Burning Issues-Areca Nut

Health Hazards of Chewing Areca Nut,
Betel-Quid, and Gutkha

By Kamlesh Asotra, Ph.D and Rajesh N. Sharan, Ph.D.

This is the first of a two part article that the authors prepared for Burning Issues. The addictive practices of people world wide often do and don’t include tobacco products. With the steady growth of peoples from the Indian sub-continent and other parts of the world, it behooves tobacco control researchers and advocates to familiarize themselves with their tobacco and other addictive practices. The 2nd part of this article will appear in the July edition of Burning Issues. (PG).

Figure 1. Areca nut plant with betel nut fruit (adapted from Kohler’s “Medicinal Plants”)

The highest prevalence of chewing Areca nut and betel-quid, with or without tobacco, occurs in the Asian and Pacific Rim countries. Dry mixture of Areca nut, betel nut ingredients and tobacco, called gutkha, is very popular for chewing in the Indian subcontinent. Areca nut chewing results in copious salivation, which helps to extract various alkaloids in a process aided by slaked lime. This saliva is swallowed for the psychoactive, stimulant, and heightened alertness effects. Areca nut is synonymous with betel nut because of associative use of Areca nut with betel leaf in betel quid; however, betel plant does not produce a nut of its own. Approximately 600 million people in Southeast Asia and the Pacific Islands chew betel nut. These are nuts of the tree Areca catechu, a type of palm tree growing 40-100 feet in height (Figure 1), which is believed to have originated in the Philippines and Malaysia and then cultivated over a wider region. Betel-quid chewing is a distracting activity like chewing gum or smoking a cigarette. Chewing betel nut in small amounts produces a pleasant feeling and can be habit forming because of the addictive nature of its alkaloids. This practice is traced back at least 2,000 years in India and appears to have been much older in some areas, based on archeological evidence of betel nuts in caves1 and remains of human teeth showing signs of the chewing.

Several studies have demonstrated that Areca nut and betel-quid chewing, alone or with tobacco, is the major cause of oral, esophageal, and stomach cancer in Asia.2–4 Their use by pregnant women also causes reproductive health effects in women and the birth of babies that are usually smaller in body weight and size as that seen for babies of pregnant woman who smoke.5,6 Babies born to mothers addicted to Areca nut demonstrate a withdrawal syndrome.6 Areca nut and betel quid, both fresh and in dry form is readily available in several Asian grocery stores in North America, and the public health threat from its use among Cambodian users in the United States and California was first voiced about 15 years ago.7 Areca nut and betel-quid chewing is also widely practiced by immigrants from Bangladesh and India, living in the United States.4 The World Health Organization and the International Association of Cancer Research have published the cancer-causing dangers of Areca nut and betel-quid chewing.8 The California Environment Protection Agency has listed Areca nut as carcinogen subject to the rules of Proposition 65.9,10 This article highlights the public health hazards of Areca nut and betel-quid chewing.

Chronology of Areca nut and Betel-quid Use
As hunters and gatherers, humans explored and experimented with grains and fruits and other parts of plants for sustenance. In this quest, humans also discovered pleasure-giving properties of several plant products that resulted in the most prevalent addictions, respectively, to alcoholic beverages, tobacco, coffee, and Areca nut. Legendary and archeological evidence suggests that modern man began producing alcohol at least ten thousand years ago.11 Areca nut was used in the Northern Thailand and Burma in the Indian subcontinent as early as 7,500–9,000 years ago. (1) Coffee12 and tobacco cultivation and consumption13 began nearly ten and six centuries ago, respectively.

Areca nut and betel-quid chewing has a long and storied history in Asia. In Pali, a kingdom in India, a princess is believed to have given a present of betel to her lover around 500 years before common era (BCE). Somewhere around 430 BCE, Theophrastus described use of Areca nuts as a component of the betel morsel. Areca nut is mentioned in Sanskrit scriptures such as Vagbhata (4th century) and Bhavamista (13th century) under the name guvaka as a therapeutic agent, and in Chinese texts dating from 150 BCE, it was called pinlang (a Malay name). In Persia (modern Iran), there were 30,000 shops that sold betel nut in the capital town during the reign of Khosrau II, the King of Persia during 590 to 628 AD. Arabs and Persians who visited India in the 8th and 9th centuries found the habit deeply rooted. Ali al-Masudi, an Arab historian who traveled through India in 916 AD, described the chewing of betel nut as a national custom. Legend has it that betel nut was used in the funeral pyre of deceased husbands in an ancient act of self-immolation called “Sati” by Hindu widows. People who did not use betel nut were socially isolated .14

