A review of the systemic adverse effects of areca nut or betel nut

DARK Classics in Chemical Neuroscience: Arecoline

Arecoline is a naturally occurring psychoactive alkaloid from areca (betel) nuts of the areca palm ( Areca catechu) endemic to South and Southeast Asia. A partial agonist of nicotinic and muscarinic acetylcholine receptors, arecoline evokes multiple effects on the central nervous system (CNS), including stimulation, alertness, elation, and anxiolysis. Like nicotine, arecoline also evokes addiction and withdrawal symptoms (upon discontinuation). The abuse of areca nuts is widespread, with over 600 million users globally. The importance of arecoline is further supported by its being the world's fourth most commonly used human psychoactive substance (after alcohol, nicotine, and caffeine). Here, we discuss neuropharmacology, pharmacokinetics, and metabolism of arecoline, as well as social and historical aspects of its use and abuse. Paralleling clinical findings, we also evaluate its effects in animal models and outline future clinical and preclinical CNS research in this field.

Arecoline Promotes Migration of A549 Lung Cancer Cells through Activating the EGFR/Src/FAK Pathway

Arecoline is the primary alkaloid in betel nuts, which are known as a risk factor for oral submucosal fibrosis and oral cancer. Lung cancer is a severe type of carcinoma with high cell motility that is difficult to treat. However, the detailed mechanisms of the correlation between Arecoline and lung cancer are not fully understood. Here, we investigated the effect of Arecoline on migration in lung cancer cell lines and its potential mechanism through the muscarinic acetylcholine receptor 3 (mAChR3)-triggered EGFR/Src/FAK pathway. Our results indicate that different concentrations of Arecoline treatment (10 µM, 20 µM, and 40 µM) significantly increased the cell migration ability in A549 and CL1-0 cells and promoted the formation of the filamentous actin (F-actin) cytoskeleton, which is a crucial element for cell migration. However, migration of H460, CL1-5, and H520 cell lines, which have a higher migration ability, was not affected by Arecoline treatment. The EGFR/c-Src/Fak pathway, which is responsible for cell migration, was activated by Arecoline treatment, and a decreased expression level of E-cadherin, which is an epithelial marker, was observed in Arecoline-treated cell lines. Blockade of the EGFR/c-Src/Fak pathway with the inhibitors of EGFR (Gefitinib) or c-Src (Dasatinib) significantly prevented Arecoline-promoted migration in A549 cells. Gefitinib or Dasatinib treatment significantly disrupted the Arecoline-induced localization of phospho-Y576-Fak during focal adhesion in A549 cells. Interestingly, Arecoline-promoted migration in A549 cells was blocked by a specific mAChR3 inhibitor (4-DAMP) or a neutralizing antibody of matrix metalloproteinase (MMP7 or Matrilysin). Taken together, our findings suggest that mAChR3 might play an essential role in Arecoline-promoted EGFR/c-Src/Fak activation and migration in an A549 lung cancer cell line.

Point-of-care, smartphone-based, dual-modality, dual-view, oral cancer screening device with neural network classification for low-resource communities

Oral cancer is a growing health issue in a number of low- and middle-income countries (LMIC), particularly in South and Southeast Asia. The described dual-modality, dual-view, point-of-care oral cancer screening device, developed for high-risk populations in remote regions with limited infrastructure, implements autofluorescence imaging (AFI) and white light imaging (WLI) on a smartphone platform, enabling early detection of pre-cancerous and cancerous lesions in the oral cavity with the potential to reduce morbidity, mortality, and overall healthcare costs. Using a custom Android application, this device synchronizes external light-emitting diode (LED) illumination and image capture for AFI and WLI. Data is uploaded to a cloud server for diagnosis by a remote specialist through a web app, with the ability to transmit triage instructions back to the device and patient. Finally, with the on-site specialist's diagnosis as the gold-standard, the remote specialist and a convolutional neural network (CNN) were able to classify 170 image pairs into 'suspicious' and 'not suspicious' with sensitivities, specificities, positive predictive values, and negative predictive values ranging from 81.25% to 94.94%.

Zebrafish as an alternative method for determining the embryo toxicity of plant products: a systematic review

The toxicological assessment of plant products and pharmaceutical chemicals is a necessary requirement to ensure that all compounds are safe to be exposed to humans. Many countries are trying to reduce the use of animals; thus, alternative techniques, such as ex vivo tests, in vitro assays, and ex uteri embryos, are used. Toxicological assays using zebrafish embryos are an advantageous technique because they are transparent, have rapid embryonic development, and do not require invasive techniques. This paper comprehensively reviews how toxicity testing with plant products is conducted in zebrafish embryos. The search terms zebra fish, Danio rerio, zebrafish, zebra danio, Brachydanio rerio, zebrafish, and embryos were used to search for English-language articles in PUBMED, SCOPUS, and WEB OF SCIENCE. Twelve articles on plant product toxicity studies using zebrafish were selected for reading and analysis. After analyzing the articles and comparing with results in mammals, it was possible to prove the similarity among the results and thus corroborate the further development of zebrafish as a valid tool in toxicity tests.

