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ScienceDirect Comprehensive Psychiatry 57 (2015) 79 – 84 www.elsevier.com/locate/comppsych
The prevalence and clinical features of the night eating syndrome in psychiatric out-patient population Özge Saraçlı a,⁎, Nuray Atasoy a , Asena Akdemir b , Olga Güriz c , Numan Konuk d , Güzin Mukaddes Sevinçer e , Handan Ankaralı f , Levent Atik a a
Department of Psychiatry, Bülent Ecevit University Faculty of Medicine, Zonguldak, Turkey b Department of Psychiatry, Selçuk University Faculty of Medicine, Konya, Turkey c Department of Psychiatry, Ankara Dışkapı Yıldırım Beyazıt Education and Research Hospital, Ankara, Turkey d Department of Psychiatry, İstanbul University Cerrahpaşa Faculty of Medicine, Istanbul, Turkey e İstanbul Gelişim University, Istanbul, Turkey f Department of Biostatistics, Düzce University Faculty of Medicine, Düzce, Turkey
Abstract Objective: In this study we aimed to investigate the prevalance and clinical correlations of night eating syndrome (NES) in a sample of psychiatric outpatients. Method: Four hundred thirthy three consecutive psychiatric out-patients older than 18 years were evaluated in the outpatient clinics using clinical interview according to the DSM-IV with regard to psychiatric diagnosis. Participants were also screened for presence of NES utilizing both clinical interview and self report based on Night Eating Questionnaire (NEQ) instruments. Sociodemographic and clinical features such as age, gender, education level, socioeconomic level and body mass index (BMI) were also recorded. The Body Shape Questionnaire (BSQ) and the Symptom Checklist-90 Revised (SCL-90R) were administered. Results: Based on the proposed diagnostic criteria of the NES via utilizing clinical interview method, 97 (32 male, 65 female) of the sample met diagnostic criteria for NES. The point prevalence of NES was 22.4%. No statistically significant differences were found between the two groups in terms of age, gender, marital status, education and BMI. The patients with NES had higher NEQ, BSQ and SCL-90R subscale scores than patients without NES. Prevalance of depressive disorder, impulse control disorder, and nicotine dependency was higher among patients with NES. No differences were found with regard to the medication (antipsychotics, antidepressants and mood stabilizers). Conclusion: Night eating syndrome is prevalent among psychiatric outpatients and associated with depression, impulse control disorder, and nicotine dependency. Body dissatisfaction and higher symptom severity are also other risk factors for the development of NES. © 2014 Elsevier Inc. All rights reserved.
1. Introductıon Night eating syndrome (NES) is a disorder of circadiandelayed food intake that behaviorally manifests as evening hyperphagia (EH) (the consumption of N25%
⁎ Corresponding author at: Bülent Ecevit Üniversitesi Psikiyatri A.D. esenköy/Kozlu/Zonguldak/Turkey. Tel.: +90 533 3450519. E-mail addresses: [email protected] (Ö. Saraçlı), [email protected] (N. Atasoy), [email protected] (A. Akdemir), [email protected] (N. Konuk), [email protected] (G.M. Sevinçer), [email protected] (H. Ankaralı), [email protected] (L. Atik). http://dx.doi.org/10.1016/j.comppsych.2014.11.007 0010-440X/© 2014 Elsevier Inc. All rights reserved.
of total daily food intake after the evening meal; EH) and/or nocturnal awakening and ingestion of food (NI) (N2/week; NI) with intact circadian sleep patterns [1]. The prevalence of NES has been reported to be 1–1.5% in the general population, 6–16% in patients in weight reduction programmes and 8–42% in candidates for bariatric surgery [2–4]. There are several factors related with NES such as; obesity, gender, medications, and presence of psychiatric disorders. There are few studies in the literature that have studied the presence of NES in psychiatric outpatients [5–9]. The frequencies of NES in psychiatric patients and methods of studies are shown in Table 1. Lundgren and colleagues found that 12.3% of psychiatric patients met criteria for NES
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Table 1 Studies of NES in psychiatric patients. Study sample
BMI (kg/m2, mean ± SD)
Frequency of NES based on a diagnostic interview
[5] Lundgren et al 2006
399 psychiatric out-patients
NESHI 12.3%
[6] Lundgren et al 2010
68 overweight and obese individuals with schizophrenia spectrum disorder or mood disorder and evidence of impaired functioning for at least 2 years 384 psychiatric out-patients
Subjects with NES 33.1/without NES 27.7; p b 0.001 37.2 ± 8 .1
[8] Cengiz et al 2011
[7] Orhan et al 2011
162 depressed patients and 172 healthy control participants
[9] Palmese et al 2012
100 overweight and obese outpatients with schizophrenia or schizoaffective disorder
25.7 ± 5.2; no difference in BMI was found between the NES with non-NES (p = 0.059) Depressed group 25.94 ± 4.93 control group 24.99 ± 4.72; p N .05 38.2 ± 7.7 No difference in BMI was found between the NES with non-NES
Frequency of NES with NEQ (cutoff 24/25)
– EH ≥25% and/or ≥3 NI/week 40.0% – EH ≥50% and/or ≥3 NI/week 25.0%
Mean NEQ score 19 ± 7.3
–
19.8%
35.2%
12%
25%
BMI: body mass ındex; NES: night eating syndrome; NEQ: Night Eating Questionnaire; EH: evening hyperphagia; NI: nocturnal ingestions; NESHI: Night Eating Syndrome History and Questionnaire (unpublished).
