The relationship between Night Eating Syndrome, depression and
chronotype in a non-clinical adolescent population

Night Eating Syndrome, depressione e cronotipo in un campione di adolescenti

GIULIA RICCOBONO1, ASSUNTA POMPILI1, ANGELA IANNITELLI1, FRANCESCA PACITTI1
E-mail: francesca.pacitti@cc.univaq.it

1Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, Italy


SUMMARY. Purpose. The aim of the current study was to assess the prevalence of Night Eating Syndrome (NES) in a population of non-clinical adolescents and to investigate the relationship between NES, depression and eveningness dimension. Methods. The data were collected from a sample of 301 subjects, 181 females and 120 males, aged between 15 and 19 (mean value 17.64, SD=1.3). All subjects were invited to answer demographic questions and to take a self-report battery composed by three questionnaires: the Night Eating Questionnaire (NEQ), the Morningness Eveningness Questionnaire (MEQ) and the Beck Depression Inventory (BDI). Results. The distribution of chronotypes in the sample was: morning type 9%, intermediate 68.4% and evening type 22.6%. 4% of the participants (12 subjects) reached the criteria for NES. The data indicate that MEQ and NEQ scores are significantly inversely correlated (r=-0.157; p<0.01); 58.3% of the participants who reached the criteria for NES received low scores on the MEQ. The BDI scores resulted significantly associated with the NEQ variable (r=0.275; p=0.001). Conclusions. This is the first study, as far as we are aware, which has investigated the relationship between chronotype, depression and NES in an adolescent non-clinical population. The findings of our study highlight the high prevalence of NES in the adolescent population and indicate a significant association between eveningness dimension, Depression and NES.

KEY WORDS: NES, Night eating, chronotype, eveningness.


RIASSUNTO. Introduzione. Lo scopo del presente studio è stato quello di valutare la prevalenza della Night Eating Syndrome (NES) in una popolazione non clinica di adolescenti e di indagare la relazione tra NES, depressione e cronotipo. Metodi. I dati sono stati raccolti all’interno di un campione di 301 soggetti, 181 femmine e 120 maschi, di età compresa tra i 15 e i 19 anni (valore medio 17,64, SD=1,3). Tutti i partecipanti hanno fornito informazioni demografiche e hanno effettuato una batteria di test self-report composta dai seguenti strumenti: il Night Eating Questionnaire (NEQ), il Morningness Eveningness Questionnaire (MEQ) e il Beck Depression Inventory (BDI). Risultati. All’interno del nostro campione, il 9% dei soggetti ha ottenuto alti punteggi al MEQ (che indicano un cronotipo mattutino), il 68,4% dei soggetti è, invece, risultato intermedio e il 22,6% aveva un cronotipo serotino. Il 4% dei partecipanti (12 soggetti) soddisfaceva i criteri per la diagnosi di NES. I dati indicano che i punteggi ottenuti al MEQ e al NEQ sono inversamente correlati in modo significativo (r=-,157; p<0,01); il 58,3% dei partecipanti che soddisfacevano i criteri per la diagnosi di NES aveva bassi punteggi al MEQ (che indicano un cronotipo serotino). Inoltre, i punteggi ottenuti al BDI sono risultati correlati con i punteggi NEQ (r=0,275; p=0,001). Conclusioni. Questo è il primo studio che ha indagato la relazione tra NES, cronotipo e depressione in una popolazione non clinica di adolescenti. I nostri risultati sottolineano l’alta prevalenza di NES tra gli adolescenti e indicano una correlazione tra NES, cronotipo serotino e depressione.

PAROLE CHIAVE. NES, cronotipo, serotino, alimentazione notturna.

INTRODUCTION
The Night Eating Syndrome (NES), included for the first time in the DSM-5 as a “Other Specified Feeding or Eating Disorder”, was originally described by Stunkard1 in a population of obese patients. The syndrome is characterized by morning anorexia, sleep maintenance insomnia2, a delayed circadian rhythm of food intake3 and/or nocturnal awakenings with ingestion of food4,5. Different studies suggested that patients with NES present depressed mood that worsens in the evening4,6,7, low self-esteem8,9, high levels of State and Trait Anxiety10, elevated perceived stress11-13 and impairment in the functioning. Recent researches14,15 revealed that patients with NES present abnormalities in melatonin, cortisol, leptin, ghrelin, insulin and glucose rhythms and increased TSH levels.