Effect of geraniol against arecoline induced toxicity in the third instar larvae of transgenic Drosophila melanogaster (hsp70-lacZ) Bg9

In the present study geraniol at the final concentration of 10, 20, 30, and 40 µM was mixed in the diet along with 80 µM of arecoline and the third instar larvae of transgenic Drosophila melanogaster (hsp70-lacZ) Bg⁹ were allowed to feed on it for 24 hrs. After the exposure of 24 hrs the larvae were subjected to ONPG, X-gal, trypan blue exclusion test, oxidative stress markers and apoptotic and comet assays. The exposure of larvae to geraniol showed a dose dependent decrease in the activity of β-galactosidase, tissue damage and oxidative stress markers. A dose dependent decrease in apoptosis and DNA damage was also observed. Molecular docking studies also support the protective role of geraniol against the arecoline induced toxicity. The results suggest that geraniol is potent in reducing the toxicity induced by arecoline in the third instar larvae of transgenic Drosophila melanogaster (hsp70-lacZ) Bg⁹.

A qualitative study of attitudes to and perceptions of betel quid consumption and its oral health implications in Taiwan

OBJECTIVES

Betel quid (BQ) chewing is extremely prominent in South and Southeast Asia because it considered by users to be of social, cultural and religious importance. BQ chewing has been recognized as a risk factor for oral premalignant lesions and oral cancer. Because BQ chewing has become a severe health risk in Taiwan, the development of prevention and cessation programmes is essential. The purpose of this study was to explore the attitudes and perceptions associated with BQ consumption and its oral health implications in an attempt to inform the development of health promotion initiatives and BQ cessation efforts in Taiwan, where the dental profession could have a pivotal role in preventing and controlling BQ use among persons at risk.

METHODS

This qualitative study used data gathered from focus groups and individual interviews. A convenience sample of 41 adults from Jhushan and Lugu Townships (Nantou County) and Taichung City, Taiwan, participated in this study (27 men, 14 women; 31 Han, 10 aboriginals from the Paiwan tribe; mean age 40.3, SD 9.2 years).

RESULTS

Among the seven themes that emerged from the original study, five (Initiation, Health Risk Perception, Health Consequences, Withdrawal Symptoms and Help from Healthcare Providers) had oral/dental implications.

CONCLUSIONS

Our study highlights research areas relevant to further investigation, such as incorporating brief BQ prevention and cessation counselling when early oral and dental signs associated with BQ consumption are detected. Undertaking behavioural interventions in dental settings might help to reduce the prevalence of BQ chewing in Taiwan.

Association of betel nut chewing with exercise performance in a military male cohort: the CHIEF study

INTRODUCTION

Betel nut chewing may cause obesity, neurohormonal activation and inflammation, possibly impairing exercise performances.

METHODS

We examined the cross-sectional association in 4388 military male adults aged 18-50 years from the cardiorespiratory fitness in armed forces study in Taiwan between 2013 and 2014. The status of betel nut chewing was classified as current and former/never based on each participant's response to a questionnaire. Physical fitness was evaluated by three basic exercise tests including 3000 m running, 2 min sit-ups and 2 min push-ups. Multiple logistic regression for the best 10% and the worst 10% performers in each exercise, and linear regression were used to determine the relationship.

RESULTS

There were 564 current chewers and 3824 non-current chewers for the analysis. The linear regression shows that current betel nut chewing was positively correlated with 3000 m running duration (r=0.37, p=0.042) after adjusting for age, service specialty, body mass index, exercise frequency and alcohol intake. In addition, the logistic regression shows that as compared with non-current chewers, current chewers had lower odds of being the top 10% performers in 2 min push-ups and higher odds of being the bottom 10% performers in 2 min sit-ups (ORs and 95% CIs: 0.71 (0.50 to 0.99) and 1.32 (1.00 to 1.75), respectively). However, the associations between betel nut chewing and physical fitness were all insignificant after further adjusting for current smoking.

CONCLUSIONS

Our findings suggest that the impairment of physical fitness associated with betel nut chewing of military young men might be mainly mediated or moderated by the coexisted cigarette smoking.

Dohra- a mixture of potent carcinogens

BACKGROUND & OBJECTIVES

Dohra is a areca nut preparation used with or without tobacco in a few of the areas of Uttar Pradesh (UP), India. There is evidence that it causes potentially malignant disorders and oral cancer. This study was undertaken to provide information on dohra by searching through literature and also through a survey in three areas of Uttar Pradesh (UP), India.

METHODS

The information on dohra was collected through literature search, study tour to different areas of UP, where group discussions with dohra vendors and with community members of different age group were done to obtain information.

RESULTS

Dohra was prepared by the users for their personal use or prepared by small-scale industry for sale. It was available mostly in betel shops or any other store/kiosks and was also available in special dohra shops. Dohra was available in both dry and wet form. Its common constituents were areca nut, catechu (Acacia catechu), edible lime, peppermint (Mentha piperita), cardamom (Elettaria cardamomum) and some flavoring agents. Dohra was consumed as such or with tobacco.

INTERPRETATION & CONCLUSIONS

Different varieties of Dohra were available such as sukha dohra, sukha mulethi dohra and geela dohra. Different processing methods for producing dohra existed. As dohra increases the risk of cancer, it needs to be banned or it should be sold in packets with the details of its constituents and also statutory warning about its adverse health effects.

Areca nut trade, globalisation and its health impact: perspectives from India and South-east Asia

AIM:

Areca nut (AN) is consumed globally by 600 million people, and 10%-20% of the world population uses betel quid, a preparation containing areca nut. India and other South-east Asian countries are the largest consumers of AN in the world. The aim of this article is to review the economic impact and oral health effects of the consumption of AN. It will also discuss the role of dentists and auxiliary healthcare providers for increasing public awareness and the need for a strong public health policy.

METHOD:

To address the concerned area, PubMed, Scopus and Google Scholar databases were explored from the year 1965 until 2017. Studies focusing on various aspects of AN only, and articles published in English were included. Anecdotal reports, case reports and unpublished data were excluded.

