Association of Pica with Anemia and Gastrointestinal Distress among Pregnant Women in Zanzibar, Tanzania

Sera L. Young Department of Pediatrics, University of California Davis Medical Center, Sacramento, California; Division of Nutritional Sciences, Department of International Nutrition, Cornell University, Ithaca, New York; Public Health Laboratory–Ivo de Carneri, Chake Chake, Pemba Island, Zanzibar, Tanzania; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland

Search for other papers by Sera L. Young in
Current site
Google Scholar
PubMed
Close
,
Sabra S. Khalfan Department of Pediatrics, University of California Davis Medical Center, Sacramento, California; Division of Nutritional Sciences, Department of International Nutrition, Cornell University, Ithaca, New York; Public Health Laboratory–Ivo de Carneri, Chake Chake, Pemba Island, Zanzibar, Tanzania; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland

Search for other papers by Sabra S. Khalfan in
Current site
Google Scholar
PubMed
Close
,
Tamer H. Farag Department of Pediatrics, University of California Davis Medical Center, Sacramento, California; Division of Nutritional Sciences, Department of International Nutrition, Cornell University, Ithaca, New York; Public Health Laboratory–Ivo de Carneri, Chake Chake, Pemba Island, Zanzibar, Tanzania; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland

Search for other papers by Tamer H. Farag in
Current site
Google Scholar
PubMed
Close
,
Justine A. Kavle Department of Pediatrics, University of California Davis Medical Center, Sacramento, California; Division of Nutritional Sciences, Department of International Nutrition, Cornell University, Ithaca, New York; Public Health Laboratory–Ivo de Carneri, Chake Chake, Pemba Island, Zanzibar, Tanzania; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland

Search for other papers by Justine A. Kavle in
Current site
Google Scholar
PubMed
Close
,
Said M. Ali Department of Pediatrics, University of California Davis Medical Center, Sacramento, California; Division of Nutritional Sciences, Department of International Nutrition, Cornell University, Ithaca, New York; Public Health Laboratory–Ivo de Carneri, Chake Chake, Pemba Island, Zanzibar, Tanzania; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland

Search for other papers by Said M. Ali in
Current site
Google Scholar
PubMed
Close
,
Hamad Hajji Department of Pediatrics, University of California Davis Medical Center, Sacramento, California; Division of Nutritional Sciences, Department of International Nutrition, Cornell University, Ithaca, New York; Public Health Laboratory–Ivo de Carneri, Chake Chake, Pemba Island, Zanzibar, Tanzania; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland

Search for other papers by Hamad Hajji in
Current site
Google Scholar
PubMed
Close
,
Kathleen M. Rasmussen Department of Pediatrics, University of California Davis Medical Center, Sacramento, California; Division of Nutritional Sciences, Department of International Nutrition, Cornell University, Ithaca, New York; Public Health Laboratory–Ivo de Carneri, Chake Chake, Pemba Island, Zanzibar, Tanzania; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland

Search for other papers by Kathleen M. Rasmussen in
Current site
Google Scholar
PubMed
Close
,
Gretel H. Pelto Department of Pediatrics, University of California Davis Medical Center, Sacramento, California; Division of Nutritional Sciences, Department of International Nutrition, Cornell University, Ithaca, New York; Public Health Laboratory–Ivo de Carneri, Chake Chake, Pemba Island, Zanzibar, Tanzania; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland

Search for other papers by Gretel H. Pelto in
Current site
Google Scholar
PubMed
Close
,
James M. Tielsch Department of Pediatrics, University of California Davis Medical Center, Sacramento, California; Division of Nutritional Sciences, Department of International Nutrition, Cornell University, Ithaca, New York; Public Health Laboratory–Ivo de Carneri, Chake Chake, Pemba Island, Zanzibar, Tanzania; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland

Search for other papers by James M. Tielsch in
Current site
Google Scholar
PubMed
Close
, and
Rebecca J. Stoltzfus Department of Pediatrics, University of California Davis Medical Center, Sacramento, California; Division of Nutritional Sciences, Department of International Nutrition, Cornell University, Ithaca, New York; Public Health Laboratory–Ivo de Carneri, Chake Chake, Pemba Island, Zanzibar, Tanzania; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland

