Fpsyg 05 01076

HYPOTHESIS AND THEORY ARTICLE
published: 23 September 2014

doi: 10.3389/fpsyg.2014.01076
Pickles and ice cream! Food cravings in pregnancy:

hypotheses, preliminary evidence, and directions for future
research
Natalia C. Orloff* and Julia M. Hormes
Health Behaviors Laboratory, Department of Psychology, University at Albany – State University of New York, Albany, NY, USA
Edited by: Women in the United States experience an increase in food cravings at two specific
Adrian Meule, University of Würzburg, times during their life, (1) perimenstrually and (2) prenatally. The prevalence of excess
Germany
gestational weight gain (GWG) is a growing concern due to its association with adverse
Reviewed by:
Adrian Meule, University
health outcomes in both mothers and children. To the extent that prenatal food cravings
of Würzburg, Germany may be a determinant of energy intake in pregnancy, a better understanding of craving
Kelly Costello Allison, Perelman etiology could be crucial in addressing the issue of excessive GWG. This paper reviews the
School of Medicine of the University available literature to corroborate and/or dispute some of the most commonly accepted
of Pennsylvania, USA
hypotheses regarding the causes of food cravings during pregnancy, including a role of (1)
*Correspondence:
Natalia C. Orloff, Health Behaviors
hormonal changes, (2) nutritional deficits, (3) pharmacologically active ingredients in the
Laboratory, Department of desired foods, and (4) cultural and psychosocial factors. An existing model of perimenstrual
Psychology, University at Albany – chocolate craving etiology serves to structure the discussion of these hypotheses.The main
State University of New York, Social hypotheses discussed receive little support, with the notable exception of a postulated role
Sciences 399, 1400 Washington
Avenue, Albany, NY 12222, USA
of cultural and psychosocial factors.The presence of cravings during pregnancy is a common
e-mail: [email protected] phenomenon across different cultures, but the types of foods desired and the adverse
impact of cravings on health may be culture-specific. Various psychosocial factors appear to
correlate with excess GWG, including the presence of restrained eating. Findings strongly
suggest that more research be conducted in this area. We propose that future investigations
fall into one of the four following categories: (1) validation of food craving and eating-
related measures specifically in pregnant populations, (2) use of ecological momentary
assessment to obtain real time data on cravings during pregnancy, (3) implementation of
longitudinal studies to address causality between eating disorder symptoms, food cravings,
and GWG, and (4) development of interventions to ensure proper prenatal nutrition and
prevent excess GWG.
Keywords: pregnancy, craving, restraint, eating disorders, food, chocolate, perimenstrual
OVERVIEW a potentially modifiable determinant of energy intake and nutri-

Food cravings are a common phenomenon, especially in women tional quality in pregnancy. We will begin with a brief introduction
in the United States (U.S.), and have been implicated in a range to food cravings both in general and specifically in pregnancy,
of weight- and eating-related pathology. Cravings in women have followed by an overview of the adverse health effects of excess
been shown to increase in frequency and intensity at two distinct GWG. We will then introduce a theoretical framework of craving
times: during the perimenstrum (i.e., a period of about eight days etiology that integrates key results from work on perimenstrual
around the onset of menstruation) and in pregnancy. Perimen- chocolate craving and argue that this framework can serve as
strual cravings for chocolate have been the focus of significant a useful blueprint for the study of food cravings in pregnancy.
attention from researchers in recent years, resulting in enhanced We will review major hypotheses regarding craving etiology and
insight into the mechanisms underlying craving etiology. Cravings examine the extent to which they are supported or refuted by
in pregnancy, on the other hand, remain relatively understudied. the existing literature on prenatal eating behaviors. We will con-
This gap in the literature is especially striking given the steady rise clude with thoughts on future directions for research in this
in prevalence of excess gestational weight gain (GWG) during the area. It is important to note that an exhaustive review of the
end of the last century, which is related to adverse health outcomes literature in this field is beyond the scope of the present paper.
in mothers and their children, along with a growing understand- Instead, we aim to call attention to the importance of studying
ing of the causal role of food cravings in the etiology of overweight food cravings in pregnancy in so far as they may be implicated
and obesity. Thus, a call for a renewed focus on research in this in the growing rates of gestational overweight and obesity and
area is warranted. associated adverse health effects in U.S. mothers and their chil-
This paper seeks to highlight the importance of gaining a bet- dren. Our primary goal is to take advantage of the knowledge
ter understanding of the mechanisms underlying food cravings as gained from the study of cravings in other domains to formulate
www.frontiersin.org September 2014 | Volume 5 | Article 1076 | 1

