response rate was 80.3%. In Bangkok, subjects were recruited via a media campaign, and the sampling technique was similar to the scheme used in Khon Kaen, where subjects were randomly selected from 5 districts within the city of Bangkok.All Khon Kaen subjects were farmers, while Bangkok subjects were office workers, factory workers or house workers. Twenty-one subjects were excluded from analysis because of bone disorders, chronic diseases, history of taking medications that are deemed to affect calcium and bone metabolism, such as the use of steroids or thyroid hormone; and 4 women were excluded on the basis of pregnancy, lactation, delivery or abortion within the previous 3 months, previous history of oophorectomy and premature menopause. The study was conducted in accordance with the Helsinski Declaration in 1975 and as revised in 1983 and was approved by the Ethics Committee of Faculty of Medicine Ramathibodi Hospital Mahidol University (Bangkok) and Khon Kaen University (Khon Kaen), and written informed consent was obtained from all subjects.2, was measured by dual-energy X-ray absorptiometry with a Lunar DXP-IQ densitometer . The two study sites (Bangkok and Khon Kaen) used the same model of the DXA machine and the same protocol of measurements. The radiation dose with this method is < 0.1 μGy. The coefficient of variation of BMD for normal subjects is 0.96 and 0.98 at proximal femur and lumbar spine, respectively.BMD at the femoral neck and lumbar spine (L2-4) in g/cmBody weight (including light indoor clothing) was measured using an electronic balance (accuracy 0.1 kg) and standing height (without shoes) with a standiometer (nearest 0.1 cm). Body mass index (BMI) was calculated as ratio of weight (in kg) over height (in meter squared).Descriptive statistics were computed for each residential region and sex separately. In order to test for difference between urban and rural regions, an analysis of covariance (ANCOVA) model was performed. In this model, BMD was treated as outcome variables; age and weight (or BMI) were treated as covariates; and residence  was the factor. Interactions between age and BMI or age and residence variable were also considered in the model. Estimates of the model parameters were based on the least square method via the SPSS version 9.0 .P < 0.001), whereas urban women had a greater height (P < 0.001) but equivalent weight (P = 0.72) compared with rural women  were analysed. There was no significant difference between urban and rural subjects with respect to age or sex distribution. The mean age was 49 and 50 years old in men and women, respectively. However, urban men had higher weight and greater height than rural men P < 0.00, whereasr = 0.13, P = 0.017 for femoral neck, and r = 0.37, P < 0.001 for lumbar spine) and in women . On the other hand, advancing age was associated with a significant reduced BMD in men  and women .In the entire sample, higher weight was associated with higher BMD in men  BMD in urban subjects .However, the strength of relationship between age and BMD in urban subjects was less pronounced than in rural subjects, such that rural women had a higher cross-sectional "rate of bone loss" than urban women, particularly at the femoral neck. For example, in women, each 5-year increase in age was estimated to associate with a 2.1% and 1.2% decrease in femoral neck BMD for rural and urban group, respectively; in men, the respective rate of decrease was 1.3% and 0.8%. As a result, among those aged 502 significantly higher (P < 0.001) than in urban men and women, respectively; but the difference was lower for the lumbar spine BMD . The statistical significance of the age-by-residence interaction term in the ANCOVA model suggested that the urban-rural difference in BMD decreased with advancing age . This trend was consistent for men and women. However, for lumbar spine BMD, no significant urban-rural difference was observed in most subgroups, with the exception of women aged ≥ 50 years and BMI < 25 kg/m2 in whom BMD was lower in the rural group compared to the urban group  and higher BMI . This finding was partially consistent with a previous study [The present study's data and design can not elucidate any underlying factors that are responsible for the difference but some propositions could be put forward. The urban-rural difference in femoral neck BMD could be due to the difference in the peak of bone mass levels. In this study, both rural men and women aged between 20 and 30 years had significantly higher BMD than urban counterparts. For example, young rural men and women had significantly higher than urban subjects  declare that they have no competing interests.Chatlert Pongchaiyakul had an active role in the conduct of this study, obtained and analysed data, and drafted the manuscript. Tuan V Nguyen was involved in the conceptual discussion of this study, and had an active role in data analysis, drafting of the manuscript. Vongsvat Kosulwat, Nipa Rojroongwasinkul, and Somsri Charoenkiatkul had an active role in the study design, and was involved in the conceptual discussion. Rajata Rajatanavin conducted and established this study. All authors contributed to the last version of the manuscript.The pre-publication history for this paper can be accessed here:


