The importance of dietary fat and essential fatty acids (EFAs) in maintaining mental and physical health cannot be underestimated. Although dietary fat has been much maligned over the years, scientists have determined that essential fats are necessary for good health—hence their designation, “essential”!
Most of us continue to associate fat with “bad” and make food choices based upon the assumption that all fats are inherently unhealthy.
This is absolutely false.
Not all fats are alike, and not all fats are bad. Since the 1970s, the mainstream medical community has been successfully convincing the American public that fat is unhealthy. This nutritional myth has left many Americans deficient in key omega-3 fatty acids by creating a dietary mentality that severely limits all forms of fat.
There are many scientists who believe that a deficiency of omega-3s, found in fish, nuts, and seeds, is a very common nutrient deficiency.1
Patients with anorexia nervosa, in particular, are caught in a nutritional nightmare as a result of the dissonance between popular myth and scientific reality, with many such patients often restricting all dietary fats, sometimes for years. Fatty acid levels must be restored for sustained recovery from anorexia, especially in light of the facts about their essential roles in human biology, and their documented benefits for health.2
Fat helps protect and maintain the structural integrity of every cell in your body. Without proper fat intake, your cells are like houses with crumbling walls.
The Three Forms of Natural Dietary Fats:
- Saturated fats are solid at room temperature. Saturated fats are commonly found in butter, lard, tallow, coconut, and palm oils.
- Monounsaturated fats tend to be liquid at room temperature but solidify when refrigerated. Monounsaturated fats are found in olive oil, sesame oil, peanut oil, avocado oil, and nuts such as macadamias, cashews, and pecans.
- Polyunsaturated fats are liquid even when refrigerated. These fats are found in vegetable oils, flax seeds, chia seeds, walnuts, cod liver oil, and cold-water fish. They include omega-6 and omega-3 fatty acids.
Omega-3 and Omega-6 Fatty Acids
A healthy body with sufficient levels of vitamins, minerals, and amino acids can synthesize many of the fatty acids that it needs to function properly. However, there are two classes of “essential” polyunsaturated fatty acids that the body cannot produce; omega-3 and omega-6 fatty acids.
There are three major types of omega-3 fatty acids:
- Alpha-linolenic acid (ALA), found primarily in plants (as mentioned above, ALA is one of the essential omega-3 fatty acids; our bodies cannot make this)
- Eicosapentaenoic acid (EPA), found primarily in seafood
- Docosahexaenoic acid (DHA), found primarily in seafood
Your body is able to create both EPA and DHA from ALA, but the rate of conversion is low, and the conversion process itself may be further hindered by low zinc levels. Zinc is required for the chemical reaction responsible for synthesizing EPA and DHA from ALA and zinc deficiency is common among individuals with anorexia.
Major types of omega-6 fatty acids include:
- Linoleic acid (LA), from which the body can make gamma-linolenic acid (GLA)
- Arachidonic acid (AA)
A healthy body requires both omega-3 and omega-6 fatty acids. However:
- Omega-6 fatty acids can promote inflammation under certain circumstances, while omega-3s can help quell inflammation. Therefore, it’s important to maintain a proper ratio of omega-6s to omega-3s.
- Omega-6 and omega-3 fatty acids compete with each other for use in the body. Your body does not naturally create equilibrium—you have to implement equilibrium through the foods you eat. Excessive intake of omega-6s can also inhibit the body’s production of EPA and DHA from ALA.
There’s Too Much Omega-6 in Our Diets!
Ironically, despite the decades-long campaign against fat waged by the medical establishment, Americans’ overall intake of omega-6 fatty acids has increased greatly. This is due to the large volume of plant oils, such as corn and soybean oil, that exist in the average American diet. High concentrations of omega-6s have crowded out most of the omega-3s that we obtain from our food.
A high omega-6 / low omega-3 diet will eventually tip the “scales” of the body in a proinflammatory direction, rendering the body more susceptible to inflammatory health conditions such as cardiovascular disease and metabolic disorders.
