ORIGINAL ARTICLE. Night eating syndrome in class II III obesity: metabolic and psychopathological features

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1 (2009) 33, & 2009 Macmillan Publishers Limited All rights reserved /09 $ ORIGINAL ARTICLE Night eating syndrome in class II III obesity: metabolic and psychopathological features S Calugi 1, R Dalle Grave 1 and G Marchesini 2 1 Department of Eating and Weight Disorder, Villa Garda Hospital, Garda (Vr), Italy and 2 Unit of Clinical Dietetics, Alma Mater University of Bologna, Policlinico S. Orsola, Bologna, Italy Objective: To investigate the relationship of metabolic disorders and psychological features with the night eating syndrome (NES) in individuals with moderate-to-severe obesity. Design: Cross-sectional observation. Subjects: A total of 266 consecutive participants with class II III obesity, entering an inpatient weight loss program. Measurements: Participants who reported consuming either a large amount of their caloric intake after the evening meal (roughly self-assessed as X25% of daily calories) or the presence of nocturnal feeding at the Night Eating Questionnaire (NEQ) (N ¼ 49) were interviewed by the Night Eating Syndrome History and Inventory (NESHI). Assessment also included the clinical/ biochemical parameters of the metabolic syndrome and several questionnaires of psychopathology. NES was diagnosed by NESHI criteria (evening hyperphagia (X25% of daily food intake after the evening meal) and/or waking at night to eat at least three times a week) in the last 3 months. Results: Twenty-seven participants (10.1%) met NESHI criteria. Differences were not observed between participants with and without NES as to age, body mass index (BMI), prevalence of metabolic syndrome, Binge Eating Scale and Body Shape Questionnaire. NES participants had significantly higher scores of Beck Depression Inventory (BDI) and Impact of Weight on Quality of Life (IWQOL). Among NES cases, the BDI score was indicative of moderate depression in 18.5% of cases and of severe depression in 44.4%. Logistic regression analysis, adjusted for confounders, identified the BDI score as the only variable significantly associated with the diagnosis of NES. Conclusion: Diagnosing NES does not help identify obese individuals with specific medical complications, but indicates more severe psychological distress and depression. (2009) 33, ; doi: /ijo ; published online 9 June 2009 Keywords: night eating; depression; binge eating; psychological distress; obesity treatment; eating disorders Introduction The night eating syndrome (NES), a candidate for a new eating disorder diagnostic entity, 1,2 has been frequently described in obese patients. 3 Its prevalence among obese patients seeking weight loss treatment in medical units ranges from 6 4 to 14%, 5 whereas in those admitted for bariatric surgery it ranges from 8 6 to 42%. 7 An even greater prevalence (from 51 to 64%) has been reported among patients with severe obesity refractory to treatments. 8,9 The co-occurrence of NES and obesity is also confirmed by the observation that obesity is present in 57.1% of participants with night eating and overweight in 28.6% of outpatient Correspondence: Professor G Marchesini, Unit of Clinical Dietetics, Alma Mater, University of Bologna, Policlinico S. Orsola, Via Massarenti, 9, Bologna I-40138, Italy. giulio.marchesini@unibo.it Received 24 February 2009; revised 28 April 2009; accepted 4 May 2009; published online 9 June 2009 psychiatric individuals with night eating. 10 However, the association between NES and obesity remains controversial and a few epidemiological studies found no relationships between the two conditions. 11,12 Also the association between NES and psychopathology has not been defined yet. A few studies in obese participants observed a positive association between NES, life stress, psychoneuroticism, 13 depression and low mood. 5,9,14 However, only few studies controlled the associations between NES and the psychological variables for binge eating. 15 A study comparing obese participants seeking treatment for weight loss with and without NES found that night eaters had higher depression and lower self-esteem, and that the association was not due to confounding effects of binge eating disorder. 5 Another study, after controlling NES and psychological variables for binge eating, reported that the differences in psychological functioning and quality of life between NES and non-nes in obese individuals were largely cancelled out. 15

