August 2019 Issue

CPE Monthly: Clean Eating — What Does It Really Mean?
By Ginger Hultin, MS, RDN, CSO
Today’s Dietitian
Vol. 21, No. 8, P. 42

Suggested CDR Learning Codes: 5200, 5370, 6010
Suggested CDR Performance Indicators: 1.1.3, 2.2.2, 4.1.2, 9.1.3
CPE Level 2

Take this course and earn 2 CEUs on our Continuing Education Learning Library

Interest in the term “clean eating” is high; a search of the hashtag #cleaneating on Instagram yields almost 45 million posts, and a search for books on the topic returns more than 8,000 results. Clean eating was termed one of the top potentially unhealthful celebrity diets in 2017 by the British Dietetic Association, even though there’s no particular clean eating diet.1,2 It’s a diet fad that’s been embraced by movie stars and models, including Miranda Kerr, Gwyneth Paltrow, and Jessica Alba, as well as some chefs, journalists, and nutritionists.3 It’s clearly a trending topic, but there’s little agreement about what it means, making it challenging to discuss and assess and leaving the definition up to individual interpretation. To some, it may refer to a way of eating, a type of diet, or a lifestyle, though there remains confusion about its principles. Thus, RDs working with clients eager to explore clean eating must counsel each individual differently after determining what meaning they derive from the term and what outcomes they desire.

This continuing education course reviews the ambiguity of the term “clean eating,” explores the various interpretations that have emerged, and examines the evidence for and against claims pertaining to clean eating. It also highlights the need for RDs to determine what outcomes their clients hope to achieve through clean eating and how to help them meet their needs using an evidence-based approach.

Aspects of Clean Eating
While the term may have arisen from good intentions for more healthful eating, its usefulness may be limited by its ambiguity. Dictionary definitions of the two words in the term may offer clues to what it may mean to individuals, though the following dictionary definitions don’t offer a great deal of information about how clean eating might be achieved:

clean: “Free from dirt, marks, or stains (‘the room was spotlessly clean’); morally uncontaminated, pure, innocent (‘clean living’)”; and
eat: “Put (food) into the mouth and chew and swallow it.”4

If taken literally, clean eating means consuming food free from dirt. But it appears that it can mean much more than that and suggests many different things to different people. An article in Consumer Affairs, for example, states that the clean eating diet is based on consumption of fresh fruits and vegetables and the avoidance of processed foods.2 The British Dietetic Association broadens the concept by suggesting that clean eating means avoiding all processed foods and cooking from scratch, eliminating refined sugar, and choosing foods in their natural state.1

These definitions don’t encompass all approaches to clean eating. To some, the term also may mean avoiding meat or animal products; keeping a diet free from chemical additives, colors, or flavors; avoiding foods containing gluten or GMOs; choosing all organically grown foods; or making all of these changes. More extreme interpretations may encourage a raw-food diet or juice cleanse.1

The term “clean” refers not only to food that lacks dirt (or, perhaps, such things as additives, gluten, and dairy) but also to the concepts of purity and innocence, which may appeal to some consumers. And for some, clean eating is associated not only with food but also with lifestyle, encompassing exercise and environmental activism. To some, it might mean a combination of all these practices, and to others it might be something entirely different. When moving beyond a definition of clean eating as consuming food without dirt, the possible interpretations are endless.

Research is emerging that explores what clean eating is and how to define it. Some researchers have created a new way to classify foods based on the extent and purpose of their processing as more studies emerge about links between processed foods and negative health outcomes. Some people define clean eating as consuming fewer processed foods.5 A consensus about a definition could help clear confusion and enable nutrition professionals to more confidently educate clients. Until that time, RDs can try to determine the clean eating outcomes that clients may desire and help them achieve their goals of improving their nutrition status.

