There’s something in the air…

 

“This isn’t going to be an ordinary Wednesday,” I thought to myself last week, rushing through a quick shower and shave, trying not to slice and dice my upper lip. I could feel it in my bones. Out the door I go as I speed over to one of our off site clinics for another fun-filled, Wednesday morning. I arrive and learn my first patient is in 10 minutes. I quickly run through the mountain of information in the previous charts. Great! History of anxiety, asthma, obesity and severe iron deficiency.

 

Meet the patient, I do. Vitals, off to the room. She’s well dressed. I still have that fancy zebra-striped, loose shirt in my mind. Cool shirt! She’s bright, cheery, alert and energetic. Hmm, she seems to be doing well, likely having a hemoglobin less than 7. A little bit of banter, now onto the meat and potatoes. The story is relayed and I’m eating up every bit of it…

 

“… … WAIT A SECOND!”

“Could you repeat that please?”

 

“I carry 14 inches of foam in my purse.”

“Oh, that’s interesting. May I ask why?”

“I snack on it throughout the day.”

“Really. How long have you been doing that?”

“Many years.”

“Interesting… could I have a piece?”

“Excuse me?”

“Rip me off a piece. I’d like to try it.”

 

She stares at me for a second, definitely perplexed. I proceed to try this piece of foam. In it goes. Hmm… My brow furrows. It’s fluffy and tastes like nothing. I’m chewing, it’s not breaking apart very easily. I end up making a small sphere out of it in my mouth before chewing a few more times and then swallowing.

 

She laughs.

 

“How was it?”

“Well. It’s the best piece of foam I’ve ever eaten.”

“Really?”

“Yes. Because it is the only piece of foam I’ve ever eaten.”

 

Now we’re both laughing hysterically. 

 

The name behind the behavior

 

Eating non food materials is referred to as Pica. Those suffering pica have cravings, generally for items that don’t provide substantial nutritional value. This includes, chalk, clay, plastic, paint, dirt, sand, gravel, glass, metals and fabric. It is considered an eating disorder with it’s own set of diagnostic criteria. There are many types. For instance, pagophagia refers to craving ice. Ever seen someone inhale their soft drink and proceed to use their teeth to destroy every single cube of ice in their cup? Then there’s malacia, which is typically transient and occurs during pregnancy. And acuphagia, or eating metal. Or the cuprophagia… eating feces. I don’t know if I’d prefer feces or sharp objects. The list goes on!

 

The cause is unknown, but it is associated with all of the following:

 

Mental disorders

Emotional Deprivation

Female gender

Poor iron status

Parasitic infection

Menstrual irregularities

Pregnancy

Inflammatory bowel disease and Peptic ulcers

Mechanical issues

 

Now if you look at the list of potential causes, it is real tempting to first consider micronutrient deficiency and specifically iron.

 

Parasitic infections result in inflammation. Inflammation is essentially the skirmish your homeland security wages against the invader. It is necessary, but damages the intestinal terrain. And a consequence of that is impaired activity of machinery that helps you absorb the minerals and vitamins that you are liberating from food. On top of that parasites will get first dibs on whatever nutrients are passing through. An example of this is dyphllobrothium, which is tapeworm found in raw fish. This worm is pretty greedy when it comes to vitamin B-12, consuming at least 80% of what you’re trying to assimilate from food. Many parasites also result in blood loss. Hookworms are an example of intestinal parasites that suck your blood! So you have potential blood loss, plus competition, plus impaired absorption!

 

Menstrual irregularities make sense. Did your period last longer than usual? Was your flow heavier than usual? Maybe it was both. Women lose an average of 30-40 milliliters of blood during menses. Too much bleeding is considered 80mL or greater. There isn’t a really good way of assessing blood loss during your periods, precisely. Some folks argue this tampon or pad holds this much volume and so if you’re saturating this many you’re bleeding this much. Yeah, sure. There may be some value to that, but the hygiene practices and the fluid content of secretions vary considerably between ladies. And so your best bet is your own perception of how much blood you are losing (you know what is more or less than usual for you), coupled with your history and a workup.

 

Pregnancy! Women invest a lot of energy and resources in creating a small human. Mom has to expand the oxygen carrying capacity in her blood by creating more of the taxi for oxygen which are your red blood cells. And baby him/herself needs iron to build a brand new body. The iron cost of pregnancy is around 800 milligrams. Considering your average female’s body iron content is around 2.8 grams, that’s a pretty hefty iron need. Point being, we should expect pregnancy to be a meaningful contributor to many cases of pica.

 

Other GI disorders that result in chronic blood loss may predispose for pica. This includes peptic ulcer disease, various forms of colitis, and Crohn’s disease. Interestingly, the woman I interacted with has been dealing with stomach ulcers for many years. One of our suggestions was that she see her gastroenterologist and see if they were still bleeding.