RESULTS AND DISCUSSION:

This narrative review suggests India is the world's largest producer of AN along with the largest AN consuming population followed by other South-east Asian countries. AN chewing causes oral submucous fibrosis (OSF) and it is most commonly observed in people of India and South-east Asia. AN use is associated with various social and unsocial aspects. Dentists and dental auxiliaries can increase the knowledge and awareness of a health issue (OSF) among the target audience as well as the detrimental effects of AN chewing.

CONCLUSION:

There is a need for more aggressive public health measures and dentists and dental auxiliaries should be employed to bring awareness to the general public regarding AN use.

Sub-chronic toxicity study of arecae semen aqueous extract in Wistar rats

ETHNOPHARMACOLOGICAL RELEVANCE

Arecae semen, the ripe seed of Areca catechu L., has been used as vermifuge and digestant in traditional Chinese medicine (TCM). However, the potential toxicity effect of arecae semen has not been completely investigated.

THE AIM OF THE STUDY

The present study was aimed at evaluating the sub-chronic toxicity of arecae semen by oral administration in Wistar rats.

MATERIALS AND METHODS

A total of 120 Wistar rats were randomly divided into 4 groups (15 males and 15 females per group). The treated groups were given arecae semen aqueous extract (ASAE) at the dose of 750, 1500 and 4500mg/kg/day by oral administration respectively, and the control group was received distilled water only. The rats and their consumed feed were weighted every 3 days. The clinical changes and mortality were observed and recorded daily. Hematological parameters, biochemical parameters, organ weights, urinalysis and histopathological examination of all rats were tested at the end of the 30-day treatment period and another 10-day recovery period.

RESULTS

Deaths, weight loss, diarrhea, sluggish action, tremors and body curl up were observed in the 1500 and 4500mg/kg groups during the study. The relative organ weights of liver and testis in male rats of 4500mg/kg group were significantly different compared with the control group at the end of the treatment period. As for laboratory parameters, there were no significant differences at the dose of 1500 and 4500mg/kg groups compared with the control group in the study, except the white blood cell count (WBC), aspartate aminotransferase (AST), alanine aminotransferase (ALT), albumin (ALB), blood urea nitrogen (BUN), creatinine (Cr), glucose (GLU) and total cholesterol (CHOL). In addition, the results of histopathological examination and feed intake showed no significant difference compared with the control group.

CONCLUSIONS

The results showed that ASAE at the dose of 750mg/kg/day was safe, but long-term oral administration of ASAE with high dosage was toxic. Moreover, the toxic ingredients of ASAE including arecoline, and also some other compounds should be researched.

Areca nut chewing is associated with common mental disorders: a population-based study

INTRODUCTION

Forms of habitual substance use including cigarette smoking and alcohol consumption have been documented as risk factors of common mental disorders (CMDs). The effects of areca nut chewing on biophysiological tests, metabolic syndromes, and liver function have been reported previously; however, the relationship between areca nut chewing and CMDs remains unclear. This study examined the association between areca nut chewing and CMDs and explored the relationships between areca nut chewing and biophysiological indicators.

METHODS

A total of 4477 community dwellers who had enrolled in a cohort study and participated in health examinations in 2 consecutive years were selected for analysis in the present study. The community cohort was established in northern Taiwan during 2006-2012. The Chinese health questionnaire (CHQ-12) was used as a self-reported screening instrument to assess the potential for developing psychotic mental disorders (CHQ-12 score ≥ 3) among the community residents. Biophysiological tests performed 1 year before CMD assessment were analyzed to examine the causal pathways between areca nut chewing and CMDs. Multiple logistic regression and stratified analyses were performed.

RESULTS

A total of 18.23% of the participants were diagnosed as having CMDs. Factors including areca nut chewing [odds ratio (OR) 1.828; 95% confidence interval (CI) 1.165-2.869], sex (women; OR 1.828; 95% CI 1.165-2.869), age (30-49; OR 1.302; 95% CI 1.073-1.579), and socioeconomic status (lower status; OR 1.373; 95% CI 1.084-1.738) were associated with CMDs in a multiple logistic regression model. Areca nut chewers exhibited significantly more triglycerides (220.04 vs. 124.16 mg/dL) and white blood cells (65.17 102/μL vs. 60.36 102/μL) and significantly higher diastolic blood pressure (78.83 vs. 75.84 mmHg) and glutamic oxaloacetic transaminase (30.30 vs. 25.45 U/L) than did the controls.

CONCLUSIONS

This study demonstrated the association between areca nut chewing and CMDs and its effects on biophysiological tests in a community-based population in Taiwan. The findings suggest the existence of mechanistic effects of areca nut chewing on CMDs exerted through multiple pathways that may interact with pre-existing biophysiological abnormalities. Lifestyle variables should be considered for the prevention and management of mental disorders in the future.

Betel nut chewing and the risk of chronic kidney disease: evidence from a meta-analysis

PURPOSE

To investigate and quantify the potential association between betel nut chewing and the risk of chronic kidney disease (CKD).

METHODS

We searched five online databases including PubMed, EMBASE, ISI Web of Science, Wanfang and CNKI to identify observational studies that published prior to May, 1, 2017. The primary outcome was the association between betel nut chewing and CKD expressed as odds ratio (OR) and the corresponding 95% confidence interval (95%CI) after adjustment for other covariates. Meta-analysis was performed using RevMan 5.3 software; the leave-one-out sensitivity analysis was used to confirm the stability of drawn conclusion.