Several researches provided a strong evidence that identify NES and Binge Eating Disorder (BED) as two distinct clinical entities5, although findings indicate that BED and NES frequently co-occur16-21.
NES was originally associated with elevated Body Mass Index (BMI)1,22, but many researchers suggested that this association is clearer in the clinical samples than in the normal subjects23-25. Gallant26 in a longitudinal study among obese parents observed that NES symptoms severity doesn’t predict weight gain. Gluck et al.27 finding suggested that, in an obese sample, subjects with nocturnal ingestions of food gain more weight over 3.4 years than subjects without the night eating behavior (6.2 vs 1.7 kg). These studies suggested that night eating behavior may be implicated in the weight gain. A recent research28 indicated that age may play an important role in the relationship between NES and BMI. The findings revealed that there is no association in young subjects; on the other hand a strong correlation has been found between NES and BMI in subjects aged 55-60 years. These results are consistent with the hypothesis that night eating behavior may precede weight gain29. Several researches also suggested an association between Emotional Eating (EE) and NES25,30,31 and the results indicate that EE may play an important role as moderator in the relationship between NES and both BED and BMI32.
Chronotypes are one of the main interpersonal differences in the temporal organization of biological and behavioral rhythms33; they can be defined as the individual preference for activity and sleep during the early morning (morningness) or the later afternoon (eveningness)34-36. Morning type and evening type subjects differ in sleep-wake cycle timing, in the feeling after the awakening and in the peak performance times.
Several researches also reported main differences in personality traits between chronotypes; the morning-type subjects resulted more conscientious, well-organized, compliant and disciplined, while evening-types appeared more anxious, hostile, depressed, impulsive and vulnerable37-40.
Some researchers41-46 found an association between mood and chronotypes, e.g. evening type and depression; these findings suggest that eveningness could be considered a vulnerability factor to depression.
Different researches showed findings that indicate an association between the evening chronotype and unhealthy dietary habits and obesity47 and demonstrated that evening-type subjects have the tendency to skip breakfast more often compared to morning-types48. Several studies also revealed that subjects who prefer to wake up in the early morning tend to present more flexible diet control and greater ability to regulate their amount of food intake, compared to evening-types49. These findings suggest an association between the tendency to stay up late at night and the night eating49. The eveningness dimension was also associated with NES and BED in the clinical population50.
Recent researches51-53 revealed that Bright Light Therapy (BLT) is effective in the treatment of NES. Two case reports51,52 revealed that BLT is effective in the treatment of NES. A recent pilot trial53 showed promising results: in a sample of 15 adults the BLT improved night eating behavior, mood and sleep. These results were similar to the ones obtained with cognitive-behavioral therapy54 and SSRI, such as sertraline55. The effectiveness of BLT in the treatment of NES underlines the need of further systematic investigation of the relationship between NES, mood and circadian rhythms.
The aim of the current study was to investigate the relationship between NES, depression and chronotype in a sample of non-clinical adolescents. We hypothesized an association between evening type, depression and NES; we assumed that evening type subjects would reach higher scores on the Beck Depression Inventory (BDI) and on the Night Eating Questionnaire (NEQ), as other studies observed in the clinical population2.
METHODS
Participants
The data were collected from 301 students (F=181; M=120; aged 15-19) of two high schools in the district of Sassari (Italy). The subjects reported a mean height of 1.68, weight of 60.60 and BMI of 21.35.
Informed consent was obtained from the headmasters of all the schools, from the parents of the students who took part in the study, and from each student. The confidentiality of all the information provided was guaranteed.
Measures
All subjects were invited to answer demographic questions (sex, age, height, weight, education level) and to take a self-report battery composed by three questionnaires: the NEQ, the Morningness Eveningness Questionnaire (MEQ) and the Beck Depression Inventory (BDI). The BMI was calculated with the formula: weight (kg)/height (m)². The subjects were divided in three BMI categories: <18.5 (underweight); ≥18.5 to <24.9 (healthy); ≥25 to <29.9 (overweight).
