Understanding Night Eating Syndrome

Up to 3.4 million people in the UK are thought to be affected by eating disorders, with some of the most common being anorexia nervosa and bulimia. Night eating syndrome (NES) is also categorised as a form of eating disorder, although it is thought to also intersect with sleep, stress and mood disorders.

Night eating syndrome is still an emerging area of research, with ongoing work needed to find effective treatments. It is thought that up to 1.5% of the general population may be affected by the condition and this number is significantly higher for people who are obese.

NES often coexists alongside other types of eating disorders or mental health conditions and, left untreated, it can have a significant effect on a person’s physical, emotional and mental health.

What is Night Eating Syndrome?

Night eating syndrome was first discussed in 1955, although it did not begin to be properly researched until the 1990s when experts began to look into the relationship between certain eating-related disorders and an increase in obesity levels.

Also known as NES, night eating syndrome is characterised by a person feeling like they cannot control their eating habits and that they must eat in order to fall asleep. Often, they will wake up several times in the night to eat as well.

Sometimes people with NES fail to intake sufficient calories during the day and then begin to binge at night-time, often consuming more than a quarter of their daily calorie intake once the sun has gone down. This behaviour can make it difficult to maintain a healthy weight and also increases the risk of other health problems, such as diabetes or cardiovascular disease.

The impact that night eating syndrome has on sleep can also begin to have an effect on people’s day-to-day life and can lead to increased levels of depression, anxiety and low mood.

Symptoms and Diagnosis

The signs of night eating syndrome may vary between patients. Widely accepted criteria used for diagnosing NES suggests that the following symptoms must be present:

• Regularly intaking at least 25% of daily calories after evening mealtime (also called evening hyperphagia)
• Waking up in the night to eat (twice a week or more)

In addition, to receive a diagnosis of NES, clinicians look for at least three of the following five criteria:

• Morning anorexia (skipping breakfast on purpose and being reluctant to eat early in the day)
• Food cravings in the evening and during the night
• A feeling that without eating at night you will not be able to sleep
• Regular insomnia (at least four times per week) where you struggle to fall asleep or stay asleep
• Low mood in the evenings

They also want to see that you are aware of your night eating episodes and are able to remember them (to rule out parasomnias, such as sleep related eating disorder (SRED)). Your doctor will also ask whether your night-time eating behaviour has a negative effect on your daily activities.

Night eating syndrome is not always easy to diagnose as it can coexist with other conditions. NES can be misdiagnosed as a type of parasomnia (sleep disorder) such as sleepwalking, as sometimes people may try to cook or eat whilst having a sleepwalking episode. The difference with NES is that you will be actively aware of your night eating, whereas people usually do not recall activities that happen during sleepwalking episodes.

Many people who suffer from NES also report feeling:

• Depressed
• Anxious
• Having low self-esteem

The overlap between NES and mental health may lead to the night eating being seen as simply a symptom of depression where a person eats to feel better, rather than a separate condition. It is important that all underlying causes or coexisting conditions are looked at in order to receive effective treatment.

If you have any concerns about your eating habits, weight, sleep or mental health, you should make an appointment to see your GP as soon as possible.

To get the right diagnosis it is important to be honest with your doctor about your symptoms even if you feel upset or embarrassed by your behaviour. Keeping a diary of your eating habits, including mealtimes and calorie intake, as well as a mood diary is a good idea. Keeping these diaries will help you to collect data to support your case.

Your doctor will want to speak to you about your symptoms and may use a type of structured questionnaire or inventory to assess you. Self-reporting tools are also available that may be used during pre-screening.

Some of the diagnostic tools that have been developed to help clinicians to diagnose NES include:

• Night Eating Questionnaire (NEQ)
• Night Eating Syndrome Questionnaire (NESQ)
• Night Eating Diagnostic Questionnaire (NEDQ)
• Night Eating Symptom Scale (NESS)
• Eating Disorder Examination (EDE)
• Night Eating Syndrome History and Inventory (NESHI)

The NEQ is the most widely used self-screening tool for NES and is now available in multiple languages including Arabic, German, Portuguese and Spanish. For those who score high on self-reporting questionnaires, additional diagnostics, including structured interviews, may be used by doctors.

You should also be prepared to speak about your eating habits, mental health, overall health and any medication you are taking. You can expect routine diagnostics to be taken at your first GP appointment, including:

• Weight
• Blood pressure

You may be referred for additional tests or to a specialist. This may include a sleep study and polysomnography which will measure your breathing, brain waves and heart rate as you sleep.

If you receive a NES diagnosis, you will be able to go through the different treatment options that are available to you. Treatments for night eating syndrome include a combination of therapies, lifestyle modifications and medicine.