Orloff and Hormes Food cravings in pregnancy
testable hypotheses about the underlying causes of food cravings pronounced increase in chocolate craving frequency and intensity
in pregnancy. during the perimenstrum, an eight days period beginning about
four days prior to the onset of menstruation, for around half of
FOOD CRAVINGS: AN INTRODUCTION female cravers (Rozin et al., 1991; Zellner et al., 2004; Hormes and
Food cravings are strong urges for foods that are more specific Rozin, 2009). In addition to the characteristic perimenstrual rise
than mere hunger and very difficult to resist (Gendall et al., 1997; in chocolate craving, it appears that many U.S. women may also
Pelchat, 2002; Hormes and Rozin, 2010). Food cravings are a com- experience an increase in food cravings during pregnancy (Pope
mon phenomenon, at least in some areas of the world. Between et al., 1992). In spite of a growing interest in the study of mecha-
68 and 97% of college-aged men and women in North Amer- nisms involved in the etiology of cravings in other domains, food
ica report ever having experienced a craving for a specific type cravings in pregnancy are poorly understood and widespread spec-
of food (Weingarten and Elston, 1990; Zellner et al., 1999). It ulation about their meaning and significance by laypersons and the
is tempting to think of food cravings as far less harmful than media stands in stark contrast to a lack of empirical research on
strong urges for alcohol, tobacco, and other drugs, which are the subject.
known to trigger relapse and interfere with successful abstinence
from substance use (Bottlender and Soyka, 2004; Sinha et al., FOOD CRAVINGS IN PREGNANCY
2006; Ferguson and Shiffman, 2009; Evren et al., 2012). How- An estimated 50–90% of U.S. women experience cravings for spe-
ever, a growing body of research now points to a significant role of cific foods during pregnancy (Worthington-Roberts et al., 1989;
food cravings in the development and maintenance of eating- and Pope et al., 1992). Very few women report food cravings exclusively
weight-related pathology, including overweight, obesity, bulimia during pregnancy; most have a history of pregravid cravings for a
nervosa, binge eating disorder, and failure to sustain weight losses variety of substances (Gendall et al., 1997). In terms of temporal
(Gendall et al., 1997; Lafay et al., 2001; Lowe, 2003; Lowe and patterns, it has been reported that food cravings typically emerge
Levine, 2005; Forman et al., 2007; Vander Wal et al., 2007). For by the end of the first trimester. For example, among a sample of
example, food cravings have been identified not only as reli- 400 white adult women 76% reported craving at least one food
able predictors of subsequent consumption of the desired food item by the 13th week of pregnancy (Tierson et al., 1985). The
(Forman et al., 2007), but also as potential triggers for episodes most common trajectory of food cravings across gestation shows
of binge eating, especially in bulimic and overweight individ- a peak in frequency and intensity during the second trimester, fol-
uals (Bjoervell et al., 1985; Kales, 1990). In spite of a steadily lowed by a subsequent decline as the pregnancy progresses to term
growing number of studies in this field, the exact mechanisms (Pope et al., 1992; Bayley et al., 2002; Belzer et al., 2010). Research
underlying the etiology of food cravings have yet to be elucidated. has also consistently documented a significant drop in cravings
There has been a recent increase in efforts to develop interven- following delivery (Worthington-Roberts et al., 1989; Belzer et al.,
tions targeting food cravings and studies have tested the efficacy 2010).
of diverse approaches, including brief guided imagery (Hamilton A 1978 study retrospectively examined prevalence and types of
et al., 2013), use of self-help manuals (Rodriguez-Martin et al., cravings in a group of 250 pregnant women and demonstrated that
2013), acceptance based strategies (Forman et al., 2007; Alberts the most commonly craved items included sweets (i.e., ice cream
et al., 2010), and biofeedback (Meule et al., 2012) in preventing and candy), dairy, starchy carbohydrates, fruits, vegetables, and
or reducing food cravings. It should be noted that most of these fast food (Hook, 1978). A 1992 survey of pregnant adolescents
interventions were developed specifically for individuals who iden- found frequent reports of cravings for sweets, fruits, fast foods,
tify as strong cravers (Meule et al., 2012), non-clinical populations pickles, ice cream, and pizza (Pope et al., 1992). More recent stud-
(Forman et al., 2007; Hamilton et al., 2013), or those enrolled in ies showed similar cravings, with women endorsing a desire for
weight loss trials (Batra et al., 2013). More work to test the effi- fruit juice, fruit, sweets, desserts, dairy, and chocolate (Flaxman
cacy of these interventions specifically in clinical populations is and Sherman, 2000; King, 2000). Prenatal cravings for salty or
warranted. savory foods are somewhat less commonly reported (Hook, 1978;
The prevalence and nature of food cravings varies signifi- Pope et al., 1992; Bayley et al., 2002), with the notable exception
cantly depending on the geographic region under investigation of women who experience cravings exclusively during pregnancy
(Hormes and Rozin, 2010; Hormes, 2014). Food cravings seem (Gendall et al., 1997). This subset of women were found to endorse
to be most commonly reported by individuals in North America cravings for savory, rather than sweet foods (Gendall et al., 1997).
and chocolate has consistently been found to be the most com- Given the lack of current data on the nature of food cravings
monly craved food in the U.S. (Rozin et al., 1991; Osman and in pregnancy we recently conducted a small pilot study exam-
Sobal, 2006). Within the U.S., the type, frequency, and inten- ining women’s posts on pregnancy-related blog websites about
sity of reported food cravings vary markedly by demographic the topic of food cravings1 . Among 200 posts surveyed, the most
characteristics. Younger individuals are more likely to experi-
ence food cravings, with prevalence decreasing steadily with age 1 This study sought to gather information on the types of food cravings currently
(Pelchat, 1997). Women primarily report strong urges to consume reported by pregnant women in the U.S. by surveying women’s posts on the topic
sweets, while men typically crave savory foods, especially when of food cravings on two popular pregnancy-related websites: www.thebump.com
and www.whattoexpect.com. Data were collected in the fall of 2012. We searched
stressed (Zellner et al., 1999, 2007). Women in the U.S. are twice
the “community” forums on the two websites for the term “craving” and examined
as likely to experience cravings for chocolate as compared to men. responses contained in the first 20 message threads generated by that search, resulting
This difference in prevalence appears attributable, primarily, to a in a sample of 200 unique posts. We excluded search results that were unrelated to
Frontiers in Psychology | Eating Behavior September 2014 | Volume 5 | Article 1076 | 2

commonly reported cravings were for sweets, calorically dense stress (Mills, 2007). Estimates of prevalence of pica in the U.S.
savory carbohydrates like pizza or chips, animal proteins, and vary widely. In our convenience sample of women posting on
fruits (Table 1). Prior research also points to certain temporal pat- pregnancy-related websites in the U.S. only 3.0% (n = 6) indi-
terns in the types of foods craved over the course of pregnancy. cated strong urges for non-food substances, which is consistent
Cravings for savory substances appear to be strongest during the with an early study citing prevalence rates of pica around 1.6%
first trimester, with a tapering of urges during the later stages of (Hook, 1978). However, since then it has been reported that as
peripartum (Belzer et al., 2010). In a large number of women, a many as one fifth of women who are considered as having a
preference for sweet foods reaches peak intensity during the sec- high-risk pregnancy endorse pica behaviors (Mills, 2007). Pica
ond trimester (Bowen, 1992). Urges for salty substances tend to in pregnancy is more common in certain demographic groups,
emerge later on in pregnancy, with preference for and intake of with relatively higher prevalence in African–Americans, immi-
salty foods increasing in the later stages of gestation in both preg- grants to the U.S., women living in rural areas, and those that
nant adults (Bowen, 1992; Crystal et al., 1999) and teens (Skinner have a family history of pica (Horner et al., 1991; Thihalolipavan
et al., 1998). et al., 2013). Of note, the practice of consuming non-nutritive
It is important to distinguish food cravings in pregnancy substances is thought to be present in a number of different
from pica, a condition characterized by (1) persistent eating cultures across the world (Geissler et al., 1999) and the con-
of non-nutritive substances such as soils and clay (geophagia), sumption of non-nutritive substances as part of culture-specific
ice (pagophagia), and laundry or corn starch (amylophagia; practices has been observed in countries like Kenya where preg-
Anderson, 2001; Corbett et al., 2003) for a period of at least one nant women were found to eat clay on a regular basis because
month, (2) consumption of non-nutritive substances in a manner of beliefs about its impact on fertility and reproduction (Geissler
that is inappropriate to the developmental level of the individ- et al., 1999).
ual, and (3) eating of non-nutritive substances that is not part
of a culturally supported or socially normative practice (Amer- ADVERSE HEALTH EFFECTS OF EXCESS GESTATIONAL
ican Psychiatric Association, 2013). The presence of pica is not WEIGHT GAIN
exclusive to pregnant women and the condition can be diagnosed Food intake in pregnancy has been the focus of increasing atten-
in non-pregnant individuals of all ages. A number of theories tion from researchers, health care providers, and policy makers
attempting to explain the etiology of pica have been discussed alike due in part to a growing awareness of the rising preva-
in detail elsewhere (Young, 2010) and typically implicate factors lence and significant adverse consequences of excess GWG for
such as nutritional deficiencies, a preference for the taste, smell, the health of both mothers and their children. The Institute of
or texture of the craved substances (Cooksey, 1995), or the con- Medicine (IOM) defines excess GWG in singleton pregnancies as
sumption of non-food items as a coping mechanism to relieve 35+ pounds in women of normal pre-pregnancy weight, 25+
pounds in overweight women, and 20+ pounds in women who
food cravings, as well as posts that prompted women to comment on specific types are obese (Rasmussen and Yaktine, 2009). While there are multiple
of cravings (e.g., “Is anyone else craving lemonade?”) so as not to skew our results components of GWG, including the weight of the fetus, placenta,
in favor of any one type of food or beverage. We categorized responses according to and amniotic fluid, much of the variance in weight gained in preg-
specific categories (e.g., fast food, prepared dishes, pre-packaged foods) and types
of foods (e.g., fruits, vegetables, sweets), as well as certain flavor profiles (e.g., sour, nancy is accounted for by an increase in fat mass (Kaiser et al., 2008;
sweet, salty). We also coded responses noting cravings for beverages or non-food Rasmussen and Yaktine, 2009). Despite efforts to combat obesity
substances. In addition, we looked for mentions of specific hypotheses regarding in the U.S., the prevalence of excess GWG is on the rise: according
the perceived causes of cravings, efforts to resist cravings, negative affect related to
to the National Research Council (NRC) and the IOM there was
cravings, or the notion that pregnancy may serve as an excuse to consume otherwise
forbidden foods. a 20–25% increase in U.S. women gaining more than 40 pounds
during pregnancy from 1990 to 2003 (National Research Council
and Institute of Medicine, 2007), and around half of all pregnan-
Table 1 | Most common cravings (overlapping %) reported by pregnant cies currently result in GWG that exceeds IOM guidelines (Oken
women (n = 200) posting on popular pregnancy blogs.
et al., 2007; Wrotniak et al., 2008; Chu et al., 2009; Rasmussen and
Yaktine, 2009).
Rank Substance Craved %
While maternal underweight and insufficient GWG have long
1 Sweets (e.g., chocolate, candy) 25.9
been known to have serious adverse effects on the health and
growth of the fetus (Ehrenberg et al., 2003; Han et al., 2011), exces-
2 Carbohydrates, high-calorie, savory (e.g., pizza, chips) 19.3
sive gestational weight is emerging as a potentially even greater
2 Animal protein (e.g., steak, chicken) 19.3 threat to the health and wellbeing of both women and children
4 Fruit 18.8 (Kaiser et al., 2002, 2008). Excess GWG has been linked to a num-
5 Dairy, high-calorie, savory (e.g., cheese, sour cream) 17.8 ber of adverse short- and long-term health outcomes in mothers
5 Carbohydrates, other (e.g., pretzels, cereal) 17.8 and their offspring (Cox and Phelan, 2008), and excess weight is
7 Fast food (e.g., Chinese, Mexican, falafel) 17.3
currently among the most common high-risk obstetric conditions
(Galtier-Dereure et al., 2000). Overweight and obesity are linked
8 Cold foods (e.g., ice cream, slurpee) 13.2
to higher rates of cesarean sections and greater cost of obstetric
9 Vegetables 12.2 care (Galtier-Dereure et al., 2000; Stotland et al., 2004; Vahratian
10 Dairy, high-calorie, sweet (e.g., ice cream, milkshakes) 11.7 et al., 2005). Additional complications associated with excess GWG