Since there’s little consensus on the overall definition of clean eating, it’s necessary to examine what value there may be in each component identified as a potential aspect of clean eating and what evidence exists for that value. For example, it can be viewed as a dietary pattern that includes vegetarian and gluten-free diets and limits processed foods. Other aspects include avoiding GMOs or emphasizing consumption of organic food. Depending on the interpretation of clean eating, for some people, it can lead to restrictive tendencies and even disordered eating patterns.

Clean Eating as a Dietary Pattern
A popular magazine, EatingWell, recently ran an article on clean eating that suggests limiting processed foods, eating more veggies and fruits, cutting back on saturated fats, reducing alcohol intake, limiting added sugars, limiting sodium to 2,300 mg per day, choosing whole over refined grains, and eating less meat.6 When described in this way, the clean eating diet closely aligns with the Dietary Approaches to Stop Hypertension (DASH) eating plan, which recommends eating vegetables, fruits, whole grains, fat-free or low-fat dairy products, fish, poultry, beans, nuts, and vegetable oils; limiting foods that are high in saturated fat, such as fatty meats, full-fat dairy products, and tropical oils such as coconut, palm kernel, and palm oils; and limiting sugar-sweetened beverages and sweets.7 This definition of clean eating also aligns with the Mediterranean dietary pattern, which is characterized by a high intake of fruits, vegetables, legumes, and complex carbohydrates; a moderate consumption of fish and seafood; and the consumption of olive oil as the main source of fats. It includes a low to moderate amount of red wine during meals.8

Dietitians who work with clients who express an interest in this type of clean eating can educate them about the DASH diet, a research-based diet that supports health. It’s been found to result in significant decreases in systolic (25.2 mm Hg, p=0.001) and diastolic blood pressure (22.6 mm Hg, p=0.001), total cholesterol (20.2 mmol/L p=0.001), and LDL cholesterol (20.1 mmol/L, p=0.03). Researchers state that the DASH diet is an effective nutritional strategy to prevent CVD.9

Alternatively, RDs can educate clients on the Mediterranean dietary pattern, which also is associated with positive health outcomes, including significant reduction of overall mortality (relative risk [RR]=0.92; 95% confidence interval [CI]: 0.9, 0.94), cardiovascular incidence or mortality (RR=0.9; 95% CI: 0.87, 0.93), cancer incidence or mortality (RR=0.94; 95% CI: 0.92, 0.96), and neurodegenerative diseases (RR=0.87; 95% CI: 0.81, 0.94).9 These two diets may be appropriate patterns for clients desiring to follow a more structured plan for proven positive health outcomes and preventing or treating chronic disease.

Gluten-Free Diets
Some people attempt to eat clean by restricting specific ingredients or foods in their diets. For example, many people who don’t suffer from celiac disease or other allergies or sensitivities needlessly restrict intake of gluten. A study of 1,000 Australian adults by Staudacher and colleagues published in the British Journal of Nutrition found that participants perceived benefit of a gluten-free diet for health, weight loss, treating disease, and/or minimizing future disease risk. A survey of participants showed that almost 11% had chosen to avoid wheat, although only 1% had been diagnosed with celiac disease. The researchers listed the potential negatives of following a gluten-free diet if not medically indicated as including impaired dietary palatability, increased cost, isolation and social consequences, risk of developing an eating disorder because of dietary restriction, and nutritional inadequacy due to the nutrients found in whole wheat.10

Because studies show there’s no published experimental evidence to support that restricting foods such as gluten is helpful from a nutritional or health stance, dietitians can educate their clients that gluten-free eating isn’t necessary if not medically indicated.10,11 For clients who express an interest in following a gluten-free diet as a means to eat clean, ask them about their desired outcome, use open-ended questions and motivational interviewing, and ask permission to counsel them if they’re willing to listen. Educate them about the current research on some of the social and health challenges of unnecessarily restricting foods and about the nutritional content of whole wheat. Then help them ensure that with or without wheat, they can achieve a balanced diet. Wheat isn’t critical to human health as there are other sources of the nutrients and fiber it provides. Dietitians can support clients who remain committed to eliminating wheat gluten from the diet by suggesting alternatives.