Many people with NES report feeling like they have no control over their eating behaviour. Getting a diagnosis will not only help you to understand your actions and get the right treatment, but it can also help you to claim back some semblance of control over the condition

Causes and Triggers

It is not fully understood why some people develop NES, although it is thought that some people may be more likely to develop the condition, for example, if they:

• Are overweight or obese
• Have mental health issues such as depression or anxiety
• Abuse drugs (such as cannabis which can cause users to experience food cravings and interrupt natural sleep patterns)
• Overuse or abuse alcohol (alcohol can also affect sleep and blood sugar levels)
• Have another eating disorder (such as bulimia nervosa or binge eating disorder)

Other factors that may influence a person developing NES include:

• Genetics
• Problems with the body’s circadian rhythm or ‘body clock’
• Mental health
• Restricted food intake during the day (either through deliberate dieting or having a busy schedule/long working hours)

Impact on Health and Wellbeing

Eating large quantities of food at night and waking up to eat can have various negative effects on the body, such as:

• Poor quality sleep
• Tiredness or lethargy the next day
• Weight gain/obesity
• Altered blood sugar levels (leading to increased risk of diabetes)
• Heart problems
• Endocrine and metabolic disturbances

Additionally, eating too many calories at night may also lead to digestive issues such as heartburn or indigestion.

People may experience feelings of embarrassment or shame due to their night-time eating episodes and this may exacerbate their pre-existing depression or low mood. Not getting enough good quality sleep also has an impact on mental health, leaving people with NES trapped in a vicious cycle of emotional eating, poor sleep and low mood.

Treatment and Management

Research into night eating syndrome is ongoing and the efficacy of certain treatment options is still being studied by experts. As night eating syndrome often exists alongside other issues, such as depression or anxiety, some treatment options may focus on treating the underlying cause of the condition rather than primarily focusing on NES.

Some treatments that have been trialled for NES include:

• Cognitive behavioural therapy (CBT) – a type of structured, talking therapy that aims to help patients reframe their negative thought cycles and develop techniques to deal with problematic thinking and behaviour.
• Other behaviour therapies such as those used for mood and sleep disorders – goal oriented therapies may be useful for people with NES, such as devising a reward plan for reaching small goals, thus slowly reducing how many nights a week a patient binges until the problem is under control.
• Progressive muscle relaxation (PMR) – this is a technique where patients work through areas of the body and strategically tense and release various muscle groups. It has been shown to alleviate symptoms of stress, anxiety and even physical pain.
• Phototherapy – used to treat seasonal affective disorder (SAD), phototherapy exposes patients to light which boosts melatonin levels. As melatonin plays a significant role in regulating the circadian rhythm of the body it can be a useful way to help regulate the body clock in people who have night eating syndrome.

Medications that target serotonin or the circadian timing of eating may also be an option to treat NES, for example:

• Antidepressants (such as selective serotonin reuptake inhibitors (SSRIs) that can help improve mood and regulate emotions), for example sertraline.
• Melatonin supplements (melatonin is a hormone that aids the natural wake-sleep cycle. Taking supplements can help people with NES to fall asleep and stay asleep during the night).

Lifestyle Changes

Some simple lifestyle changes may help you to manage your night eating syndrome, such as:

• Avoid triggers such as drugs and alcohol.
• Try to eat a healthy, balanced diet as far as possible with a focus on fresh vegetables, healthy fats (such as oily fish, chia seeds and avocado) and home cooking rather than convenience foods or sugary snacks.
• Use stress management techniques, for example practising mindfulness, breathing techniques or meditation.
• Take all medication as prescribed and attend your therapy appointments.
• Try to maintain good sleep hygiene (regular bedtimes, a relaxed and quiet sleeping space, a comfortable bed).
• Exercise and get fresh air regularly to boost feel-good endorphins in the brain and help with weight management.
• Reach out for help when needed for both your mental and physical health and don’t let things get on top of you.

Raising Awareness

Night eating syndrome is an area of ongoing research and is a condition that is still not fully understood by experts. It is sometimes confused with other parasomnias or eating disorders, such as binge eating, despite being a unique condition in its own right. Diagnosing and treating NES can be further complicated by the fact it often exists alongside other issues, including depression.

Increased understanding about the condition and the use of structured diagnostic tools should make it easier for doctors to spot the signs of NES in patients and help them to access the treatment that they need more quickly.

Night eating syndrome can have a significant impact on a person’s lifestyle and health, including their sleep quality and weight. In addition to improving diagnostics and reducing stigma, raising awareness and spreading information about health is vital to:

• Normalise reaching out for help
• Help patients to understand the importance of diet and healthy eating
• Open up difficult conversations (about physical health and mental health)
• Help people to make lifestyle changes to reduce their risk factors for NES
• Prioritise stress management and wellness

Being overweight or obese is a potential risk factor for NES and it is known that if you have night eating syndrome it is also more difficult to lose weight. Both obesity and mental health continue to have a social stigma attached to them. Raising awareness about NES, its causes and its impacts can start to make people feel less judged and more empowered to embrace treatment and make the necessary changes that will benefit them in the long term.