have been described in detail (Rasmussen and Yaktine, 2009) and Popular hypotheses regarding the causes of food cravings in
include increased risk of gestational diabetes, hypertension, pregnancy implicate hormonal fluctuations, changes in sensory
preeclampsia, delivery complications, perinatal fatality, neural perception, maternal and/or fetal nutritional needs and pref-
tube defects, neonatal hypoglycemia, and failure to initiate breast- erences, adaptive mechanisms protecting the fetus from toxins,
feeding (Hilson et al., 1997, 2006; Galtier-Dereure et al., 2000; cultural norms and practices, and cognitive or affective charac-
Kaiser et al., 2002, 2008; Thorsdottir et al., 2002). teristics of the pregnant woman (King, 2000; Patil, 2012). In the
By following guidelines for GWG women may be able to avoid small pilot study mentioned earlier we sought to gather qualitative
excessive postpartum weight retention, which results in greater information about pregnant women’s own beliefs about the mean-
short- and long-term risk of maternal overweight and obesity ing and significance of their food cravings. Of the women who
(Rooney and Schauberger, 2002; Linne et al., 2004; Rooney et al., posted to the blog websites surveyed, 16.2% (n = 32) mentioned a
2005; Amorim et al., 2007; Nohr et al., 2008). Interestingly, data perceived cause for their cravings. Responses varied widely but
suggest that the correlation between inadequate GWG and poor the more commonly cited hypotheses aligned closely with the
fetal growth is weaker than the relationship between excess weight existing literature: women speculated about cravings as a reac-
gain in pregnancy and maternal postpartum weight retention tion to food restrictions (either self-imposed or prescribed by
(Scholl et al., 1995; Kaiser et al., 2002). Excess GWG is also a a physician, n = 6) or nutritional deficits (n = 5). Some pos-
strong predictor of macrosomia (Stotland et al., 2004) and over- tulated that cravings were indicative of the gender of the child
weight/obesity in children and adolescents (Oken et al., 2007, 2010; (n = 5) or reflective of the parents’ or fetus’ food preferences
Wrotniak et al., 2008), highlighting the potential impact of excess (n = 3). A few women thought their cravings were largely due
weight gain in pregnancy on risk for weight-related pathology to external cues or triggers (n = 3) while others saw them as a
across the lifespan. byproduct of gestational diabetes (n = 2), a response to thirst
Prior research has sought to identify risk factors for excessive (n = 2), a reaction to nausea or morning sickness (n = 2), or
weight gain in pregnant women. A range of physiological vari- the result of changes in taste perception brought on by pregnancy
ables, such as insulin sensitivity and basal metabolic rate, have (n = 2).
been hypothesized to influence GWG (Rasmussen and Yaktine,
2009). Environmental context, including lack of access to physi- PERIMENSTRUAL CHOCOLATE CRAVING: A BLUEPRINT
cal spaces for exercise (Laraia et al., 2007), and sociodemographic In examining popular hypotheses regarding craving in pregnancy
variables, such as race/ethnicity (Chu et al., 2009), higher levels their close resemblance to the theorized causes of perimenstrual
of education (Chu et al., 2009), younger age (Howie et al., 2003), chocolate craving is striking. Chocolate, by far the most com-
and food insecurity (Olson and Strawderman, 2008), have been monly craved food in the U.S., is unique in many ways: it
shown to be at least weakly correlated with an increased risk for has a very recognizable smell, high caloric density, and dis-
excess GWG. For example, white women in the U.S. gain on aver- tinctive melt-in-your-mouth feel (Rozin et al., 1991; Hormes,
age 2.0 kg more than their African–American counterparts, which 2014). The characteristic pattern of cyclically fluctuating choco-
is an increase from a survey conducted at the same hospital three late craving in many U.S. women described earlier has motivated
decades prior that showed only a 0.9 kg difference between the two a body of research specifically examining perimenstrual choco-
(Eastman and Jackson, 1968; Caulfield et al., 1996). Psychosocial late craving. Major findings from this work have previously
factors including depression, anxiety, stress, internal locus of con- been summarized in some detail elsewhere (Hormes, 2014).
trol, and self-esteem have all been found to correlate with excess Accounts regarding the etiology of perimenstrual chocolate crav-
GWG (Abraham et al., 1994; Clark and Ogden, 1999; Gee and ing can be categorized as focusing on biochemical/physiological
Troop, 2003; Hill et al., 2013). versus contextual/psychosocial mechanisms. Popular hypothe-
There is also preliminary evidence to suggest that food crav- ses attribute craving to cyclic fluctuations in levels of ovarian
ings may be an important determinant of prenatal energy intake hormones, pre- and perimenstrual nutritional deficits, and phar-
and risk factor for excess GWG. This assertion is supported in macologically active ingredients in chocolate that serve to alleviate
part by a recent study which found that cravings during preg- symptoms that arise specifically around the onset of menstru-
nancy were the only significant predictor of excess GWG in a ation. More recently, research has shifted toward exploring the
sample of overweight African–American women (Allison et al., role of cultural and psychosocial factors in the emergence of
2012). As noted earlier, food cravings are known to lead to perimenstrual chocolate craving. These parallels suggest that exist-
an increase in consumption of the desired foods in both the ing research on the causes of perimenstrual chocolate craving
general and certain clinical populations. Research points to a sim- may serve as a sort of blueprint for the study of cravings in
ilar effect of food cravings in pregnancy: cravings for sweets, pregnancy.
desserts, and chocolates have been shown to result in a gen- We have previously proposed a model that integrates findings
eral increase in consumption of sugary foods and beverages and regarding the role of contextual and psychosocial factors in crav-
overall caloric intake in pregnant women (Tierson et al., 1985; ing etiology and provides a conceptual framework for the study
Pope et al., 1992; Belzer et al., 2010). In order to be able to of cravings across multiple domains, including food cravings in
target food cravings as a means of preventing or minimizing pregnancy (Figure 1; Hormes, 2014). The model postulates that
excess GWG, a better understanding of the mechanisms under- craving results from ambivalence or a tension between approach
lying strong urges for specific foods specifically during pregnancy (i.e., the desire to indulge) and avoidance (i.e., efforts to restrict
is critical. consumption) tendencies toward highly palatable foods. It is

