Wake up to eat

Finally: An Explanation of Night Eating?

Even though many of us wake up in the middle of the night thirsty and/or needing a bathroom, few of us decide to stay awake to eat another dinner. To be sure, we may munch on a graham cracker, nibble on some leftover pie, or drink a glass of milk with some cookies. But with the exception of a category of people called night eaters, we rarely are hungry enough to eat a full meal, even though it has been hours since we last ate.

The almost physical inability to put much food in our stomachs is evident with the lackluster appetite we may approach breakfast served on a transatlantic flight at 2 or 3 in the morning. We are awake, more or less, but our stomachs are not. Conversely, some of us can tell time by the mid-day and early evening rumbles in our stomach signaling, “Time to eat!” Why are we hungry for lunch or dinner five or fewer hours since the previous meal, and yet not hungry in the middle of the night, eight or nine hours after we had dinner? By the time we leave infancy, most of us are unlikely to wake up for a 2 A.M. feeding.

A hormone, secreted by the stomach but acting on the brain, may be the answer. Ghrelin (rhythms with Mary Ellen) seems to initiate eating at certain times over a 24-hour cycle, but not at other times. Although it seems as if we eat by the clock as in, “It is noon so I must be hungry,” this is apparently not the case (at least not in a research situation). About seven years ago, in a study published in the American Journal of Physiology by D.E. Cummings and colleagues, ghrelin levels were measured in volunteers whenever they started eating a meal. The researchers found that when the volunteers were most hungry, right before they started a meal, their ghrelin levels were high. After eating, ghrelin levels in the blood decreased and, as time passed, slowly began to rise again. Five or six hours after the previous meal, hunger and ghrelin levels again were high, and the subjects started on their next meal.

So why are we all not in the kitchen at 1 or 2 A.M. looking for something to eat, 6 or 7 hours after dinner? Most of us are asleep and if awakened would probably turn down a sandwich or some scrambled eggs. We are not hungry. The reason? According to research reported in the European Journal of Endocrinology by Natalucci, et al, the level of the hunger hormone is lowest between midnight and 7 A.M.

But some people do wake up every night hungry enough to eat more than a few crackers and drink some milk. These so-called night eaters may actually consume as many calories as the rest of us eat at dinnertime. They are not eating in order to fall back asleep but because they are hungry. It is unclear if they wake up because they are hungry or notice how hungry they are when they wake up for other reasons such as noise or a need to go to the bathroom. Hungry they are, however, and apparently because night eaters have an abnormally high level of ghrelin in the blood between midnight and morning. It is as if this hormone is out of sync with the other hormones, primarily melatonin, that should be keeping them asleep, not microwaving pizza or defrosting a steak in the middle of the night.

No one quite knows what to do about the high levels of the hunger hormone in the wee hours of the morning. Researchers acknowledge that the rise of gherlin is delayed, so that instead of increasing late in the afternoon/early in the evening, when we normally would be eating our evening meal, it seems to peak five or six hours later. One thought is to expose night eaters to early morning light therapy similar to the lightboxes used by people with SAD (Seasonal Affective Disorder). According to a paper by Goel N. Stunkard and others in the Journal of Biological Rhythms, night eaters who have been exposed to early morning light respond by eating at normal meal times and will decrease their nightly food consumption. Maybe the light changes the rhythm of ghrelin release so that it approximates the normal sleep/wake cycle. Or perhaps waking people up early to sit in front of a lightbox gets them to eat breakfast early in the morning (although it is hard to believe they will be hungry) and this sets up a normal ghrelin prior to lunch and then dinner time.

Or, perhaps, the answer is to move to Spain where everyone seems to eat supper after the late show.

Night Eating Syndrome

Night eating syndrome is an eating disorder, characterized by a delayed circadian pattern of food intake.

Night eating syndrome is not the same as binge eating disorder, although individuals with night eating syndrome are often binge eaters. It differs from binge eating in that the amount of food consumed in the evening/night is not necessarily objectively large nor is a loss of control over food intake required. It was originally described by Dr. Albert Stunkard in 1955 and is currently included in the “Other Specified Feeding or Eating Disorder” category of the DSM-5.

Individuals with night eating syndrome feel like they have no control over their eating patterns, and often feel shame and guilt over their condition.

Night eating syndrome affects an estimated 1.5% of the population, and is equally common in men and women, according to the National Institute of Mental Health.