Vegetarian Diets
Some clients may inquire about eliminating meat or animal products, including dairy, in an effort to eat clean. The position of the Academy of Nutrition and Dietetics states that “appropriately planned vegetarian, including vegan, diets are healthful, nutritionally adequate, and may provide health benefits for the prevention and treatment of certain diseases.” Reducing or eliminating animal products from the diet may in fact be beneficial. RDs can explore with clients why they want to reduce or eliminate animal products and educate them about how to do so in a healthful and balanced manner. For example, vegans need a reliable source of vitamin B12 from supplements or fortified foods. Because vegetarians and vegans are at reduced risk of certain health conditions, including ischemic heart disease, type 2 diabetes, hypertension, certain types of cancer, and obesity, this may be a positive change in their diets.12

Avoiding Processed Foods
Clean Eating, a magazine founded in 2010, states that “In every way, clean eating is all about consuming whole food in its most natural state, or as close to it as possible.”13 This conception of clean eating—as an effort to consume only whole or minimally processed foods—could be beneficial, depending on how the client defines processed foods.14 Any effort to limit processed meats, sugar-sweetened soft drinks, and high-calorie foods with low nutritive value could promote better health.5,15,16 When consumers interpret clean eating as an effort to avoid processed foods and attempt to read labels to determine how much processing a food has undergone and how healthful it may be, dietitians can help. They can support proven beneficial dietary patterns such as the DASH and Mediterranean diets that include unprocessed and minimally processed foods, or they can counsel their clients on simply consuming fewer highly processed foods, addressing nutrients of concern in these items and including more unprocessed and minimally processed foods based on their goals and lifestyle.

There’s evidence of increased rates of obesity and diet-related noncommunicable diseases in people from cultures that move from a more traditional, less processed dietary pattern to one that includes more refined sugar, salt, and saturated and trans fats found in many processed foods.17 Evidence supports that sugar-sweetened beverages, including soda and juice, as well as ultraprocessed foods (defined as industrial formulations that include substances not used in culinary preparations) affect Americans’ health and impact their diabetes risk and adiposity.15,16 A study in the British Medical Journal found that up to 82.1% of Americans consuming the highest quintile of calories from processed foods consumed more than the suggested 10% of the calories from added sugars.16

Although a group of researchers in Brazil don’t directly use the term “clean eating” in their research, they explore the belief that more processed foods are linked to negative health outcomes. This study classifies foods on a spectrum of less to more processed, and researchers say they believe that the potential health consequences of food processing have been overlooked. The premise of their study is that the consumption of industrially processed food and drink has a direct link to obesity and related chronic diseases.5

They classify unprocessed or minimally processed foods into Group 1. These are foods that have been cleaned, portioned, or naturally preserved in some way including drying, chilling, or freezing. Fresh meat, milk, legumes, nuts, fruits and vegetables, water, tea, and coffee all fit into this category. Group 2 includes substances extracted or purified from Group 1 foods by physical or chemical processing such as milling, refining, and hydrogenating, eg, flours, oils, salt, and sugar. The researchers observe that these foods are unpalatable on their own and need to be combined as culinary ingredients to make other products. Group 3 includes processed foods that are ready to eat with little to no preparation. Processing includes salting, sugaring, baking, frying, curing, smoking, pickling, and canning. These foods are known as fast food or convenience foods that are made ready to eat and shelf stable and include bread, cookies, canned fruit in syrup, chocolate, soda, hot dogs, sausages, baby food, and infant formula.5

The researchers say that the increased consumption of industrially processed foods and beverages is one direct cause of the pandemics of obesity and related chronic diseases, including type 2 diabetes, citing studies about the effects of sugar-sweetened beverages and fast food choices on obesity and other health outcomes.5

