Metabolic effects of the consumption of Areca catechu

A review of the traditional uses, pharmacology, and toxicology of areca nut

BACKGROUND

Areca nut, the fruit of A. catechu, is an important Chinese herbal medicine and is the first of China's "four southern medicines". The main chemical components are alkaloids, phenols, polysaccharides, amino acids, and terpenoids. The flowers, leaves, fruits and seeds of A. catechu contain high medicinal value. However, with the emergence of adverse reactions in people who chew areca nut, people have doubts about the safety of the use of areca nut.

PURPOSE

In view of the two sides of pharmacology and toxicology of areca nut, this study comprehensively reviewed the components of different parts of A. catechu, the mechanism of pharmacology and toxicology, and the relationship between dosage and pharmacology and toxicology, in order to provide a new reference for the safe application of areca nut.

METHODS

We used "Areca nut", "Betel nut", and known biologically active ingredients in areca nut, combined with "natural active ingredients", "pharmacological activity", and "toxicological effect" as keywords to search in PubMed, Web of Science, Science Direct and CNKI up to March 2024.

RESULTS

A large number of studies have shown that low-dose areca nut has pharmacological effects such as deworming, anti-inflammatory, improving gastrointestinal function, lowering blood lipids, preventing atherosclerosis, anti-depression properties. The important mechanism involved in these effects is to reduce the generation of ROS, inhibit the activation of NADPH oxidase, increase the activity of antioxidant enzymes, affect MAPK, AKT, TLR, NF-κB, Nrf-2, PI3 K, STAT3 signaling pathway, reduce COX-2, IL-1β m RNA, MCP-1 and ICAM-1 mRNA gene expression, reduce IL-6, IL-8, IGE levels, activate AMPK signaling pathway, change the ion level in cells, and increase Bax/Bcl-2 ratio. It interferes with the biochemical metabolic process of bacteria. Long-term consumption of areca nut in large quantities will cause some adverse reactions or related malignant diseases to the human body.

CONCLUSION

We reviewed the pharmacological and toxicological effects and related mechanisms of areca nut, revealed the relationship between dose and pharmacological and toxicological effects, and discussed how to reduce the toxicity of areca nut and improve the comprehensive utilization of areca nut. It provides a reference for the study of the relationship between areca nut and human health, as well as the safe and rational use and full development and utilization of areca nut.

Impact of MAOA Gene Polymorphism on the Efficacy of Antidepressant Treatment and Craving Severity for Betel Quid Use Disorder

Betel quid (BQ) use disorder (BUD) is prevalent in many Asian countries, impacting approximately 600 million people. We conducted a randomized clinical trial to analyze the impact of MAOA genetic variations on the severity of BQ craving. This was measured using DSM-5 criteria and the Yale-Brown Obsessive-Compulsive Scale modified for betel quid use (Y-BOCS-BQ). Participants were grouped according to the severity of BUD and MAOA gene single-nucleotide polymorphism (SNP) rs5953210 genotypes. The Y-BOCS-BQ scores were assessed at baseline (week 0) and during follow-up at weeks 2, 4, 6, and 8. The AA genotype group showed significantly greater reductions in Y-BOCS-BQ at weeks 2 (p = 0.0194), 4 (p = 0.0078), 6 (p = 0.0277), and 8 (p = 0.0376) compared to the GG genotype group. Additionally, within the antidepressant group, the AA genotype showed significant reductions in the Y-BOCS-BQ scores at weeks 2 (p = 0.0313), 4 (p = 0.0134), 6 (p = 0.0061), and 8 (p = 0.0241) compared to the GG genotype. The statistical analysis revealed a significant interaction between the treatment and placebo groups based on MAOA genotypes, with the AA genotype in the treatment group exhibiting a more pronounced decrease in Y-BOCS-BQ score (p interaction <0.05) at week 6. Our study highlights the importance of considering genetic factors when developing personalized treatment plans for BUD.

Inhibition of cortical synaptic transmission, behavioral nociceptive, and anxiodepressive-like responses by arecoline in adult mice

Areca nut, the seed of Areca catechu L., is one of the most widely consumed addictive substances in the world after nicotine, ethanol, and caffeine. The major effective constituent of A. catechu, arecoline, has been reported to affect the central nervous system. Less is known if it may affect pain and its related emotional responses. In this study, we found that oral application of arecoline alleviated the inflammatory pain and its induced anxiolytic and anti-depressive-like behavior. Arecoline also increased the mechanical nociceptive threshold and alleviated depression-like behavior in naïve mice. In the anterior cingulate cortex (ACC), which acts as a hinge of nociception and its related anxiety and depression, by using the multi-electrode field potential recording and whole-cell patch-clamp recording, we found that the evoked postsynaptic transmission in the ACC of adult mice has been inhibited by the application of arecoline. The muscarinic receptor is the major receptor of the arecoline in the ACC. Our results suggest that arecoline alleviates pain, anxiety, and depression-like behavior in both physiological and pathological conditions, and this new mechanism may help to treat patients with chronic pain and its related anxiety and disorder in the future.

Brief psychotic disorder related to areca nut use: a case report

Background

Areca Nut (AN) is the fourth most commonly abused drug after nicotine, ethanol, and caffeine, due to its psychoactive properties provided by bioactive substances. Although previous studies have demonstrated AN's anxiolytic-like activity and potential benefits in ameliorating symptoms of depression and schizophrenia, there remains limited awareness regarding its association with brief psychotic disorder.

Case presentation

This case report presents the clinical profile of a 30-year-old male patient with a history of betel nut chewing for the past 2 years, who exhibited sudden onset delusions, hallucinations, and disorganized speech and behavior upon increasing the dosage of betel nut consumption. The patient displayed a positive response to antipsychotic treatment, and symptoms resolved upon discontinuation of betel nut consumption. However, one month after discharge, the patient experienced a recurrence of auditory hallucinations upon resuming betel nut chewing. Through counseling and support, the importance of abstaining from betel nut use and maintaining medication compliance was emphasized, resulting in no recurrence of psychotic symptoms during the six-month follow-up.

Conclusions

This case report highlights the related role of betel nut with brief psychotic disorder, especially when the chewing dosage is abruptly increased. It underscores the importance of considering betel nut as a potential precipitant related to acute psychiatric disorders in clinical settings.

Spatial Transcriptomic and Metabolomic Landscapes of Oral Submucous Fibrosis-Derived Oral Squamous Cell Carcinoma and its Tumor Microenvironment

In South and Southeast Asia, the habit of chewing betel nuts is prevalent, which leads to oral submucous fibrosis (OSF). OSF is a well-established precancerous lesion, and a portion of OSF cases eventually progress to oral squamous cell carcinoma (OSCC). However, the specific molecular mechanisms underlying the malignant transformation of OSCC from OSF are poorly understood. In this study, the leading-edge techniques of Spatial Transcriptomics (ST) and Spatial Metabolomics (SM) are integrated to obtain spatial location information of cancer cells, fibroblasts, and immune cells, as well as the transcriptomic and metabolomic landscapes in OSF-derived OSCC tissues. This work reveals for the first time that some OSF-derived OSCC cells undergo partial epithelial-mesenchymal transition (pEMT) within the in situ carcinoma (ISC) region, eventually acquiring fibroblast-like phenotypes and participating in collagen deposition. Complex interactions among epithelial cells, fibroblasts, and immune cells in the tumor microenvironment are demonstrated. Most importantly, significant metabolic reprogramming in OSF-derived OSCC, including abnormal polyamine metabolism, potentially playing a pivotal role in promoting tumorigenesis and immune evasion is discovered. The ST and SM data in this study shed new light on deciphering the mechanisms of OSF-derived OSCC. The work also offers invaluable clues for the prevention and treatment of OSCC.

What Motivates Betel Quid Chewers to Quit? An Analysis of Several Cessation-Relevant Variables

Introduction: Betel quid (BQ) is globally the fourth most consumed psychoactive substance. It is consumed by an estimated 600 million people worldwide, accounting for nearly 8% of the world's population. There have been very few studies assessing chewers' motivation to quit. Objectives: In the current study, we sought to understand the relationship between several cessation-relevant variables and chewers' motivation to quit. Hypotheses: Based on analogous research on cigarette smoking, we hypothesized that the following cessation-relevant variables would be associated with motivation to quit: health risk perceptions, number of chews per day, cost, degree of BQ dependence, withdrawal symptoms, number of quit attempts, reasons for use, personal health improvement, and type of BQ chewed. Methods: A total of 351 adult BQ chewers from Guam participated in the survey and served as the sample for the analyses. Results: Majority of chewers want to quit and intend to quit. Chewers relatively high in motivation to quit evinced greater health risk perceptions of BQ chewing, greater perceived health benefits to quitting, and a greater number of past quit attempts, compared to those relatively low in motivation to quit. Conclusions: Understanding which factors are associated with chewers' motivation to quit can be helpful for designing BQ cessation programs. The results suggest that BQ cessation programs could be improved by an increased emphasis on information about the negative health effects of BQ chewing and relapse-prevention.