Medical Impact of Night Eating Syndrome

Individuals with night eating syndrome are often obese or overweight, which makes them susceptible to health problems caused by being overweight, including high blood pressure, diabetes and high cholesterol. Those who are obese increase their risk of heart diseases, many types of cancer and gallbladder disease.

Individuals with night eating syndrome often have a history of substance abuse, and may also suffer from depression. They typically report being more depressed at night. They also frequently have sleep disorders.

Signs of Night Eating Syndrome

Those with night eating syndrome may be overweight or obese. They feel like they have no control over their eating behavior, and eat in secret and when they are not hungry. They also feel shame and remorse over their behavior.

They may hide food out of shame or embarrassment. Those with night eating syndrome typically eat rapidly, eat more than most people would in a similar time period and feel a loss of control over their eating. They eat even when they are not hungry and continue eating even when they are uncomfortably full. Feeling embarrassed by the amount they eat, they typically eat alone to minimize their embarrassment. They often feel guilt, depression, disgust, distress or a combination of these symptoms.

Those with night-eating syndrome eat a majority of their food during the evening. They eat little or nothing in the morning, and wake up during the night and typically fill up on high-calorie snacks.

Traits of patients with night-eating syndrome may include being overweight, frequent failed attempts at dieting, depression or anxiety, substance abuse, concern about weight and shape, perfectionism and a negative self-image.

Causes of Night Eating Syndrome

Causes of night eating syndrome vary, but there are usually a variety of contributing factors. Sometimes college students pick up the habit of eating at night and are unable to break the habit when they become working adults. High achievers sometimes work through lunches, and then overcompensate by eating more at night.

Night eating syndrome, ironically, may be a response to dieting. When people restrict their intake of calories during the day, the body signals the brain that it needs food and the individual typically overcompensates at night. Night eating may also be a response to stress.

Those with night eating syndrome are often high achievers, but eating patterns can affect their ability to socialize or manage work-related responsibilities. They may also have different hormonal patterns, resulting in their hunger being inverted so that they eat when they should not and do not eat when they should.

Treating Night Eating Syndrome

As with other eating disorders, successful treatment of night eating syndrome typically requires a combination of therapies.

Treatment for night eating syndrome typically begins with educating patients about their condition, so they are more aware of their eating patterns and can begin to identify triggers that influence how they eat. Just identifying that they have night eating syndrome and that it is not their fault can be an important first step toward recovery.

Treatment of night eating syndrome also includes nutrition assessment and therapy, exercise physiology, and an integration of cognitive-behavioral therapy (CBT), dialectical behavioral therapy (DBT), interpersonal therapy (IT) and stress management. An additional online component may also help patients gain control over their disorders.

It is important for individuals with night eating syndrome to change their behavior by changing their beliefs. If they believe that they are powerless to change the way they eat, they will not be able to change.

Helping Someone With Night Eating Syndrome

If you suspect you or someone you know has Night Eating Syndrome (NES), do something about it. Night Eating Syndrome can have a dramatic impact on a person. Seek professional counseling immediately.

6 Reasons You’re Waking Up Hungry

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Here are six reasons why your middle-of-the-night hunger pangs just won’t quit, and the dietary tweaks you can make to keep them from continuing.

1. You’ve Changed Up Your Workout

When you’ve been cruising along with a particular workout for a while, your body adapts and becomes more efficient at completing that workout, ultimately burning fewer calories. So if you decide to switch up your workout to one that’s not only different, but longer or more intense, you may experience a temporary increase in calorie burn—and not bumping up your food intake during the transition can lead to an energy deficit that causes you to wake up with hunger pangs, says Suzanne Dixon, RD, registered dietitian with The Mesothelioma Center in Portland, Oregon.

“It’s unlikely the energy deficit change is more than a few hundred calories,” says Dixon. “For this reason, you can probably fix the problem by adding in a 200- to 300-calorie balanced snack in the evening, about one to two hours before going to bed.” (For example, Greek yogurt and a banana or a few berries.)

2. You Eat Large Meals Too Close to Bedtime

“Some people are more sensitive to large doses of carbs, which can lead to low blood sugar after a big meal,” says Dixon. “Their bodies can ‘overshoot’ a bit on insulin production in response to a carb-rich meal (especially if the carbs are simple).” The result? Blood glucose can drop too low an hour or so after eating, and this could be why someone wakes up super hungry after eating a big meal right before bed.