The NEQ23 is the most widely used instrument to assess the night eating behavior. The Italian version of the NEQ was used to screen the subjects for NES. The NEQ is composed by 15 items assessing mood, insomnia, morning anorexia, food cravings, food intake after suppertime, nocturnal awakenings with ingestion of food, awareness and feelings of control during the eating episodes. The presence of NES was evaluated using the method introduced by Runfola24, focusing on the items that most closely match the DSM-5 criteria.
The MEQ56 was used to assess the chronotype. The Italian version of the MEQ is composed by 19 items assessing individual differences in the timing of the sleep-wake cycle, activities and in the performance peak. The questions are characterized by four possible answers. The subjects, according to their total score, are divided in three different categories: morning type (scores 59-86), intermediate type (score 42-58) and evening type (score 16-41).
The BDI57 is widely used to measure the severity of depressive symptoms. The scale is composed by 21 items, each one is characterized by four possible answers, that can be scored from 0 to 3. The score of 16 and above indicates the presence of moderate or severe depression.
Procedure
Descriptive statistics were used to examine the frequencies and percentages. Data are presented as mean±SD (standard deviation) for continuous variables and percent frequency for categorical variables. Student’s t-test and Pearson’s correlation (r) were used to analyze continuous dependent variables. Chi-square (χ2) was used for categorical data. Two-tailed p values <0.05, were required for statistical significance.
All the statistical analyses were performed with IBM SPSS Statistics for Windows, Version 20.0. (IBM Corp, Armonk, NY, USA).
RESULTS
The sample was composed by 301 subjects, 181 females and 120 males, aged between 15 and 19 (mean value 17.64, SD=1.3); the participants presented mean height of 1.68 (SD=0.89), weight of 60.60 (SD=11.9) and BMI of 21.35 (SD=3.35) (Table 1).
The distribution of chronotypes in the sample was: morning type 9%, intermediate 68.4% and evening type 22.6%. 4% of the participants (12 subjects) reached the criteria for NES.
The data indicate that MEQ and NEQ scores are significantly inversely correlated (r=-0.157; p=0.006). 58.3% of the participants who reached the criteria for NES, received low scores on the MEQ; the results highlight a significant association between evening type and NES.
The BDI scores resulted significantly associated with the NEQ variable (r=0.275; p=0.001) (Table 2).






DISCUSSION
The current study was the first one, as far as we are aware, that investigated the relationship between morningness/eveningness dimension, depression and NES in an adolescent non-clinical population. The main findings of this research indicate a significant association between eveningness dimension, depression and NES and night eating behavior resulted more often associated with an evening chronotype, compared to morning chronotype.
The prevalence of NES in our population of high school students was 4%, similar to the one observed in previous researches. Runfola et al.24 assessed the presence of NES in a population of university students, using a self-report measure, and found an incidence of 4%. Nolan and Geliebter25 assessed the presence of NES in college students with a survey and a semi-structured interview, the incidence found was 5.7%. Both studies used the same diagnostic criteria.
In our sample, according to prior studies24, the NEQ cutoff of 25 points failed to identify subjects who met the criteria for NES. Consistently with Runfola’s findings subjects with evening hyperphagia, in the absence of nocturnal ingestions, do not score above 25 on the NEQ. Thus, in our findings, the incidence using the NEQ cutoff of 25 was 3.4%.
The literature is not concordant about the correlation between evening-type and NES. Different researches suggested that subjects with NES present a significant circadian delay exclusively in their food intake; in fact the delay doesn’t affect the global functioning3,14,15. On the other hand other studies suggested an association between NES and circadian rhythm disruption11,14, specifically subjects with NES reported to consider themselves to function better in the late hours of the day. Consistently with this hypothesis our findings indicated an association between NES and eveningness dimension and suggest that eveningness dimension could be considered a risk factor for NES. Further researches and longitudinal studies are needed to determine the relationship between eveningness and NES.
