Betel quid chewing in rural Bangladesh: prevalence, predictors and relationship to blood pressure

Maternal betel quid use during pregnancy and child growth: a cohort study from rural Bangladesh

BACKGROUND

Chewing betel quid (BQ) - a preparation commonly containing areca nut and slaked lime wrapped in betel leaf - is entrenched in South Asia. Although BQ consumption during pregnancy has been linked to adverse birth outcomes, its effect on postnatal growth remains largely unexplored.

OBJECTIVE

We examined the associations of BQ use during pregnancy with children's height-for-age and body mass index-for-age z-scores (HAZ and BAZ, respectively) and fat and fat-free mass along with sex-based differences in association in rural Bangladesh.

METHODS

With a prospective cohort design, we assessed BQ use among mothers enrolled in the Preterm and Stillbirth Study, Matlab (n = 3140) with a structured questionnaire around early third trimester. Children born to a subset of 614 women (including 134 daily users) were invited to follow-up between October 2021 and January 2022. HAZ and BAZ were calculated from anthropometric assessment, and fat and fat-free mass were estimated using bioelectric impedance. Overall and sex-specific multiple linear regression models were fitted.

RESULTS

Growth data were available for 501 children (mean age 4.9 years): 43.3% of them were born to non-users, 35.3% to those using prior to or less-than-daily during the survey, and 21.3% to daily users. No statistically significant associations were observed after adjusting for sex, parity, maternal height and education, and household wealth.

CONCLUSIONS

There was no effect of BQ use during pregnancy on postnatal growth in this study. Longitudinal studies following up those born to heavy users beyond childhood are warranted for capturing long-term implications of prenatal BQ exposure.

Association between habitual betel quid chewing and risk of adverse cardiovascular outcomes: A systematic review

INTRODUCTION

Habitual betel quid chewing, a tobacco product, is a leading cause of oral cancer in Asia-Pacific countries where this practice is most prevalent. However, it is not well understood whether betel quid chewing is also a cause of adverse cardiovascular outcomes. To address this gap, we conducted a systematic literature review of peer-reviewed published studies evaluating the association between habitual betel quid use on the risk of adverse cardiovascular outcomes.

METHODS

We searched PubMed for studies assessing the correlation between betel quid chewing and cardiovascular health. We included studies if (i) they included human subjects; (ii) were peer-reviewed articles in indexed journals; and (iii) were in English. We extracted data from eligible studies and stratified them by geographical location, study designs and cardiovascular outcomes. Finally, we did a narrative synthesis of the data to identify adverse cardiovascular outcomes associated with chronic betel quid use.

FINDINGS

We reviewed data from 19 studies that met the inclusion criteria. Habitual betel quid chewing was associated with hypertension, atherosclerosis, inflammation and ischaemic heart disease. In addition, betel quid use was a risk factor for arrhythmias. Interestingly, betel quid use was an independent risk factor for cardiovascular disease in women. Long-term betel quid consumption was associated with higher risks for all-cause mortality and increased overall cardiovascular risk.

CONCLUSIONS

Habitual betel quid chewing is an important cardiovascular risk factor in populations where the practice is prevalent.

Enhanced Knowledge Inversed Attitude of Oral Cancer Risk Habit Associated With Sociocultural: A Quantitative and Qualitative Pilot Study

Aim

In 2023, the global incidence of oral cancer reached 54,540 new cases, with risk factors including smoking (S), alcohol consumption (A), and betel quid chewing (BQC). The knowledge and attitudes about these risk factors impact this practice, particularly in communities that follow local traditions. The aim of this study was to determine the level of knowledge and attitude regarding risk factors for oral cancer on Flores Island, East Indonesia.

Materials and Methods

This was an analytical observational study with a cross-sectional design using quantitative and qualitative approaches. Structured questionnaires and focus group discussions (FGDs) were conducted with the community, local government, and dentists to obtain data; quantitative analysis was performed using regression; and qualitative analysis was performed using themes.

Results

Of 542 participants (men 66.42 %; women 33.57 %), 64.4% had a high level of knowledge and a low level of attitude for S = 62.5%, A = 66.7%, and BQC = 50.0%. There was a correlation between knowledge and attitudes about S (P = 0.009) and BQC (P = 0.011). The FGDs yielded 14 subjects (five men and nine women) with three themes of knowledge (betel nut ingredients, causes of cancer, and impacts of habits) and three themes of attitude (type of habit, desire to stop, and oral cancer prevention programs). On the basis of FGDs, most of the subjects already knew the causes of oral cancer, but the desire to stop and prevent oral cancer was difficult.

Conclusion

The population on Flores Island has a high level of knowledge but a low level of attitude. Nevertheless, it is difficult to minimize or eliminate oral cancer-risk behaviors due to their cultural and socioeconomic conditions.

Betel quid use is associated with anemia among both men and women in Matlab, Bangladesh

Anemia accounts for 8.8% of total disability burden worldwide. Betel quid use among pregnant women has been found to increase anemia risk. Betel quid is prepared by wrapping the betel (or areca) nut, with spices and other additions, in betel or tobacco leaf and it is chewed or placed in the mouth. We explored the association between betel quid use and anemia among men and non-pregnant women. We collected data from a random sample of women and their husbands in Matlab, Bangladesh. Participants reported their current betel quid use and individual characteristics. We assessed hemoglobin (a biomarker of anemia) with a hemoglobinometer and soluble transferrin receptor (a biomarker of iron deficiency) and C-reactive protein (a biomarker of inflammation) in dried blood spots via enzyme immunoassay. We estimated logistic regression models to evaluate the association between betel quid use and anemia and structural equation models (SEM) to evaluate mediating roles of iron deficiency and elevated inflammation. A total of 1133 participants (390 men and 743 non-pregnant women) were included. After controlling for important confounders, any betel quid use was positively associated with anemia among men (OR: 1.80; 95% CI: 1.12, 2.89). Among women, betel quid use was associated with anemia only among the most frequent users (OR: 1.62; 95% CI: 1.03, 2.53). SEM did not reveal indirect paths through inflammation or iron deficiency. Betel quid use may contribute to the burden of anemia among adults in Bangladesh. Our findings suggest the burden of disease attributed to betel quid use has been underestimated.