2 900 Finally, the relationship between NES and the medical complications of obesity has been scarcely evaluated. A NES prevalence of 9.7% has been reported in diabetes, and participants with night eating symptoms were more likely to be obese, to have unsatisfactory metabolic control and two or more diabetes complications. 16 In obese persons with type 2 diabetes, NES was reported as more frequent than binge eating disorder (3.8 vs. 1.4%), 17 but no data are available on the relationship between NES and other features of the metabolic syndrome in obese participants. At present, the clinical utility of a NES diagnosis in obese individuals is challenged. In particular, it is not settled whether obese participants with NES have more psychological and physical problems than those with the same level of obesity without NES. This piece of information is fundamental in defining NES either as a distinctive eating disorder of clinical severity 3,18 or simply a variant of normal eating that promotes weight gain and obesity. 15 The aim of the study was to investigate the presence of the features of the metabolic syndrome and distinctive psychological characteristics in class II III obese individuals with NES in comparison with non-nes participants seeking treatment in a specialist medical unit. Methods Participants Two hundred and sixty-six individuals (195 females and 71 males) were consecutively admitted to the Department of Eating and Weight Disorder, Villa Garda Hospital, in the period between January and December 2007 for a cognitive behavior inpatient treatment of obesity. They were referred from all over Italy by general practitioners or by outpatients obesity specialists. Nearly all participants had failed less intensive treatment (e.g., outpatient treatment), had a body mass index (BMI) X35 kg m 2 and were in the age range years. Patients with active substance abuse, bulimia nervosa, major depression, schizophrenia and other psychotic disorders were not included in the study. At entry, they filled a package of self-administered questionnaires, and signed an informed consent to participate in clinical studies (including the NES study). The specific research on NES was reviewed and approved by the Institutional Review Board of the Department. Demographic, clinical and metabolic variables All evaluations took place on the first day of admission. Demographic and clinical variables, including family data and a detailed medical, diet and weight history, were obtained by physicians with a direct interview. The physical and laboratory assessment included anthropometry, blood pressure measurement and an evaluation of vascular risk factors. The presence of the metabolic syndrome was defined according to the modified Adult Panel Treatment-III proposal, as the co-occurrence of three or more of the following features: 19 waist circumference 488 cm for women or 4102 cm for men; fasting plasma glucose X100 mg 100 ml 1 (5.5 mmol l 1 ) or drug treatment for diabetes; blood pressure X135/85 mm Hg or treatment for hypertension; plasma triglycerides X150 mg 100 ml 1 (1.7 mmol l 1 ) or treatment for hypertriglyceridemia (with niacin or fibrates); and high density lipoprotein (HDL)-cholesterol p40 mg 100 ml 1 (1.03 mmol l 1 ) in men or p50 mg 100 ml 1 (1.3 mmol l 1 ) in women. NES diagnosis The diagnosis of NES wad generated by means of a two-stage assessment. The Night Eating Questionnaire (NEQ) was used as screening test. 20 Participants who reported consuming a large amount of their caloric intake after their evening meal (item 5), roughly estimated as X25% of daily calories or nocturnal food ingestion (waking after sleep onset to eatfitem 9) were interviewed by a clinical psychologist with the Night Eating Syndrome History and Inventory (NESHI). The NESHI is an unpublished semi-structured interview designed to confirm the diagnosis of NES. It assesses a typical 24-h food intake, including a recall of all meals and snacks, sleeping patterns, mood symptoms and life stressors, weight and diet history, and previous treatment strategies for NES. Based on the recall of all meals and snacks, the interviewer judged the exact caloric intake after the evening meal and how often nocturnal food intake occurred in the last 3 months. Participants were diagnosed as NES if they reported (1) evening hyperphagia (i.e., consuming X25% of total daily calories after dinner) and/or (2) nocturnal awakenings with ingestion of food X3 times per week in the last 3 months. These criteria are those suggested by Stunkard et al., 2 with the addition of the 3-month period criterion, more recently proposed, 21 to include only participants with persistent NES features. Insomnia and early morning hypophagia were not considered as additional diagnostic criteria. Psychosocial measures The participants also completed a battery of self-administered questionnaires for the assessment of binge eating (Binge Eating ScaleFBES), 22 body image dissatisfaction and concern about body shape (Body Shape QuestionnaireFBSQ), 23 depression (Beck Depression InventoryFBDI), 24 and obesity-specific quality of life (Impact of Weight on Quality of LifeFIWQOL). 