Prior researches indicated that patients with NES reach higher scores on depression rating scales2,6,8,58,59; different studies reported the presence of night eating behavior in depressed patients60-62 and pointed out high lifetime prevalence of depression in subjects with NES11,63,64. Consistently with the literature data our findings suggest that increased symptoms of night eating behavior are significantly associated with increased depressive symptoms. The association between eveningness dimension, depressed mood and NES has some major clinical implications and explains the effectiveness of Bright Light Therapy (BLT) in the treatment of NES51-53. Therefore further researches are needed to investigate the relationship between eveningness dimension, depression and NES in the clinical population.
The current study has some limitations. The subjects who met the criteria for NES and depression were not clinically evaluated. The sample was composed primarily by high school students and the sample size was not large enough to be representative of the general Italian adolescent population; further researches and longitudinal studies are needed to investigate the relationship between age, eveningness and NES.

Conflict of interests: no conflict of interest exists for all the participating authors.
References
 1. Stunkard AJ, Grace WJ, and Wolff HG. The night-eating syndrome; a pattern of food intake among certain obese patients. Am J Med 1955; 19: 78-86.
 2. Rogers NL, Dinges DF, Allison KC, et al. Assessment of sleep in women with night eating syndrome. Sleep 2006; 29: 814-9.
 3. O’Reardon JP, Ringel BL, Dinges DF, et al. Circadian eating and sleeping patterns in the night eating syndrome. Obes Res 2004; 12: 1789-96.
 4. Birketvedt GS, Florholmen J, Sundsfjord J, et al. Behavioral and neuroendocrine characteristics of the night-eating syndrome. JAMA 1999; 282: 657-63.
 5. 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.
 6. Geliebter A, McOuatt H, Tetreault CB, et al. Is night eating syndrome associated with obstructive sleep apnea, BMI, and depressed mood in patients from a sleep laboratory study? Eat Behav 2016; 23: 115-9.
 7. Striegel-Moore RH, Franko DL, Thompson D, et al. Exploring the typology of night eating syndrome. Int J Eat Disord 2008; 41: 411-8.
 8. 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.
 9. Striegel-Moore RH, Rosselli F, Wilson GT, et al. Nocturnal eating: association with binge eating, obesity, and psychological distress. Int J Eat Disord 2010; 43: 520-6.
10. Pawlow LA, O’Neil PM, Malcolm RJ. Night eating syndrome: effects of brief relaxation training on stress, mood, hunger, and eating patterns. Int J Obes Relat Metab Disord 2003; 27: 970-8.
11. Lundgren JD, Allison KC, O’Reardon JP, Stunkard AJ. A descriptive study of non-obese persons with night eating syndrome and a weight-matched comparison group. Eat Behav 2008; 9: 343-51.
12. Caredda M, Roscioli C, Mistretta M, Pacitti F. [Stress vulnerability and night eating syndrome in the general population]. Riv Psichiatr 2009; 44: 45-54.
13. Pacitti F, Maraone A, Zazzara F, Biondi M, Caredda M. [Stress and night eating syndrome: a comparison study between a sample of psychiatric outpatients and healthy subjects]. Riv Psichiatr 2011; 46: 195-202.
14. Goel N, Stunkard AJ, Rogers NL, et al. Circadian rhythm profiles in women with night eating syndrome. J Biol Rhythms 2009; 24: 85-94.
15. Allison KC, Ahima RS, O’Reardon JP, et al. Neuroendocrine profiles associated with energy intake, sleep, and stress in the night eating syndrome. J Clin Endocrinol Metab 2005; 90: 6214-7.
16. Allison KC, Lundgren JD, O’Reardon JP, et al. Proposed diagnostic criteria for night eating syndrome. Int J Eat Disord 2010; 43: 241-7.
17. Allison KC, Crow SJ, Reeves RR, et al. Binge eating disorder and night eating syndrome in adults with type 2 diabetes. Obesity (Silver Spring) 2007; 15: 1287-93.
18. Allison KC, Wadden TA, Sarwer DB, et al. Night eating syndrome and binge eating disorder among persons seeking bariatric surgery: prevalence and related features. Obesity (Silver Spring) 2006; 14 Suppl 2: 77S-82S.