[5], a rate that is significantly higher than the prevalence of NES in the general population [2] and similar to the prevalence of NES among obese samples which is 6–16% [3]. Higher prevalence of major depressive disorder [7,10,11], anxiety disorders [11], schizophrenia [6,9] and substance use disorders [5] is noted among persons with NES compared with controls. There may be a reciprocal relationship between NES and psychopathology. Although NES was not formally included in previous versions of the DSM, for the first time, in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the proposed diagnostic criteria for NES were described under Feeding or Eating Disorders Not Elsewhere Classified [12]. There is not enough data on etiology of NES. New studies that investigate the phenomenology of NES in different populations will be useful for describing the risky groups especially in psychiatric population. The aim of the present study was to investigate the prevalence and clinical correlations of NES in a sample of psychiatric outpatients in the Turkish population to determine if the pattern of correlation is similar or different. 2. Methods 2.1. Participants Overall 1188 consecutive patients (777 female, 411 male) older than 18 years were evaluated in the outpatient clinics of the Department of Psychiatry in the Faculty of Medicine at Bülent Ecevit University in Turkey between 1 and 31 January 2011. Physician approval to participate indicated that participants could comprehend study materials, and they are diagnosed with a psychiatric disorder. Pregnant women, shift workers and individuals with severe, uncontrolled medical
illnesses were excluded. The study sample was composed of 433 psychiatric out-patients who met study criteria. 2.2. Ethical considerations The written informed consent was obtained from the patients before enrollment. This study was approved by the ethics committee of the Faculty of Medicine of Bülent Ecevit University. These data are the part of the The Night Eating Questionnaire (NEQ) reliability and validity study [13]. 2.3. Procedures The diagnosis of Axis I psychiatric disorders was made by routine clinical interview in accordance with the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. The interviews were conducted by an experienced psychiatrist at the outpatient center where the patients were being treated. The diagnosis of NES was made, relying on self report by same clinician in accordance with the proposed research diagnostic criteria for NES [1]. Participants were also screened based on Night Eating Questionnaire (NEQ). The demographic questionnaire obtained information about each participant's age, gender, marital status, education, occupation, monthly income, smoking status, subjective self assessment of body shape, medical illnesses and drugs that are used for treatment purposes. Height and body weight were measured by a psychiatrist. The height and weight were recorded while the participants were wearing light clothing with their shoes removed. Body mass ındex (BMI) was calculated as the weight in kilograms divided by the height in meters squared. Obesity was defined as a BMI of ≥30 kg/m 2. Participants with BMIs between 25 and 29.9 kg/m 2 were accepted as overweight, and participants with BMIs of less than 25 kg/m 2 were accepted as having normal weight.
Ö. Saraçlı et al. / Comprehensive Psychiatry 57 (2015) 79–84
2.4. Measures 2.4.1. The Night Eating Questionnaire (NEQ) Developed by Allison and colleagues [14], the Night Eating Questionnaire is designed as a Likert scale self-report measure to assess the presence and frequency of night eating behaviors. The primary behaviors evaluated by the NEQ are: evening hyperphagia, nocturnal awakenings with ingestion of food, morning anoreksia, initial insomnia, and mood disturbances. The Turkish version of NEQ has been demonstrated to be valid and reliable in the Turkish psychiatric population with a Cronbach's α = 0.69 [13]. 2.4.2. The Body Shape Questionnaire (BSQ) The BSQ is a 34-item self-report questionnaire that assesses body image and concerns about body shape. The participants have to respond to items regarding how they have felt about their body shape in the last few weeks, choosing among 6 degrees of severity. Higher scores reflect greater body dissatisfaction. The reliability and validity of BSQ for Turkish population were shown by Akdemir et al. as it is in its original version [15,16]. 2.4.3. The Symptom Checklist-90 Revised (SCL-90R) The SCL-90R is a well-established, self-report, clinical rating scale that assesses outpatient symptomatic psychological disturbance [17,18]. It comprises the following 9 primary symptom scales and one additional item: somatization, obsession–compulsion, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, psychoticism, and the additional item of eating and sleep disorder scale. 2.5. Statistical and data analyses For the comparison of continuous variables, Student's t-test was used. The values were presented as the mean ± the standard deviation (SD) and percentages. For comparison between the groups, the chi-square test and Fisher's exact test were used. The Pearson correlation was used to determine the significance of correlations between NEQ, BSQ, BMI, and SCL-90R scores. The odds ratios and the 95% confidence intervals (CIs) were calculated, and a p value of b0.05 was considered as statistically significant. Data were computerized with the use of the Statistical Packages for the Social Sciences software (SPSS v.15.0; SPSS Inc., Chicago, IL, USA).
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prevalence of NES, based on the total group of 433 participants, was 22.4%. In comparison, using data obtained from the selfreport measure the NEQ, 40% of the patients scored 18 and above; 19.4% scored 25 and above and 9.0% scored 30 and above. The average Night Eating Questionnaire (NEQ) score for the sample was 18.00 ± 7.7 points (out of 52 points). When the patients with NES (n = 97) were compared with those without NES (n = 336) with regard to age, gender, marital status, education, height, weight, and BMI; no statistically significant differences were found between the two groups (Table 2). The rate of patients with NES was not different on the basis of BMI classification (Table 2, p = 0.106). When the subjective self-perception of the patient's category of BMI was analyzed, 48% of the participants perceived their weight accurately, 40.4% of them underestimated, and 11.5% of them overestimated their category of BMI. BSQ mean score was significantly higher in overestimating group than accurate and underestimating groups (respectively p b 0.001 and p b 0.001). NEQ mean score was significantly higher in overestimating group than accurate (p = 0.028). Also NES diagnosis was more frequent in overestimating group than accurate and underestimating group (36.0, 19.7, and 21.7% respectively; p = 0.044). The patients with NES had higher NEQ, BSQ, and SCL-90R subscales scores than patients without NES (Table 2). The difference was statistically significant (p b 0.001). There was a positive correlation between NEQ and BSQ total score (r = 0.367, p b 0.001) when controlling for BMI; between BMI and BSQ total score (r = 0.302 p b 0.001); and between SCL-90 R general severity index score and BSQ (r = 0.428 p b 0.001) and NEQ total scores (r = 0.549 p b 0.001). Table 3 presents the rate of psychiatric diagnosis between groups (with NES vs. without NES). Intermittent explosive disorder (six patients), pathological gambling (five patients), and trichotillomania (three patients) were classified as impulse control disorder. Prevalence of depressive disorder and impulse control disorder were higher among patients with NES (p b 0.001). Prevalence of nicotine dependency was higher in those with NES as well (p = 0.004). Anxiety disorder was reported at higher rates among patients without NES (p b 0.001). No differences were found with regard to the medication used as antipsychotics, antidepressants and mood stabilizers (p N 0.05).
