Pica Practices of Pregnant Women are Associated with Lower Maternal Hemoglobin Level at Delivery

doi:10.1016/S0002-8223(98)00069-8

Journal of the American Dietetic Association

Volume 98, Issue 3, March 1998, Pages 293-296

https://doi.org/10.1016/S0002-8223(98)00069-8 Get rights and content

Abstract

Objective To determine the prevalence of pica during pregnancy, maternal hemoglobin levels at delivery, and the association of pica with 2 adverse pregnancy outcomes: low birth weight and preterm birth.

Design A retrospective cohort study was conducted using eligible subjects (n=281) from a cross-sectional survey (n=366).

Subjects/setting Mothers aged 16 to 30 years with infants younger than 1 year of age who participated in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) were interviewed at 4 WIC clinics in Houston and Prairie View, Tex. Medical records from 31 hospitals were abstracted.

Main outcome measures Maternal hemoglobin levels at delivery, mean birth weight, and mean gestational age were compared for women who reported pica and women who did not.

Statistical analyses χ² Tests, orthogonal t tests, analysis of variance, and regression analysis were used to test the relationships among study variables.

Results Pica prevalence categorized by substance was as follows: ice, 53.7%; ice and freezer frost, 14.6%; other substances such as baking soda, baking powder, cornstarch, laundry starch, baby powder, clay, or dirt, 8.2%; and no pica, 23.5%. Women in all 3 pica groups had lower hemoglobin levels (mean±standard deviation, 114±12 g/L, 110±13 g/L, and 113±12 g/L, respectively) at delivery than women who did not report pica (118±11 g/L) (P<.01 for all pica groups vs no pica). There were no differences in mean birth weight or mean gestational age of infants born to women from the 3 pica groups and the No Pica group.

Applications The findings suggest that pica practices are associated with significantly lower maternal hemoglobin levels at delivery but are not associated with pregnancy outcomes. Dietitians should ask pregnant women with anemia about pica and should counsel women who report pica regarding the health risks associated with it. J Am Diet Assoc. 1998; 98:293-296.

Section snippets

Subjects

The inclusion criteria for subjects were as follows: mother aged 16 to 30 years at delivery, infant younger than 1 year of age (no multiple births), eligibility for Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) benefits, and English speaker. Subjects were also free of the following health conditions: diabetes (overt or gestational), preeclampsia or eclampsia, hypertension, seizure disorder, and abruptio placenta.

The University of Texas Health Science Center

Results

Pica prevalence by substance was as follows: ice, 53.7%; ice and freezer frost, 14.6%; other, 8.2%; and no pica, 23.5%. All but 2 subjects who ate other substances consumed ice and/or freezer frost in addition. Statistical analyses were performed using the 4 groups of Ice Pica (n=151), Ice/Freezer Frost Pica (n=41), Other Pica (n=23), and No Pica (n=66).

Table 1 provides demographic characteristics for the 281 eligible subjects. Most of the subjects were African-American, high school graduates,

Discussion

The prevalence of ice and ice/freezer frost pica found in this study was much higher than expected, based on results of previous studies (2), (3), (12), (13), (14), (15) that included ice and freezer frost as pica substances. The 8.2% prevalence of other pica in this study was higher than the 5.5% reported by Corbett (12) and the 3% reported by Edwards et al (3), but was lower than the 15.2% that Smulian et al (15) found.

The women in the Ice Pica group were similar to those in the No Pica group

Applications

This study has provided useful information for dietetics professionals on pica prevalence, characteristics of women who practice pica, and outcome of pregnancy in a population of women aged 16 to 30 years who were eligible for WIC in Houston and Prairie View, Tex. Pregnant women who have anemia should be asked about pica. Women who report pica should be counseled regarding the health risks. Those who eat ice risk fracture of teeth, a risk not well-documented in medical literature. Health risks

References (18)

