Clinical Manifestation and Management of Night Eating Syndrome

Night eating syndrome (NES) is an eating disorder characterised by the clinical features of morning anorexia, evening hyperphagia, and insomnia with awakenings followed by nocturnal food ingestion. The core clinical feature appears to be a delay in the circadian timing of food intake. Energy intake is reduced in the first half of the day and greatly increased in the second half, such that sleep is disrupted in the service of food intake.

The syndrome can be distinguished from bulimia nervosa and binge eating disorder by the lack of associated compensatory behaviours, the timing of food intake and the fact that the food ingestions are small, amounting to repeated snacks rather than true binges. NES also differs from sleep-related eating disorder by the presence of full awareness, as opposed to parasomnic nocturnal ingestions.

NES is of importance clinically because of its association with obesity. Its prevalence rises with increasing weight, and about half of those diagnosed with it report a normal weight status before the onset of the syndrome. The recognition and effective treatment of NES may be an increasingly important way to treat a subset of the obese population. Treatment of the syndrome, however, is still in its infancy. One clinical trial has reported efficacy with the SSRI sertraline. Other treatments, such as the anticonvulsant topiramate, phototherapy and other SSRIs, may also offer future promise.

Clinical psychologists are increasingly called to participate in the treatment of obesity, a condition that affects about one-third of adults in the United States. A disorder gaining increased recognition for its role in the development and maintenance of obesity is Night Eating Syndrome (NES), a relatively novel disorder involving morning anorexia, evening hyperphagia and/or nocturnal ingestions, and insomnia. NES affects men and women from various racial groups and tends to run in families. NES tends to co-occur with mood, anxiety, eating, sleep, and substance use disorders and may have implications for weight and diabetes management. Relatively little is known about the successful treatment of NES. Limited evidence suggests that serotonergic-based pharmacological treatments may be beneficial. Psychological interventions, such as psychoeducation, eating modification, relaxation strategies, sleep hygiene, cognitive restructuring, physical activity, and social support facilitation may also yield beneficial results. The purpose of the present paper is to provide an introduction to NES, including diagnosis, clinical presentation, assessment, comorbidities, clinical implications, and pharmacological and psychological treatment approaches. Areas for further study and development are discussed. NES is an emerging area for clinical description, evaluation, and intervention.

Nighttime eating is categorized as either night eating syndrome (NES) or the sleep-related eating disorder (SRED). Both diseases are often connected with an increase of the body mass, obesity, and with psychiatric disturbances. NES is characterized by evening hyperphagia, abnormally increased food intake after the evening meal, nocturnal awakings with ingestions, morning anorexia, and insomnia. Patients suffering from NES are aware of their nocturnal ingestions. It is suggested that NES is an abnormality in the circadian rhythm of meal timing that occurs in people with normal circadian rhythm of sleep. Other factors underlying NES include genetic predispositions, hormonal and neurochemical disturbances, and mood disorders. SRED is characterized by recurrent episodes of eating or drinking after arousal from nighttime sleep, unaware in tight the most cases, with adverse consequences. The distinctive features of SRED are amnesia of night eating episodes and consumption of non-typical food or dangerous articles. SRED is frequently associated with other sleep disorders, e.g., restless leg syndrome, periodic limb movement disorder, obstructive sleep apnea, and somnambulism. It can be also induced by medicines applied by a patient (e.g. zolpidem). It is hypothesized that the syndrome represents a variation of somnambulism.

Night eating syndrome, or NES, also “midnight hunger”, is an emerging eating disorder diagnosis, which primarily characterizes an ongoing, persistent pattern of late-night binge eating. NES was originally described by Dr Albert Stunkard in 1955[3] and is currently proposed for inclusion in the next edition of the Diagnostic and Statistical Manual of Mental Disorders. The diagnosis is controversial; its validity and clinical utility have been questioned[5] and there are currently no official diagnostic criteria. It affects between 1 and 2% of the population. Although it can affect all ages and both sexes, it is more common in young women. People with NES were shown to have higher scores for depression and low self-esteem, and it has been demonstrated that nocturnal levels of the hormones melatonin and leptin are decreased.[8] NES is often accompanied by or confused with nocturnal sleep related eating disorder, which is primarily a sleep disorder rather than an eating disorder, in which people are unaware of having eaten while asleep. There is debate as to whether these should be viewed as separate diseases, or part of a continuum.

Symptoms and behavior

People who suffer from night eating syndrome generally: Skip breakfast, and go several hours after waking before their first meal.
Consume at least 25% of[10] their calories after dinner. (Many sources would list this as after 9 or 10 pm; dessert is generally not included, if one is eaten.)
Late-night binges almost always consist of consuming carbohydrates. However, this eating is typically spread over several hours, which is not consistent with a typical eating binge as evidenced by other eating disorders. Episodes of late-night binge-eating can be repeated throughout the night, with many separate visits to the fridge or cupboard.
Suffer from depression or anxiety, often in connection with their eating habits.
These night eating episodes typically bring guilt rather than hedonistic enjoyment.
Have trouble sleeping in general; see insomnia.
Are more likely than the general public to sleepwalk.
To be considered a bona fide disorder, this pattern should continue for two months or more.

Management

Treatment of NES both non-pharmacological methods (psychotherapy, phototherapy) as well as the pharmacotherapy (aimed to increase serotoninergic neurotransmission in the brain, predominantly by sertraline, a selective serotonin re-uptake inhibitor) are used. SRED can be treated by controlling comorbid sleep disorders and eliminating provocative sedative hypnotics.

Night eating disorder tends to lead to weight gain; as many as 28% of those seeking gastric bypass surgery were found to suffer from NES in one study. The disorder is accompanied by what sufferers describe as an uncontrollable desire to eat, akin to addiction, and is often treated chemically.

The selective serotonin reuptake inhibitor, Sertraline (or Zoloft) has shown some ability to help NES sufferers.

Therapy to increase the natural nocturnal rise in melatonin, reduce the body’s adrenal stress response and raise leptin levels or improve leptin sensitivity are options that may help these patients overcome the disorder. Another key may involve the availability of tryptophan, an important amino acid, in the body. More than 70% of the night time eating to combat anxiety involved binging on carbohydrates. These foods are believed to increase the amount of tryptophan available for conversion to serotonin, the calming neurotransmitter in the brain that promotes an overall sense of well-being and, in turn, converts to melatonin.

References

1. Night eating syndrome: a critical review of the literature. Vander Wal JS. Clin Psychol Rev. 2012 Feb;32(1):49-59.
2. O’Reardon JP, et al. Night eating syndrome : diagnosis, epidemiology and management.CNS Drugs. 2005;19(12):997-1008.

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