Systemic and Local Effects Among Patients With Betel Quid-Related Oral Cancer

The major predisposing factors of developing oral cancer include smoking, alcohol drinking, and betel quid chewing. Betel quid chewing could cause the abrasion and damage of oral mucosa by crude fibers, chemical insults by additive slaked lime, and arecoline from areca nut. These would lead to the local consequence of oral submucosal fibrosis, which is regarded clinically as a precancer lesion and a major cause of trismus. In addition, the components and additives in betel quid contain chemical toxins and carcinogens, which would further affect the oral mucosa and gradually develop a malignancy. Following literature review, aside from having a greater total tumor burden and more local diseases in the oral cavity and digestive tract, patients with betel quid-related oral cancer also have more systemic diseases from metabolic syndrome, hypertension, cardiovascular disease, type II diabetes mellitus, and obesity than those without this habit. In conclusion, those patients who have the history of smoking, alcohol drinking, and betel quid chewing would present much more unique clinical characteristics than those who only have a history of smoking and alcohol drinking. More attention should therefore be paid to pretreatment evaluation, treatment strategy, and posttreatment follow-up among betel quid chewers.

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 quid chewing and its prevalence and determinants: data from Myanmar Demographic Health and Survey of 2015-2016

BACKGROUND

Although betel quid chewing with tobacco use is one of the major behavioral risk factors for chronic diseases, the prevalence is rather on the increase in Myanmar. This study determined prevalence of betel quid chewing at the national and subnational levels and its associations with tobacco and sociodemographic factors.

METHODS

This study is a secondary data analysis of Myanmar demographic health survey 2015-2016 with a total of 11 773 women and 4251 men aged 18-49 years. Chi-square tests and multivariable logistic regression tests were performed.

RESULTS

Prevalence of betel quid chewing was 61.8% in men and 19.5% in women and by regions it ranged from 34 to 82.2% and from 5-8 to 52.9%, respectively. The prevalence of the concurrent use with tobacco was 25.8 and 2.3%, respectively. Women with older age, low education and low wealth and occupation and living with spouse were associated with betel quid chewing, while low education, living with spouse and Myanmar speaker were associated with men. Tobacco use was inversely and positively associated with betel quid chewing in men and women, respectively (P-interaction <0.0001).

CONCLUSION

Implementation of culturally sensitive intervention and policies including effective community awareness campaigns for anti-betel quid chewing is strongly recommended in Myanmar.

Mapping white matter structural and network alterations in betel quid-dependent chewers using high angular resolution diffusion imaging

BACKGROUND

To evaluate brain white matter diffusion characteristics and anatomical network alterations in betel quid dependence (BQD) chewers using high angular resolution diffusion imaging (HARDI).

METHODS

The current study recruited 53 BQD chewers and 37 healthy controls (HC) in two groups. We explored regional diffusion metrics alternations in the BQD group compared with the HC group using automated fiber quantification (AFQ). We further employed the white matter (WM) anatomical network of HARDI to explore connectivity alterations in BQD chewers using graph theory.

RESULTS

BQD chewers presented significantly lower FA values in the left and right cingulum cingulate, the left and right thalamic radiation, and the right uncinate. The BQD has a significantly higher RD value in the right uncinate fasciculus than the HC group. At the global WM anatomical network level, global network efficiency (p = 0.008) was poorer and Lp (p = 0.016) was greater in the BQD group. At the nodal WM anatomical network level, nodal efficiency (p < 0.05) was lower in the BQD group.

CONCLUSION

Our findings provide novel morphometric evidence that brain structural changes in BQD are characterized by white matter diffusivity and anatomical network connectivity among regions of the brain, potentially leading to the enhanced reward system and impaired inhibitory control.

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.

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.

Social and behavioural determinants of areca nut consumption in adolescents

OBJECTIVE

This study aimed to investigate the prevalence of areca nut consumption and to identify social and behavioural determinants among a Taiwanese adolescent population.

SUBJECTS AND METHODS

A random sample of 5,343 high school students aged between 15-18 years in Kaohsiung, Taiwan, participated in the study. Participants underwent a clinical dental examination and completed a self-administered questionnaire. Data analyses were performed using multivariate logistic regression to establish a relationship between areca nut consumption as well as social and behavioural characteristics.

RESULTS

The prevalence of areca nut consumption was 3.0%. The chewing habit was more prevalent among older adolescents (p < .001, OR = 1.50, 95% CI: 1.26, 1.78), males (p < .001, OR = 17.91, 95% CI: 8.57, 37.40), pupils living with non-birth parent(s) (p = .003, OR = 2.13, 95% CI: 1.29, 3.50), children of family heads with primary (p = .001, OR = 2.90, 95% CI: 1.50, 5.59) or secondary level of education (p < .001, OR = 2.78, 95% CI: 1.74, 4.46), frequent risk takers (p < .001, OR = 1.35, 95% CI: 1.27, 1.43) and students of low physical fitness (p < .001, OR = 3.65, 95% CI: 1.81, 7.35).

CONCLUSIONS

Areca nut consumption has become an ongoing pertinent issue in adolescent health. Future investigations into neurocognitive influences of risk-taking behaviour on areca nut consumption and social dependence of the habit are indicated.

Oral submucous fibrosis: a contemporary narrative review with a proposed inter-professional approach for an early diagnosis and clinical management

Oral Submucous fibrosis (OSMF) has traditionally been described as "a chronic, insidious, scarring disease of the oral cavity, often with involvement of the pharynx and the upper esophagus". Millions of individuals are affected, especially in South and South East Asian countries. The main risk factor is areca nut chewing. Due to its high morbidity and high malignant transformation rate, constant efforts have been made to develop effective management. Despite this, there have been no significant improvements in prognosis for decades. This expert opinion paper updates the literature and provides a critique of diagnostic and therapeutic pitfalls common in developing countries and of deficiencies in management. An inter-professional model is proposed to avoid these pitfalls and to reduce these deficiencies.

Prevalence and Correlates of Betel Quid Chewing among Bhutanese Adults

Background: Chewing of betel quid, popularly known as doma khamdo, is prevalent in Bhutan and is associated with Bhutanese customs and traditions. The objective of this paper was to determine the prevalence and explore the correlates of current betel quid use in Bhutan. Materials and methods: This is a retrospective study of secondary data from the National Health Survey 2012 (NHS 2012) of Bhutan. The outcome variable of interest was current betel quid use. The self-reported demographic characteristics were obtained using a questionnaire developed following the WHO STEPwise approach to the surveillance of non-communicable diseases (STEP). Univariate and multivariate logistic regression were performed to identify correlates for betel quid use. Results: The prevalence of current betel quid use in this study was 45.0%. The correlates associated with current betel quid use were: being female; having a primary, high school or a monastic education; being professionals in the armed forces, managers, technicians, service and sales workers, and machine operators; being current smokers; alcohol consumption; and intake of drugs. Correlates associated with decreased betel quid use were: having a diploma/certificate-level and non-formal education, and living in urban areas. Conclusion: The findings indicate that betel quid was consumed by nearly half of the Bhutanese population. Bhutan should immediately initiate national prevention programs targeting these correlates of betel quid use.

