nutrients

Article
“It’s Healthy Because It’s Natural.” Perceptions of
“Clean” Eating among U.S. Adolescents and
Emerging Adults
Suman Ambwani 1, * , Gina Sellinger 2 , Kelsey L. Rose 2 , Tracy K. Richmond 3 and
Kendrin R. Sonneville 2
1 Department of Psychology, Dickinson College, P.O. Box 1773, Carlisle, PA 17013, USA
2 Department of Nutritional Sciences, University of Michigan School of Public Health, Ann Arbor, MI 48109,
USA; [email protected] (G.S.); [email protected] (K.L.R.); [email protected] (K.R.S.)
3 Division of Adolescent Medicine, Boston Children’s Hospital, Boston, MA 02115, USA;
[email protected]
* Correspondence: [email protected]; Tel.: +1-717-245-1022




Received: 22 April 2020; Accepted: 4 June 2020; Published: 7 June 2020


Abstract: Definitions for the culturally trendy “clean” eating phenomenon vary: whereas some
characterize it as natural and healthy, others adopt more restrictive, moralizing, and affectively-laden
definitions that may reflect disordered eating. We examined levels of familiarity with “clean” eating,
sources of information, and perceptions of this dietary trend among a large, diverse sample of
U.S. adolescents and emerging adults recruited from the National MyVoice Text Message Cohort
(n = 1266; ages 14–24 years). Participants answered five questions assessing knowledge of “clean”
eating, definitions, perceived healthiness vs. harm, and willingness to adopt “clean” eating, and
responses were coded by three trained researchers. Results indicate that 55% of respondents had
previously heard of “clean” eating, most commonly through social media, other online sources, and
peers. Definitions were heterogeneous, with 40% offering “non-processed” or “whole foods” and 13%
noting “non-GMO” or “organic” components. Few respondents (0.6%) expressed outright skepticism
about “clean” eating, but many (30%) identified dietary avoidance and restriction as part of the
definition. Overall, 71% characterized “clean” eating as a healthy approach, whereas 6% flagged it
as “unhealthy”, and 18% noted elements of both healthfulness and harm. Notably, 41% reported
they “probably would” try “clean” eating themselves, with greater willingness to try “clean” eating
among cisgender women. Present findings highlight high levels of awareness and positive attitudes
toward “clean” eating among young people in the U.S., with little recognition of the potential risks of
dietary restriction. Further research should examine actual dietary behaviors to clarify potential risks
of “clean” eating and related trends and thus inform strategies for eating disorder prevention.

Keywords: eating; diet; text-messaging; disordered eating; adolescents; emerging adults;

awareness; attitudes

1. Introduction
Dieting is a popular endeavor, particularly when it is framed as a health pursuit; a 2019 survey of
over 1000 U.S. adults indicated that 38% had followed a diet over the past year, of which “clean” eating
was the most commonly cited diet [1]. “Clean” diets and labels are heterogeneous entities, without
clear definitions or oversight from regulatory authorities, resulting in their broad usage by industry
and varied interpretation by consumers [2]. For instance, whereas some “clean” diets emphasize the
consumption of whole, unprocessed foods, others involve eliminating entire food groups such as dairy,
refined sugar, wheat, and “alkaline” foods [3,4]. While “clean” recipes may be no more nutritious than