RESULTS

Five studies comprising a total of 10,562 CKD patients and 34,038 subjects without CKD that analyzed the relationship between betel nut chewing and CKD were included in our study; all the included studies were performed in Taiwan. After the adjustment for covariates, the combined adjusted ORs showed that betel nut used had 1.44 times higher risk to develop CKD compared with non-chewers (OR 1.44, 95%CI 1.08-1.92).

CONCLUSIONS

Betel nut chewing could significantly increase the risk of CKD, indicating that betel nut chewing may exist as an independent risk factor for CKD. Further investigation should be warranted.

The risk of cirrhosis in non-alcohol drinkers is greater in female than male betel nut chewers

Background and Aim

The association of betel nut with liver cirrhosis among alcohol drinkers has been clearly shown. However, very few studies have shown such an association among non-alcohol drinkers. The aim of this study was to assess the relationship between betel nut chewing and cirrhosis among non-alcohol drinkers.

Materials and Methods

This study retrospectively analyzed data retrieved from the 2012 Adult Preventive Medical Services and the National Health Insurance Research Datasets in Taiwan. Participants’ information included physical examination and lifestyle, alongside laboratory tests. Betel nut chewers were grouped into three categories: never, occasional and frequent. Diseases were diagnosed using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Initially, 1573024 adults aged 40 years and above who engaged in the free adult preventive medical services in 2012 were recruited. However, only 1065246 of them were included in the analysis. Chi-square test and logistic regression were used for the analyses.

Results

After multivariable adjustments, there were significant relationships between cirrhosis and betel nut chewing in both sexes (P-trend < 0.0001). The risk of cirrhosis was greater in females than males. The odds ratios of cirrhosis in occasional and frequent female chewers were respectively 2.91; 95% C.I: 1.75–4.83 and 3.06; 95% C.I: 1.69–5. However, they were respectively 1.76; 95% C.I: 1.47–2.10 and 2.32; 95% C.I: 1.90–2.85 in occasional and frequent male chewers.

Conclusions

This study demonstrated significant relationships between betel nut chewing and cirrhosis in both male and female non-alcohol drinkers. The risk of cirrhosis was greater in female than male chewers.

Areca (betel) nut chewing practices of adults and health behaviors of their children in the Freely Associated States, Micronesia: Findings from the Children's Healthy Living (CHL) Program

BACKGROUND

Chewing areca (betel) nut has been deemed carcinogenic. The practice has become a public health concern in Micronesia. The Children's Healthy Living (CHL) Program included an areca (betel) nut questionnaire in a survey of household characteristics in the Freely Associated States (FAS). This paper describes areca (betel) nut chewing practices of adults and the health behaviors of their children.

METHODS

A cross-section of 1200 children (2-8 year-olds) and their caregivers in Chuuk, Kosrae, Pohnpei, Republic of Palau, Republic of the Marshall Islands (RMI), and Yap were recruited. Socio-demographics, adult areca (betel) nut chewing practices, and other health behaviors of children and adults were assessed. Child anthropometric measurements were collected to estimate weight status.

RESULTS

The FAS areca (betel) nut chewing prevalence was 42%, ranging from 3% (RMI) to 94% (Yap). Among chewers, 84% added tobacco, 97% added slaked lime, 85% added betel leaf, and 24% mixed the components with alcohol. Among FAS children, 95% practiced daily teeth-brushing and 53% visited the dentist annually. Compared to non-chewing households, areca (betel) nut chewing households were more likely to have very young children enrolled, more highly educated adults, and members that used tobacco and alcohol.

CONCLUSION

The FAS areca (betel) nut chewing prevalence (42%) is above the world prevalence of 10-20%, with wide variability across the islands. The oral health findings in this study may inform future oral cancer prevention programs or policies. Regular monitoring of areca (betel) nut use is needed to measure the impact of such programs or policies.

Epidemiology of areca (betel) nut use in the mariana islands: Findings from the University of Guam/University of Hawai`i cancer center partnership program

BACKGROUND

Areca (betel) nut is considered a Group 1 human carcinogen shown to be associated with other chronic diseases in addition to cancer. This paper describes the areca (betel) nut chewing trend in Guam, and health behaviors of chewers in Guam and Saipan.

METHODS

The areca (betel) nut module in the Guam Behavioral Risk Factor Surveillance Survey was used to calculate the 5-year (2011-2015) chewing trend. To assess the association between areca (betel) nut chewing and health risks in the Mariana Islands, a cross-section of 300 chewers, ≥18years old, were recruited from households in Guam and Saipan. Self-reported socio-demographics, oral health behaviors, chronic disease status, diet, and physical activity were collected. Anthropometry was measured. Only areca (betel) nut-specific and demographic information were collected from youth chewers in the household.

RESULTS

The 5-year areca (betel) nut chewing prevalence in Guam was 11% and increased among Non-Chamorros, primarily other Micronesians, from 2011 (7%) to 2015 (13%). In the household survey, most adult chewers (46%) preferred areca nut with betel leaf, slaked lime, and tobacco. Most youth chewers (48%) preferred areca nut only. Common adult chronic conditions included diabetes (14%), hypertension (26%), and obesity (58%).

CONCLUSION

The 5-year areca (betel) nut chewing prevalence in Guam is comparable to the world estimate (10-20%), though rising among Non-Chamorros. Adult and youth chewers may be at an increased risk for oral cancer. Adult chewers have an increased risk of other chronic health conditions. Cancer prevention and intervention strategies should incorporate all aspects of health.