The adaptive radiations of cichlid fishes in East Africa are well known for their spectacular diversity and their astonishingly fast rates of speciation. About 80% of all 2,500 cichlid species in East Africa, and virtually all cichlid species from Lakes Victoria (~500 species) and Malawi  are haplochromines. Here, we present the most extensive phylogenetic and phylogeographic analysis so far that includes about 100 species and is based on about 2,000 bp of the mitochondrial DNA.sensu lato are relatively species poor, albeit widely distributed in Africa, whereas a fourth newly defined lineage – the 'modern haplochromines' – contains an unparalleled diversity that makes up more than 7% of the worlds' ~25,000 teleost species. The modern haplochromines' ancestor, most likely a riverine generalist, repeatedly gave rise to similar ecomorphs now found in several of the species flocks. Also, the Tanganyikan Tropheini are derived from that riverine ancestor suggesting that they successfully re-colonized Lake Tanganyika and speciated in parallel to an already established cichlid adaptive radiation. In contrast to most other known examples of adaptive radiations, these generalist ancestors were derived from highly diverse and specialized endemics from Lake Tanganyika. A reconstruction of life-history traits revealed that in an ancestral lineage leading to the modern haplochromines the characteristic egg-spots on anal fins of male individuals evolved.Our analyses revealed that all haplochromine lineages are ultimately derived from Lake Tanganyika endemics. We find that the three most ancestral lineages of the haplochromines We conclude that Lake Tanganyika is the geographic and genetic cradle of all haplochromine lineages. In the ancestors of the replicate adaptive radiations of the 'modern haplochromines', behavioral , morphological (egg-spots) and sexually selected (color polymorphism) key-innovations arose. These might be – together with the ecological opportunity that the habitat diversity of the large lakes provides – responsible for their evolutionary success and their propensity for explosive speciation. H. Greenwood (1983)With estimated numbers of about 1,000 and 500 species respectively the assemblages of cichlid fishes of East African lakes Malawi (LM) and Victoria (LV) are, by far, the most species-rich species flocks . In Lakee.g., [Not all haplochromines are lacustrine, however, and some 200 species inhabit rivers and occur in northern-, eastern-, southern- and central-Africa but are virtually absent from West Africa ,12 , discrete adaptive radiations of non-haplochromines are comprised by about a dozen species at most. Thus, which evolutionary novelties might be causally related to the explosive speciation that distinguish the haplochromines from all other cichlid lineages remains a crucial question for the understanding of the explosive patterns of cichlid evolution in East Africa. Haplochromines furthermore represent prime examples for parallel evolution, and it is particularly the lacustrine haplochromine species flocks that independently evolved morphologies and color-patterns that are convergent between species of different lakes ,18.In order to gain a deeper understanding of the adaptive radiations of cichlids in general and the formation of East African cichlid species flocks in particular, several crucial questions still remain to be answered: (i) What evolutionary lineages from which geographic ranges make up the diversity of haplochromines? (ii) Which were the founding lineages of the lacustrine adaptive radiations and were they riverine generalists? (iii) Can particular behavioral and/or morphological key-innovations be identified that might be causally related with the diversification of haplochromines? With the aim of addressing these questions, we conducted the most extensive phylogenetic and phylogeographic study of haplochromine cichlids so far, analyzing a portion of up to 2,000 bp of the mitochondrial genome of about 100 species. We included representatives of relevant cichlid tribes from LT ,9,15 as The neighbor-joining analysis based on 304 complete mitochondrial control region sequences Fig.  could noLimnochromis auritus, Triglachromis otostigma) plus Cyphotilapia frontosa, and all remaining taxa. Among these, a clade that includes four LT tribes  plus the Orthochromis species from the Malagarasi drainage, which had so far been considered to belong to the Haplochromini, was recovered as sister group to the remaining haplochromine representatives. The latter, the haplochromines sensu lato, clustered into four distinct groups, with a Congolese/South-African lineage (CSA) sister to the Pseudocrenilabrus-, the Astatoreochromis-lineage, and the 'modern haplochromines' . Bayesian inference revealed the same branching order for the different lineages. In the strict consensus topology of the 78,617 most parsimonious trees , the Eretmodini were again resolved as sister group to the Lamprologini, the Limnochromini plus C. frontosa, four LT tribes plus the Malagarasi Orthochromis and the