25 BDI scores were categorized for descriptive presentation, with the following cut points: normal, 0 9; mild depressive symptoms, 10 15; moderate depressive symptoms, 16 22; and severe depressive symptoms, Statistical analyses Continuous variables were categorized as mean (s.d.) and categorical variables as frequency and percentage. In part of

3 the analysis, weight data (in kilograms) were transformed into BMI units to allow comparison between genders. The basal clinical characteristics of NES and non-nes cases were tested for differences using t-test or Mann Whitney U-test for continuous data (for normally or non-normally distributed data respectivelyfshapiro Wilk normality test) and w 2 -tests for categorical data. Logistic regression analysis tested the association between the presence/absence of NES and clinical and psychopathological variables (BSQ, BDI, IWQOL total scores and the presence of the metabolic syndrome), after controlling for gender and BMI. Further adjustment for BES total score was also tested. Results Forty-nine participants reported food intake exceeding 25% of their daily calories after the evening meal or waking after sleep onset to eat at NEQ, but only 27 participants (10.1% of the whole sample) met the criteria for NES at the more restrictive NESHI interview. The 22 participants who did not meet the diagnostic criteria were all excluded because they overestimated the amount of food intake after evening meal. NES cases (NESHI positive) in comparison with false positive NES cases (NEQ positive and NESHI negative) had significantly higher scores of NEQ (24.4±5.8 vs. 21.3±4.1, z ¼ 2.02, P ¼ 0.044), but no differences were found in the BDI, BSQ, BES and IWQ total scores. Table 1 presents the demographic and clinical data at baseline between participants with and without NES. No significant differences emerged between groups in age, education, parent status, BMI, BMI at age 20, maximum BMI, maximum expected 1-year BMI loss, previous weight loss attempts, prevalence of the metabolic syndrome and of its individual components. The psychopathological evaluation is reported in Table 2. The prevalence of binge eating and body image dissatisfaction was similar. NES participants had higher scores on NEQ, 901 Table 1 Demographic and clinical characteristics of participants with and without NES non-nes (N ¼ 239) NES (N ¼ 27) Test statistics and P-value Age (years) 50.4 (16.3) 53.8 (14.4) z ¼ 0.90, P ¼ Female gender* 176 (73.6) 19 (70.4) w 2 ¼ 0.13, P ¼ Education* None 3 (1.4) 1 (3.8) w 2 (senior high school vs. others) ¼ 0.37, P ¼ Elementary School 34 (15.7) 6 (23.1) Junior High School 54 (25.0) 7 (26.9) Senior High School 105 (48.6) 11 (42.3) Degree 20 (9.3) 1 (3.8) Marital status* Single 74 (33.8) 9 (33.3) w 2 (married vs. others) ¼ 0.04, P ¼ Married 118 (53.9) 14 (51.9) Separated/Divorced 7 (3.2) 2 (7.4) Widowed 20 (9.1) 2 (7.4) Current BMI (kg m 2 ) 42.7 (6.7) 44.4 (6.3) z ¼ 1.72, P ¼ BMI at age 20 (kg m 2 ) 26.5 (5.7) 26.3 (7.3) z ¼ 0.14, P ¼ Maximum BMI (kg m 2 ) 43.9 (8.8) 45.5 (7.5) z ¼ 0.05, P ¼ Previous maximum BMI loss (kg m 2 ) 7.7 (5.5) 7.2 (3.8) z ¼ 1.25, P ¼ Expected 1-year BMI loss o10 kg* 23 (9.9) 4 (14.8) w 2 ¼ 1.41, P ¼ kg* 131 (56.5) 14 (51.9) kg* 38 (16.4) 3 (11.1) X30 kg* 40 (17.2) 6 (22.2) Previous weight loss attempts* 210 (93.3) 24 (92.3) w 2 ¼ 0.04, P ¼ Parameters of the metabolic syndrome Waist circumference 4102cm for men or 488 cm for women* 239 (100) 27 (100) F Blood pressure X130/85 mm Hg or treated for hypertension* 48 (20.1) 7 (25.9) w 2 ¼ 0.50, P ¼ HDL-cholesterolo40 mg 100 ml 1 for men or o50 mg 100 ml 1 for women* 155 (64.9) 15 (55.6) w 2 ¼ 0.91, P ¼ Triglycerides X150 mg 100 ml 1 or treated for dyslipidemia* 88 (36.8) 12 (44.4) w 2 ¼ 0.60, P ¼ Fasting plasma glucose X100 mg 100 ml 1 or treated for diabetes* 97 (40.6) 12 (44.4) w 2 ¼ 0.15, P ¼ Metabolic syndrome (three or more criteria)* a 157 (65.7) 16 (59.3) w 2 ¼ 0.44, P ¼ Abbreviations: BMI, body mass index; NES, night eating syndrome and s.d., standard deviation. a Adult treatment panel-iii revised classification. 19 Mean (s.d.) or *number of cases (%).