R.D Horner et al.
Pica practices of pregnant women
J Am Diet Assoc.
(1991)
N.R Cooksey
Pica and olfactory craving of pregnancyhow deep are the secrets?
Birth.
(1995)
C.H Edwards et al.
Pica in an urban environment
J Nutr.
(1994)
D.G Federman et al.
Picaare you hungry for the facts?
Conn Med.
(1997)
M.K Mitchell
Nutrition Across the Life Span
(1997)
CDC criteria for anemia in children and childbearing-aged women. MMWR
(1989)
Institute of Medicine (US). Committee to Study the Prevention of Low Birthweight, Division of Health Promotion and...
B.N Dunston
Pica, Hemoglobin, and Prematurity and Perinatal Mortality
(1961)
L Keith et al.
Amylophagia during pregnancy
Obstet Gynecol.
(1968)

There are more references available in the full text version of this article.

Cited by (62)

Prevalence of Pica in Patients on Dialysis and its Association With Nutritional Status
2019, Journal of Renal Nutrition
Citation Excerpt :
Such an intake (including intake of ice, starch, soil, clay, grass, paper, or cigarettes) must not have been initiated in childhood, in the last year, or be a cultural/community habit.2 Pica has been more frequently described in children, pregnancy, mental illness, autism, and during developmental growth alterations,3 with a heterogeneous prevalence (38-70%).3-8 In end-stage renal disease (ESRD) patients on hemodialysis (HD) or peritoneal dialysis (PD), few studies have analyzed epidemiology of pica; almost all of them are case reports,9-13 and there are no data in kidney transplant.
Pica could be strongly implicated in nutritional status of patients on dialysis; however, very scarce data are currently available. The objective of this study was to evaluate the prevalence of pica and its association with nutritional status in dialysis patients.
This is a cross-sectional study in a tertiary care teaching hospital. Four-hundred patients on dialysis, without previous pica diagnosis or transplant, pregnancy, mental illness, or infection, were included in the study. Pica, according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, was classified as no pica, ice pica, or hard pica. Dialysis Malnutrition Score, 24-hour dietary recall, and biochemical measurements were obtained from patients. As part of statistical analysis, point prevalence and 95% confidence interval of pica were calculated. Comparisons between groups were performed by means of analysis of variance, Kruskal-Wallis test, χ², or Fisher exact tests, as appropriate. A multivariate analysis was performed by multinomial logistic regression.
Prevalence of pica was 42% (ice pica, 46%; soil, 29%; two substances, 14%; red brick, 5%; paper, 3%; soap, 2%; and cattle pasture, 1%). Comparing patients with pica (hard pica and ice pica) versus no pica, subjects with pica were of younger age (25 ± 7, 27 ± 9, 30 ± 11 years, respectively), were more frequently educated <9 years (57%, 46%, 30%, respectively), and had longer dialysis duration (36 ± 19, 32 ± 18, 27 ± 16 months, respectively). Patients with pica achieved the recommended calorie and macronutrients intake target less frequently than those without pica (40-64% vs. 66-77%, P <.05). Malnutrition was present in 74% of the whole sample: (1) 67% in no pica group, (2) 80% in ice pica group, and (3) 89% in hard pica group (P = .001). In the multivariate analysis (R², 0.27; P < .0001), malnutrition, C-reactive protein, and lower educational level significantly predicted both ice and hard pica.
A worse nutritional status was observed in patients with pica, who additionally were younger, had lower educational level, longer dialysis duration, and worse macronutrient intake routine than patients without pica. Malnutrition, C-reactive protein, and lower educational level significantly predicted both ice and hard pica.
Pica is prevalent and strongly associated with iron deficiency among Hispanic pregnant women living in the United States
2018, Appetite
Citation Excerpt :
On the other hand, some pica items, e.g. clay-rich earth may have positive health effects, such as relief from gastrointestinal distresses (Dominy, Davoust, & Minekus, 2004; Young et al., 2010), preventing exposures to harmful toxins and pathogens (Dominy et al., 2004; Johns and Duquette, 1991), and being a source of micronutrients (Hooda et al., 2004; Yanai et al., 2009). In the United States, pica has been reported by pregnant women from all ethnic groups, but a higher proportion of minority women report pica than white women (Bakhireva et al., 2013; Cooksey, 1995; Corbett et al., 2003; Edwards et al., 1994; Rainville, 1998; Simpson, Mull, Longley, & East, 2000). While Hispanics constitute the largest ethnic minority group in the United States (17% of the total population), our understanding of pica among them is limited.
