May 26, 2016

Sleep Issues and Eating Disorders in Overweight Patients: Q&A with Ralph Carson, LD, RD, PhD

Q: How is sleep related to disordered eating in overweight patients?

Dr. Carson:
When deprived of sleep, the basic biological response is an increase in ghrelin (“I’m hungry” hormone), a decrease in leptin (”I’m full” hormone, patients feel unsatisfied even after a meal) and an increase in cortisol (stress hormone). People tend to eat more, eat impulsively, crave sugar and choose more calorie-dense food options; they lose muscle mass, their metabolism slows and they gain weight.

Sleep issues are especially prevalent in overweight patients struggling with bulimia nervosa (BN) and binge eating disorder (BED).  Binge eating is more likely to occur at night, and fatigue associated with sleeplessness triggers daytime grazing and overeating (“Food will give me energy so I won’t feel so tired”).

Considering these factors in tandem with the biological response to sleep deprivation, we can see more clearly how lower sleep efficiency and less time spent sleeping leads to the onset and perpetuation of disordered eating and weight concerns.

Unfortunately, the connection between sleep, disordered eating and weight is commonly overlooked in healthcare settings.  When a patient reports sleep disturbances (including difficulty falling asleep, sleep fragmentation, awakening during the night, early morning awakening, mid-sleep awakening and excessive daytime sleepiness), well-meaning healthcare professionals will often prescribe medication (trazedone, Ambien, Lunesta, etc.). This intervention does not help patients struggling with disordered eating because it doesn’t allow them to correct the underlying medical and behavioral issues causing sleep issues, overeating and weight concerns.

A recent Harvard study found that sleep hygiene (good sleep habits) is 40 percent more effective than medication in helping patients to sleep better and longer. Unacknowledged and untreated, sleep issues can challenge eating disorder recovery in even the most committed and well-intentioned patients.  Addressing sleep issues as part of the treatment process not only targets serious health consequences, but also eliminates the daytime fatigue that prevents patients from engaging meaningfully in the therapy, dietary education and skill building that fosters lasting eating disorder recovery.

Q: Which sleep disorders are most commonly associated with BN and BED?

Dr. Carson: Sleep-related eating disorders and night eating syndrome are hybrids of sleep and eating disorders that can interfere with balanced nutrition, cause embarrassment and result in depression and weight gain. Obstructive sleep apnea and delayed sleep phase syndrome are also sleep disorders associated with obese and overweight eating disorder patients.

Sleep-related eating disorders (SRED) — involve people eating while they are asleep, including walking into the kitchen and preparing food without a recollection for having done so. People suffering with SRED may consume different foods than they would favor during the daytime or even inedible foods during these episodes. Many of these individuals diet during the day, which might leave them hungry and vulnerable to binge eating at night when their control is weakened by sleep. In some cases, people with SRED have histories of alcoholism, drug abuse and other sleep disorders. SRED is more common among women, affecting up to three percent of the general population and as many as 15 percent of people with eating disorders.

Night eating syndrome (NES) — occurs when a person eats during the night with full awareness and is usually unable to fall asleep again unless he or she eats. A unique combination of insomnia, stress and disordered eating, NES is characterized by morning anorexia, whereby one is typically not hungry and consumes negligible amounts of food in the morning. Most people do not start eating until noon, experience reduced daytime hunger and have little success in their attempts at weight loss. Bingeing occurs at night when there is less light, as individuals tend to lose their inhibition toward eating because they are less self-aware. Evenings are marked by hyperphagia, with 50 percent or more of calories consumed after 6:00pm and 34 percent of total calories consumed between midnight and 4:00am. Most people with NES struggle with insomnia and have difficulty falling asleep and staying asleep, waking up an average of 3.5 times per night (52 percent of waking episodes are associated with food). There is a high incidence of depression (45 percent), particularly after 4:00pm. The pattern is for people to wake up feeling okay (perhaps a bit groggy), with depressed mood increasing as the day goes on in anticipation of another evening of bingeing and unsettling sleep. Approximately 28 percent of severely obese bariatric surgery candidates were evaluated as having NES prior to surgery (Rand, 1997), and 80 percent of those individuals continued to struggle with this condition after surgery (Adami, 1999), underscoring the elevated incidence of this pattern of disordered eating in people with overweight bodies.

Obstructive sleep apnea — affects the majority of overweight individuals. In this condition, the tissue in the back of the throat temporarily collapses, causing a brief episode of interrupted breathing resulting in a lack of blood oxygen, an increase in carbon dioxide and a rise in blood pressure. Eventually the sleeper awakens, gasps loudly for air and begins breathing again with little awareness of the interruption. These episodes can last from 10 to 60 seconds and can repeat hundreds of times during the night (60 or more times in an hour). People with obstructive sleep apnea have highly fragmented night sleep.  A lack of restorative sleep results in daytime sleepiness, disordered eating (the fatigued body believes it needs to eat for energy) as well as cognitive impairment (difficulty learning and focusing). Several health complications accompany this condition, including diabetes, high blood pressure, heart disease, increased mortality rate and increased likelihood of stroke. A study from the Woolcock Institute of Medical Research in Sydney, Australia found a two-fold increase in stroke risk among individuals with obstructive sleep apnea, while it is estimated that 87 percent of obese patients with Type II diabetes have undiagnosed sleep apnea.