4 902 Table 2 Psychological characteristics of obese persons with and without the Night Eating Syndrome (NES) (mean (s.d.)) non-nes (N ¼ 239) NES (N ¼ 27) Test statistics and P-value Night eating questionnaire 12.9 (5.2) 24.4 (5.8) z ¼ 7.24, Po0.001 Beck depression inventory 14.3 (9.6) 20.0 (11.0) z ¼ 2.74, P ¼ Body shape questionnaire 73.1 (33.5) 75.9 (35.2) z ¼ 1.20, P ¼ Binge eating scale 14.4 (9.8) 17.9 (12.7) t ¼ 1.39, P ¼ Impact of weight on quality of life (IWQOL) Total score (47.7) (46.5) z ¼ 2.33, P ¼ Health 33.5 (8.4) 37.7 (9.2) z ¼ 2.25, P ¼ Social interaction 20.4 (9.3) 22.2 (9.7) z ¼ 1.09, P ¼ Work 12.6 (6.6) 12.6 (5.8) t ¼ 0.01, P ¼ Mobility 30.9 (10.4) 36.4 (11.2) t ¼ 2.57, P ¼ Self-esteem 28.0 (9.3) 31.7 (9.4) z ¼ 1.90, P ¼ Sexual life 16.7 (7.0) 20.6 (6.6) z ¼ 2.48, P ¼ Activities of daily living 18.0 (6.7) 21.4 (7.4) z ¼ 2.03, P ¼ Comfort with food 30.2 (7.5) 33.6 (8.6) z ¼ 2.24, P ¼ Figure 1 Correlation between the total score of Beck Depression Inventory (BDI) and the score of the Night Eating Questionnaire (NEQ) in the whole population. It should be noted that night eating syndrome (NES) participants, as identified by the Night Eating Syndrome History and Inventory (NESHI) interview (closed circles), largely segregate in the area of higher Night Eating Questionnaire (NEQ) scores. The correlation is maintained in participants with and without a definite diagnosis of NES (NES cases, r ¼ 0.479, P ¼ 0.011; non- NES cases, r ¼ 0.356, Po0.001). controlling for BDI score, statistical differences were no longer present between individuals with and without NES on the total score and the subscale scores of IWQOL. Similar results were found comparing patients who met the criteria for NES at the NEQ and patients who did not meet the same criteria. In particular, NEQ positive patients showed significant higher scores of BDI (z ¼ 3.38, P ¼ 0.001), of IWQOL total score (z ¼ 3.16, P ¼ 0.002), as well as individual subscales of health (z ¼ 2.66, P ¼ 0.008), mobility (z ¼ 2.98, P ¼ 0.003), sexual life (z ¼ 2.63, P ¼ 0.009), activities of daily living (z ¼ 2.65, P ¼ 0.008) and self-esteem (z ¼ 2.27, P ¼ 0.023) than NEQ negative patients. No significant differences were found in BES, BSQ and scores of other IWQOL subscales and in the prevalence of the metabolic syndrome between the two groups. In logistic regression analysis, only the BDI total score was independently associated with the presence of NES, after controlling for BMI and gender (odds ratio (OR), 1.05; 95% confidence interval (CI): ). Data did not change after further adjustment for BES total score (odds ratio, 1.05; 95% confidence interval, ). BDI, total IWQOL, as well as five IWQOL subscales (health, mobility, sexual life, activities of daily living and comfort with food) than non-nes participants with similar obesity. A significant correlation was observed between BDI total score and NEQ (Figure 1), and the correlation was maintained in NES, as well as non-nes cases. Sixty-three percent of participants with NES and only 35% participants without NES had a BDI total score higher than the accepted cut-off of 17 (w 2 ¼ 7.97, P ¼ 0.005). In particular, according to the predefined BDI cut-offs, 18.5% of NES had moderate depressive symptoms and 44.4% had severe depressive symptoms. The BDI sensitivity to discriminate NES cases from non-nes individuals was 70%, whereas the specificity was 58%. After Discussion In this large convenient sample of individuals with class II III obesity seeking weight loss treatment at an inpatient medical unit, we could not detect any difference between participants diagnosed as NES and non-nes on the basis of NESHI criteria in metabolic complications and most psychological features, with the notable exception of depression. Our study sample was indeed a representative of the large population of participants with moderate-to-severe obesity referred to obesity clinics for weight loss treatment. They were characterized by a large prevalence of metabolic disorders, a long history of failures with weight loss

5 treatment, and only severe psychopathology was considered an exclusion criterion. A definite diagnosis of NES was present in 10% of participants. This prevalence is within the range found in obesity clinics as well as among morbidly obese candidates to bariatic surgery. 4 7,27 The different diagnostic criteria and the methods of assessment explain the wide range of prevalence reported across studies. 28 Although the diagnostic criteria for NES are not definitely settled, 21 the semistructured NESHI interview is an accepted tool, and may be the basis for comparison among different studies. 