3. Results 4. Discussion Enrolled participants are on average 37.75 ± 12.02 years old, 70.7% of them (n = 306) are female; and 65.8% of them (n = 285) are married. Participants' BMI's ranged from 16.6 to 48.0 kg/m 2 (mean = 27.4 ± 5.4). The mean BMI for the sample was 27.4 ± 5.4. The demographic characteristics of the patients are presented in Table 2. Based on the proposed diagnostic criteria of the NES via utilizing clinical interview method, 97 (32 male, 65 female) of the sample met full diagnostic criteria for NES. The point
The present study investigated the prevalance and clinical correlations of NES in a sample of psychiatric outpatients. Within this population, based on a diagnostic interview, 22.4% met the criteria for NES. When we analyzed the frequencies of NES in psychiatric patients and methods of studies as shown in Table 1, compatible with the literature, the frequencies of NES with self-report of NEQ waeres higher than clinical diagnosis [9]. The difference between the
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Table 2 Demographic and clinical characteristics in participants with and without NES.
Age (year) (mean ± SD) Gender n (%)
Male Female
Education (year) (mean ± SD) Income (monthly) (mean ± SD) Marital status n (%) Single Married Divorced–widowed Height (mean ± SD) Weight (mean ± SD) BMI (mean ± SD) Normal (BMI b 25) n (%) Overweight (25–29.9) n (%) Obese (BMI N 30) n (%) Waist circumference (mean ± SD) Hip circumference (mean ± SD) NEQ (mean ± SD) BSQ (mean ± SD) SCL-90R General Severity Index (mean ± SD) Somatization Obsession–compulsion Interpersonal sensitivity Depression Anxiety Hostility Phobic anxiety Paranoid ideation Psychoticism Eating and sleep disorder
NES-positive individuals (n = 97)
NES-negative individuals (n = 336)
p
37.34 ± 11.2 32 (33%) 65 (67%) 7.88 ± 3.3 1164 ± 757 25 (25.8%) 59 (60.8%) 13 (13.4%) 1.65 ± 0.09 76.53 ± 15.8 28.1 ± 5.9 33 (34.4%) 26 (27.1%) 37 (38.5%) 92.0 ± 13.5 107.65 ± 11.9 27.4 ± 7.0 94.4 ± 43.5 1.8 ± 0.7 2.1 ± 1.0 1.9 ± 0.7 2.0 ± 0.9 1.9 ± 0.8 1.8 ± 0.9 1.7 ± 1.0 1.4 ± 0.9 1.8 ± 1.0 1.4 ± 0.9 1.8 ± 0.8
37.87 ± 12.3 95 (28.3%) 241 (71.7%) 8.21 ± 3.7 1339 ± 939 91 (27.1%) 226 (67.3%) 19 (5.7%) 1.64 ± 0.08 73.97 ± 16.1 27.3 ± 5.3 108 (32.2%) 130 (38.8%) 97 (29.0%) 91.4 ± 15.1 105.91 ± 11.1 15.2 ± 5.4 66.0 ± 32.2 1.1 ± 0.7 1.4 ± 0.9 1.3 ± 0.8 1.2 ± 0.8 1.3 ± 0.8 1.2 ± 0.8 1.1 ± 0.9 0.8 ± 0.7 1.1 ± 0.8 0.8 ± 0.7 1.1 ± 0.7
0.702⁎ 0.373⁎⁎ 0.420⁎ 0.146⁎ 0.054⁎⁎ 0.317⁎ 0.168⁎ 0.216⁎ 0.106⁎⁎ 0.734⁎ 0.186⁎ b0.001⁎ b0.001⁎ b0.001⁎ b0.001⁎ b0.001⁎ b0.001⁎ b0.001⁎ b0.001⁎ b0.001⁎ b0.001⁎ b0.001⁎ b0.001⁎ b0.001⁎
⁎ Student's t-test. ⁎⁎ The chi-square test.
studies may be related to the employment of different diagnostic criteria and methods. Palmese et al. speculate that major discrepancy between the interview and NEQ may be related to poor understanding and/or misinterpretation of some questions by some patients with schizophrenia [9]. Remarkably, the frequency of NES based on NEQ cutoff 25 and above found in this sample (19.4%) was identical to those previously recorded in a sample of psychiatric patients
by Cengiz et al. (19.8%) in Turkey [8]. But, our figure is higher than that of Lundgreen et al, who reported the prevalence as 12.3% among general psychiatric samples [5]. Another study of Ludgren et al. reported a NES rate of 40% when diagnosis was based on the proposed diagnostic criteria in patients with serious mental illnesses [6]. This difference may be due to the cultural factors or severity of psychiatric illness severity in the study sample. In our
Table 3 The psychiatric diagnoses among patients with or without NES.
Anxiety disorders⁎ Major depression⁎ Bipolar disorder Psychotic disorder Somatoform disorder Impulse control disorder⁎ Adjustment disorder Alcohol dependence Nicotine dependence⁎⁎ The chi-square test and Fisher's exact t est. ⁎ p b 0.001. ⁎⁎ p = 0.004.