Nutrients 2020, 12, 1708; doi:10.3390/nu12061708 www.mdpi.com/journal/nutrients

Nutrients 2020, 12, 1708 2 of 11

matched control recipes [5], the pursuit of “wellness” through “clean” eating is closely tied to the values
of healthism, an approach that singularly focuses on individual responsibility to pursue health [3].
Although pursuers of “wellness” benefit from social acceptance and ‘moral citizenship’ [6], the cultural
moralization of eating behavior, signaled by the ambiguous language of “clean” (vis à vis “dirty”)
foods could increase harmful dietary restriction and preoccupation with so-called “healthy” eating
among vulnerable groups including individuals at risk for eating disorders. Furthermore, cultural
preoccupations with “clean” eating may promote dichotomous thinking, an approach characterized by
extreme “all bad” or “all good” views toward food.
Although dieting is a well-established risk factor for disordered eating in adolescents and young
adults [7–12], research linking the two has historically focused on diets explicitly branded for weight
loss. However, research also suggests that following a special diet (e.g., vegan/raw, paleo, gluten-free)
may be linked with higher rates of eating disorders [13], evidence that is particularly salient within the
backdrop of a burgeoning wellness industrial complex [14,15]. Nonetheless, the impact of new waves
of “wellness” focused diets remains poorly understood.
“Clean” diets may require particular scrutiny for their ability to mask eating disorder symptoms as
ostensibly “healthy” behaviors and thereby prevent detection and intervention [16]. Indeed, research
suggests that positive attitudes toward “clean” diets are linked with disordered eating attitudes
and behaviors [4] and those who followed advice from “clean” eating websites exhibited higher
dietary restraint, a risk factor for disordered eating [17]. Although not yet recognized as a standalone
diagnosis, research suggests that orthorexia nervosa (ON) reflects an unhealthy preoccupation with
healthy eating, one associated with substantial distress and functional impairment mirroring eating
disorder psychopathology [18,19]. Moreover, the National Eating Disorder Association suggests
that the “clean” eating trend may be associated with ON [20], and scholars often describe ON as an
extreme variant of “clean” eating (e.g., [6,21,22]). Thus, “clean” eating may involve excessive dietary
restriction resembling an eating disorder [23] and thereby increase risk for nutritional deficiencies [24].
Even more concerning is the potentially expansive reach of “clean” diets: individuals who may not
have been susceptible to dietary restriction for weight loss may be vulnerable to new diet approaches
promoting the obsessive pursuit of wellbeing [3]. For instance, a recent pilot investigation reported
generally favorable perceptions of “clean” diets among a small sample of U.S. undergraduates, even
when those diets were linked with substantial distress and dysfunction [4]. Thus, these new dietary
approaches need to be better understood, particularly among a larger swath of adolescents and young
adults, in order to facilitate macro-level eating disorder prevention, a key priority for eating disorder
research [25,26].
Whereas research suggests that adolescents and emerging adults are particularly susceptible to
dieting and disordered eating [11], perceptions of “wellness” oriented diets among adolescents and
emerging adults remain poorly understood. Further understanding of how young people view “clean”
eating could inform prevention and intervention efforts to reduce risk for nutritional deficiencies and
disordered eating and thereby promote public health. Thus, the purpose of the current exploratory
study was to examine impressions of “clean” eating and gender differences in attitudes toward “clean”
diets among a large, diverse sample of young people in the United States.

2. Method

2.1. Participants
Participants were from the MyVoice Text Message Cohort (n = 1266 respondents; [27]). A group
of individuals aged 14–24 years were recruited via targeted Facebook and Instagram ads to match
national demographics based on weighted samples from the 2016 American Community Survey (ACS).
Demographic features for those who responded to at least one question on the current survey (n = 1020)
are reported in Table 1. This study was approved by the University of Michigan Institutional Review
Nutrients 2020, 12, 1708 3 of 11

Board (HUM00119982). Participants provided consent online and were compensated $1 for responding
to the survey.

Table 1. Demographic features of respondents.

Self-Reported Characteristic n (%)

Gender
Female 539 (52.8%)
Male 391 (38.3%)
Transgender 45 (4.4%)
Nonbinary 25 (2.5%)
Other 15 (1.5%)
Race
American Indian or Alaskan Native 30 (2.9%)
Asian 143 (14%)
Black or African-American 150 (4.7%)
Native Hawaiian or other Pacific Islander 12 (1.2%)
White or Caucasian 752 (73.7%)
Other 50 (4.9%)
Hispanic or Latino 149 (14.6%)
Educational Level (self)
8th grade or less 48 (4.7%)
Some high school 541 (53%)
High school graduate 102 (10%)
Some vocational school 2 (0.2%)
Some college 200 (19.6%)
Completed vocational school 7 (0.7%)
Completed an Associate’s degree 22 (2.2%)
Completed a Bachelor’s degree 70 (6.9%)
Some graduate school 16 (1.6%)
Completed a Master’s degree 7 (0.7%)
Some graduate training beyond a Master’s degree 2 (0.2%)
Received free or reduced school lunch in middle/high school 385 (37.7%)

2.2. Measures
Demographics. Participants self-reported age, gender, race, zip code, marital status, education
level (self and parent/guardian), and socioeconomic status as part of their registration in the MyVoice
cohort. We did not assess current dietary behaviors. Additional details about the cohort have previously
been published [27].
Perceptions and attitudes toward “clean” eating questions. Participants were prompted to answer
five predominantly open-ended questions about “clean” eating, described as “an approach to eating
that has been getting a lot of attention lately.” Questions were presented individually in the following
order and could not be answered retroactively: (1) Have you previously heard about “clean” eating?
If so, how did you hear about it? (2) How would you define “clean” eating? (3) “Clean” eating usually
means eating natural, whole foods, and strictly avoiding processed foods. Knowing that, what is your
opinion of “clean” eating? (4) Do you think “clean” eating is healthy or harmful? Tell us why. (5) How
likely would you be to try “clean” eating for yourself? (1 = probably will not try it; 2 = not sure;
3 = probably will try it). Questions were pilot-tested with the MyVoice team prior to administration.

