May 2021 Issue
CPE Monthly: Night Eating Syndrome
By Mireille Blacke, MA, LADC, RD, CD-N
Vol. 23, No. 5, P. 42
Suggested CDR Performance Indicators: 8.3.6, 9.1.3, 9.6.4, 10.2.2
CPE Level 2
Unlike the eating disorders anorexia nervosa, bulimia nervosa, and binge eating disorder (BED), night eating syndrome (NES) is relatively unknown except to professionals and researchers involved in behavioral health (BH), obesity, and/or maladaptive eating patterns. The lack of awareness about NES on the part of health care providers and the public makes the condition easy to miss, underreport, misdiagnose, and/or fail to treat.
This continuing education course reviews the primary characteristics of NES, a challenging but relatively unknown form of disordered eating that negatively and significantly impacts an individual’s metabolic functioning, mood, weight, sleep, and overall well-being. Based on the presented research on NES, this course provides practical recommendations nutrition professionals can use to educate and counsel clients about NES, known comorbidities, and relevant interventions that may reduce NES episodes and improve clients’ health-related quality of life.
NES is characterized by morning anorexia, evening hyperphagia (ie, consuming a minimum of 25% of daily caloric intake after the evening meal), and insomnia four to five times per week, stemming from a disruption in circadian rhythms, usually in response to significant life stressors.1-3 Additional clarifying criteria include a minimum of waking up at least two times per week with the strong urge to eat, and the belief that eating is necessary to sleep or return to sleep.1,4,5
To differentiate between other sleep and eating disorders, individuals with NES have partial or full awareness and recall of the eating episodes, unlike those with sleep-related eating disorder (SRED), often referred to as “sleep eating.”4,6 Individuals with NES consume more calories during the evening hours, with amplified hunger leading to increased nocturnal snacking that’s skewed toward high-carbohydrate snack foods.2,5,6 For those trying to lose weight, this often leads to stalled weight loss or regain of lost pounds.7-11
One explanation for underreporting this syndrome may be that, as with BED, individuals struggling with NES typically experience loss of control (LOC) and feelings of shame and guilt regarding their eating behaviors, which usually occur as compulsive, solitary activities, hidden from others due to embarrassment.3,6 Such negative self-regard may deter individuals from seeking professional help, particularly if neither the individual nor their providers know of NES and that treatment for it exists.12
NES was first described by Stunkard and colleagues in 1955, and while research into the topic has been limited in the decades since, an association between NES and degrees of obesity has emerged.13-16 Although NES affects individuals of normal weight, the condition is commonly comorbid with metabolic imbalance and obesity.6,15,17,18
The prevalence of NES in the United States is estimated to be 1.5% of the adult population.6 However, incidence is higher in certain populations, such as people with obesity (BMI≥30, 6% to 16%), morbid obesity and those in the process of qualifying for bariatric surgery (BMI≥40, 2% to 55%), BH conditions (8% to 25%), obstructive sleep apnea (8.6%), and type 2 diabetes (4% to 12%).14,15,17,19,20
Despite the prevalence of NES, many RDs may not recognize its traits in their clients, nor even consider assessing them for the condition, unless they work with populations where NES is more apparent.
While it’s important to define what NES is, RDs, other nutrition professionals, and health care providers need to recognize what it isn’t. NES is distinct from BED, emotional eating, nighttime snacking, grazing, and compulsive eating. As noted, NES also differs from SRED, though NES does share some traits with both BED and SRED. In fact, NES appears to be a complex combination of eating, sleep, endocrine, and mood functioning and dysregulation.4,6,12,21
To differentiate between the three conditions, the accompanying table provides a breakdown of overlapping and differential BED, NES, and SRED characteristics.
Further complicating the issue, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders no longer uses the catch-all “eating disorder not otherwise specified” for conditions such as NES, replacing the former category with “other specified feeding and eating disorders.”22 Recognizing NES as an eating disorder, or as the combination of disorders mentioned above, can be confusing for providers across health care specialties. For optimal and comprehensive patient care, providers should collaborate on multidisciplinary teams. Benefits associated with this collaboration include the providers’ opportunities to learn about multifactorial conditions such as NES and its different possible presentations, and brainstorming treatment interventions together.
