Association of Food Taboos and Pica with Dietary Patterns in Pregnant Women

By Muneeba Tahir, Zil E Rubab, Umaid Zafar, Noor Ur Rehman

Affiliations

1. Al-Shifa School of Public Health, Al-Shifa Trust Eye Hospital, Rawalpindi, Pakistan

doi: 10.29271/jcpsp.2025.12.1617

ABSTRACT
Objective: To find out the association of food taboos and pica with dietary patterns in pregnant women.
Study Design: A cross-sectional survey.
Place and Duration of the Study: Al-Shifa School of Public Health, Al-Shifa Eye Trust Hospital, Rawalpindi, Pakistan, from April to September 2023.
Methodology: Pregnant women were selected through a non-probability consecutive sampling. The Chi-square test was applied to determine the association between dietary practices and pica, food taboos, and socio-demographic characteristics of pregnant women.
Results: Out of 139 pregnant women, the majority were between the age of 20 and 30 years (n = 89, 64%). It was noted that 58% of respondents (n = 81) did not know about food taboos. Fifty-six women (40%) reported avoiding some food items during pregnancy for multiple reasons. Nearly 49% women (n = 68) were unaware of pica, and 45% women (n = 63) were reported taking non-food items during pregnancy. Overall, it was noted that women with poor dietary practices were higher (n = 72, 58%) as compared to those with good dietary practices. Dietary practices were significantly associated with the educational, income, and residential status of women and their husbands (p <0.05). Sources of nutritional information, food avoided during pregnancy, and the types of foods avoided during pregnancy were also significantly associated with dietary practices among pregnant women (p <0.05).
Conclusion: Poor dietary practices were slightly more common than good practices in pregnant women. Food taboos significantly affect dietary habits, while pica is not significantly associated with dietary intake.

Key Words: Dietary practices, Food taboos, Pica, Pregnant women, Public hospitals.

INTRODUCTION

Inadequate nutrition during this crucial phase results in poor fetal growth and increases the risk of non-communicable diseases later in life.¹ Dietary patterns are highly influenced by the sociocultural circumstances and economic status of an individual.² Food taboos exist in nearly all societies, and they are mainly linked with religion, culture, and tradition. However, food taboos associated with culture are more prone to change due to the level of literacy that prevails in the society.³

Pregnancy is linked with various physical and psychological changes in a woman. During this period, the craving for particular foods may sometimes increase. However, craving a sub- stance not commonly documented as food is termed pica and is usually observed among pregnant women.
 

The Diagnostic and Statistical Manual of Mental Disorders describes pica as the persistent intake of non‐nutritive substances for at least one month that is inappropriate for the developmental level and not part of a culturally supported or socially normative practice.⁴ The most common types of pica are geophagia (consumption of earth), amylophagia (consumption of raw starches such as corn‐starch or uncooked rice), and pagophagia (the consumption of large quantities of ice).⁵

In the United States, the prevalence of pica in pregnant women is 68%.⁶ Various factors are associated with the development of these practices. These include cultural influences, religious practices, or sometimes in response to some underlying deficiency.⁷ The current study aimed to highlight the association and the prevalence of pica and food taboos with the dietary patterns of pregnant women. The results would be beneficial in creating awareness of how food taboos and pica practices affect dietary  patterns  among  females  during  pregnancy.

METHODOLOGY

A cross-sectional study was conducted at Al-Shifa School of Public Health, Al-Shifa Eye Trust Hospital, Rawalpindi, Pakistan, from April to September 2023. One hundred and thirty-nine pregnant women of childbearing age visiting public healthcare facilities who met the inclusion criteria were consecutively included in this study. Those with twin pregnancies were excluded from the study. The sample size was calculated using the proportion formula for sample size calculation in the Open-Epi menu, Version 3.01 software. Selection of public hospitals was carried out using simple random sampling through the lottery method, while pregnant women were selected using a non-probability convenience sampling.

Data were collected using an interview-based questionnaire that included the sociodemographic characteristics of the pregnant women, pica practices, food taboos, and dietary patterns. The questionnaire consisted of five sections. Section 1 included questions related to the sociodemographic characteristics of the pregnant women: Section 2 included antenatal information about the pregnant mothers, such as history of disease and pregnancy issues; Section 3 and Section 4 included knowledge of the pregnant mothers regarding food taboos and pica practices, and the questions were adapted from previous studies conducted in Eastern Ethiopia, Ghana, and Pakistan;^4,6,8 Section 5 included a Food Frequency Questionnaire (FFQ) to determine the dietary practices of pregnant mothers. The questionnaire contained questions regarding different food items such as cereals, meat, other protein sources, fats, oils, dairy products, fruits, vegetables, etc. It was a 4-point Likert Scale, ranging from 0 = never to 3 = daily. The total number of items was 26. Dietary practices among pregnant women were taken as outcome variables assessed using FFQ, while the sociodemographic variables, knowledge about pica, and food taboos were taken as independent variables assessed using a structured questionnaire.