2.3. Procedure
Participants responded to questions via text message between January–February 2019. Due to
the carefully curated nature of the MyVoice cohort and the use of captcha and text message response
procedures for providing consent [27], there were no concerns about random responding by bots.
All responses were checked by the primary author (S.A.) to exclude nonsensical or implausible answers
(e.g., strings of letters or digits, random answers that did not match the questions) and correct any
Nutrients 2020, 12, 1708 4 of 11

misalignments in data due to the text messaging system (e.g., long responses that might have carried
over to the next column of data). After data cleaning, the number of total respondents varied by
question (n = 945–1020).

2.4. Data Analyses

For the open-ended questions, length of responses varied from 2 to 967 characters, with specific
character counts per question as follows: question 1 (M = 32.35, SD = 36.22), question 2 (M = 54.47,
SD = 40.49), question 3 (M = 75.92, SD = 69.35), and question 4 (M = 93.26, SD = 76.27). We used
qualitative content analysis to code responses to these questions to capture nuances and identify distinct
themes based on the data [28]. Analysis proceeded in four phases. First, the primary author (S.A.)
generated initial themes based on reviewing the first 100 responses for each question. The investigative
team (S.A., K.R.S., T.K.R.) then reviewed those data to generate additional themes and reached a
consensus on primary themes. Second, the themes were clarified and revised slightly based on
feedback from coding 25 additional responses by three coders (K.L.R., G.S., H.S.). Third, these coders
independently coded the responses for each question in the data set (responses could be coded
for multiple themes). Inter-coder reliability was determined by calculating agreement between all
three coders. A total of 151 responses (~15% of total responses) were triple-coded, at which point
agreement statistics consistently indicated over 90% agreement. Fourth, two coders (K.L.R., H.S.)
independently coded the remaining responses and the third coder (G.S.) received the double-coded
responses in batches, calculated agreement at each round, and provided continuous clarification on the
final themes. Final estimates for interrater agreement ranged from 78–99% for each theme (M = 94.37%;
SD = 0.06) and discrepancies were resolved by the third coder. We conducted frequency analyses
(counts and percentages) to summarize the occurrence of various themes in participant responses.
We then conducted exploratory chi-squared analyses of independence to compare interest in “clean”
diets across gender categories, followed by Bonferroni-corrected post-hoc analyses to compare those
who were interested versus unsure or uninterested in trying “clean” diets.

3. Results
Among those in the MyVoice cohort, 1020 participants provided interpretable responses to at least
one of the questions in the current survey (80.57% response rate). Over half of the respondents had
heard about “clean” eating (54.6%), and they reported learning about it from a wide variety of sources,
with social media most commonly specified (see Table 2).
Participant definitions of “clean” eating were heterogeneous, with many highlighting elements
of perceived healthiness (38.7%), dietary restriction (29.7%), and processed or whole foods (39.7%),
and few identifying weight loss goals (<1%), detoxification (2%) or outright skepticism about “clean”
diets (<1%) as part of their definition (see Table 3). Participant opinions of “clean” eating included
comments on its perceived healthiness (with 88.3% viewing it as healthy), impact on wellbeing (with
75% viewing it as having a positive impact), ambiguous opinions (of which 88% were positively hued),
and ambivalent or neutral opinions (7.5%), and others highlighted financial considerations, feasibility,
and environmental considerations in shaping their opinions (1.2–15.3%). When asked to identify
whether “clean” eating was healthy or harmful, most respondents identified it as healthy (70.8%), but
some participants identified elements of healthfulness and harm (18%), such as through increased
risk for eating disorders. In terms of willingness to try “clean” eating, 24.1% (220/912) reported they
probably would not try it, 41.2% (376/912) probably would, and 34.6% (316/912) were unsure.
Nutrients 2020, 12, 1708 5 of 11

Table 2. Awareness of “clean” eating and sources of information.

Have You Previously Heard about “Clean” Eating?