NES and Sleep-Wake Cycles
As research into the disorder continues, NES has been established as a consequence of disrupted or delayed circadian rhythms.23-25 NES also has been linked to increased risks of metabolic syndrome, hypertension, central adiposity, and dyslipidemia.24,26,27 In a 2020 narrative review of 110 articles published between 2000 and 2019, Mohd Azmi and colleagues investigated circadian rhythm disruption and psychosocial well-being in shift workers, and found that shift workers experience desynchronization of circadian rhythms due to erratic sleep-wake cycles. The authors strongly recommended that shift workers with disrupted circadian rhythms meet with nutrition professionals for tailored interventions that address meal timing and most appropriate foods to consume during shift work.24
Research into NES continues to reflect its foundation as a disorder primarily stemming from and exacerbated by disrupted sleep-wake cycles rather than dysregulated appetite or emotional urges. In a 2018 cross-sectional study investigating eating habits associated with insomnia and depression, Wrzosek and colleagues found a bidirectional relationship between quality of sleep and NES behaviors in 361 participants with BMI≥40. Insomnia was a stronger predictor than depression for daily snacking, suggesting that excessive and/or frequent night-time snacking may be a coping response to inadequate or disrupted sleep.28
In a 2020 cross-sectional study in Japan, Matsui and colleagues analyzed 3,347 web-based questionnaires from individuals aged 19 to 25 for similarities and differences between parasomnias, including NES and SRED. The study determined that a delayed sleep-wake cycle characterized NES but not SRED.29 Both of these studies suggest that successful interventions for NES require clients to make adequate, undisturbed sleep a priority.30
Pharmacotherapy for NES
Research into pharmacological treatment for NES primarily has focused on selective serotonin reuptake inhibitors (SSRIs), one glutamatergic antagonist, and a selective melatonin agonist.31-35
SSRIs, such as sertraline (Zoloft), escitalopram (Celexa), and paroxetine (Paxil), increase postsynaptic serotonin levels, help restore the circadian function, and often result in weight loss in individuals with NES.31,32,36,37 However, there have been mixed results in terms of reducing NES symptoms with SSRIs. In 2013, Allison and colleagues found that escitalopram significantly reduced NES symptoms (eg, number of NES episodes per week) in a 12-week open-label trial.32 However, in a 2012 12-week randomized controlled trial with 40 participants with NES, Vander Wal and colleagues found no significant difference between the escitalopram and placebo groups in reducing NES symptoms.38
Topiramate (Topamax), an anticonvulsant medication, treats NES primarily by enhancing gamma-aminobutyric acid activity.14,31 Topiramate has been shown to relieve symptoms of anxiety and depressed mood, as well as greatly reduce NES symptoms in individuals struggling with the disorder, according to reviews of several case reports.31,33,39 However, with discontinuation of the medication, symptoms returned. Clients prescribed topiramate should be advised about possible side effects, including cognitive impairment, kidney stones, drowsiness, and dizziness.33,39
Melatonin is a hormone normally secreted by the brain to promote sleep, when triggered by darkness.40 When melatonin levels drop, an individual may experience difficulty falling or staying asleep.34 Low melatonin levels often are found in individuals with NES.23,31,41 As a selective melatonin agonist and antidepressant analog of melatonin, agomelatine may improve NES symptoms, primarily by regulating the disrupted sleep-wake cycle and secondarily reducing depression and anxiety.31,34,35,39 Several case reports showed agomelatine was effective in reducing NES symptoms and improved mood, but long-term, controlled studies are required to further investigate this treatment option.34,35,39,42
Notably, one prescription sleep medication is considered a contraindication to SRED and, based on current findings, should be reassessed if used regularly by clients with NES: zolpidem (Ambien).4,43 Although longitudinal studies into this specific phenomenon are needed, there’s evidence that individuals taking zolpidem fall asleep initially, but later eat during the night, with little to no memory of their eating behaviors during the nocturnal episodes.4 A 2020 descriptive study by Ho and colleagues found a direct relationship between zolpidem use at any dose and SRED, with full or partial amnesia and compulsive night eating present in all cases. After reviewing 40 published case reports, the authors reported that 60% of the individuals experienced SRED symptoms nightly while taking zolpidem, with frequency of SRED episodes increasing with a zolpidem dosage of ≥10 mg. Most notably, SRED behaviors stopped in 100% of the case reports when zolpidem was discontinued.43
NES and BH
In a large 2017 Italian study on emotional regulation and obesity pathology, Micanti and colleagues excluded participants with NES because the researchers classified it as the result of disrupted circadian rhythms, causing an impairment between sleeping and eating, instead of resulting from an impaired emotional regulation system.44 This exclusion is noteworthy, as it indirectly acknowledges the directionality of NES and BH symptom development, with the latter being comorbid conditions or sequelae.