How Areca Nut is Prepared and Used
Areca catechu fruit is usually harvested in unripe or ripe forms during September through November. The most popular variety used is the sun-dried Areca nut. The ripe Areca nuts are “cured” by boiling the nuts for several hours in an aqueous solution containing the bark from the plant Eugenia jambolana, jaggery of brown sugar, and various edible oils, and then sun-dried for several weeks. The sun-dried and relatively hard nut is cut into small pieces for chewing. The raw and wet variety of betel nut is mostly used in Taiwan as well as North Eastern and Southern states of India. The North-East Indian variety of Areca nut, locally called kwai or tambul is the raw, unprocessed betel nut chewed as betel-quid. This form of kwai chewing causes an instant thermogenic response in the user lasting 2–3 minutes, with significant sweating on the forehead and reddening of the ears and face This effect is remarkably different from that of the sun-dried, “cured” Areca nut cured used elsewhere in the world.2

Figure 2. The betel-quid: Wet variety of Areca nut (‘Kwai’) used in the NE India. (Clockwise from top left: a betel nut (‘Kwai’) as plucked from tree, the ‘Kwai’ (wet variety of betel nut) after de-shelling – ready to use now, a ‘Kwai’ cut into two pieces, actual size of nut (usually a quarter of the whole nut) which is chewed, the ‘Kwai’ or betel- quid – half of betel leaf + slacked lime + 1/4th of Areca nut, a betel leaf.

The nut is chewed with a betel leaf (Piper betle) from an evergreen perennial vine, a small amount of either lime (calcium oxide) or slaked lime (calcium hydroxide), and catechu — a dye extracted by boiling the Areca tree bark in water. Various flavoring ingredients, such as cardamom, cloves, licorice, peppermint, grated coconut, fennel seed, and sugar syrup are added to betel-quid, and tobacco might be included. The betel leaf is used to wrap up the ingredients into folded packet, commonly called a quid, which is then chewed (Figure 2).

Women manage and control Areca nut and betel-quid business in the matrilineal society of Meghalaya state of North-East India. Teenage girls (Figure 3) in Meghalaya are mostly involved in shelling the Areca nut (left panel), preparation of betel quid (middle panel), and as a chewer (right panel). Areca nut, betel leaf, and other ingredients of the betel quid are also marketed in dry form in India as “Paan Masala.” The tobacco-containing variety of paan masala, called “Gutkha” is being used in India at an alarmingly increasing rate.


Figure 3. Khasi tribe teen girls of from Meghalaya are professionally shelling Areca nuts from unripe harvest fruit, to make betel-quid. Photographs: Kamlesh Asottra

The Good…..
Areca nut and betel leaf have been widely used for medicinal and social purposes in Asia and the Pacific Rim countries for a long time. In India, betel leaf has been used as a stimulant, a digestive aid, an antiseptic, a breath freshener, and as an aphrodisiac. In Malaysia the betel leaf is used for relief from headache, arthritis, and joint pain, while in Indonesia, the masticated juice from Areca nut and betel-leaf chewing is swallowed for relief from cough and asthma. Betel leaf contains the phenolic compound chavicol, a potent antiseptic, and the alkaloid arakene, with neurological properties resembling cocaine. Hydroxychavicol (HC), another betel leaf component, is a potent COX-1/COX-2 inhibitor and ROS scavenger, which inhibits platelet calcium signaling, thromboxane B2 production and aggregation. HC could be a potential therapeutic agent for prevention and treatment of atherosclerosis and other cardiovascular diseases through its anti-inflammatory and antiplatelet effects, without effects on haemostatic functions.15

In China, Areca nut has been used as a de-worming agent since the 6th century, and is still used as such in other parts of the country. In Thailand and China, the betel plant root is crushed, mixed with salt, and used for toothache. Betel leaves are used as a part of salads in Asia and for culinary purposes. Both Areca nut and betel leaf are widely used in religious and marriage ceremonies in India, Pakistan, and Bangladesh. In New Guinea and Melanesia, Areca nut is as avidly used in the Indian subcontinent and Taiwan. A compound isolated from betel leaf called chlorogenic acid, has been shown to selectively kill chronic myeloid leukemia.16 The plant dye called catechu, isolated from the bark of Areca catechu, is also extracted in saliva by chewing the Areca nut. Areca nut contains antioxidant polyphenols — catechin, quercetin, flavanoids, leukocytes and hexahydroflavans. Catechin and quercetin are the good compounds also found in tea. However, Areca nut yields a number of alkaloids that are extremely harmful agents.