When your dinners are of the last-minute variety, the best solution is to nosh on a smaller meal that includes lean protein, complex carbs, and a bit of fat, says Dixon. (Too much fat makes food sit in your stomach longer, and right before bed would be a recipe for heartburn and tossing and turning.) A low-key, satisfying option would be yogurt and cereal—just make sure the cereal is a high-fiber, low-added sugar variety.

3. Your Sleep Habits Have Changed

A lack of sleep can cause an imbalance of hormone levels, making you feel hungry even when your body doesn’t need food, says Petre. The hunger hormones ghrelin and leptin stimulate and suppress appetite, respectively—and when you’re sleep-deprived, ghrelin levels go up and leptin levels go down. “This leads to increased hunger and more inadvertent snacking during the day and night,” says Petre. Best to get a grip on any habits that are getting in the way of you scoring quality shuteye so that cranky stomach of yours can follow suit.

4. You’ve Been Skipping Meals

These days, with our jam-packed schedules and constant rushing around, it’s easier than ever to skip meals. And if the calorie deficit becomes too large, this can interrupt sleep. “The hunger cues may be strong enough to wake a person up because the body and brain are prioritizing eating over sleep,” says Dixon. Do your best to break this bad habit—and when you do eat, make sure your meals and snacks consistently contain a mix of lean protein, fiber, and heart-healthy fats. “Eating this way will keep your blood sugar and energy levels steady, helping you to stave off hunger and sleep sounder,” says Petre.

5. You’re Actually Thirsty

Being that every cell in the body needs H20 to function optimally, it’s no surprise that when you’re running low, your body will sound the alarm—even if that’s in the middle of the night, says Amy Sunderman, RD, director of science and innovation for Swanson Health. It can be easy to confuse hunger pangs with thirst, so consider leaving a glass of water by your bedside and drink it first to confirm it’s actually your appetite calling the shots.

6. Your Blood Sugar’s out of Whack

If you’re diabetic or pre-diabetic, your cells aren’t able to absorb energy (in the form of glucose) properly because they’re not responding to insulin—the hormone that regulates the amount of glucose in the blood—the way they should, says Dixon. This means, even if you’re eating, your body still senses that you’re “hungry” because your cells aren’t getting any fuel, and these hunger cues may wake you up.

If you aren’t dieting, haven’t changed your eating or lifestyle habits much, and you’re suddenly waking up famished all the time, says Dixon, consult with your doc about getting some basic lab work done to check your glucose and insulin levels.

Sleep-Related Eating Disorders

Sleep-related eating disorder (SRED) is a type of parasomnia (sleep disorder) characterized by abnormal eating patterns during the night.

Sleep-related eating disorder can occur during sleepwalking. People with this disorder eat while they are asleep. They often walk into the kitchen and prepare food without remembering they did so. During these episodes, people with SRED may consume different foods than they would typically eat during the daytime, and may even eat inedible substances or strange combinations of foods.

Many diet during the day, which might leave them hungry and vulnerable to binge eating at night when their control is weakened by sleep. In some cases, people with SRED have histories of alcoholism, drug abuse, and other sleep disorders.

If SRED occurs often enough, people with the condition may:

  • Gain weight.
  • Develop metabolic conditions (Type 2 diabetes or elevated cholesterol).
  • Have unrefreshing sleep and feel sleepy or tired during the day.
  • Injure themselves preparing food (lacerations, burns).
  • Become ill from inadequately cooked food or ingesting toxic substances.
  • Develop cavities or tooth decay from eating sugary foods.

What is nocturnal eating syndrome?

A closely related disorder, known as nocturnal eating syndrome (NES), is diagnosed when a person eats during the night with full awareness and is usually unable to fall asleep again unless he or she eats.

Symptoms of NES include:

  • Little or no appetite for breakfast
  • Eating more food after dinner than during the meal
  • Eating more than half of daily food intake after dinner hour
  • A persisting pattern for at least 2 months

SRED and NES differ in that people with NES are fully aware that they are eating. Patients with SRED may have no recollection or faulty recollection.

Even if patients with SRED are aware of eating, they seem to have no control of what they are doing. Patients with NES consciously make the decision to eat at night. There is much overlap with these two disorders in that they both are hybrids of sleep and eating disorders. Both of these conditions can interfere with an individual’s good nutrition, cause embarrassment, and result in depression and weight gain.

Both men and women can have this disorder, but it is more common among women. Onset is typically age 20-40. About 1% to 3% of the general population appears to be affected by SRED. Ten to 15% of people with eating disorders are affected. A history of sleepwalking is common. Other sleep disorders or medical conditions that disrupt sleep or cause abrupt awakenings can also trigger SRED.

