On Nutrition

I remember clearly my introduction to clean eating over a decade ago, by way of books and magazines aimed at women who wanted to be fitness models — or look just like them. That early incarnation of clean eating seems almost quaint now. It resembled a straight-up weight-loss diet with a strong focus on unprocessed foods like then-exotic quinoa and kale.

Today, the clean-eating trend is going strong, edging out intermittent fasting, gluten-free and low-carb diets in the International Food Information Council’s 2019 Food and Health Survey, and leaving paleo and Whole30 in the dust. But some of clean eating’s current incarnations have taken on a more desperate tone. That’s not a good thing.

Certainly, abundant evidence demonstrates the role a nutritious, balanced diet plays in maintaining good health. While there’s no official definition for “clean” in the context of clean eating, it typically means food that’s whole or minimally processed, organic, natural, local and fresh. Clean eating can be a way to eat a nutritious diet based on fruits, vegetables, beans and whole grains, with healthy fats, either plant- or animal-based protein food for balance, and minimal sugar and ultra-processed foods.

But for some “clean eaters,” the desire for perfect health and the pursuit of a perfect diet takes on a greater urgency, evolving into a rigid and highly restrictive regimen. Many clean-eating advocates aim to avoid all traces of added sugar, high-fructose corn syrup, preservatives, artificial colors and flavors, and other additives. Other versions go further, banning caffeine, alcohol, grains (especially those containing gluten), soy, legumes, nightshade vegetables, meat and dairy. In many cases, this is encouraged by wellness bloggers and celebrities who claim their version of clean eating will change your life or cure health issues. But these influencers have no nutrition qualifications or evidence to back up their promises.

What’s especially alarming is that for some, clean eating can become more of an identity than a diet. It crosses the line from “The food I eat is clean” to “I am clean.” This quest for purity may be fueled by fear — of the food system, of disease. It may provoke intense anxiety and shame after any perceived dietary slip-up. In susceptible people, this ideal of a clean and pure diet can morph into orthorexia, otherwise known as “an unhealthy obsession with healthy eating.”

The tipping point

When does prioritizing healthy eating become unhealthy? While the line between healthy eating and orthorexia is a fine one, it does, in fact, exist. Orthorexia is not an official eating disorder, but like diagnosed disorders, it can harm both physical and mental well-being and lead to malnutrition, excessive weight loss, social isolation and severe psychological strain, among other health consequences.

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In a 2017 editorial in Eating and Weight Disorders, Steven Bratman, MD, who coined the term “orthorexia” in 1997, said that the condition has two stages. The first is simply choosing to eat a healthy diet. The second is “an intensification of that pursuit into an unhealthy obsession.” Some people are drawn to trends and regimens that restrict certain food groups — like vegetarian, vegan, gluten-free, raw food, alkaline, “autoimmune,” paleo and ketogenic diets. But following a restrictive diet is not in and of itself a sign of orthorexia — the response to that diet is what matters.

A diet intended to support health becomes unhealthy when it becomes all-consuming, entangled with obsessive thinking, compulsive and ritualistic behavior, and self-punishment. Someone with orthorexia may use their diet to achieve a feeling of perfection, purity or moral superiority. They often spend excessive amounts of time planning and researching “pure” foods to the point that it interferes with participation in normal social activities. When faced with the prospect of eating a food deemed “unhealthy,” they tend to experience significant emotional distress. It’s one thing to generally try to eat organic or eat whole instead of refined grains. It’s another to become so fixated on avoiding pesticides, GMOs or white flour that your diet becomes inflexible, you refuse to go out to restaurants, and you won’t let family, friends, spouses or partners cook for you.

Who is at risk?

A review of the current research on orthorexia published in May in the journal Appetite found that certain factors are necessary to develop orthorexia, including access to organic, whole foods; time and money for food research, planning and preparation; and positive reinforcement for clean eating from friends, social media or other sources. But these aren’t enough on their own to trigger the condition. Those who cross the line from clean eating to orthorexia also tend to have obsessive-compulsive and perfectionist tendencies, and anxiety or depression. In fact, some experts argue that orthorexia may be one manifestation of obsessive compulsive disorder (OCD).

Although orthorexia, anorexia and OCD all share certain traits such as rigidity, perfectionism, need for control and anxiety, orthorexia differs from anorexia in that it generally doesn’t position thinness as a goal. The focus is on the quality of food and how it’s prepared, not the amount. Men and women appear to be equally susceptible to orthorexia; indeed, the current male-dominated trends of “life extension” and “biohacking” could lead to it.

Food for thought

At one end of the clean-eating spectrum, you’ll find good nutrition and an abundance of whole or minimally processed foods; at the other, restricted diets and stringent avoidance of foods considered unhealthy or impure. But clean eating, when executed properly, should broaden your food world, not shrink it. Focusing on eating more fruits and vegetables and cooking more from scratch as time and budget allow will give you more of the nutrients you need for good health, while reducing your intake of ingredients that might concern you — and you don’t even need to use the term “clean.”