Abstract
Background: Night eating syndrome (NES) is a clinical syndrome, which is related to sleep disturbance and depression. NES may be associated with obesity and may negatively affect quality of life of university students. The aim of this study was to examine the relationship between NES with obesity and health related quality of life in female university students.
Methods: A total of 293 female university students aged 18-29 were recruited to study. The demographic characteristics of students were questioned. Students filled out the Night Eating Questionnaire and an instrument determining health related quality of life (SF-36). Anthropometric measurements (height, weight and waist circumference) of participants were taken by professionals. Correlation and linear regression analysis were run to analyze collected data.
Results: About 57% of students’ mothers were illiterate or had primary school degrees. The NES prevalence was 6.8% in students. There was no significant relationship between anthropometric measurements (body mass index, waist circumference) and the presence of NES and quality of life scores (p>0.05). However, higher NES scores were associated with lower quality of life sub-scores (physical function, role limitations due to emotional problems, vitality, emotional well-being, social functioning, pain, general health perception) (p<0.05). Simple linear regression analysis results also showed that NES scores were related to lower physical and mental health related quality of life scores (p<0.05).
Conclusions: Although night eating syndrome was not associated with obesity in female university students, it directly affects the physical and mental quality of life of students, adversely. Strategies to cope with night eating syndrome should be developed for university students.
Keywords: anthropometry, night eating syndrome, quality of life, university students
Introduction
Night eating syndrome (NES) is a clinical syndrome characterized by evening hyperphagia, nocturnal eating, and associated sleep and mood symptoms.[1] The descriptive characteristics of the NES are morning anorexia or skipping breakfast ≥ 4 mornings per week, tending to eat after dinner or during the night, difficulty in sleep onset or maintenance ≥4 times a week, believing that eating is necessary to fall or return to sleep and depressed mood in the evening.[2] The NES prevalence ranges between 1.5% and 4.6% in general population.[3,4]
University students are a high-risk group for developing NES. Insufficient and irregular sleep in university students is present at alarming levels.[5] Skipping breakfast, evening snacks, and eating late at night are also commonly observed poor eating habits among university students.[6,7] It is reported that disturbed eating behaviour is more prevalent in university students particularly females than in the general population.[8,9] University students especially females are vulnerable to developing anxiety and depressive symptoms, as well.[10,11] Being away from family, facing psychological distress due to trials of everyday academic life, class schedules, the double burden of both work and study and disorganization of daily routine may be the reasons for developing poor eating habits in university students.[12]
NES is seen as one of the main eating behaviors causing obesity. It is known that overweight and obesity prevalence is rising among university students.[13] While some studies suggest that NES triggers obesity, others report conflicting results.[14,15] Studies declared that NES prevalence is higher in psychiatric outpatients and NES is related to depression and low self-esteem among obese people.[16,17]
Health-related quality of life (HRQL) has been surveyed for many years to support healthcare in general and disease-specific populations. Measuring health-related quality of life can be helpful to predict and indicate morbidity and mortality in a large population. Studies reported that obesity is negatively associated with HRQL in adults and children.[18,19] HRQL was also proved to be lower among female university students.[20] Due to disrupting sleep and causing daytime fatigue, NES may also be harmful to HRQL.[21] The relationship between NES and HRQL is scarce among university students. Female university students were at risk of obesity, NES and low HRQL more than males. Therefore, the aim of the study was to examine the relationship between NES with HRQL and obesity among female university students.
Material and Methods
Study design
A cross-sectional study was conducted on 300 volunteer female university students aged 18-29 years at Karamanoğlu Mehmetbey University in Karaman in October 2024. Participants were selected by incidental sampling. Students who were younger than 18 years or older than 29 years, declined to participate and did not allow their weight and height to be measured were excluded from the study. Before the study, the minimum sample size was determined between 74 and 305 from various studies according to the calculation by taking the alpha value of 0.05, and the theoretical power of 0.80 and 0.95.[22,23]
A total of 300 female students were surveyed, however, 7 participants were excluded from the study due to incomplete data and being younger than 18 years. Therefore, 293 students completed the study. Written informed consent was obtained from students. The research adhered to the declarations of Helsinki.