This study is similar to another presented in the British Medical Journal in which researchers classified food items according to a food classification system called NOVA, which is based on the extent of food processing. For example, minimally processed foods include fresh, dried, or frozen fruits and vegetables; grains; legumes; meat; fish; and milk. Processed culinary ingredients include table sugar, oil, fats, and salt. Ultraprocessed foods include those in which colors, sweeteners, emulsifiers, and other additives are used.16

Some consumers attempt to simplify the concept of clean eating or choosing fewer processed foods by following common headline nutrition tips. One popular suggestion is to shop the periphery of the grocery store. Another is to choose foods with three or fewer ingredients on the label, which could indicate a less processed food product. Dietitians know that a food having fewer ingredients doesn’t necessarily make it more healthful. A box or can could have a long list of vegetables, herbs, spices, grains, and beans and still be a very nutritious food. Clients should be educated to better understand how to read ingredients on labels to determine whether the products are highly processed or based on whole foods.

Shopping the periphery of the grocery store to avoid processed boxed or canned foods, however, may exclude potentially healthful products such as beans, whole grains, frozen vegetables, or tomato sauce. When assessing whether a food is more or less processed in an effort to eat clean, clients could erroneously perceive foods labeled “gluten-free,” “natural,” or “low-sodium” as being more healthful or “clean” products. Clients also may misunderstand words and phrases such as “organic,” “natural,” “light,” and “zero trans fats” while shopping, believing that these products labeled with those words are automatically “clean” because they don’t contain certain ingredients or forms of processing. In a recent report, “Consumers and ‘Clean’ Food,” Shelley Balanko, PhD, states that “for the majority of consumers, clean eating is still about avoiding things that sound artificial or unnatural, or, put more simply, eating food that is ‘made simply and grown naturally.’”18 Education on these topics is needed from dietary professionals who can help consumers understand whether the product they’re consuming is truly minimally processed.

As consumer interest grows, food companies are introducing more labeling pertaining to clean eating and the desire to eat fewer processed foods. For example, Panera has a clean food promise to its customers: “100% of our food is 100% clean.” To this company, that means no artificial preservatives, sweeteners, flavors, or colors. It applies to the chain’s US food menu and Panera at Home grocery products. Its “No No list” includes more than 80 items not allowed on the menu, including lard, sulfites, or artificial smoke flavor.19,20 Other companies on the same path responding to consumer desire for fewer ingredients that appear to be unnatural include Subway, which has stopped using a dough conditioner called azodicarbonamide, and Chipotle, which now touts all non-GMO ingredients.21 As consumer interest in clean eating continues, it likely will drive further change to businesses and health care.

Because highly processed foods that are energy dense and high in fat, sugar, and salt are linked in some studies to obesity and obesity-related diseases, working with clients to create a diet based on fresh, whole foods as opposed to highly processed foods may be a good strategy.5,15,16 To educate clients on eating less processed foods, the term “clean eating” doesn’t have to be used unless clients already associate it with eating a primarily whole foods diet; in these cases, there’s a possibility that using the term could be helpful.22 Dietitians should remove any of their own biases and use motivational interviewing to determine a client’s drivers for change and then move into a personalized nutrition plan.

Avoiding GMOs
Clean eating, to some, means avoiding GMOs. Consumer questions about GMOs and health are important to address, and they may come up in the context of clean eating. For example, Chipotle touting all non-GMO ingredients may raise the question for some clients of the importance of doing so.21 While some consumers already have strong opinions and feel passionate about the subject, studies show that consumer knowledge of GMOs generally is low, so clients may have a variety of questions.23 Consumers likely will have noticed “Non-GMO Project Verified” symbols on labels in grocery stores; this is a project driven by a nonprofit organization “dedicated to building and protecting a non-GMO food supply.”24 As a result, questions about labeling of genetically modified (GM) ingredients also may surface. Whether a dietitian or client is for or against GMO labeling, questions should be addressed according to the client’s questions and desired health outcomes. RDs can inquire about what the client already has heard and how the information will be helpful to them.