Defining a global research and policy agenda for betel quid and areca nut

Betel quid and areca nut are known risk factors for many oral and oesophageal cancers, and their use is highly prevalent in the Asia-Pacific region. Additionally, betel quid and areca nut are associated with health effects on the cardiovascular, nervous, gastrointestinal, metabolic, respiratory, and reproductive systems. Unlike tobacco, for which the WHO Framework Convention on Tobacco Control provides evidence-based policies for reducing tobacco use, no global policy exists for the control of betel quid and areca nut use. Multidisciplinary research is needed to address this neglected global public health emergency and to mobilise efforts to control betel quid and areca nut use. In addition, future research is needed to advance our understanding of the basic biology, mechanisms, and epidemiology of betel quid and areca nut use, to advance possible prevention and cessation programmes for betel quid and areca nut users, and to design evidence-based screening and early diagnosis programmes to address the growing burden of cancers that are associated with use.

Intoxication and substance use disorder to Areca catechu nut containing betel quid: A review of epidemiological evidence, pharmacological basis and social factors influencing quitting strategies

AIM

We present a systematic review of substance use disorder (SUD) to Areca catechu nut (AN) and AN containing betel quid (ANcBQ) with emphasis on dependence resulting from chewing of tobacco-free ANcBQ. We examined pharmacology of intoxication and addiction, and factors influencing quitting strategies.

METHODS

Epidemiological publications of SUD were included according to PRISMA criteria. Pharmacological publications were retrieved from the PUBMED database and websites of the WHO, United Nations, and Sigma-Aldrich.

RESULTS

Nine epidemiological studies show clear evidence of abuse and dependence in tobacco-free ANcBQ and/or ANcBQ+Tobacco chewers. Dependency is greater if ANcBQ contains tobacco. In both groups higher dependency scores were positively correlated with higher frequency of chewing. Dependency on AN+Lime is associated with altered brain morphology, resting state brain activity, neurochemistry and deterioration of working spatial memory. ANcBQ contains a complex mixture of neuroactive compounds that have the potential to act directly upon all major cerebral neurotransmitter systems. Of these compounds, only arecoline (muscarinic agonist) has been the focus of limited pharmacological investigation. In animal studies, arecoline increases dopamine transmission in the mesocorticolimbic circuit and this action may be one factor contributing to ANcBQ dependency in humans. Societal and familial acceptance of ANcBQ consumption is paramount for commencement and persistence of chewing.

CONCLUSIONS

ANcBQ SUD remains an orphan disease. The limited understanding of pharmacological basis of intoxication and SUD determines there are no pharmacological replacement therapies for ANcBQ SUD. The addictive properties of ANcBQ coupled with social acceptance of ANcBQ chewing limits the effectiveness of counseling-based quitting programs.

Effects of alcohol consumption, cigarette smoking, and betel quid chewing on upper digestive diseases: a large cross-sectional study and meta-analysis

Cigarette smoking is a well-known risk factor of upper digestive diseases. Findings on alcohol's effect on these diseases are inconsistent and with the exception of its association with esophageal cancer, little is known about betel quid chewing. This study investigated the association between use of these three substances and upper digestive diseases. We collected data from 9,275 patients receiving upper endoscopies between April 2008 and December 2013. Polynomial regressions were used to analyze the association between risk factors and diseases of the esophagus, stomach and duodenum. Meta-analysis for use of these substances and esophageal diseases was also performed. Participants who simultaneously consumed cigarettes, alcohol and betel quid had a 17.28-fold risk of esophageal cancer (95% CI = 7.59-39.33), 2.99-fold risk of Barrette's esophagus (95% CI = 2.40-4.39), 1.60-fold risk of grade A-B erosive esophagitis (95% CI = 1.29-2.00), 2.00-fold risk of gastric ulcer (95% CI = 1.52-2.63), 2.12-fold risk of duodenitis (95% CI = 1.55-2.89) and 1.29-fold risk of duodenal ulcer (95% CI = 1.01-1.65). Concurrent consumption of more substances was associated with significantly higher risk of developing these diseases. Meta-analysis also revealed use of the three substances came with a high risk of esophageal diseases. In conclusions, cigarette smoking, alcohol drinking and betel quid chewing were associated with upper digestive tract diseases.

Consumption of Energy Drinks among Undergraduate Students in Taiwan: Related Factors and Associations with Substance Use

Background: This study aimed to investigate the consumption of energy drinks and associated factors among undergraduate students in Taiwan. Methods: Data came from a cross-sectional survey conducted in 2015. Eligible participants completed a self-administered questionnaire assessing use and perceptions of energy drinks, tobacco, alcohol, and betel nut. Results: Among 606 surveyed undergraduate students, 24.8% reported consuming energy drinks in the past 30 days. The major reasons for use included keeping alert at work (48.7%), being curious about the products (32.0%), enjoying the flavor (31.3%), or preparing for school exams (26.7%). Among energy drink users, half have never read the nutrition label, and 15.3% reported that they had ever mixed energy drinks with alcohol. Most participants showed negative attitudes toward using tobacco, alcohol, or betel nut, while 54.1% reported positive attitudes toward consuming energy drinks. Being male, living away from parents’ home, tobacco use, alcohol use, and positive perceptions of energy drink’s effects significantly predicted energy drink consumption. Conclusions: In addition to exploring motivations of energy drink consumption in undergraduate students in Taiwan, the study findings indicated that energy drink consumption might relate to the use of tobacco and alcohol, which should be taken into account in substance use prevention programs.