Search for other papers by Rebecca J. Stoltzfus in
Current site
Google Scholar
PubMed
Close
Restricted access

The etiology of pica, the purposive consumption of non-food substances, is not understood, despite its ubiquity among gravidae. We examined correlates of pica in a representative obstetric population (n = 2,368) on Pemba Island, Zanzibar, Tanzania to examine proposed etiologies. Cross-sectional data were collected on socioeconomic characteristics, food intake, geophagy (earth consumption), amylophagy (raw starch consumption), anthropometry, iron status, parasitic burden, and gastrointestinal morbidities. Amylophagy was reported by 36.3%, geophagy by 5.2%, and any pica by 40.1%. There was a strong additive relationship of geophagy and amylophagy with lower hemoglobin (Hb) concentration and iron deficiency anemia. By multivariate logistic regression, any pica was associated with Hb level (odds ratio [OR] = 0.76, 95% confidence interval [CI] = 0.72–0.81), nausea (OR = 1.45, 95% CI = 1.20–1.73), and abdominal pain (OR = 1.22, 95% CI = 1.01–1.48). These striking results indicate that the nature of the relationship between pica, pregnancy, gastrointestinal distress, and iron deficiency anemia merits further investigation.

Author Notes

*Address correspondence to Sera L. Young, Department of Pediatrics, University of California Davis Medical Center, Ticon II, Suite 334, 2516 Stockton Boulevard, Sacramento, CA 95817. E-mails: slyo@ucdavis.edu or sly3@cornell.edu

Financial support: This study was supported by the Bill and Melinda Gates Foundation and the United Nations Children's Fund–Zanzibar. Sera L. Young was supported by the National Institutes of Health (grant TG #5 T32 HD007331), the Einaudi Center for International Studies at Cornell University, the Division of Nutritional Sciences Small Grants at Cornell University, and Sigma Xi.

Disclosure: None of the authors have any conflicts of interest.

Authors' addresses: Sera L. Young, Department of Pediatrics, University of California Davis Medical Center, Sacramento CA, and Division of Nutritional Sciences, Department of International Nutrition, Cornell University, Ithaca, NY, E-mails: slyo@ucdavis.edu or sly3@cornell.edu. Sabra S. Khalfan, Said M. Ali, and Hamad Hajji, Public Health Laboratory–Ivo de Carneri, Chake Chake, Pemba Island, Zanzibar, Tanzania. Tamer H. Farag, Justine A. Kavle, and James M. Tielsch, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Kathleen M. Rasmussen, Gretel H. Pelto, and Rebecca J. Stoltzfus, Division of Nutritional Sciences, Department of International Nutrition, Cornell University, Ithaca, NY.

Reprint requests: Sera L. Young, Department of Pediatrics, University of California Davis Medical Center, Ticon II, Suite 334, 2516 Stockton Boulevard, Sacramento, CA 95817, E-mails: slyo@ucdavis.edu or sly3@cornell.edu.

  • 1.

    Laufer B, 1930. Geophagy 18(2). Chicago: Field Museum of Natural History.

  • 2.

    Danford D, 1982. Pica and nutrition. Annu Rev Nutr 2: 303322.

  • 3.

    Young SL, Wilson MJ, Miller D, Hillier S, 2008. Toward a comprehensive approach to the collection and analysis of pica substances, with emphasis on geophagic materials. PLoS One 3: e3147.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4.

    Jenkins CL, 1980. Geophagy in Fayette county, Tennessee: a symbolic interpretation. Tennessee Anthropologist 5: 7391.

  • 5.

    Krishnamani R, Mahaney W, 2000. Geophagy among primates: adaptive significance and ecological consequences. Anim Behav 59: 899915.

  • 6.

    Kreulen DA, 1985. Lick use by large herbivores: a review of benefits and banes of soil consumption. Mammal Rev 15: 107123.

  • 7.

    Rothenberg S, Manalo M, Jiang J, Khan F, Cuellar R, Reyes S, Sanchez M, Reynoso B, Aguilar A, Diaz M, Acosta S, Jauregui M, Johnson C, 1999. Maternal blood lead level during pregnancy in south central Los Angeles. Arch Environ Health 54: 151157.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8.