Treatment of nocturnal eating behaviors begins with a clinical interview and might include an overnight stay in a sleep laboratory, where brain activity is monitored during the night. Medicine sometimes can be helpful for these disorders. Additional treatments might include methods to decrease stress and anxiety. Examples of these methods include stress management classes, counseling, and a limited intake/avoidance of alcohol and caffeine.

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Curbing nocturnal binges in sleep-related eating disorder

Ms. G, age 39, has a body mass index (BMI) >35 kg/m2 and is pursuing bariatric surgery to treat obesity. She is frustrated with dieting and describes a decade of unconscious nocturnal eating, including peanut butter and uncooked spaghetti.

This behavior began after her divorce 10 years ago. Initially she had partial recall of the nocturnal binges, but now describes full amnesia. Treatment for a depressive episode did not control her nocturnal eating.

Sleep-related eating disorder (SRED) can be associated with disrupted sleep, weight gain, and major chronic morbidity. In SRED—involuntary eating while asleep, with partial or complete amnesia—the normal suppression of eating during the sleep period is disinhibited. The disorder can be idiopathic, associated with medication use, or linked to other sleep disorders such as somnambulism (sleepwalking), restless legs syndrome (RLS), periodic limb movement disorder (PLMD), or obstructive sleep apnea (OSA).

SRED is more common in women than men; it usually begins in the third decade of life but can begin in childhood or middle age. About one-half of SRED patients also have a psychiatric illness, usually a mood disorder. Unremitting SRED may lead to psychopathology, as the onset of sleep-related eating usually precedes the onset of a psychiatric disorder by years.

SRED often is unrecognized, but it can be effectively identified and treated. This article examines how to:

  • distinguish SRED from nocturnal eating syndrome (NES) and other disorders
  • identify precipitating causes
  • select effective pharmacologic therapy.

Box

Sleeping and eating: Closely linked activities

Because hormones that regulate appetite, food intake, and body weight also play a role in sleep regulation, patients with eating disorders often have associated sleep disorders. For example, obesity is related to obstructive sleep apnea (OSA)—weight gain is a risk factor for OSA, and weight loss often is an effective treatment.1 Moreover, patients with anorexia nervosa frequently demonstrate sleep initiation and maintenance insomnia.2

Conversely, epidemiologic studies have demonstrated that sleep duration is inversely correlated with body mass index. In particular, individuals with shorter sleep times are more likely to be overweight.3 The nature of this association is unclear; however, hormones that normally regulate appetite are disrupted in patients with sleep deprivation. For instance, leptin is an appetite suppressant that is normally released from adipocytes during sleep, so sleep deprivation may promote hunger by restricting its secretion.4

Differentiating SRED from NES

Eating and sleeping—and disorders of each—are closely linked (Box).1-4 SRED and night eating syndrome (NES) are 2 principal night eating disorders. SRED is characterized by inappropriately consuming food after falling asleep,5 whereas NES is characterized by hyperphagia after the evening meal, either before bedtime or after fully awakening during the night.6

To meet diagnostic criteria for SRED, patients must experience involuntary nocturnal eating and demonstrate at least 1 other symptom, such as:

  • eating peculiar, inedible, or toxic substances
  • engaging in dangerous behavior while preparing food (Table 1).

Level of consciousness. In both SRED and NES, patients demonstrate morning anorexia. However, patients with NES report being awake and alert during their nocturnal eating, whereas patients with SRED describe partial or complete amnesia. SRED patients with partial awareness often describe the experience as being involuntary, dream-like, and “out-of-control.” Interestingly, hunger is notably absent during most episodes in which patients have at least partial awareness.

Typically, patients cannot be awakened easily from a sleep-eating episode. In this regard, SRED resembles sleepwalking. Sleepwalking without eating often precedes SRED, but once eating develops it often becomes the predominant or exclusive sleepwalking behavior. This pattern has led many researchers to consider SRED a “sleepwalking variant disorder.”

Eating episodes in SRED are often characterized by binge eating, and many patients describe at least one episode per night.5 They usually eat high-calorie foods. The spectrum of cuisine is broad, ranging from dry cereal to hot meals that require more than 30 minutes to prepare. Patients treated at our sleep center report eating foods that are high in simple carbohydrates, fats, and—to a lesser extent—protein. Peanut butter—a preferred item—can lead to near-choking episodes when patients fall asleep with peanut butter in their mouths and wake up gasping for air. Alcohol consumption is rare.