HYPOTHESIS 1: CRAVING IS CAUSED BY FLUCTUATING

LEVELS OF HORMONES
Given the cyclic nature of perimenstrual chocolate craving, early
hypotheses implicated fluctuations in the ovarian hormones estro-
gen and progesterone in craving etiology. Though initially quite
compelling, there is generally a lack of empirical support in favor
of this view. Levels of hormones involved in regulating the men-
strual cycle are not significantly correlated with changes in the
frequency or intensity of craving for chocolate (Rodin et al., 1991),
and premenstrual administration of progesterone was not found
to be effective in reducing cravings (Michener et al., 1999). A rela-
tively high prevalence of women who continue to crave chocolate
after menopause provides additional evidence against a significant
causal role of hormonal fluctuations in craving etiology (Hormes
and Rozin, 2009).
There is a lack of literature examining direct links between
FIGURE 1 | Proposed model of craving etiology. Craving is hypothesized
to be due to competing approach-avoidance conflicts brought about by fluctuations in hormones and craving frequency and intensity in
exposure to foods that are perceived as being simultaneously appealing pregnancy; however, hormones have been implicated in prenatal
(due to an innate preference for high-calorie, sweet, and fatty foods) and craving etiology in more indirect ways. Pregnancy significantly
forbidden (due to cultural norms prescribing restrained intake and a thin
figure). While most individuals are thought to attempt to resolve the
alters sensory perception, possibly due to changes in secretion of
resulting ambivalence in favor of abstinence (represented by the solid hormones (Kuga et al., 2002; Nordin et al., 2004). When consum-
lines), pregnancy is hypothesized to be a culturally sanctioned permissive ing plant products we ingest so-called “secondary compounds”
factor, allowing women to circumvent their usual conflicting response and that serve to fend off the plants’ biotic enemies and, coinciden-
efforts to restrict intake and indulge in foods that they would otherwise
avoid, resulting in increased intake and heightened risk for weight gain tally, give them their distinctive and flavorful aroma. In small
specifically during pregnancy (represented by the dashed lines). quantities these secondary compounds have little adverse – and
potentially even beneficial – effects; however, consumed in large
quantities they can be allergens, mutagens, carcinogens, terato-
assumed that most individuals – and U.S. women in particular – gens, and abortifacients. Expectant mothers and fetuses may be
seek to resolve this ambivalence in favor of abstinence, thereby especially susceptible to these harmful effects and it has been spec-
de facto increasing the likelihood that they will crave the avoided ulated that an increase in taste and olfactory sensitivity may serve
food due to an enhanced salience of relevant cues. The model to discourage consumption of potentially toxic foods in pregnancy
furthermore proposes that certain culturally defined cues signal (Nordin et al., 2004), and could also be responsible for changing
occasional permission to break restraint, resulting in episodic con- food preferences and patterns of consumption.
sumption (and, potentially, overconsumption) of craved foods. It As many as 26% of pregnant women report altered taste sensi-
is hypothesized that in the U.S., both the perimenstrum (“PMS”) tivity (Nordin et al., 2004), and changes in olfactory perception
and pregnancy act as such culturally sanctioned disinhibitors, were reported by 65.4% of pregnant women surveyed in one
resulting in the characteristic patterns of increased craving fre- study, with 75% of these women adjusting their dietary habits
quency and intensity (and, as a result, consumption) specifically due to their increased sensitivity to odors (Cantoni et al., 1999).
at these times. In other words, contrary to previous models of In our pilot study 18.7% of blog posts (n = 37) mentioned crav-
craving etiology, our model does not consider the perimenstrum ings for foods that were disliked prior to pregnancy. Conversely,
and pregnancy a direct cause of cravings, but instead views them a vast majority of pregnant women quit drinking coffee due to a
as a catalyst or permissive factor, allowing women to acknowledge unique aversion to its taste (Lawson et al., 2004), possibly driven
and give in to otherwise unacceptable desires for highly palatable by an increase in bitter sensitivity (Nordin et al., 2004). Parallels in
foods. changes in taste perception and the trajectory of increasing crav-
In the remainder of this paper we will examine major hypothe- ing intensity during the first trimester (Kuga et al., 2002) constitute
ses regarding craving etiology in more detail, starting with a preliminary evidence in favor of a connection between changing
discussion of the role of hormonal, nutritional, and pharmaco- sensory perception and food cravings (and, possibly, aversions)
logical factors, followed by an overview of evidence in favor of a in pregnancy, however the exact nature of this link remains to be
role of cultural and psychosocial variables. We will review findings elucidated. More research is also needed to link known fluctua-
from research on perimenstrual chocolate craving and explore the tions in levels of hormones across gestation with reported food
extent to which the literature on eating behaviors in pregnancy cravings.
supports or refutes translation of the proposed theoretical model
into the domain of food cravings in pregnancy. We will attempt HYPOTHESIS 2: CRAVING IS A RESPONSE TO NUTRITIONAL
to point to gaps in the literature and outline directions for future DEFICITS
research, keeping in mind the ultimate goal of identifying targets It has been speculated that perimenstrual chocolate craving is
for interventions to reduce the prevalence of excess GWG and caused by a deficiency in certain nutrients that arises around the
associated adverse health effects. onset of menstruation and is alleviated by ingredients in the craved