NES-positive individuals (n = 97) n (%)
NES-negative individuals (n = 336) n (%)
Total (N = 433) n (%)
29 (29.9) 32 (33.0%) 14 (14.4) 7 (7.2) 1 (1.0) 7 (7.2) 4 (4.1) 3 (3.1) 46 (47.4%)
157 (46.7) 62 (18.5%) 43 (12.8) 40 (11.9) 16 (4.8) 7 (2.1) 7 (2.1) 4 (1.2) 105 (31.3%)
186 (43.0) 94 (21.7%) 57 (13.2) 47 (10.9) 17 (3.9) 14 (3.2) 11 (2.5) 7 (1.6) 151 (34.9%)
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sample, we did not assess severe psychiatric patients; but we found out that general severity index and also subscales scores were higher in NES positive patients. It is important to describe other risk factors that may affect the development of NES. Data regarding the relationship between gender and NES are limited. Some authors found NES prevalence to be comparable between genders [3,4,19]. On the other hand, three studies have reported male sex as a risk factor for NES [7,20,21]. We did not find any relationship between gender and NES in our study. The degree of BMI was also reported as a risk factor for NES in the literature. However, BMI was not different between the groups of our study sample. In the literature, it is frequently noted that obesity or higher BMI commonly correlates with NES in general population [2,3,19]. In the studies that have compared NES with non-NES in psychiatric participants, BMI was greater in the NES group in only one study [6]. Lundgren and colleagues reported that, although their sample was, on average, overweight (mean BMI = 29.1 kg/m 2), obese psychiatric patients (i.e. those with a BMI of ≥30 kg/m 2) were five times more likely to meet the criteria for NES compared to non-obese (i.e. those with a BMI of 18.5–25.9 kg/m 2) psychiatric patients [6]. BMI was not found to be significantly different between psychiatric participants with-NES and without-NES in the previous studies [6–8]. This result may be explained with the higher prevalance of BMI in psychiatric outpatients compared to the community sample. Future studies are needed to examine the prospective changes in weight among psychiatric outpatients with NES of all weight ranges. In the present study, we found that body dissatisfaction and night eating problems were higher in over-estimating group than others. In agreement with our findings, Lundgren et al. found that night eaters had higher concerns about dietary restraint, weight, body shape, and eating [22]. In contrast with the aforementioned studies, it was also reported that NES does not involve the same degree of overconcern with body weight or shape as BED [10]. There is a need for further studies on this issue. We found that there was a positive correlation between NEQ and BSQ total score (r = 0.367, p b 0.001) after controlling for BMI. In addition, there was a positive correlation between BMI and BSQ total score (r = 0.302 p b 0.001). This correlation shows that body dissatisfaction is an important feature of NES. We think that body dissatisfaction may affect eating behaviors in some ways but it is important to distinguish the origin of the higher BSQ score, which can stem from changing the eating pattern of the higher BMI or NEQ as mentioned in literature [23]. Another finding of our study that needed to be explained was the presence of comorbid psychiatric disorders within NES groups. We have found that depressive disorder (33 and 18.5%, p b 0.001) and impulse control disorders (7.2 and 2.1%, p b 0.001) were higher in patients with NES than without NES. Consistent with our study, depression rates in
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NES patients were higher and the symptoms and diagnosis of depression were generally more frequent among individuals with NES in the previous studies [10,19]. In a descriptive study of NES, de Zwaan and colleagues found that 56% of patients had a lifetime history of a major depressive disorder, which was higher than the rate seen among the healthy control group [11]. Orhan et al. found that the rates of NES in depression outpatients (35.2%) were higher when compared to the healthy control (19.2%) participants [7]. In another study from Turkey, in contrast to our study, Cengiz et al. found that there was no relationship between psychiatric disorders and NES. However, their study was undertaken in general psychiatric population [8]. Turkish culture leads to low rates of alcohol dependence, but high rates of nicotine dependence. We think that this cultural feature may have led fewer people to be diagnosed with alcohol use disorders in our study (n = 3, 4 respectively). However nicotine dependence was more frequent in the NES group (p = 0.004). On the contrary, Lundgren et al. found out that 30.6% of the patients with NES met criteria for a lifetime substance use disorder, compared with 8.3% of non-night eaters [5]. Considering the high percentage of impulse control disorder, and nicotine use in NES group, we think that these findings may indicate that presence of another risky behavior in addition to bad eating behavior may contribute to the development of NES. We could not find any literature that supports our finding. The prevalence of NES is high among those with psychiatric disorders [5,6], particularly in those with bulimia nervosa [24], sleep disorders [22] and schizophrenia [9]. We found no relationship between these psychiatric diagnosis and NES in our psychiatric outpatient sample. It is important to investigate the effects of medicines on NES. It was reported that patients with NES were more likely to be prescribed more than one atypical antipsychotic than patients without NES (38.8 vs. 30.8%, respectively) [5]. In our sample we found no relationship between the use of medicines (antipsychotics, antidepressants, mood stabilizers) and the presence of NES. We suggest that new studies that investigate especially the effect of atypical antipsychotics among NES groups are needed, and these studies should take the relation between these medications and higher body mass index into consideration. There are various limitations in our study. Absence of normal controls is an important limitation. Several other factors may explain the high prevalence of NES in this sample, including life stress, sleep disturbance, cultural issues. Pychiatric patients face daily life stressors including poor health, limited financial resources, and stigma which could increase the likelihood of nocturnal ingestions of food. We did not analyze these issues. The high prevalence, however, could also be due to the sample size. Future studies are needed to corroborate these findings in a larger population, to understand why this population is under an increased risk for NES, and to determine the effects of NES on health outcomes among psychiatric patients.
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References [1] Allison KC, Lundgren JD, O'Reardon JP, Geliebter A, Gluck ME, Vinai P, et al. Proposed diagnostic criteria for night eating syndrome. Int J Eat Disord 2010;43:241-7. [2] Rand CSW, Macgregor MD, Stunkard AJ. The night eating syndrome in the general population and among post-operative obesity surgery patients. Int J Eat Disord 1997;22:65-9. [3] Cerú-Björk C, Andersson I, Rössner S. Night eating and nocturnal eating-two different or similar syndromes among obese patients? Int J Obes Relat Metab Disord 2001;25:365-72. [4] Allison KC, Wadden TA, Sarwer DB, Fabricatore AN, Crerand C, Gibbons L, et al. Night eating syndrome and binge eating disorder among persons seeking bariatric surgery: prevalence and related features. Obesity 2006;14:77-82. [5] Lundgren JD, Allison KC, Crow S, O'Reardon JP, Berg KC, Galbraith J, et al. Prevalence of the night eating syndrome in a psychiatric population. Am J Psychiatry 2006;163:156-8. [6] Lundgren JD, Rempfer MV, Brown CE, Goetz J, Hamera E. The prevalence of night eating syndrome and binge eating disorder among overweight and obese individuals with serious mental illness. Psychiatry Res 2010;175:233-6. [7] Orhan FÖ, Özer UG, Özer A, Altunören Ö, Çelik M, Karaaslan MF. Night eating syndrome among patients with depression. Isr J Psychiatry Relat Sci 2011;48:212-7. [8] Cengiz Y, Toker SG, Karamustafalıoğlu KO, Bakım B, Özçelik B. Prevalence of night eating syndrome and comorbidity with other psychiatric disorders in psychiatric outpatient population. Yeni Symposium, 49; 2011. p. 83-8. [9] Palmese LB, Ratliff JC, Reutenauer EL, Tonizzo KM, Grilo CM, Tek C. Prevalence of night eating in obese individuals with schizophrenia and schizoaffective disorder. Compr Psychiatry 2013;54:276-81. [10] Allison KC, Grilo CM, Masheb RM, Stunkard AJ. Binge eating disorder and night eating syndrome: a comparative study of disordered eating. J Consult Clin Psychol 2005;73:1107-15. [11] De Zwaan M, Roerig D, Crosby R, Karaz S, Mitchell J. Nighttime eating: a descriptive study. Int J Eat Disord 2006;39:224-32.
