Written by Emily Green
No, I’m not talking about midnight snacking!
Night eating syndrome is an eating disorder you may not be familiar with. It is estimated to affect 1.5% of the general population (1) and is a rare clinical condition which causes marked distress and disruption to daily life. Night eating syndrome is not the same as eating fast food at 2am after a night out and it is not as a result of boredom - let’s dive into what it is.
Relatively new to the list of eating disorder diagnoses, Night Eating Syndrome is characterised by excessive eating in the evening or during the night, lack of appetite in the morning and insomnia. The diagnosis was first formulated in 2008 at the First International Night Eating Symposium (2) and later included in the DSM-V in 2013 (3).
What are the diagnostic criteria for night eating syndrome? (2,3)
A. Significantly increased intake in the evening and/or nighttime, as manifested by one or both of the following:
1. At least 25% of food intake is consumed after the evening meal
2. At least 2 episodes of nocturnal eating a week
B. Individual has awareness and recall of evening and nocturnal eating episodes:
C. Clinically characterised by at least 3 of the following features:
Lack of desire to eat in the morning and/or skipping breakfast on 4 or more mornings per week
Presence of a strong urge to eat between dinner and sleep onset and/or upon waking during the night
Sleep onset and/or sleep maintenance insomnia are present 4 or more nights per week
Presence of a belief that one must eat in order to initiate or return to sleep
Mood is frequently depressed and/or mood worsens in the evening
D. Associated with significant distress or impairment in functioning
E. The disordered eating has continued for at least 3 months
F. Not attributable to substance abuse, medical disorder, medication or another psychiatric disorder
Characteristics of night eating syndrome
Six core clinical features were established to inform the diagnosis of night eating syndrome (2), these include:
Evening Hyperphagia
This relates to the timing (evening) and amount of food eaten; hyperphagia consists of ‘hyper’ meaning excessive and ‘phagia’ relating to eating. To meet this criterion, at least 25% of daily energy intake is consumed after the main evening meal. A specific time was not included to allow for cultural differences such as a late European dinner time or breaking the fast after dark during Ramadan which are normal, not disordered eating habits.
Awareness During Night Eating Episodes
Lack of awareness during eating is something seen during binge eating episodes associated with Bulimia Nervosa or Binge Eating Disorder diagnoses. With night eating syndrome the individual is consciously aware at the time. This also differentiates it from a separate condition called Sleep Related Eating Disorder.
Absence of Morning Appetite
This may show up as a lack of hunger upon waking, feeling full or ill from the night before and in some cases, skipping breakfast. Not eating breakfast can be the first step in disrupting the daily eating pattern as it causes an uneven distribution of food throughout the day and may lead to increased hunger signals later on. As it's a common challenge in recovery, we've shared some suggestions on overcoming poor appetite to help.
Urge to Eat After Evening Meal
This urge could be late in the evening or during the night after a period of sleep. The urge to eat is strong and difficult to ignore, perhaps coupled with a disturbed mood. The individual believes they must eat something to be able to return to sleep, adding a psychological aspect to the hunger.
Sleep Difficulties
Difficulties with falling asleep or staying asleep at least 4 nights per week are common symptoms in night eating syndrome. This disruption of the circadian rhythm places insomnia as a key characteristic of this eating disorder.
Belief That Eating Will Allow One to Sleep
This belief coupled with the strong urge to eat drives the behaviour of eating during the night. It may also contribute to anxiety or depression linked to the nocturnal eating episodes.
Mood Disturbances
This may present as a depressed mood or particularly, the mood becoming worse (more depressed) during the evening hours.
Who does night eating syndrome affect?
Night eating syndrome tends to onset during early adulthood and can be active during stressful periods in life. There are no clear differences in gender or racial distribution but there appears to be a tendency for the condition to run in families, specifically between first-degree relatives (4). Commonly it will be present alongside other conditions such as depression, insomnia, substance abuse or anxiety. The prevalence also increases with body mass index (BMI), indicating a link with obesity (5). Read more on BMI and eating disorders in our article.
It is estimated that night eating syndrome affects 1.5% of the population, although if we look at specific patient groups the prevalence is much higher. For example, studies have shown night eating syndrome to be present in 4.3-8.9% of weight loss samples, 15% of morbidly obese adults (6) and 37% of women who report weekly binge eating (7).
How is night eating syndrome different from binge eating disorder?
Individuals with binge eating disorder tend to have difficulties with body image and often binge eat in order to control or numb emotions or manage distress. This is not characteristic of night eating syndrome, which has been conceptualised as ‘a disorder of biological rhythm’ (8).
With a similar disruption in the pattern of eating and distribution of food intake across the day, there are some similarities between night eating syndrome and binge eating disorder. However, the crux is the timing of eating. Nocturnal ingestions account for at least 1/4 of daily food intake consumed after the evening meal or upon waking after being asleep. Furthermore, the quantity of food consumed in nocturnal eating episodes tends to be lower than that of an objective binge (6).
A typical 24 hours with night eating syndrome may look like this:
How is night eating syndrome treated?
The goal of night eating syndrome treatment is to reduce the frequency of night time awakenings or the desire to eat in the evenings. This involves achieving a more typical daily pattern of eating where food is evenly distributed throughout the day, meals are nutritionally balanced and addressing stimuli such as stress and poor sleep hygiene (9).
It should be noted that treatment will be different for every individual and the research for treatment so far is often carried out on small numbers of participants due to the rare nature of this eating disorder. However there have been some promising results!