*Article is dedicated to the loving memory of Mrs. Kamini Grover, who passed away on February 16, 2008 in Winnipeg, Canada, after a battle with stomach cancer. Kamini was best known for her remarkable cheer, grit and helping nature. All family members and friends will dearly miss Kamini.

Kamlesh Asotra, Ph.D., Research Administrator, Tobacco-Related Disease Research Program, University of California Office of President, Oakland, CA 94612, USA. Tel: (510) 287-3366, E-mail: kamlesh.asotra@ucop.edu

Rajesh N. Sharan, Ph.D.
Professor of Biochemistry
North Eastern Hill University, Shillong-793 022 Meghalaya, India. Tel: +91-(364) 272-2121, E-mail: rnsharan@nehu.ac.in

References
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2. Sharan, R.N. (1996). Association of betel nut with carcinogenesis. The Cancer Journal, 9: 13-19.

3. Nair, U., Bartsch, H., Nair, J. (2004). Alert for an epidemic of oral cancer due to use of the betel quid substitutes gutkha and paan masala: a review of agents and causative mechanisms. Mutagenesis, 19: 251-262.

4. Changrani, J., Gany, F.M., Cruz, G. et al. (2006). Paan and Gutka use in the United States: A pilot study in Bangladeshi and Indian-Gujrati immigrants in New York city. J. Immigr. Refug. Stud., 4(1): 99-110.

5. Yang M.S., Chung, T.C., Yang, M.I. et al. (2001). Betel quid chewing and risk of adverse birth outcomes among aborigines in eastern Taiwan. J. Toxicol. Environ. Health A, 64: 465-472.

6. Lopez-Vilchez, M.A., Seidel, V., Farre, M. et al. (2006). Areca-nut abuse and neonatal withdrawal syndrome. Pediatrics, 117: e129-e131.

7. Pickwell, S.M., Schimelpfening, S. and Palinkas, L.A. (1994). “Betelmania”. Betel quid chewing by Cambodian women in the United Sates and its potential health effects. West. J. Med., 160(4): 326-330.

8. World Health Organization, IARC (2004). Monographs on the Evaluation of Cancer Risks to Human. “Betel-quid and Areca-nut Chewing and Some Areca-nut derived Nitrosamines”. Vol. 85.

9. Office of Environmental Health Hazard Assessment, Chemicals Listed effective February 3, 2006 as Known to the State of California to Cause Cancer: “Areca nut” and “betel quid without tobacco” (http://www.oehha.ca.gov/prop65/docs_admin/listArecabetel.html)

10. California Environmental Protection Agency.

11. Hanson, David J. Preventing Alcohol Abuse: Alcohol, Culture and Control. Wesport, CT: Praeger, 1995. (http://www2.potsdam.edu/hansondj/controversies/1114796842.html).

12. http://www.coffeeresearch.org/coffee/history.htm

13. Borio, Gene. The tobacco timeline. (http://www.tobacco.org/History/Tobacco_History.html)

14. Lewin, Louis (1998). Phantastica: A Classic Survey on the Use and Abuse of Mind-Altering Plants. Park Street Press.

15. Cang, M.C., Uang, B.J., Tsai, C.Y. et al. (2007). Hydroxychavicol, a novel betel leaf component, inhibits platelet aggregation by suppression of cyclooxygenase, thromboxane production and calcium mobilization. British Journal of Pharmacology, 152, 73–82.

16. Bandhyopadhyay, G.M., Biswas, T., Roy, K.C. et al. (2004). Chlorogenic acid inhibits Bcr-Abl tyrosine kinase and triggers p38 mitogen-activated protein kinase-dependent apoptosis in chronic myelogenous leukemic cells. Blood, 104(8): 2514-22.