haplochromines sensu lato. Here, the Astatoreochromis-lineage was resolved as most ancestral lineage, and as sister group to a clade comprised by the Pseudocrenilabrus- and the CSA lineage, and the modern haplochromines. Also, the neighbor-joining analysis recovered a tree (not shown) with the Eretmodini as sister-group to the Lamprologini, the Limnochromini plus C. frontosa, the four LT tribes including the Malagarasi River Orthochromis species, and the haplochromines sensu lato. In the neighbor-joining tree, the Pseudocrenilabrus-lineage occupied the most ancestral branch in the haplochromines sensu lato, followed by the Congolese/South-African clade, the Astatoreochromis-lineage and the modern haplochromines. A Shimodaira-Hasegawa test [sensu lato received support greater than 50%.In the maximum likelihood tree of the dataset including 100 taxa Fig.  the LT Eawa test  revealedawa test  none of sensu lato. The most recent common ancestor in the CSA-clade was estimated to have lived about 2.0 MYA (1.15 – 3.89 MYA), the split of the CSA lineage from the common ancestor with the Pseudocrenilabrus-, Astatoreochromis-, and modern haplochromine lineage was dated to about 2.4 MYA (1.22 MYA – 4.02 MYA). The test for shifts in the probabilities of speciation in the haplochromines sensu lato according to [pc < 0.01) along three branches in the maximum likelihood, the Bayesian inference and the neighbor-joining trees: (i) the branch leading to Astatoreochromis-lineage plus the modern haplochromines; (ii) the branch leading to the modern haplochromines; and (iii) the branch leading to the LV region superflock  sequence data have a long and successful history in the study of East African cichlid evolution , or bec, [e.g., -29). Nev, [e.g., ; for phy, [e.g., ,31; and , [e.g., . Also, b, [e.g., ).The different phylogenetic algorithms, with which we analyzed our data, revealed largely congruent results. In all analyses, and in agreement with previous results , we founsensu lato. These are further divided into four distinct groups, a Congolese/Southern African lineage (CSA), the genera Pseudocrenilabrus (Ps.) and Astatoreochromis (As.), and the modern haplochromines (MH). While the respective monophyly of these four lineages was supported by high bootstrap values and Bayesian posterior probabilities, our analyses could not unambiguously resolve the exact relationships between these four lineages [maximum likelihood and Bayesian inference  ancestral to Southern African genera  was resolved as sister group to a clade comprised by solely Congo drainage taxa . Within the Pseudocrenilabrus- and Astatoreochromis-clades, branch lengths were relatively short and a more detailed phylogeographic sampling would be necessary to resolve the relationships between the different geographic lineages.The CSA lineage is composed of several widespread and moderately species-rich groups of the Congo drainage and Southern Africa and consists of two main clades: A clade with a species from the Congo drainage  sister-group to a clade comprised by the entire species flock of LM  and several East African riverine and lacustrine lineages (~200 species) plus the LV region superflock (~600 species). With approximately 1,800 species this – here phylogenetically defined – monophyletic lineage makes up about 7% of all known teleost fish.e.g., [Astatotilapia emerges as polyphyletic genus, with representatives assigned to both the East African riverine clade in the modern haplochromines and the LV region superflock.Our phylogenies show that several genera are in fact polyphyletic, and major taxonomic revisions will be required in the future to take our phylogenetic results into consideration. For example, and in agreement with previous studies , Thoracochromis, represented in our analysis by T. brauschi, has also been shown to be polyphyletic before [T. brauschi from the Congo drainage as a more ancestral lineage, and T. petronius and T. pharyngealis from the Nile drainage with affinities to the LV region superflock . Further analyses including nuclear DNA sequence data and more taxa assigned to the genus will be necessary to address this problem.The genus c before , with T.romis of  are consromis in ). The plogeny of  seems topport in . Also, tuaudi in ) as singuaudi in  indicateOrthochromis lineage, which is confined to the Malagarasi River system and two isolated rivers, East of LT [Orthochromis are biparental caregivers [sensu lato are all maternal mouthbrooders. Thus, the Orthochromis-species from the Malagarasi area, a group of exclusively riverine fish, should be placed into its own tribe. The name Orthochromis is, however, also used for riverine species from the Congo drainage. In our analyses, Orthochromis polyacanthus and O. stormsi from the Congo River system fall – according to their distribution – into the CSA-clade leaving also the genus Orthochromis polyphyletic  for the Malagarasi area species, since this name was repeatedly used for some species of that complex . We sugescribed , and Schee e.g., ,34,35).e.g., [sensu lato, and about 2 MYA (1.15 – 3.89 MYA) for the first branching events within the CSA clade. The spread of Congo drainage taxa