Some core components to consider for treatment of night eating syndrome include:
Psychoeducation
Dietary changes
Relaxation strategies like deep breathing and progressive muscle relaxation (PMR)
Sleep hygiene
Medication
Cognitive Behavioural Therapy (CBT)
CBT for night eating syndrome involves psychoeducation around the condition, healthy eating and sleep hygiene to build the individual’s awareness and understanding. Implementing dietary modifications can help make progress towards a more typical eating pattern and address any environmental triggers for night eating. Sleep hygiene improvement may include managing stress, limiting stimulants like caffeine, finishing eating 2 hours before bed and reducing screen time.
Medication
Studies researching the effect of certain selective serotonin reuptake inhibitors (SSRIs) such as paroxetine, fluvoxamine and sertraline have shown success in reducing episodes of nocturnal eating in small samples (10,11). Use of medications such as SSRIs may also help with depressed moods associated with the syndrome.
If any of the eating difficulties detailed in this blog resonate with and apply to you, please contact your GP or get in touch with us directly for specialist support with the TC Nutrition clinic and complete an enquiry form where our team will be in touch.
Emily Green
TCN Intern
Emily is studying MSc Clinical Nutrition, after having graduated from a degree in Nutrition & Psychology from Newcastle University. She has an interest in supporting people to overcome disordered eating, find food freedom and keep a healthy mind. You can find Emily on Instagram @nutritionupontyne and on her blog nutritionupontyne.co.uk
REFERENCES:
Rand, C., Macgregor, A. and Stunkard, A., 1997. The night eating syndrome in the general population and among postoperative obesity surgery patients. International Journal of Eating Disorders, [online] 22(1), pp.65-69. Available at: <https://onlinelibrary.wiley.com/doi/epdf/10.1002/%28SICI%291098-108X%28199707%2922%3A1%3C65%3A%3AAID-EAT8%3E3.0.CO%3B2-0> [Accessed 16 July 2022].
Allison, K., Lundgren, J., O'Reardon, J., Geliebter, A., Gluck, M., Vinai, P., Mitchell, J., Schenck, C., Howell, M., Crow, S., Engel, S., Latzer, Y., Tzischinsky, O., Mahowald, M. and Stunkard, A., 2009. Proposed diagnostic criteria for night eating syndrome. International Journal of Eating Disorders, [online] 43(3), p.NA-NA. Available at: <https://onlinelibrary.wiley.com/doi/epdf/10.1002/eat.20693> [Accessed 16 July 2022].
DSM-V, 2013. Feeding and Eating Disorders. [online] DSM Library. Available at: <https://doi.org/10.1176/appi.books.9780890425596.dsm10> [Accessed 10 June 2022]
Lundgren, J., Allison, K. and Stunkard, A., 2006. Familial aggregation in the night eating syndrome. International Journal of Eating Disorders, [online] 39(6), pp.516-518. Available at: <https://onlinelibrary.wiley.com/doi/abs/10.1002/eat.20269> [Accessed 19 July 2022].
Marshall, H., Allison, K., O'Reardon, J., Birketvedt, G. and Stunkard, A., 2004. Night eating syndrome among nonobese persons. International Journal of Eating Disorders, [online] 35(2), pp.217-222. Available at: <https://onlinelibrary.wiley.com/doi/epdf/10.1002/eat.10241> [Accessed 20 July 2022].
Vander Wal, J., 2012. Night eating syndrome: A critical review of the literature. Clinical Psychology Review, [online] 32(1), pp.49-59. Available at: <https://www.sciencedirect.com/science/article/pii/S027273581100184X> [Accessed 17 July 2022].
Colles, S., Dixon, J. and O'Brien, P., 2007. Night eating syndrome and nocturnal snacking: association with obesity, binge eating and psychological distress. International Journal of Obesity, [online] 31(11), pp.1722-1730. Available at: <https://www.nature.com/articles/0803664> [Accessed 16 July 2022].
Stunkard, A. and Costello Allison, K., 2003. Two forms of disordered eating in obesity: binge eating and night eating. International Journal of Obesity, [online] 27(1), pp.1-12. Available at: <https://www.nature.com/articles/0802186> [Accessed 20 July 2022].
Allison, K. and Tarves, E., 2011. Treatment of Night Eating Syndrome. Psychiatric Clinics of North America, [online] 34(4), pp.785-796. Available at: <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3222864/> [Accessed 20 July 2022].
Miyaoka, T., Yasukawa, R., Tsubouchi, K., Miura, S., Shimizu, Y., Sukegawa, T., Maeda, T., Mizuno, S., Kameda, A., Uegaki, J., Inagaki, T. and Horiguchi, J., 2003. Successful treatment of nocturnal eating/drinking syndrome with selective serotonin reuptake inhibitors. International Clinical Psychopharmacology, [online] 18(3), pp.175-177. Available at: <https://journals.lww.com/intclinpsychopharm/Abstract/2003/05000/Successful_treatment_of_nocturnal_eating_drinking.10.aspx> [Accessed 22 July 2022].
O'Reardon, J., Stunkard, A. and Allison, K., 2003. Clinical trial of sertraline in the treatment of night eating syndrome. International Journal of Eating Disorders, [online] 35(1), pp.16-26. Available at: <https://onlinelibrary.wiley.com/doi/epdf/10.1002/eat.10224?saml_referrer> [Accessed 22 July 2022].
Talia Cecchele Nutrition is a team of registered dietitians that specialise in eating disorder recovery, disordered eating, gut health and sports nutrition. We aim to bring balance back to nutrition, help you to break free from food rules and find food freedom. We offer virtual consultations and group programs so whether you are based in London, the United Kingdom or around the world we would love to support you. To enquire about a private consultation please fill out a contact form.
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