% (n)
Yes 54.6% (557)
No 45.4% (463)
If So, How Did You Hear about It?
% (n)
Source was specified (yes) 47% (480)
Social media 194/480; 40.4%
Unspecified 52.6% (102)
Instagram 22.2% (43)
Tumblr 1.0% (2)
Twitter 1.0% (2)
YouTube 10.3% (20)
Facebook 12.9% (25)
Reddit 1/5% (3)
Pinterest 5.7% (11)
Other social media 0.5% (1)
Online (unspecified) 102/480; 21.3%
Commercials 18/480; 3.8%
Blogs 13/480; 2.7%
Human contact 150/480; 31.3%
Unspecified/other 32.7% (49)
Parent 14.0% (14)
Peer 44.7% (67)
Sibling 4.0% (6)
Health professional 8.0% (12)
Educator 1.7% (4)
Exercise/fitness/trainer 1.7% (4)
Educational resources 3/480; 0.6%
Schools 28/480; 5.8%
TV programs 25/480; 5.2%
Magazines 23/480; 4.8%
Media (other/unspecified) 40/480; 8.3%
Note: Numbers indicate the percentage of respondents whose answers reflected the theme.

A chi-squared analysis of independence comparing willingness to adopt “clean” diets across

gender categories was significant, χ2 (6) = 34.56, p < 0.01, with 46.8% (249/532) of cisgender women,
37.6% (118/314) of cisgender men, and 13.6% (9/66) of those identifying with other genders reporting
that they “probably would” try “clean” eating themselves. Post-hoc analyses using a Bonferroni
correction compared respondents who “probably would” to those who would not or were unsure;
results indicated significant differences between all gender groups, including, cisgender men and
cisgender women (χ2 (1) = 6.84, p = 0.009)), cisgender women and other gender (χ2 (1) = 26.33, p < 0.001),
and cisgender men and other gender (χ2 (1) = 14.05, p < 0.001), with greater willingness to try “clean”
eating among cisgender women, followed by cisgender men, than their other gender counterparts.
Nutrients 2020, 12, 1708 6 of 11

Table 3. Definitions of “clean” eating, opinions, and perceptions of healthiness vs. harm.

Theme
Code Definition Sample Responses
% (n)
How would you define “clean” eating?
Response notes that “clean eating” is “healthy” or “Eating healthy”
Perceived healthiness
“good for you” or alternately involves avoiding things “Eating foods based on dietary guidelines. A lot of green foods, close to no
38.7% (382)
that are seen as “unhealthy”. junk food, eating foods that are organic and a lot of vegetables and fruits.”
“Eating foods perceived to be healthier than other foods (fresher, less
processed, colorful but only naturally colorful) even when there is no
Skepticism Response indicates a critical or skeptical perspective of
scientific evidence that these foods are healthier”
0.6% (6) “clean eating”.
“Clean eating is just any eating or food that is healthier sounding, but
might not actually be healthy . . . ”
Detox/cleanse Response notes that “clean eating” involves purifying, “ . . . maybe it’s some sort of cleanse.”
2.0% (20) de-toxification, or cleansing the body in some way. “A way to cleanse your body and eat healthy”
Environment/
References environment and sustainability benefits to “ . . . no waste other than compostable items”
sustainability
“clean eating”. “Only eating food grown organically and sustainably”
4.2% (41)
Non-diet-related Response includes other types of “cleanliness” that are “Eating with rinsed or sanitized foods”
2.2% (22) unrelated to diet/nutrition or environment. “Not eating really messy”
“Eating only things that are good for you”
Limit/avoid/restrict foods Response uses dieting/restricting terminology such as “Healthy eating, no fats no fried food, no juices”
29.7% (293) “avoid” “restrict” “only eat if . . . ” and so forth. “Eating nothing but veggies and fruit, very low or no carb. No sugar or
fat”
Calorie reduction/weight loss Definition explicitly notes fewer calories and/or weight “Avoiding unhealthy food in an explicit way to lose weight”
0.9% (9) loss as part of “clean eating.” “ . . . cutting off calories in order to get a better diet.”
Body functionality/ Response identifies being in tune with one’s bodily
“ . . . eating healthy foods in order to take care of your body.”
mindfulness needs/cues/functions and/or being mindful/present in
“Eating mindfully”
2.6% (26) the moment in one’s approach toward eating.
Response comments on processed/unprocessed foods, “Eating things without preservatives or artificial colors or flavoring.”
Processed/whole foods
raw foods, natural foods, or whole foods in some “Eating food that has not been processed/minimally processed.”
39.7% (391)
manner (including use of artificial colors/flavors). “avoiding processed foods”
Genetically modified (GMO)/organic Response comments on GMO or organic foods in some “Eating organic”
13.4% (132) manner. “It sounds like a diet in which you only eat organic foods.”
Other farming practices Response comments on pesticides, cage-free/free-range, “ . . . food that has no pesticides on it”
1.8% (18) or other farming practices not noted above. “Eating healthy things with no chemicals”
Nutrients 2020, 12, 1708 7 of 11

Table 3. Cont.

