Pica - Do You Know What Your Patients Are Eating?

Janelle Gonyea

As a member of the dialysis team, you are concerned about how well your patients are eating and how it is affecting their nutritional status, but do you give much thought to everything they may be eating? Maybe it’s not pork chops and applesauce, but perhaps clay, laundry starch, or burnt match heads. The compulsive ingestion of unsuitable substances that have little or no nutritional value is referred to as pica (Fagen, 2000). This form of disordered eating can also include the compulsive eating of normal foods in abnormal quantities (Rose, Porcerelli, & Neale, 2000). Depending upon the type and amount of a substance or food that is being ingested, there can be dire consequences for patients with kidney disease.

Pica has been practiced throughout the ages, as reference to it can be found in ancient manuscripts. Traditionally, individuals who are at most risk for pica have been pregnant women, children, mentally disabled persons, those with iron deficiency, those who reside in southeastern United States, and those with a family history of pica (Lackney, 1993). In fact, it can be so main stream that clay and sterilized dirt can be purchased in grocery stores in southern portions of the United States. Pica, however, is infrequently considered with kidney disease, which is quite unfortunate, as the potential for harm is great in this patient population.

Incidence and Consequences

Due to underreporting, the incidence of pica in the general population is unknown. It is thought that perhaps the uremic state can trigger this type of behavior so incidence in the renal population may actually be relatively high (Ward & Kutner, 1999). One group found the incidence of pica to be 19.5% in their patients on dialysis and 14.7% in their patients with renal insufficiency (Ojanen, Oksa, & Pasternack, 1990). If the incidence of pica is indeed as high as 1 in 5 patients on dialysis, nephrology care providers should have a high level of suspicion for this practice with their patients, especially when reported food intake and lab values don’t match up.

While some forms of pica in the general population may seem relatively harmless, this is likely not the case in patients with kidney disease, given their inability to eliminate fluid and waste products. Depending upon the types and quantities of substances or foods consumed, possible consequences in kidney disease include toxicity, bowel impaction/perforation, interference with nutrient absorption, parasitic infections, dental injury, inadequate nutrient intake, excessive fluid intake, and excessive calorie intake (Lackney, 1993).

Patients with kidney disease practicing pica most commonly consume clay or dirt (geophagia), laundry starch (amylophagia), or ice (pagophagia), but the list of potential pica substances can be quite extensive. Other substances commonly reported include baking soda, coffee grounds, lemons, tomato seeds, cigarette butts, moth balls, and toilet tissue (Lackney, 1993). Some forms of pica are potentially more harmful than others. For example, what if your patient practiced geomelophagia? Since this is the ingestion of raw chilled potatoes, the patient may have serious consequences related to higher serum potassium levels. Conversely, if the patient consumes corn starch, the mineral load is minimal and thus not likely to cause problems. However, depending upon the amount consumed, corn starch can significantly increase caloric intake and result in an undesirable weight gain, satisfy hunger displacing more nutritious foods such as protein rich foods, contribute to blood glucose in patients with diabetes, and cause dry mouth leading to increased fluid intake.

Etiology

The etiology of pica is unclear, but likely multifactorial as there can be many factors involved, such as nutritional, psychological, cultural, and pharmacological. It has been proposed that pica results from an innate ability to recognize a deficiency, but conversely it has also been proposed that pica results after ingestion of substances that may cause gastrointestinal abnormalities and thus produce a nutrient deficiency. The most common nutrient deficiency believed to contribute to pica is iron, but zinc deficiency has also been implicated.

From a psychology perspective, it has been proposed that pica is a means of fulfilling unmet oral needs, as typically, the food or substance of choice is “brittle and crunched by the teeth” (Kensit, 1979). This can unfortunately lead to dental injury. Culturally speaking, pica may also be a common practice within a region that has been passed down from generation to generation and possibly related to food shortages that occurred long ago. Some pica practices may be seeking a pharmacologic effect. For example, those who consume ground coffee may be doing so for the caffeine (Feldman, 1996). Whatever the reason may be, pica is typically problematic in patients with chronic kidney disease and thus should be addressed.

Diagnosis and Treatment

The diagnosis of pica can be difficult to make unless you or a family member have witnessed the behavior first hand. In many cases, pica is diagnosed when a patient experiences complications such as anemia, intestinal disturbances, persistently abnormal laboratory values, unexplained weight gain, or excessive fluid gains between dialysis treatments. Inquiry into pica practices should be done in a private setting using an openminded, nonjudgmental approach. Ongoing discussion of concerns should be done in a sympathetic manner to maintain the patient’s trust. Embarrassment is the most common barrier preventing patients from discussing their pica practices, thus a patient is not likely willing to offer this information to someone they do not trust. Also, depending upon their culture or family practices, patients may not perceive their actions as odd, thus preventing them from reporting it to the care team. When initially broaching the subject, it is helpful to offer examples of pica to allow patients and their families to identify their own pica practices and also to reassure them that pica is common so they do not feel as though they are being singled out.

For patients with kidney disease who have a pica tendency, treatment is essential to prevent potentially disastrous consequences. Treatment options include repletion of nutrients, education, and behavioral therapy. In the event that the pica is caused by a nutrient deficiency such as iron or zinc, repletion of these substances has, in many cases, helped the pica behavior to lessen or cease entirely. When the substance being consumed is causing or likely to cause difficulties, the entire team must commence with treatment to help the patient. If it is a food substance that the patient is consuming, suggesting a more reasonable option with a lower potential for health problems may be helpful (Haopian & Adelinis, 2001). When the etiology of the pica is more culturally based, a thorough explanation of the concern and possible complications resulting from the practice may be enough to dissuade patients from continued pica practice. As in all areas of their care, family members need to be educated as well, as they are in a better position to monitor the patient’s behavior and provide ongoing support to be pica free. When the treatment options that the nephrology care team can provide have been exhausted and the patient persists with harmful behaviors, it becomes necessary to pursue psychological or behavioral counseling.

Pica is likely quite common in the renal population. Consequently, it is imperative that the nephrology care team be vigilant in their suspicion of pica to dissuade the practice, thus avoiding the potentially serious complications of this behavior.

References
CFagen, C. (2000). Nutrition during pregnancy and lactation. In L.K. Mahan & S. Escott-Stump (Eds.) Krause’s food, nutrition & diet therapy (pp. 167 – 195). Philadelphia: W.B. Saunders.

Feldman, M.D. (1986). Pica: Current perspectives. Psychosomatics, 27(7), 519-523.

Hagopian, L.P., & Adelinis, J.D. (2001). Response blocking with and without redirection for the treatment of pica. Journal of Applied Behavior Analysis, 34(4), 527–530.

Kensit, M. (1979). Appetite disturbances in dialysis patients. Journal of the American Association of Nephrology Nurses & Technicians, 6(4), 194–199.

Lackney, L. (1993). Pica: ESRD patients and the incredible inedibles. Contemporary Dialysis & Nephrology, April, 18–19, 34.

Ojanen, S., Oksa, H., & Pasternack, A. (1990). Pica in renal patients. Dialysis & Transplantation, 19(8), 429-433.

Rose, E.A., Porcerelli, J.H., & Neale, A.V. (2000). Pica: Common but commonly missed. The Journal of the American Board of Family Practice, 13(5), 353-358.

Ward, P., & Kutner, N.G. (1999). Reported pica behavior in a sample of incident dialysis patients. Journal of Renal Nutrition, 9(1), 14-20.