into southern river systems occurred at a later stage, most likely at the relatively shallow watershed between upper branches of the Congo River and the Zambezi River – a scenario that is also supported by the placement of Serranochromis sp. (from Lake Mweru in the upper Congo) as sister group to the Zambezi/Southern African genera Sargochromis and Pharyngochromis in our phylogenies. However, further sampling in that area would be necessary to reconstruct the southward spread of the CSA lineage.We note that the application of a molecular clock for estimating divergence times has the potential of not being without problems for several reasons . Howe.g.,   and LM (Pseudocrenilabrus) region – the genera Astatoreochromis and Pseudocrenilabrus never underwent considerable speciation. The three described Astatoreochromis species occur in the LV region including Lakes Edward and George , in the rivers Rusizi and Lukuga (A. straeleni), and in the Malagarasi River (A. vanderhorsti). The three species of Pseudocrenilabrus occur from the Nile system to the LV region (P. multicolor), in Eastern- and Southern Africa including LM (P. philander), and in the central Congo basin (P. nicholsi). All analyzed representatives are relatively closely related suggesting a recent spread of these lineages in East Africa. However, we did not include P. nicholsi, which is morphologically different from P. multicolor and P. philander and would – if it really belonged to the Pseudocrenilabrus-lineage – represent the only haplochromine in the Congo drainage that is not a member of the CSA lineage.At essentially the same time as the CSA lineage, the ancestors of the The most recent common ancestor of the modern haplochromines was dated to have existed about 1.8 MYA 0.66 – 3.78 MYA) Fig. . This an.78 MYA FHaplochromis gracilior form Lake Kivu [H. paludinosus that occurs in the Malagarasi , as welested by ,42. Thissensu lato is the particular type of cranial apophysis for the upper pharyngeal bones [sensu lato are maternal mouthbrooders with the females alone incubating the eggs in their buccal cavities [maternal mouthbrooding behavior displayed by haplochromines is believed to being a derived character state [One of only few synapomorphies of the haplochromines al bones . The disal bones , is charal bones ,3,10,43.al bones  might fucavities . Mouthbrcavities -46, has cavities ,47,48. Ter state ,46,47. Me.g., some deep-water lineages of LM, have lost their egg-spots secondarily. In mimicking real eggs to attract females, these egg-spots function as natural releasers [ocelli) [Astatoreochromis-lineage and the modern haplochromines. There are other cichlid species in which males display yellow or red marks on their pelvic, dorsal or anal fins, but only in these lineages true egg-spots on the males' anal fins with a yellow, orange or red center and a colorless/transparent outer ring [Astatoreochromis-lineage and the modern haplochromines is the one with a pronounced potential for an increased rate of speciation  ,23 to thter ring ,22 are fsee Fig. . Based osee Fig.  it seemsAnother innovation that further distinguishes the exceptionally species-rich modern haplochromines from all other cichlids is the occurrence of numerous color morphs, often accompanied by sexual color dimorphism. Inter- and intra-specific polychromatism combined with maternal mouthbrooding involving egg-spots as releasers can be hypothesized to being permissive for sexual selection through female choice and, hence, the haplochromines' propensity for species formation, as sexual selection is probably a major causal factor in the origin of isolating mechanisms and the maintenance of reproductive isolation ,49-53. TAstatoreochromis, Astatotilapia, Pseudocrenilabrus, and Haplochromis , are ancestral to the adaptive radiations of the Tropheini of LT, and/or the radiations of LM and the LV region superflock. These genera are widely distributed and not confined to Eastern Africa, and they are the only ones that could inhabit the waterways that – over geological time spans – connected the lakes of Eastern Africa.A common feature of many adaptive radiations is that their founders are believed to have had a more generalist's lifestyle, while adaptive radiations themselves are defined by being composed of highly specialized species with narrower niche widths ,55. TheoThe phylogeny presented here Fig.  reveals i.e., generalists arose from highly specialized lineages, yet, apparently retained their high propensity for speciation and level of evolvability (see [In an apparent contrast to most other known examples of adaptive radiations  is the fity (see ). The faity see ,9,58), b,58, bi.eity , yetAntilles ,12,13,17It has been noted before that lineages of LT origin have left the lake secondarily  ,58. HereOrthochromis species of the Malagarasi area apparently do not belong to the radiation of the haplochromine cichlids and should be placed into a new tribe, we defined four new lineages within the haplochromines sensu lato: A clade combining Congolese and South-African genera (CSA-lineage), the Pseudocrenilabrus-, the Astatoreochromis-lineage, and the exceptionally species-rich modern