food. While it is possible that menstruation causes certain nutri- Prior studies found no evidence for a significant associa-
tional deficits such as low levels of iron due to blood loss (Harvey tion between food cravings and dietary quality in pregnancy
et al., 2005), it is unlikely that chocolate would serve to alleviate (Worthington-Roberts et al., 1989) and interestingly, potentially
these needs more effectively than a variety of other foods that are beneficial foods like meat and other high-protein foods appear to
not commonly craved perimenstrually (e.g., foods like red meat, be among the most common aversions in pregnancy (Hook, 1978;
egg yolks, or dark leafy greens, which provide large amounts of Pope et al., 1992; King, 2000; Bayley et al., 2002). Research also sug-
iron), effectively ruling out a causal role of nutritional deficits in gest that the typical dietary intakes in middle- to upper-income
the emergence of perimenstrual chocolate craving (Pelchat and pregnant women in the U.S. are likely to meet all dietary needs
Schaeffer, 2000; Hormes, 2014). to the point where the widespread practice of prescribing pre-
Fetal demands can double requirements for certain nutrients, natal vitamin supplements may lead to excessive nutrient intakes
and proper nutrition during pregnancy is critical in ensuring (Turner et al., 2003). Taken together, findings therefore do not
healthy fetal development (King, 2000). For example, a lack of support a nutritional deficits hypothesis for food cravings in preg-
adequate intake of iron can result in iron deficiency anemia and nancy. Similarly, food cravings are unlikely to be due to a need for
inadequate placental and fetal growth (Allen, 2000; Kaiser et al., a general increase in caloric intake since they tend to emerge in the
2008). Nutritional guidelines for pregnancy tend to highlight the first half of gestation, long before a majority of fetal growth (and
importance of ensuring sufficient intake of a range of micronu- thus fetal demand for nutrients) takes place (King, 2000).
trients, including iron, folic acid, B vitamins, zinc, magnesium,
iodine, vitamin A, and calcium (Kaiser et al., 2002). It has been HYPOTHESIS 3: CRAVING IS DUE TO PHARMACOLOGICALLY
speculated that food cravings serve to prevent or alleviate nutri- ACTIVE INGREDIENTS IN THE DESIRED FOODS
tional deficits (or, perhaps, simply encourage the expectant mother Potentially pharmacologically active ingredients in chocolate have
to consume foods that provide added energy). This “nutritional been implicated in perimenstrual craving etiology due to their
deficits” hypothesis, which views craving as a mechanism to ensure hypothesized reinforcing effects or ability to alleviate physical –
adequate and balanced nutrition in pregnancy (Tierson et al., and perhaps psychological – symptoms associated with menstru-
1985), would predict that pregnant women primarily report urges ation, such as fatigue, irritability, bloating, or cramps (Bruinsma
for foods high in levels of micronutrients that are lacking and/or and Taren, 1999). The methylxanthines, a group of compounds
of particular importance during gestation. Such foods include with potentially energizing effects, are one example of a hypothe-
dark leafy greens, which contain high levels of B vitamins, iron, sized active ingredient in chocolate (Rogers and Smit, 2000; Smit
magnesium and vitamin A, legumes, such as beans and lentils, et al., 2004). However, methylxanthines are not present in large
which are a good source of folate, iron, and magnesium, as well enough quantities in a normal serving size of chocolate to have
as whole unrefined grains, which contain B vitamins and mag- a noticeable effect on anyone but the most sensitive individuals
nesium (Kaiser et al., 2002). Additionally, because the nutritional (Mumford et al., 1994; Hormes, 2014): a 60 g serving of milk
needs of the fetus increase as development progresses, the intensity chocolate contains only around 12 mg of caffeine, which is far
of cravings should follow the same rising trajectory (Tierson et al., less than the amount found in a serving of coffee, and substan-
1985). tially below the reliable placebo-discriminable dose (Shivley and
A majority of studies found sweets, high-fat foods, and fast Tarka, 1984; Michener and Rozin, 1994; Mumford et al., 1994).
foods to be the predominately craved substances during preg- Other potentially active ingredients are present in even smaller
nancy (Flaxman and Sherman, 2000; Fessler, 2002; Kaiser et al., quantities in the amount of chocolate typically consumed in
2002). Data from our pilot study of online posts about cravings one sitting, making it highly unlikely that their effects would be
in pregnancy suggests that while some women crave potentially causally involved in the emergence of cravings (Rogers and Smit,
beneficial proteins, fruits, or vegetables, many of the most com- 2000). The study that perhaps most compellingly demonstrates
monly reported cravings are for high-calorie, sugary, and fatty that pharmacologically active ingredients do not play a key role
foods (see Table 1). This data is largely consistent with previ- in the satisfaction of cravings for chocolate (during the perimen-
ous studies examining cravings in a college population that found strum or otherwise) found that white chocolate (which contains
cravings for nutrient dense foods, such as fruits and vegetables, none of the pharmacologically active ingredients of milk or dark
to be rarely reported (Weingarten and Elston, 1991). Thus, as is chocolate, with the possible exception of the fat-soluble cannabi-
the case with perimenstrual chocolate craving, the foods typically noid anandamide) is far more effective at alleviating cravings
desired by expectant women are unlikely to be the best source of than capsulated cocoa powder, which contains all of the phar-
nutrients needed in pregnancy. For example, an average serving of macologically active ingredients of milk and dark chocolate, but
ice cream (1/2 cup, ∼60g, ∼230 calories) contains around 78 mg in isolation of its oro-sensory properties (Michener and Rozin,
of calcium while the same serving size of tofu (∼60g, ∼90 calo- 1994).
ries) contains up to 160 mg of calcium and would thus constitute As is the case with the perimenstrum, a variety of unpleasant
a much better source of nutrition. It should be noted that the symptoms like aversions to specific foods, nausea, and vomiting
available data appear to point to a higher prevalence of cravings are widely considered hallmarks of pregnancy and it has been the-
for fruit in pregnant women, compared to other groups studied orized that food cravings serve to encourage intake of substances
to date. More work is needed to systematically examine the seem- that may help alleviate these symptoms. Prevalence estimates are
ingly higher prevalence and potential function of cravings for fruit somewhat varied, but it appears that between 54 and 85% of expec-
specifically in pregnancy. tant women report dislike of at least one specific food, 60–80% feel

nausea, and around 55% experience vomiting (Tierson et al., 1985; cravings for foods providing relief from nausea may not develop
Bayley et al., 2002). Pregnant women tend to identify a connec- for up to 2 weeks after the initial onset of the illness (Bayley et al.,
tion between food aversions and nausea and vomiting (Schwab 2002). More research is needed to assess the temporal dynamics
and Axelson, 1984; Finley et al., 1985), a link that appears con- in the relationship between food aversions and cravings and the
tingent on principles of classical conditioning (Bernstein, 1991), hypothesized role of craved foods in alleviating prenatal nausea
suggesting that a learned taste aversion may be a possible mech- and vomiting.
anism underlying the development of specific food avoidances in
pregnancy (Bayley et al., 2002). In Pavlovian terms, the avoided HYPOTHESIS 4: CRAVING IS CAUSED BY CULTURAL AND
food acts as the conditioned stimulus, while the nausea and/or PSYCHOSOCIAL FACTORS
vomiting acts as the unconditioned stimulus. Findings regarding Culture has long been known to be a powerful determinant of
demographic variables such as age or parity that may be predic- eating behaviors and our proposed model of craving etiology
tive of a greater likelihood of morning sickness2 have been largely hypothesizes a key role of cultural norms in the emergence of food
inconclusive (Bayley et al., 2002). cravings (Figure 1). In the absence of strong evidence in favor of
It has been suggested that prenatal food aversions may serve physiological and biochemical causes of perimenstrual chocolate
the adaptive function of protecting the mother and fetus from craving, studies have consistently identified significant differences
foodborne illness. Indeed, nausea and vomiting have been asso- in the overall prevalence, types, and gender ratio of food crav-
ciated with positive pregnancy outcomes, including lower risk ings across various cultures. For example, while chocolate is by
of miscarriage and preterm or stillbirth (Sherman and Flaxman, far the most commonly craved food in the U.S., hardly anyone in
2002; Czeizel and Puho, 2004; Weigel et al., 2011). The “functional Egypt endorses strong urges for chocolate or general sweet cravings
adaptation”hypothesis (largely synonymous with the Hook-Profet (Parker et al., 2003). Rice is the most widely craved food among
“maternal and embryo protection hypothesis”) proposes that nau- women in Japan (Komatsu, 2008), a finding that highlights the
sea and vomiting are a way for women to expel and learn to avoid strong influence of culture and culinary tradition on food-related
food-borne teratogens and abortifacients, including certain tox- preferences. As noted previously, American women are about twice
ins found in vegetables and beverages (Hook, 1980; Profet, 1992; as likely as U.S. men to crave chocolate (91 versus 59%), but men
Flaxman and Sherman, 2000; Bayley et al., 2002; Fessler, 2002; and women in Spain are almost equally likely to report strong
Fessler et al., 2005). The view of nausea and vomiting in preg- urges for chocolate (90 and 78%, respectively; Osman and Sobal,
nancy as a protective mechanism is supported by research showing 2006). The word “craving” does not translate into most languages
that the common aversions in pregnancy are to foods high in outside of English, suggesting that the construct may be less impor-
levels of potentially teratogenic or abortifacient agents, such as tant or altogether unknown in other cultures (Hormes and Rozin,
bitter vegetables, eggs, meats, and dairy products (Profet, 1992; 2010). Taken together these findings support the view that culture
Fessler, 2002). In addition, the most pronounced periods of nau- plays a central role in the emergence of perimenstrual chocolate
sea coincide with peak vulnerability of the developing fetus to craving and highlight the importance of studying the role of con-
outside toxins (Profet, 1992; Flaxman and Sherman, 2000). How- textual and psychosocial factors in the etiology of cravings in other
ever, emerging discrepancies between predictions of the functional domains.
adaptation hypothesis and the available research data have led Conflicting attitudes toward foods like chocolate that are
some to suggest that this account is overly simplistic and insuf- perceived to be simultaneously appealing and “forbidden” have
ficient in explaining food aversions in pregnancy (Weigel et al., recently been hypothesized to be associated with a greater like-
2011). lihood of craving (Cartwright and Stritzke, 2008; Hormes and
In light of the high prevalence of nausea and vomiting in preg- Rozin, 2011). Ambivalent feelings toward chocolate and sim-
nancy it has been speculated that cravings may have developed as a ilar foods are likely to be especially common in U.S. women
way to encourage consumption of foods known to prevent or alle- who are exposed to a culture that promotes largely unrealis-
viate these symptoms (Bayley et al., 2002). This view parallels the tic ideals of female beauty (Thompson and Stice, 2001), while
theorized “medicinal” effects of ingredients in chocolate in less- at the same time providing easy access to large quantities of
ening perimenstrual symptoms and is supported to some extent highly palatable and calorically dense foods in what has been
by the fact that food aversions and cravings frequently co-occur termed an “obesogenic” environment (Swinburn et al., 1999).
(Bayley et al., 2002), with some indication that aversions precede Evidence suggests that efforts to avoid foods that cause these
the development of cravings (Tierson et al., 1985; Bayley et al., conflicting feelings may have the paradoxical effect of increas-
2002). There is also evidence of a positive correlation between the ing the likelihood of craving. The result is a sort of “vicious
occurrence of pregnancy sickness and the development of food cycle” of alternating restraint and overconsumption or binge
cravings (Whitehead et al., 1992). It should be noted that the exact eating. Multiple studies have demonstrated that dieting to lose
nature of a possible causal relationship between food aversions weight and restricting intake of well-liked foods are associ-
and cravings may be difficult to determine due to the fact that ated with an increase in the salience of (internal and external)
cues related to that food and, as a result, in the frequency of
cravings (Placanica et al., 2002; Hill, 2007; Smeets et al., 2009;
2 It should be noted that the term “morning sickness” is somewhat of a misnomer,
Kemps and Tiggemann, 2009; Hollitt et al., 2010; Durkin et al.,
with only about 17% of women who felt nausea and 31% of women who experienced
vomiting during pregnancy reporting that symptoms occurred exclusively in the 2012; Massey and Hill, 2012). A recent study found that U.S.
morning (Whitehead et al., 1992). women who experience cyclical increases in chocolate craving