Theme
Code Definition Sample Responses
% (n)
“Clean” eating usually means eating natural, whole foods, and strictly avoiding processed foods. Knowing that, what is your opinion of “clean” eating?
Healthy:
Comments on “healthiness”
“ . . . a healthy eating style”
“Healthy”
Unhealthy:
88.3% (211) Response specifically indicates that it is unilaterally a
“I do not support it, because it encourages restrictive eating and cutting
“Unhealthy” healthy or unhealthy strategy, or, suggests both healthy
out food groups, two harmful practices that can lead to eating disorders.”
4.6% (11) and unhealthy features.
Both Healthy and Unhealthy:
“Both healthy and unhealthy”
“It can be good for your general health, but when taken too far it can
7.1% (17)
become dangerous”
Code 1:
Comments on “wellbeing”
“ . . . could definitely benefit you in a plethora of ways”
“Positive”
Response is characterized by positive or negative views Code 2:
75.0% (129)
on the impact of “clean” eating on one’s general “it sounds bothersome, having to know what foods are okay to eat and
“Negative”
well-being, or, suggests both positive and negative what aren’t, according to that definition. And I’m not sure what benefits it
6.4% (11)
perspectives. would provide, it sounds like it’s not worth it.”
“Both positive and negative”
Code 3:
18.6% (32)
“I think clean eating can be good, but some people go overboard with it”
Ambiguous
Positive:
“Positive” Response that indicates a generally positive or negative
“Seems like it would be good”
88.0% (345) impression but does not offer a specific reason and does
Negative:
“Negative” not refer to any component of well-being or health.
“Not good”
12.0% (47)
“I believe it is the persons [sic] choice whether or not they want to eat
natural foods however personally, I will eat whatever foods processed or
Ambivalent Response offers ambivalent or neutral impressions
not.”
7.5% ( 72) toward “clean” eating.
“I think that it makes sense if some people want to live that way but
processed foods aren’t that bad”
“it’s a smart choice for those who have the time and money for those
Consideration of cost/finances Response highlights the financial aspects of pursuing options”
14.2% (136) “clean eating”. “I think that it’s peoples’ choice to do what they want. A lot of people
can’t afford clean eating, and a lot of stuff that is bad for you is tasty.”
Consideration of practicality/feasibility Response highlights practical implications (i.e., lack of “ . . . it might be hard. It sounds ideal, but I’m not sure I’d be able to
15.3% (147) feasibility) regarding the pursuit of “clean” eating. completely eradicate processed foods.”
Consideration of environment/ “I think it’s good for your body and the environment.”
Response comments on environment/sustainability
sustainability “It’s good considering how much processed foods contribute to our
components to “clean” eating.
1.2% (12) climate change . . . ”
Nutrients 2020, 12, 1708 8 of 11

Table 3. Cont.