haplochromines. The ca. 1,800 species of modern haplochromines are comprised of the entire haplochromine species flocks of Lake Malawi and the Lake Victoria region, some 200 riverine and lacustrine species, as well as the Tanganyikan Tropheini, which are likely to have evolved from a riverine ancestor and secondarily colonized Lake Tanganyika. This proposed "out of Tanganyika" scenario of haplochromine evolution is in agreement with the geological and palaeo-geological history of East Africa. Based on a character-state reconstruction from this new phylogeny, we were able to discover the evolution of several key-innovations that arose in the lineage leading to the modern haplochromines. These character reconstructions suggest that a combination of behavioral  and morphological characteristics  as well as ecological opportunities (after the colonization of large lakes) might have predestined this particular lineage to give rise to replicate adaptive radiations and, therefore, be causally related to the extraordinary success of these particular cichlid fish radiations.Our phylogenetic analyses that include representatives of all major haplochromine lineages show that all haplochromines are derived from Lake Tanganyika cichlids. While the For this study, a total of 304 specimens were analyzed. We combined all available GenBank entries from previous studies ,15,25,62Sample preparation, polymerase chain reaction (PCR) amplification and DNA sequencing have been performed as described elsewhere  for bothThe complete sequences of the mitochondrial control region (895 bp) and the ND2 gene  were aligned using the computer program Clustal W ; alignmeTylochromis, which is ancestral to the Tilapiini). We did not include representatives of three LT tribes – the Bathybatini, Trematocarini and Tylochromini -, as these ancient lineages were shown to have existed before the primary radiation of mouthbrooders in LT [10 rearrangements. For neighbor joining, we used the HKY model and conducted a bootstrap analysis with 5,000 replicates. Bootstrap analyses for maximum likelihood were performed with 100 replicates and for maximum parsimony with 1,000 replicates. We also applied Bayesian inference of phylogeny with Mr. Bayes 3.0b4 [sensu lato into four groups according to the four lineages that were recovered from the phylogenetic analyses .For phylogenetic reconstruction we performed maximum likelihood, maximum parsimony and neighbor-joining methods in parallel using the computer program PAUP* 4.0b10 . Two taxrs in LT ,15,67. Ars in LT . For thees 3.0b4  running es 3.0b4  under a es 3.0b4 . To esties 3.0b4 ,70 in whpc [versus lacustrine), breeding behavior, and the occurrence of true egg-spots on the maximum likelihood tree using MacClade 4.0  for maximum parsimony character state reconstructions and Mesquite [To test whether or not shifts in the probabilities of speciation occurred on certain branches of the obtained phylogeny, we quantitatively tested the fit of this tree to a Markovian null model in which the probability of speciation is equally distributed along branches. Therefore, we calculated the cumulative probability pc  for releMesquite  for maxiMesquite  applyingMesquite . ConfideMesquite ,75, the Mesquite ,4,25 as Mesquite ,77. An eMesquite ,76-79. TAstatoreochromis; bp, base pairs; CSA, Congo/South Africa; LM, Lake Malawi; LT, Lake Tanganyika; LV, Lake Victoria; MH, modern haplochromines; mtDNA, mitochondrial DNA; MYA, million years ago; ND2, NADH Dehydrogenase Subunit II; Ps., Pseudocrenilabrus.As., WS, EV, and AM designed the study and were involved in sampling. WS and TM carried out the molecular work and the analyses. All authors contributed to the preparation of the manuscript. They read and approved the final version.Table 1 – Specimen information, geographic origin and GenBank accession numbers of all taxa included in this study. This table lists the species and tribe names, geographic origin, source of specimens, names of collectors and collection numbers (if available), and GenBank accession numbers for both mitochondrial gene segments. The taxa that are included in Fig. Click here for file


Toxoplasma gondii is a zoonotic parasite of importance to both human and animal health. The parasite has various transmission routes, and the meat of infected animals appears to be a major source of human infections in Europe. We aimed to estimate T. gondii prevalence in a selection of animal host species. A systematic literature review resulting in 226 eligible publications was carried out, and serological data were analyzed using an age-dependent Bayesian hierarchical model to obtain estimates for the regional T. gondii seroprevalence in livestock, wildlife, and felids. Prevalence estimates varied between species, regions, indoor/outdoor rearing, and types of detection methods applied. The lowest estimated seroprevalence was observed for indoor-kept lagomorphs at 4.8% (95% CI: 1.8–7.5%) and the highest for outdoor-kept sheep at 63.3% (95% CI: 53.0–79.3%). Overall, T. gondii seroprevalence estimates were highest within Eastern Europe, whilst being lowest in Northern Europe. Prevalence data based on direct detection methods