Analysis of Alkaloids in Areca Nut-Containing Products by Liquid Chromatography-Tandem Mass Spectrometry

Chewing of areca nut in different forms such as betel quid or commercially produced pan masala and gutkha is common practice in the Indian subcontinent and many parts of Asia and is associated with a variety of negative health outcomes, particularly oral and esophageal cancers. Areca nut-specific alkaloids arecoline, arecaidine, guvacoline, and guvacine have been implicated in both the abuse liability and the carcinogenicity of the areca nut. Therefore, variations in the levels of areca alkaloids could potentially contribute to variations in addictive and carcinogenic potential across areca nut-containing products. Here, we developed an accurate and robust liquid chromatography-tandem mass-spectrometry (LC-MS/MS) method for simultaneous quantitation of all four areca alkaloids and applied this method to the analysis of a range of products obtained from India, China, and the United States. The results of the analyses revealed substantial variations in the levels of alkaloids across the tested products, with guvacine being the most abundant (1.39-8.16 mg/g), followed by arecoline (0.64-2.22 mg/g), arecaidine (0.14-1.70 mg/g), and guvacoline (0.17-0.99 mg/g). Substantial differences in the relative contribution of individual alkaloids to the total alkaloid content were also observed among the different products. Our results highlight the need for systematic surveillance of constituent levels in areca nut-containing products and a better understanding of the relationship between the chemical profile and the harmful potential of these products.

A case control study investigating factors associated with high infant death in Saiha district of Mizoram, India bordering Myanmar

Background

Infant mortality has dropped considerably in India over the last 5 years. A sharp contrast to this decline in national average of infant mortality is the rate recorded during 2014–2015 from the southernmost district of Saiha, Mizoram having a common international border with Myanmar. As this district specific rate (113 per 1000 live births) is 3 times higher compared to the national and state average, the present investigation was carried out to identify associated factors.

Methods

We examined secondary data made available by the national health mission, consulted with local community members and generated primary data through interviews. A case-control study design was followed. Mothers, who delivered a child during 2013–2015 and subsequently lost them due to infant death, formed the case group and controls were selected from same neighborhood as with case-mothers. The mother and child tracking system maintained by the district specific national health mission office was used for recruiting cases and controls. A total of 195 mothers were interviewed; 66 of them belonged to ‘cases’ and 129 were ‘controls’.

Results

The mean age of the respondents was 27 years (median 27; SD ± 5; minimum 17 & maximum 44). In uni-variate analyses ‘child delivery at home’, ‘low birth weight’, ‘non-attendance of school by mothers’, ‘completed standard of school education by mothers’, ‘both parents working’, ‘mothers receiving blood transfusion during last pregnancy’, and ‘fourth or more birth order during last pregnancy’ were associated with infant deaths. Intriguingly, the number of daily kuhva (raw areca nut) intake during last pregnancy was significantly higher among case-mothers compared to controls. In conditional logistic regression, ‘low birth weight’ (adjusted OR (AOR) 14.7; 95% CI 2.1–101.8; p = 0.006), and ‘consumption of 4 or more kuhva per day’ (AOR 8; 95% CI 1.9–34.3; p = 0.005) were independently associated with infant-death-experiences.

Conclusion

The present investigation merits due attention from policy makers and health planners for immediate improvement in peri-natal and neonatal care services in the remote district of Saiha. Need for further research exploring socio-behavioural issues around areca nut consumption and effects of interventions to reduce areca nut intake on maternal and children health are underscored.

Effect of Areca Nut Consumption on Hypoxia-inducible Factor-1 Alfa Expression in Patients with Oral Squamous Cell Carcinoma

Introduction

Oral squamous cell carcinoma (OSCC) is a major health problem in Southeast Asia, including India. Areca nut chewing is a major health hazard in India, which has been implicated in the etiology of OSCC. Hypoxia-inducible factor-1 (HIF-1) is a major transcription factor involved in adaptation under hypoxic condition, a common finding in solid tumors. The present study was conducted to evaluate the effect of different habits including areca nut chewing on HIF-1 expression in patients with OSCC.

Materials and methods

It was a hospital-based observational case-control study. The study comprised 50 histologically proven cases of OSCC and 50 healthy controls. The HIF-1α level was measured by commercially available enzyme-linked immunosorbent assay (ELISA) in the blood samples. The data were analyzed using Statistical Package for the Social Sciences (SPSS) software version 20.

Results

The HIF-1α levels were found significantly higher in the patients with areca nut consumption in addition to other addictive habits. Isolated influence could not be discerned as there was only one patient who gave history of only areca nut chewing.

Conclusion

Our findings prove that HIF-1α expression is upregulated by areca nut chewing, which leads to worse prognosis. This calls for widespread awareness programs regarding the deleterious effects of areca nut chewing among the general population.

How to cite this article

Prasad J, Goswami B, Agarwal K, Mehra P, Kumar S, Pahuja BK, Chauhan A, Ahirwar AK. Effect of Areca Nut Consumption on Hypoxia-inducible Factor-1 Alfa Expression in Patients with Oral Squamous Cell Carcinoma. Indian J Med Biochem 2017;21(2):81-85.

Awareness and Use of South Asian Tobacco Products Among South Asians in New Jersey

South Asians are the third largest Asian group in the US and among the fastest growing racial groups in New Jersey. Tobacco consumption among South Asians is characterized by several smoked and smokeless tobacco products indigenous to the Indian subcontinent. However, there is a paucity of research on tobacco use behaviors among South Asians in the US. The goal of this study was to examine the awareness and use of South Asian tobacco products such as bidis, gutkha, paan, paan masala, and zarda as well as other potentially carcinogenic products such as supari, their context of use, and their cultural significance among South Asians living in the US. Eight focus groups were conducted with South Asian adults living in Central New Jersey. Overall, participants were aware of a wide variety of foreign and American tobacco products with older South Asians identifying a greater variety of indigenous products compared to younger South Asians. Hookah was consistently recognized as popular among the younger generation while products such as paan or paan masala were more commonly identified with elders. Use of tobacco-related products such as paan and supari were described as common at social gatherings or after meals. In addition, light or social users of South Asian tobacco products, including products not consistently defined as tobacco, may not report tobacco use on a survey. Better understanding of the use of these products among South Asians and how some may classify tobacco usage can inform future research and public health interventions in these communities.