Oral epithelial dysplasia: Causes, quantification, prognosis, and management challenges

Oral epithelial dysplasia is a spectrum of architectural and cytological epithelial changes caused by accumulation of genetic changes, and is associated with an increased risk of progression to squamous cell carcinoma. It is a microscopic diagnosis of immense clinical importance. The initial reports of oral potentially malignant disorders with oral epithelial dysplasia transforming to oral cancer helped in understanding the nature of oral malignancies. Since then, clinical studies on oral potentially malignant disorders have combined microscopic findings of oral epithelial dysplasia to assess the malignant transformation potential of different grades of epithelial dysplasia. A significant amount of scientific literature has amassed on oral epithelial dysplasia relating to aspects of its diagnosis and management. However, the evidence base is weak as a result of the significant variability of published research. Poorly described study methods, variability in different oral epithelial dysplasia grading systems, inter- and intra-examiner variability causing issues of reliability, inadequate sample size, and inconsistent durations of follow-up are some of the methodological issues contributing to the failure to provide dependable information. Randomized clinical trials on the malignant transformation potential of oral epithelial dysplasia and its treatment outcomes are limited. This comprehensive literature review on oral epithelial dysplasia summarizes the scientific knowledge published in the scientific literature in English since its first description. The historical development, etiological factors, grading systems, diagnostic criteria, assessment of risk factors and prevention of malignant transformation, management principles of different grades of oral epithelial dysplasia (surgical and nonsurgical), recommendations on follow-up, and prognostic indicators are discussed in detail.

Smokeless tobacco and public health in Bangladesh

Despite the high prevalence of smokeless tobacco (SLT) use among adults in Bangladesh, SLT was not included in the Tobacco Control Law till 2013. Information on SLT use among Bangladeshi people is inadequate for policymaking and implementing effective control measures. With the aim to identify the prevalence and trends of different SLT products, health and economic impacts, manufacture, and sale of and policies related to SLT in Bangladesh, we carried out a literature review, which involved literature search, data extraction, and synthesis. Evidence suggests that in Bangladesh, SLTs range from unprocessed to processed or manufactured products including Sada Pata, Zarda, Gul, and Khoinee. Over 27% of Bangladeshi adults aged 15 years and older use SLT in one form or other. SLT use is associated with age, sex, education, and socioeconomic status. SLT consumption has reportedly been associated with increased prevalence of heart diseases, stroke, and oral cancer and led to around 320,000 disability adjusted life years lost in Bangladesh in 2010. No cessation service is available for SLT users in public facilities. Compared to cigarettes, taxation on SLT remains low in Bangladesh. The amendment made in Tobacco Control Law in 2013 requires graphic health warnings to cover 50% of SLT packaging, ban on advertisement of SLT products, and restriction to sale to minors. However, implementation of the law is weak. As the use of SLT is culturally accepted in Bangladesh, culturally appropriate public awareness program is required to curb SLT use along with increased tax and cessation services.

Differences in prevalence and determinants of hypertension according to rural-urban place of residence among adults in Bangladesh

This cross-sectional study analysed Bangladesh Demographic and Health Survey 2011 data with the aim of investigating the prevalence of, and risk factors for, hypertension in individuals aged over 35 by rural-urban place of residence. After estimation of the stratified prevalence of hypertension by background characteristics, multivariable logistic regression analysis was conducted to calculate the adjusted odds (AORs) and 95% confidence intervals (CIs) for selected factors. Of the 7839 participants, 1830 were from urban areas and 6009 from rural areas. The overall prevalence of hypertension was 32.6% (95% CI: 30.5-34.8) in urban areas and 23.6% (95% CI: 22.5-24.7) in rural areas. The prevalence and odds of hypertension increased with increasing age, female sex, concomitant diabetes and overweight/obesity and richer wealth status in both urban and rural regions. Although residence in Khulna and Rangpur divisions and higher education level were associated with increased odds of hypertension in urban regions, this was not the case in rural regions (p>0.05). Residence in Sylhet and Chittagong divisions had lower odds of hypertension in rural regions. Furthermore, the proportions of overweight/obese, diabetic and higher wealth status participants were higher in urban than in rural regions. The prevalence and odds of hypertension were found to be associated with several common factors after stratifying by place of residence. Some of these factors are more concentrated in urban regions, so urban residents with these risk factors need to be made more aware of these in order to control hypertension in Bangladesh. Public health programmes also need to be tailored differently for urban and rural regions, based on the different distribution of these significant factors in the two areas.

Associations Between Unhealthy Lifestyle Behaviors and Metabolic Syndrome by Gender in Young Adults

OBJECTIVE

Unhealthy lifestyle behaviors, such as smoking, drinking, betel-quid chewing, insufficient exercise, and inadequate sleep are significantly correlated with metabolic syndrome (MetS). To further understand this relationship, this study examined the main effect of unhealthy lifestyle behaviors and their interaction on MetS by gender in young adults.

METHOD

A cross-sectional study involving 694 young adults from a national survey was performed in which demographic characteristics, unhealthy lifestyle behaviors, anthropometric measurements, and blood chemistry panels were collected during face-to-face interviews.

RESULTS

The prevalence of MetS among young adults was 17.4% and was greater in males than females (19.0% vs. 7.8%). The unhealthy lifestyle-behavior risk factors associated with MetS included smoking (odds ratio [ OR] = 4.53) and physical activity ( OR = 0.51) among males and betel-quid chewing ( OR = 8.90) and less sleep ( OR = 0.08) among females. Significant interaction effects were observed between the abovementioned behaviors and gender for the risk of developing MetS.

CONCLUSION

These results can guide health-care providers in reducing MetS risk by encouraging young adult males to reduce or quit cigarette smoking and maintain optimum levels of physical activity and young adult females to quit chewing betel quid and obtain appropriate amounts of sleep.

Effect on blood pressure and eye health symptoms in a climate-financed randomized cookstove intervention study in rural India

BACKGROUND

Air pollution from cooking with solid fuels is a potentially modifiable risk factor for increased blood pressure and may lead to eye irritation.

OBJECTIVES

To evaluate whether a climate motivated cookstove intervention reduced blood pressure and eye irritation symptoms in Indian women.