    Abrahams P, Follansbee M, Hunt A, Smith B, Wragg J, 2006. Iron nutrition and possible lead toxicity: an appraisal of geophagy undertaken by pregnant women of UK Asian communities. Appl Geochem 21: 98108.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9.

    Patterson EC, Staszak DJ, 1977. Effects of geophagia (kaolin ingestion) on the maternal blood and embryonic development in the pregnant rat. J Nutr 107: 20202025.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10.

    Thomas FB, Falko JM, Zuckerman K, 1976. Inhibition of intestinal iron absorption by laundry starch. Gastroenterology 71: 10281032.

  • 11.

    Minnich V, Okcuoglu A, Tarcon Y, Arcasoy A, Cin S, Yorukoglu O, Renda F, Demirag B, 1968. Pica in Turkey. II. Effect of clay upon iron absorption. Am J Clin Nutr 21: 7886.

  • 12.

    Hooda PS, Henry CJ, Seyoum TA, Armstrong LD, Fowler MB, 2004. The potential impact of soil ingestion on human mineral nutrition. Sci Total Environ 333: 7587.

  • 13.

    Luoba A, Geissler P, Estambale B, Ouma J, Alusala D, Ayah R, Mwaniki D, Magnussen P, Friis H, 2005. Earth-eating and reinfection with intestinal helminths among pregnant and lactating women in western Kenya. Trop Med Int Health 10: 220227.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14.

    Saathoff E, Olsen A, Kvalsvig JD, Geissler PW, 2002. Geophagy and its association with geohelminth infection in rural schoolchildren from northern KwaZulu-Natal, South Africa. Trans R Soc Trop Med Hyg 96: 485490.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15.

    Young S, Goodman D, Farag T, Ali S, Khatib M, Khalfan S, Tielsch J, Stoltzfus R, 2007. Geophagia is not associated with Trichuris or hookworm transmission in Zanzibar, Tanzania. Trans R Soc Trop Med Hyg 101: 766772.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16.

    Abrahams P, Follansbee M, Hunt A, Smith B, Wragg J, 2006. Iron nutrition and possible lead toxicity: an appraisal of geophagy undertaken by pregnant women of UK Asian communities. Appl Geochem 21: 98108.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17.

    Yanai J, Noguchi J, Yamada H, Sugihara S, Kilasara M, Kosaki T, 2009. Function of geophagy as supplementation of micronutrients in Tanzania. Soil Sci Plant Nutr 55: 215223.

  • 18.

    Dominy N, Davoust E, Minekus M, 2004. Adaptive function of soil consumption: an in vitro study modeling the human stomach and small intestine. J Exp Biol 207: 319324.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19.

    Gilardi JD, Duffey SS, Munn CA, Tell LA, 1999. Biochemical functions of geophagy in parrots: detoxification of dietary toxins and cytoprotective effects. J Chem Ecol 25: 897922.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20.

    Johns T, Duquette M, 1991. Detoxification and mineral supplementation as functions of geophagy. Am J Clin Nutr 53: 448456.

  • 21.

    Horner R, Lackey C, Kolasa K, Warren K, 1991. Pica practices of pregnant women. J Am Diet Assoc 91: 3438.

  • 22.

    Reid RM, 1992. Cultural and medical perspectives on geophagia. Med Anthropol 13: 337351.

  • 23.

    Vermeer D, Frate D, 1979. Geophagia in rural Mississippi: environmental and cultural contexts and nutritional implications. Am J Clin Nutr 32: 21292135.

  • 24.

    Young SL, 2010. Pica in pregnancy: new ideas about an old condition. Annu Rev Nutr (in press). doi: 10.1146/annurev.nutr.012809.104713

  • 25.

    Government of Zanzibar, UNICEF, 2001. Situation Analysis for Women and Children in Zanzibar. Zanzibar: Ministry of Finances and Economic Affairs and UNICEF.

  • 26.

    Ash LR, Orihel TC, Savioli L, 1994. Bench Aids for the Diagnosis of Intestinal Parasites. Geneva: World Health Organization.

  • 27.

    Farag T, Stoltzfus R, Khalfan S, Tielsch J, 2007. Helicobacter pylori infection is associated with severe anemia of pregnancy on Pemba Island, Zanzibar. Am J Trop Med Hyg 76: 541548.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28.

