Treatment of Nocturnal Eating Syndrome
The treatment of nocturnal eating syndrome should include both pharmacological intervention with sertraline (an SSRI) and non-pharmacological approaches such as cognitive-behavioral therapy to address the underlying circadian rhythm disturbances and psychological factors. 1
Types of Nocturnal Eating Disorders
There are two main types of nocturnal eating disorders that require different treatment approaches:
Night Eating Syndrome (NES):
- Characterized by evening hyperphagia (>25% calorie intake after dinner)
- Morning anorexia
- Nocturnal awakenings with food intake
- Full awareness during eating episodes
- Often associated with mood disorders and obesity
Sleep-Related Eating Disorder (SRED):
- Characterized by recurrent episodes of eating during sleep
- Typically involves amnesia of eating episodes
- Consumption of unusual food combinations or inedible/toxic substances
- Often associated with other sleep disorders or medication side effects
- May represent a form of parasomnia (similar to sleepwalking) 2
Diagnostic Assessment
Before initiating treatment, a comprehensive diagnostic evaluation should include:
- Assessment of eating patterns, including timing and amount of food intake 3
- Screening for other eating disorders (binge eating disorder, bulimia) 3
- Evaluation of sleep patterns and sleep disorders 3
- Assessment for comorbid psychiatric conditions (depression, anxiety) 4
- Medication review to identify potential triggers (especially sedative-hypnotics like zolpidem) 2
- Physical examination and laboratory testing to rule out medical causes 4
Treatment Algorithm for Night Eating Syndrome (NES)
First-line pharmacotherapy:
- Sertraline (SSRI) starting at 50mg daily, titrating up to 100-200mg as needed 1
- Aim to increase serotonergic neurotransmission to regulate circadian rhythm and mood
Alternative pharmacotherapy (if SSRIs ineffective):
- Topiramate starting at 25mg nightly, gradually increasing to 100-200mg 5
- Benefits include reduction in nocturnal eating and weight loss
Non-pharmacological interventions:
- Cognitive-behavioral therapy focused on eating patterns
- Phototherapy (light therapy) to help reset circadian rhythms 2
- Sleep hygiene education
- Stress management techniques
Treatment Algorithm for Sleep-Related Eating Disorder (SRED)
Address underlying sleep disorders:
- Treat comorbid conditions like restless leg syndrome, sleep apnea, or somnambulism 2
- Discontinue medications that may trigger episodes (especially sedative-hypnotics)
Pharmacotherapy options:
- Topiramate (starting at 25mg, increasing to effective dose) 5
- Dopaminergic agents for cases associated with restless leg syndrome
- Consider low-dose benzodiazepines in selected cases
Sleep hygiene measures:
- Regular sleep-wake schedule
- Safe sleeping environment to prevent injury during episodes
- Securing food access during nighttime hours
Monitoring and Follow-up
- Regular weight monitoring
- Food and sleep diaries to track progress
- Follow-up visits every 2-4 weeks initially, then monthly
- Laboratory monitoring as needed based on medication choice
Special Considerations
- For patients with obesity: Focus on both nocturnal eating control and weight management strategies 1
- For patients with comorbid psychiatric disorders: Address underlying mood or anxiety disorders concurrently 2
- For medication-induced SRED: Consider medication alternatives when possible
Treatment Challenges
- Limited high-quality evidence for treatments beyond case studies and small trials 6
- Underdiagnosis due to lack of awareness among clinicians 6
- Potential for relapse, requiring long-term management strategies
- Need to differentiate from other eating disorders for appropriate treatment
The treatment of nocturnal eating disorders remains challenging due to limited research, but a structured approach addressing both the eating behavior and underlying factors can lead to significant improvement in symptoms and quality of life.