report significantly greater levels of dietary restraint, less flexible is relieved (Obeyesekere, 1963). These data provide preliminary
control over food intake, more guilt when consuming chocolate, support in favor of a role of cultural associations in the types
and higher body mass indices (Hormes and Timko, 2011), sup- of food cravings in pregnancy, though more work is needed
porting the notion that eating-related pathology may play a causal to systematically compare and contrast the nature, prevalence,
role in craving etiology. and significance of food cravings in pregnancy across diverse
Given these findings it seems warranted to examine cultural cultures.
differences related to food cravings in pregnancy, and to try and As noted previously, it has been speculated that food cravings
identify contextual and psychosocial factors involved in their emer- may be a risk factor for excess weight gain in pregnancy. How-
gence. Evidence in favor of cross-cultural differences in craving ever, interesting cultural differences in the prevalence of excess
prevalence and a causal role of psychosocial factors such as con- weight gain in pregnancy suggest that a link between cravings and
flicting attitudes toward highly palatable foods, eating disorder GWG may be unique to the U.S. (or perhaps North America)3 :
symptoms, and dietary restraint would support the applicability of compared to more than 50% of U.S. women gaining too much
the proposed model in understanding food cravings in pregnancy. weight prenatally, only 14.5% of obese and 30.4% of normal-
There is a small body of literature examining the prevalence, types, weight women in Sweden were found to gain more than 16 kg
and correlates of prenatal food cravings and aversions as well as (35.3 lbs) during singleton term pregnancies (Cedergren, 2006).
rates of nausea, vomiting, and pica in pregnancy in countries out- Just over 20% of German mothers reported GWG of more than
side the U.S. Evidence suggests that all these phenomena exist in 17 kg (37.5 lbs; von Kries et al., 2011). In a prospective study
diverse cultures. For example, in a sample of 99 pregnant British of pregnant Vietnamese women, only 19.6% gained between 15
women 61% reported experiencing strong urges for specific foods and 20 kg (33.1–44.1 lbs), and a mere 2.7% experienced GWG
(Bayley et al., 2002). Between 64.9 and 79% of pregnant women exceeding 20 kg (44.1 lbs; Ota et al., 2011). Based on these data it
in Tanzania have been found to experience food cravings, with can be speculated that some factor that is unique to U.S. culture
craving intensity peaking in the first trimester (Nyaruhucha, 2009; increases the likelihood that women gain excess weight in preg-
Patil, 2012; Steinmetz et al., 2012). In India the term dola-duka nancy. This hypothesis is supported by the finding that weight gain
is used to describe the experience of food aversions and crav- in pregnancy appears to be tied to a woman’s level of accultura-
ings in pregnant women (Obeyesekere, 1963). Duka refers to the tion to U.S. culture: Hispanic women who spent <10 years living
period in which a woman experiences nausea, vomiting, and weak- in the United Sates were 50% less likely to gain above the threshold
ness. Dola appears synonymous with what U.S. culture would for GWG recommended by the IOM compared to third genera-
deem a craving and refers to the desire to obtain a substance for tion women (Chasan-Taber et al., 2008). Level of acculturation
consumption. to U.S. culture in Hispanic women was also found to be a deter-
Prenatal cravings thus seem to exist outside the U.S. and preva- minant of the types of foods consumed during pregnancy such
lence appears fairly stable across the different countries surveyed that the less acculturated women reported consuming primarily
to date. However, data also suggest that there are culture-specific traditional foods (Tovar et al., 2010).
differences in reported types, perceived meaning, and psychoso- A feeling of ambivalence toward highly palatable and calorically
cial correlates of cravings in pregnancy. An early study found dense foods is a central aspect of the proposed model of crav-
that pregnant Indo-Ceylon women experience nausea, vomiting, ing etiology. It is thought that these ambivalent feelings heighten
and aversions associated with foods reflective of their traditional the salience of food-related cues, resulting in an increased likeli-
role as a wife and mother (e.g., time and effort spent prepar- hood of craving and subsequent consumption of the desired food
ing traditional foods like rice, everyday curries, tortillas from (Hormes, 2014). There is some evidence for conflicting feelings
millet, and jiggery; Obeyesekere, 1963). Cravings reported by related to food in pregnant women. For example, it has been
these women were categorized as childhood foods (e.g., sweets), argued that in U.S. women, the idea of “eating for two” takes
foods expressing hostility, rare or expensive foods, festival foods, on moral significance such that healthful eating in pregnancy
sour foods, male or phallic foods, and idiosyncratic foods (i.e., is consistent with the perceived ideal of a good mother, while
those that have personal significant meaning to the individual; consumption of unhealthy foods is the cause of a considerably con-
Obeyesekere, 1963). Pregnant women in Nigeria proclaimed that flicting feeling (Copelton, 2007). Similarly, a survey of pregnant
their most craved foods (fruits, vegetables, and cereals) pro- women with gestational diabetes in Canada found that cravings
vide nutritional benefits, justifying their consumption with the were frequently perceived to be specifically for “forbidden” foods,
belief that they are a good source of body building nutrients, such as sweets (Hui et al., 2014).
serve as a mild laxative, and are easy to prepare (Olusanya and
Ogundipe, 2009). The most common cravings reported by a sam- 3 Of note, there are marked differences in guidelines for GWG in different countries.
ple of 545 Tanzanian pregnant women (i.e., reported by more In a review comparing national GWG and energy intake recommendations (EIR),
than 25% of cravers) were meat and fish, vegetables, fruits, 13 of 22 countries surveyed had guidelines similar to those put forth by the IOM
and adopted by the U.S., Canada, Finland, Italy, parts of Australia, and parts of
and grains (Patil, 2012). Provision of craved foods to preg- Asia (specifically, Vietnam and Singapore). All either used the 2009 IOM or very
nant women by their husband and his family is considered an comparable guidelines (Alavi et al., 2013). Parts of Western Europe recommend
expression of social support in rural Tanzania (Patil, 2012). In GWG in the lower end of the IOM suggestions (10–15 kg or 22–33 lbs). In India and
Africa (8–10 kg or 17.6–22 lbs), the Phillipines (11–12.5 kg or 24.3–27.6 lbs), and
Indo-Ceylon cultures, the dola cannot be satisfied until the sub-
Chile (12–13 kg or 26.5–28.7 lbs), official guidelines all suggest significantly lower
stance is consumed, and if it is not satisfied the woman is said weight gains for a normal weight expectant mother, compared to the thresholds
to endure significant anxiety and stress until the compulsion recommended by the IOM (Alavi et al., 2013).