    WHO Expert Committee, 2002. Prevention and Control of Schistosomiasis and Soil-Transmitted Helminthiasis. Geneva: World Health Organization.

  • 29.

    Young SL, Wilson MJ, Hillier S, Delbos E, Ali SM, Stoltzfus R, 2010. Differences and commonalities in physical, chemical, and mineralogical properties of Zanzibari geophagic soils. J Chem Ecol 36: 129140.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30.

    Morris S, Carletto C, Hoddinott J, Christiaensen L, 2000. Validity of rapid estimates of household wealth and income for health surveys in rural Africa. J Epidemiol Community Health 54: 381387.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31.

    Izugbara CO, 2003. The Cultural context of geophagy among pregnant and lactating Ngwa women of south eastern Nigeria. Am Anthropol 10: 180199.

  • 32.

    Luoba AI, Geissler PW, Estambale B, Ouma JH, Magnussen P, Alusala D, Ayah R, Mwaniki D, Friis H, 2004. Geophagy among pregnant and lactating women in Bondo District, western Kenya. Trans R Soc Trop Med Hyg 98: 734741.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33.

    Vermeer DE, 1971. Geophagy among the ewe of Ghana. Ethnology 10: 5672.

  • 34.

    Thomson J, 1997. Anaemia in pregnant women in eastern Caprivi, Namibia. S Afr Med J 87: 15441547.

  • 35.

    Antelman G, Msamanga G, Spiegelman D, Urassa E, Narh R, Hunter D, Fawzi W, 2000. Nutritional factors and infectious disease contribute to anemia among pregnant women with human immunodeficiency virus in Tanzania. J Nutr 130: 19501957.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36.

    Hunter JM, 1993. Macroterme geophagy and pregnancy clays in southern Africa. J Cultural Geography 14: 6992.

  • 37.

    Adam I, Khamis AH, Elbashir MI, 2005. Prevalence and risk factors for anaemia in pregnant women of eastern Sudan. Trans R Soc Trop Med Hyg 99: 739743.

  • 38.

    Knudsen J, 2002. Akula udongo (Earth eating habit): a social and cultural practice among Chagga women on the slopes of Mount Kilimanjaro. Indilinga 1: 1926.

  • 39.

    Kawai K, Saathoff E, Antelman G, Msamanga G, Fawzi WW, 2009. Geophagy (soil-eating) in relation to anemia and helminth infection among HIV-infected pregnant women in Tanzania. Am J Trop Med Hyg 80: 3643.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 40.

    Geissler P, Shulman C, Prince R, Mutemi W, Mnazi C, Friis H, Lowe B, 1998. Geophagy, iron status and anaemia among pregnant women on the coast of Kenya. Trans R Soc Trop Med Hyg 92: 549553.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 41.

    Corbett R, Ryan C, Weinrich S, 2003. Pica in pregnancy: does it affect pregnancy outcomes? MCN Am J Matern Child Nurs 28: 183189; quiz 190–191.

  • 42.

    Rainville AJ, 1998. Pica practices of pregnant women are associated with lower maternal hemoglobin level at delivery. J Am Diet Assoc 98: 293296.

  • 43.

    Keith D, Keith L, Berger GS, Foot J, Webster A, 1975. Amylophagia during pregnancy: some maternal and perinatal correlations. Mt Sinai J Med 42: 410414.

  • 44.

    Rowles-Sewing S, 1981. “We're Made from Clay, It Won't Hurt Nobody”: A Cross-Cultural Study of Geophagia in Houston. Houston: Department of Anthroplology, University of Houston.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 45.

    Hunter JM, de Kleine R, 1984. Geophagy in Central America. Geogr Rev 74: 157169.

  • 46.

    Ward P, Kutner NG, 1999. Reported pica behavior in a sample of incident dialysis patients. J Ren Nutr 9: 1420.

  • 47.

    Kettaneh A, Eclache V, Fain O, Sontag C, Uzan M, Carbillon L, Stirnemann J, Thomas M, 2005. Pica and food craving in patients with iron-deficiency anemia: a case-control study in France. Am J Med 118: 185188.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 48.