Association between Single Nucleotide Polymorphisms in Monoamine Oxidase and the Severity of Addiction to Betel Quid

Betel quid (BQ) is the fourth most popular psychoactive substance in the world, and BQ use disorder (BUD) is prevalent in Asian countries. Although the mechanisms underlying BUD remain unclear, studies have reported influences from monoamine oxidase inhibitor. We enrolled 50 patients with BUD and assessed their BQ consumption habits, emotional conditions, and the clinical severity of addiction-assessed using the Diagnostic and Statistical Manual of Mental Disorders [Fifth Edition] (DSM-5) criteria, Substance Use Severity Rating Scale, and Yale-Brown Obsessive Compulsive Disorder Rating Scale for BQ. Patients were categorized into the severe group when showing six or more symptoms defined by DSM-5. A genome-wide association study was conducted for single nucleotide polymorphisms in BRCA1, COL9A1, NOTCH1, HSPA13, FAT1, and MAOA by using patients' blood samples. More severe BUD symptoms were associated with younger age of using BQ and poor oral hygiene and with severe craving for and more anxiety toward BQ use. The MAOA rs5953210 polymorphism was significantly associated with severe BUD (odds ratio, 6.43; 95% confidence interval, 5.12-7.74; p < 0.01) and might contribute to BQ-associated cancer risk. Further studies are required to investigate the addictive properties of BQ and the development of novel diagnostic tools and pharmacotherapeutic alternatives to BUD treatment.

Supplementation of dietary areca nut extract modulates the growth performance, cecal microbiota composition, and immune function in Wenchang chickens

Introduction

The study was aimed at evaluating the effects of areca nut extract (ANE) on the growth performance, cecal microbiota, and immunity of Wenchang chickens.

Methods

For this study, 42-day-old healthy Wenchang chickens (n = 450) with similar body weight were chosen. The animals were randomly divided into five groups, with six replicates per group and 15 chickens per replicate. One group was fed a basal diet (control; CCK). The remaining four groups were fed a basal diet supplemented with varying ANE concentrations: 0.038, 0.063, 0.100, and 0.151 g/kg, with the groups denoted as CNT1, CNT2, CNT3, and CNT4, respectively. The feeding experiment lasted 35 days. The ligated cecum segments of the control and experimental groups were collected for metabolomic and metagenomic analysis, while the bone marrow samples were extracted for tandem mass tag (TMT)-based proteomic analysis.

Results

All the experimental groups exhibited significantly higher average daily gain (ADG) and significantly lower feed-to-weight (F/G) ratios than CCK. Metabolomic screening of the cecum contents revealed the presence of 544 differential metabolites, including several gut health-related metabolites, such as xanthine, hydroxy hypoxanthine, 2,5-dimethylhydrazine, ganoderic acid, and 2-aminohexanoic acid. Metagenomic analysis of the cecum contents showed an upregulation in the abundance of Prevotella spp. in the experimental groups. However, we observed no significant differences in the abundances of other cecal microbes at phylum and genus levels. Furthermore, we observed significant associations between Prevotella spp. and the differentially abundant metabolites, such as cherubins, thiaburimamide, and 3,4-dihydroxy-L-phenylalanine, (r)-mevalonate, 5-O-methylalloptaeroxylin, nalidixic acid, and deoxyloganin (p < 0.05). Proteomic analysis revealed that the differentially expressed proteins (such as interferon-induced protein with tetratricopeptide repeats 5 (IFIT5), MHC-BF1, and death domain-associated protein (Daxx)) in the bone marrow of the chickens were primarily enriched in the immune network for IgA production and B cell receptor signaling pathway.

Conclusion

In conclusion, dietary ANE supplementation was found to enhance metabolic activity and energy utilization, improve growth performance, modulate cecal microbiota, and strengthen the immunity of Wenchang chickens.

Executive function deficit in betel quid-dependence: Evidence from functional and effective connectivity of executive control network

Betel quid (BQ) ranks fourth in global self-administered psychoactive agents, after caffeine, alcohol and nicotine, with 600 million consumers. Patients with BQ dependence (BQD) disorder demonstrate deficits in executive function. However, the neural correlates of the resting-state executive control network (ECN) and BQD-related pathopsychological characteristics still remain unclear. The present study aimed to assess the functional and effective connectivity of the ECN using resting-state functional magnetic resonance imaging (rs-fMRI). Fifty-five BQD individuals and 54 healthy controls (HCs) were recruited in this study. The executive function of all participants was tested by three tasks. Independent component and Granger causal analysis were employed to investigate the functional connectivity within ECN and ECN-related directional effective connectivity, separately. Behavioural results suggested a marked deficit of executive function in BQD individuals. Compared with HCs, BQD individuals showed overall weaker functional connectivity in the ECN, mainly including dorsolateral prefrontal cortex (DLPFC), inferior parietal lobule (IPL) and middle frontal gyrus (MFG). We observed decreased outflow of information from the right DLPFC and IPL to the precentral/pre-supplement motor area (SMA) and increased outflow of information from the MFG to the middle occipital gyrus in BQD individuals. Correlation analysis revealed that the effective connectivity from IPL to precentral/pre-SMA was negatively correlated to the BQD scales in BQD individuals. Our findings revealed impaired executive function, functional connectivity of the ECN and causal interaction between networks in patients with BQD. These results could potentially direct future targets for the prevention and intervention of BQD.

Dynamic functional connectivity changes associated with decreased memory performance in betel quid dependence

The temporal variability of the dynamic functional connectivity (dFC) has been suggested as a useful metric for studying abnormal cognitive function. This study aimed to explore the associations between the temporal properties of dFC and memory performance in betel quid dependence (BQD). Sixty-four BQD individuals and 47 gender- and age-matched healthy controls (HCs) underwent functional magnetic resonance imaging and a series of neuropsychological assessments. The dFC was constructed by calculating the Pearson correlation coefficients within a sliding window and was clustered into three functional connectivity states using k-means clustering. The dFC temporal properties derived from the cluster results were compared between the BQD and HC groups. The results showed that States 1 and 3 featured more frequent and weak connectivity, and State 2 featured less frequent and strong connectivity. There were significant differences for mean dwell time (MDT) in State 3 (p = 0.022) and fraction of time in State 2 (p = 0.018) between the BQD and HC groups. Pearson correlation analyses showed that the MDT in State 1 was negatively correlated with long delay free recall and short delay free recall, and the MDT in State 3 was positively correlated with false positive of long delay recall. Our findings provide strong evidence that MDT match the memory performance and suggest new insights into the pathophysiological mechanism of memory disorders in BQD individuals.

Chemical Composition of Areca Nut and Its Adverse Effects on Human Health

Areca nut (AN) is one of the addictive substances consumed widely in the world. The composition of AN is very complex, and each component has variable properties. This study aims to review the composition of AN and its adverse effects on humans. For this review, the literature search was performed by an electronic search of the Pubmed/Medline, Scopus, and Google Scholar databases using proper MESH headings and retrieved the articles published from 1997 to 2022. The eligibility criteria included human studies, a form of AN, the composition of AN, harmful effects of AN, the effect of AN on the oral cavity, the effect of AN on vital organs, and articles published in English. Data were extracted regarding the composition of AN, forms of AN, and harmful effects of AN on the oral cavity and on other systems. A total of 449 articles were identified from various databases, and 36 studies were selected that met the inclusion criteria. The active components of AN, which produce harmful effects, are primarily alkaloids, polyphenols, tannins, and certain trace elements. AN is consumed in different forms, and based on the form, its composition also varies. AN is known to cause deleterious effects on the oral cavity as well as various body organs. The most dangerous and widely reported impacts of AN on the oral cavity are the development of oral submucous fibrosis, a premalignant condition, and oral malignancy. However, during the chewing process, excretory products of AN are released and circulate in the body of "chronic habitual" and affect the other body parts. Thus, AN consumption may contribute to cardiac, liver, endocrinal, metabolic, respiratory, and reproductive system disorders also. AN composition is complex, and its consumption is harmful to human health. In regard to controlling the issue of the harmful effects of this habit, preventive measures should be established.

Epidemiology, Risk Factors, and Prevention of Head and Neck Squamous Cell Carcinoma

Head and neck squamous cell carcinoma (HNSCC) is a group of malignancies, involving the oral cavity, pharynx, hypopharynx, larynx, nasal cavity, and salivary glands, that together compose the seventh most common cancer diagnosis worldwide. With 890,000 new cases and 450,000 deaths annually per GLOBOCAN estimates, HNSCC accounts for roughly 4.5% of cancer diagnoses and deaths. In the developing world, the incidence of HNSCC is growing with increasing consumption of tobacco (smoked or chewed), alcohol, and areca nut (betel quid). Alcohol and tobacco have a synergistic effect, with the heavy consumption of both increasing HNSCC risk 40-fold. In developed nations, HPV-related HNSCC surpasses tobacco- and alcohol-related disease. HPV-related HNSCC more commonly affects the oropharynx, hypopharynx, and larynx than the oral cavity, and is associated with a significantly longer median survival (130 months vs. 20 months). Discrepancies in etiology as well as disparities in lifestyle choices and access to healthcare may account for the greater incidence and poorer survival of HNSCC among minority and lower-socioeconomic-status communities in developed nations. Pharmacotherapy and counseling together have been shown to be effective in promoting smoking and alcohol cessation. Education on cancer risk and community engagement have reduced areca nut consumption in Asia as well as in diaspora communities. HPV vaccination, starting at age 11-12 for both sexes, has been shown to reduce the prevalence of high-risk HPV serologies and prevent pre-cancerous lesions of the cervix, vagina, and vulva. As of 2020, 58.6% of eligible adolescents in the US have received the full two-vaccine series. Increased adoption of vaccination, education on safe sex practices, and routine visual oral screening for high-risk patients would curb growing HNSCC incidence in developed nations.