Pilot testing was performed before starting the main data collection by including 10% of the actual sample size, which is (n = 16). The questionnaire was tested for any future changes; no major changes were made after pilot testing. The reliability of the scale (0.71) was assessed using Cronbach's alpha in SPSS version 26. The computed response for FFQ was calculated for each respondent by adding the individual responses to SPSS. Computed scores for all food item domains were also calculated. Continuous variables were categorised to proceed with the analysis. Dietary practices were categorised into two categories—poor and good—based on a median score of 43. Respondents with an FFQ score of less than 43 were categorised as having poor dietary intake, while those with scores greater than 43 were categorised as having good dietary intake.

Data were analysed using SPSS version 26. Descriptive analysis was carried out using frequencies and percentages, while Pearson’s Chi-Square test of independence was used to determine the association between dietary practices and pica, food taboos, and the socio-demographic characteristics of the pregnant women. A p-value of less than 0.05 was considered statistically significant.

Table I: Association between the socio-demographic characteristics and dietary practices.
 

Sociodemographic characteristics	Dietary practices		χ2 (df)	p-values
	Poor n (%)	Good n (%)
Age			1.05 (1)	0.305
20-30 years	49 (55)	40 (45)
31-40 years	23 (46)	27 (54)
Trimester			1.82 (2)	0.402
1st	21 (62)	13 (38)
2nd	19 (48)	21 (52)
3rd	32 (49)	33 (51)
Residence			7.56 (1)	0.006**
Urban	51 (46)	60 (54)
Rural	21 (75)	7 (25)
Education of women			12.30 (4)	0.015*
Illiterate	17 (81)	4 (19)
Primary to secondary	15 (63)	9 (78)
FA/FSC	15 (47)	17 (53)
Bachelors	14 (37)	24 (63)
Master’s and above	11 (46)	13 (54)
Occupation of women			4.19 (3)	0.241
Student	2 (67)	1 (33)
Housewife	62 (55)	50 (45)
Government employee	5 (31)	11 (69)
Private employee	3 (38)	5 (62)
Husband’s education			21.26 (4)	<0.001*
Illiterate	17 (85)	3 (15)
Primary to Secondary	14 (70)	6 (30)
FA/FSC	4 (20)	16 (80)
Bachelors	25 (51)	24 (49)
Master’s and above	12 (40)	18 (60)
Monthly income			20.53 (4)	<0.001
>25000	35 (78)	10 (22)
>50000	17 (35)	32 (65)
75000	9 (56)	7 (44)
100000	6 (43)	8 (57)
>100000	5 (33)	10 (67)
The Pearson's Chi-square test of association was applied to find out the association between socio-demographic characteristics and dietary practices.

Table II: Association of dietary practices with food taboos.

Food taboos	Dietary practices		χ2 (df)	p-values
	Poor n (%)	Good n (%)
Have you heard about food taboos?			0.82 (1)	0.364
Yes	26 (46)	30 (54)
No	44 (54)	37 (46)
How do you define food taboos?			1.08 (1)	0.298
Not know	46 (55)	37 (45)
Foods that will lead to miscarriage	26 (46)	30 (54)
Source of nutritional information			14.53 (5)	0.013*
Nil	41 (53)	37 (47)
Social media	15 (79)	4 (21)
Book	1 (100)	0 (0)
Social media and book	7 (28)	18 (72)
Mother-in-law	3 (33)	6 (67)
Neighbours	5 (71)	2 (29)
Is there any food you are avoiding during pregnancy?			4.30 (1)	0.038*
Yes	35 (63)	21 (37)
No	37 (45)	46 (55)
Food avoided during pregnancy.			16.56 (7)	0.007**
Nil	36 (44)	46 (56)
Proteins	12 (52)	11 (48)
Fats and oils	0 (0)	1 (100)
Fruits	10 (77)	3 (23)
Vegetables	9 (90)	1 (10)
Ice	2 (29)	5 (71)
Wheat	2 (100)	0 (0)
Sweets	1 (100)	0 (0)
Reasons to avoid food			11.68 (7)	0.06
Nil	35 (44)	44 (56)
Nausea/vomiting	28 (68)	13 (32)
Allergic reaction	0 (0)	2 (100)
Fear of affecting foetus	1 (25)	3 (75)
Fear of miscarriage	4 (50)	4 (50)
Hypertension	2 (67)	1 (33)
Stomach pain	1 (100)	0 (0)
The Pearson’s Chi-square test of association was applied to determine the association of dietary practices with food taboos.