There are several GM foods currently available in the marketplace, including soybean products, canola, potatoes, eggplant, strawberries, corn, tomatoes, lettuce, cantaloupe, carrots, sugar beets, and many more.25

Some of the benefits of GM foods include a lower cost to consumers, as these foods may grow faster and crops can be more productive as well as increase farmers’ profits.26 GM foods also can reduce the need for use of topical pesticides. However, there are potential negatives as well, including environmental and economic concerns, GM cross-pollination methods that may damage other organisms in the environment, the increased use of the herbicide glyphosate, and that developing countries may not be able to afford this technology, making them reliant on industrialized countries for food.25,27,28 The National Academy of Sciences notes that “the genetic transformation of food has the potential to produce unanticipated allergens or toxins that may alter the nutritional quality of food” but those outcomes have yet to be observed.23,28

When it comes to health, at this time there’s little evidence that GMOs are harmful or that avoiding them is more healthful. Studies have shown that they’re equal to non-GM foods in nutrient composition, and the National Academy of Sciences has reviewed the safety of GM crops, concluding that they pose no unique health risks.23,26,28 That said, long-term studies on the health outcomes of GM foods are lacking, as this technology is still relatively new, and some studies state there are many unknowns when it comes to the risks of GM foods.23,25,28

If asked about the risk and benefits of GM foods, dietitians can present the facts to their clients. If clients are concerned that GM foods are unhealthful for them, perhaps with more education they can understand that studies at this time show GM foods don’t pose health threats to humans when consumed. If they inquire about a clean eating lifestyle and cite environmental concerns, then it may be best for them to avoid GM foods.

Organic vs Conventional Food
The clean eating lifestyle for some includes the desire to eat more organically grown foods. Organic products must follow growing requirements that include standards of production, labeling, and certification. USDA organic products meet requirements such as being produced without prohibited methods such as genetic engineering, ionizing radiation, or sewage sludge; being produced only with allowed substances; and being overseen by a USDA National Organic Program-authorized certifying agent, following all USDA organic regulations.29

Australian researchers Smith and Paladino have explored the relationship between consumers’ environmental concerns and their organic food purchases. These researchers found that, rather than citing the certification process of organic farming when choosing organic, consumers commonly believe that organic means “natural” or “unprocessed” instead. Consumers often choose organic foods because they perceive them to be more healthful than conventional foods. Their research also showed that the greater their concern about the environment, the more likely consumers are to choose organic.30 Caring about the environment and one’s impact is, of course, a good thing, but many clients may have misconceptions regarding health benefits of organic vs conventional foods. Eating organic foods doesn’t necessarily equate to health, weight loss, or eating clean.

Discussion of organic products with consumers must be targeted to how eating organic foods fits in with their desire to eat clean. Regarding health, the differences in the composition between organic and conventionally grown crops aren’t significant. Some studies have shown a modestly higher content of antioxidants in organic produce, as well as lower content of the mineral cadmium in organic cereal. Organic dairy and meat products have been shown to have higher content of essential omega-3 fatty acids compared with conventional products.31 One large prospective study by Bradbury and colleagues (n=623,080) of the consumption of organic food intake and reduced risk of soft tissue sarcoma, breast cancer, non-Hodgkin lymphoma, and other common cancers in women found little or no decrease in the incidence of cancer, except possibly for non-Hodgkin lymphoma (RR=0.79, 95% CI: 0.65, 0.96).32 From the available research, the evidence for the health effect of choosing organic food isn’t convincing enough to recommend that clients choose it for this reason alone.33