Prevalence, Habit Pattern, and Awareness on Harmful Effects of Tobacco/Areca Nut Use among Patients Visiting a Tertiary Care Center in Sri Lanka

Background The carcinogenicity of tobacco and areca nut is well established worldwide. Areca nut is the fourth most common psychoactive substance identified recently. The effects of areca nut on the autonomic nervous system make the users dependent on the habit which has been an emerging health issue among Sri Lankan adults and adolescents. This study aimed to evaluate the prevalence and patterns of these risk habits among the patients attending a tertiary care center in Sri Lanka, and their awareness of the harmful effects of the habit.

Method A hospital-based cross-sectional study was conducted among 512 patients using an interviewer-administered questionnaire.

Results The sample consisted of 167 (33%) tobacco consumers. The average age of the initiation of tobacco consumption was 23.66 years (standard deviation ± 8.04). Age (p = 0.001), gender (p = 0.001), income (p = 0.005), and educational level (p = 0.001) are significantly associated with tobacco consumption. There is a strong likelihood for tobacco consumers to consume areca nut (odds ratio [OR] 30.58, 95% confidence interval [CI] 17.05–54.88) and alcohol (OR 11.16, 95% CI 6.91–17.98) at any stage in their lives. The majority of the tobacco consumers (61%) were smokeless tobacco users. Areca nut consumers are 0.44 times more likely to know its carcinogenic effects than nonconsumers (95% CI 0.28–0.69). Tobacco consumers are more likely to be aware of the harmful effects of tobacco consumption than nonconsumers (OR 1.11, 95% CI 0.45–2.74). Sixty percent have made at least one attempt to quit the habit. Sixty-two percent of the unsuccessful quitters reported the reason as “addiction.”

Conclusion Prevalence of smokeless tobacco consumption prevails at a high level among Sri Lankans. Tobacco and areca nut users are more likely to be aware of its harmful effects than the nonconsumers but unable to quit the habit due to the psychoactive properties of tobacco and areca nut.

Association of Metabolic Syndrome and Other Factors with the Presence of Diabetic Nephropathy in Type 2 Diabetic Patients

INTRODUCTION

Diabetic nephropathy (DN) is a severe diabetes mellitus (DM) complication that contributes to medical and financial burdens. This study aimed to investigate risk factors for DN among type 2 diabetes mellitus (T2DM) patients by stratifying the participants based on the presence of metabolic syndrome (MetS).

MATERIALS AND METHODS

Between June 2017 and June 2022, Taiwan Hospital was chosen for this retrospective case-control study. Following the completion of a standardized interview and the donation of blood samples for this study, participants were divided into two groups according to whether they had MetS. We contrasted how the potential DN-related factors impacted these two groups.

RESULTS

A total of 1212 patients were included, and 639 patients (52.7%) had MetS. Multivariable analysis showed that the level of educational qualifications, fasting glucose, and uric acid (UA) were associated with DN. However, chewing betel nut behavior, higher systolic blood pressure (SBP), and higher glycated hemoglobin (HbA1c) were found to be risk factors of DN among the patients who had both T2DM and MetS. Notably, betel nut chewing increased the chance of DN in T2DM patients with MetS.

CONCLUSIONS

This study found that the level of education, chewing betel nut behavior, HbA1c, fasting glucose, SBP, and UA were significant risk factors for the development of DN in diabetic individuals with concurrent MetS. Our research reveals that managing the aforementioned risk factors is crucial to lowering the prevalence of DN, particularly in individuals with lower levels of education.

Decreased functional connectivity in salience network is associated with symptom severity in betel quid-dependent chewers

BACKGROUND

Betel quid (BQ) is the fourth most popular psychoactive agent worldwide. Neuroimaging studies have showed that substance-addicted individuals including alcohol, heroin, nicotine and other addictive substance exhibit altered activity patterns of the salience network (SN). However, no study has yet investigated the neural correlates of the resting-state SN and BQ dependence (BQD)-related physiopathological characteristics.

METHODS

Thirty-two BQ-dependent (BQD) chewers and 32 healthy controls were recruited to participate in this study. Resting-state functional magnetic resonance imaging (fMRI) data were analysed by independent component analysis (ICA).

RESULTS

BQD chewers exhibited decreased functional connectivity in bilateral insula, anterior cingulate cortex (ACC), medial superior frontal gyrus (MSFG) and inferior orbital frontal gyrus (IOFG) [false discovery rate (FDR) correction, p < 0.05]. In the BQD group, the decreased functional connectivity in left ACC correlated negatively with BQDS (BQD Scale) and the duration of BQ.

CONCLUSIONS

We reported decreased functional connectivity in resting-state SN of BQD individuals. The decreased functional connectivity in left ACC correlated negatively with BQDS and the duration of BQ. Our findings provided evidence for the importance of the SN in the pathophysiology of BQD and indicated that the SN dysfunction might provide a potential mechanism in BQD development.

Metabolism of the areca alkaloids - toxic and psychoactive constituents of the areca (betel) nut

Areca nut (AN) is consumed by millions of people for its therapeutic and psychoactive effects, making it one of the most widely self-administered psychoactive substances in the world. Even so, AN use/abuse is associated with myriad oral and systemic side effects, affecting most organ systems in the body. Alkaloids abundant in the nut (e.g. arecoline, arecaidine, guvacoline, and guvacine), collectively called the areca alkaloids, are presumably responsible for the major pharmacological effects experienced by users, with arecoline being the most abundant alkaloid with notable toxicological properties. However, the mechanisms of arecoline and other areca alkaloid elimination in humans remain poorly documented. Therefore, the purpose of this review is to provide an in-depth review of areca alkaloid pharmacokinetics (PK) in biological systems, and discuss mechanisms of metabolism by presenting information found in the literature. Also, the toxicological relevance of the known and purported metabolic steps will be reviewed. In brief, several areca alkaloids contain a labile methyl ester group and are susceptible to hydrolysis, although the human esterase responsible remains presumptive. Other notable mechanisms include N-oxidation, glutathionylation, nitrosamine conversion, and carbon-carbon double-bond reduction. These metabolic conversions result in toxic and sometimes less-toxic derivatives. Arecoline and arecaidine undergo extensive metabolism while far less is known about guvacine and guvacoline. Metabolism information may help predict drug interactions with human pharmaceuticals with overlapping elimination pathways. Altogether, this review provides a first-of-its-kind comprehensive analysis of AN alkaloid metabolism, adds perspective on new mechanisms of metabolism, and highlights the need for future metabolism work in the field.

Betel Nut Chewing Increases the Risk of Metabolic Syndrome and Its Components in a Large Taiwanese Population Follow-Up Study Category: Original Investigation

Betel nut chewing is a popular habit in Taiwan, and it is associated with adverse metabolic effects. The aim of this study was to investigate correlations between betel nut chewing with metabolic syndrome (MetS) and its components in a longitudinal study using data from the Taiwan Biobank. A total of 121,423 participants were included in the baseline study, and 27,002 received follow-up examinations after a median of 4 years. The association between betel nut chewing and MetS was analyzed using multiple logistic regression after controlling for confounders. The baseline prevalence of MetS was 22.5%. Multivariable analysis showed that a history of chewing betel nut was significantly associated with baseline MetS (odds ratio (OR) = 1.629; 95% confidence interval (CI) = 1.535 to 1.730, p < 0.001) and five components of MetS in all participants. A long history of chewing betel nut (per 1 year; OR = 1.008; 95% CI = 1.004 to 1.013, p < 0.001) was associated with baseline MetS, abdominal obesity, hypertriglyceridemia and low high-density lipoprotein (HDL) cholesterol. In addition, high cumulative dose (per 1 year × frequency × daily score; OR = 1.001; 95% CI = 1.001−1.002; p < 0.001) was significantly associated with baseline MetS. At the end of the follow-up, a history of chewing betel nut (OR = 1.352; 95% CI = 1.134 to 1.612, p = 0.001) was significantly associated with MetS and its components including abdominal obesity, hypertriglyceridemia and low HDL-cholesterol in the participants without baseline MetS. In addition, a longer history of betel nut chewing was associated with MetS (per 1 year; OR = 1.021; 95% CI = 1.008 to 1.035, p = 0.002), abdominal obesity and hypertriglyceridemia at follow-up. However, cumulative dose (p = 0.882) was not significantly associated with follow-up MetS. Chewing betel nut and a long history of betel nut chewing were associated with baseline MetS and its components. In the participants without MetS at baseline, chewing betel nut and a long history of chewing betel nut were associated with the development of MetS after 4 years of follow-up. However, a cumulative dose of betel nut chewing was not associated with follow-up MetS. Betel nut chewing cessation programs are important to reduce the incidence of MetS in Taiwan.

