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The lifetime prevalence of eating disorders, including anorexia nervosa, bulimia nervosa, and binge eating disorder, hovers just under 5 percent. Individuals with eating disorders are likely to experience sleep issues, particularly difficulty falling asleep, frequent nighttime awakenings, and short sleep overall. In many cases, these issues share a directional relationship: the more severe their eating disorder is, the worse the individual sleeps.
Researchers hypothesize that increased stress levels and hormonal imbalances, due to the strain of food restriction, weight fluctuation, and disturbed sleep, may exacerbate symptoms of both the eating disorder and related sleep problems. Additionally, comorbid mental health issues like depression may contribute to and intensify symptoms.
Eating disorders affect people of all genders, ages, and ethnic groups. About 4.5 percent of adults may develop an eating disorder at some point during their life times, including anorexia nervosa, bulimia nervosa, and binge eating disorder.
Eating disorders rarely exist in isolation. Often, they are accompanied by sleep problems such as insomnia and disrupted sleep. For example, one study found that insomnia (difficulty falling and staying asleep) is twice as common among female patients with anorexia or bulimia than women in the general population.
Insomnia itself is associated with an increased risk of eating disorders, and eating disorders are associated with increased instances of insomnia and disrupted sleep. Problematically, a lack of adequate sleep can worsen symptoms of eating disorders, and cause comorbidities like depression or anxiety.
In the Netherlands, researchers observed the body mass index (BMI), eating disorders, sleep disorders, and daytime functioning among a group of 574 young adults between ages 18 and 35. Of the group, about 12 percent screened positive for an eating disorder. When compared to the participants without eating disorders, these individuals were significantly more likely to have sleep apnea, insomnia, and imapired daytime functioning.
In the charts below, ESP represents the participants’ average scores on the Eating Disorder Screen for Primary Care.
Sleep apnea is a sleep-related eating disorder where the individual momentarily stops breathing during sleep, resulting in a gasping or choking sound that disrupts their sleep cycle, whether they wake up or remain subsconscious. Sleep apnea has been linked to depression, obesity, diabetes, and a three times increased risk of death.
Insomnia describes a chronic difficulty of falling or staying asleep. Temporary insomnia affects about 15 to 20 percent of the population, and usually only lasts a few days to weeks. Chronic insomnia describes a more persistent, severe form of the disorder and lasts for months or more. It affects about 10 percent of the general population.
Impaired daytime functioning describes the effects of sleep deprivation, like that caused by sleep apnea or insomnia. Even one night of sleep deprivation can result in impaired cognitive performance, poor mood or irritability, impaired judgment, delayed reaction times, and reduced wellbeing.
The weight loss, starvation, and malnutrition symptomatic of anorexia can all negatively impact sleep. In a meta analysis reporting on nearly four decades’ worth of studies (from 1970 to 2015), researchers observed that individuals with anorexia experience shorter sleep overall, and poorer sleep quality.
Polysomnograms confirmed these findings, showing that individuals with anorexia spend less time asleep, particularly in slow wave, or deep, sleep. They also have a reduced sleep efficiency. In other words, of the time they spend in bed, less of it is spent asleep.
Chronic starvation, such as that practiced by individuals with anorexia, is likewise linked to fragmented sleep and reductions in deep sleep. Fragmented sleep leads to less restorative sleep overall, as the mind has to effectively “restart” the sleep cycle all over again. A good night’s sleep is uninterrupted, allowing the individual to cycle through light sleep to deep sleep to REM sleep, and back again, several times a night.
But for those with anorexia, a full night’s sleep may be out of reach. Their sleep may be disrupted and restless, resulting in impaired mood and functioning — making it more challenging to cope on a day-to-day basis. Fortunately, studies show that when these individuals restore their weight, even partially, their sleep gets restored as well, leading to deeper and more restful sleep. They can sleep longer and with fewer nighttime awakenings.
Sleep problems are highly correlated with binge eating in women, according to a Swedish study. Women who engaged in binge-eating were significantly more likely to get insufficient sleep, report poor sleep quality, have trouble falling and staying asleep, and feel sleepy during the day.
Another study analyzed the sleep patterns of 400 women with anorexia or bulimia. Nearly 60 percent of the women in both groups reported sleep issues. While the researchers didn’t find any differences in the sleep patterns among the two groups, they did find that those who binge-ate or purged were nearly twice as likely to have sleep issues than those who did not, regardless of their eating disorder diagnosis. Disturbances included difficulty falling asleep and waking up during the night.
The research suggests that eating disorders can worsen sleep, but what explains this connection? In many of the studies, researchers make note that sleep problems tend to worsen eating disorder symptoms, and that purging and binge-eating behaviors exacerbate sleep problems in turn.