SRED episodes can be hazardous, with risks of drinking or eating excessively hot liquids or solids, choking on thick foods, or receiving lacerations while using knives to prepare food. Patients may consume foods to which they are allergic or eat inedible or even toxic substances (Table 2).5,7-9

Table 1

Differences between expressive and supportive psychotherapy

  1. Recurrent episodes of involuntary eating and drinking during the main sleep period
  2. One or more of the following must be present with these recurrent episodes:
  3. The disturbance is not better explained by another sleep, medical, or neuropsychiatric disorder

Source: International classification of sleep disorders: diagnostic and coding manual, 2nd ed. Westchester, IL: American Academy of Sleep Medicine; 2005:174-5.

Sleep-Related Eating Disorder: Causes, Treatment, and More

Sleep-related eating disorder (SRED) is a parasomnia that links eating disorders to partial arousal during the transition between wakefulness and non-rapid eye movement (NREM) sleep. It is characterized by dysfunctional eating and drinking upon partial arousal from a stage of NREM sleep (also known as slow-wave sleep). As a form of sleepwalking, it entails partial or complete amnesia of the event. According to one study, the estimated prevalence of SRED was nearly 5% in the general population. The disorder is more common than generally recognized, and we can agree it requires more public awareness.

This type of connection between two entirely different disorders presents a rather complex pattern of cause and effect. To understand it better, let’s first look into NREM arousal parasomnias, as sleep-related eating disorder is a variant of them.

NREM Sleep Arousal Disorders among adults

Behaviors classified as non-rapid eye movement sleep arousal disorders typically occur in the first third of the night and they include:

  • Sleepwalking
  • Confusional arousals
  • Sleep terrors

They’re best described as partial or incomplete arousals from deep sleep, where the states of sleep and wakefulness are mixed with one another. That makes the affected person experience episodes during which they are simultaneously partially asleep and partially awake. They are heavily linked to genetics and common among children at various stages of development, with episodes subsiding as a child ages. In most adult cases, a nightmare disorder may develop as a symptom of post-traumatic stress disorder. But otherwise, severe and persistent cases of non-REM sleep arousal disorders occur in significantly lower percentages in the general adult population.

Sleepwalking (somnambulism) is reported to be present among 2-3% of the general adult population. It consists of a series of complex behaviors initiated during slow-wave sleep. Sleep-related eating disorder occurs among adults and it features the characteristics of sleepwalking and partial arousals combined with binge eating disorder. During these episodes, individuals consume uncontrollably and in partial wakefulness foods that they would typically not choose under usual circumstances. These are mostly high-calorie foods and even unusual, sloppy combinations of foods, and fruits and vegetables are typically avoided. But oftentimes affected individuals also ingest inedible substances from the kitchen, making this condition even more hazardous.

Causes of SRED

Although the definitive mechanism and causes of SRED are still not known, research points to different contributing factors. Studies have shown a higher frequency of individuals with prior history of sleepwalking being affected by sleep-related eating disorder, although that may not always be the case. There has been no evidence of a hereditary predisposition to developing SRED, but various conditions that disrupt sleep, such as restless leg syndrome or obstructive sleep apnea, are known to be a potential trigger. A stressful lifestyle or experiencing a particularly stressful period can also play a role, as it affects individuals both mentally and physically. The overproduction of cortisol is known to disrupt sleep patterns and often result in craving unhealthy foods and emotional eating.

The most valuable insight we can get on the cause of SRED is its connection to daytime eating disorders. Studies point to nearly 5% of the general population being affected by SRED, but the number rises among eating disorder patients: roughly 9-17% of patients with eating disorders develop SRED. These statistics contribute to the hypothesis that sleep-related eating disorder may be developed as a result of daytime dieting.

Whether suffering from an eating disorder or simply adhering to a strict weight loss regime, it is believed that individuals who restrict their eating during the day or have an unhealthy relationship with food are more vulnerable to binge eating in a state of half-sleep, when they have no control and seek to satisfy suppressed cravings. Although there are male patients, SRED is most prevalent among women between 20 and 40 years of age, which may be a result of the relentless pressure young women experience to maintain a desirable body weight.

The use of sedative-hypnotic medications can also put individuals at an increased risk of developing SRED.