Altered Spontaneous Brain Activity in Betel Quid Dependence Chewers: A Resting-State Functional MRI Study With Percent Amplitude of Fluctuation

OBJECTIVE

This study aimed to investigate brain spontaneous neural activity changes in betel quid dependence (BQD) chewers using the percent amplitude of fluctuation (PerAF) method.

METHODS

This study included 48 BQD chewers. The healthy control (HC) group comprised 35 volunteers who were matched with BQD chewers in age, gender, and educational status. All subjects underwent resting-state functional magnetic resonance imaging (rs-fMRI) and neuropsychological tests. The PerAF method was used to identify BQD-related regional brain activity changes. An independent samples t-test was used to evaluate the PerAF difference across two groups. The association between PerAF changes and clinical features such as BQD scores, duration of BQD, Hamilton Depression Rating Scale-24 item (HAMD-24), and Hamilton Anxiety Rating Scale-14 item (HAMA-14) was evaluated by using Spearman's correlation analysis. It assessed the ability of the PerAF method to distinguish between BQD chewers and HCs using a receiver operating characteristic (ROC) curve.

RESULTS

Compared to the control group, BQD chewers showed decreased PerAF in right anterior cingulate cortex (ACC), right middle frontal gyrus (MFG), right insula, right precuneus, left putamen, left supramarginal gyrus (SMG), and left cerebellum and increased PerAF in right orbitofrontal and left superior temporal gyrus (STG) [P < 0.05, Gaussian random field (GRF) corrected]. PerAF values of the right MFG and right ACC had a significant negative relationship with the duration of BQD (P < 0.05). The average values of PerAF in the left putamen, left cerebellum, and left STG showed significant discriminatory power in distinguishing BQD chewers from HCs, with relatively prime area under the curve (AUC) values.

CONCLUSION

Our findings suggested that betel quid chewing is associated with spontaneous neural activity alterations in the impulsivity areas (MFG and ACC), cognitive (MFG, ACC, precuneus, and the cerebellum), and reward (orbitofrontal, putamen, and insula) systems, which may be correlated with neuropathological mechanisms of BQD. Also, PerAF may be useful as a potential sensitive biomarker for identifying spontaneous brain activity changes in BQD chewers.

Risk of liver disease in areca nut habitual: A systematic review

Background:

Areca nut (AN) is one of the addictive substances known to cause deleterious effects on oral cavity as well as on various body organs including liver. But, scanty information is available reporting the adverse effects of AN chewing on the liver.

Aim:

To study the risk of liver disease in AN habitual based on the relevant published data.

Methods:

The literature search was performed by an electronic search of the PubMed/Medline, Scopus and Google Scholar databases using proper MESH headings and retrieved the articles published from 1998 to 2021. The eligibility criteria included: Human studies, AN habitual as study participants, use of controls and articles published in English. Data were extracted regarding characteristics of studies, characteristics of AN exposure, effect estimate and outcome of the studies.

Results:

Total 253 articles were identified from various databases and 15 studies were selected that met the inclusion criteria. Among these, thirteen studies showed an association between AN habit and attenuation of risk of liver disease as determined by relative risk/odds ratio/hazard ratio. Eleven studies described additive effect of AN and HBsAg and/or Anti hepatitis C virus status on development of liver disease. However, two of the studies showed opposite results. The heterogeneity in the study designs, exposure characteristics, outcomes and confounders precluded further meta-analysis.

Conclusion:

The association between AN chewing and an increased risk of developing liver disease is noted which necessitates the need for AN cessation campaign.

The Reasons for Betel Quid Chewing Scale (RBCS) for Ex-Chewers: Assessment of Factor Structure, Reliability, Validity and Measurement Invariance across Gender in a Guamanian Sample

BACKGROUND

Over 600 million people chew betel nut worldwide and the behavior is classified by the World Health Organization (WHO) as a Group 1 carcinogen. Having a reliable and valid scale of reasons for chewing betel nut that can be used consistently across gender for both chewers and ex-chewers will assist practitioners to create culturally appropriate risk reduction and cessation programs and address an important public health concern.Purpose/Objectives: We sought to: 1) examine factor structure, reliability, and validity of the Reasons for Chewing Scale (RBCS) for ex-chewers; 2) examine the influence of social-cultural factors on chewing behaviors; and 3) examine if measurement invariance (MI) of the RBCS held consistently across gender groups.

METHODS

A Confirmatory Factor Analysis (CFA), a multigroup CFA for testing measurement invariance (MI), and Structural Equation Modeling (SEM) were applied to the RBCS using a convenience sample of (N = 223) of ex-chewers from Guam.

RESULTS

The majority of the items in the RBCS were found to be moderately or strongly correlated to each other. The CFA model fit the ex-chewers' data well and the model suggested that the RBCS was found to be reliable and valid. The multi-group CFA showed this scale functions equivalently for both male and female groups.Conclusions/Importance: The RBCS is a valid and reliable measure that is invariant across gender and type of ex-chewer.

Volatiles Composition and Antimicrobial Activities of Areca Nut Extracts Obtained by Simultaneous Distillation-Extraction and Headspace Solid-Phase Microextraction

The volatile components of areca nuts were isolated by headspace solid-phase microextraction (HS-SPME, DVB/CAR/PDMS fiber extraction) and simultaneous hydrodistillation-extraction (SHDE) and analyzed by gas chromatography/mass spectrometry. Furthermore, all SHDE fractions were tested for antimicrobial activity using the disk diffusion method on nine Gram-negative and Gram-positive bacteria (Bacillus subtilis, Enterococcus faecalis, Escherichia coli, Pseudomonas aeruginosa, Staphylococcus aureus, Streptococcus agalactiae, Streptococcus canis, Streptococcus pyogenes, and Candida albicans). In total, 98 compounds (mainly alcohols, carbonyl compounds, fatty acids, esters, terpenes, terpenoids, and aliphatic hydrocarbons) were identified in SHDE fractions and by using SPME extraction Fatty acids were the main group of volatile constituents detected in all types of extracts. The microorganism most sensitive to the extract of the areca nut was Streptococcus canis. The results can provide essential information for the application of different treatments of areca nuts in the canning industry or as natural antibiotics.

Label-free quantitation of the changes in salivary proteome associated with the chronic consumption of the betel nut (Areca catechu)

Areca nut or betel nut chewing is most frequently used in Pakistan and is associated with a high risk for oral cancer. Until now, however, there has not been any research conducted on the long-term effect(s) of betel nut chewing on the saliva proteome. In the present study, initially, the changes in the saliva proteome associated with betel nut chewing were investigated. Secondly, the analysis was focused on the changes in salivary proteome with respect to prolonged usage of betel nuts. After extraction, the saliva proteins were digested into peptides and these were subsequently analyzed using mass spectrometry. Data are available via ProteomeXchange with identifier PXD029768. Label-free quantitation of saliva samples revealed a total of 12 proteins that were differentially expressed between betel nut addicts (BNAs), and the control group. The study groups were further divided into three subgroups, the BNA-1, BNA-2, and BNA-3 groups, with respect to the extent of consumption of betel nuts in terms of years. The data analysis revealed a more detailed profiling of proteins expressed after five, ten, and more than ten years of betel nut consumption. A total of 30, 17, and 22 proteins were found to be differentially expressed when divided into the BNA-1, BNA-2, and BNA-3 groups. The present study shows that the chronic usage of betel nuts leads to the expression of proteins, such as SPARC1, profilin, and SBSN, which are known to be involved in head and neck cancers.

Characteristics of tobacco consumption among cancer patients at a tertiary cancer hospital in South India-A cross-sectional study

Introduction

Cancer patients commonly present with antecedent addiction to tobacco consumption. Our study describes the characteristics of this substance use. Following the diagnosis of cancer, continued consumption of tobacco results in reduced tolerance to treatment, failure of treatment, tumor progression, other primary tumors, secondary cancers, and poor quality of life. The aim of our study is to enumerate the clinico-social aspects of tobacco consumption among cancer patients.

Methods

This cross-sectional study includes 100 cancer patients admitted to Healthcare Global cancer hospital, Bangalore, India. The study subjects were assessed for tobacco consumption, as well as other substance use such as intake of alcohol. We assessed various dimensions of exposure to tobacco consumption such as duration, intensity, and cumulative dose as independent risk factors for cancer.

Results

Among the study subjects, 46.2% were found to smoke filter cigarettes. The mean duration of tobacco consumption among beedi users was found to be longer (25.9 years, SD: 14.4). When stratified for exclusive consumption, the mean durations were as follows: beedis (29 ± 14.4 years), cigarettes (23.8 ± 13.3 years), and chewing (15.9 ± 9.6 years). Along with tobacco, a large proportion (59.3%) of patients consumed alcohol as well. After attempts to quit, 89.01% patients had reversal of tobacco substance use. The data did not show significance for duration, intensity, and cumulative dose of tobacco consumption.

Conclusion

The diagnosis of cancer is a life-altering event, which results in higher motivation to quit the use of tobacco. Smoking cessation initiatives can reduce the risk of developing tobacco-related malignancies.