METHODS

Households using traditional stoves were randomized to receive a rocket stove or continue using traditional stoves. Systolic (SBP) and diastolic blood pressure (DBP), and self-reported eye symptoms were measured twice, pre-intervention and at least 124 days post-intervention in women > 25 years old in control (N = 111) and intervention (N = 111) groups in rural Karnataka, India. Daily (24-h) fine particle (PM_2.5) mass and absorbance (Abs) were measured in cooking areas at each visit. Mixed-effect models were used to estimate before-and-after differences in SBP, DBP and eye symptoms.

RESULTS

We observed a lower SBP (-2.0 (-4.5, 0.5) mmHg) and DBP (-1.1 (-2.9, 0.6) mmHg) among exclusive users of intervention stove, although confidence intervals included zero. Stacking or mixed use of intervention and traditional stoves contributed to a small increase in SBP 2.6 (-0.4, 5.7) mmHg) and DBP (1.2 (-0.9, 3.3) mmHg). Exclusive and mixed stove users experienced higher post-intervention reductions, on average, in self-reported eye irritation symptoms for burning sensation in eyes, and eyes look red often compared to control. Median air pollutant concentrations increased post-intervention in all stove groups, with the lowest median PM_2.5 increase in the exclusive intervention stove group.

CONCLUSIONS

Health benefits were limited due to stacking and lower-than-predicted efficiency of the intervention stove in the field. Stove adoption and use behavior, in addition to stove technology, affects achievement of health co-benefits. Carbon-financing schemes need to align with international guidelines that have been set based on health outcomes to maximize health co-benefits from cookstove interventions.

Epidemiologic studies targeting primary cardiovascular disease prevention in South Asia

South Asia has experienced a 73% increase in healthy life years lost due to ischemic heart disease between 1990 and 2010. There is a lack of quality data relating to cardiovascular risk factors and disease from this region. Several observational and prospective cohorts in South Asia have been established in recent times to evaluate the burden of cardiovascular disease and their risk factors. The Prospective Rural Urban Epidemiology (PURE) study is the largest of these studies that has provided data on social, environmental, behavioral and biologic risk factors that influence heart disease and diabetes. Some studies have also borrowed data from large datasets to provide meaningful insights. These studies have allowed a better understanding of cardiovascular disease risk factors indigenous to the South Asian population along with conventional risk factors. Culturally sensitive interventions geared towards treating risk factors identified in these studies are needed to fully realize the true potential of these epidemiologic studies.

Patient pathways and perceptions of hypertension treatment, management, and control in rural Bangladesh: a qualitative study

PURPOSE

Hypertension is an increasing threat to global public health, a leading cause of premature death, and an important modifiable risk factor for cardiovascular and cerebrovascular disease. Despite evidence on the efficacy of antihypertensive medication for blood-pressure control and mortality prevention, a large proportion of individuals are undiagnosed and untreated, especially in resource-constrained settings. This qualitative study explored patient pathways to care, as well as knowledge of and adherence to hypertension care.

METHODS

We conducted in-depth interviews with 20 hypertensive patients in two rural districts in Bangladesh. Interviews were conducted and transcribed in Bangla and translated to English. QSR NVivo 10 software was used for analyses. We mapped patient pathways and report here on patient experiences accessing care from local pharmacies, the government, and private clinics.

RESULTS

Overall, most patients reported hypertension awareness prior to diagnosis and were conscious about consequences of hypertension. However, patients had little knowledge about prevention and treatment strategies. Most patients considered hypertension an important disease, albeit reporting taking medication only when symptomatic. Patients were aware of dietary advice; however, they were largely sedentary. Qualified doctors in both private and government settings diagnosed hypertension in the majority of the patients, and some were diagnosed by an informal provider and a few reported self-care at home. Patients followed three pathways: specialized hospitals for acute care, private hospitals/local pharmacy for nonacute symptoms, and incidental hypertension identification while being treated for another condition.

CONCLUSION

We identify barriers to access to hypertension prevention and care that prevented patients from seeking and receiving treatment from government facilities. Challenges included a lack of support to enable community screening by government health workers, long waiting times, and inadequate supplies for hypertension treatment. Expanding community-health workers' scope in the dissemination of chronic-disease information may improve patient pathways to hypertension care in rural communities in Bangladesh.

Areca Nut Chewing and the Risk of Re-hospitalization and Mortality Among Patients With Acute Coronary Syndrome in Pakistan

Objectives

Areca nut is widely consumed in many parts of the world, especially in South and Southeast Asia, where cardiovascular disease (CVD) is also a huge burden. Among the forms of CVD, acute coronary syndrome (ACS) is a major cause of mortality and morbidity. Research has shown areca nut chewing to be associated with diabetes, hypertension, oropharyngeal and esophageal cancers, and CVD, but little is known about mortality and re-hospitalization secondary to ACS among areca nut users and non-users.

Methods

A prospective cohort was studied to quantify the effect of areca nut chewing on patients with newly diagnosed ACS by categorizing the study population into exposed and non-exposed groups according to baseline chewing status. Cox proportional hazards models were used to examine the associations of areca nut chewing with the risk of re-hospitalization and 30-day mortality secondary to ACS.

Results

Of the 384 ACS patients, 49.5% (n=190) were areca users. During 1-month of follow-up, 20.3% (n=78) deaths and 25.1% (n=96) re-hospitalizations occurred. A higher risk of re-hospitalization was found (adjusted hazard ratio [aHR], 2.05; 95% confidence interval [CI], 1.29 to 3.27; p=0.002) in areca users than in non-users. Moreover, patients with severe disease were at a significantly higher risk of 30-day mortality (aHR, 2.77; 95% CI, 1.67 to 4.59; p<0.001) and re-hospitalization (aHR, 2.72; 95% CI, 1.73 to 4.26; p<0.001).

Conclusions

The 30-day re-hospitalization rate among ACS patients was found to be significantly higher in areca users and individuals with severe disease. These findings suggest that screening for a history of areca nut chewing may help to identify patients at a high risk for re-hospitalization due to secondary events.

Adverse Health Effects of Betel Quid and the Risk of Oral and Pharyngeal Cancers

Global reports estimate 600 million betel quid (BQ) chewers. BQ chewing has been demonstrated not only to be a risk factor for cancers of the oral cavity and pharynx and oral potentially malignant disorders (OPMD) but also to cause other cancers and adverse health effects. Herein, we summarized the international comparison data to aid in the understanding of the close relationship between the prevalence of BQ chewing, the occurrence of oral and pharyngeal cancers, and adverse health effects. Potential biomarkers of BQ carcinogens, such as areca nut, alkaloids, and 3-methylnitrosaminopropionitrile (MNPN), are closely associated with human health toxicology. Molecular mechanisms or pathways involving autophagy, hypoxia, COX-2, NF-κB activity, and stemness are known to be induced by BQ ingredients and are very closely related to the carcinogenesis of cancers of oral and pharynx. BQ abuse-related monoamine oxidase (MAO) gene was associated with the occurrence and progress of oral and pharyngeal cancers. In summary, our review article provides important insights into the potential roles of environmental BQ (specific alkaloid biomarkers and nitrosamine products MNPN) and genetic factors (MAO) and offers a basis for studies aiming to reduce or eliminate BQ-related OPMD and oral/pharyngeal cancer incidences in the future.