RESULTS

A total of 139 pregnant women were involved in this study. Most of the pregnant women were aged between 20 and 30 years (n = 89, 64%), were in their third trimester (n = 65, 4%), and belonged to urban areas (n = 111, 80%). The outcomes of the study showed that the number of women whose husbands' education was bachelor's level was slightly higher than that of others (n = 49, 35%), and had no living children (n = 53, 38%). However, most of the respondents consulted doctors for antenatal care (n = 138, 99%), engaged in physical activity (n = 81, 58%), and reported no pregnancy-related issues (n = 94, 67%) or family history of disease (n = 112, 81%) (Table I). While many of the pregnant women (n = 58, 42%) were taking multivitamins, it was reported that nearly 42% women (n = 58) reported having some food taboos. More than half of the respondents did not know food taboos (n = 83, 60%), and sixty-eight women (49%) did not know about pica. However, 63 (45%) women reported that they used to consume non-food items during pregnancy. The majority of the women, who used to take non-food items, reported that they consumed raw rice during pregnancy (n = 25, 18%). Dietary practices of pregnant women, assessed using FFQ, showed good intake of proteins (n = 92, 66%), milk and other dairy products (n = 79, 57%), fruits (n = 126, 91%), and vegetables (n = 127, 91%). Women with suboptimal dietary practices were slightly more in number (n = 72, 52%) as compared to those with good dietary practices (n = 67, 48%).

The association of dietary practices with pica practices among pregnant women was determined, and no factor related to pica practices was found significantly associated with dietary practices among pregnant women (p >0.05, Table II). However, it was found that women who knew pica reported good dietary practices (n = 36, 51%) as compared to those who did not have any knowledge about pica (n = 31, 46%), but the difference was not statistically significant (p >0.05).

DISCUSSION

The present study assessed the association of food taboos and pica with dietary practices among pregnant women attending public hospitals in Rawalpindi. The findings revealed that poor dietary practices were slightly more common than good dietary practices. Food taboos significantly influenced dietary intake, while pica showed no statistically significant association with the overall dietary practices. Socio-demographic factors, including women’s and their husband’s educational status, household income, and residence, were also significantly associated with dietary patterns.

Results of the study revealed that more than half of the respondents did not know about food taboos (n = 81, 58%). In a previously conducted study by Amare et al., it was reported that 52% of the studied women were aware of pregnancy-related food taboos.⁸ Similarly, another study conducted in Ethiopia revealed that nearly 28% of the studied pregnant women knew about food taboos and avoided different food items during pregnancy.⁹

The findings of this study also showed that nearly 49% (n = 68) pregnant women were not aware of pica practices, while 45% (n = 63) reported the intake of non-food items during pregnancy. A previous study conducted by Konlan et al. reported that 82% pregnant women were aware of pica in their study population, while 6% considered it harmless for health.⁴

In the current study, it was noted that the number of women with poor dietary habits was higher than those with good dietary practices. Out of the total, 52% pregnant women reported poor dietary habits. This could be due to various cultural, social, and economic factors. This study also found some factors that significantly influenced the dietary patterns of pregnant women. Results revealed a significant association between dietary patterns and the residence of the respondents (p = 0.006). Women who were living in rural areas reported poorer dietary practices than those living in urban areas. These findings are consistent with the previous study. A study conducted in Ghana in 2020 found that nutrient deficiency was more prevalent in rural residents than in urban residents (p = 0.022).¹⁰ It could be explained by the fact that in urban areas, diverse sources of dietary information are readily available.

Moreover, the education level and income level of urban people were relatively better than those living in rural areas. More importantly, women are more empowered in urban areas, which also improves their dietary intake. In the current study, it was also observed that the education of women was significantly associated with dietary practices (p = 0.015). Women with no formal education had poor dietary intake, and dietary practices showed an improving trend with increasing education level. These findings can be supported by the previous literature. A study conducted in 2016 in Bangladesh found that the diet diversity score was significantly higher among pregnant women who had higher educational achievement (p = 0.009).¹¹

This study included only those women visiting public hospitals; therefore, further investigation is needed before the results can be generalised. However, this study included a diverse sample, with respondents from different educational backgrounds, places of residence and income levels, and used a validated tool (FFQ). Several limitations should be considered when interpreting these findings. The cross- sectional design prevents the inference of causal relationships. As data were collected from hospital attendees, the findings may not be generalisable to all pregnant women, particularly those in rural or underserved areas. The information was self-reported and may be subject to recall or social desirability bias. Finally, only bivariate analysis (Chi-square test) was conducted, and the lack of multivariate adjustment limits the ability to control for potential confounders.