[12] DSM-5 development [webpage on the Internet]. Arlington, VA: American Psychiatric Association; 2012 [Available from:, http://www. dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=26. Accessed February 7, 2013]. [13] Atasoy N, Saraçlı Ö, Konuk N, Ankaralı H, Güriz SO, Akdemir A, et al. The reliability and validity of Turkish version of The Night Eating Questionnaire in psychiatric outpatient population. Anatol J Psychiatry 2014;15:238-47. [14] Allison KC, Lundgren JD, O'Reardon JP, Martino NS, Sarwer DB, Wadden TA, et al. The Night Eating Questionnaire (NEQ): psychometric properties of a measure of severity of the night eating syndrome. Eat Behav 2008;9:62-72. [15] Akdemir A, Inandi T, Akbas D, Karaoglan Kahilogullari A, Eren M, Canpolat BI. Validity and reliability of a Turkish version of the body shape questionnaire among female high school students: preliminary examination. Eur Eat Disord Rev 2012;20:114-5. [16] Cooper PJ, Taylor MJ, Cooper Z, Fairburn CG. Development and validation of the body shape questionnaire. Int J Eat Disord 1987;6:485-94. [17] Derogatis LR. SCL-90: Administration, scoring and procedure manual-1 for the revised version. Baltimore, MD: John Hopkins Univ., School of Medicine, Clinical Psychometrics Unit; 1977. [18] Dağ I. Belirti Tarama Listesi (SCL-90R)’nin üniversite öğrencileri için güvenirliği ve geçerliği. Turk Psikiyatri Derg 1991;2:5-12. [19] Gluck ME, Geliebter A, Satov T. Night eating syndrome is associated with depression, low self-esteem, reduced daytime hunger, and less weight loss in obese outpatients. Obes Res 2001;9:264-7. [20] Grilo CM, Masheb RM. Night-time eating in men and women with binge eating disorder. Behav Res Ther 2004;42:397-407. [21] Aronoff NJ, Geliebter A, Zammit G. Gender and body mass index as related to the night-eating syndrome in obese outpatients. J Am Diet Assoc 2001;101:102-4. [22] Lundgren JD, Allison KC, O’Reardon JP, Stunkard AJ. A descriptive study of non-obese persons with night eating syndrome and a weightmatched comparison group. Eat Behav 2008;9:343-51. [23] Johnson F, Cooke L, Croker H, Wardle J. Changing perceptions of weight in Great Britain: comparison of two population surveys. BMJ 2008;337:a494 [10]. [24] Lundgren JD, Shapiro JR, Bulik CM. Night eating patterns of patients with bulimia nervosa: a preliminary report. Eat Weight Disord 2008;13:171-5.
ScienceDirect Comprehensive Psychiatry 57 (2015) 79 – 84 www.elsevier.com/locate/comppsych
The prevalence and clinical features of the night eating syndrome in psychiatric out-patient population Özge Saraçlı a,⁎, Nuray Atasoy a , Asena Akdemir b , Olga Güriz c , Numan Konuk d , Güzin Mukaddes Sevinçer e , Handan Ankaralı f , Levent Atik a a
Department of Psychiatry, Bülent Ecevit University Faculty of Medicine, Zonguldak, Turkey b Department of Psychiatry, Selçuk University Faculty of Medicine, Konya, Turkey c Department of Psychiatry, Ankara Dışkapı Yıldırım Beyazıt Education and Research Hospital, Ankara, Turkey d Department of Psychiatry, İstanbul University Cerrahpaşa Faculty of Medicine, Istanbul, Turkey e İstanbul Gelişim University, Istanbul, Turkey f Department of Biostatistics, Düzce University Faculty of Medicine, Düzce, Turkey
Abstract Objective: In this study we aimed to investigate the prevalance and clinical correlations of night eating syndrome (NES) in a sample of psychiatric outpatients. Method: Four hundred thirthy three consecutive psychiatric out-patients older than 18 years were evaluated in the outpatient clinics using clinical interview according to the DSM-IV with regard to psychiatric diagnosis. Participants were also screened for presence of NES utilizing both clinical interview and self report based on Night Eating Questionnaire (NEQ) instruments. Sociodemographic and clinical features such as age, gender, education level, socioeconomic level and body mass index (BMI) were also recorded. The Body Shape Questionnaire (BSQ) and the Symptom Checklist-90 Revised (SCL-90R) were administered. Results: Based on the proposed diagnostic criteria of the NES via utilizing clinical interview method, 97 (32 male, 65 female) of the sample met diagnostic criteria for NES. The point prevalence of NES was 22.4%. No statistically significant differences were found between the two groups in terms of age, gender, marital status, education and BMI. The patients with NES had higher NEQ, BSQ and SCL-90R subscale scores than patients without NES. Prevalance of depressive disorder, impulse control disorder, and nicotine dependency was higher among patients with NES. No differences were found with regard to the medication (antipsychotics, antidepressants and mood stabilizers). Conclusion: Night eating syndrome is prevalent among psychiatric outpatients and associated with depression, impulse control disorder, and nicotine dependency. Body dissatisfaction and higher symptom severity are also other risk factors for the development of NES. © 2014 Elsevier Inc. All rights reserved.
1. Introductıon Night eating syndrome (NES) is a disorder of circadiandelayed food intake that behaviorally manifests as evening hyperphagia (EH) (the consumption of N25%
⁎ Corresponding author at: Bülent Ecevit Üniversitesi Psikiyatri A.D. esenköy/Kozlu/Zonguldak/Turkey. Tel.: +90 533 3450519. E-mail addresses: [email protected] (Ö. Saraçlı), [email protected] (N. Atasoy), [email protected] (A. Akdemir), [email protected] (N. Konuk), [email protected] (G.M. Sevinçer), [email protected] (H. Ankaralı), [email protected] (L. Atik). http://dx.doi.org/10.1016/j.comppsych.2014.11.007 0010-440X/© 2014 Elsevier Inc. All rights reserved.