Studies routinely have found that consumers who regularly purchase organic food tend to incorporate more vegetables, fruit, and whole grain products while consuming less meat. They tend to have more healthful overall dietary patterns.31 A study by Eisinger-Watzl and colleagues found that people who purchased organic food consumed 17% more fruit, 23% more vegetables, 25% less meat, and 58% fewer soft drinks than did people who didn’t purchase organic foods (p<0.001). The study also found that people who bought organic food exhibited more healthful lifestyle characteristics such as less smoking, more physical activity, and a healthier body weight.34 The positive associations in studies may be related to this fact rather than to the organic foods being more healthful than conventional. Given this research, dietitians can educate their clients on the pros and cons of choosing organic but primarily focus on overall healthful lifestyle patterns to emphasize that consumption of organic foods can’t compensate for the negative effects of a sedentary lifestyle, smoking, or other unhealthful behaviors.

Potential Dangers of Clean Eating
As restaurants remove certain ingredients from their foods and consumers read popular articles about foods to restrict, they may strive to eliminate foods they determine as unclean from their diets. This could be beneficial to health in some ways if consumers are moving from a highly processed, calorically dense diet to one that follows the current 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 current 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, hyponatremia, metabolic acidosis, pancytopenia, low testosterone, and bradycardia.36 Using clean eating as an excuse for restriction 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 misinformation 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.

Learning Objectives

After completing this continuing education course, nutrition professionals should be better able to:
1. Distinguish the challenges of defining clean eating.
2. Evaluate the potential benefits and drawbacks to using the term “clean eating” with clients.
3. Communicate effectively with clients who express a desire to eat clean, determine what outcomes they desire, and counsel them about how to achieve their nutrition goals.

CPE Monthly Examination

1. Clean eating could be defined in which of the following ways?
a. It’s completely unclear.
b. Eating food that’s free from dirt, marks, or stains
c. A collection of healthful eating habits
d. Following a Mediterranean diet

2. What is orthorexia?
a. Another word for binge-eating disorder
b. A condition that includes symptoms of obsessive behavior in pursuit of a healthful diet
c. A condition rooted in striving for physical perfection and thinness
d. A condition classified as an official eating disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM)

3. Clean eating is a diet trend that:
a. Was first mentioned in the 1980s.
b. Is listed in the DSM associated with orthorexia nervosa.
c. Has two possible definitions that can’t be agreed on.
d. Was one of the most popular diets in 2017.

4. According to the food classification system presented by Monteiro and colleagues, which of the following is true?
a. Group 1 foods are ultraprocessed.
b. Group 1 foods contain three ingredients or fewer.
c. Group 1 foods are considered unprocessed.
d. Group 3 foods are the most healthful.

5. Which of the following is true about the Dietary Approaches to Stop Hypertension (DASH) diet eating plan?
a. It’s been found to result in significant decreases in systolic and diastolic blood pressure and in total and LDL cholesterol.
b. It’s been found to result in significant decreases in systolic and diastolic blood pressure with no clinically significant changes in total and LDL cholesterol.
c. It’s been found to result in an improvement in immune response because of improvements in blood pressure.
d. It’s been found to result in significant decreases in systolic and diastolic blood pressure, A1c, and C-reactive protein.

6. A study presented in the British Journal of Nutrition by Staudacher and colleagues found that following a gluten-free diet when not medically necessary may have drawbacks, including which of the following?
a. Social isolation and possible development of an eating disorder
b. A deficiency in carbohydrate intake
c. A deficiency in many major micronutrients
d. A reduction in happiness scores

7. According to the study in the journal Appetite by Barnett and colleagues, some consumers use which of the following types of food choices as socially acceptable ways to restrict their diets?
a. Conventionally grown foods
b. Locally sourced foods
c. Foods from the Paleo diet plan
d. Foods from the fruitarian diet

8. A study by Eisinger-Watzl and colleagues suggests that:
a. There was no significant difference in dietary pattern between people who purchased organic food and those who didn’t.
b. People who purchased organic food consumed about the same amount of fresh produce but less meat and fewer soft drinks as did people who purchased conventional foods.
c. People who purchased organic food consumed more fruits and vegetables but equal amounts of meat as people who purchased conventional foods.
d. People who purchased organic food consumed more fruits and vegetables yet less meat and soft drinks than did people who purchased conventional foods.