19. Allison KC, Grilo CM, Masheb RM, Stunkard AJ. High self-reported rates of neglect and emotional abuse, by persons with binge eating disorder and night eating syndrome. Behav Res Ther 2007; 45: 2874-83.
20. Lundgren JD, Allison KC, Stunkard AJ. Familial aggregation in the night eating syndrome. Int J Eat Disord 2006; 39: 516-8.
21. Colles SL, Dixon JB, O’Brien PE. Night eating syndrome and nocturnal snacking: association with obesity, binge eating and psychological distress. Int J Obes (Lond) 2007; 31: 1722-30.
22. 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.
23. Allison KC, Lundgren JD, O’Reardon JP, 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.
24. Runfola CD, Allison KC, Hardy KK, Lock J, Peebles R. Prevalence and clinical significance of night eating syndrome in university students. J Adolesc Health 2014; 55: 41-8.
25. Nolan LJ, Geliebter A. Night eating is associated with emotional and external eating in college students. Eat Behav 2012; 13: 202-6.
26. Gallant A, Lundgren J, O’Loughlin J, et al. Night-eating symptoms and 2-year weight change in parents enrolled in the QUALITY cohort. Int J Obes (Lond) 2015; 39: 1161-5.
27. Gluck ME, Venti CA, Salbe AD, Krakoff J. Nighttime eating: commonly observed and related to weight gain in an inpatient food intake study. Am J Clin Nutr 2008; 88: 900-5.
28. Meule A, Allison KC, Brahler E, de Zwaan M. The association between night eating and body mass depends on age. Eat Behav 2014; 15: 683-5.
29. Marshall HM, Allison KC, O’Reardon JP, Birketvedt G, Stunkard AJ. Night eating syndrome among nonobese persons. Int J Eat Disord 2004; 35: 217-22.
30. Nolan LJ, Geliebter A. “Food addiction” is associated with night eating severity. Appetite 2016; 98: 89-94.
31. Imperatori C, Fabbricatore M, Vumbaca V, et al. Food Addiction: definition, measurement and prevalence in healthy subjects and in patients with eating disorders. Riv Psichiatr 2016; 51: 60-5.
32. Meule A, Allison KC, Platte P. Emotional eating moderates the relationship of night eating with binge eating and body mass. Eur Eat Disord Rev 2014; 22: 147-51.
33. Van Dongen HP, Kerkhof GA, Souverijn JH. Absence of seasonal variation in the phase of the endogenous circadian rhythm in humans. Chronobiol Int 1998; 15: 623-32.
34. Natale V, Cicogna P. Morningness-eveningness dimension: is it really a continuum? Personality and Individual Differences 2002; 32: 809-16.
35. Bersani FS, Iannitelli A, Pacitti F, Bersani G. Sleep and biorythm disturbances in schizophrenia, mood and anxiety disorders: a review. Riv Psichiatr 2012; 47: 365-75.
36. Bersani G, Liberati D, Rasa A, et al. Premorbid sleep, appetite, energy, and cognitive circadian profile in patients with depressive disorders. Eur Psychiatry 2010; 25: 461-4.
37. Tonetti F, Natale. Relationship between circadian typology and big five personality domains. Chronobiol Int 2009 26; 2: 337-47.
38. Tonetti L, Adan A, Caci H, et al. Morningness-eveningness preference and sensation seeking. Eur Psychiatry 2010; 25: 111-5.
39. Lee S, Park JE, Cho SJ, et al. Association between morningness-eveningness and temperament and character in community-dwelling Korean adults. Asia Pac Psychiatry 2014; 6: 77-82.
40. Lee K, Lee HK, Jhung K, Park JY. Relationship between chronotype and temperament/character among university students. Psychiatry Res 2017; 251: 63-8.
41. Drennan MD, Klauber MR, Kripke DF, Goyette LM. The effects of depression and age on the Horne-Ostberg morningness-eveningness score. J Affect Disord 1991; 23: 93-8.
42. Danilenko KV, Putilov AA. Melatonin treatment of winter depression following total sleep deprivation: waking EEG and mood correlates. Neuropsychopharmacology 2005; 30: 1345-52.