Theme
Code Definition Sample Responses
% (n)
Do you think “clean” eating is healthy or harmful? Tell us why.
“Healthy! Does nothing but good for your body because you’re only
Healthy Answer specifies that “clean eating” is strictly healthy
putting good stuff in”
70.8% (669) or good for one’s body.
“Healthy because you wouldn’t be eating addictive chemicals”
“I think it’s harmful because people might not be eating enough. My
friends are eating similar to this and are not eating enough and worry too
Harmful Answer specifies that “clean eating” is strictly
much about food.”
5.8% (55) unhealthy or harmful.
“Harmful . . . .I believe that it is a very disordered way of eating that puts
foods in categories of only “clean” i.e., good or “dirty” i.e., bad . . . ”
“Healthy but can be harmful if not getting all your carbs and food groups
Both, healthy and harmful Answer specifies that “clean eating” is both healthy and in per day”
18.0% (170) harmful in the context of one’s health. “Healthy when used as a guideline. It’s unhealthy when you obsess over
food and count calories”
“I think neither, because I know nothing about it. The words make me
Neither healthy nor harmful Answer specifies that “clean eating” is neither healthy
think *healthy* but I don’t form opinions without science to back it up.”
2.3% (22) nor unhealthy.
“It’s neither, you can be healthy and not clean or vice versa”
“I think it’s harmful for the environment because the energy needed to
Other Answer does not address healthiness/unhealthiness of
produce Whole Foods may offset the pollution saved from having this
1.7% (16) “clean eating”.
lifestyle”
“Harmful, because it encourages harmful practices like restrictive eating.”
Answer notes that clean eating can involve harmful
Why? Restrictive behavior. “I think it is harmful because it encourages people to unduly restrict their
dietary behaviors such as rigidly following a diet and/or
8.6% (81) diets and to see certain foods as “bad.” This is also a hallmark of
restricting one’s food intake.
disordered eating.”
“Harmful because it perpetuates the myth that people need to have bad
Answer notes that “clean eating” promotes feelings of foods and good foods which is part of diet culture”
Why? Negative emotion.
guilt/shame or other negative emotions about eating “ . . . Lastly, having a healthy relationship with food is more important
2.3% (22)
behavior. that eating 100% clean. The idea that some foods are bad is harmful.
Nobody should feel guilty about eating.”
Answer notes that “clean eating” promotes thinking “ . . . It’s unhealthy when you obsess over food and count calories”
Why? Rigid cognition.
obsessively and/or ruminating/worrying about food, “Harmful because it’s not moderation and an obsession of you don’t get
2.0% (19)
spending too much time thinking/planning food. the right nutrients”
“Could go either way. It could lead to anorexia or other eating disorders.”
If the answer goes beyond behavioral restriction,
Why? Eating disorder risk. “Mostly healthy. but some people might push this diet to the extreme and
negative emotion, and/or cognitive preoccupation, and
1.6% (15) not understand the full definition. For example, if they think that clean
explicitly specifies risk of eating disorders.
eating means eating less food, this could turn into an eating disorder”
Note. Due to non-mutually exclusive coding, percentages in the table sum to greater than 100%.
Nutrients 2020, 12, 1708 9 of 11

4. Discussion
Dietary fads such as “clean” eating have potentially wide-reaching public health implications,
ranging from increased eating disorder risk [17] to the potential for nutritional deficiencies among
vulnerable individuals [24]. Our findings suggest high levels of awareness, largely favorable
impressions, and high levels of interest in pursuing “clean” eating in a large, diverse sample of
U.S. adolescents and young adults. Although definitions varied widely, our data suggest that “clean”
eating is frequently characterized by unprocessed or whole foods (such as raw foods, natural foods,
or foods without artificial colors or flavors) and sometimes within the context of farming practices
such as non-genetically modified (GMO), organic or environmentally-friendly/sustainable farming
methods. These predominantly positive impressions may reflect the ways in which “clean” diets are
marketed and the cultural moralization inherent in the language of clean/dirty. Moreover, a minority
of respondents demonstrated awareness of the potential for harm conferred by “clean” eating pursuits.
Public health messaging that highlights these risks may facilitate a more nuanced understanding about
“clean” diets and related “wellness” health trends among a broader swath of young people.
Notably, very few participants identified weight loss or calorie reduction as key themes in their
definition of “clean” eating, and although “clean” eating was frequently defined using language
of dietary restriction, few respondents offered restrictive dietary behaviors as a potential harmful
consequence of following “clean” diets. In a recent analysis of women bloggers’ experiences with
orthorexia nervosa, participants reported that their diets were initially motivated by health problems
(such as digestive issues) and a desire to be healthy, but that social influences (such as social comparisons
of “healthiness”, and praise for pursuing “healthy” behaviors) and lack of awareness fueled their
difficulties [22]. These data suggest that weight loss is likely not a defining feature for those who may
eventually go on to pursue “clean” diets in an unhealthy manner, and that further research is needed
to identify pathways that tip the balance from healthy to unhealthy pursuits.
Given recent calls to address macro-environmental factors for eating disorder risk [25,26], current
findings signal a need to direct greater attention toward “clean” diets in prevention campaigns directed
toward adolescents and young adults in the U.S. These results also suggest a need to promote social
media literacy, which was identified as the top source of information for “clean” eating among our
respondents. Indeed, social media is an important source of information about healthy eating (e.g.,
Facebook and Instagram are used to guide nutrition-related decision-making; [29]), but it is easy to
imagine how social media promotion of “clean” eating can be harmful. For instance, one participant in
a qualitative investigation described this process as follows: “Twitter and Instagram are filled with
celebrities and health bloggers attributing their glowing appearance to eating ‘clean’ . . . but in trying
to emulate them, I became so obsessed with eating the perfect diet that it took over my life” (p. 598) [6].
The present investigation is limited by our use of a cross-sectional survey design with a limited
number of questions. We are thus unable to comment on how perceptions of “clean” diets are linked
with actual dietary behaviors. Further, we defined “clean” diets mid-way through the survey (to assist
those who had never heard of the term in completing the survey), and although we used both negative
(“strict avoidance”) and positive (“natural, whole”) descriptors, our definition may have influenced
willingness to try “clean” diets among participants. Moreover, although we measured definitions of
“clean” eating, we did not directly assess motivational features underpinning the pursuit of “clean”
diets and therefore cannot comment on the many reasons why people may pursue these diets.
Overall, our findings offer a useful glimpse into perspectives on the “clean” dietary trend from a
large, diverse sample of young people in the U.S. Given the constantly evolving nature of dietary fads,
researchers face an ongoing challenge to understand their impact. Nonetheless, future studies should
assess actual dietary behaviors to investigate the potential benefits of “clean” diets and the mechanisms
by which formerly healthy behaviors may devolve into disordered eating. For instance, the pursuit of
“clean” diets may in some cases represent (and indeed, mask) underlying body dissatisfaction and
related eating disorder symptomatology, and thus warrant further scrutiny to prevent harm. Future
researchers may also seek to identify strategies for effective public health communication to mitigate
Nutrients 2020, 12, 1708 10 of 11