What’s more, a high omega-6 to omega-3 ratio has been shown to increase the risk of depression, possibly by altering the balance of neurotransmitters related to mood.3-5 On the flip side, omega-3 fatty acids in the form of EPA have been demonstrated to be beneficial as a treatment for depressive disorders.4,6-7
Essential Fatty Acids and Anorexia Nervosa
Patients with anorexia have an immense fear of gaining weight, which usually inspires them to shun all forms of dietary fat. Over a short time, this fat avoidance significantly affects their bodies’ levels of EFAs. Various research teams have confirmed that prolonged fat avoidance results in EFA deficiencies in the cell membranes of patients suffering from anorexia.2,8-9
Not surprisingly, multiple anorexia-related complications have been linked to EFA deficiencies.2 Among the more concerning of these are constipation, elevated cholesterol, dry skin, vulnerability to osteoporosis, depression, suicide, and an increased risk of cardiac death. Suicide and cardiac death are in fact two of the most common causes of mortality among anorexia sufferers, and both are associated with omega-3 fatty acid deficiencies.10-15
Omega-3 and Mood
Multiple studies show that omega-3 status is correlated with mood in patients with anorexia nervosa. A team of researchers from Sweden examined the relationship between polyunsaturated fatty acid status and depression in adolescents with eating disorders and discovered that the ratio of omega-6 to omega-3 was higher in subjects who reported symptoms of depression.16 The results of this study highlight balancing of the omega3:omega-6 ratio through supplementation may improve depressive symptoms.17
Weight Loss Depletes Omega-3 Levels
Weight loss and the restrictive eating patterns characteristic of anorexia nervosa result in a drastic depletion of omega-3 fats. Deprived of adequate calories, the body quickly burns through its stores of omega-3s to produce energy, but the omega-3s are not replenished. Plummeting omega-3 levels increase inflammation and slow the body’s rate of metabolism.
With a slowed metabolism, individuals may gain weight more quickly when normal caloric intake is resumed. Such weight gain can heighten and perpetuate the fears around food consumption that torture so many patients with anorexia.
Symptoms of Essential Fatty Acid Deficiencies:
- Excessive thirst
- Extreme tiredness (fatigue)
- Sleep disturbances
- Poor memory
- Dry skin on the hands and feet
- Oily skin on the face
- Sensitivity to sunlight
- Heart arrhythmias
- Joint pain
- Unstable moods
- An inability to fight infections
- Poor circulation
Sources of Essential Fatty Acids
Fish, nuts, and seeds are the primary dietary sources of essential fatty acids.18,19 Cold-water wild-caught fish—such as salmon, mackerel, halibut, sardines, tuna, and herring—is an excellent source of both EPA and DHA. Other dietary sources include some vegetables, including seaweed.20
ALA, the essential precursor to EPA and DHA, is found in flaxseeds, canola, soybeans, pumpkin seeds, and walnuts in addition to oils that are derived from these plants. Because the conversion of ALA to the other forms of omega-3 fatty acids can easily be interrupted, most health experts recommended direct supplementation with EPA and DHA.
Recommended Intakes of Essential Fatty Acids
The American Heart Association (AHA) recommends at least two servings of fish per week for those without a history of heart disease.21 Similarly, a subcommittee of the American Psychiatric Association recommended that all adults should eat fish at least twice per week and patients with mood, impulse control, and psychotic disorders should consume one gram per day of EPA plus DHA.22
There are no guidelines that have been established for essential fatty acid intake in patients with anorexia nervosa.23 I recommend supplementation with a combination of both omega-3 from fish oil and omega-6 from evening primrose oil or borage oil. Supplements should be taken two times a day with meals, for a total of approximately three grams of omega-3 and one gram of omega-6 fatty acids per day.
As you increase your intake of omega-3 fatty acids through supplementation, it is important to make sure you are also consuming adequate antioxidants, with at least 500 mg of vitamin C and 100 IU of vitamin E per day. Fish oil can easily oxidize, or become damaged in the body. Antioxidants, like vitamin C and E, can help prevent this. A high-quality multivitamin would be sufficient in this regard.
A small percentage of patients develop side effects when taking EFA supplements. Most side effects disappear with the addition of digestive enzymes or by changing brands of fish oil. A few patients may develop loose stools, belching, or flatulence. Freezing fish oil supplements can help minimize side effects when starting fish oil, particularly “fish burps.”
- Stark KD, Van Elswyk ME, Higgins MR, Weatherford CA, Salem N Jr. Global survey of the omega-3 fatty acids, docosahexaenoic acid and eicosapentaenoic acid in the blood stream of healthy adults. Prog Lipid Res. 2016;63:132-152.
- Yehuda S, Rabinovitz S. The role of essential fatty acids in anorexia nervosa and obesity. Crit Rev Food Sci Nutr. 2016;56(12):2021-2035.
- Zhang R, Sun J, Li Y, Zhang D. Associations of n-3, n-6 fatty acids intakes and n-6:n-3 ratio with the risk of depressive symptoms: NHANES 2009-2016. Nutrients. 2020;12(1):240.
