My patient was a 37-year-old executive assistant at a movie studio, and though I had known her for a long time, this was the first time she’d ever mentioned that she liked to eat paper. The craving, she told me, had been with her for years. Regarding it as an odd but harmless quirk, she hadn’t really shared her desire for paper with anyone before.
“Well, how much paper do you eat?” I asked. I didn’t want to embarrass her by suggesting some large amount, so I grabbed a scratch pad that I keep handy in my exam room, tore off a corner of a page, and held it up. “Like this much?”
She laughed. “Are you kidding? I could eat two or three of those pages at lunch. There’s a pad on my desk in my office, and I nibble all day long. And you know what else? I love the smell of cement, especially wet cement.”
She practically licked her lips as she told me this. “Sometimes I pause in the concrete stairwell at work just to enjoy the smell. Nuts, huh?” She giggled, certain I thought she was crazy.
Crazy was not what I was thinking. I was thinking pica. Pica is an eating disorder in which a person habitually eats nonnutritive substances at an age that is developmentally inappropriate. Up to 24 months of age, kids will put anything in their mouths, but by the time you’re an adult you are supposed to know better. Outside the pediatric realm, pica usually turns up in this country among adults with mental disabilities or psychiatric disorders. People have been documented to eat everything from dirt, clay, and hair to pebbles, cigarette butts, laundry starch, and feces. Patients with serious psychiatric conditions have ingested buttons, needles, coins, and even lightbulbs.
In many regions, however, pica can be a learned behavior. Eating white clay to treat morning sickness, for example, has been a practice in some rural African American communities. But my paper-munching patient wasn’t pregnant, nor was she developmentally disabled. She had never shown any signs of a psychiatric disorder.
I considered other reasons for her unusual craving. I recalled that certain nutritional deficiencies are associated with pica. Iron deficiency, in particular, can induce strange tastes, though it’s not known why. In any event, correcting the iron shortage fixes the problem. Interestingly, in most picas associated with known deficiencies, the substance being craved doesn’t even contain the missing mineral. As you might guess, there isn’t a lot of iron in a paper towel.
I drew blood for testing, and the results soon confirmed that my patient was low in iron. Why would that be? For a woman in her childbearing years, the most frequent reason is menstrual blood loss, and I presumed that this was the cause in my patient. After checking to make sure that she did not have any hard-to-detect bleeding in her intestinal tract, I prescribed an oral iron supplement and asked her to come back in two months. I told her I was certain that this would cure both her deficiency and her paper craving.
Alas, at our next meeting she told me she still had a penchant for paper, and a repeat iron test showed that she was still low in this vital mineral. She assured me that she had been taking the iron supplement. So why wasn’t she better? She was ingesting the iron, but apparently her body wasn’t absorbing it. Some conditions of malabsorption can lead to iron deficiency, but these are almost always associated with other symptoms, like diarrhea. Although my patient had never complained of intestinal problems, I decided to ask about her bowel habits. She told me they were normal and hadn’t changed for years.
“Well, how many times a day do you have a bowel movement?” I asked. “On average.”
“Five or six,” she said.
There’s a pad of paper on my desk, and I nibble all day long.
“You have five or six BMs a day? Every day?” I queried, my raised eyebrows no doubt betraying my surprise.
“Sure,” she said. “Doesn’t everybody?”
I remembered an old adage: Listen to your patients; they’ll tell you what’s wrong. I ordered new blood tests, and the results suggested that my patient had celiac disease, one of the most common causes of malabsorption. A biopsy of her small bowel confirmed the diagnosis. Celiac disease is a disorder that can crop up among people with a genetically influenced sensitivity to a protein found in wheat and related foods. When one eats these foods, the intestine becomes so inflamed that nutrients aren’t absorbed well. Other symptoms are cramps and diarrhea of varying severity.
The treatment for celiac disease is to eliminate gluten, the offending protein, from the diet. That means avoiding all foods containing wheat, rye, and barley. Once gluten is no longer present in the diet, the gut heals itself and regains its ability to absorb nutrients.
I told my patient of her diagnosis and explained that the problem was readily fixable. The new, wheat-free dietary regimen outlined by the dietitian to whom I referred her wasn’t terribly appealing; she agreed to stick to it nonetheless. Three months later, her iron level was up to normal. She in turn reported that her paper craving had subsided considerably and her BMs were much less frequent.
“Well, there you go,” I said to myself. “Diarrhea gone, iron deficiency gone, and pica gone. A diagnostic puzzle turned into a therapeutic hat trick.” But my self-satisfied ruminations were cut short when my patient grumbled, “You put me on this wheat-free diet.”
“Yes,” I said, “and you’re doing much better, no?”
“No. Look at me. I’ve gained more than 15 pounds. None of my clothes fit me anymore.”
I checked her chart to confirm the weight gain. In a flash I realized that this once slender woman not only had regained the ability to absorb iron but was also now absorbing most of the calories she ate. In the past she had been able to consume whatever she wanted with impunity. Not anymore. She’d gotten heavier, and it was my fault. I had to suppress a rueful smile as another old adage came to mind: No good deed shall go unpunished.
My patient worked in an industry that placed a premium on personal appearance, and the frustration in her voice made it clear that she would willingly have returned to her six daily visits to the toilet and frequent snacks of Post-its if only she could have her thinner body back. I empathized with her and explained what had happened. I then spoke to her about a low-calorie diet to reduce her weight. Given how highly motivated she was, it wasn’t long before she shed the unwanted pounds.
H. Lee Kagan is an internist in Los Angeles. The cases described in Vital Signs are real, but patients’ names and other details have been changed.