 

The most likely reason for poor iron status on average is low intake. Men need around 8 mg per day and women about twice that. What you really need to understand is there are two types of iron. Iron in plants and iron in animal product. Heme iron in animal products is much more easily absorbed. And so if you are relying only on plant foods you are stacking the cards against you in terms of maintaining good iron status. Sorry, eschewers of meat. Don’t get mad at me, I didn’t make the rules. This has to do with a more simple means of moving heme-iron across the intestinal wall, whereas non heme iron in plants needs it’s oxidation state changed and relies on copper dependent machinery to get the deed done. So eat your vegetables, nuts and seeds, but include things like oysters, liver and red meat in your dietary approach.

 

When things aren’t as strange…

 

Sometimes it isn’t foam, dirt, sand, metal and the like. In a case report of two females, their pica was expressed “rhizophagia”, craving uncooked bastmati rice. The first woman lived in India and had years of this craving, that was more intense during pregnancy. She was also found to be iron deficient, with a hemoglobin of 8.2 g/dL (normal is 12-15). Her iron deficit was attributed to heavy periods and having given birth to several children.

 

The second woman lived in Pakistan and had the same type of history, with the exception being that she was a strict vegetarian. Her hemoglobin was 9.5 g/dL.

 

Both women were treated with intravenous iron dextran and experienced complete resolution of the raw rice chow down after the first infusion of 500mg.

 

Here’s another report of pica expressed as “tomatophagia.” Here we have a 66 year old woman with arthritis and heartburn. She explained she had an unusual craving for tomatoes over the previous two months and would consume 6-10 whole tomatoes a day! Her hemoglobin was 5.3g/dL and her total iron binding capacity was 498ug/dL (upper end 450). Her iron deficiency was attributed to a bleeding esophagus and stomach erosions. She was treated with two units of blood and prescribed ferrous sulfate. Her tomato crushing resolved in 8 weeks.

 

Potato pica anyone? Another case expressed as a craving for raw potatoes. The authors called it “geomelophagia.” In this case report we learn of a 68 year old woman with a history of squamous cell carcinoma of the lung. For the previous two to three months, she had desire to eat raw potatoes, which she would chill in ice water. She denied ice eating. She reported eating 3-5 medium to large potatoes daily. The authors learned that she experienced this 30 years prior during her third trimester of pregnancy. Her workup revealed a hemoglobin of 9.3g/dL and a peripheral blood smear revealing a microcytic, hypochromic anemia. Her chilled spud craving chilled out within a week of being treated with 900mg of ferrous sulfate daily.

 

The saga continues. Here is a 33 year female expressing a craving for salt. Not a craving like you and I. She would consume half a pound of salt per week. She even carried salt packets with her. This patient had a history of blood donations several times annually. Her hemoglobin was found to be 9.2g/dL. She was unresponsive to oral iron supplementation and so she was was given iron injections. Two weeks after starting the injections her salt craving reduced dramatically.

 

There have been other reports of pica being expressed as consumption of vinegar and other acid beverages, unriped fruit, carrots, radishes, strong tasting cheese, celery, croutons, life savers, licorice and spices. The account of an English Physician during the 1600s reads, “a young Maide, whose meat for two years was pepper.” Straight pepper. Get a load of that.

 

Interestingly, by calories, spices are the most nutrient dense food on the planet. Thing is, it isn’t practical to rely on them as a source of micronutrients because you’d have to eat a potentially harmful amount of spice. The point is, this supports the idea that some cases of pica are a compensatory response by the body in the face of marginal nutritional status.

 

It’s not always iron… but it very well could be!

 

Iron deficiency affects over 30% of the world’s population. We don’t know what the prevalence of pica is worldwide because it tends to be unrecognized and underreported. I see how this could be the case. Had the patient not offered up the fact that she carried foam in her purse and allowed me to partake, I would have been none the wiser. It turns out to be something adults tend to keep to themselves.

 

That being said, a recent study found that pica occurs in 22-33% of pregnancies worldwide. And on a global scale, iron deficiency is pretty darn common.

 

So what else could it be? Pica has also been associated with psychiatric disorders like schizophrenia, anxiety, obessive compulsive disorder and depression. Emotional deprivation is also a big factor, as in kids not getting enough love from mom and dad. It could also simply be learned or inherited behavior. Geophagy or clay eating was discovered to be a ritualistic occurrence among many African tribesmen in the mid 1900s. And now we have clay you can chug on the shelf of your local health food store, go figure.

 

So what do I do?

 

 

First you need to recognize what pica is. The criteria is:

 

-Eating non food items for a period lasting longer than one month.

-Eating these non food items is inappropriate for the developmental level of the individual. Meaning children and those with mental retardation may put things in their mouth that is considered within normal behavior range for those individuals.

-The eating behavior is not part of a culturally supported or socially normative practice.

-If occurring with another mental disorder, or during a medical condition, it is severe enough to warrant independent clinical attention.