In 2014, De Zwaan and colleagues found a direct relationship between NES and depression, anxiety, eating disorder pathology, and bodyweight.45 There’s evidence that severity of depression increases in those with NES, and that NES prevalence increases in individuals diagnosed with BED.46 In 2017, Borges and colleagues administered a questionnaire to 200 Brazilian university students to measure the association between NES and various psychosocial stressors. The cross-sectional study occurred over four months and reflected NES prevalence of 15% of the university students, roughly 10 times higher than the general population and excessive compared with prevalence rates of university students in other countries (eg, Egypt at 5.8%). Results from this study also showed that NES symptoms were positively associated with severity levels of depression, anxiety, and stress.17
It’s important to note that BED and NES share the trait of LOC with regard to eating behavior.47 LOC eating may be more informative to the nutrition provider than volume/amount of food eaten; as an RD working with clients who report any form of disordered eating, assessing LOC eating (or fear of it) may be extremely beneficial.
As with other eating disorders or BH conditions such as depression or anxiety, it’s necessary for providers and patients to acknowledge that NES isn’t cured once overt symptoms are no longer present. Instead, once NES symptoms are well controlled, the condition may be considered in remission. Moreover, as with other maladaptive eating patterns or psychological conditions, signs and symptoms of NES should be monitored on a regular basis by providers, particularly if the patient is dealing with significant psychosocial stressors.
The intractable nature of NES warrants a multidisciplinary team of providers to assist patients with developing the necessary communication and coping skills to express their feelings, identify cravings, and manage triggers and stressors. In particular, NES has a tendency to reemerge in individuals who have had bariatric surgery.7,10,11,41
NES and Bariatric Surgery
Although NES’ impact on postoperative outcomes has garnered less investigative attention than the effects of BED, grazing, and alcohol use, untreated NES may resurface after bariatric surgery.11,48,49 In addition, the recurrence of night eating behavior is correlated with greater BMI and lower satisfaction with bariatric surgical outcomes.2,10,49 Though limited, these data emphasize the specific need to educate and counsel clients who experience preoperative night eating behavior to minimize the risk of NES recurrence (and all that comes with it) after bariatric surgery.
Research has shown individuals with morbid obesity seeking bariatric surgery to have higher prevalence of NES than the general public, with rates broadly ranging between 2% and 55% across studies, with differences in assessment tools and a revised definition of NES being partly responsible for the large discrepancies.15,17,19
Multiple studies have shown that weight regain after bariatric surgery is linked to poor coping skills, an inability to manage life stressors, and the reemergence of maladaptive eating behaviors, including NES.9,10,48,50 When evidence-based bariatric meal planning and mindful eating practices are challenged by postoperative psychosocial stressors in clients with untreated preoperative NES, regression to previous NES habits are more likely to resurface at approximately 18 months to two years after surgery, hindering optimal weight loss efforts and contributing to inadequate weight loss or weight regain.2,7,8,10
In a 2015 longitudinal study investigating eating patterns and behavior present in individuals before bariatric surgery, Mitchell and colleagues found that 17.7% of 2,266 preoperative participants met criteria for NES compared with 15.7% who met criteria for BED. Specific NES symptoms, such as nocturnal eating and evening hyperphagia, were found in 31.1% of participants with BED, more than double found in those participants without BED (14.7%).47 That NES was the most common of the disordered eating patterns, including BED, is consistent with recommendations for bariatric programs to screen for NES before surgery to reduce postoperative risk of NES and subsequent weight regain.7,9,39,47 Due to high co-occurrence of NES and BED, it’s appropriate to recommend that individuals diagnosed with BED (independent of bariatric surgery status) also may benefit from NES screening.