9. A study by Bradbury and colleagues on the consumption of organic food intake found which of the following to be true?
a. Little or no decrease in the incidence of cancer except possibly for non-Hodgkin lymphoma
b. A slightly increased risk of cancer in those who chose organic foods most of the time
c. A slightly reduced risk of cancer in those who chose organic foods most of the time
d. Little or no decrease in the incidence of cancer in those who chose organic foods most of the time

10. What is the first step RDs should take when helping clients who want to try a clean eating diet?
a. Educate them that many people who follow a clean eating pattern develop anorexia.
b. Inform them that clean eating has no real meaning and that there’s no specific clean eating diet.
c. Inquire as to how they heard about clean eating, what it means to them, and what they hope to get out of it.
d. Advise them to try the DASH diet.


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2. Huffman M. “Clean” eating may be 2016’s biggest food trend. Consumer Affairs website. Published January 5, 2016. Accessed January 8, 2017.

3. McCartney M. Clean eating and the cult of healthism. BMJ. 2016;354:i4095.

4. website. Accessed January 31, 2017.

5. Monteiro CA, Levy RB, Claro RM, Castro IR, Cannon G. A new classification of foods based on the extent and purpose of their processing. Cad Saude Publica. 2010;26(11):2039-2049.

6. Valente L. 7 tips for clean eating. EatingWell website. Accessed February 5, 2017.

7. DASH eating plan. National Heart, Lung, and Blood Institute website. Accessed February 5, 2017.

8. Sofi F, Abbate R, Gensini GF, Casini A. Accruing evidence on benefits of adherence to the Mediterranean diet on health: an updated systematic review and meta-analysis. Am J Clin Nutr. 2010;92(5):1189-1196.

9. Siervo M, Lara J, Chowdhury S, Ashor A, Oggioni C, Mathers JC. Effects of the dietary approach to stop hypertension (DASH) diet on cardiovascular risk factors: a systematic review and meta-analysis. Brit J Nutr. 2015;113(1):1-5.

10. Staudacher HM, Gibson PR. How healthy is a gluten-free diet? Brit J Nutr. 2015;114(10):1539.

11. Gaesser GA, Angadi SS. Gluten-free diet: imprudent dietary advice for the general population? J Acad Nutr Diet. 2012;112(9):1330-1333.

12. Melina V, Craig W, Levin S. Position of the Academy of Nutrition and Dietetics: vegetarian diets. J Acad Nutr Diet. 2016;116(12):1970-1980.

13. About the magazine. Clean Eating website. Accessed January 8, 2017.

14. Subica AM, Grills CT, Villanueva S, Douglas JA. Community organizing for healthier communities: environmental and policy outcomes of a national initiative. Am J Prev Med. 2016;51(6):916-925.

15. Forouhi NG. Consumption of sugar sweetened beverages, artificially sweetened beverages, and fruit juice and incidence of type 2 diabetes: systematic review, meta-analysis, and estimation of population attributable fraction. BMJ. 2015;351:3576.

16. Steele EM, Baraldi LG, da Costa Louzada ML, Moubarac JC, Mozaffarian D, Monteiro CA. Ulta-processed foods and added sugars in the US diet: evidence from a nationally representative cross-sectional study. BMJ. 2016;6(3):9892.

17. Baker P, Friel S. Processed foods and the nutrition transition: evidence from Asia. Obes Rev. 2014;15(7):564-577.

18. Watson E. Special report: consumers and ‘clean’ food: where is the clean label trend going next? FoodNavigator-USA website. Updated April 27, 2017. Accessed April 29, 2017.

19. What does clean food mean to Panera? Panera Bread website. Accessed April 29, 2017.

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