Anecdotal evidence suggests that pica occurs among Hispanic women in the United States, especially during pregnancy. However, the prevalence and socio-demographic and biological factors associated with pica in this population have not been adequately identified.
Trained, bilingual study personnel conducted structured interviews at public health clinics in Salinas Valley, California with 187 pregnant Hispanic women in their 2nd or 3rd trimesters of pregnancy. Hemoglobin was measured using Hemocue; concentrations of transferrin receptor (TfR) and alpha-1 acid glycoprotein (AGP) were measured in dried blood spots. Multivariable stepwise regression analyses were conducted with pica during pregnancy as the dependent variable and individual- and family-level factors as independent variables to identify significant associations. Additionally, multivariable models were built to explore the associations between pica and iron status (iron deficiency and anemia).
Half of all participants (51.3%) had ever engaged in pica, and 37.6% had done so during the current pregnancy. Pica substances included large quantities of ice, frost, raw starches, and various earthen items. Pica during the current pregnancy was significantly associated with higher TfR concentrations [OR: 1.29; 95% CI: 1.11, 1.51] indicative of low iron stores and greater food insecurity [OR: 1.20, 95% CI: 1.03, 1.40]. Women who engaged in pica during the current pregnancy were more likely to be iron deficient [adjusted OR: 2.58; 95% CI: 1.19, 5.60], but not anemic [adjusted OR: 1.40; 0.60, 3.23].
Among pregnant Hispanic women, pica was prevalent and strongly associated with iron deficiency and food insecurity. Clinicians should screen for pica during pregnancy in Hispanic populations, and future studies should elucidate the underlying etiology and consequences of engaging in pica during pregnancy.
Pica Practices among Apparently Healthy Women and Their Young Children in Ghana
2017, Physiology and Behavior
Citation Excerpt :
Furthermore, an association between pica and ID/anemia in pregnant women have been previously reported ([2]: [5]). After delivery, if the food security situation in the mothers household did not change [40]), her child grows up facing the same environmental risk factors for ID, and may develop ID/IDA which may be presented as pica. Same analogy could be used to explain the observed weak association between a mothers’ current pica and that of children and, also between mothers’ pica during pregnancy and her current pica practice.
Pica is an increased appetite/craving for food or non-food substances like clay, and chalk, and is strongly associated with iron deficiency (ID) anemia. This study assessed pica practices among non-pregnant mothers and their children, 12-to-59 months, in an anaemia endemic population in Ghana.
A cross-sectional quantitative survey was conducted in two randomly selected districts in Northern Ghana. The researchers developed semi-structured questionnaires with components on pica practice, history and experiences and administered via structured face-to-face interviews with mothers (N = 161) and all their children 6-59 months. Of this population, 132 mothers had children 12-to-59 months (N = 139) in April 2012. Pica practice among children was reported by their mothers. Data was analysed using SPSS version 23.0.
Few mothers (3%) spontaneously reported pica (for uncommon food and/or non-food substances) at the time of the interview, however, 16 (12.1%) mothers with pica were confirmed after further probing. Twelve (8.6%) children were reported to have ingested/craved clay/soil/dust (11 / 91.7 %), paper (1 / 7.1%) and chalk (1/7.1%) prior to the interview. One child had poly-pica (pica for two substance). Pica was reported to have been practised by expecting mothers during 37 (26.6%) of the pregnancies of the children involved in the study, and was mostly for clay/soil (33 / 89.1%), kola nut (5 / 3.6%), uncooked rice and bambara beans. Children’s pica practices were significantly associated (χ² = 6.33; p = 0.011) with their mothers’ pica practices during pregnancy as well as with mothers’ pica practices at the time of the study (χ² = 5.98; p = 0.035). A logistic regression analysis seemed to show that pica of the mother during pregnancy was more strongly associated with the child’s pica than later pica behaviour of the mother. Many myths and misconceptions associated with the practice of pica were also reported in these communities.