The demographic characteristics such as age, gender, mother and father education and sibling numbers were questioned. Night Eating Questionnaire and Short Form Health Survey (SF-36) were applied with face to face interviews by professionals. The anthropometric measurements were taken by professionals who were not involved in the study.
Ethical approval
The study was approved by Karamanoğlu Mehmetbey University Ethics Committee (Ethical code: 02-2024/22. Approval date:02.10.2024)
Anthropometric measurements
The body weights of female students were measured to the nearest 0.1 kg with a portable scale. Height to the nearest 0.1 cm was measured with a tape. Body mass index was calculated by dividing weight (in kilograms) by the square of height (in meters) for each subject. Students were classified as underweight, normal, overweight and obese according to World Health Organization.[24]
Night Eating Questionnaire (NEQ)
NEQ was developed to determine NES and consists of 14 items, each item is scored between 0-4 with a likert-type measurement, and only the 13th question is not included in total score. Therefore, the total score is between 0-52. In addition, questions 1, 4 and 14 are reverse scored. The cut-off score was determined as ≥25 to identify NES.[25] Turkish validation was performed by Atasoy et al.[26] in 2014.
SF-36
SF-36 is an instrument that was developed to determine HRQL and consists of 36 questions. The questionnaire is simple and brief. SF-36 has eight subgroups, namely physical function, role limitations due to emotional problems, vitality, role limitations due to physical health, emotional wellbeing, social functioning, pain, general health perception. Each subgroup has distinct scores (0-100) and higher scores indicate better quality of life within that subgroup.[27] Turkish validation was performed by Bilir Kaya and İçağasıoğlu.[28] Physical component score (PCS) and mental component score (MCS) were calculated by obtaining Z-scores of subscores, using respective factor coefficients of each subscore and finally T-scores (mean=50, SD=10).[29] To reduce inconsistent results between the SF-36 subscores with PCS and MCS, it was suggested that uncorrelated (orthogonal) summary scores should be used along with the correlated (obliquely derived) summary scores. Therefore, we used both uncorrelated PCS, MCS (PCSuc, MCSuc) and correlated PCS, MCS (PCSc, MCSc).[30,31]
Statistical analysis
All statistical analyses were carried out with Statistical Package for Social Sciences (IBM SPSS 21.0). Numeric variables such as anthropometric data, NEQ score, SF-36 subscores were reported as means and standard deviations (SD)s. Since variables were parametric, Pearson’s correlation test was used to determine relationships between the anthropometric measurements, NEQ score, SF-36 subscores, PCSuc, MCSuc, PCSc, MCSc. We ran two simple linear regression analyses to examine the effect of NEQ on PCSc, MCSc. The independent variable was NEQ in both models. In the first model, PCSc was the dependent variable and in the second model, MCSc was the dependent variable. After simple linear regression analysis, multiple linear regression models were tried. However, they did not meet the regression criteria and perform well. Therefore simple regression models were shown in this study. Statistical significance was defined as p<0.05
Results
A total of 293 female students completed the study. The mean age of the female students was 20.9±1.7 years (18-29). The mean NEQ score was 16±5 among students and 6.8 % of them had NES. About 57% of students’ mothers were illiterate or had primary school degrees. Most of the students (61.1%) had three or more siblings. The mean BMI of the students was 21.5±3 (16.0-35.3). Only 13.3% of them were overweight and obese (Table 1).
| * N (%) | |
| Table 1. Demographic and anthropometric characteristics and NES prevalence of university students (N=293) | |
|
|
|
| Age (years) |
|
| Age groups * | |
| 18-19 |
|
| 20 |
|
| 21 |
|
| 22 |
|
| 23-29 |
|
| Mother Education* | |
| Illiterate |
|
| Literate |
|
| Primary |
|
| Secondary |
|
| High school |
|
| University |
|
| Paternal Education* | |
| Illiterate |
|
| Literate |
|
| Primary |
|
| Secondary |
|
| High school |
|
| University |
|
| Siblings* | |
| ≤ 1 |
|
| 2 |
|
| ≥3 |
|
| BMI* | |
| Below 18.5 (underweight) |
|
| 18.5-24.9 (normal) |
|
| 25.0-29.9 (overweight) |
|
| 30 and above (obese) |
|
| BMI (kg/m2) |
|
| Weight (kg) |
|
| Waist Circumference (cm) |
|
| NES presence (N=293)* | |
| Yes |
|
| No |
|
The mean physical functioning, vitality and social functioning scores were 83.98±13.42, 55.07±18.94, 68.89±22.54 among university students, respectively (Table 2).