the potential harms of these new waves of diets on vulnerable youth. Indeed, current findings suggest
that “clean” eating holds different meanings for different people, so public health messaging must
carefully consider these impressions and promote a more nuanced understanding that acknowledges
the potential risks of such “wellness” oriented diet fads.

Author Contributions: Conceptualization, S.A., T.K.R., and K.R.S.; formal analysis, S.A., G.S., and K.L.R.; funding
acquisition, S.A.; methodology, S.A., G.S., K.L.R., T.K.R., and K.R.S.; project administration, K.R.S.; supervision,
S.A.; writing—original draft, S.A.; writing—review and editing, G.S., K.L.R., T.K.R., and K.R.S. All authors have
read and agreed to the published version of the manuscript.
Funding: Participants were compensated though funding provided by a Research and Development Committee
Scholarly/Creative Grant from Dickinson College. Funding for MyVoice was initially provided by the University
of Michigan MCubed program and the Department of Family Medicine Building Blocks grant. None of these
agencies had any role in the study design, collection, analysis or interpretation of the data, writing the manuscript,
or the decision to submit the paper for publication.
Acknowledgments: The authors thank Harriet Sidford for her assistance with data coding.
Conflicts of Interest: The authors declare no conflict of interest.

References
1. International Food Information Council (IFIC). 2019 Food and Health Survey; International Food Information
Council Foundation: Washington, DC, USA, 2019.
2. Negowetti, N.; Ambwani, S.; Karr, S.; Rodgers, R.F.; Austin, S.B. Taming the Wild West of “clean” eating
marketing: Public health considerations and opportunities for increased federal oversight. 2020, under review.
3. McCartney, M. Clean eating and the cult of healthism. BMJ 2016, 354, i4095. [CrossRef] [PubMed]
4. Ambwani, S.; Shippe, M.; Gao, Z.; Austin, S.B. Is #cleaneating a healthy or harmful dietary strategy?
Perceptions of clean eating and associations with disordered eating among young adults. J. Eat. Disord. 2019,
7, 17. [CrossRef] [PubMed]
5. Dickinson, K.M.; Watson, M.S.; Prichard, I. Are clean eating blogs a source of healthy recipes? A comparative
study of the nutrient composition of foods with and without clean eating claims. Nutrients 2018, 10, 1440.
[CrossRef] [PubMed]
6. Cinquegrani, C.; Brown, D.H.K. ‘Wellness’ lifts us above the Food Chaos’: A narrative exploration of the
experiences and conceptualisations of Orthorexia Nervosa through online social media forums. Qual. Res.
Sport Exerc. Health 2018, 10, 585–603. [CrossRef]
7. Polivy, J. Psychological Consequences of Food Restriction. J. Am. Diet. Assoc. 1996, 96, 589–592. [CrossRef]
8. Neumark-Sztainer, D.; Wall, M.; Guo, J.; Story, M.; Haines, J.; Eisenberg, M. Obesity, disordered eating, and
eating disorders in a longitudinal study of adolescents: How do dieters fare 5 years later? J. Am. Diet. Assoc.
2006, 106, 559–568. [CrossRef]
9. Hsu, L.G. Can dieting cause an eating disorder? Psychol. Med. 1997, 27, 509–513. [CrossRef]
10. Patton, G.C.; Selzer, R.; Coffey, C.; Carlin, J.B.; Wolfe, R. Onset of adolescent eating disorders: Population
based cohort study over 3 years. BMJ 1999, 318, 765–768. [CrossRef]
11. Liechty, J.M.; Lee, M.-J. Longitudinal predictors of dieting and disordered eating among young adults in the
U.S. Int. J. Eat. Disord. 2013, 46, 790–800. [CrossRef]
12. da Luz, F.Q.; Sainsbury, A.; Mannan, H.; Touyz, S.; Mitchison, D.; Girosi, F.; Hay, P. An investigation of
relationships between disordered eating behaviors, weight/shape overvaluation and mood in the general
population. Appetite 2018, 129, 19–24. [CrossRef]
13. Barnett, M.J.; Dripps, W.R.; Blomquist, K.K. Organivore or organorexic? Examining the relationship between
alternative food network engagement, disordered eating, and special diets. Appetite 2016, 105, 713–720.
[CrossRef] [PubMed]
14. Blei, D. JSTOR Daily. 2017. Available online: https://daily.jstor.org/the-false-promises-of-wellness-culture/
(accessed on 6 June 2020).
15. Arenas-Jal, M.; Suñé-Negre, J.M.; Pérez-Lozano, P.; García-Montoya, E. Trends in the food and sports nutrition
industry: A review. Crit. Rev. Food Sci. Nutr. 2019, 1–17. [CrossRef] [PubMed]
Nutrients 2020, 12, 1708 11 of 11

