unclean from their diets. This could be beneficial to health
in some ways if consumers are moving from a highly pro-
cessed, calorically dense diet to one that follows the cur-
rent dietary recommendations for vegetables, whole grains,
and protein intake. But it also could have a damaging effect.
Research has shown that people with disordered eating
behaviors may use restrictive behavior, including clean
eating, to rationalize and justify their practices.34,35 If the
opposite of clean is dirty, then using the term could imply that
anyone who isn’t eating clean is “eating dirty” or living a less
than wholesome lifestyle.
Orthorexia nervosa is a pathological obsession with proper
nutrition that leads to dietary restrictions and a rigid avoidance
of foods deemed unhealthful or unclean.^36 It’s a disordered
eating pattern that stems not from the desire for a thinner
physical appearance but rather from wanting to eat purely or
perfectly to the point that it creates unhealthful self-imposed
limitations. Orthorexia isn’t recognized as an eating disorder
by the American Psychiatric Association or listed in the cur-
rent Diagnostic and Statistical Manual of Mental Disorders, but
it’s a disordered eating pattern that clinicians may encounter.
When restrictive behavior reaches the point of a disorder, it’s
moved beyond self-care and a healthful lifestyle.^35
Patients suffering from orthorexia may cite wanting to eat
unprocessed, natural foods and also may take medical and
ethical concerns into consideration when limiting food choices
and consumption.^35 These patients commonly omit entire food
groups and have been shown to suffer the same complications
as do those with anorexia, including osteopenia, anemia, hypo-
natremia, metabolic acidosis, pancytopenia, low testosterone,
and bradycardia.^36 Using clean eating as an excuse for restric-
tion and elimination of many types of foods can easily stray into
disordered eating territory, including orthorexia.
A 2016 study by Barnett and colleagues in the journal
Appetite found that some consumers may use restrictions
such as clean eating as a socially acceptable way to cut back
calories or intake. The food paradigm that favors organic or
clean food views conventional or conventionally grown food
as poor quality, unethical, and ecologically irresponsible. At
the same time, this paradigm positions the consumption of
alternative, organically grown, or clean eating foods as high
quality, healthful, and ethically correct.^37
Of course, the majority of consumers who prefer to eat
organically, locally, or sustainably don’t experience disordered
restrictive eating behavior. When working with clients who
cite the desire to remove impure foods from their diets in an
effort to eat clean, dietitians can ask open-ended questions to
learn more about the root of these desires. RDs may uncover
a fear of food or disordered eating pattern, or they may simply
need to help the client recognize some myths and focus on
evidence-based nutrition education. Some clients really may
need to remove an ingredient or type of food from their diets
for medical reasons, in which case a dietitian can help them
create a nutritionally balanced and safe diet.
Putting It Into Practice
When clients ask about following a clean eating diet, it’s an
opportunity for RDs to discuss what it means, what it doesn’t
mean, and where the research lies, then make suggestions for
more healthful eating.
The first step when working with clients who express a
desire to eat clean is to identify what it means to them. Ask
open-ended questions to learn more about where they learned
the term, what they believe it involves, why they want to eat
clean, and what their desired health outcomes are. They may
be influenced by a celebrity diet, online personas, or misinfor-
mation about what a clean eating diet is. Dietitians shouldn’t
shy away from discussing clients’ exposure to social media or
other sources of information when they come with questions
about eating clean.
Perhaps some clients want to lose weight. Some may be
concerned about soil health, biodiversity, or other aspects of
the environment. Others may have concerns about the safety
of GMOs. By determining what their clients’ concerns are, RDs
can better assist them. Upon exploration, RDs may discover
other motives and disordered eating patterns may become
apparent. Dietitians may need to educate clients whose desire
to eat clean led them to restrict their diets or exhibit eating
disordered behavior.
If clients state a desire to eat clean and cite the hope to
reduce processed foods or follow a more structured plan to
target specific outcomes, dietitians can assess their current
dietary intakes. If clients consume diets high in processed
foods, trans fat sources, or excess added sugars, moving
toward a more whole, unprocessed diet could be helpful.
Commonality among clean eating recommendations includes
reducing foods high in saturated fat, added sugars, and sodium,
a strategy that closely mimics principles of the DASH and
Mediterranean diets. If clients seek a more structured dietary
plan with proven health outcomes, this could be one way
to educate them. This research-backed diet plan to reduce
hypertension includes many foods similar to those commonly
cited as clean eating while also restricting sodium.^6
If eating clean is important to clients, explain that there’s no
actual definition and help them create their own healthful eating
plan that fits into their unique lifestyle, values, and goals.— Ginger Hultin, MS, RDN, CSO, is a nutrition and health writer
and certified specialist in oncology nutrition in Seattle. She’s past
chair of the Vegetarian Nutrition Dietetic Practice Group and past
president of the Chicago Academy of Nutrition and Dietetics. You
can see her work on her blog, Champagne Nutrition.For references, view this article on
our website at http://www.TodaysDietitian.com.august 2019 http://www.todaysdietitian.com 47