The pharmacology, toxicology and potential applications of arecoline: a review

CONTEXT

Arecoline is an effective constituent of Areca catechu L. (Arecaceae) with various pharmacological effects. However, investigations also revealed that long use of arecoline could arouse some oral diseases.

OBJECTIVE

The present review gathers the fragmented information available in the literature (before 1 October 2015) regarding pharmacology and toxicology of arecoline. We also discussed the potential developments and applications of arecoline in the future.

METHODS

All the available information regarding the arecoline is compiled from scientific databases, including Science Direct, PubMed, Web of Science, Scopus, etc.

RESULTS

Previous research demonstrated that arecoline is one of the major effective constituents in A. catechu. Additionally, arecoline has a wide spectrum of pharmacological activities including effects on nervous, cardiovascular, digestive and endocrine systems and anti-parasitic effects. What's more, arecoline is reported to be the primary toxic constituent of A. catechu, and the main toxic effects include oral submucous fibrosis (OSF), oral squamous cell carcinoma (OSCC) and genotoxicity.

CONCLUSION

Arecoline has great potential to be a therapeutic drug for various ailments. However, further investigations are needed in the future to reduce or eliminate its toxicities before developing into new drug.

Dietary Practices, Addictive Behavior and Bowel Habits and Risk of Early Onset Colorectal Cancer: a Case Control Study

BACKGROUND

The abrupt rise of colorectal cancer in developing countries is raising concern in healthcare settings. Studies on assessing relationships with modifiable and non-modifiable risk factors in the Pakistani population have been limited. The present investigation was designed to examine associations of dietary practices, addictive behavior and bowel habits in developing colorectal cancer (CRC) among patients in a low-resource setup.

MATERIALS AND METHODS

An age-gender matched case control study was conducted from October 2011 to July 2015 in Karachi, Pakistan. Cases were from the surgical oncology department of a public sector tertiary care hospital, while their two pair-matched controls were recruited from the general population. A structured questionnaire was used which included questions related to demographic characteristics, family history, dietary patterns, addictive behavior and bowel habits.

RESULTS

A family history of cancer was associated with a 2.2 fold higher chance of developing CRC. Weight loss reduced the likelihood 7.6 times. Refraining from a high fat diet and consuming more vegetables showed protective effects for CRC. The risk of CRC was more than twice among smokers and those who consumed Asian specific addictive products as compared to those who avoid using these addictions (ORsmoking: 2.12, 95% CI: 1.08 - 4.17, ORpan: 2.92, 95% CI: 1.6 - 5.33, ORgutka: 2.13, 95% CI: 1.14 - 3.97). Use of NSAID attenuated risk of CRC up to 86% (OR: 0.14, 95% CI: 0.07 - 0.31).

CONCLUSIONS

Most of the findings showed concordance with the literature elucidating protective effects of consuming vegetables and low fat diet while documenting adverse associations with family history, weight loss, constipation and hematochezia. Moreover, this study highlighted Asian specific indigenous addictive products as important factors. Further studies are needed to validate the findings produced by this research.

Chemical morphology of Areca nut characterized directly by Fourier transform near-infrared and mid-infrared microspectroscopic imaging in reflection modes

Fourier transform near-infrared (NIR) and mid-infrared (MIR) imaging techniques are essential tools to characterize the chemical morphology of plant. The transmission imaging mode is mostly used to obtain easy-to-interpret spectra with high signal-to-noise ratio. However, the native chemical compositions and physical structures of plant samples may be altered when they are microtomed for the transmission tests. For the direct characterization of thick plant samples, the combination of the reflection NIR imaging and the attenuated total reflection (ATR) MIR imaging is proposed in this research. First, the reflection NIR imaging method can explore the whole sample quickly to find out typical regions in small sizes. Next, each small typical region can be measured by the ATR-MIR imaging method to reveal the molecular structures and spatial distributions of compounds of interest. As an example, the chemical morphology of Areca nut section is characterized directly by the above approach.

Arecoline Induces Neurotoxicity to PC12 Cells: Involvement in ER Stress and Disturbance of Endogenous H2S Generation

Arecoline is a major alkaloid of areca nut and has been effect on central nervous system. Although arecoline-induced neurotoxicity has been reported, the possible underlying neurotoxic mechanisms have not yet been elucidated. Increasing evidences have shown that both excessive endoplasmic reticulum (ER) stress and disturbance of hydrogen sulfide (H2S) production are involved in the pathophysiology of numerous neurodegenerative diseases. Here, the purpose of present study was to verify whether ER stress and the disturbance of endogenous H2S generation are also involved in arecoline-caused neurotoxicity. We found that treatment of PC12 cells with arecoline induced the down-regulation of cells viability and up-regulation of apoptosis and the activity of caspase-3, indicating the neurotoxic role of arecoline to PC12 cells. In addition, arecoline also increased the expression of Bax (pro-apoptotic protein) and attenuated the expression of Bcl-2 (anti-apoptotic protein) in PC12 cells. Simultaneously, arecoline caused excessive ER stress in PC12 cells, as evidenced by the up-regulations of Glucose-regulated protein 78 (GRP78), CCAAT/enhancer binding protein homologous protein (CHOP), and Cleaved caspase-12 expressions. Notably, the level of H2S in the culture supernatant and the expressions of cystathionine β-synthase and 3-mercaptopyruvate sulfurtransferase (two major enzymes for endogenous H2S generation in PC12 cells) were also reduced by arecoline treatment. These results indicate that arecoline-caused neurotoxicity to PC12 cells is involved in ER stress and disturbance of endogenous H2S generation and suggest that the modulation of ER stress and endogenous H2S generation may be potential therapeutic approach in treatment of arecoline-caused neurotoxicity.