Risks

Patients have varying degrees of consciousness during these nocturnal binge eating episodes, but having no control over their actions, the risk of injury is very high. Not only do they often consume inedible substances, but the episodes include preparation of food and using kitchen utensils in a hypnotized state. They can harm themselves at any time, ingest something toxic or something they’re allergic to, or choke while eating.

Needless to say, numerous health implications can arise from eating high-calorie food you wouldn’t normally choose, so weight gain is a common result, along with a higher risk of developing type-2 diabetes. But another hazard of SRED that we cannot overlook is its effect on mental health. Patients feel sluggish in the morning, but those who are aware of their condition feel depressed, guilty, and embarrassed by the lack of control — these emotions are best associated with binge eating disorder.

That’s why reaching out for help and treatment for sleep-related eating disorder is not just a matter of safety, but physical and mental health.

Diagnosis

Although an individual might be completely unaware of their nocturnal episodes, SRED rarely goes unnoticed: a partner or family member will awaken during an episode or there will be evidence of activity in the kitchen. It’s important to seek help from a physician in order to approach treatment properly — a disorder such as this one stems from other issues and they need to be tended to before things get out of hand.

Doctors rely on a questionnaire to assess the individual’s medical history, sleeping patterns, and habits. A questionnaire, along with any useful information from a partner or family members, can be enough for a doctor to determine the underlying cause. However, they might require a sleep study for proper diagnosis. A polysomnogram will determine the sleeping patterns of affected individuals and point to any other arousal disorders that may be present. More specifically, if a condition such as obstructive sleep apnea is diagnosed, it’s likely the cause of waking during the NREM phase, so it would need to be treated accordingly first. Likewise, if SRED is the direct result of a daytime eating disorder, the focus of treatment will shift on that disorder as the underlying cause.

Treatment

Because this is a disorder heavily linked to lifestyle issues (disrupted sleep and an unhealthy relationship with food), SRED is always initially treated by introducing various lifestyle changes, closely monitored by a physician. These changes are targeted at overall well-being and mental health. By introducing healthier dieting habits, increasing the level of physical activity, and working on their sleeping patterns, the lifestyle changes aim to regulate stress hormones and give way to a healthier relationship with food. Doctors recommend methods to reduce stress and anxiety, as these common conditions are often triggers to both sleeping and eating disorders. These methods may include counseling or meditation among others, and it’s highly recommended to decrease caffeine and alcohol intake. A proper eating regimen and a more mindful, balanced emotional state will help deal with the cravings, suppression of which could be the cause of developing sleep-related eating disorder.

Also, during diagnosis, the doctor will make an assessment of the medications the affected individual consumes. Any medications that could be a potential trigger to SRED (sleep medication, some antidepressants or antipsychotics) needs to be discontinued and properly substituted.

Lastly, follow-ups are conducted frequently at the physician’s judgment, and it’s usually recommended that the patient keeps a sleep diary. Additional medication to treat the condition is prescribed by doctors only as a last resort, if previous methods of treatment don’t prove effective over time, and that also depends on the assessed cause and the patient’s medical condition.

Getting help

If you or someone you know may be affected by SRED, rid yourself of the stigma and find the courage to start the conversation — it could be life-changing. Keep in mind that this disorder must be treated professionally — a partner or family member “monitoring” the affected person doesn’t really solve the problem in the long run.

Most people prefer to talk to their family doctor to get advice first. If you know someone who’s affected, offer support and go to the doctor with them, and take it from there. Online eating disorder support groups can also be a supportive environment if you’re taking the first step towards treatment.

SRED is a disorder just like any other, so just like the others, it requires openness and a strong will to change things.

Sleep-Related Eating Disorder: Causes, Treatment, and More

Snacking While Asleep? The Truth About Nocturnal Eating Disorders

Sure, everyone likes a good bedtime snack, but for some people, nighttime eating stretches beyond that final bowl of ice cream before turning in. These people find themselves inadvertently snacking the night away, either knowing or unknowingly, in the form of nocturnal eating disorders, or NEDs.

There are two types of these eating disorders, nocturnal eating syndrome (NES) and sleep-related eating disorder (SRED). The main difference between the two sleep disorders is that during NES, the person is fully aware of their actions, but with SRED, the person only partially wakes up and then unknowingly begins sleep eating. Between 1 and 3 percent of the general population is thought to have one of these nocturnal eating disorders, which are considered both an eating disorder and a sleep disorder.

People with NES will wake up during the night and have an uncontrollable urge to eat, regardless of how hungry they are. In fact, many people with NES are unable to fall back to sleep unless they eat.