These collective results underscore the importance of reinforcing bariatric nutrition and behavior change principles postoperatively during routine, follow-up provider visits.7,8,50 Evaluation and monitoring specifically for NES are appropriate at each follow-up surgical, MNT, and BH office visit.7,8
Impacts of COVID-19
The COVID-19 pandemic has generated high-risk settings for maladaptive eating, weight changes, and impaired nutrition status. Individuals are spending more time in self-quarantine, more people are working from home when possible, and others may be struggling with job loss stemming from the pandemic. Social distancing has become the norm, leading to physical and emotional isolation and, in some cases, limited access to food.51 For others, boredom may lead to grazing or overeating.7 Increased financial and psychosocial stressors may disrupt sleep, mood, and physical activity, and trigger maladaptive/disordered eating, substance use, and/or weight gain.51,52
Early in the pandemic (April 2020), Phillipou and colleagues investigated the eating and exercise behaviors of 5,469 Australian participants who completed surveys via self-report, and concluded that the pandemic negatively affected mental health; led to increased maladaptive eating behaviors such as binging, restricting, and purging; and decreased exercise in both individuals diagnosed with eating disorders and the general public. Importantly, due to the psychological distress caused by the pandemic, the authors suggested increased provider support and monitoring for individuals, irrespective of eating disorder status.51
In practice, providers in the United States can use HIPAA-compliant telehealth software to make remote MNT and BH services available and accessible for clients, while fervent research continues in this nascent area.
Due to the complexity of NES, nutrition professionals who provide MNT to clients with NES often collaborate with members of a multidisciplinary team and, in particular, with BH professionals. While RDs educate and assist clients with shifting food intake to earlier in the day, BH professionals work with clients to interrupt, challenge, and reframe distorted thoughts and beliefs.4 In addition, BH professionals may work with clients on addressing feelings of shame, guilt, and embarrassment around the NES episodes, as well as the LOC eating and/or feelings of addiction to certain foods (eg, carbohydrates, sweets, and desserts).31,47,53,54
Support groups for individuals with disordered eating/NES should offer an environment where clients feel safe and comfortable. When feeling welcomed, accepted, and not judged, attendees with shame-based conditions frequent support groups more, allowing for earlier interventions.7,11,55 Support group topics and activities that enhance self-efficacy and body acceptance, reinforce goal setting and maintenance, develop non– food-based coping skills, and demonstrate appropriate stress management techniques would most benefit individuals struggling with NES.7,39
A 2015 six-week pilot study by Himes and colleagues investigated the usefulness of cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT) treatments for weight regain after bariatric surgery due to behavioral nonadherence. Twenty-eight participants were treated in a group setting weekly and showed improvement in unhealthful eating patterns. Results showed that a combination of CBT and DBT techniques helped jumpstart stalled weight loss, reverse weight regain, decrease grazing and binge eating behaviors, and slightly improve mood.11
Despite the small sample size and duration of this study, such brief tailored interventions in support group settings cofacilitated by specialized BH and/or MNT professionals may benefit clients diagnosed with NES.7,11 Specifically, in 2008, Vinai and colleagues discovered the fundamental component in distinguishing NES from BED and other disorders: Individuals with NES hold the pervasive belief that unless they eat, they won’t be able to initially fall asleep or resume sleeping.4,5 This ingrained belief is the type of cognitive distortion that would be appropriately addressed by CBT or DBT techniques in a support/group setting or individual therapy.
Because NES episodes worsen with stress and may be shameful and stigmatizing for the individual, the benefits of support groups include anonymity, freedom from judgment, cost, low-pressure participation, and education along with support. Moreover, due to the pandemic, virtual options now exist, broadening access. In person or online, these settings may appeal to those who struggle with requesting help, or benefit from role-playing activities such as setting boundaries. Developing such practical life skills with the help of a licensed MNT or BH professional, in the regular presence of peers, often leads clients to feel empowered and more confident in their abilities to manage triggers and maladaptive eating habits.7,24,39,54,56
Stress reduction seems to lessen NES symptoms.37 One method of stress reduction is progressive muscle relaxation (PMR), a therapeutic technique involving tension and release of muscle groups to obtain overall muscular relaxation. In terms of NES, PMR has shown promise, with significant decreases in nocturnal eating and morning anorexia.4
In 2015, Vander Wal and colleagues conducted a pilot randomized controlled trial to compare three behavioral interventions (exercise, psychoeducation, and PMR) on NES. Forty-four participants were randomly assigned to the three groups, and all groups saw improvement in NES symptoms at one and three weeks; however, the PMR group had the greatest impact on reducing volume of food eaten after the evening meal (approximately 30%), in addition to lowering depression and perceived stress.36 As with most research on PMR, this study was limited by small sample size and duration; most studies on this topic provide data for no longer than 12 weeks.4,57
Many integrative medicine departments offer stress reduction or adjunctive therapy programs for patients using hospital services. Adjunctive therapies include yoga, acupuncture, aromatherapy, meditation, art therapy, and phototherapy.37,56
Phototherapy, or bright light therapy, has shown promise in alleviating NES symptoms, as bright light increases postsynaptic serotonin levels and helps regulate circadian rhythms.57,58 A 2015 pilot study by McCune and Lundgren showed a significant reduction in mood and sleep disturbances and NES symptoms in 15 participants over two weeks of daily bright light therapy (10,000 lux administered in the morning).57 As with other studies into NES, larger sample sizes and longer durations are needed for future research in this area.