Identifying new compounds with potential pharmaceutical and physiological activity in Areca catechu and Areca triandra via a non-targeted metabolomic approach

INTRODUCTION

The fruits of Areca catechu, also called areca nuts, are widely used as popular masticatory and traditional herbal medicine in Asia. Besides arecoline and related alkaloids, limited information is available about further primary and secondary metabolites and their potential biological activities.

OBJECTIVE

Here we aimed to further enhance our knowledge on phytochemical profiles of A. catechu and Areca triandra fruits. We intended to comprehensively identify metabolites in A. catechu and A. triandra fruits.

METHODOLOGY

Metabolites were identified by ultra-performance liquid chromatography triple-quadrupole tandem mass spectrometry (UPLC-MS/MS). The occurrence of 12 selected bioactive compounds in 4 different developmental stages of A. catechu and A. triandra was quantified by LC-MS/MS.

RESULTS

A total of 791 metabolites was identified. Of these, 115 metabolites could successfully be mapped to 44 Kyoto Encyclopedia of Genes and Genomes metabolic pathways, and 154 metabolites occurred at significantly different levels in A. catechu compared to A. triandra. Several components with known biological activities were identified for the first time in A. catechu and A. triandra. The abundance of many of these new components was similar in A. catechu and A. triandra, but significantly different between the pericarp and the seeds of A. catechu fruits.

CONCLUSIONS

Metabolic profiles indicate that fruits of the Areca species compared here have similar primary and secondary metabolites. Our findings provide new insights into A. catechu and A. triandra as valuable sources for traditional medicine and they pave the way for further studies to potentially improve the underlying pharmaceutical and physiological effects.

Areca catechu-(Betel-nut)-induced whole transcriptome changes in a human monocyte cell line that may have relevance to diabetes and obesity; a pilot study

BACKGROUND

Betel-nut consumption is the fourth most common addictive habit globally and there is good evidence linking the habit to obesity, type 2 diabetes (T2D) and the metabolic syndrome. The aim of our pilot study was to identify gene expression relevant to obesity, T2D and the metabolic syndrome using a genome-wide transcriptomic approach in a human monocyte cell line incubated with arecoline and its nitrosated products.

RESULTS

The THP1 monocyte cell line was incubated separately with arecoline and 3-methylnitrosaminopropionaldehyde (MNPA) in triplicate for 24 h and pooled cDNA indexed paired-end libraries were sequenced (Illumina NextSeq 500). After incubation with arecoline and MNPA, 15 and 39 genes respectively had significant changes in their expression (q < 0.05, log fold change 1.5). Eighteen of those genes have reported associations with T2D and obesity in humans; of these genes there was most marked evidence for CLEC10A, MAPK8IP1, NEGR1, NQ01 and INHBE genes.

CONCLUSIONS

Our preliminary studies have identified a large number of genes relevant to obesity, T2D and metabolic syndrome whose expression was changed significantly in human TPH1 cells following incubation with betel-nut derived arecoline or with MNPA. These findings require validation by further cell-based work and investigation amongst betel-chewing communities.

A multivariate pattern analysis of resting-state functional MRI data in Naïve and chronic betel quid chewers

Betel quid (BQ) is the fourth most commonly consumed psychoactive substance in the world. However, comprehensive functional magnetic resonance imaging (fMRI) studies exploring the neurophysiological mechanism of BQ addiction are lacking. Betel-quid-dependent (BQD) individuals (n = 24) and age-matched healthy controls (HC) (n = 26) underwent fMRI before and after chewing BQ. Multivariate pattern analysis (MVPA) was used to explore the acute effects of BQ-chewing in both groups. A cross-sectional comparison was conducted to explore the chronic effects of BQ-chewing. Regression analysis was used to investigate the relationship between altered circuits of BQD individuals and the severity of BQ addiction. MVPA achieved classification accuracies of up to 90% in both groups for acute BQ-chewing. Suppression of the default-mode network was the most prominent feature. BQD showed more extensive and intensive within- and between-network dysconnectivity of the default, frontal-parietal, and occipital regions associated with high-order brain functions such as self-awareness, inhibitory control, and decision-making. In contrast, the chronic effects of BQ on the brain function were mild, but impaired circuits were predominately located in the default and frontal-parietal networks which might be associated with compulsive drug use. Simultaneously quantifying the effects of both chronic and acute BQ exposure provides a possible neuroimaging-based BQ addiction foci. Results from this study may help us understand the neural mechanisms involved in BQ-chewing and BQ dependence.

Reduction in and Preventive Effects for Oral-Cancer Risk with Antidepressant Treatment

Areca nut (AN) was identified as carcinogenic to humans. Around 600 million people globally use AN in some form, yet no effective therapeutic drug is available to overcome AN addiction. This preclinical study examines the effects of antidepressants on AN use with animal models. We produced AN powder and dissolved it into drinking water, training 55 C57BL/6 mice in free self-selection to drink AN water or normal water. Then, the mice were randomly divided into four groups. Selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs), and tricyclic antidepressants (TCAs) were given as three treatment groups and one placebo group for four weeks. In the follow-up period, the preference and amount of free selection of AN and normal water, and oral pathological change were evaluated. There was a significant decrease in preference for AN drinking during the first four weeks, and the 36th week after drug withdrawal in the MAOI and SSRI groups (all p < 0.05). The drug-reducing effect of AN water in the 1–4-week period was significant in the MAOI group (p < 0.0001) and was also significant in the 3–4-week period in the SSRI group (p = 0.03). The TCA group did not show a decrease effect. At the endpoint (60 weeks), oral mucosal fibrosis (OSF) levels and risk in the SSRI (p = 0.0081) and MAOI (p = 0.01) groups were significantly lower than those in the control group. Antidepressant drugs MAOIs and SSRIs could reduce the amount of AN use and decrease the early stage of oral fibrosis in mice, but SSRIs may need to be boosted again.

Areca Nut Chewing: Initiation, Addiction, and Harmful Effects Emphasizing the Barriers and Importance of Cessation

Areca nut is a highly addictive substance with carcinogenic properties and causes many harmful effects to the human body. Alkaloids are the major chemicals found in areca nut, and their mechanism of action has been studied for several years. About 600 million people around the world use areca nut, and its usage is higher in Asian countries. Areca nut chewers get used to the habit mainly due to social influence, stress, or lack of awareness. Some studies have reported a dependence syndrome related to areca nut chewing. Even though there are many ongoing research studies regarding tobacco addiction, less concern has been given to the areca nut addiction. There are only few studies related to areca nut cessation, and even those few cessation programs are mainly designed using tobacco cessation methodology. Sociocultural influence, behavioral factors, and accessibility are the main barriers to cessation. Behavior changing interventions proved to be more effective in areca nut cessation, but recently studies on pharmacological therapies are also emerging.

Betel quid chewing and its associated factors in Myanmar: A quantitative study

BACKGROUND

Betel quid is more widely consumed than tobacco in Myanmar. It brings adverse health effects regardless of whether it contains tobacco; however, Myanmar has no clear prevention strategy. This study aims to show a broader picture of the prevalence of betel quid chewing and the observable characteristics of its consumers in Myanmar by comparing it to tobacco usage.

METHODS

This study used the 2015-2016 Myanmar Demographic and Health Survey data. First, we identified characteristics of betel quid consumers by a logit model. Next, we focused on exploring who would be likely to become heavy users, conditioned on being a betel quid consumer by controlling for possible sample selection bias.

RESULTS

We found differences in characteristics for betel chewers and tobacco smokers, and for betel quid users and heavy users.

CONCLUSION

These results suggest that betel quid consumption should be regulated by a specific prevention strategy rather than by Myanmar's existing tobacco prevention strategy.

A Qualitative Study of Perceptions and Practices Related to Areca Nut Use Among Adolescents in Mumbai, India

INTRODUCTION

Areca nut, commonly known as supari, is widely used in India. In addition to tobacco and alcohol, it has been identified as one of the contributory factors for high rates of oral cancer in the country.

METHODS

This qualitative study explored perceptions and practices around the use of areca nut by conducting in-depth interviews and focus group discussions with 61 school-going adolescents in the city of Mumbai, India.

RESULTS

Respondents used low-priced sachets of sweetened, flavored areca nut called supari. They perceived supari as harmless because it was sweet, it had a fresh after-taste as compared to bitter-tasting smokeless tobacco products. How can something sweet be harmful was a common argument offered by respondents. Respondents invariably compared and contrasted areca nut to more harmful and addictive tobacco products; perceiving supari to have milder or inconsequential health effects. Supari use was initiated with friends, a sibling, or a cousin. It was almost always used with friends. Respondents also reported difficulty in refusal to use when offered supari by friends. Parental response to finding out about the child's supari use was often muted in comparison to extreme reactions associated with the child's tobacco use.

CONCLUSIONS

Perceptions of low risk or relative harmlessness of the product, social influence, and the features of the product itself influence adolescents' use of areca nut. Although more research on perceptions of risk, with larger samples, is required, these findings are useful for school-based tobacco prevention and cessation programs and health policy-makers.