People with SRED partially awaken in the middle of the night in a situation similar to sleepwalking and other sleep disorders, and then start sleep-eating, which normally entails unconsciously eating a large amount of typically unhealthy, high-calorie foods. Unlike NES, during which people remember their nighttime eating, those with SRED may not remember sleep eating or may only partially recall the event in the morning. Many times, when they find their kitchen a mess the next morning, they have no idea how it got that way.

Nocturnal eating disorders, if left untreated, can lead to significant weight gain and other health problems, such as type 2 diabetes, hypertension, and depression. “If you suspect you have a nighttime eating disorder, speak with your doctor,” said David Schulman, MD, MPH, chief of pulmonary and critical care medicine at Emory University Hospital in Atlanta.

The Causes Behind Nocturnal Eating Disorders

Sleep eating disorders are seen in both children and adults. They are more common in women, as most eating disorders are, and occur more often in people under the age of 50. Nocturnal eating disorders can be the result of an underlying medical problem, such as stomach ulcers, sleep apnea, or depression, other eating disorders such as bulimia, other sleep disorders such as sleepwalking, or a traumatic event. Zolpidem (Ambien), a prescription sleep aid, may also cause nighttime eating.

In addition, SRED can affect people who are on diets or who are under a large amount of stress. They may go to bed hungry because of their restricted diet and then unconsciously eat at night.

The Signs of Nocturnal Eating Disorders

If you exhibit the following behaviors for at least two months, you may have nocturnal eating syndrome:

  • You frequently wake at night and feel that you must eat in order to go back to sleep.
  • You eat more food after dinner than during dinner — more than half of your daily food intake comes after dinner.
  • You have little or no appetite for breakfast.

Symptoms of sleep-related eating disorder may include:

  • Seeing evidence of nocturnal eating when you get up in the morning, such as food left out on a counter or a disheveled kitchen
  • Having little or no appetite in the morning
  • Experiencing significant weight gain

Treating Nocturnal Eating Disorders

If you suspect that you have a nocturnal eating disorder, talk to your doctor about getting a full health evaluation to rule out other conditions that may be causing the symptoms. A sleep study may be recommended to detect unusual sleep behaviors.

Once an accurate diagnosis is made, medications may be prescribed to treat nocturnal eating. Topiramate (Topamax) is an anti-seizure medication that can be used to treat both NES and SRED. “It works on the appetite center of the brain to dull it a little,” explains Dr. Schulman. “It also helps with weight loss.”

If depression is causing your nighttime eating, an antidepressant may be prescribed along with counseling and support. In addition to drug treatment, minimizing alcohol consumption, which can disrupt sleep, and reducing stress may help prevent nocturnal eating.

If you think you may have a nocturnal eating disorder, take steps to get help. Nocturnal eating “is a medical disorder that can be treated,” says Schulman. “If you suspect you have it, talk to your doctor.”

Not your ordinary midnight snack: Sleep eating disorders

Believe it or not, some people eat while they are asleep. They literally get up to prepare and consume food in the middle of measurable sleep stages during the night. There are also people who wake up needing to eat in order to fall asleep again.

We’re not talking about that late-night craving we sometimes get when we know there’s an extra piece of birthday cake calling from the kitchen.

Nor are we referring to snacking after we’ve done a long spate of studying or other work late into the night.

These are situations of compromised sleep hygiene. They have their own consequences and are not technically considered sleep disorders—just bad judgment calls.

And we’re not even describing the conscientious diabetic who may need a quick carbohydrate bite to balance insulin and glucose, or the nursing mom who grabs a cup of yogurt after the midnight feeding to replace her calcium.

No, sometimes the eating is automatic and happens only during clinical sleep or as part of an unhealthy sleep pattern.

Welcome to the world of sleep eating: Nocturnal Sleep Related Eating Disorders (NS-RED) and Night Eating Syndrome (NES).

Sleep eating disorders are real and serious

Our media tends to address these legitimate health problems either as amusing or freakish, but the fact is that they are serious, life-altering, even threatening, conditions that require diagnosis and treatment.

Sleep eating disorders are not the result of “poor willpower” or some other judgmental explanation. While they’re uncommon, they do exist and are considered part of the Rare Disease category.

Make no mistake: Sleep eating disorders can definitely make life hard for those suffering. For instance, uncontrolled weight gain in either NS-RED or NES can lead to anxiety and depression, as feelings of shame and powerlessness can be brought on by these unusual behaviors.

