Reprinted from Eating Disorders Review
September/October 2003 Volume 13, Number 5
©2002 Gürze Books
Fears about dietary fat are rampant among patients in the eating disorders community. For example, to boost flavor but avoid fat, clients sometimes use “culinary creations” such as ketchup instead of dressing on salad.
Beliefs about the perils of fat come from many sources. The most influential source, the media, has been a long-time and harsh critic of fat. It is not surprising that we live in a fat-phobic society, given the constant messages we receive about reducing our fat intake. Individuals with eating disorders may take these messages too far by believing if low-fat eating is good, no-fat eating must be even better.
For this reason, dietitians working with clients with eating disorders may choose not to use the nutrition education tools designed for the general public. The American Food Pyramid and the Canada Food Guide recommend a low-fat intake because a large segment of the North American population deal with chronic diseases associated with high-fat diets. Clients struggling with eating disorders are usually at the other extreme. They present with physical symptoms related to not enough fat in their diets. To promote moderation and balanced eating, dietitians may create their own nutrition guides.
Nutrition Education Ideas
Helping patients improve their fat intake requires an exploration of their beliefs. Providing them with accurate nutrition information can then allow the patient to determine whether their beliefs are true or not. Nutrition education alone will not necessarily change the client’s attitude or behavior about eating fat.
A common barrier to change is the belief that fat calories are stored more efficiently than calories from protein or carbohydrates. Another popular belief is that dietary fat is automatically converted to body fat. I challenge these beliefs by referring to relevant research findings. Although fats are a more concentrated source of food energy (9 kcal/gram) as opposed to protein or carbohydrates (both are 4 kcal/gm), a calorie is essentially a calorie. Too many calories from any source results in weight gain.
Another common belief among patients is that fat has no nutritional value. Clients are often surprised to learn that they can develop a dietary deficiency from extreme avoidance of fat. Essential fatty acid deficiency is often seen in patients who are severely protein- and calorie-malnourished. The body cannot manufacture adequate quantities of linoleic acid and linolenic acid; therefore, we depend on food sources such as vegetable oils to get these nutrients. Physical manifestations of essential fatty acid deficiency are: dry, cracked, scaling skin, coarsening of the hair, hair loss, impaired wound healing, and possibly diarrhea.
Antioxidants. Some foods in the fats and oils group (e.g., avocados, nuts and seeds, vegetable oils, and wheat germ) are also excellent sources of the antioxidant nutrient, vitamin E. Antioxidants may play a role in preventing diseases that are related to the aging process such as cancer, heart disease, and cataracts. Another important function of dietary fat is facilitating the absorption of all the fat-soluble vitamins (e.g., vitamins A, D, E, and K).
A sense of satiety. Having a moderate amount of fat in a meal or snack also helps to create a feeling of satiety after eating. Fatty acids produced in the digestion of fat stimulate the release of cholecystokinin. This hormone slows the gastric emptying rate and may play a role in limiting food intake. Feeling more satisfied after a meal may help patients reduce their preoccupation with food, a symptom related to semi-starvation. Because clients are usually frustrated by the amount of time they devote to thinking about food and eating, this can be an attractive function of fat. I often ask patients to test this function by assessing their level of food preoccupation and hunger after having meals that contain a moderate amount of fat versus meals that contain hardly any hidden or added fat.
What is Moderate Fat Intake?
A moderate intake of fat can be defined as 30% of the patient’s daily energy intake; both Dietitians of Canada and the American Dietetic Association endorse this recommendation. Often, patients balk at this suggestion and are even more surprised when they learn that the recommended intake for protein is even lower than thisapproximately 20% of their daily energy consumption.
An example of a moderate fat intake is that a client with an 1800-kcal meal plan needs a total of 65 gm of fat from both hidden and added sources. This is equivalent to about 12 to 13 teaspoons of oil. I am cautious about discussing the recommended number of fat grams with patients. Many do not find this information helpful, especially if they are struggling with counting calories and/or fat grams.
When I think the client is eating too little fat, I occasionally estimate her fat intake by reviewing her typical eating pattern. Then, I give her feedback about her intake by comparing it to the recommendation of 30% of total calories per day. Informing the client that she is eating only half the amount of fat advised for moderation may be a good reality check.
Strategies for Improving Dietary Fat Intake
Monounsaturated fats may be easier to incorporate into a patient’s eating pattern than other types of fats. These fatty acids are found mostly in nuts, such as almonds, cashews, hazelnuts, pecans, and peanuts. Other good sources are olives, olive oil, peanut oil, canola oil, and avocados. Appropriate servings of these foods are: 1 tablespoon of chopped nuts (with no shells), 1 teaspoon of oil, 10 small or 5 large olives, and 1/8th of a medium avocado.
Many patients are aware that, unlike saturated fats (fatty acids that come from land animal sources), monounsaturated fats do not raise serum cholesterol levels. Another bonus is that they do not lower serum levels of the “good cholesterol,” high-density lipoprotein (HDL).
Nut butters, like peanut or almond butter, may be more attractive options for patients who cope better with less-visible fats. These foods will also be excellent sources of monounsaturated fats if they have not been hydrogenated. Natural nut butters are often marketed as “old-fashioned style,” and need to have the liquid oil, which is usually floating on the top, mixed into the butter before it is eaten. Two teaspoons of nut butter is an appropriate serving of fat.
A Healthful Trio:
ALA, EPA, and DHA
Flaxseed oil seems to be a popular choice for clients who regularly visit health food stores. Flaxseed is the richest source of alpha-linolenic acid (ALA), an essential omega-3 fatty acid. A 1-tablespoon serving of flaxseed is appropriate. Canola oil, soybean oil, and walnuts also contain ALA. Cold-water marine animals such as salmon, tuna, herring, and mackerel are excellent sources of two other kinds of omega-3 fatty acids, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). These fatty acids down-regulate inflammatory prostaglandins, and may have a beneficial effect against autoimmune diseases like arthritis, lupus, and other inflammatory conditions. Research has also demonstrated that ocean fish, fish oils, and fish oil capsules containing EPA and DHA may lower cholesterol and triglycerides, which could lower the rates of sudden cardiac deaths.
Fish oil capsules should not be used as a way of improving a client’s intake of dietary fat. In high doses, the capsules can cause harm, especially if the individual regularly takes aspirin or blood- thinning medications such as warfarin.
A Step-By-Step Process
The best approach for incorporating fat into the diets of extremely resistant patients is to start them out with low-fat food items (e.g., light cream cheese, diet margarine, or low-fat salad dressing). However, I do not recommend using ultra-low-fat foods as an option. After the client has been able to master this addition, I ask her to double the amount of the low-fat item, and use this as a “baby step” toward eating the regular fat version of the food.
Linda M. Watts, MA, RD