of total daily food intake after the evening meal; EH) and/or nocturnal awakening and ingestion of food (NI) (N2/week; NI) with intact circadian sleep patterns [1]. The prevalence of NES has been reported to be 1–1.5% in the general population, 6–16% in patients in weight reduction programmes and 8–42% in candidates for bariatric surgery [2–4]. There are several factors related with NES such as; obesity, gender, medications, and presence of psychiatric disorders. There are few studies in the literature that have studied the presence of NES in psychiatric outpatients [5–9]. The frequencies of NES in psychiatric patients and methods of studies are shown in Table 1. Lundgren and colleagues found that 12.3% of psychiatric patients met criteria for NES
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Table 1 Studies of NES in psychiatric patients. Study sample
BMI (kg/m2, mean ± SD)
Frequency of NES based on a diagnostic interview
[5] Lundgren et al 2006
399 psychiatric out-patients
NESHI 12.3%
[6] Lundgren et al 2010
68 overweight and obese individuals with schizophrenia spectrum disorder or mood disorder and evidence of impaired functioning for at least 2 years 384 psychiatric out-patients
Subjects with NES 33.1/without NES 27.7; p b 0.001 37.2 ± 8 .1
[8] Cengiz et al 2011
[7] Orhan et al 2011
162 depressed patients and 172 healthy control participants
[9] Palmese et al 2012
100 overweight and obese outpatients with schizophrenia or schizoaffective disorder
25.7 ± 5.2; no difference in BMI was found between the NES with non-NES (p = 0.059) Depressed group 25.94 ± 4.93 control group 24.99 ± 4.72; p N .05 38.2 ± 7.7 No difference in BMI was found between the NES with non-NES
Frequency of NES with NEQ (cutoff 24/25)
– EH ≥25% and/or ≥3 NI/week 40.0% – EH ≥50% and/or ≥3 NI/week 25.0%
Mean NEQ score 19 ± 7.3
–
19.8%
35.2%
12%
25%
BMI: body mass ındex; NES: night eating syndrome; NEQ: Night Eating Questionnaire; EH: evening hyperphagia; NI: nocturnal ingestions; NESHI: Night Eating Syndrome History and Questionnaire (unpublished).
[5], a rate that is significantly higher than the prevalence of NES in the general population [2] and similar to the prevalence of NES among obese samples which is 6–16% [3]. Higher prevalence of major depressive disorder [7,10,11], anxiety disorders [11], schizophrenia [6,9] and substance use disorders [5] is noted among persons with NES compared with controls. There may be a reciprocal relationship between NES and psychopathology. Although NES was not formally included in previous versions of the DSM, for the first time, in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the proposed diagnostic criteria for NES were described under Feeding or Eating Disorders Not Elsewhere Classified [12]. There is not enough data on etiology of NES. New studies that investigate the phenomenology of NES in different populations will be useful for describing the risky groups especially in psychiatric population. The aim of the present study was to investigate the prevalence and clinical correlations of NES in a sample of psychiatric outpatients in the Turkish population to determine if the pattern of correlation is similar or different. 2. Methods 2.1. Participants Overall 1188 consecutive patients (777 female, 411 male) older than 18 years were evaluated in the outpatient clinics of the Department of Psychiatry in the Faculty of Medicine at Bülent Ecevit University in Turkey between 1 and 31 January 2011. Physician approval to participate indicated that participants could comprehend study materials, and they are diagnosed with a psychiatric disorder. Pregnant women, shift workers and individuals with severe, uncontrolled medical
illnesses were excluded. The study sample was composed of 433 psychiatric out-patients who met study criteria. 2.2. Ethical considerations The written informed consent was obtained from the patients before enrollment. This study was approved by the ethics committee of the Faculty of Medicine of Bülent Ecevit University. These data are the part of the The Night Eating Questionnaire (NEQ) reliability and validity study [13]. 2.3. Procedures The diagnosis of Axis I psychiatric disorders was made by routine clinical interview in accordance with the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. The interviews were conducted by an experienced psychiatrist at the outpatient center where the patients were being treated. The diagnosis of NES was made, relying on self report by same clinician in accordance with the proposed research diagnostic criteria for NES [1]. Participants were also screened based on Night Eating Questionnaire (NEQ). The demographic questionnaire obtained information about each participant's age, gender, marital status, education, occupation, monthly income, smoking status, subjective self assessment of body shape, medical illnesses and drugs that are used for treatment purposes. Height and body weight were measured by a psychiatrist. The height and weight were recorded while the participants were wearing light clothing with their shoes removed. Body mass ındex (BMI) was calculated as the weight in kilograms divided by the height in meters squared. Obesity was defined as a BMI of ≥30 kg/m 2. Participants with BMIs between 25 and 29.9 kg/m 2 were accepted as overweight, and participants with BMIs of less than 25 kg/m 2 were accepted as having normal weight.
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2.4. Measures 2.4.1. The Night Eating Questionnaire (NEQ) Developed by Allison and colleagues [14], the Night Eating Questionnaire is designed as a Likert scale self-report measure to assess the presence and frequency of night eating behaviors. The primary behaviors evaluated by the NEQ are: evening hyperphagia, nocturnal awakenings with ingestion of food, morning anoreksia, initial insomnia, and mood disturbances. The Turkish version of NEQ has been demonstrated to be valid and reliable in the Turkish psychiatric population with a Cronbach's α = 0.69 [13]. 2.4.2. The Body Shape Questionnaire (BSQ) The BSQ is a 34-item self-report questionnaire that assesses body image and concerns about body shape. The participants have to respond to items regarding how they have felt about their body shape in the last few weeks, choosing among 6 degrees of severity. Higher scores reflect greater body dissatisfaction. The reliability and validity of BSQ for Turkish population were shown by Akdemir et al. as it is in its original version [15,16]. 2.4.3. The Symptom Checklist-90 Revised (SCL-90R) The SCL-90R is a well-established, self-report, clinical rating scale that assesses outpatient symptomatic psychological disturbance [17,18]. It comprises the following 9 primary symptom scales and one additional item: somatization, obsession–compulsion, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, psychoticism, and the additional item of eating and sleep disorder scale. 2.5. Statistical and data analyses For the comparison of continuous variables, Student's t-test was used. The values were presented as the mean ± the standard deviation (SD) and percentages. For comparison between the groups, the chi-square test and Fisher's exact test were used. The Pearson correlation was used to determine the significance of correlations between NEQ, BSQ, BMI, and SCL-90R scores. The odds ratios and the 95% confidence intervals (CIs) were calculated, and a p value of b0.05 was considered as statistically significant. Data were computerized with the use of the Statistical Packages for the Social Sciences software (SPSS v.15.0; SPSS Inc., Chicago, IL, USA).