The role of RDs in NES treatment is considerable. The foundation for successful nutrition interventions for NES involves correcting disrupted circadian rhythms and incorporating principles of chrononutrition, which combines principles of circadian biology, human metabolism, and meal timing to promote optimal nutrition and overall wellness.59-62 RDs may teach clients behavior modification techniques to help them redirect or replace compulsive NES behaviors with more healthful, deliberate behaviors, adopting coping strategies unrelated to food or trigger foods.
Meal Planning and Chrononutrition
Nutrition professionals working with clients diagnosed with NES may find principles of chrononutrition useful in meal planning. Specifically, establishing a regular routine for eating, sleeping, and physical activity may reduce episodes of NES by collectively calming disruptions in circadian rhythms.30,56 Since skipping breakfast in particular is common among people with NES, establishing an eating schedule that shifts food intake to earlier times of day is necessary.4,39,59,62 In addition, stimulants such as caffeine should be limited in quantity and to earlier times of the day.53
Scheduling regular eating times using basic meal planning and intentionally selecting foods that promote satiety may be challenging for people with NES; recognizing physical fullness and using self-monitoring abilities may take extra practice.37,59 Therefore, the nutrition professional should encourage clients accordingly, as monitoring food consumption and maintaining regular eating patterns are critical in reducing NES symptoms.20,39,56 Over time, the RD may empower clients through offering self-selection of their nutrition and/or behavior change goals, with the RD’s guidance/input as appropriate.
Because self-monitoring and establishing an eating routine may be new to clients with NES, it’s extremely important for RDs to be patient, nonjudgmental, and encouraging with clients during this stage of treatment or they may disengage from treatment. Before each visit ends, RDs may review the basic points of meal planning for NES and provide clients with a summary sheet of those meal-planning goals in a simple format. Starting with three to four points, and adding one or two per week, based on the client’s level of motivation/readiness will help prevent overwhelming the client. An example of a realistic goal is “I will not skip breakfast more than two days each week until my next appointment.” This type of goal-setting realistically guides the client’s progress and encourages personal accountability.
In practicing self-monitoring and meal planning, clients will implement aspects of mindful eating. Instead of presenting each mindful eating technique as a rule to follow, it’s helpful for nutrition professionals to educate clients with the evidence-based rationale behind the recommendation. The technique of chewing slowly, such as 20 times per bite or putting utensils down between bites, has the goal of decreasing eating speed, as rapid eating has been linked with eating in response to emotional cues, overeating at meals, increased risk of obesity, and weight gain.50,63,64
A 2015 systematic review and meta-analysis by Ohkuma and colleagues of 23 published cross-sectional, case-controlled, and cohort studies into the relationship between eating rate and obesity found a direct correlation between rapid eating and increased body weight/BMI.63
Moreover, a 2018 retrospective study by Canterini and colleagues measured associations between eating rate and non–hunger-based eating cues using self-administered questionnaires from 116 female participants. Results of this study showed that rapid eating was positively correlated with emotional eating and triggered by external cues.50
Additional mindful eating techniques may be suggested when clients have mastered initial goals and won’t become overwhelmed by taking on more. For more examples and outstanding resources on mindful eating for nutrition professionals, RDs can refer to amihungry.com.
Please see the accompanying handout for a series of open-ended questions nutrition professionals can use to evaluate/monitor clients for NES; phrases may be adjusted accordingly for shift workers. Responses provided are typical examples of client responses that may indicate the presence of NES.