Betel nut chewing associated with increased risk of arterial stiffness

BACKGROUND

Betel nut chewing is associated with certain cardiovascular outcomes. Subclinical atherosclerosis may be one link between betel nut chewing and cardiovascular risk. Few studies have examined the association between chewing betel nut and arterial stiffness. The aim of this study was thus to determine the relationship between betel nut chewing and arterial stiffness in a Taiwanese population.

METHODS

We enrolled 7540 eligible subjects in National Cheng Kung University Hospital from October 2006 to August 2009. The exclusion criteria included history of cerebrovascular events, coronary artery disease, and taking lipid-lowering drugs, antihypertensives, and hypoglycemic agents. Increased arterial stiffness was defined as brachial-ankle pulse wave velocity (baPWV) ≥1400cm/s. According to their habit of betel nut use, the subjects were categorized into non-, ex-, and current chewers.

RESULTS

The prevalence of increased arterial stiffness was 32.7, 43.3, and 43.2% in non-, ex- and current chewers, respectively (p=0.011). Multiple logistic regression analysis revealed that ex-chewers (odds ratio [OR] 1.69, 95% confidence interval (CI)=1.08-2.65) and current chewers (OR 2.29, 95% CI=1.05-4.99) had elevated risks of increased arterial stiffness after adjustment for co-variables.

CONCLUSIONS

Both ex- and current betel nut chewing were associated with a higher risk of increased arterial stiffness. Stopping betel nut chewing may thus potentially be beneficial to reduce cardiovascular risk, based on the principals of preventive medicine.

The association between socioeconomic status and subclinical atherosclerosis in a rural Bangladesh population

BACKGROUND

In Bangladesh, CVD accounts for the majority of non-communicable mortality. The purpose of this study was to determine the role of socioeconomic status (SES) on subclinical atherosclerosis measured as carotid intima-media thickness (IMT) in a rural Bangladesh population.

METHODS

Carotid IMT was measured between 2010 and 2011 in 1022 participants (average age 46, 40% male) randomly selected from the Health Effects of Arsenic Longitudinal Study (HEALS), a population-based prospective cohort study based in rural Bangladesh. SES was measured as occupation type, land ownership, educational attainment, and television ownership.

RESULTS

Half of the participants received formal education (53%) and under half owned land (48%) and a television (44%). Women were primarily homemakers (95%) and men worked as factory workers (24%), laborers (18%), or in business (55%). In univariate analysis, those owning greater than one acre of land (p=0.03), owning a television (p=0.02), or laborers and business owners compared to factory workers had higher levels of carotid IMT (p<0.01). In multivariate analysis after adjustment for confounders, only men employed in the business sector had elevated carotid IMT compared to factory workers. The association was strongest in older men (58.7μm, 95% CI 17.2-100.0, ≥50years old) compared to younger men (13.7μm, 95% CI -7.8-35.2, <50years old).

CONCLUSION

Business sector employment was positively associated with subclinical atherosclerosis after adjustment for confounders. This finding is consistent with evidence from other developing nations suggesting that certain SES factors are independent predictors of CVD.

Risks associated with betel quid chewing

Betel quid is one of the most commonly used psychoactive substances in the world, especially among Asian communities, just after caffeine, nicotine and alcohol. The mixture that is chewed usually contains betel leaves, areca nut and slaked lime, nonetheless, its ingredients and the preparation manner tend to vary. Areca nut contains four main alkaloids - arecoline, arecaidyne, guvacine and guvacoline that are responsible for its psychoactive effects. The act of betel chewing might have a negative impact on an overall health and can cause pathological lesions or diseases to develop and/or progress, both directly and indirectly. Also, it may happen that the negative impact of betel chewing on one system might have indirect harmful influence on another. Still an association has been drawn between betel chewing and the presence of metabolic diseases, cancers and proteinuria, as well as cardiovascular disorders - including hypertension, chronic renal failure, diabetics type II and obesity. Likewise, it is a known risk factor in the development of oral and esophagus cancer. Moreover, a correlation between betel chewing and smoking exists in that betel chewing might theoretically hinder the abandonment of tobacco smoking. Tissues of oral cavity and the upper part of digestive system are additionally exposed to the mechanical injuries caused by the areca nut. Therefore, they tend to be the most prone to be pathologically affected by betel quid chewing.

Socioeconomic status and non-communicable disease behavioural risk factors in low-income and lower-middle-income countries: a systematic review

BACKGROUND

Non-communicable diseases are the leading global cause of death and disproportionately afflict those living in low-income and lower-middle-income countries (LLMICs). The association between socioeconomic status and non-communicable disease behavioural risk factors is well established in high-income countries, but it is not clear how behavioural risk factors are distributed within LLMICs. We aimed to systematically review evidence on the association between socioeconomic status and harmful use of alcohol, tobacco use, unhealthy diets, and physical inactivity within LLMICs.

METHODS

We searched 13 electronic databases, including Embase and MEDLINE, grey literature, and reference lists for primary research published between Jan 1, 1990, and June 30, 2015. We included studies from LLMICs presenting data on multiple measures of socioeconomic status and tobacco use, alcohol use, diet, and physical activity. No age or language restrictions were applied. We excluded studies that did not allow comparison between more or less advantaged groups. We used a piloted version of the Cochrane Effective Practice and Organisation of Care Group data collection checklist to extract relevant data at the household and individual level from the included full text studies including study type, methods, outcomes, and results. Due to high heterogeneity, we used a narrative approach for data synthesis. We used descriptive statistics to assess whether the prevalence of each risk factor varied significantly between members of different socioeconomic groups. The study protocol is registered with PROSPERO, number CRD42015026604.

FINDINGS

After reviewing 4242 records, 75 studies met our inclusion criteria, representing 2 135 314 individuals older than 10 years from 39 LLMICs. Low socioeconomic groups were found to have a significantly higher prevalence of tobacco and alcohol use than did high socioeconomic groups. These groups also consumed less fruit, vegetables, fish, and fibre than those of high socioeconomic status. High socioeconomic groups were found to be less physically active and consume more fats, salt, and processed food than individuals of low socioeconomic status. While the included studies presented clear patterns for tobacco use and physical activity, heterogeneity between dietary outcome measures and a paucity of evidence around harmful alcohol use limit the certainty of these findings.