Two other potential contributors include comorbid mental health conditions and hormonal imbalances.
Those who engage in binge-eating and purging behaviors are more likely to have increased scores on the Eating Disorders Inventory-2 subscale, specifically regarding body dissatisfaction, perfectionism, and asceticism. These findings led researchers to conclude that the emotions behind eating disorders, such as anger and depression, may be related to their sleep problems. Depression is highly correlated with insomnia.
Further, more than one study has found that individuals with eating disorders spend more time in slow-wave deep sleep, and consequently less time in REM sleep. Deep sleep is important for restoring our physical health, repairing our bone and muscle tissue from the stresses of the day, while REM sleep restores our mental and emotional health. In REM, our brain dreams, commits learnings to memory, and sorts and processes emotions. Given the link between eating disorders and mental health issues, missing out on this critical REM sleep may intensify the destructive cycle of poor sleep and eating disorders.
There could also be a hormonal explanation behind the sleep problems commonly experienced among those with eating disorders. Specifically, researchers have observed how sleep deprivation disrupts the body’s regulation of stress and appetite hormones.
Leptin and ghrelin are two hormones primarily responsible for regulating your appetite. Leptin reduces appetite, while ghrelin increases it. One effect of sleep deprivation, whether after one night or on a chronic basis, is an increase in ghrelin levels. According to animal studies, food restriction creates this same effect.
Individuals with eating disorders strictly control their dietary intake, and they also tend to miss out on sleep. Either or both of these conditions could lead to an increase in their ghrelin levels, increasing their risk of binge eating and further disrupting their sleep.
Stress hormones could also be involved. When you experience stress, you experience it at a hormonal level: your cortisol levels (the stress hormone) increase. Increased cortisol levels are linked to both insomnia and binge-eating. When cortisol increases, leptin decreases (the appetite-regulating hormone). As a result, the individual’s sense of hunger, and tendency to binge-eat, may increase.
Addressing sleep problems is a critically important step during recovery from an eating disorder. With better sleep, you’re less likely to feel fatigued and emotionally exhausted during the day, making it easier to engage in therapy and stay motivated during recovery.
If you or someone you know is living with an eating disorder, consider the following treatment options for eating disorders and sleep loss.
The goal of treatment is to learn healthy ways to cope with stress and anxiety, develop healthier thoughts and emotions around food, and re-normalize your eating patterns. It can be helpful to see a psychotherapist, who can develop a comprehensive treatment plan that addresses your feelings around food, sleep problems, and other underlying issues like depression or anxiety.
Because eating disorders and sleep loss are so intertwined, clinicians recommend including cognitive behavioral therapy for insomnia (CBT-I) as part of the treatment. CBT is widely considered the best treatment for insomnia; it’s significantly more effective than medication. CBT helps the patient identify the negative thought patterns and habits they have surrounding sleep, and learn to replace them with more productive, healthier behaviors. Negative thought patterns are common among both individuals with insomnia and eating disorders.
Incorporating a focus on sleep habits into acceptance and commitment therapy can also be helpful. Acceptance and commitment therapy uses mindfulness strategies to help the patient increase their “psychological flexibility.” Instead of fighting their inner feelings, patients learn to accept them and learn how to adjust them to achieve the behavioral changes they wish to make in their lives.
Given the association between sleep problems and eating disorders, researchers often recommend including sleep hygiene education in the treatment plan. Below are five good sleep hygiene practices to start with.
In addition to psychotherapy, there are residential and outpatient programs for treating eating disorders and sleep issues. These programs are designed to treat the emotional and behavioral factors that contribute to disordered eating and sleeping. Registered dietitians can also be a good resource in helping you adjust your approach to meal planning as you introduce more nutrition into your life.
To locate resources near you and receive confidential help, contact the National Eating Disorders Helpline (800-931-2237, available Monday through Thursday 9am to 9pm, or Friday 9am to 5pm Eastern), or the National Association of Anorexia Nervosa and Associated Disorders (630-577-1330, available weekdays from 9am to 5pm Central). These helplines are manned by trained volunteers who can provide encouragement and support, talk through the feelings that may affect your eating, and help guide you toward resources for eating disorder treatment.
If you or someone you know has an eating disorder, know that it is common to experience sleep issues like difficulty falling asleep, frequent nighttime awakenings, and trouble functioning during the day. These issues are experienced by 50 to 60 percent of individuals with eating disorders.
Fortunately, with treatment comes better sleep. And as you sleep better, you’ll feel better, which will make it easier to stick to your recovery. Treating eating disorders and related sleep issues takes time, but there are people and resources available to help. Start practicing better sleep habits and find a psychotherapist trained in treating eating disorders.
Learn more about the intersection of eating disorders and sleep at the links below.