| Table 2. SF-36 subgroup scores of female university students | |
| SF-36 Subgroup Scores (N= 293) |
|
| Physical functioning |
|
| Role limitations due to emotional problems |
|
| Vitality |
|
| Role limitations due to physical health |
|
| Emotional wellbeing |
|
| Social functioning |
|
| Pain |
|
| General health perception |
|
No correlation was found between BMI, waist circumference with SF-36 subgroup scores, physical and mental component scores and NEQ score (Table 3).
| Pearson correlation | |||
| Table 3. The correlation coefficients between anthropometric measurements with SF-36 subgroup scores and NEQ score (r) | |||
|
|
|
|
|
| Physical functioning |
|
|
|
| Role limitations due to emotional problems |
|
|
|
| Vitality |
|
|
|
| Role limitations due to physical health |
|
|
|
| Emotional wellbeing |
|
|
|
| Social functioning |
|
|
|
| Pain |
|
|
|
| General health perception |
|
|
|
| PCSuc |
|
|
|
| MCSuc |
|
|
|
| PCSc |
|
|
|
| MCSc |
|
|
|
| NEQ score |
|
|
|
NEQ score was negatively correlated with physical functioning (p<0.015), role limitations due to emotional problems, vitality, emotional wellbeing, social functioning, pain, general health perception subscores among university students (p<0.001). Higher NEQ score was also related to lower physical and mental health related quality of life scores (p<0.001) (Table 4).
| Pearson correlation, *p<0.05, **0.001 | ||
| Table 4. The correlation coefficients between SF-36 subgroup scores and NEQ score (r) | ||
|
|
|
|
| Physical functioning |
|
|
| Role limitations due to emotional problems |
|
|
| Vitality |
|
|
| Role limitations due to physical health |
|
|
| Emotional wellbeing |
|
|
| Social functioning |
|
|
| Pain |
|
|
| General health perception |
|
|
| PCSuc |
|
|
| MCSuc |
|
|
| PCSc |
|
|
| MCSc |
|
|
According to regression analysis, the NEQ score was directly related to lower physical and mental component scores (p<0.001). NEQ score was significantly associated with a 38% decrease in PCSc and 27% decrease in MCSc. The models with NEQ scores explained 8% and 19% of the variances in PCSc and MCSc, respectively (Table 5).
| Unstandardized coefficient (B) with 95% confidence interval (CI), coefficient of determination (R2) for overall model fit. PCS: physical component score; MCS: mental component score. | |||||
| Table 5. Simple linear regression analysis for physical and mental component scores with NEQ score | |||||
| Dependent variable |
|
||||
|
|
|
|
|
||
|
|
|
||||
| Independent variable | |||||
| NEQ score |
|
|
|
|
|
| Dependent variable |
|
||||
|
|
|
|
|
||
|
|
|
||||
| Independent variable | |||||
| NEQ score |
|
|
|
|
|
Discussion
This study aimed to examine the relationship between NES with obesity and HRQL among female university students.
NES prevalence was 6.8% in this study. Although Rand et al.[3] reported prevalence of NES is 1.5% in the general population, there is no precise prevalence for university students. The studies conducted on university students reported different results. While Yahia et al.[32], Ahmad et al.[33] and Tekin and Öner[34] reported high prevalences of NES (11.46%, 33.9% and 67%); Runfola et al.[35] and Özgür and Uçar[15] reported low prevalence of NES (4.6%, 1.4%) among female university students. Some departments where students studied such as health science, medicine and biology may increase the nutritional knowledge of the students due to being directly related to health. This may affect the food choice of the students and can cause bias in the results. Because it has been known that nutritional knowledge causes healthy eating attitudes and practices.[36] Therefore, the lower prevalence of NES in some studies may be due to the nutrition education of the participants. Besides, ethnic and cultural differences may be another factor affecting the results.