Menstrual cravings have previously been found to be associated a sample of African–American women levels of restraint were
with elevated levels of eating disorder symptomology (Hormes relatively low and were not found to be predictors of excess
and Timko, 2011), and it can be hypothesized that maladaptive GWG (Allison et al., 2012), suggesting that restraint may be more
eating-related attitudes and behaviors may also increase the likeli- prevalent in certain cultures and ethnicities, and as a result have
hood of prenatal cravings. It has been suggested that the presence a different effect on GWG. The notion that pregnancy consti-
of disordered eating behaviors could specifically heighten the risk tutes a culturally sanctioned excuse for dieters and women high
of overconsumption in response to external and internal food- in dietary restraint (and potentially eating disorder symptoms)
related cues in pregnancy (Fairburn and Welch, 1990; Abraham to consume (and possibly overconsume) highly palatable foods
et al., 1994; Clark and Ogden, 1999). The prevalence of eating that are otherwise perceived as taboo due to their high caloric
disorders in pregnant women (1%) is generally estimated to be content is consistent with the proposed model. Interestingly,
equal to or perhaps even lower than that in the general population the idea that pregnancy is a time when one does not need to
(1–3.5%; Hudson et al., 2007). In fact, a majority of women expe- feel accountable for one’s food intake, (i.e., a time of disinhibi-
rience a decrease in dietary restraint and an increase in energy tion), has been found to be most commonly endorsed by women
intake, weight, and overall body satisfaction during pregnancy classified as habitual dieters prior to pregnancy (Fairburn et al.,
(Fairburn and Welch, 1990; Wiles, 1993; Clark and Ogden, 1999). 1992; Clark and Ogden, 1999; Mumford et al., 2008). Of note, it
In a number of studies it has been found that for individuals has been suggested that continuous pregravid dieting may affect
diagnosed with bulimia nervosa, episodes of bingeing and purg- the women’s ability to accurately distinguish hunger and satiety
ing decreased during pregnancy (Crow et al., 2004). However, for cues, which may contribute to excess energy intake in pregnancy
women with a history of problematic eating, pregnancy can trig- (Mela and Rogers, 1998; Conway et al., 1999; Mumford et al.,
ger an increase in weight concern, sensitivity about body shape, 2008).
and even maladaptive eating-related behaviors like bingeing and Additional support for the view of pregnancy as a socially
purging (Clark and Ogden, 1999). An early study suggests that acceptable time for women to indulge comes from sociological
both food cravings and aversions may be especially common in research that finds that pregnant women take on a more functional
women who were particularly “picky” or had high levels of food view of their body, which legitimizes divergence from cultural ide-
faddiness as children, as well as those who endorse stress-induced als of thinness and restraint (Bailey, 2001; Dworkin and Wachs,
appetite changes (Dickens and Trethowan, 1971). Women with 2004). In our qualitative pilot study, among the women post-
a lower pre-pregnancy body mass index (BMI) and a history of ing about their cravings on the pregnancy-related blogs, negative
disordered eating appear at greater risk to exceed guidelines for affect related to cravings was rare and only mentioned by 6.1%
recommended GWG (Chu et al., 2009; Laraia et al., 2009). Preg- (n = 12) of respondents. This low number may be due in part to
nant women with a recent or past eating disorder were also found the fact that the nature of the message board encouraged reports of
to be more likely to abuse laxatives, to engage in self-induce vom- cravings, but it may also reflect a more general sense that cravings
iting, and to exercise as compared to normal controls (Micali et al., in pregnancy are acceptable or maybe even enjoyable. Remark-
2007). ably, only 4.5% (n = 9) of respondents described efforts to resist
Episodes of binge eating are the most frequent disordered eat- their cravings. These figures stand in stark contrast to the high
ing behavior in pregnant women (Fairburn and Welch, 1990; levels of negative affect and conflicting approach-avoidance ten-
Abraham et al., 1994; Soares et al., 2009). The frequency of binge dencies typically found to be associated with craving in the general
eating during pregnancy has significant effects on the mother’s population (Macdiarmid and Hetherington, 1995; Cartwright and
health, particularly regarding GWG (Soares et al., 2009). Cau- Stritzke, 2008; Hormes and Rozin, 2011).
casian women deemed restrained eaters (i.e., those who frequently It thus appears that in the U.S., culture-specific norms, beliefs,
think about their diet and weight and make attempts to restrict and customs may allow or even encourage prenatal cravings and
their dietary intake) are significantly more likely than unrestrained intake of foods that may otherwise be considered “taboo” (Snow
eaters to exceed guidelines for recommended GWG (Conway and Johnson, 1978). As a result these views on cravings may
et al., 1999), a finding that supports the hypothesis that preg- leave pregnant women susceptible to overconsuming high calo-
nancy acts as a time for women to legitimize seemingly excessive rie foods, resulting in excess weight gain, especially for women
food intake, disregarding any previous attitudes and intentions high in restraint and those with pre-existing eating disorder
to eat less (Clark and Ogden, 1999). Similar to restrained eaters, symptoms.
dieters4 have also been found to endorse more episodes of overeat-
ing during pregnancy, compared to non-dieters (Fairburn and CONCLUSION AND DIRECTIONS FOR FUTURE RESEARCH
Welch, 1990). There are two possible explanations for this find- While some have argued that the mechanisms underlying food
ing: women either (a) began dieting in response to already having cravings in pregnancy differ from cravings experienced at other
gained excess weight, or (b) abandoned prior dieting attempts times (Gendall et al., 1997), we believe that the evidence pre-
while pregnant and engaged in disinhibited eating, resulting in sented here strongly supports the assumption that our proposed
excess weight gain (Fairburn and Welch, 1990). Interestingly, for model of craving etiology applies to cravings in both the peri-
menstrum and pregnancy. We have reviewed evidence in favor
4 Individuals were classified as “dieters” if they gave a clear history of dieting prior of and against four major hypotheses regarding the etiology of
to pregnancy. Of those assessed, 54% reported having dieted in the past to modify perimenstrual and pregnancy cravings, implicating hormones,
their shape and/or weight (Fairburn and Welch, 1990). nutritional deficits, rewarding or reinforcing ingredients in the