IMPLICATIONS

The study findings have implications for prevention and cessation programs, and policymakers. School-based health education programs should allocate special sessions on areca nut use. Focused mass media communication campaigns describing its harms and association with oral cancer are required for the larger community. As was done for tobacco, Indian policymakers will have to evaluate the marketing, commerce, and distribution of areca nut and create appropriate laws. More research, with larger nationwide samples, is required to examine perceptions of areca nut.

Association between Betel Nut and Presence of Diverticulum in Male: A Cross-Sectional Study

Although several studies have reported the multiple systemic effects of betel nut (BN) chewing, analyses performed on the colonic system have been few. To analyze the association between BN chewing and diverticulosis, we conducted a cross-sectional study of 5,586 eligible participants who underwent colonoscopy at a medical center in Taiwan from 2010 to 2016. BN chewing was recorded based on an assessment of personal history. Diverticulosis was categorized based on whether colonoscopies had been performed during health examinations by trained physicians at Tri-Service General Hospital. The association between different exposures, including cigarette, alcohol, BN, and diverticulosis, was also analyzed. Our study included 3,161 males and 2,425 females, and males have significantly higher prevalence rates of BN chewing than females (11.1% versus 0.3%, respectively). In the male group, BN chewing had an adjusted odd ratio (OR): 1.65(95% confident interval (CI): 1.12–2.44) with the presence of diverticulosis. Among the combination of exposures of cigarette, alcohol, and BN, the group with BN chewing combined with smoking and drinking showed significant association between diverticulosis with adjusted OR: 1.909 (95% CI, 1.188–3.065). Further subgroup analysis displayed adjusted OR: 2.310 (95% CI, 1.245–4.287) in obesity and OR: 2.406 (95% CI, 1.205–4.803) in elderly male. Thus, BN chewing is independently associated with diverticulosis in male.

Assessment of areca nut use, practice and dependency among people in Guwahati, Assam: a cross-sectional study

Background

Areca nut is the fourth most commonly used psychoactive substance worldwide after tobacco, alcohol and caffeine. In India, it is perceived in various ways, ranging from a ‘fruit of divine origin’ in Hindu religious ceremonies to a mouth freshener. Areca nut use both on its own and with tobacco additives is addictive. The aim of this study was to understand the pattern of areca nut consumption, to determine the Knowledge, Attitude and Practices (KAP) among areca nut users and the dependency associated with areca nut use.

Methods

A cross sectional study was conducted in Guwahati, Assam using a self-administered questionnaire eliciting the pattern of areca nut consumption, KAP among users and understanding their dependency using Betel Quid Dependence Scale. The chewers of areca nut alone with or without betel quid, gutkha and tobacco participated in the study. Areca nut users were selected using purposive sampling method from the vendor shops of all the four assembly areas of the city. Their participation was voluntary and free not to answer or quit the survey. The data was analysed using SPSS software.

Results

A total of 500 participants were approached in all four areas, 479 completed the survey (response rate 95%). The people who participated in the study were mostly male with an average age of 40 years, educated to secondary level or higher, married and self-employed. Betel quid with tamul was the most prevalent form of areca nut chewing in both men and women. About 441 (92%) participants experienced pleasure when chewing areca nut and 327 (68%) chewed it to relieve stress. Only 86 (18%) of subjects had ever tried to quit chewing areca nut and 387 (81%) thought that it was highly addictive. The results revealed relatively high levels of endorsement for ‘physical and psychological urgent need’ (mean = 43%) and ‘increasing dose’ (mean = 50%), whereas endorsement level for ‘maladaptive use’ was low (mean = 16%).

Conclusion

Areca nut use (tamul) is of major concern in India and many Southeast Asian countries and its use has been increasing across the globe. The evidence suggests a dependence similar to tobacco use and policy makers need to refine its strategy for control of its use by engaging with multiple stakeholders and adapting it to local context with surveillance and cessation guidelines in order to address this issue.

Acute Effect of Betel Quid Chewing on Brain Network Dynamics: A Resting-State Functional Magnetic Resonance Imaging Study

Betel quid (BQ) is one of the most popular addictive substances in the world. However, the neurophysiological mechanism underlying BQ addiction remains unclear. This study aimed to investigate whether and how BQ chewing would affect brain function in the framework of a dynamic brain network model. Resting-state functional magnetic resonance imaging scans were collected from 24 male BQ-dependent individuals and 26 male non-addictive healthy individuals before and promptly after chewing BQ. Switching rate, a measure of temporal stability of functional brain networks, was calculated at both global and local levels for each scan. The results showed that BQ-dependent and healthy groups did not significantly differ on switching rate before BQ chewing (F = 0.784, p = 0.381, analysis of covariance controlling for age, education, and head motion). After chewing BQ, both BQ-dependent (t = 2.674, p = 0.014, paired t-test) and healthy (t = 2.313, p = 0.029, paired t-test) individuals showed a significantly increased global switching rate compared to those before chewing BQ. Significant corresponding local-level effects were observed within the occipital areas for both groups, and within the cingulo-opercular, fronto-parietal, and cerebellum regions for BQ-dependent individuals. Moreover, in BQ-dependent individuals, switching rate was significantly correlated with the severity of BQ addiction assessed by the Betel Quid Dependence Scale scores (Spearman's rho = 0.471, p = 0.020) before BQ chewing. Our study provides preliminary evidence for the acute effects of BQ chewing on brain functional dynamism. These findings may provide insights into the neural mechanisms of substance addictions.

Betel quid dependence mechanism and potential cessation therapy

BACKGROUND

Global reports estimate the number of betel quid (BQ) chewers up to 600 million. The proportion of betel quid dependence (BQD) is 20%-90% among current users. BQD mechanisms are not fully understood, and no pharmacological solution exists for its cessation therapy.

METHODS

We present a systematic review on BQD mechanisms and examine potential cessation therapeutic drugs. We conducted a systematic literature search in PubMed and Web of Science databases and identified the latest 10 years' relevant articles for reviews.

RESULTS

Functional magnetic resonance imaging results demonstrate that neurological mechanisms link the brain reward, cognitive, and impulsive systems in BQ or BQD users. The use of the areca nut increases both brain serotonin and noradrenaline levels, whereas arecoline, a potentially addictive areca nut component, has monoamine oxidase-A (MAO-A) inhibitor-like properties. MAO-A inhibitors prevent neurotransmitter breakdown and increase dopamine and serotonin concentrations in the brain. A reduction of daily BQ use was observed among patients with depression after antidepressant therapy, including MAO-A inhibitor and selective serotonin reuptake inhibitor (SSRI). Arecoline is a nicotinic acetylcholine receptor agonist expressed in Xenopus oocytes. However, relatively negligible amounts of nicotine are detected in the areca nut.

CONCLUSION

In conclusion, the current evidence provides a better understanding of the neurological and pharmacological mechanisms behind BQD. Arecoline, an MAO-A inhibitor, may account for BQD. Future translational studies are needed to verify the efficacy of potential BQD cessation drugs. MAO-A inhibitor and SSRI would thus be potentially promising targets for clinical trials.

Betel Nut Arecoline Induces Different Phases of Growth Arrest between Normal and Cancerous Prostate Cells through the Reactive Oxygen Species Pathway

Prostate cancer (PCa) is a reproductive system cancer in elderly men. We investigated the effects of betel nut arecoline on the growth of normal and cancerous prostate cells. Normal RWPE-1 prostate epithelial cells, androgen-independent PC-3 PCa cells, and androgen-dependent LNCaP PCa cells were used. Arecoline inhibited their growth in dose- and time-dependent manners. Arecoline caused RWPE-1 and PC-3 cell cycle arrest in the G2/M phase and LNCaP cell arrest in the G0/G1 phase. In RWPE-1 cells, arecoline increased the expression of cyclin-dependent kinase (CDK)-1, p21, and cyclins B1 and D3, decreased the expression of CDK2, and had no effects on CDK4 and cyclin D1 expression. In PC-3 cells, arecoline decreased CDK1, CDK2, CDK4, p21, p27, and cyclin D1 and D3 protein expression and increased cyclin B1 protein expression. In LNCaP cells, arecoline decreased CDK2, CDK4, and cyclin D1 expression; increased p21, p27, and cyclin D3 expression; had no effects on CDK1 and cyclin B1 expression. The antioxidant N-acetylcysteine blocked the arecoline-induced increase in reactive oxygen species production, decreased cell viability, altered the cell cycle, and changed the cell cycle regulatory protein levels. Thus, arecoline oxidant exerts differential effects on the cell cycle through modulations of regulatory proteins.

CYP26A1 Is a Novel Biomarker for Betel Quid-Related Oral and Pharyngeal Cancers

Betel quid (BQ) has been classified as a Group I human carcinogen in light of evidence demonstrating an association with an elevated risk of oral and pharyngeal cancers. To date, the incidence rate of oral and pharynx cancers among Taiwanese men ranks the highest worldwide. However, no study has yet confirmed variants of CYP26A1 was associated with the risks of oral and pharyngeal cancers. A case-control study was conducted (n = 339). CYP26A1 polymorphism was performed using SNP assay. Real-time qRT-PCR and Western blotting were used to determine the levels of CYP26A1 expression. The cancer cell model involved treatment with arecoline. Our findings showed that the downregulation of CYP26A1 mRNA and protein expression are more frequently observed in cancerous tissues than adjacent normal tissues in patients with oral and pharynx cancers (p < 0.01). We found that CYP26A1 was downregulated as the arecoline dose increased. We hypothesized that lower levels of CYP26A1 mRNA expression can be utilized a clinically biomarker causes oral and pharynx cancers. Arecoline appears to modulate CYP26A1 expression through specific pathways. Carriers of CYP26A1 SNP, rs2068888 (G/G)/rs4418728 (G/G) and who have lower levels of CYP26A1 expression are associated with an increased risk of oral and pharyngeal cancers.