29 Our data confirm that a positive association is present between depressed mood and NES. 5,14,30 In our series depression was the only variable associated with the presence of NES, the association was not influenced by binge eating, and almost half of NES cases reported severe depressive symptoms. The significant differences in IWQOL total score between NES and non-nes participants disappeared after controlling for BDI score, suggesting that depression negatively influences the perceived IWQOL in NES participants. We found no differences in the prevalence of the metabolic syndrome and in its individual components between participants with and without NES. The prevalence of metabolic syndrome in the population, although high, was not so high to implicate a ceiling effect preventing any additional effect of NES. Data suggest that night eating per se does not have a role in metabolic complications, and that the high prevalence of metabolic syndrome is merely a reflection of the associated obesity. We also found no differences between the two samples in BMI, BMI at age 20 years, maximum BMI and previous weight loss attempts. These data indicate that night eating has a marginal role in the severity and in the history of obesity too. Also the expected weight loss at admission was similar, an original observation of a variable that has been reported to influence the drop-out rate in clinical settings. 31 Future longitudinal studies should investigate the exact role of depression in NES, and if depression is a risk factor, a consequence, a maintaining factor of night eating or if the abnormal pattern of eating is only a marker of clinical depression. In a cross-sectional study of participants with diabetes, participants with night-eating symptoms had higher BMI, a higher number of complications and were more likely to have unsatisfactory metabolic control, 16 suggesting that NES might contribute to adverse outcomes. This evidence does not hold true in our obese population, with a low prevalence of impaired fasting glucose or diabetes, where obesity per se is the leading metabolic defect, without BMI differences between participants with and without NES. The reported difference in the diabetes population might indeed stem from the higher BMI in NES-positive participants, 16 not directly from their disordered eating behavior. About 40% of NEQ-positive participants were false positive when tested by the direct NESHI interview. These data make a direct, detailed interview mandatory in the diagnosis of NES according to well-defined criteria. NEQ has a low specificity (high number of false positives), largely because of an overestimation by patients themselves of the amount of daily calories introduced after the evening meal. The study was not designed to test the specificity of the questionnaire (NEQ-negative participants were not interviewed), an important issue that needs to be addressed before proposing NEQ as first-step screening test in the diagnostic flow of NES, to limit the number of time-consuming interviews. The study has some limitations. First, its cross-sectional design does not provide any clue on NES history and its impact on future weight loss and depression. Second, our sample belonged to a well-characterized subgroup of participants with moderate-to-severe obesity admitted to a specialized inpatient unit serving as a third-level referral center, and the results might not apply to participants with less severe obesity. Third, the NES criteria adopted by our study, although widely adopted by NES researchers, have not yet received a general consensus. Our data have clinical implications. NES is a relatively common problem in morbidly obese individuals seeking treatment, but does not identify a cohort with specific somatic or psychological problems, with the notable exception of a higher depression rate. Obese participants with NES do not have a higher frequency of metabolic complication associated with obesity and therefore, do not require more intense medical treatment than those without NES. Longitudinal outcome data are needed to define whether these patients require specific strategies, complementary to the standard weight loss program, to treat NES as an additional symptom. In general, the high prevalence of depressive symptoms, the poorer perceived IWQOL, and the more disturbed eating pattern associated with NES, could be potential obstacles to weight loss. This idea is indirectly supported by the long history of unsuccessful weight loss attempts usually reported by night eaters. 32 The few available data indicate a potential beneficial effect of sertraline, 33 cognitive behavior therapy 34 and relaxation training, 35 but we still lack large randomized trials to evaluate the role of these procedures in the management of NES associated with morbid obesity. In general, the clinical utility of a NES diagnosis in obese patients seems mainly related to the identification of additional psychological distress and more severe depression, but this conclusion should be confirmed in longitudinal and intervention studies. Conflict of interest The authors declare no conflict of interest. References 1 Geliebter A. Night-eating syndrome in obesity. Nutrition 2001; 17:

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