INTERPRETATION

Despite significant heterogeneity in exposure and outcome measures, clear evidence shows that the burden of behavioural risk factors is affected by socioeconomic position within LLMICs. Governments seeking to meet Sustainable Development Goal (SDG) 3.4-reducing premature non-communicable disease mortality by a third by 2030-should leverage their development budgets to address the poverty-health nexus in these settings. Our findings also have significance for health workers serving these populations and policy makers tasked with preventing and controlling the rise of non-communicable diseases.

FUNDING

WHO.

Betel Nut Chewing Is Associated With Reduced Tacrolimus Concentration in Taiwanese Liver Transplant Recipients

PURPOSE

Studies have shown that arecoline, the major alkaloid component of betel nuts, alters the activity of enzymes in the cytochrome P450 (CYP-450) family. Tacrolimus, an immunosuppressant that protects against organ rejection in transplant recipients, not only is mainly metabolized by CYP3A enzymes but also has a narrow therapeutic range. We aimed to investigate whether dose-adjusted blood trough levels of tacrolimus differed over time between betel nut-chewing and non-betel nut-chewing liver transplant recipients.

METHODS

In this retrospective case-control study, 14 active betel nut-using liver recipients were matched at a 1:2 ratio to 28 non-betel nut-using liver recipients by sex, age, graft source, duration of follow-up after liver transplantation, and estimated glomerular filtration rate. Differences in liver function index, renal function index, and dose-adjusted blood trough levels of tacrolimus over an 18-month period were compared between the 2 groups by using the Generalized Estimating Equation approach.

RESULTS

Dose-adjusted blood trough levels of tacrolimus tended to be significantly (P = .04) lower in betel nut chewers (mean = 0.81, medium = 0.7, 95% confidence interval [CI] = 0.73 to 0.90) than in nonchewers (mean = 1.12, medium = 0.88, 95% CI = 1.03 to 1.22) during the 18-month study period. However, there was no significant difference in renal and liver function index between the 2 groups.

CONCLUSION

Liver transplant recipients receiving tacrolimus tend to have lower blood trough levels of the drug over time if they chew betel nuts.

Prevalence of Risk Factors for Cardiovascular Diseases in Bangladesh: A Systematic Review and Meta-Analysis

BACKGROUND

Given the rising incidence of cardiovascular diseases (CVDs) in Bangladesh, an improved understanding of the epidemiology of CVD risk factors is needed. Therefore, we reviewed published studies on CVD modifiable risk factors e.g., Type 2 Diabetes Mellitus (T2DM), hypertension (HTN), dyslipidemia and smoking as well as studies on CVDs and conducted a meta-analysis of risk factors and disease prevalence.

METHODS

We searched the GLOBAL HEALTH, MEDLINE, EMBASE 'BanglaJol' databases for all studies in English on CVDs and its associated modifiable risk factors. Random effects meta-analysis methods were used to estimate pooled prevalence.

RESULTS

There were 74 eligible studies (outcome: T2DM = 32, HTN = 24, dyslipidaemia = 8 and smoking = 25; CVDs = 10). Due to high between study heterogeneity (p<0.001, I2> 95%) in the prevalence of CVD risk factors, we presented median and interquartile range (IQR) instead of the pooled estimates as the summary measures. Median (IQR) prevalence of T2DM, HTN, dyslipidemia and smoking were 5.9% (1.97%-8.25%); 15.1% (10.52%-17.60%); 34.35% (10.66%-48.50%) and 40.56% (0.80%-55.95%), respectively. The prevalence of T2DM and dyslipidemia were significantly higher in urban compared to rural populations (13.5 vs 6%, p<0.001; 41.5 vs 30%, p = 0.007, respectively).

CONCLUSIONS

The prevalence of risk factors for CVDs is high in Bangladesh, more so in urban areas. Ageing of the population may be a factor but urbanization seems to have an influence, possibly related to changes in dietary and physical activity patterns. Further research, in particular longitudinal studies, is needed to explore the complex interaction of these factors and to inform policies and programs for the prevention and management of CVDs in Bangladesh.

Short-term acute effects of gutkha chewing on heart rate variability among young adults: A cross-sectional study

BACKGROUND AND OBJECTIVES

An increase in the consumption of smokeless tobacco has been noticed among high school, college students, and adults. Despite the antiquity and popularity of chewing tobacco in India, its effects have not been investigated systematically in humans. The aim of this study was to investigate acute effects of gutkha chewing on heart rate variability (HRV) among healthy young adults.

MATERIALS AND METHODS

A total of 60 young adult males were included in the study. Each individual was asked to chew tobacco and subjected to HRV analysis. HRV analysis using short-term electrocardiogram recording was used to measure HRV parameters before gutkha chewing and at 5, 15, and 30 min after chewing tobacco. One-way analysis of variance and paired t-test was used to assess changes over time.

RESULTS

There was a significant increase in heart rate (HR) during tobacco chewing. Mean HR at baseline measured 73.0 ± 6.2 bpm. There was a rise in mean HR to 83.7 ± 9.1 bpm at 5 min during tobacco chewing and gradual reduction to baseline observed after 15 min followed by no significant change till 30 min. The normalized low-frequency power and LF/high-frequency (HF) power ratio were elevated after 5 min; however, normalized HF power was reduced after 5 min tobacco chewing.

CONCLUSION

Gutkha is closely associated with traditional cardiovascular risk factors as detected by a transient enhancing sympathetic activity during tobacco chewing in the form of increased HRV parameters or an imbalance between sympathetic and parasympathetic neural activity among healthy young adults.

Betel quid use and mortality in Bangladesh: a cohort study

OBJECTIVE

To evaluate the potential effects of betel quid chewing on mortality. (A quid consists of betel nut, wrapped in betel leaves; tobacco is added to the quid by some users).

METHODS

Prospective data were available on 20 033 individuals aged 18-75 years, living in Araihazar, Bangladesh. Demographic and exposure data were collected at baseline using a standardized questionnaire. Cause of death was defined by verbal autopsy questionnaires administered to next of kin. We estimated hazard ratios (HR) and their 95% confidence intervals (CI) for associations between betel use and mortality from all causes and from specific causes, using Cox proportional hazards models. We adjusted for age, sex, body mass index, educational attainment and tobacco smoking history.

