When a woman can enter her pregnancy in optimum health, she has a greater chance of a healthy pregnancy and delivering a healthy baby. Our work in Kenya is ensuring that women receive iron and folic acid (IFA) supplements to prevent and treat anaemia, which may cause pica cravings.
Pica is the craving and deliberate consumption of items that are not considered to be food, such as earth, charcoal, ash and raw starches. In some places, ice is also very commonly craved and consumed. It may also involve food items consumed in much larger amounts than normal because of the strong craving.
Pica has been observed on every continent and for over thousands of years. It occurs equally among rich and poor people, and among people with very high and very low education. Pregnant women are more likely than the general population to report pica symptoms, and because pica can be an indicator of anaemia, it is important to understand how it can affect maternal and child health.
Earth is probably the most commonly craved and consumed item by women with pica, and most often that earth is rich in clay. Chunks of clay, pottery, bricks and pieces of earthen walls are the most commonly consumed forms of eaten earth.
Uncooked starch is another very commonly craved item. This can take the form of corn starch, uncooked rice, raw tubers and raw flour. This is called amylophagy.
Other non-food items frequently craved include dry powdery substances like baby powder, ash, chalkboard chalk, baking powder and charcoal. Less often, flakes of paint, coffee grounds, cigarette butts, foam and stuffing from furniture have been reported.
Eating ice in your drinking glass is not considered pica, but pica can apply to ice when people eat very large quantities of ice every day. Often times, they have very strong cravings for particular kinds of ice as well, most often preferring the texture of crushed ice or small cubes. This is called pagophagy.
Eating non-food items by accident is not pica, nor is it pica if you eat a non-food item because someone tells you to eat it. For example, the consumption of holy earth because it was recommended by a healer is not pica, because there were no cravings involved.
Similarly, if a pregnant woman eats earth although she doesn’t crave it, this is considered geophagy rather than pica. In some cases it’s deliberate, where certain clays have proven health benefits – such as to reduce nausea and diarrhoea – or where earth is recommended locally as healthy, but without any scientific evidence.
Anyone can experience pica, but pregnant women are by far the most likely population group to report these non-food cravings. The prevalence of pica behavior during pregnancy has ranged from very low (0.02 per cent in Denmark) to as high as 64 per cent (in Dar es Salaam, Tanzania) and 71 per cent (in Kinshasa). In most cases, these cravings subside after delivery.
The implications of pica for pregnant women relate to anaemia. Anaemia during pregnancy can sap the energy of the pregnant mother and increase the risk of preterm delivery and low birth weight. Pica is often a clue that a person is anaemic. While the connection between pica and anaemia is not yet understood, it appears that anaemia triggers pica cravings. Pica may also cause anaemia by binding with iron or other micronutrients. Due to this association, it’s important that pregnant women inform their health care provider about any pica cravings, so they can be checked for anaemia.
There is no evidence that pregnant women develop pica symptoms in order to consume substances containing iron or folic acid, both of which can contribute to a healthy pregnancy. Even when iron is present in earth consumed by a pregnant woman, very little of this iron can be absorbed by the digestive system.
Additionally, there is research indicating that some pica substances can prevent micronutrients, like iron and folic acid, from being absorbed by the body. It is very important that pregnant women take their iron and folic acid tablets, regardless of their pica status.
The consequences of pica are not well understood. Some pica substances are clearly very dangerous, such as pottery with lead glaze or earth contaminated with harmful bacteria. Other pica substances are not obviously toxic, but can be harmful when eaten in large quantities.
For example, eating too much earth or foam rubber can obstruct the passage of food through the gut. Large quantities of baking soda have caused high blood pressure and can damage muscles in the body, including the heart.
Pica affects the digestive system as well, although the body of research in this area is limited. While earth cannot be digested, the clay in earth can bind to the mucin layer of the intestinal wall for a period of time and create a barrier. This barrier could be helpful if it keeps out harmful substances like pathogens (bacteria, viruses, parasites) and toxins (harmful chemicals). But it could be harmful if it keeps out needed substances, like micronutrients. The barrier could also mix with food we ingest, and similarly “hold up” those potentially harmful and helpful substances.
Most pica cravings are not considered a mental disorder, but they can be present within a range of severe mental problems, including obsessive compulsive disorder, autism and schizophrenia. People who have cravings to eat non-food items should not be labelled “crazy.”
Cravings for items that aren’t considered food have been observed for hundreds of years – in many cultures, and in many hundreds of species of animals – yet little is known about pica. Because we understand so little about the causes and consequences of pica, no public health policy has been developed to address the issue.
Given the prevalence and the potential health consequences of pica, research to understand the actual health benefits or harm of pica should be made a public health priority. This will give health care providers skills to help women with pica manage their symptoms, and ensure they are consuming iron and folic acid if they are anemic.
What we can do in the meantime is reduce the stigma that is sometimes associated with pica, so that women can feel comfortable discussing their cravings with their families and health care providers – particularly during pregnancy. Fostering an open discussion about pica can also prevent someone from consuming any obviously dangerous items.
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