Polite Dissent

Pica is one the more interesting medical conditions a physician can encounter. Technically, pica is the eating of non-food items such as paint chips, dirt, soap, and other similar substances. Eating ice is one of the more common types of pica. Not the casual crunching on ice after finishing a drink, but instead purposefully eating ice as a meal. I also consider severely abnormal eating habits and bad food cravings a form of pica as well. A doctor who looks just for “non-food items” instead of unusual eating habits will miss a lot of patients with this diagnosis.

While pica can be associated with many medical conditions, there is no single clear cause. I have seen it associated with iron deficiency anemia most commonly, but it seems to be a chicken-or-the-egg scenario. Did the pica lead to the anemia, or does the anemia lead to the pica? I’ve seen it both ways.

While seeing patients in a military hospital during medical school, I was introduced to a very nice elderly lady who was in the hospital for hip-replacement surgery. When she was in the hospital, it was discovered that she had a significant anemia. On careful questioning (a medical student specialty), she admitted to eating iceberg lettuce, three meals a day, because it was a vegetable and therefore “healthy.” Never mind that iceberg lettuce is the nutritional equivalent of cardboard. In this case, her anemia was certainly caused by her pica.

Several years later during residency, I was having a discussion about nutrition with a patient. It was just a general discussion that I like to have with patients about healthy eating. She mentioned that about twenty years ago in an effort to gain some weight she had started eating starch. I pictured her eating spoonfuls of cornstarch, but she helpfully dug in her purse and came up with a box of laundry starch. For the past twenty years she had been eating laundry starch two meals or three meals a day. I checked a blood count on her and found the lowest levels of hemoglobin I have ever seen in a living person. It was one-third the normal level, well below the usual transfusion threshold. She had been living comfortably at this level for years and her body had become used to it. Another case of the pica causing the anemia, and a difficult case as well because she refused to stop eating the laundry starch.

About six months ago, I was having a routine visit with one of my patients to follow up on her high blood pressure. In the middle of our discussion, she reached into her purse and pulled out a jar of Vlassic pickles. She opened it and started munching on them in the exam room right in front of me. This struck me as bizarre and definitely not a normal eating habit. She mentioned that though she ate three good meals a day, she had been craving pickles “something fierce” for the past several months. Since I was drawing some blood anyway, I checked her hemoglobin and found a serious anemia. In this case, I didn’t feel that the pica alone could explain her anemia. The most common causes of anemia are nutritional deficiency and blood loss. Since she had normal eating habits (other than the pickles), blood loss seemed a more likely reason for the anemia. Because the gastrointestinal tract is the most common source of blood loss, I arranged a colonoscopy for her. And there was the answer. She had a large bleeding colon cancer, which has since been successfully removed surgically. In this case, the anemia seemed to be causing the pica instead of the other way around.

I bring this topic up because this patient came back to see me for a six-month follow-up. She’s not eating pickles now. Instead, she’s drinking carrot juice three meals a day – often instead of eating a normal meal. Now I have to wonder all over again is this pica or just poor nutrition?

More information on pica is available here.