In a previous blog on five ‘weird addictions’ I briefly mentioned pagophagia, a craving and compulsion for chewing ice. Pagophagia is a type of pica (which I also covered in a previous blog). Pica is defined as the persistent eating of non-nutritive substances for a period of at least one month, without an association with an aversion to food. Although the incidence of pagophagia appears to have increased over the last 30 years in westernized cultures, Dr. B. Parry-Jones (in a 1992 issue of Psychological Medicine) carried out some historical research and pointed out that both Hippocrates and Aristotle wrote about the dangers of excessive intake of iced water. Parry-Jones also noted that references to disordered eating of ice and snow were also recorded in medical textbooks from the sixteenth century. However, the first contemporary reference to pagophagia appears to have been a 1969 paper by Dr. Charles Coltman in the Journal of the American Medical Association entitled ‘Pagophagia and iron lack’.
Pagophagia is closely associated with iron deficiency anemia but can also be caused by other factors (biochemical, developmental, psychological, and/or cultural disorders). If pagophagia is due to iron deficiency (such as case studies of those with sickle cell anemia), it may sometimes be accompanied by fatigue (e.g., being tired even when performing normally easy tasks). Dr. Youssef Osman and his colleagues published a number of case reports of pagophagia in a 2005 issue of the journal Pediatric Haematology and Oncology including the case of a child with sickle cell anemia and rectal polyps (that caused a lot of bleeding and made the anemia worse):
“An 8-year-old Omani boy, a known case of sickle cell anemia…presented with history of craving for ice. The child was noticed over the last 4 months to like drinking very cold water and to open the deep freezer and scratch the ice and eat it. The parents tried to stop him from doing so, but they failed…The child was started on oral iron therapy…and his craving for ice was completely stopped. Meanwhile, the rectal polyp was removed surgically”.
Other potential health side effects include constant headaches (a ‘brain freeze’ similar to ‘ice cream headache’) and teeth damage although this is thought to be relatively rare. However, a recent paper by Dr. Yasir Khan and Dr. Glen Tisman in the Journal of Medical Case Reports highlighted the case of a 62-year-old Caucasian man who presented with bleeding from colonic polyps associated with drinking partially frozen bottled water.
Khan and Tisman also suggested that some people who are deficient in iron experience tongue pain and glossal inflammation (glossitis). Others claim that chewing ice may help those with stomatitis (i.e., inflammation of the mucous lining inside the mouth). A recent 2009 case study published by Dr. Tsuyoshi Hata and his colleagues in the Kawasaki Medical Journal, reported the case of a 37-year old Japanese women who ate copious amounts of ice to relieve the pain of temporomandibular joint disorder (i.e., chronic pain in the joint that connects the jaw to the skull). Khan and Tisman also claim that the classical symptoms of pagophagia have changed in the last 40 years since Dr. Coltman’s initial paper in the Journal of the American Medical Association.
“This may probably be the result of advances in technology and changes in culture. When initially described [by Coltman], pagophagia was defined as the excessive ingestion of ice cubes from ice trays and the ingestion of ice scraped from the wall of the freezer. With the advent of ice cube makers and auto defrosters, the presentation of pagophagia has changed in a subtle manner as described in…our patients. Now we observe a subtler ingestion and/or sucking of ice cubes from large super-sized McDonald’s-like cups and from the use of popular bottled water containers that have been frozen”.
There have been few epidemiological studies examining the prevalence of pagophagia. Such estimates vary widely within particular populations but (according to Dr. Youssef Osman and his colleagues) have been shown to be more common in low socioeconomic and underdeveloped areas. Pagophagia is thought to be relatively harmless in itself or to one’s health, although there are some claims in the literature that pagophagia can be addictive. However, empirical reviews suggest that pagophagia (and pica more generally) is part of the obsessive-compulsive disorder spectrum of diseases. As a consequence, some case studies even suggest that ice chewing compromises their ability to maintain jobs or personal relationships.
Treatment for pagophagia can often be overcome with iron therapy and Vitamin C supplements (to supplement iron deficiency if that is the cause). For instance, Dr. Mark Marinella in a 2008 issue of the Mayo Clinic Proceedings successfully treated a 33-year old woman with pagophagia following complications with gastric bypass surgery:
“The patient received red blood cells, iron sucrose, and levofloxacin. On further questioning, the patient denied taking vitamin, mineral, or iron supplements since surgery and reported prolonged, heavy menstrual cycles. She consumed large amounts of ice daily for several months. The patient’s husband frequently observed her in the middle of the night with her head in the freezer eating the frost off the icemaker. The patient admitted to awakening several times nightly for months with an uncontrollable compulsion to eat the frost on the icemaker. This craving resolved after transfusion and iron administration”
However, if the condition is psychologically or culturally based, iron and vitamin supplements are unlikely to work, and other psychological treatments (such as cognitive-behavioural therapy) are likely to be employed.
Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Coltman, C.A. (1969). Pagophagia and iron lack. Journal of the American Medical Association, 207, 513-516.
de Los Angeles, L., de Tournemire, R. & Alvin, P. (2005). Pagophagia: pica caused by iron deficiency in an adolescent. Archives of Pediatrics, 12, 215-217.
Edwards, C.H., Johnson, A.A., Knight, E.M., Oyemadej, U.J., Cole, O.J., Westney, O.E., Jones, S. Laryea, H. & Westney, L.S. (1994). Pica in an urban environment. Journal of Nutrition (Supplement), 124, 954-962.
Hata, T., Mandai, T., Ishida, K., Ito, S., Deguchi, H. & Hosoda, M. (2009). A rapid recovery from pagophagia following treatment for iron deficiency anemia and TMJ disorder accompanied by masked depression. Kawasaki Medical Journal, 35, 329-332.
Khan, Y. & Tisman, G. (2010). Pica in iron deficiency: A case series. Journal of Medical Case Reports, 4, 86. Located: http://www.jmedicalcasereports.com/content/4/1/86
Kirchner, J.T (2001). Management of pica: A medical enigma. American Family Physician, 63, 1177-1178.
Marinella, M. (2008). Nocturnal pagophagia complicating gastric bypass. Mayo Clinic Proceedings, 83, 961
Osman, Y.M., Wali, Y.A. & Osman, O.M. (2005). craving for ice and iron-deficiency anemia: a case series. Pediatric Hematology and Oncology, 22, 127-131.
Parry-Jones, B. (1992). Pagophagia, or compulsive ice consumption: A historical perspective. Psychological Medicine, 22, 561-571.