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prevalence of NES, based on the total group of 433 participants, was 22.4%. In comparison, using data obtained from the selfreport measure the NEQ, 40% of the patients scored 18 and above; 19.4% scored 25 and above and 9.0% scored 30 and above. The average Night Eating Questionnaire (NEQ) score for the sample was 18.00 ± 7.7 points (out of 52 points). When the patients with NES (n = 97) were compared with those without NES (n = 336) with regard to age, gender, marital status, education, height, weight, and BMI; no statistically significant differences were found between the two groups (Table 2). The rate of patients with NES was not different on the basis of BMI classification (Table 2, p = 0.106). When the subjective self-perception of the patient's category of BMI was analyzed, 48% of the participants perceived their weight accurately, 40.4% of them underestimated, and 11.5% of them overestimated their category of BMI. BSQ mean score was significantly higher in overestimating group than accurate and underestimating groups (respectively p b 0.001 and p b 0.001). NEQ mean score was significantly higher in overestimating group than accurate (p = 0.028). Also NES diagnosis was more frequent in overestimating group than accurate and underestimating group (36.0, 19.7, and 21.7% respectively; p = 0.044). The patients with NES had higher NEQ, BSQ, and SCL-90R subscales scores than patients without NES (Table 2). The difference was statistically significant (p b 0.001). There was a positive correlation between NEQ and BSQ total score (r = 0.367, p b 0.001) when controlling for BMI; between BMI and BSQ total score (r = 0.302 p b 0.001); and between SCL-90 R general severity index score and BSQ (r = 0.428 p b 0.001) and NEQ total scores (r = 0.549 p b 0.001). Table 3 presents the rate of psychiatric diagnosis between groups (with NES vs. without NES). Intermittent explosive disorder (six patients), pathological gambling (five patients), and trichotillomania (three patients) were classified as impulse control disorder. Prevalence of depressive disorder and impulse control disorder were higher among patients with NES (p b 0.001). Prevalence of nicotine dependency was higher in those with NES as well (p = 0.004). Anxiety disorder was reported at higher rates among patients without NES (p b 0.001). No differences were found with regard to the medication used as antipsychotics, antidepressants and mood stabilizers (p N 0.05).
3. Results 4. Discussion Enrolled participants are on average 37.75 ± 12.02 years old, 70.7% of them (n = 306) are female; and 65.8% of them (n = 285) are married. Participants' BMI's ranged from 16.6 to 48.0 kg/m 2 (mean = 27.4 ± 5.4). The mean BMI for the sample was 27.4 ± 5.4. The demographic characteristics of the patients are presented in Table 2. Based on the proposed diagnostic criteria of the NES via utilizing clinical interview method, 97 (32 male, 65 female) of the sample met full diagnostic criteria for NES. The point
The present study investigated the prevalance and clinical correlations of NES in a sample of psychiatric outpatients. Within this population, based on a diagnostic interview, 22.4% met the criteria for NES. When we analyzed the frequencies of NES in psychiatric patients and methods of studies as shown in Table 1, compatible with the literature, the frequencies of NES with self-report of NEQ waeres higher than clinical diagnosis [9]. The difference between the
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Table 2 Demographic and clinical characteristics in participants with and without NES.
Age (year) (mean ± SD) Gender n (%)
Male Female
Education (year) (mean ± SD) Income (monthly) (mean ± SD) Marital status n (%) Single Married Divorced–widowed Height (mean ± SD) Weight (mean ± SD) BMI (mean ± SD) Normal (BMI b 25) n (%) Overweight (25–29.9) n (%) Obese (BMI N 30) n (%) Waist circumference (mean ± SD) Hip circumference (mean ± SD) NEQ (mean ± SD) BSQ (mean ± SD) SCL-90R General Severity Index (mean ± SD) Somatization Obsession–compulsion Interpersonal sensitivity Depression Anxiety Hostility Phobic anxiety Paranoid ideation Psychoticism Eating and sleep disorder
NES-positive individuals (n = 97)
NES-negative individuals (n = 336)
p
37.34 ± 11.2 32 (33%) 65 (67%) 7.88 ± 3.3 1164 ± 757 25 (25.8%) 59 (60.8%) 13 (13.4%) 1.65 ± 0.09 76.53 ± 15.8 28.1 ± 5.9 33 (34.4%) 26 (27.1%) 37 (38.5%) 92.0 ± 13.5 107.65 ± 11.9 27.4 ± 7.0 94.4 ± 43.5 1.8 ± 0.7 2.1 ± 1.0 1.9 ± 0.7 2.0 ± 0.9 1.9 ± 0.8 1.8 ± 0.9 1.7 ± 1.0 1.4 ± 0.9 1.8 ± 1.0 1.4 ± 0.9 1.8 ± 0.8
37.87 ± 12.3 95 (28.3%) 241 (71.7%) 8.21 ± 3.7 1339 ± 939 91 (27.1%) 226 (67.3%) 19 (5.7%) 1.64 ± 0.08 73.97 ± 16.1 27.3 ± 5.3 108 (32.2%) 130 (38.8%) 97 (29.0%) 91.4 ± 15.1 105.91 ± 11.1 15.2 ± 5.4 66.0 ± 32.2 1.1 ± 0.7 1.4 ± 0.9 1.3 ± 0.8 1.2 ± 0.8 1.3 ± 0.8 1.2 ± 0.8 1.1 ± 0.9 0.8 ± 0.7 1.1 ± 0.8 0.8 ± 0.7 1.1 ± 0.7
0.702⁎ 0.373⁎⁎ 0.420⁎ 0.146⁎ 0.054⁎⁎ 0.317⁎ 0.168⁎ 0.216⁎ 0.106⁎⁎ 0.734⁎ 0.186⁎ b0.001⁎ b0.001⁎ b0.001⁎ b0.001⁎ b0.001⁎ b0.001⁎ b0.001⁎ b0.001⁎ b0.001⁎ b0.001⁎ b0.001⁎ b0.001⁎ b0.001⁎
⁎ Student's t-test. ⁎⁎ The chi-square test.
studies may be related to the employment of different diagnostic criteria and methods. Palmese et al. speculate that major discrepancy between the interview and NEQ may be related to poor understanding and/or misinterpretation of some questions by some patients with schizophrenia [9]. Remarkably, the frequency of NES based on NEQ cutoff 25 and above found in this sample (19.4%) was identical to those previously recorded in a sample of psychiatric patients
by Cengiz et al. (19.8%) in Turkey [8]. But, our figure is higher than that of Lundgreen et al, who reported the prevalence as 12.3% among general psychiatric samples [5]. Another study of Ludgren et al. reported a NES rate of 40% when diagnosis was based on the proposed diagnostic criteria in patients with serious mental illnesses [6]. This difference may be due to the cultural factors or severity of psychiatric illness severity in the study sample. In our
Table 3 The psychiatric diagnoses among patients with or without NES.