The reported pica practice among mothers and their children was lower than what has been observed in other studies. Knowledge and perceptions regarding pica were mostly inaccurate. Education on pica and associated dangers of its practices should be included in nutrition interventions in communities with known high anemia prevalence.
Pica in end-stage chronic kidney disease: Literature review
2019, Nefrologia
Citation Excerpt :
More importantly, we know that 37% of patients are repeat offenders, i.e. they are being treated for a new episode even though they were on treatment, and this highlights the great difficulty of completely eliminating this type of behaviour.2 Table 1 shows a list of epidemiological studies3–9 in populations vulnerable to pica (pregnant women, children and subjects with autism) and their clinical and pathophysiological findings. Studies on pica and pregnancy show that most pregnant women with pica have low haemoglobin and haematocrit levels and iron and zinc deficiencies.
Pica is an individual entity in the patient with chronic kidney disease (CKD), which phenomenon has not been widely studied despite the high reported prevalence. Moreover, pica complications (anaemia, altered electrolytes, poor absorption of micro and macronutrients and malnutrition) could be exacerbated in CKD and limit the quality of renal replacement therapy.
The intake of non-caloric and non-nutritional substances could be harmful and cause effects on satiety and metabolic/electrolyte imbalance and modify the biocompatibility of micronutrients, toxins and pathogens worsening health status.
In daily practice, pica could be under-reported because patient's shame to recognise it, or fear that such behaviour influences their treatment. Additionally, clinicians who not investigate the presence of pica or its complications contribute to the lack of information about the magnitude and relevance of this problem in CKD.
La pica como entidad individual en el paciente con enfermedad renal crónica (ERC) no ha sido ampliamente estudiada, a pesar de que se ha reportado una alta prevalencia en esta población, y de que las complicaciones propias de la pica (anemia, alteración en electrolitos, mala absorción de micro y macronutrientes y desnutrición) podrían verse exacerbadas en la ERC, lo cual limitaría alcanzar una mejor calidad de la terapia de remplazo renal.
La ingesta de sustancias no calóricas y no nutricionales podría ser perjudicial por los efectos en la saciedad y en el descontrol metabólico/electrolítico, y por afectar la biocompatibilidad de los micronutrientes, toxinas y patógenos, lo que finalmente puede empeorar el estado de salud.
En la práctica diaria es posible que la pica resulte subreportada debido a la vergüenza del paciente a reconocerlo, o el miedo a que dicho comportamiento pueda influir en su tratamiento. Adicionalmente, los clínicos, al no investigar la presencia de pica o sus complicaciones contribuyen a la falta de información acerca de la magnitud y la relevancia de este trastorno de la conducta alimentaria en la ERC.
Update on the Global Prevalence of Pica in Pregnant Women: A Meta-analysis
2023, International Journal of Women's Health and Reproduction Sciences
Nutrition for Women
2023, Women’s Healthcare in: Advanced Practice Nursing, Third Edition

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Journal of the American Dietetic Association

Abstract

Section snippets

Subjects

Results

Discussion

Applications

References (18)

Pica practices of pregnant women

J Am Diet Assoc.

Pica and olfactory craving of pregnancyhow deep are the secrets?

Birth.

Pica in an urban environment

J Nutr.

Picaare you hungry for the facts?

Conn Med.

Nutrition Across the Life Span

CDC criteria for anemia in children and childbearing-aged women. MMWR

Pica, Hemoglobin, and Prematurity and Perinatal Mortality

Amylophagia during pregnancy

Obstet Gynecol.

Cited by (62)

Prevalence of Pica in Patients on Dialysis and its Association With Nutritional Status

Pica is prevalent and strongly associated with iron deficiency among Hispanic pregnant women living in the United States

Pica Practices among Apparently Healthy Women and Their Young Children in Ghana

Pica in end-stage chronic kidney disease: Literature review

Update on the Global Prevalence of Pica in Pregnant Women: A Meta-analysis

Nutrition for Women