Do you find that your patients are not hungry in the morning, start eating later in the day and even wake up during the night to eat? If this is the case, they may have a specific eating disorder called Night Eating Syndrome [NES]. NES affects about 1.5% of the general population, and for those with obesity, the chances increase to around 6-14%.
The lack of awareness surrounding NES in both the professional and public space makes the condition easy to miss, underreported due to lack of recognition or embarrassment and often not pursued for treatment. It’s important to understand this syndrome and how to assist someone that has NES.
What exactly is Night Eating Syndrome?
Night Eating Syndrome is an eating disorder first described in 1955 with the characteristics of morning anorexia, increased eating in the evening and insomnia. It’s not particularly clear how NES develops, but it’s thought to be related to issues with the sleep-wake cycle and hormone dysregulation. It is more prevalent in those that have a history of depression, anxiety, or substance abuse; as well as people with obesity, obstructive sleep apnea, type 2 diabetes and those in the process of pursuing bariatric surgery.
Characteristics of Night Eating Syndrome include:
- Lack of appetite and not eating in the morning
- Eating 25% or more of daily calories after the evening meal during the night and early morning hours
- Insomnia 4-5 times per week
- Waking up at least 2 times per week with the strong urge to eat
- Belief that eating is necessary to sleep or return to sleep
- Awareness (either full or partial) and the ability to recall evening or nighttime eating
- Depressed mood during the evening hours
NES can often be confused with other eating patterns, such as Binge Eating Disorder [BED], grazing, compulsive eating, emotional eating, eating when someone is sleeping or eating when taking a sleep-aid medication.
To understand the difference, let’s look at NES in comparison to a couple of similar eating disorders. Those with BED do not usually consume most of their calories throughout the night and typically eat an increased amount of food at one sitting. Whereas those with NES tend to eat smaller amounts of food either once or several times through the night. Like BED, those with NES experience a similar loss of control, along with feelings of shame and guilt regarding their eating behaviors. These eating behaviors are usually solitary activities and hidden from others, sometimes with a sense of compulsion.
Sleep Related Eating Disorder [SRED] is similar to NES, but with one distinct difference. Someone with SRED does not have awareness of their waking and eating and does not recall this episode the next day. The feelings of shame or guilt are not usually accompanied with this disorder.
How Night Eating Syndrome can impact your client’s health and goals
Night eating syndrome can affect someone’s weight loss or gain, but they also experience more depression, anxiety, lower self-esteem, poorer quality of life, difficulty in maintaining work and social lives, and greater psychological distress compared to people without NES.
To assess someone for NES, evaluate their medical history, eating patterns, awareness around those eating patterns and perform sleep studies to gather baseline information. The Night Eating Diagnostic Questionnaire can also be utilized for further diagnostic criteria. Simply the acknowledgement of this disorder and the understanding that professional help exists can be a significant first step towards recovery.
Night eating syndrome can develop for a variety of reasons and involves a combination of factors, which can be confusing for both the patient as well as health care providers. For optimal care, collaboration with a multidisciplinary team is recommended.
Some treatment modalities that have been used in reference to night eating syndrome:
- Education surrounding the disorder and starting with the basics of sleep hygiene and healthy eating habits
- Eating schedule or structure, especially in exploring hunger cues
- Techniques for relaxation and anxiety reduction, for example progressive muscle relaxation
- Creation of bedtime routines to establish new sleep related behaviors, including regular sleep and wake times
- Treating any other comorbid symptoms or diagnosis (depression, anxiety, sleep apnea, etc.)
- Bright light therapy to regulate hormones for the sleep/wake cycle. This therapy is also used as an effective treatment in seasonal affective disorder.
For some patients, they can make significant strides toward recovery through learning about the disorder, committing to new habits, and having support. Recovery from NES can be especially difficult and due to the complexity, a team approach can allow the different layers of this syndrome to be addressed.
Medications have been used as an effective adjunct to reduce anxiety, nighttime awakenings and/or nighttime eating episodes. Certain selective serotonin reuptake inhibitors (SSRI) have been shown to be highly effective, as well as any other medications that address underlying anxiety or mood. In addition, addressing sleep results from a sleep study overall and possibly utilizing medications or melatonin to address the sleep/wake cycle.
Behavioral health professionals address the thought processes surrounding NES. They work to disrupt the cycle of the pattern by interrupting, challenging, and reframing thoughts in collaboration with this eating disorder. They may also address the feelings of shame, guilt, embarrassment, and loss of control that come up in relation to this eating behavior. Interventions that may be used include cognitive behavior therapy (CBT), psychotherapy, support groups, and overall stress reduction techniques.
Nutrition professionals may provide medical nutrition therapy (MNT) to educate and assist clients in shifting food intake, as well as nutrient balance to earlier in the day. A liquid based nutrition product may be used to gradually shift nutrient intake when a patient is not used to eating during the daytime. Meal planning and mindful eating are two techniques that may also be used to shift this balance. Behavior modification techniques are also used to adopt different coping mechanisms and strategies to overcome barriers to sleep and regular eating. Along with their behavioral health colleagues, nutrition professionals will assist with redirecting compulsive food behaviors, reframing thoughts around food and food guilt associated with NES.
People may respond best with the addition of other techniques that help to change the underlying response associated with NES. Examples of these therapies include yoga, acupuncture, aromatherapy, meditation, art therapy, and phototherapy.
Night eating syndrome is a complex combination of eating, sleeping, endocrine and mood functioning and dysregulation. It is often not recognized but can severely affect an individual’s ability to thrive. Gaining education and awareness around this eating disorder can help both the provider and patient recognize the characteristics and create a pathway toward recovery. Since NES can provide such a sense of shame and embarrassment, it may not be easily mentioned during a regular visit. Health care providers can be essential in recognizing this disorder, providing at home strategies, and connecting patients with a multidisciplinary team. Knowing that there are effective treatment strategies and steps toward increased health can be the key to a positive experience.
By Katie Chapmon, MS, RD
About the Author:
Katie Chapmon, MS, RD is a Registered Dietitian Nutritionist specializing in Bariatric Nutrition, GI Issues and Hormonal Health and with 10+ years of hands-on clinical experience for leading medical providers. She is the proud recipient of the 2010 Recognized Young Dietitian of the Year Award and 2018 Excellence in Weight Management Practice Award through the Academy of Nutrition and Dietetics.
She spent the first decade of her career as the lead dietitian for Kaiser Permanente Southern California. For the past several years, she has been working with industry partners and consumers to improve nutrition education within the field and maintains a virtual private practice. In April 2021, she launched Bariatric Nutrition Pro – to provide healthcare practitioners education to start (or continue!) their bariatric career with the confidence and knowledge to succeed.
She is a past Chair of the American Society of Metabolic and Bariatric Surgery Integrated Health Clinical Issues Committee and Chapter author of the 3rd Edition of the Academy of Nutrition and Dietetics Pocket Guide to Bariatric Surgery. She is a national speaker and enjoys time hiking and cooking in the kitchen. Katie also partners with Nutritional Resources (d/b/a HealthWise) for creation of educational content for weight management professionals.