Facial Atrophy in Oral Submucous Fibrosis: An Association or a Coincidence

The anecdotal clinical presentation of OSMF that includes vesicle formation, burning sensation, intolerance to hot and spicy food, and trismus due to circumoral fibrous bands has been ringing in our ears for decades but the current paper flags novelty by portraying a rare presentation of an advanced stage of OSMF.

Arecoline-induced pro-fibrotic proteins in LLC-PK1 cells are dependent on c-Jun N-terminal kinase

Areca nut (AN) chewing is associated with chronic kidney disease (CKD). However, the molecular mechanisms of AN-induced CKD are not known. Thus, we studied the effects of arecoline, a major alkaloid of AN, on proximal tubule (LLC-PK1) cells in terms of cytotoxicity, fibrosis, transforming growth factor-β (TGF-β) and c-Jun N-terminal kinase (JNK). We found that arecoline dose (0.1-0.5mM) and time (24-72h)-dependently induced cytotoxicity without causing cell death. Arecoline (0.25 mM) also time-dependently (24-72h) increased fibronectin and plasminogen activator inhibitor-1 (PAI1) protein expressions. Arecoline (0.25 mM) time-dependently (24-72h) increased TGF-β gene transcriptional activity and supernatant levels of active TGF-β1. Moreover, arecoline (0.25 mM) activated JNK while SP600125 (a JNK inhibitor) attenuated arecoline-induced TGF-β gene transcriptional activity. SP600125, but not SB431542 (a TGF-β receptor type I kinase inhibitor), attenuated arecoline-induced fibronectin and PAI1 protein expressions. Finally, tubulointerstitial fibrosis occurred and renal cortical expressions of fibronectin and PAI1 proteins increased in arecoline-fed mice at 24 weeks. We concluded that arecoline induced tubulointerstitial fibrosis in mice while arecoline-induced TGF-β and pro-fibrotic proteins (fibronectin, PAI1) are dependent on JNK in LLC-PK1 cells.

Neurochemical abnormalities in anterior cingulate cortex on betel quid dependence: a 2D (1)H MRS investigation

The effects of betel quid dependence (BQD) on biochemical changes remain largely unknown. Individuals with impaired cognitive control of behavior often reveal altered neurochemicals in Magnetic Resonance Spectroscopy Imaging (MRSI) and those changes are usually earlier than structural alteration. Here, we examined BQD individuals (n = 33) and age-, sex-, and education-matched healthy control participants (n = 32) in an 2D (1)H-MRS study to observe brain biochemical alterations in the anterior cingulated cortex (ACC) associated with the severity of BQD and duration of BQD. In the bilateral ACC, our study found NAA/Cr were lower in BQD individuals compared to the healthy controls, Cho/Cr and Glx/Cr were higher in individuals with BQD compared to the healthy group, but increase was noted for mI/Cr in BQD individuals only in the left ACC. NAA/Cr ratios of the right ACC negatively correlated with BQDS and duration, NAA/Cr ratios of the left ACC negatively correlated with duration, Glx/Cr ratios of the right ACC positively correlated with BQDS. The findings of the study support previous analyses of a role for ACC area in the mediation of BQ addiction and mechanistically explain past observations of reduced ACC grey matter in BQD patients. These data jointly point to state related abnormalities of BQ effect and provide a novel strategy of therapeutic intervention designed to normalize Glu transmission and function during treating BQ addiction.

Nicotinic Activity of Arecoline, the Psychoactive Element of "Betel Nuts", Suggests a Basis for Habitual Use and Anti-Inflammatory Activity

Habitual chewing of "betel nut" preparations constitutes the fourth most common human self-administration of a psychoactive substance after alcohol, caffeine, and nicotine. The primary active ingredient in these preparations is arecoline, which comes from the areca nut, the key component of all such preparations. Arecoline is known to be a relatively non-selective muscarinic partial agonist, accounting for many of the overt peripheral and central nervous system effects, but not likely to account for the addictive properties of the drug. We report that arecoline has activity on select nicotinic acetylcholine receptor (nAChR) subtypes, including the two classes of nAChR most related to the addictive properties of nicotine: receptors containing α4 and β2 subunits and those which also contain α6 and β3 subunits. Arecoline is a partial agonist with about 6-10% efficacy for the α4* and α6* receptors expressed in Xenopus oocytes. Additionally, arecoline is a silent agonist of α7 nAChR; while it does not activate α7 receptors when applied alone, it produces substantial activation when co-applied with the positive allosteric modulator PNU-120696. Some α7 silent agonists are effective inhibitors of inflammation, which might account for anti-inflammatory effects of arecoline. Arecoline's activity on nAChR associated with addiction may account for the habitual use of areca nut preparations in spite of the well-documented risk to personal health associated with oral diseases and cancer. The common link between betel and tobacco suggests that partial agonist therapies with cytisine or the related compound varenicline may also be used to aid betel cessation attempts.