Egr-1 mediates low-dose arecoline induced human oral mucosa fibroblast proliferation via transactivation of Wnt5a expression

Background

Arecoline is an alkaloid natural product found in the areca nut that can induce oral submucous fibrosis and subsequent development of cancer. However, numerous studies have shown that arecoline may inhibit fibroblast proliferation and prevent collagen synthesis.

Results

High doses of arecoline (> 32 μg/ml) could inhibit human oral fibroblast proliferation, while low doses of arecoline (< 16 μg/ml) could promote the proliferation of human oral fibroblasts. Wnt5a was found to be both sufficient and necessary for the promotion of fibroblast proliferation. Egr-1 could mediate the expression of Wnt5a in fibroblasts, while NF-κB, FOXO1, Smad2, and Smad3 did not. Treatment with siRNAs specific to Egr-1, Egr inhibitors, or Wnt5a antibody treatment could all inhibit arecoline-induced Wnt5a upregulation and fibroblast proliferation.

Conclusions

Egr-1 mediates the effect of low dose arecoline treatment on human oral mucosa fibroblast proliferation by transactivating the expression of Wnt5a. Therefore, Egr inhibitors and Wnt5a antibodies are potential therapies for treatment of oral submucosal fibrosis and oral cancer.

Prevalence of pain in oral cancer: A retrospective study

OBJECTIVE

This study aimed to estimate the prevalence of pain among treatment-naïve patients with oral cancer and to identify the clinical and histopathological characteristics of oral cancer associated with pain occurrence.

MATERIALS AND METHODS

A retrospective chart review was conducted of patients presenting with biopsy-proven oral cancer between January 2015 and December 2019. Variables, including demographic data, medical history, clinical presentation, and histopathological information, were extracted and analyzed. Appropriate descriptive and analytic statistics were computed.

RESULTS

Among 1,067 participants, 682(63.9%) were males. The prevalence of pain was 67.5%. It was found to be significantly associated with the duration of symptoms, history of betel or areca nut, squamous cell carcinoma, presence of disease in tongue, palate, and lips, lesion size, clinical nodal involvement, depth of invasion, TNM classification, limited mouth opening, bleeding, and restricted tongue mobility. Logistic regression analysis suggested that pain in oral cancer was positively associated with the occurrence of disease in the tongue and negatively with TNM stage I.

CONCLUSIONS

There is a high prevalence of pain among patients with oral cancer even before the initiation of any therapeutic intervention. Occurrence is significantly higher in patients with the presence of disease in the tongue and among those with TNM stage II or more.

Higher Trait Impulsivity and Altered Frontostriatal Connectivity in Betel-Quid Dependent Individuals

Objective: Betel quid dependency (BQD) is characterized by functional and structural brain alterations. Trait impulsivity may influence substance dependence by impacting its neurobiological underpinnings in the frontostriatal circuit. However, little is known about the trait impulsivity and its neural correlates in individuals with BQD.

Methods: Forty-eight participants with BQD and 22 normal controls (NCs) were recruited and scanned on a 3T MRI scanner. Barratt impulsiveness scale (BIS) was used to measure trait impulsivity: motor, attention, and no plan impulsivity. We used voxel-based morphometry (VBM) to assess the relationship between trait impulsivity and gray matter volumes. The relevant clusters identified were served as regions of interest (ROI) seeds. The whole-volume psycho-physiological interactions (PPI) analysis was used to investigate the changes of functional connectivity related to ROI seeds in the cue-reactivity task condition (BQ and control images).

Results: Behaviorally, the BQD group showed significantly higher trait impulsivity including motor and no plan impulsivity than the NCs group. VBM analyses showed that motor impulsivity was negatively associated with gray matter volume of right caudate in the whole sample. No difference in gray matter volume between the two groups was observed. PPI analyses showed that there was a significantly decreased functional connectivity between the right caudate and right dorsolateral prefrontal cortex (DLPFC) when watching BQ related images than control images in individuals with BQD. Furthermore, functional connectivity between the right caudate and right DLPFC was negatively correlated with BQ dependency scores.

Conclusions: Our study demonstrated the structural basis of trait impulsivity in the caudate and provided evidence for abnormal interactions within frontostriatal circuitsin individuals with BQD, which may provide insight into the selection of potential novel therapeutic targets for the treatment of BQ dependency.

Betel-Quid Chewing, Heart Failure, and Premature Ventricular Contractions in Patients with Cardiopulmonary Symptoms

Betel-quid (BQ) is a commonly used psychoactive substance that renders a specific cardiotoxicity. The purpose of this study was to investigate the association between BQ chewing and premature ventricular contractions (PVC) in patients with cardiopulmonary symptoms, and examine the potential influences of cardiovascular and chronic diseases on such relationship. Participants were 146 patients with cardiopulmonary symptoms who participated in 24-h Holter electrocardiogram monitoring during 2012–2018 in a hospital serving residents that lived in a BQ high prevalence area. Data on substance uses and medical histories for cardiovascular and chronic diseases were collected. Baron–Kenny method was employed to evaluate possible mediation. In patients with cardiopulmonary symptoms, 36.3% were BQ users and 63.7% were nonusers. Adjusting for covariates, BQ chewing was significantly associated with heart failure and diabetes mellitus (adjusted odds ratio (aOR) = 3.4 and 2.3, respectively), but only heart failure was significantly correlated with a low and high level of PVC. Additionally controlling for the effect of heart failure, the risk of high PVC for BQ users reduced from 3.60 to 2.88; however, the risk for BQ chewers remained significant (95% CI: 1.06–7.84). Heart failure was found to explain 27.7% of the excessive effect of BQ use on high PVC. In conclusion, BQ use is directly associated with an elevated risk of high PVC in patients with cardiopulmonary symptoms. The higher risk might be elevated among patients who suffered heart failure. Given several research limitations, the findings from this study offer future opportunities for validation.

Pharmacology of Herbal Sexual Enhancers: A Review of Psychiatric and Neurological Adverse Effects

Sexual enhancers increase sexual potency, sexual pleasure, or libido. Substances increasing libido alter the concentrations of specific neurotransmitters or sex hormones in the central nervous system. Interestingly, the same pathways are involved in the mechanisms underlying many psychiatric and neurological disorders, and adverse reactions associated with the use of aphrodisiacs are strongly expected. However, sexual enhancers of plant origin have gained popularity over recent years, as natural substances are often regarded as a safer alternative to modern medications and are easily acquired without prescription. We reviewed the psychiatric and neurological adverse effects associated with the consumption of herbal aphrodisiacs Areca catechu L., Argemone Mexicana L., Citrus aurantium L., Eurycoma longifolia Jack., Lepidium meyenii Walp., Mitragyna speciosa Korth., Panax ginseng C. A. Mey, Panax quinquefolius L., Pausinystalia johimbe (K. Schum.) Pierre ex Beille, Piper methysticum G. Forst., Ptychopetalum olacoides Benth., Sceletium tortuosum (L.) N. E. Brown, Turnera diffusa Willd. ex. Schult., Voacanga africana Stapf ex Scott-Elliot, and Withania somnifera (L.) Dunal. A literature search was conducted on the PubMed, Scopus, and Web of Science databases with the aim of identifying all the relevant articles published on the issue up to June 2020. Most of the selected sexual enhancers appeared to be safe at therapeutic doses, although mild to severe adverse effects may occur in cases of overdosing or self-medication with unstandardized products. Drug interactions are more concerning, considering that herbal aphrodisiacs are likely used together with other plant extracts and/or pharmaceuticals. However, few data are available on the side effects of several plants included in this review, and more clinical studies with controlled administrations should be conducted to address this issue.

Betel Quid Health Risks of Insulin Resistance Diseases in Poor Young South Asian Native and Immigrant Populations

Betel quid, traditionally prepared with areca nut, betel leaf, and slaked lime, has been consumed for thousands of years, mainly in the form of chewing. Originally used for cultural, medicinal, and ceremonial purposes mainly in South Asian countries, its use has recently spread across the globe due to its psychoactive, euphoric, and aphrodisiac properties. Now it is widely used as a social lubricant and source of financial profit. Unfortunately, the profit motive has led to high rates of habitual consumption with eventual conversion to addiction among young girls and boys. Moreover, the worrisome practice of including tobacco in quid preparations has grown, particularly among pregnant women. Major health concerns include increased rates of malignancy, oral pathology, and cardiovascular, hepatic, fertility, metabolic, and neuropsychiatric disorders. Metabolic disorders and insulin resistance disease states such as type 2 diabetes, obesity, and metabolic syndrome contribute to cognitive decline and neurodegeneration. Mechanistically, the constituents of areca nut/betel quid are metabolized to N-nitroso compounds, i.e., nitrosamines, which are carcinogenic at high doses and cause insulin resistance following chronic low-level exposures. From an epidemiological perspective, the rising tide of insulin resistance diseases including obesity, diabetes, and dementias that now disproportionately burden poor countries has been propagated by rapid commercialization and enhanced access to betel quid. Public health measures are needed to impose socially and ethically responsible barriers to yet another cause of global health disparity.