    Thomson J, 1997. Anaemia in pregnant women in eastern Caprivi, Namibia. S Afr Med J 87: 15441547.

  • 49.

    Geissler P, Shulman C, Prince R, Mutemi W, Mnazi C, Friis H, Lowe B, 1998. Geophagy, iron status and anaemia among pregnant women on the coast of Kenya. Trans R Soc Trop Med Hyg 92: 549553.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 50.

    Kawai K, Saathoff E, Antelman G, Msamanga G, Fawzi WW, 2009. Geophagy (soil-eating) in relation to anemia and helminth infection among HIV-infected pregnant women in Tanzania. Am J Trop Med Hyg 80: 3643.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 51.

    Smulian J, Motiwala S, Sigman R, 1995. Pica in a rural obstetric population. South Med J 88: 12361240.

  • 52.

    Wiley AS, Katz SH, 1998. Geophagy in pregnancy: a test of a hypothesis. Curr Anthropol 39: 532545.

  • 53.

    Hunter JM, 1973. Geophagy in Africa and in the United States: a culture-nutrition hypothesis. Geogr Rev 63: 170195.

  • 54.

    Hooda PS, Henry CJ, Seyoum TA, Armstrong LD, Fowler MB, 2004. The potential impact of soil ingestion on human mineral nutrition. Sci Total Environ 333: 7587.

  • 55.

    Talkington KM, Gant NF, Scott DE, Pritchard JA, 1970. Effect of ingestion of starch and some clays on iron absorption. Am J Obstet Gynecol 108: 262267.

  • 56.

    Wilson MJ, 2003. Clay mineralogical and related characteristics of geophagic materials. J Chem Ecol 29: 15251547.

  • 57.

    Smith B, Rawlins B, Cordeiro M, Hutchins M, Tiberindwa J, Sserunjog IL, Tomkins A, 2000. The bioaccessibility of essential and potentially toxic trace elements in tropical soils from Mukono District, Uganda. J Geol Soc London 157: 885891.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 58.

    Lukmanji Z, Hertzmark E, Mlingi N, Assey V, Ndossi G, Fawzi W, 2008. Tanzania Food Composition Tables. Available at: http://www.hsph.harvard.edu/nutritionsource/files/tanzania-food-composition-tables.pdf.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 59.

    Hui YH, Smith RA, Spoerke DG, 2001. Foodborne Disease Handbook. Volume 1. Diseases Caused by Bacteria. New York: Marcel Dekker, Inc.

  • 60.

    Hui YH, Smith RA, Spoerke DG, 2001. Foodborne Disease Handbook. Volume 3. Plant Toxicants. New York: Marcel Dekker, Inc.

  • 61.

    Brouillard MY, Rateau JG, 1989. Adsorption potency of 2 clays, smectite and kaolin on bacterial enterotoxins. In vitro study in cell culture and in the intestine of newborn mice [in French]. Gastroenterol Clin Biol 13: 1824.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 62.

    Dornai D, Mingelgrin U, Frenkel H, Bar-Joseph M, 1993. Direct quantification of unadsorbed viruses in suspensions of adsorbing colloids with the enzyme-linked immunosorbent assay. Appl Environ Microbiol 59: 31233125.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 63.

    Barr M, 1957. Adsorption studies on clays. II. The adsorption of bacteria by activated attapulgite, halloysite, and kaolin. J Am Pharm Assoc 46: 490492.

  • 64.

    Gonzalez R, De Medina FS, Martinez-Augustin O, Nieto A, Galvez J, Risco S, Zarzuelo A, 2004. Anti-inflammatory effect of diosmectite in hapten-induced colitis in the rat. Br J Pharmacol 141: 951960.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 65.

    Gardiner KR, Anderson NH, McCaigue MD, Erwin PJ, Halliday MI, Rowlands BJ, 1993. Adsorbents as antiendotoxin agents in experimental colitis. Gut 34: 5155.

Past two years Past Year Past 30 Days
Abstract Views 528 528 41
Full Text Views 1092 125 0
PDF Downloads 471 29 0
 
Membership Banner
 
 
 
Affiliate Membership Banner
 
 
Research for Health Information Banner
 
 
CLOCKSS
 
 
 
Society Publishers Coalition Banner
Save