FINDINGS

There were 1072 deaths during an average of 10 years of follow-up. Participants who had ever used betel were significantly more likely to die from all causes (HR: 1.26; 95% CI: 1.09-1.44) and cancer (HR: 1.55; 95% CI: 1.09-2.22); but not cardiovascular disease (HR: 1.16; 95% CI: 0.93-1.43). These findings were robust to adjustment for potential confounders. There was a dose-response relationship between mortality from all causes and both the duration and the intensity of betel use. The population attributable fraction for betel use was 14.1% for deaths from all causes and 24.2% for cancer.

CONCLUSION

Betel quid use was associated with mortality from all causes and from cancer in this cohort.

A critical review of arsenic exposures for Bangladeshi adults

Groundwater, the most important source of water for drinking, cooking, and irrigation in Bangladesh, is a significant contributor to the daily human intake of arsenic. Other arsenic intake pathways, established as relevant for Bangladeshi adults through this review, include consumption of contaminated edible plant parts and animal-origin food, inhalation of contaminated air, soil ingestion, betel quid chewing, and tobacco smoking. This review qualifies and quantifies these arsenic intake pathways through analysis of the range of arsenic levels observed in different food types, water, soil, and air in Bangladesh, and highlights the contributions of dietary intake variation and cooking method in influencing arsenic exposures. This study also highlights the potential of desirable dietary patterns and intakes in increasing arsenic exposure which is relevant to Bangladesh where nutritional deficiencies and lower-than-desirable dietary intakes continue to be a major concern.

Oral submucous fibrosis: an update

Oral submucous fibrosis (OSF) is a premalignant condition caused by betel chewing. It is very common in Southeast Asia but has started to spread to Europe and North America. OSF can lead to squamous cell carcinoma, a risk that is further increased by concomitant tobacco consumption. OSF is a diagnosis based on clinical symptoms and confirmation by histopathology. Hypovascularity leading to blanching of the oral mucosa, staining of teeth and gingiva, and trismus are major symptoms. Major constituents of betel quid are arecoline from betel nuts and copper, which are responsible for fibroblast dysfunction and fibrosis. A variety of extracellular and intracellular signaling pathways might be involved. Treatment of OSF is difficult, as not many large, randomized controlled trials have been conducted. The principal actions of drug therapy include antifibrotic, anti-inflammatory, and antioxygen radical mechanisms. Potential new drugs are on the horizon. Surgery may be necessary in advanced cases of trismus. Prevention is most important, as no healing can be achieved with available treatments.

Relationship between betel quid chewing and risks of cardiovascular disease in older adults: a cross-sectional study in Taiwan

BACKGROUND

The association between betel quid (BQ) chewing and oral cancer is well established. However, evidence regarding the relationship between BQ chewing and cardiovascular disease (CVD) is still insufficient.

METHODS

This cross-sectional study included 2002 men and 1175 women aged 50 and older in a city-level health examination survey of an agricultural and fishing population in 2013. In addition to anthropometric parameters, CVD risks were estimated using high-sensitivity C-reactive protein (hs-CRP), brachial-ankle pulse wave velocity (baPWV) and ankle-brachial index. Age, gender, smoking and alcohol drinking status were all incorporated into the multivariate logistic regression model to delineate the effect of BQ chewing on CVD risks.

RESULTS

Two hundred forty-one (12%) males and eight (0.7%) females were ever chewers. BQ chewing was an independent risk factor for general obesity (odds ratio [OR] 1.43, 95% confidence interval [CI] 1.07-1.91, p=0.017), central obesity (OR 2.27, 95% CI 1.53-3.37, p<0.001) and an elevated hs-CRP level (OR 1.38, 95% CI 1.03-1.85, p=0.029). Subjects who chewed more frequently had a higher systolic blood pressure (p=0.025) and baPWV (p=0.006). The waist circumference (p=0.015) and waist-to-height ratio (p=0.022) were greater in current chewers than in former chewers.

CONCLUSION

These findings suggest that BQ chewing is associated with obesity and a higher CVD risk as estimated by hs-CRP. Furthermore, potential beneficial effects of BQ chewing cessation on central obesity were also found.

The role of betel-quid chewing in smoking cessation among workers in Taiwan

BACKGROUND

Current smokers exhibit a higher rate of betel-quid chewing than non-smokers. However, little is known regarding the extent to which betel-quid chewing may affect attempts to quit smoking and smoking cessation. The aim of the present study is to examine the association between betel-quid chewing and patterns of quitting smoking. Specifically, we explore whether betel-quid chewing is associated with (1) current smokers who have never attempted to quit versus those who have attempted to quit and have failed, those who are in the process of quitting, and successful cessation smokers, and (2) current smokers who have attempted to quit and have failed versus those who have successfully quit smoking.

METHODS

A telephone survey of 7,215 workers was conducted and obtained an 88.6% response rate. In the survey, the respondents' smoking and betel-quid chewing statuses were recorded and a list of covariates was assessed.

RESULTS

After controlling for the effect of the covariates, betel-quid chewing was found to be more highly associated with current smokers who have never attempted to quit, compared to current smokers who are in the process of quitting (OR = 12.72; 95% CI = 1.05-154.26), successful cessation smokers (OR = 3.62; 95% CI = 2.32-5.65), and smokers who have attempted to quit and have failed (OR = 1.37; 95% CI = 1.06-1.77), respectively. In addition, betel-quid chewing is more highly associated with a failure to quit smoking than with successfully quitting smoking (OR = 3.46; 95% CI = 2.17-5.51).

CONCLUSION

The findings support four plausible reasons why betel-quid chewing may dissuade smokers from quitting. These reasons highlight additional avenues for potentially reducing the smoking population in workplaces, such as considering work contexts and social norms, and product sales in smoking-cessation campaigns.

A prospective study of arm circumference and risk of death in Bangladesh

BACKGROUND

Epidemiological studies have observed protective effects of mid-upper arm circumference (MUAC) against all-cause mortality mostly in Western populations. However, evidence on cause-specific mortality is limited.

METHODS

The sample included 19 575 adults from a population-based cohort study in rural Bangladesh, who were followed up for an average of 7.9 years for mortality. Cox proportional hazards regression was used to evaluate the effect of MUAC, as well as the joint effect of body mass index (BMI) and MUAC, on the risk of death from any cause, cancer and cardiovascular disease (CVD).

RESULTS

During 154 664 person-years of follow-up, 744 deaths including 312 deaths due to CVD and 125 deaths due to cancer were observed. There was a linear inverse relationship of MUAC with total and CVD mortality. Each 1-cm increase in MUAC was associated a reduced risk of death from any cause [hazard ratio (HR) = 0.85; 95% confidence interval (C), 0.81-0.89) and CVD (HR = 0.87; 95% CI, 0.80-0.94), after controlling for potential confounders. No apparent relationship between MUAC and the risk of death from cancer was observed. Among individuals with a low BMI (<18.5 kg/m(2)), a MUAC less than 24 cm was associated with increased risk for all-cause (HR = 1.81; 95% CI, 1.52-2.17) and CVD mortality (HR = 1.45; 95% CI, 1.11-1.91).

