Comments by Allan Geliebter, August, 2019

Albert J. “Mickey” Stunkard, who passed away in 2014, had a major impact on my research career. He conducted pioneering studies of two obesity-related eating disorders: night eating syndrome (NES) in 1955 [1] and binge eating disorder (BED) in 1959 [2]. His enthusiasm for these two disorders was contagious, and I have been studying them for much of my career.

While identifying NES and BED, Stunkard was careful to note that most individuals with obesity have little or no psychopathology, which he later documented with Tom Wadden [3]. Nevertheless, he observed that both disorders were much more common among those with obesity, and that the two disorders could be factors in the etiology of obesity [4]. BED became recognized as a full-fledged eating disorder by the American Psychiatric Association in the DSM-5 in 2013 [5], and NES became listed as an Otherwise Specified Feeding and Eating Disorder [5]. Stunkard wisely rejected the idea that obesity was itself an eating disorder or the result of a single disorder, given the different features of NES and BED [2][4][5][6].

In the representative classic paper I chose [1], Stunkard describes the night eating syndrome (NES) based on clinical observations of patients with severe obesity referred to him at a specialized obesity clinic he set up while at New York Hospital-Cornell Medical Center. Although others had previously noted the NES pattern, they did not describe it in detail or classify it as a distinct eating disorder. Trained as a psychoanalyst, Stunkard broke away from this approach towards a more empirical style of scientific observation. The clinical observations were of 25 patients, most with severe obesity (68% above normal weight on average), with whom he had at least 4 clinic visits. He described NES as characterized by evening hyperphagia, insomnia, and morning anorexia. Twenty of the 25 patients exhibited at least two of these three behavioral symptoms, and 18 of the 20 reported that NES was associated with stressful experiences.

Stunkard prescribed a standard diet of 1200 kcal/day to his patients with obesity and observed that 13 of the 20 with NES failed to lose any weight while in the clinic, and that as a group they lost much less than the five without NES. Additionally, in their past attempts at weight loss, many had developed psychiatric complications, such as depressed mood. Stunkard compared these 25 patients to 32 other individuals without obesity, none of whom reported NES. Man y of Mickey’s keen observations were confirmed in more scientific studies later on [7] [8]. In a subsequent paper with an expanded clinical group of 40 patients, he noted that 28 had NES and three had BED (Stunkard, 1959). He described BED as characterized by uncontrollable binge eating episodes, also often associated with stress, and often followed by self-condemnation.

At the First International Night Eating Symposium, which I attended as did Stunkard in Minnesota in 2008 [9], the consensus for the proposed criteria for NES strongly resembled what he had described in 1955 [1]. The core criteria were (1) consumption of at least 25% of daily intake after the evening meal, and/or (2) nocturnal awakenings with ingestions at least twice per week. The person needs to be aware of the eating episodes in contrast to sleep-related eating disorder (SRED), where eating occurs in a state of sleep. There should also be distress or impairment in functioning. Three of five additional criteria need to be present, including morning anorexia, a strong urge to eat after dinner, insomnia, a belief that one must eat to fall asleep, and depressed mood, which usually worsened in the evening as compared to most cases of clinical depression where mood improves later in the day [8]. These criteria must be met for a minimum period of 3 months. Based on these proposed criteria, we updated a diagnostic instrument, the Night Eating Diagnostic Questionnaire (NEDQ) [11] [12], which we had previously developed [8]. At a SSIB meeting at the University of Pennsylvania in 2001, a small group of us met informally to discuss night eating, and at the time, we likely represented most of the researchers studying NES
(see Fig 1).

The distinction between NES and SRED is sometimes difficult. Early in my part-time clinical practice, I saw a young female patient with severe obesity, who was perplexed that she was not losing weight even though she was following an 800 kcal/day diet. I asked her to keep a daily food record for a week, and the recorded intake was consistent with 800 kcal/day. I then asked her if she might be eating at night, which she denied. The following week at the next visit, she told me that she realized that she was indeed awakening at night, going to the bathroom, and then making a pit stop at the refrigerator, where there was always a large bowl of pasta for her large extended Italian family. She would pick up the bowl, remove the cover, and scoop pasta with her hands into her mouth while leaning over the sink, leaving no trace, and no one noticed the decrease in pasta in the large bowl. This apparently happened almost every night. Once fully aware of her behavior, and instructed not to have any liquids for 2 hours before going to sleep to reduce the likelihood of needing to urinate at night, she started losing weight. I considered this to be a case of lack of full awareness rather than eating in her sleep as people may forget what they do at night. There may also have been some denial involved.

I remember when I was first invited to Stunkard’s office at Penn to discuss NES. I was standing at the doorway as he beckoned me in, and observed tall stacks of paper, almost covering the floor, as his apparent personal filing system. I had to think for a few seconds about how to navigate to make it to Mickey’s desk at the other end of the room. I figured out a mental path and made my way through the maze, without knocking down any stacks, and Mickey smiled approvingly. It is possible I followed the same path he took to get to his desk. Mickey Stunkard’s numerous academic descendants have followed in his path and have continued to study the two disorders he described over 60 years ago.

References

[1] Stunkard AJ, Grace WJ, Wolff HG. The night-eating syndrome—a pattern of food intake among certain obese patients. Am J Med. 1955;19(1):78–86.

[2] Stunkard AJ. Eating patterns and obesity. Psychiatr Q. 1959;33: 284–95.

[3] TA Wadden, AJ Stunkard. (1987). Psychopathology and obesity. Ann N Y Acad Sci. 1987;499:55-65.

[4] Stunkard AJ. Eating disorders and obesity. Psychiatr Clin North Am. 2011 Dec;34(4):765-71. doi: 10.1016/j.psc.2011.08.010.

[5] American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013.

[6] Allison KC, Stunkard AJ. Obesity and eating disorders. Psychiatr Clin North Am. 2005 Mar;28(1):55-67.

[7] Stunkard AJ, Allison KC. Two forms of disordered eating in obesity: binge eating and night eating. Int J Obes Relat Metab Disord. 2003;27(1):1–12.

[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 Apr;9(4):264-7.

[9] Allison KC, Lundgren JD, O'Reardon JP, Geliebter A, Gluck ME, Vinai P, Mitchell JE, Schenck CH, Howell MJ, Crow SJ, Engel S, Latzer Y, Tzischinsky O, Mahowald MW, Stunkard AJ. Proposed diagnostic criteria for night eating syndrome. Int J Eat Disord. 2010 Apr;43(3):241-7. doi: 10.1002/eat.20693.

[10] Nolan LJ, Geliebter A. Night eating is associated with emotional and external eating in college students. Eat Behav. 2012 Aug;13(3):202-6. doi: 10.1016/j.eatbeh.2012.02.002. Epub 2012 Feb 10. Erratum in: Eat Behav. 2014 Dec;15(4):700. PubMed PMID: 22664397; PubMed Central PMCID: PMC3368284.

[11] 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 Apr 1;111:86-95. doi:10.1016/j.appet.2016.12.027. Epub 2016 Dec 23. PubMed PMID: 28017909.