Delayed sleep phase syndrome (DSPS) — is a circadian rhythm disorder in which a person’s sleep is delayed (shifted) by two or more hours beyond the socially acceptable or conventional bedtime. Individuals describe themselves as “night owls” and say they function best or are most alert during the evening or night hours. This delay in falling asleep provides extended opportunity for grazing, eating out of boredom and nighttime bingeing episodes.  As an example, rather than falling asleep at 10:00pm and waking at 6:30am, a binge eater with DSPS will fall asleep well after midnight and have great difficulty getting up in time for work or scheduled morning appointments. Given freedom to keep their delayed bed and wake times, individuals wake up unassisted, refreshed and without any problems with sleepiness.  However, this syndrome generally interferes with performance at work, school and family commitments, and insufficient sleep results in the daytime fatigue that encourages overeating and hormonal imbalance that contributes to weight gain. A key characteristic of DSPS is lengthy sleep-ins with awakening occurring late morning to midafternoon, especially on weekends.

Q: How can referring professionals identify sleep issues that may be contributing to disordered eating and weight concerns?

Dr. Carson: A good start is for healthcare providers to understand the essential connection among sleep, eating and weight. They should make a point to screen all people with overweight bodies for sleep disturbances as well as disordered eating, including a health physical and lab work. The following questions may be helpful in identifying sleep issues that may be contributing to disordered eating and weight concerns.
  • Do you have difficulty falling asleep, staying asleep or achieving restorative sleep?
  • Do you experience daytime sleepiness and fatigue associated with restless or fragmented sleep?
  • Do you find evidence of nighttime binges, or do you experience unexplained fullness in the morning?
  • Do you tend to eat most of your calories in the evening?
  • Do you ever feel the need to eat if you wake during the night?
  • Do you have trouble going to bed at a reasonable hour or consider yourself a “night owl”?
  • Do you struggle to wake up for work, school, family commitments or morning appointments?
  • Does a loved one report that you snore loudly with repeated periods interrupted breathing often followed by choking or gasping for air?
  • Have your attempts at weight loss been unsuccessful?
Q: How does ERC address sleep issues in treatment for patients struggling with overeating?

Dr. Carson:
Specific to patients with overweight bodies struggling with BN and BED, the Comprehensive Overeating Recovery program strongly emphasizes sleep issues in treatment. Program creator Julie Friedman, PhD and I both bring strong backgrounds in sleep, and the treatment team understands the importance of quality and duration of sleep in reducing eating disorder behaviors and stabilizing weight. The program provides a compassionate recovery community that understands and supports patients that are overweight, and offers solutions to eliminate emotional, medical and quality of life issues related to overeating. At the Residential level of care, patients are fully contained and supported 24 hours-per-day to interrupt behaviors related to nocturnal eating, practice sleep hygiene and foster longer and better sleep.  In some cases, sleep studies and medical interventions like a CPAP machine may be necessary to support effective sleep.

Help for binge eating disorder and compulsive overeating

ERC offers eating disorder treatment programs for people with overweight bodies. Patients in these programs are overweight or obese and also struggle with bulimia nervosa, binge eating disorder, compulsive overeating, night eating, emotional eating and/or stress eating. These programs offer intensive multidisciplinary treatment for adults, including medical, psychiatric, behavioral and nutritional care. It is not an obesity treatment program or a weight management program. Unlike traditional weight loss programs, we recognize that both behavioral and biological factors contribute to being overweight, and that many overweight or obese individuals have a co-occurring eating disorder. This program offers a comprehensive treatment solution to normalize eating patterns, stabilize medical comorbidities, control weight and improve quality of life issues.

Levels of Care
  • Residential Program: Offers total containment, making it impossible for patients to use behaviors. Around the clock supervision and medical support are valuable for patients with serious medical issues, fall risk, limited mobility, hygiene challenges and sleeping issues.
  • Partial Hospitalization Program: Offers up to 11 hours of daily treatment (including weekend programming), after which patients return home or to supported apartments near the treatment center to practice recovery skills independently.
  • Intensive Outpatient Program: Offers up to 12 hours of intensive weekly treatment without medical support (as patients generally see outpatient providers at this level of care). 
  • Interrupt/eliminate bad eating habits
  • Normalized eating behaviors
  • Improved ability to manage stress and anxiety
  • Improved emotional state
  • Improvements in weight-related medical issues
  • Improved activity level/movement
  • Improved sleep
  • Abstinence from addictive behaviors
  • Stabilized weight*

*Patients will typically lose 5 to 15 percent of their body weight in this program. While weight loss is not specific a goal of treatment, it is a likely outcome of eliminating compulsive behaviors and stabilizing medical comorbidities.

If you are overweight or obese and identify with any or all of the following statements, ERC can help.

I feel out of control around food.
I often eat until I feel uncomfortable or sick.
I use food as a comfort.
I feel addicted to food.
I have gained more than 15 lbs in the last 6 months.
I eat/snack mindlessly throughout the day or during the night.
I have weight-related medical issues (diabetes, high blood pressure, heart disease, sleep apnea, etc.).
I have been told to lose weight by my doctor, but I cannot lose weight.
I need to lose weight before having bariatric surgery or another medical procedure.
I have regained weight following bariatric surgery.     

Ralph Carson, LD, RD, PhD is a nationally recognized clinical nutritionist and exercise physiologist, and a member of ERC's leadership team.

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