Are these sleep disorders or eating disorders?

There is some difference of opinion regarding whether either or both of these are categorized as parasomnias and/or eating disorders. However, both can wreak havoc not only on a person’s metabolic function but also on their sleep habits.

Perhaps the better question to ask is not which kind of disorder these can be labeled, but how to identify and treat these problems.

Nocturnal sleep-related eating disorder

Also known as “somnambulistic sleep eating,” NS-RED may take place during a spell of sleepwalking, which generally occurs as a kind of arousal between sleep stages.

Those who eat while asleep are not generally conscious of their behavior. Regular episodes of NS-RED can heighten the risk for developing diabetes. The body, due to circadian system demands, is not designed to manage caloric intake during sleep. The rise and fall of blood sugar during sleep can lead to problems with insulin resistance and other disorders of metabolism.

People who suffer from NES have symptoms that persist for eight weeks or longer. They wake up lacking an appetite and tend to eat more of their total daily intake of calories AFTER dinner.

Some of those who suffer from NES may be practicing unhealthy dieting patterns during the day. An example might be low-calorie daytime dieting which leads to binge eating at night. Some of their issues may also be related to addiction issues. This is because the addicted brain may lack the necessary controls to stop unhealthy behavior.

What about Sleeping Beauty Disorder?

Binge eating may also be associated with a separate sleep disorder called Kleine-Levin Syndrome. This form of hypersomnia is more popularly known as “Sleeping Beauty” disorder. Sufferers encounter extended periods of irresistible sleepiness and participate in characteristic behaviors that can include overeating.

How to treat sleep eating disorders

Treatment of these disorders combines therapy for weight loss and addiction management with some environmental adjustments. This includes placing locks on cabinets and refrigerators for those who are unaware or not in control of their nocturnal sleep eating challenges.

Current pharmaceutical treatment with topimarole shows some promise for some nighttime sleep eaters. It’s also critical that doctors review a patient’s medications to rule out drug-induced behaviors.

Resources
  • “Classification of Sleep Disorders.” Michael J. Thorpy. Neurotherapeutics. 2012 October; 9(4): 687–701. Published online 2012 September 14. doi: 10.1007/s13311-012-0145-6
  • “Sleep and Parasomnias.” Dr. Carlos Schenck. National Sleep Foundation. 2014.
  • “Sleep-related Eating Disorder.” Mayo Clinic. 2014
  • “Sleep-Related Eating Disorders.” Cleveland Clinic. 2013

Photo credit

“Midnight Snack” by Sean Murray, February 5, 2008, CC BY-SA 2.0.

This post previously appeared in a slightly different form at SleepyHeadCENTRAL in December 2014 and has been updated for use here.

Symptoms

In both disorders, you eat when you’re not hungry. “People are turning to food for comfort,” says Kelly Allison, PhD. She’s the director of clinical services at the Center for Weight and Eating Disorders at the University of Pennsylvania.

  • People with binge eating disorder often try to numb emotions, like sad or angry feelings, with food.
  • People with night eating syndrome wake up and grab a meal or snack to soothe insomnia and help themselves fall back asleep.

“Both behaviors have a driven quality,” says Cynthia Bulik, PhD. She’s the founding director of the University of North Carolina Center of Excellence for Eating Disorders. “Once the urge arises it is very difficult and, for many, impossible to resist it until they give in.”

Another difference between the two conditions:

  • People who binge eat have a lot of food in a short period of time (called a “binge” or “binge episode”).
  • Night eaters graze on food throughout the evening. They might not eat a large amount at a time. They often wake up several times a night for something like a bowl of cereal, and then they go back to bed.

You might have night eating syndrome if you:

  • Eat mostly at night, getting more than 25% of the day’s calories after the usual evening mealtime.
  • Wake up three or more times a week to eat.
  • Believe that eating will help you sleep better.
  • Don’t eat very much or feel hungry in the morning.
  • Remember that you woke up and ate. (The condition is not the same as eating that happens during sleepwalking — called “nocturnal sleep-related eating disorder” — or after taking sleep medication.)

You might have binge eating disorder if you:

  • Eat a very large amount of food in a short period of time.
  • Feel that your eating is out of control (as if you can’t stop eating).
  • Continue to have food after you’re full (even when your belly hurts).
  • Binge in secret because you’re embarrassed.
  • Overeat again and again, and feel upset or guilty afterward.

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