CONCLUSION

The dietary practices of pregnant women were affected by various factors, including social, economic, and cultural activities. Food taboos can significantly affect the dietary intake of pregnant women. It was found in the study that women practising poor dietary practices were slightly more in number compared to those who were practising good dietary patterns. The consumption of proteins, dairy products, fruits, and vegetables by pregnant women was higher compared to cereals, dry fruits, oils and fats, and drinks. Nearly half of the study population were aware of food taboos and pica. Residence, income level, and women’s and their husband’s educational status were significantly associated with dietary practices. Moreover, food taboos were also found to be significantly associated with dietary practices, while pica has no association with dietary intake.

ETHICAL APPROVAL:
The study was conducted after obtaining approval from the Institutional Review Board of Al-Shifa School of Public Health, Pakistan, and the Institute of Ophthalmology Al-Shifa Trust, Rawalpindi, Pakistan (MSPH-IRB/15-07).

PATIENTS’ CONSENT:
Informed consent was obtained from all patients before conducting the study.

COMPETING  INTEREST:
The authors declared no conflict of interest.

AUTHORS’ CONTRIBUTION:
MT: Topic selection, data analysis, data interpretation, and methodology.
ZER, UZ, NUR: Data collection, data entry, methodology, and manuscript formatting.
All authors approved the final version of the manuscript to be published.

REFERENCES

1. Olatona FA, Olowu OJ, Goodman OO, Amu EO. Dietary habits, diversity, and predictors among pregnant women attending primary health care centres for antenatal care in Lagos, Nigeria. J Family Med Prim Care 2021; 10(8): 3076-83. doi: 10.4103/jfmpc.jfmpc_397_21.
2. Mohammed SH, Taye H. Food taboo among pregnant Ethiopian women: Magnitude, drivers, and association with anaemia. Nutr J 2019; 18(1):19. doi: 10.1186/s12937-019- 0444-4.
3. Asi LN, Teri DT, Meyer-Rochow VB. Influence of food taboos on nutritional patterns in rural communities in Cameroon. Int Rev Soc Res 2018; 8(1):2-6. doi: 10.2478/irsr-2018-0013.
4. Konlan KD, Abdulai JA, Konlan KD, Amoah RM, Doat AR. Practices of pica among pregnant women in a tertiary healthcare facility in Ghana. Nurs Open 2020; 7(3):783-92. doi: 10.1002/nop2.451.
5. Ahmed MA, Al-Nafeesah A, AlEed A, Adam I. Prevalence and associated factors of symptoms of pica among adolescent schoolchildren in Northern Sudan: A cross-sectional study. J Eat Disord 2023; 11(1):66. doi: 10.1186/s40 337-023-00777-0.
6. Shah FJ, Qaisar AM, Malik IA, Jahangir R. Practices of pica among pregnant females and associated outcomes in newborn and pregnant women. Pak J Med Health Sci 2022; 16(5):317-8. doi: 10.53350/pjmhs22165317.
7. Akhtar AN, Fatima F, Suleman MA, Khurram S. Prevalence of pica among pregnant females of low-income population: A hospital-based study. Ann Abbasi Shaheed Hosp Karachi Med Dent Coll 2021; 26(4). doi: 10.58397/ashkmdc.v26 i4.250.
    
8. Amare W, Tura AK, Semahegn A, Roba KT. Food taboos among pregnant women and associated factors in eastern Ethiopia: A community-based cross-sectional study. SAGE Open Med 2022; 9:10:20503121221133935. doi: 10. 1177/20503121221133935.
9. Abere M, Azene AG. Food taboo and associated factors among pregnant women attending antenatal clinics at Bahir Dar City, North West Ethiopia, 2021: Cross-sectional study. Sci Rep 2023; 13(1):646. doi: 10.1038/s41598- 023-34964-5.
10. Ayensu J, Annan R, Lutterodt H, Edusei A, Peng LS. Prevalence of anaemia and low intake of dietary nutrients in pregnant women living in rural and urban areas in the Ashanti region of Ghana. PLoS One 2020; 15(1):e0226026. doi: 10.1371/journal.pone.0226026.
11. Shamim AA, Mashreky SR, Ferdous T, Tegenfeldt K, Roy S, Rahman AK, et al. Pregnant women's diet quality and its sociodemographic determinants in Southwestern Bangladesh. Food Nutr Bull 2016; 37(1):14-26. doi: 10. 1177/0379572116632137.