Anxiety disorders⁎ Major depression⁎ Bipolar disorder Psychotic disorder Somatoform disorder Impulse control disorder⁎ Adjustment disorder Alcohol dependence Nicotine dependence⁎⁎ The chi-square test and Fisher's exact t est. ⁎ p b 0.001. ⁎⁎ p = 0.004.
NES-positive individuals (n = 97) n (%)
NES-negative individuals (n = 336) n (%)
Total (N = 433) n (%)
29 (29.9) 32 (33.0%) 14 (14.4) 7 (7.2) 1 (1.0) 7 (7.2) 4 (4.1) 3 (3.1) 46 (47.4%)
157 (46.7) 62 (18.5%) 43 (12.8) 40 (11.9) 16 (4.8) 7 (2.1) 7 (2.1) 4 (1.2) 105 (31.3%)
186 (43.0) 94 (21.7%) 57 (13.2) 47 (10.9) 17 (3.9) 14 (3.2) 11 (2.5) 7 (1.6) 151 (34.9%)
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sample, we did not assess severe psychiatric patients; but we found out that general severity index and also subscales scores were higher in NES positive patients. It is important to describe other risk factors that may affect the development of NES. Data regarding the relationship between gender and NES are limited. Some authors found NES prevalence to be comparable between genders [3,4,19]. On the other hand, three studies have reported male sex as a risk factor for NES [7,20,21]. We did not find any relationship between gender and NES in our study. The degree of BMI was also reported as a risk factor for NES in the literature. However, BMI was not different between the groups of our study sample. In the literature, it is frequently noted that obesity or higher BMI commonly correlates with NES in general population [2,3,19]. In the studies that have compared NES with non-NES in psychiatric participants, BMI was greater in the NES group in only one study [6]. Lundgren and colleagues reported that, although their sample was, on average, overweight (mean BMI = 29.1 kg/m 2), obese psychiatric patients (i.e. those with a BMI of ≥30 kg/m 2) were five times more likely to meet the criteria for NES compared to non-obese (i.e. those with a BMI of 18.5–25.9 kg/m 2) psychiatric patients [6]. BMI was not found to be significantly different between psychiatric participants with-NES and without-NES in the previous studies [6–8]. This result may be explained with the higher prevalance of BMI in psychiatric outpatients compared to the community sample. Future studies are needed to examine the prospective changes in weight among psychiatric outpatients with NES of all weight ranges. In the present study, we found that body dissatisfaction and night eating problems were higher in over-estimating group than others. In agreement with our findings, Lundgren et al. found that night eaters had higher concerns about dietary restraint, weight, body shape, and eating [22]. In contrast with the aforementioned studies, it was also reported that NES does not involve the same degree of overconcern with body weight or shape as BED [10]. There is a need for further studies on this issue. We found that there was a positive correlation between NEQ and BSQ total score (r = 0.367, p b 0.001) after controlling for BMI. In addition, there was a positive correlation between BMI and BSQ total score (r = 0.302 p b 0.001). This correlation shows that body dissatisfaction is an important feature of NES. We think that body dissatisfaction may affect eating behaviors in some ways but it is important to distinguish the origin of the higher BSQ score, which can stem from changing the eating pattern of the higher BMI or NEQ as mentioned in literature [23]. Another finding of our study that needed to be explained was the presence of comorbid psychiatric disorders within NES groups. We have found that depressive disorder (33 and 18.5%, p b 0.001) and impulse control disorders (7.2 and 2.1%, p b 0.001) were higher in patients with NES than without NES. Consistent with our study, depression rates in
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NES patients were higher and the symptoms and diagnosis of depression were generally more frequent among individuals with NES in the previous studies [10,19]. In a descriptive study of NES, de Zwaan and colleagues found that 56% of patients had a lifetime history of a major depressive disorder, which was higher than the rate seen among the healthy control group [11]. Orhan et al. found that the rates of NES in depression outpatients (35.2%) were higher when compared to the healthy control (19.2%) participants [7]. In another study from Turkey, in contrast to our study, Cengiz et al. found that there was no relationship between psychiatric disorders and NES. However, their study was undertaken in general psychiatric population [8]. Turkish culture leads to low rates of alcohol dependence, but high rates of nicotine dependence. We think that this cultural feature may have led fewer people to be diagnosed with alcohol use disorders in our study (n = 3, 4 respectively). However nicotine dependence was more frequent in the NES group (p = 0.004). On the contrary, Lundgren et al. found out that 30.6% of the patients with NES met criteria for a lifetime substance use disorder, compared with 8.3% of non-night eaters [5]. Considering the high percentage of impulse control disorder, and nicotine use in NES group, we think that these findings may indicate that presence of another risky behavior in addition to bad eating behavior may contribute to the development of NES. We could not find any literature that supports our finding. The prevalence of NES is high among those with psychiatric disorders [5,6], particularly in those with bulimia nervosa [24], sleep disorders [22] and schizophrenia [9]. We found no relationship between these psychiatric diagnosis and NES in our psychiatric outpatient sample. It is important to investigate the effects of medicines on NES. It was reported that patients with NES were more likely to be prescribed more than one atypical antipsychotic than patients without NES (38.8 vs. 30.8%, respectively) [5]. In our sample we found no relationship between the use of medicines (antipsychotics, antidepressants, mood stabilizers) and the presence of NES. We suggest that new studies that investigate especially the effect of atypical antipsychotics among NES groups are needed, and these studies should take the relation between these medications and higher body mass index into consideration. There are various limitations in our study. Absence of normal controls is an important limitation. Several other factors may explain the high prevalence of NES in this sample, including life stress, sleep disturbance, cultural issues. Pychiatric patients face daily life stressors including poor health, limited financial resources, and stigma which could increase the likelihood of nocturnal ingestions of food. We did not analyze these issues. The high prevalence, however, could also be due to the sample size. Future studies are needed to corroborate these findings in a larger population, to understand why this population is under an increased risk for NES, and to determine the effects of NES on health outcomes among psychiatric patients.
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