By: Dr. Sherri Thomas
Have you seen this diet outlined on social media? It goes something like this:
Breakfast: ½ grapefruit, 1 slice whole wheat toast, 8oz milk
Lunch: 4oz. skinless broiled chicken breast, 1c. zucchini, herbal tea
Dinner: Large pepperoni pizza, 2 loaves garlic bread, 1 pitcher of Pepsi
Dessert: 1 sleeve of Oreos, 2 Milky Way bars, 1 qt Rocky Road ice cream with jar of hot fudge, entire Frozen Cheesecake eaten directly from the freezer
If you’re anything like me, you chuckle a little, acknowledging that a lot of your own good dietary intentions tend to fall apart towards the end of the day, and continue to scroll on. However, did you realize that this pattern is actually characteristic of Night Eating Syndrome and really does tend to be a response to stress?
Patients with NES have evening hyperphagia (consuming >25% of daily calories after the evening meal) and/or nocturnal awakening to eat 2 or more times per week. While not all patients with NES eat when they wake up at night, those who do are aware of what they are doing. This awareness is what differentiates NES from the parasomnia Sleep-Related Eating Disorder (SRED), in which patients do not remember waking up to eat. Diagnostic criteria for NES include 3/5 of the following: morning anorexia, evening hyperphagia, belief that one must eat to fall back asleep, depressed mood or anxiety that worsen in the evening hours, and/or difficulty falling asleep and/or staying asleep.
It is estimated that 1 in 10 patients with obesity also has NES and as many as 28% of patients with severe obesity. It appears to be a significant disruption of the circadian rhythm, and in my clinical practice, I have almost always found it to be driven by stress. One study that measured neuroendocrine markers in patients with NES showed that they had increased cortisol levels at the end of the day, as well as lower than normal melatonin and leptin levels at bedtime.
NES is also associated with increased incidence of depression, diabetes, hypertension and hypercholesterolemia even in patients who do not also have obesity. When patients report following the “Stress Diet”, it’s worth addressing!
Treatment options include:
- Stress management – exercise and short bouts of meditation through the day. In patients whose stress is related to work, I strongly recommend either stopping at the gym to exercise on the way home from work or even scheduling 5 minutes every hour during their work day to walk and take deep breaths whenever possible. Another recommendation is to sit in their car and doing a 10-15 minute guided breathing/meditation before going into the house. It sounds hippy dippy, but you’d be surprised at how well many of these patients respond! Their cortisol levels are elevated all day because of emotional stress, so it’s important they understand the correlation and the need for healthy coping/management strategies. These are also often the patients who kind of look like they elevated cortisol levels but they don’t have Cushing’s – skinny extremities, central adiposity, etc. When I explain to them that it’s elevated cortisol from emotional stress that is causing this, they are often much more amenable to behavioral therapies.
- Cognitive Behavioral Therapy – if your short explanations of stress management are falling on deaf or confused ears, refer them for CBT! We live in a ridiculously stressful world and it's actually very sad how few people were taught healthy coping strategies while growing up, so I am quick to offer a referral to these patients.
- Lots of protein early in the day. This can be hard to do given that they almost all report not wanting to eat in the morning. Often what can be doable for them is pouring a pre-made protein shake into their morning coffee – voila! 30 grams of protein without having to chew, and it flavors their coffee without the added sugar. I reassure them that it will take at least a few weeks to reset their circadian rhythm, so if they can just choke down that protein at breakfast time and lunch for the first week or two, it WILL get easier.
- Melatonin or ramelteon – thought to both reduce nocturnal eating episodes and improve sleep and depression symptoms. Given the low SE profiles, these can be excellent first line options.
- Sertraline 50-200mg daily. It is recommended that this intervention be tried for at least 9 weeks to determine efficacy. There does appear to be an association between consuming foods that increase serotonin (high-carb foods, which tends to be what patients with NES eat after dinner and in the middle of the night). Other SSRIs have been studied (paroxetine, escilatopram) and have had similar results to placebo. Given their usual tendency to promote weight gain, I do not use them in practice for NES.
- Topiramate 25 – 200mg. There is one article by Winkleman that is a report of 3 patients who were treated with topiramate and who responded well. My guess is that because topiramate is generic, we will never have a good randomized, controlled study. However, topiramate, both in long and short acting forms have been used regularly by obesity medicine specialists for at least the last 2 decades with good results. Topiramate 25mg po upon arrival home from work can be an inexpensive and effective starting dose that results in any SE of fatigue to help with sleep! The recommendation is to use this for at least 1 year before attempting to wean patients off therapy. Certainly, if their stress levels change, I would attempt a discontinuation earlier.
So, the next time a patient reports starting the day with the best intentions only to have it all fall apart at the end of the day, it may be worth digging a little deeper because there’s actually a lot that you can do to help.
Grethe Stoa Birketvedt, MD, PhD; J. Florholmen, J. Sundsfjord, et al. Behavioral and Neuroendocrine Characteristics of the Night-Eating Syndrome. JAMA. 1999;282(7):657-663.
Kucukgoncu S, Midura M, Tek C. Optimal management of night eating syndrome: challenges and solutions. Neuropsychiatr Dis Treat. 2015;11:751-760
Milano W, De Rosa M, Milano L, Capasso A. Agomelatine efficacy in the night eating syndrome. Case Rep Med. 2013;2013:867650
Pawlow LA, O’Neil PM, Malcolm RJ. Night eating syndrome: effects of brief relaxation training on stress, mood, hunger, and eating patterns. Int J Obes Relat Metab Disord. 2003;27(8):970–978.
Winkelman JW. Treatment of nocturnal eating syndrome and sleep-related eating disorder with topiramate. Sleep Med. 2003;4(3):243–246.
Vander Wal JS, Maraldo TM, Vercellone AC, Gagne DA. Education, progressive muscle relaxation therapy, and exercise for the treatment of night eating syndrome. A pilot study. Appetite. Epub February 4, 2015.
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