An Instagram-Based Study to Understand Betel Nut Use Culture in Micronesia: Exploratory Content Analysis

BACKGROUND

A 2012 World Health Organization report recognizes betel nut use as an urgent public health threat faced by the Western Pacific region. However, compared with other addictive substances, little is known about how betel nuts are depicted on social media platforms. In particular, image-based social media platforms can be powerful tools for health communication. Studying the content of substance use on visual social media may provide valuable insights into public health interventions.

OBJECTIVE

This study aimed to explore and document the ways that betel nut is portrayed on the photo-sharing site Instagram. The analysis focuses on the hashtag #pugua, which refers to the local term for betel nut in Guam and other parts of Micronesia.

METHODS

An exploratory content analysis of 242 Instagram posts tagged #pugua was conducted based on previous research on substance use and Instagram and betel nut practices in Micronesia. In addition, the study examined the social engagement of betel nut content on the image-based platform.

RESULTS

The study findings revealed content themes referencing the betel nut or betel nut tree, betel nut preparation practices, and the unique social and cultural context surrounding betel nut activity in Guam and Micronesia. In addition, certain practices and cultural themes encouraged social engagement on Instagram.

CONCLUSIONS

The findings from this study emphasize the cultural relevance of betel nut use in Micronesia. These findings provide a basis for empirically testing hypotheses related to the etiological roles of cultural identity and pride in shaping betel nut use behavior among Micronesians, particularly youths and young adults. Such research is likely to inform the development of culturally relevant betel nut prevention and cessation programs.

Metformin protects against mouse oocyte apoptosis defects induced by arecoline

OBJECTIVES

Arecoline is the main bioactive substance extracted from Areca catechu L, which has cell, neural and genetic toxicity. The function of arecoline in reproductive system has not been well explored.

MATERIALS AND METHODS

To investigate the toxic effects of arecoline on oocyte development, immunofluorescence staining, qPCR, Western blotting, sperm binding assays and in vitro fertilization were performed to evaluate oocyte meiosis competence and embryo development.

RESULTS

Our data revealed that arecoline exposure disrupts actin filament dynamics, spindle assembly and kinetochore-microtubule attachment stability in mouse oocytes, leading to aneuploidy and oocyte meiosis arrest. In addition, arecoline treatment disturbs the distribution of mitochondria, reduces ATP production and increases the level of oxidative stress, which ultimately induces oocyte apoptosis. Supplementation with metformin, a medicine for type 2 diabetes in the clinic, partially alleviates these damages.

CONCLUSIONS

Metformin has a protective effect on arecoline-induced mouse oocytes apoptosis.

Testing for Betel Nut Alkaloids in Hair of Papuans Abusers using UPLC-MS/MS and UPLC-Q-Tof-MS

Betel nut is the fruit of Areca palm, growing in Papua New Guinea. Mixed with limestone and stick mustard, arecoline and guvacoline, which are present in betel nut, are hydrolyzed into arecaidine and guvacine, respectively. As part of the study on dietary habits of Papuans residents, our laboratory was asked to analyze the four alkaloids in hair to document long-term exposure. Hair samples were collected from 19 adult subjects (males = 11; females = 8), by some of the authors, and were sent to the laboratory for analysis. The four alkaloids have very similar chemical structures. In order to accurately identify the drugs, two methods were developed. First, the compounds were identified using an ultra-high-performance liquid chromatography system coupled to time-of-flight mass spectrometry. Then, they were quantified by an ultra-high-performance liquid chromatography system coupled to tandem mass spectrometry. After decontamination with dichloromethane, hair samples were cut into very small segments and 20 mg were incubated in methanol for 2 h 30 min in an ultrasound bath. After cooling, the methanol was evaporated to dryness in presence of 20-μL octanol to prevent volatilization. Nicotine-d4 was used as an internal standard. Linearity was observed for concentrations ranging from the limit of quantification to 20 ng/mg for arecoline, arecaidine, guvacine and guvacoline. Measured concentrations were in the range 60 pg/mg to 18 ng/mg for arecoline (n = 19), 14 pg/mg to 2.5 ng/mg for guvacoline (n = 11), 63 pg/mg to 3.8 ng/mg for arecaidine (n = 11) and 100 pg/mg to 3.2 ng/mg for guvacine (n = 6). There was no correlation between concentrations of arecoline and arecaidine (ratio from 0.01 to 0.18) and guvacoline and guvacine (ratio from 0.06 to 3.50). However, the identification of these substances in hair is a good marker of consumption of betel nut and allows us to document a local practice that remains difficult to evaluate just by questioning.

A Study on Redox Potential of Phytochemicals and their Impact on DNA

The phytochemicals are endowed with antioxidant activities because of the presence of plentiful polyphenols and many other phytochemicals. However, some recent reports have suggested that phytochemicals from certain plant species exhibit DNA damaging properties mainly due to presence of alkaloids. In the present study, pBR322, Salmonella typhi DNA, insect DNA and human DNA were treated with hexanolic extract of Argemone mexicana and Thevesia peruviana leaves to assess their DNA damaging abilities. Another set of experiments was carried out using the methanolic extracts of Citrus lemon leaves to assess their DNA protecting abilities from damage of DNA by extracts of A. mexicana and T. peruviana at 150000 ppm for all DNAs used. The results indicated that the leaves extract of A. mexicanaand T. peruviana demonstrated significant DNA damaging potential at higher concentrations. In contrast, the extracts from C. limonat 15000 ppm showed maximum DNA protective properties for all DNAs used.

Arecoline inhibits pineal-testis function in experimentally induced hypothyroid rats

Arecoline is known to cause endocrine dysfunction. In the current article role of arecoline on pineal-testis activity was investigated in hypothyroid rats induced by propylthiouracil (PTU). PTU treatment caused thyroid dysfunction ultrastructurally with a fall in T₃ and T₄ levels followed by a rise of thyroid stimulating hormone (TSH) level. Pineal activity was impaired by PTU treatment, as evident from degenerated synaptic ribbons and mitochondria of the pinealocytes with depletion of pineal and serum N-acetyl serotonin and melatonin levels. Leydig cell function was suppressed, evident from reduced smooth endoplasmic reticulum and depletion of testosterone level. Sex accessories function was impaired by showing scanty rough endoplasmic reticulum with depletion of fructose and sialic acid levels. Arecoline treatment that caused pineal dysfunction and testicular stimulation in control rats, suppressed both pineal and testis functions after PTU treatment. The findings suggest that arecoline inhibits pineal-testis function in experimentally induced hypothyroid rats.

Betel Nut Use in Vanuatu: Investigating Opportunities to Reduce Harms to Health

Background: Betel nut chewing is a public health concern in the Asia-Pacific region and is an emerging issue in Vanuatu. Despite the significant health risks associated with betel nut chewing, few interventions have been undertaken to reduce its harm. Objectives: To investigate betel nut use in Vanuatu and to identify opportunities to reduce its harm and possible interventions, framing the responses using the World Health Organization's MPOWER tobacco control model. Method: Qualitative research design, in the form of semi-structured interviews with ten participants with expertise in health, agriculture, education or non-communicable disease in Port Vila, Vanuatu during June 2017. Recorded interviews were transcribed verbatim, and a general inductive approach was used to identify key themes. Results: Participants reported a recent increase in betel nut use in Vanuatu due to the influence from Papua New Guinea and the Solomon Islands. To reduce the harm of betel nut use in Vanuatu, participants suggested policies and strategies that aligned with the MPOWER framework that could be adopted for betel nut control, including restricting cultivation and sale of betel nut in Vanuatu and using radio and existing community networks to reach people with messages about the dangers of betel nut use. Conclusion: Betel nut use may be growing in popularity in Vanuatu, where there are potential policy options to minimize harm. The MPOWER model for tobacco control may be a useful framework to help the Vanuatu government to deliver a comprehensive approach to reducing harm from betel nut use.

Investigating Betel Nut Use, Antecedents and Consequences: A Review of Literature

Background: Betel nut use is a public health issue in the Asia-Pacific region that is often neglected. To control betel nut use, understanding of the adverse effects of betel nut use and evidence-based policies and strategies is necessary. Objectives: This narrative review aims to characterize the current situation on betel nut use at a global level regarding the epidemiology, pharmacology and toxicology, health effects, treatment options, policies and strategies. Methods: We found 139 existing literature published between 1970-2019 on the Web of Science database and other technical documents to collate the most relevant information on betel nut use. Data were categorized into appropriate themes. Results: The literature demonstrates that there is a lack of up to date statistics on betel nut use. There is limited research on the effect of policies and strategies to control betel nut use. Conclusion: Betel nut-chewing countries should focus on understanding which populations chew betel nut and implement appropriate policies, educational and cessation programs to help control betel nut use.