 

It’s more obvious when nonfood items are being consumed, like foam, metals, dirt, coal, gravel etc. But it might be trickier to detect if you do not recognize that pica may present with craving for certain foods.

 

The vast majority of cases will likely present as pagophagia or ice chewing. But do note the case studies above, which revealed pica expressing as cravings for raw potatoes, tomatoes, raw grains, and salt.

 

The two major treatment approaches are nutritional and behavioral. So some questions you need to ask.

 

Ask yourself whether the cause may be non nutritional. Did your parents have different eating behaviors? What about their parents and their siblings? Pica is a condition that can be inherited and learned. Are there any psychiatric comorbidities?

 

Behavioral therapies have been shown to reduce pica in children with behavioral issues. One studied strategy is called differential reinforcement of other behaviors technique (DRO), which you can read about here.

 

If not then consider a nutritional cause. Iron should be considered first. In the case studies, the upper end for hemoglobin that resulted in disordered eating behavior was 9.5g/dL. The other nutrient that has been studied is zinc.

 

PLEASE don’t run off and start taking iron supplements or any other high dose supplements without consulting your care provider. Read here to learn more about iron. Too much causes problems. In the case of the woman I interacted with above, it is likely the culprit, evidenced by her history of chronically low hemoglobin and gastric ulcers.

 

You then want to investigate the reason for poor micronutrient status. We discussed some of the reasons that may be above. Infections, hidden bleeding, poor diet, heavy menses, and bowel diseases. Another question to ask for moms is whether or not you noticed change in eating behavior during pregnancy that is consistent with what you may be experiencing now.

 

Depending on what is being consumed, how much and how often, it’s probably a good idea to get your upper and lower gastrointestinal tract checked. Many of the non food items folks with pica consume are not digestible and can cause some serious problems.

 

The biggest thing is being open with your doctor. He or she is there to help you. And pica often slips under the radar. The complications are potentially life threatening!

 

Cause or consequence?

 

The experts aren’t clear as to whether pica is a cause of all the factors it is associated with or a result of those factors. It doesn’t really matter. What matters is we know what the factors are and we have ideas on how to address them. Consider your context, find someone that will listen and proceed from there.

 

So there you have it. Pica and a case of such expressed as foam eating. Pass on the foam, you’re not missing out on much.

 

 

Further Reading

 

 

Material on differential reinforcement of other behaviors and other behavioral strategies for pica:

 

Bell, K. E., & Stein, D. M. (1992). Behavioral treatments for pica: A review of empirical studies.International Journal of Eating Disorders, 11(4), 377-389.

 

Case reports showing pica expressed as food cravings response to iron treatment:

 

Barton, J. C., Barton, J. C., & Bertoli, L. F. (2016). Pica for uncooked basmati rice in two women with iron deficiency and a review of ryzophagia. Case reports in medicine, 2016.

 

Marinella, Mark A. ““Tomatophagia” and iron-deficiency anemia.” New England Journal of Medicine 341.1 (1999): 60-61.

 

Johnson, Bruce E., and Ronald L. Stephens. “Geomelophagia: An unusual pica in iron-deficiency anemia.” The American journal of medicine 73.6 (1982): 931-932.

 

Shapiro, Michael D., and Stuart L. Linas. “Sodium chloride pica secondary to iron-deficiency anemia.” American Journal of Kidney Diseases 5.1 (1985): 67-68.

 

An estimation of the worldwide prevelance of pica across pregnant women:

 

Fawcett, E. J., Fawcett, J. M., & Mazmanian, D. (2016). A meta‐analysis of the worldwide prevalence of pica during pregnancy and the postpartum period. International Journal of Gynecology & Obstetrics, 133(3), 277-283.

 

A very interesting read. Highly suggest if you want to learn about the way Pica was looked at 1500s and onward.

 

Parry-Jones, B., & Parry-Jones, W. L. (1992). Pica: symptom or eating disorder? A historical assessment. The British Journal of Psychiatry, 160(3), 341-354.

 

Review of pica, common but commonly missed. Epidemiology, complications, comorbidities, and treatments:

 

Rose, Edward A., John H. Porcerelli, and Anne Victoria Neale. “Pica: common but commonly missed.” The Journal of the American Board of Family Practice 13.5 (2000): 353-358

 

Reference for iron metabolism, nutritional requirements during pregnancy:

 

Shils, M. E., & Shike, M. (Eds.). (2006). Modern nutrition in health and disease. Lippincott Williams & Wilkins.

 

Easy to digest read on everything iron related:

 

http://www.3030strong.com/news/2017/8/29/the-ultimate-iron-post

 

Diagnostic criteria for pica:

 

https://www.eatingdisorders.org.au/eating-disorders/what-is-an-eating-disorder/classifying-eating-disorders/dsm-5

 

How to use Differential Reinforcement of Other Behaviors Technique:

 

http://behavioradvisor.ipower.com/DRO.html