were scarce and were not modelled but rather directly summarized by species. The outcomes of the meta-analysis can be used to extrapolate data to areas with a lack of data and provide valuable inputs for future source attribution approaches aiming to estimate the relative contribution of different sources of T. gondii human infection. Toxoplasma gondii is an important zoonotic protozoan parasite capable of infecting potentially all warm-blooded vertebrates [T. gondii and a source of environmental oocyst contamination through shedding in feces [T. gondii rapidly multiplies, enters the host’s tissues, and forms tissue cysts. There it remains infective, enabling T. gondii to reach a new host through the carnivory of its former host [Toxoplasma gondii can also be transmitted to the fetus, causing congenital toxoplasmosis and potentially resulting in a miscarriage or stillbirth [T. gondii compared to other major food-borne parasites [tebrates . Felids in feces ,3,4. Upomer host . Infectiillbirth . The potarasites . The gloarasites . Particuarasites .T. gondii oocysts present in contaminated water, soil, or fresh produce, and a meat-borne route through the consumption of tissue cysts that may be present in the meat of infected animals. The consumption of raw or undercooked meat of infected animals appears to be the main source of transmission of the parasite for humans in Europe [T. gondii infections in the definitive hosts, felids, can give an indication of the environmental contamination with oocysts, and the surveillance of T. gondii prevalence within animal populations intended for human consumption helps to assess the risk of human infection from various meat products. Most livestock species have a herbivorous diet, therefore these animals mainly acquire the infection through ingesting sporulated T. gondii oocysts [There are two main routes of acquired infection in humans: An environmental route through the ingestion of n Europe . The pre oocysts ,11,12. W oocysts ,14.T. gondii infection is higher in animals kept outdoors, thus leading to the difference in T. gondii prevalence between animals kept indoors or outdoors, as has been well-documented in various species [Due to environmental contamination, the risk of acquiring  species ,15,16. I species , in lineT. gondii infection in animals. Direct methods such as a bioassay or PCR can be used to demonstrate the presence of the parasite or its DNA; however, indirect methods that demonstrate the presence of antibodies against T. gondii are more frequently used [T. gondii parasites are clustered in sparsely distributed tissue cysts, and in case the sample used for direct detection methods is small, tissue cysts may remain undetected with direct detection methods. Therefore, the detection of anti-T. gondii specific immunoglobulin G (IgG) antibodies is considered the most sensitive indicator of T. gondii infection in most animal species. However, in cattle, buffaloes, and equids, the seroprevalence is known not to correspond well with the presence of infective cysts in the tissue of these animals [Two types of methods are used to demonstrate tly used ,18,19. Ttly used ,21. More animals ,21,22. FThe aim of this study was to obtain age-dependent prevalence estimates in selected animal species. To this end, data on both indirect and direct detection methods were extracted from the literature, and a meta-analysis was carried out using a hierarchical Bayesian age-dependent model including relevant covariates.The literature review was conducted, and the results were reported following the PRISMA guidelines . A strucT. gondii  using both direct and indirect methods in selected host species in Europe, published in English, with at least a part of the data collected from the year 2000 onwards, were considered eligible. Experimental infection studies, case-control studies, literature reviews, meta-analyses, books, conference proceedings, grey literature, and publications with incomplete data necessary for the modelling , or cases where the full-text could not be obtained, were excluded. Each publication was screened by two randomly chosen scientists from the group, first at the level of the title and abstract, and after a consensus on inclusion between the two scientists was reached, full-text screening was performed on the remaining publications.The eligibility of retrieved publications was assessed by a team of 20 scientists from 13 countries across Europe using Cadima , an openPublications that met the inclusion criteria after full-text screening proceeded to data extraction, which was conducted by a smaller group of nine scientists. For each publication, the data were extracted by one of the nine scientists, and inputs were checked by another scientist. Inconsistencies and disagreements were discussed until an agreement was reached. A data extraction template file see  was creaAs grouping on a coarser level is more suitable for hierarchical modelling, the countries present in the dataset were assigned to one of five European regions—Western, Northern, Eastern, Southeastern, and Southwestern , as descThe detection methods described in the publications were classified as