43. Natale V, Adan A, Scapellato P. Are seasonality of mood and eveningness closely associated? Psychiatry Res 2005; 136: 51-60.
44. Hirata FC, Lima MC, de Bruin VM, Nóbrega PR, Wenceslau GP, de Bruin PF. Depression in medical school: the influence of morningness-eveningness. Chronobiol Int 2007; 24: 939-46.
45. Tirassa P, Iannitelli A, Sornelli F, et al. Daily serum and salivary BDNF levels correlate with morning-evening personality type in women and are affected by light therapy. Riv Psichiatr 2012; 47: 527-34.
46. Bersani G, Bersani FS, Prinzivalli E, et al. Premorbid circadian profile of patients with major depression and panic disorder. Riv Psichiatr 2012; 47: 407-12.
47. Ruiz-Lozano T, Vidal J, de Hollanda A, et al. Evening chronotype associates with obesity in severely obese subjects: interaction with CLOCK 3111T/C. Int J Obes (Lond) 2016; 40: 1550-7.
48. Sato-Mito N, Shibata S, Sasaki S, Sato K. Dietary intake is associated with human chronotype as assessed by both morningness-eveningness score and preferred midpoint of sleep in young Japanese women. Int J Food Sci Nutr 2011; 62: 525-32.
49. Fleig D, Randler C. Association between chronotype and diet in adolescents based on food logs. Eat Behav 2009; 10: 115-8.
50. Harb A, Levandovski R, Oliveira C, et al. Night eating patterns and chronotypes: a correlation with binge eating behaviors. Psychiatry Res 2012; 200: 489-93.
51. Friedman S, Even C, Dardennes R, Guelfi JD. Light therapy, obesity, and night-eating syndrome. Am J Psychiatry 2002; 159: 875-6.
52. Friedman S, Even C, Dardennes R, and Guelfi JD. Light therapy, nonseasonal depression, and night eating syndrome. Can J Psychiatry 2004; 49: 790.
53. McCune AM, Lundgren JD. Bright light therapy for the treatment of night eating syndrome: a pilot study. Psychiatry Res 2015; 229: 577-9.
54. Allison KC, Lundgren JD, Moore RH, O’Reardon JP, Stunkard AJ. Cognitive behavior therapy for night eating syndrome: a pilot study. Am J Psychother 2010; 64: 91-106.
55. O’Reardon JP, Allison KC, Martino NS, et al. A randomized, placebo-controlled trial of sertraline in the treatment of night eating syndrome. Am J Psychiatry 2006; 163: 893-8.
56. Horne JA, Ostberg O. A self-assessment questionnaire to determine morningness-eveningness in human circadian rhythms. Int J Chronobiol 1976; 4: 97-110.
57. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry 1961; 4: 561-71.
58. Nolan LJ, Geliebter A. Validation of the Night Eating Diagnostic Questionnaire (NEDQ) and its relationship with depression, sleep quality, “food addiction”, and body mass index. Appetite 2017; 111: 86-95.
59. de Zwaan M, Muller A, Allison KC, Brahler E, Hilbert A. Prevalence and correlates of night eating in the German general population. PLoS One 2014; 9: e97667.
60. Kucukgoncu S, Tek C, Bestepe E, Musket C, Guloksuz S. Clinical features of night eating syndrome among depressed patients. Eur Eat Disord Rev 2014; 22: 102-8.
61. Orhan FO, Ozer UG, Ozer A, et al. Night eating syndrome among patients with depression. Isr J Psychiatry Relat Sci 2011; 48: 212-7.
62. Cimbolli P, Quinones A, Ugarte C, De Pascale A. [Pilot study on nutritional and eating disorders in children and mood disorders: comorbidity or prodromal traits?]. Riv Psichiatr 2017; 52: 32-9.
63. de Zwaan M, Roerig DB, Crosby RD, Karaz S, Mitchell JE. Nighttime eating: a descriptive study. Int J Eat Disord 2006; 39: 224-32.
64. Striegel-Moore RH, Dohm FA, Hook JM, et al. Night eating syndrome in young adult women: prevalence and correlates. Int J Eat Disord 2005; 37: 200-6.