What is the treatment for nocturnal eating syndrome?

Treatment of Nocturnal Eating Syndrome

Cognitive-behavioral therapy (CBT) is the first-line treatment for night eating syndrome (NES), with sertraline (an SSRI) as an effective pharmacological option either initially or when psychotherapy alone provides insufficient response. 1, 2, 3, 4

Initial Assessment and Diagnosis

Before initiating treatment, confirm the diagnosis by identifying the core features that distinguish NES from other eating disorders:

• Evening hyperphagia (excessive food intake after the evening meal) and nocturnal ingestions (waking at night to eat with full awareness) 1, 2, 3
• Morning anorexia and insomnia with awakenings specifically for food intake 2, 4
• Absence of compensatory behaviors (distinguishing it from bulimia nervosa) and consumption of small snacks rather than true binges (distinguishing it from binge eating disorder) 4
• Full consciousness during eating episodes (distinguishing it from sleep-related eating disorder, which involves amnesia) 2, 4

The Night Eating Questionnaire can facilitate diagnosis in clinical settings 3.

Treatment Algorithm

First-Line: Behavioral and Psychological Interventions

Cognitive-behavioral therapy specifically adapted for NES should be the initial treatment approach, targeting the delayed circadian pattern of food intake and associated psychological factors 1, 3:

• Address evening hyperphagia patterns and nocturnal eating behaviors 1
• Target underlying mood disorders, anxiety, and stress that commonly accompany NES 5
• Modify maladaptive eating cognitions and behaviors 1, 3

Behavioral therapy can be used to restructure eating patterns and establish normal circadian meal timing 1, 2.

Phototherapy (light therapy) may help reset the delayed circadian rhythm of food intake, though evidence is still emerging 2, 3, 4.

Second-Line or Adjunctive: Pharmacotherapy

Sertraline (a selective serotonin reuptake inhibitor) is the most evidence-supported pharmacological treatment, aimed at increasing serotoninergic neurotransmission 2, 4:

• Consider sertraline when psychotherapy alone provides minimal response or when patients prefer medication 3, 4
• Other SSRIs may also be effective, though sertraline has the strongest evidence base 3, 4

Topiramate (an anticonvulsant) shows promise as an alternative pharmacological option 3, 4.

Melatonergic medications may be considered given the circadian rhythm disturbance underlying NES 3.

Combined Approach

A combination of psychotherapy and pharmacotherapy may be most effective, particularly for patients with concurrent psychiatric disorders (anxiety, depression) or those with severe symptoms 5.

Important Clinical Considerations

Comorbidities to Address

• Assess for concurrent eating disorders: NES frequently co-occurs with binge-eating disorder and bulimia nervosa 5
• Screen for psychiatric conditions: Depression, anxiety, and mood disorders are commonly associated with NES 3, 5
• Evaluate obesity status: NES prevalence increases with weight, and approximately half of patients report normal weight before syndrome onset 4

Common Pitfalls to Avoid

• Do not confuse NES with sleep-related eating disorder (SRED): SRED involves amnesia, consumption of non-typical or dangerous items, and is often associated with other sleep disorders (restless leg syndrome, sleep apnea, somnambulism) or medication-induced (e.g., zolpidem) 2
• Do not overlook the circadian component: NES represents a delay in circadian timing of food intake in patients with otherwise normal sleep-wake rhythms 2, 4
• Recognize that NES often goes undiagnosed: Health professionals frequently miss this diagnosis, leading to inadequate treatment 3

Treatment Individualization

Each case requires consideration of:

• Severity of nocturnal eating episodes 1
• Presence of comorbid psychiatric conditions 3, 5
• Patient preference for psychological versus pharmacological intervention 3
• Associated obesity and metabolic complications 4