In this study, no relationship was found between BMI and waist circumference with NEQ score among female university students similar to other studies.[15,32,35,37] Most of the researchers came to the conclusion that the BMI-increasing and obesity-causing effect of NES may occur in later life not in young ages.[15,32,37]
Regarding health-related quality of life, physical functioning, role limitations due to physical health had highest subscores and role limitations due to emotional problems, vitality had lowest subscores in this study. Sabbah et al.[38] reported similar findings. On the other hand, all subscores of the present study were higher than Oztasan et al.[39] but lower than Latas et al.[40] The different results may be due to conducting the studies on different samples, for instance, the departments where students study such as medicine or nursing and also having different sample sizes.[39]
No relationship was found between BMI with SF-36 subscores, PCS, similarly Sabbah et al.[38], in this study. However, other studies reported that a higher BMI or obesity is associated with lower physical component scores in HRQL, in university students.[41-43] Gender factors may be one of the reasons for the different results. This study and the study of Sabbah et al.[38] were based on female students. However, those studies reported conflicted results were conducted on both male and female students. Besides, in this study and the study of Sabbah et al.[38] the obese and overweight students were relatively less than others, which may be another confounding factor while comparing the results. MCS was not related to BMI, as well, similar to other studies.[38,44]
It was determined that high NEQ score is associated with lower HRQL (SF-36) subscores except for role limitations due to the physical health component, in this study. In addition, high NEQ score was associated with low physical and mental component scores. It has been declared that night eating syndrome is closely related to low sleep quality, therefore excessive daytime sleepiness and low subjective well-being (happiness, life satisfaction).[32,37,45] Studies stated that NES is associated with low MCS but not PCS in bariatric surgery candidates.[46,47] Having uncontrolled eating in response to emotional cues can promote poorer psychological states in these patients, which can cause low MCS.[46] Runfola et al.[35] stated people having NES have more mental health problems and less quality of life. Likewise, NES was found to be related to depression, anxiety and higher psychological distress.[48-50] However, in this study, NES was associated with low physical health, as well. Higher NEQ score is related to lower physical function, general health perceptions and higher pain. People having NES are expected to have insomnia at least four to five times per week.[51] Insomnia co-occurs with chronic pain, has an impact on physical function and is associated with reduced health perception.[52-54]
This study is important in terms of observing the relationship between NEQ and physical and mental health quality among young people. However, there are many limitations. The first one was gender. It was both a limitation and a strength, in this study. The results for female students cannot be generalized for male students and gave us limited knowledge. On the other hand, this particular demographic group provided to develop a better model. Second, the sample size was relatively small. Third, the study was limited to a specific small university. Fourth, some factors such as sleep hours, physical exercise, and emotional eating could be questioned along with SF-36 to explain better the relationship between NEQ with PCS and MCS. Fifth, the accommodation type was important to access food. For example, some dormitories may be so restrictive for sleep hours and food access. This could be questioned, as well.
Conclusion
In conclusion, NES negatively affects the quality of life of university students both physically and mentally. The direct and detrimental effect of NES on physical and mental quality of life was observed in young people, regardless of important confounding factors such as obesity. Strategies such as educational programs and dietary interventions should be developed to cope with night eating syndrome among university students. Universities may provide some educational programs to increase awareness on this issue. Healthcare professionals may organize occasional trainings to inform the public. Dietary interventions may be applied to university students suffering from NES. Governments may create a public service announcement to inform the public.
Acknowledgments
We are very grateful to health professionals who helped data collection and to the participants who participated in the study.
Ethical approval
This study has been approved by the Karamanoğlu Mehmetbey University Ethics Committee (approval date 02.10.2024, number 02-2024/22). Informed consent was obtained from the participants.
Source of funding
The author declare the study received no funding.
Conflict of interest
The author declare that there is no conflict of interest.
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