- Berger ME, Smesny S, Kim SW, et al. Omega-6 to omega-3 polyunsaturated fatty acid ratio and subsequent mood disorders in young people with at-risk mental states: a 7-year longitudinal study. Transl Psychiatry. 2017;7(8):e1220.
- Hibbeln JR, Gow RV. The potential for military diets to reduce depression, suicide, and impulsive aggression: a review of current evidence for omega-3 and omega-6 fatty acids. Mil Med. 2014;179(11 Suppl):117-128.
- Liao Y, Xie B, Zhang H, et al. Efficacy of omega-3 PUFAs in depression: a meta-analysis. Transl Psychiatry. 2019;9(1):190.
- Kiecolt-Glaser JK, Belury MA, Porter K, Beversdorf DQ, Lemeshow S, Glaser R. Depressive symptoms, omega-6:omega-3 fatty acids, and inflammation in older adults. Psychosom Med. 2007;69(3):217-224.
- Caspar-Bauguil S, Montastier E, Galinon F, Frisch-Benarous D, Salvayre R, Ritz P. Anorexia nervosa patients display a deficit in membrane long chain poly-unsaturated fatty acids. Clin Nutr. 2012;31(3):386-390.
- Holman RT, Adams CE, Nelson RA, et al. Patients with anorexia nervosa demonstrate deficiencies of selected essential fatty acids, compensatory changes in nonessential fatty acids and decreased fluidity of plasma lipids. J Nutr. 1995;125(4):901-907.
- Bhatt DL, Miller M, Brinton EA, et al. REDUCE-IT USA: results from the 3146 patients randomized in the United States. Circulation. 2020;141(5):367-375.
- Giovinazzo S, Sukkar SG, Rosa GM, et al. Anorexia nervosa and heart disease: a systematic review. Eat Weight Disord. 2019;24(2):199‐207.
- Bhatt DL, Steg PG, Miller M, et al. Cardiovascular risk reduction with icosapent ethyl for hypertriglyceridemia. N Engl J Med. 2019;380(1):11-22.
- Weiner K. Suicide Awareness Month – a link between suicide and eating disorders. The Hill. Published September 1, 2016. https://thehill.com/blogs/pundits-blog/healthcare/294140-suicide-awareness-month-the-link-between-eating-disorders. Accessed February 18, 2021.
- Jáuregui-Garrido B, Bolaños-Ríos P, Santiago-Fernández MJ, Jaúregui-Lobera I. Lipid profile and cardiovascular risk in anorexia nervosa; the effect of nutritional treatment. Nutr Hosp. 2012;27(3):908-913.
- Sublette ME, Hibbeln JR, Galfalvy H, Oquendo MA, Mann JJ. Omega-3 polyunsaturated essential fatty acid status as a predictor of future suicide risk. Am J Psychiatry. 2006;163(6):1100-1102.
- Reimers A, Ljung H. The emerging role of omega-3 fatty acids as a therapeutic option in neuropsychiatric disorders. Ther Adv Psychopharmacol. 2019;9:2045125319858901.
- Swenne I, Rosling A, Tengblad S, Vessby B. Omega-3 polyunsaturated essential fatty acids are associated with depression in adolescents with eating disorders and weight loss. Acta Paediatr. 2011;100(12):1610-1615.
- Gebauer SK, Psota TL, Harris WS, Kris-Etherton PM. n-3 fatty acid dietary recommendations and food sources to achieve essentiality and cardiovascular benefits. Am J Clin Nutr. 2006;83(6 Suppl):1526S-1535S.
- Psota TL, Gebauer SK, Kris-Etherton P. Dietary omega-3 fatty acid intake and cardiovascular risk. Am J Cardiol. 2006;98(4A):3i-18i.
- Airanthi MK, Sasaki N, Iwasaki S, et al. Effect of brown seaweed lipids on fatty acid composition and lipid hydroperoxide levels of mouse liver. J Agric Food Chem. 2011;59(8):4156-63.
- American Heart Association. Fish and omega-3 fatty acids. Heart.org. https://www.heart.org/en/healthy-living/healthy-eating/eat-smart/fats/fish-and-omega-3-fatty-acids Last reviewed March 23, 2017. Accessed February 18, 2021.
- Freeman MP, Hibbeln JR, Wisner KL et al. Omega-3 fatty acids: evidence basis for treatment and future research in psychiatry. J Clin Psychiatry. 2006;67(12):1954-67. Erratum in: J Clin Psychiatry. 2007;68(2):338.
- Shih PB, Morisseau C, Le T, Woodside B, German JB. Personalized polyunsaturated fatty acids as a potential adjunctive treatment for anorexia nervosa. Prostaglandins Other Lipid Mediat. 2017;133:11-19.