direct or indirect, depending on whether the parasite (or its DNA) or the antibody response is detected. The matrices tested were grouped into three categories—“blood”, “meat juice”, and “other”. The blood category comprised mostly serum samples but also included whole blood and plasma samples. The meat juice category consisted of liquid samples obtained by freezing and thawing muscle tissues. The “other” category incorporated mainly matrices used for direct detection  but also pleural fluids and cardiac fluids used for indirect detection see .T. gondii detection for a group of animals , resulting in several rows of data for the same population in the spreadsheet. In order to avoid counting the same animal population multiple times, a population identifier was introduced. A population was defined as a set of animals of the same species, age group, and from the same study. For each population identifier, a weighting was derived as one over the number of entries. This weighting was used in the model to scale the influence of the entry. Weighting is similarly introduced in case two direct methods are used; however, the number of entries for indirect and direct are considered separately.Some publications presented more than one set of results on Indoor animals were defined as those kept strictly in an enclosed environment  and outdoor-held animals as animals commonly kept in the open, with potential contact with the outside environment and free-roaming felids. Indoor and outdoor access were based on details from the publication or the typical holding and living conditions . For buffalo, cattle, equids, sheep, and game species , outdoor access was assumed by default. For publications that included data on animals with and without outdoor access, these data were extracted on separate rows and given a different population identifier.Since the ages of individual animals at the time of sampling were not given, we define an uncertainty distribution based on estimates of the minimum, maximum, and most probable age at sampling. The most probable age at sampling often coincides with the slaughter age. Age ranges, with the minimum, maximum, and most probable age at sampling, were extracted from publications whenever available. In case only the age range was indicated in the publication, for livestock, the arithmetic mean of the provided age range was used as a default value for the most probable age at sampling. For wildlife, in cases where age information was missing in the publication, an estimate for the minimum, maximum, and most probable age of sampling was applied based on the maximum recorded age for the animal species while taking into account the most common hunting age. Details can be found in the The amount of data from direct tests was insufficient to parameterize the full Bayesian model. Instead, the prevalence was calculated per species by dividing the number of positive animals by the total number of tested animals and multiplied by the population weighting factor  The susceptible-infected (SI) model where animals move from susceptible  to infected , and (2) the susceptible-infected-susceptible (SIS) model, where we also allow for a reversion to susceptible .γ.In both of these models, animals are born susceptible and can move into the ‘infected’ compartment based on a constant force of infection The variables S and I are fractions of the total population, dependent on age The SI model was recovered by setting A Bayesian model was built to estimate the prevalence in different animal populations and regions to quantify uncertainty. Moreover, a hierarchical model was built to be able to estimate the prevalence in countries with no data by “borrowing” estimates through partial pooling, granting us the possibility to overcome the data gaps. The Bayesian model was built based on the variables as shown in The basis of the Bayesian model was to describe the number of positive animals as a realization of a random process where each individual of the population of size The function That way, the age-distribution set for each population will be updated to facilitate the model fit in the posterior age distribution. As a prior the mean was set using Differences between species, outdoor access, sample type, and regions were taken into account using a hierarchical model. These differences were modelled as linear contributions to the logarithmic force of infection:γ analogously to λ,All hierarchically modelled forces of infection are soft-centered at zero to render the model identifiable. The parameter To prevent multiple counting of populations and resulting artificial inflation of precision, we weighted contributions to the likelihood using the weighting factor defined before.Model fitting was performed using Stan  interfacT. gondii parasite detection methods . The indirect methods used to detect specific anti-T. gondii IgG antibodies included the modified agglutination test, the direct agglutination test, the latex agglutination test, ELISA, the indirect fluorescence test, the Sabin–Feldman dye test, and the indirect Western Blot.A total of 1985 publications were retrieved, with more than 50 animal species included . Twenty-T. gondii prevalence was observed in the hearts of equids from the Eastern region  at 0.0% (95% CI: 0.0–0.4%) , lagomorphs from the Southeastern region , pigs from the Southwestern region , and wild birds from the Southwestern region . A consistently low T. gondii prevalence was observed in fecal samples of felids, especially in the Northern region at 0.2%  and the Western region at 0.2% . Average weighted prevalence estimates for included animal species reported separately for different sample matrices can be found in The highest prevalence based on direct detection data was 68.4% (95% CI: 54.8–80.1%) observed in the brains of lagomorphs in the Western region  . The low.0–0.4%) . A low pTrace plots and comparison of between and within chain estimates indicated good convergence of the model see .The effects of region, species, sample type, and outdoor access on the exponentiated force of infection and reversion rate are visualized in 15–2.93) . Given tT. gondii infection and a waiting time of For the force of infection or reversion, one over the posterior coefficient can be interpreted as an average waiting time in years until the event. For the force of infection, this yields a waiting time of The model results show clear differences in the force of infection between the animal species . In fourRegarding reversion, four animal groups  scored a reversion rate lower than the European average of approximately four years to become susceptible again. The shortest reversion rate on average was calculated for pigs at six months (s)= 3.7) .T. gondii infection in animals from the Eastern region averages approximately three months, which would be more than eight times shorter than in the Western region (approximately 3 years).The lowest overall force of infection across the species’ spectrum within the European regions was observed in the Western region (n)= 3.5) . It is eT. gondii infection was, on average, 6 months for outdoor-kept animals and 2.6 years for indoor-kept animals. Animals with unknown holding backgrounds are similar to those with outdoor access = 0.4) . The timT. gondii antibodies than blood samples  and the highest in outdoor-kept sheep at 63.3% (95% CI: 53.0–79.3). Previous attempts at estimating T. gondii seroprevalence in animals using meta-analyses were mostly bound to a single country outside of Europe [In this review, the modelled outcomes based on serological data show the lowest overall seroprevalence of f Europe ,31 or fof Europe ,33,34. Tf Europe . It is nT. gondii in cattle was determined in the current study; however, the prevalence in pigs and sheep varied greatly between the regions and matrices included  instead of via transmission between animals within one animal population [T. gondii antibodies [For the majority of animal species, the seroprevalence of with age ,20,39. T animals ,41. It spulation ,14. The tibodies , where stibodies ,44. HoweT. gondii seroprevalence. Our results show an almost five times higher force of infection in outdoor-kept animals compared to those kept strictly indoors. These findings agree with the outdoor access of animals being one of the most commonly identified risk factors for acquiring T. gondii infection [T. gondii infection in animals [Another feature of the model is the estimation of the effect of outdoor access on nfection ,15,16. Tnfection ,45,46. A animals ,14, ideaT. gondii antibody detection than when using blood or other matrices   and consider blood serum as a matrix of choice for the specific anti-T. gondii antibody detection, despite the modelled outcome. More data from a parallel indirect screening of samples from the same animal is needed to establish diagnostic test sensitivity and specificity of indirect tests when using different matrices. Adding these data as prior information could be a useful addition to the current model.Variability in the force of infection over sample type (c fluid) , suggestetection , performetection . Due to In the study by Deng et al., 2018 , separatT. gondii infection. Moreover, the modelled seroprevalence estimates, together with consumption data of the meat products of these animals, are a starting point for future risk assessments and are being implemented as such in a multi-country quantitative microbial risk assessment for T. gondii source attribution in humans.The current study describes a literature review and meta-analysis using a complex Bayesian hierarchical model including a novel dynamic transmission model, based on data obtained from an extensive meta-analysis. Age as well as all other covariates, such as indoor/outdoor status and region, can be extrapolated to obtain prevalence estimates for the actual composition of the animal population  in any European country despite data gaps. Prevalence estimates presented in this study, as well as those obtained from the model by users, could be used as a valuable tool for various purposes such as calculating adequate sample sizes for serological screening based on the seroprevalence in the region, a comparison tool, and could even provide a powerful instrument for the policymakers, e.g., to evaluate consequences of slaughtering age on the risk of