Putting It Into Practice
Clients with NES who also struggle with excess weight should be informed that obesity is a multifactorial, chronic disease and that optimal outcomes including reduction of NES symptoms and/or weight will require adherence to recommended medical, nutritional, psychological, sleep, and pharmacological treatments as needed.4,39
Nutrition professionals may assist clients with NES in understanding their diagnoses and treatment plans, offering continuous evidence-based education such as the impact of circadian rhythm disruption, and/or effects of zolpidem; reinforcing the client’s use of self-monitoring skills, mindful eating, and stress reduction practices; and providing supportive, nonjudgmental follow-up.7-9 The inclusion of well-informed RDs in multidisciplinary teams is immensely valuable due to RDs’ emphasis on client adherence to multiple providers’ recommendations as well as their own long-term follow-up, personal accountability, and relapse prevention of previous maladaptive eating and behavior patterns, all of which ultimately enhance and benefit client care.7,8,56
It’s common for clients diagnosed with NES to work with RDs and BH clinicians to optimize treatment outcomes.39 By RDs and BH providers collaborating on a mutual client’s NES treatment plan, coping skills unrelated to food will be reinforced, in addition to client accountability and sources of support.4,6,39 If the BH clinician’s approach is CBT, the client will learn to challenge the ingrained, distorted belief that night eating is necessary for sleep.4,56
Revised diagnostic criteria for lesser-known disordered eating conditions such as NES are greatly needed, particularly because maladaptive eating behaviors may be overlooked, misunderstood, misdiagnosed, or easily dismissed by health care providers. Research conducted during and after the COVID-19 pandemic also may lead to revisions in NES criteria.
NES is a complex, underreported disorder that can severely impair an individual’s ability to function and thrive.12,56 Those who suffer from NES often seek validation and treatment from health care providers only to be dismissed due to lack of awareness or education.4,41 These deficits should be addressed by increasing basic education about the condition to the lay public as well as the health care community. RDs and other health care professionals can incorporate NES assessments into practice, whether in person or via telehealth, particularly when working with populations in which NES incidence is highest.
— Mireille Blacke, MA, LADC, RD, CD-N, is an adjunct professor at the University of Saint Joseph in West Hartford, Connecticut; registered dietitian; licensed alcohol and drug counselor; and freelance health and nutrition writer.
After completing this continuing education course, nutrition professionals should be better able to:
1. Distinguish the primary characteristics of night eating syndrome (NES) and how it differs from other maladaptive eating patterns.
2. Evaluate and explain the impact of NES on clients and patients with regard to obesity, metabolic functioning, and behavioral health.
3. Counsel clients on three relevant nutrition interventions that may decrease NES episodes, and assist with their implementation.
CPE Monthly Examination
1. Night eating syndrome (NES) is marked by which of the following symptoms?
a. Sleep eating
b. Evening anorexia
c. Morning hyperphagia
d. Belief that food is necessary for sleep
2. According to the most recent research, what is the prevalence of NES in adults living in the United States?
3. Which stress management practice is related to a subsequent reduction in night eating behavior of approximately 30%?
a. Bright light therapy
b. Increased physical activity
c. Progressive muscle relaxation
d. Good sleep hygiene
4. Which of the following medications treats NES primarily by enhancing gamma-aminobutyric acid activity?
5. Which of the following may help to increase satiety in those with NES?
a. Selective serotonin reuptake inhibitor medications
b. Self-monitoring abilities
c. Progressive muscle relaxation
d. Skipping meals
6. NES and binge eating disorder have which of the following in common?
a. Excessive volume
c. Loss of control
d. Categorized in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, as stand-alone eating disorders
7. According to recent research, which of the following sleep medications may increase the risk of unremembered, compulsive nighttime eating?
8. In a pilot study, participants with NES experienced significantly reduced symptoms after undergoing which of the following therapies?
a. Cognitive behavioral therapy
b. Progressive muscle relaxation
c. Selective serotonin reuptake inhibitors
d. Bright light therapy
9. Preoperative bariatric surgery patients diagnosed with NES during the work-up process are at higher risk postoperatively of which of the following?
a. Weight regain
b. Surgical complications
c. Dental problems
d. Substance use disorder
10. Nutrition professionals who provide MNT for clients with NES collaborate particularly often with which members of the multidisciplinary team?
a. Occupational therapists
b. Primary care physicians
c. Behavioral health practitioners
d. Nurse practitioners
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