16. Segura-Garcia, C.; Ramacciotti, C.; Rania, M.; Aloi, M.; Caroleo, M.; Bruni, A.; Gazzarrini, D.; Sinopoli, F.;
De Fazio, P. The prevalence of orthorexia nervosa among eating disorder patients after treatment. Eat. Weight
Disord. 2015, 20, 161–166. [CrossRef] [PubMed]
17. Allen, M.; Dickinson, K.; Prichard, I.; Allen, M.; Dickinson, K.M.; Prichard, I. The dirt on clean eating:
A cross sectional analysis of dietary intake, restrained eating and opinions about clean eating among women.
Nutrients 2018, 10, 1266. [CrossRef] [PubMed]
18. Dunn, T.M.; Bratman, S. On orthorexia nervosa: A review of the literature and proposed diagnostic criteria.
Eat. Behav. 2016, 21, 11–17. [CrossRef] [PubMed]
19. Bratman, S.; Knight, D. Health Food Junkies: Overcoming the Obsession with Healthful Eating; Broadway Books:
New York, NY, USA, 2000.
20. NEDA Orthorexia. Available online: https://www.nationaleatingdisorders.org/learn/by-eating-disorder/
other/orthorexia (accessed on 3 August 2019).
21. Nevin, S.M.; Vartanian, L.R. The stigma of clean dieting and orthorexia nervosa. J. Eat. Disord. 2017, 5, 37–47.
[CrossRef]
22. Greville-Harris, M.; Smithson, J.; Karl, A. What are people’s experiences of orthorexia nervosa? A qualitative
study of online blogs. Eat. Weight Disord. 2019. [CrossRef]
23. Musolino, C.; Warin, M.; Wade, T.; Gilchrist, P. “Healthy anorexia”: The complexity of care in disordered
eating. Soc. Sci. Med. 2015, 139, 18–25. [CrossRef]
24. Staudacher, H.M.; Harer, K.N. When clean eating goes dirty. Lancet. Gastroenterol. Hepatol. 2018, 3, 668.
[CrossRef]
25. Hart, L.M.; Wade, T. Identifying research priorities in eating disorders: A Delphi study building consensus
across clinicians, researchers, consumers, and carers in Australia. Int. J. Eat. Disord. 2019. [CrossRef]
26. Austin, S.B. A public health approach to eating disorders prevention: It’s time for public health professionals
to take a seat at the table. BMC Public Health 2012, 12, 854. [CrossRef] [PubMed]
27. DeJonckheere, M.; Nichols, L.P.; Moniz, M.H.; Sonneville, K.R.; Vydiswaran, V.V.; Zhao, X.; Guetterman, T.C.;
Chang, T. MyVoice national text message survey of youth aged 14 to 24 Years: Study protocol. JMIR Res.
Protoc. 2017, 6, e247. [CrossRef] [PubMed]
28. Hsieh, H.-F.; Shannon, S.E. Three approaches to qualitative content analysis. Qual. Health Res. 2005, 15,
1277–1288. [CrossRef] [PubMed]
29. Mete, R.; Shield, A.; Murray, K.; Bacon, R.; Kellett, J. What is healthy eating? A qualitative exploration.
Public Health Nutr. 2019. [CrossRef]

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