craved foods, and a complex set of cultural and psychosocial vari- specifically in women in pregnancy5 . Comparable efforts have
ables. Regarding perimenstrual chocolate cravings, evidence in previously been exerted in order to validate measures of anxiety
favor of physiological/biochemical causes has been sparse. The specifically in the perinatal period (Meades and Ayers, 2011).
literature on eating behaviors in pregnancy is largely consistent Many prior studies of food cravings in general, and specif-
with these findings insofar as hormonally driven changes in sen- ically in pregnancy, are retrospective in nature (Nordin et al.,
sory perception and the effects of potentially active ingredients in 2004). Given the transient nature of the craving experience it is
craved foods seem unlikely to be causally involved in the emer- unlikely that craving episodes are accurately remembered follow-
gence of prenatal cravings. Prior research on the role of cultural ing extended delays. Real-time neural correlates of food cravings
and psychosocial factors in the etiology of food cravings in preg- are beginning to be examined using different forms of magnetic
nancy is somewhat limited; however, existing studies point toward imaging (Pelchat et al., 2004; Frankort et al., 2014); however, this
interesting cultural similarities in craving prevalence, as well as approach is not feasible in studying cravings in pregnancy due
noteworthy differences in craving types and correlates that are to the adverse effects of performing magnetic imaging on the
consistent with the assumption that culture plays a key role in health of the fetus. An area of research that has been receiv-
bringing about cravings in pregnancy. Furthermore, the observed ing increasing attention and that is appropriate for the real
link between food cravings and excess GWG gain may be unique time assessment of cravings in pregnant women is the use of
to women in the U.S. or North America. EMA. For example, EMA has recently been utilized in stud-
Factors influencing food cravings and weight gain in pregnancy ies of temptation and lapses in dieting (Carels et al., 2001), as
are complex (Paul et al., 2013), and there are several important well as cravings associated with smoking cessation (Waters et al.,
limitations inherent in existing research that must be addressed 2014), marijuana use (Buckner et al., 2011), and detoxification
in future studies. For example, cross-cultural differences in preva- from substance use (Marhe et al., 2013). Real-time assessment
lence of pregnancy cravings and GWG may simply be reflective of food cravings has also been used to examine the association
of differences in the availability of and access to certain foods. between exposure to food cues in the external environments and
The sample of Tanzanian pregnant women surveyed by one of the craving and subsequent consumption in adolescents (Grenard
study referenced earlier was described as “marginally nourished,” et al., 2013). Compared to paper and pencil methods (i.e., those
with food insecurity and hunger among the most common stres- that provide the participant with the paper and pencil mea-
sors faced by this group (Patil, 2012). Many of the key studies sures and cue them in advance to fill out the questionnaires at
examining food cravings and aversions in pregnancy are some- specific times throughout the day) electronic EMA (i.e., com-
what dated. Assuming a key role of culture in craving etiology pletion of measures in real time using an electronic device)
and given the fact that cultural norms and practices can change was found to have a higher response rate when tracking food
significantly over the course of even just a few decades it will cravings and food intake (Berkman et al., 2014). Berkman et al.
be important to replicate some of the key studies cited here (2014) aimed to identify whether certain individual character-
to determine if findings hold in current samples of pregnant istics (i.e., BMI) increased or decreased responses using EMA
women. technology. Findings showed that individuals with greater body
In addition to addressing these limitations we propose that mass indices were less likely to respond in the paper and pencil
future research in this field should focus on four specific areas of method as compared to the electronic EMA method. Further-
investigation: (1) validation of existing measures assessing food more, higher BMI was negatively correlated with latency response
cravings and related behaviors and attitudes specifically in preg- time in both groups. To the best of our knowledge, EMA has
nant women, (2) real-time assessment of food cravings using not yet been used to assess food cravings in real time in pregnant
ecological momentary assessment (EMA), (3) longitudinal track- women. Thus, it is suggested that future research aim to imple-
ing of eating disorder symptoms, food cravings, and GWG to ment the use of this technology to gage the intensity, frequency,
determine causality, and (4) identification of targets for interven- types, and temporal patterns of food cravings specifically in this
tions to increase proper nutrition and decrease the risk of excess population.
weight gain in pregnancy. The impact of GWG on maternal and child health has been
The failure of the term “craving” to lexicalize in most lan- deemed to be of great public health importance (Kaiser et al.,
guages outside of English impacts the extent to which studies can 2009), and research to identify social, cultural, and environmen-
accurately assess cross-cultural differences in the nature of food tal risk factors for excess GWG has been called for by the IOM
cravings in pregnancy (Hormes and Rozin, 2010). More work is (Rasmussen and Yaktine, 2009). Much of the work in this area
needed to determine equivalence of terminology used by women has been cross-sectional in nature and there is an urgent need
in other countries to describe strong urges for specific foods. For for longitudinal studies in order to determine with certainty the
instance, in one study a significant portion of the Hispanic women nature of the hypothesized associations between psychosocial risk
surveyed reported wanting to “eat junk food,” and it can be specu- factors, cultural variables, food cravings and consumption, and
lated that these reports may be comparable to accounts of cravings
in North American women (Tovar et al., 2010). There is also a lack 5 These measures include the Eating Disorder Diagnostic Scale (Stice et al., 2000),
of measures of food cravings and related attitudes and behaviors Dutch Eating Behavior Questionnaire (Van Strien et al., 1986), the Three Factor
Eating Questionnaire (Stunkard and Messick, 1985), Food Craving Questionnaire
that have been validated specifically in pregnant women. Future
(Cepeda-Benito et al., 2001), Food Craving Inventory (White et al., 2002), general
studies should focus on determining the psychometric proper- psychosocial assessments like the Depression, Anxiety, and Stress, Scale (Henry and
ties of key measures typically used in research on food cravings Crawford, 2005), and others.

weight gain in pregnancy (i.e., do cravers gain more weight in Allen, L. H. (2000). Anemia and iron deficiency: effects on pregnancy outcomes.
pregnancy than non-cravers, and if so, what are the causes of Am. J. Clin. Nutr. 71, 1280–1284.
Allison, K. C., Wrotniak, B. H., Pare, E., and Sarwer, D. B. (2012). Psychosocial char-
cravings?; Hook, 1978; Bayley et al., 2002). The ultimate goal of
acteristics and gestational weight change among overweight, African-American
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ACKNOWLEDGMENTS 10.1016/j.eatbeh.2007.01.006
The authors would like to thank Augusta Bargeron, Sarah Liquor- Caulfield, L. E., Witter, F. R., and Stoltzfus, R. J. (1996). Determinants of gestational
man, Aydin O’Hearn, Nicole Salierno, and Kendra Van Valkenburg weight gain outside the recommended ranges among black and white women.
for their assistance with the preparation of this manuscript. Obstet. Gynecol. 87, 760–766. doi: 10.1016/0029-7844(96)00023-3
Cedergren, M. (2006). Effects of gestational weight gain and body mass index
on obstetric outcome in Sweden. Int. J. Gynecol. Obstet. 93, 269–274. doi:
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HYPOTHESIS AND THEORY ARTICLE

published: 23 September 2014

Pickles and ice cream! Food cravings in pregnancy:

OVERVIEW a potentially modiﬁable determinant of energy intake and nutri-

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HYPOTHESIS 1: CRAVING IS CAUSED BY FLUCTUATING

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