CONCLUSIONS

MUAC may play a critical role on all-cause and CVD mortality in lean Asians.

A prospective cohort study of stroke mortality and arsenic in drinking water in Bangladeshi adults

Background

Arsenic in drinking water causes increased coronary artery disease (CAD) and death from CAD, but its association with stroke is not known.

Methods

Prospective cohort study with arsenic exposure measured in well water at baseline. 61074 men and women aged 18 years or older on January 2003 were enrolled in 2003. The cohort was actively followed for an average of 7 years (421,754 person-years) through December 2010. Based on arsenic concentration the population was categorized in three groups and stroke mortality HR was compared to the referent. The risk of stroke mortality Hazard Ratio (HR) and 95% Confidence Interval was calculated in relation to arsenic exposure was estimated by Cox proportional hazard models with adjustment for potential confounders.

Results

A total of 1033 people died from stroke during the follow-up period, accounting for 23% of the total deaths. Multivariable adjusted HRs (95% confidence interval) for stroke for well water arsenic concentrations <10, 10-49, and ≥50 μg/L were 1.0 (reference), 1.20 (0.92 to 1.57), and 1.35 (1.04 to 1.75) respectively (P_trend=0.00058). For men, multivariable adjusted HRs (95%) for well water arsenic concentrations <10, 10-49, and ≥50 μg/L were 1.0 (reference), 1.12 (0.78 to 1.60), and 1.07 (0.75 to 1.51) respectively (P_trend=0.45) and for women 1.0 (reference),1.31 (0.87 to 1.98), and 1.72 (1.15 to 2.57) respectively (P_trend=0.00004).

Conclusion

The result suggests that arsenic exposure was associated with increased stroke mortality risk in this population, and was more significant in women compared to men.

Association between betel quid chewing and carotid intima-media thickness in rural Bangladesh

BACKGROUND

Areca nut, more commonly known as betel nut, is the fourth most commonly used addictive substance in the world. Though recent evidence suggests it may play a role in the development of cardiovascular disease, no studies have investigated whether betel nut use is related to subclinical atherosclerosis.

METHODS

We evaluated the association between betel nut use and subclinical atherosclerosis in 1206 participants randomly sampled from the Health Effects of Arsenic Longitudinal Study (HEALS). Frequency and duration of betel nut use were assessed at baseline, and carotid IMT was measured on average 6.65 years after baseline.

RESULTS

A positive association was observed between duration and cumulative exposure (function of duration and frequency) of betel nut use and IMT, with above-median use for duration (7 or more years) and cumulative exposure (30 or more quid-years) corresponding to a 19.1 μm [95% confidence interval (CI): 5.3-32.8; P ≤ 0.01] and 16.8 μm (95% CI: 2.9-30.8; P < 0.05) higher IMT in an adjusted model, respectively. This association was more pronounced in men [32.8 μm (95% CI: 10.0-55.7) and 30.9 μm (95% CI: 7.4-54.2)]. There was a synergy between cigarette smoking and above-median betel use such that the joint exposure was associated with a 42.4 μm (95% CI: 21.6-63.2; P ≤ 0.01) difference in IMT.

CONCLUSION

Betel nut use at long duration or high cumulative exposure levels is associated with subclinical atherosclerosis as manifested through carotid IMT. This effect is especially pronounced among men and cigarette smokers.

Prevalence and correlates of smokeless tobacco consumption among married women in rural Bangladesh

Objective

To estimate the prevalence and identify correlates of smokeless tobacco consumption among married rural women with a history of at least one pregnancy in Madaripur, Bangladesh.

Materials and Methods

We conducted a cross-sectional survey using an interviewer administered, pre-tested, semi-structured questionnaire. All women living in the study area, aged 18 years and above with at least one pregnancy in their lifetime, who were on the electoral roll and agreed to participate were included in the study. Information on socio-demographic characteristics and smokeless tobacco consumption was collected. Smokeless tobacco consumption was categorized as ‘Current’, ‘Ever but not current’ and ‘Never’. Associations between smokeless tobacco consumption and the explanatory variables were estimated using simple and multiple binary logistic regression.

Results

8074 women participated (response rate 99.9%). The prevalence of ‘Current consumption’, ‘Ever consumption but not current’, and ‘Never consumption’ was 25%, 44% and 31%, respectively. The mean age at first use was 31.5 years. 87% of current consumers reported using either Shadapata or Hakimpuree Jarda. Current consumption was associated with age, level of education, religion, occupation, being an income earner, marital status, and age at first use of smokeless tobacco. After adjustment for demographic variables, current consumption was associated with being over 25 years of age, a lower level of education, being an income earner, being Muslim, and being divorced, separated or widowed.

Conclusion

The prevalence of smokeless tobacco consumption is high among rural women in Bangladesh and the age of onset is considerably older than that for smoking. Smokeless tobacco consumption is likely to be producing a considerable burden of non-communicable disease in Bangladesh. Smokeless tobacco control strategies should be implemented.

Tobacco (kretek) smoking, betel quid chewing and risk of oral cancer in a selected Jakarta population

PURPOSE

This study aimed to determine the association between tobacco consumption (kretek) and betel quid chewing with oral cancer risk.

MATERIALS AND METHODS

A total of 81 cases of oral cancers were matched with 162 controls in this hospital-based study. Information on sociodemographic characteristics and details of risk habits (duration, frequency and type of tobacco consumption and betel quid chewing) were collected. Association between smoking and betel quid chewing with oral cancer were analysed using conditional logistic regression.

RESULTS

Slightly more than half of the cases (55.6%) were smokers where 88.9% of them smoked kretek. After adjusting for confounders, smokers have two fold increased risk, while the risk for kretek consumers and those smoking for more than 10 years was increased to almost three-fold. Prevalence of betel quid chewing among cases and controls was low (7.4% and 1.9% respectively). Chewing of at least one quid per day, and quid combination of betel leaf, areca nut, lime and tobacco conferred a 5-6 fold increased risk.

CONCLUSIONS

Smoking is positively associated with oral cancer risk. A similar direct association was also seen among betel quid chewers.

The association between hyperuricemia and betel nut chewing in Taiwanese men: a cross-sectional study

Background

Studies have associated betel nut chewing with cancers, metabolic syndrome, cardiovascular disorders, chronic kidney disease, and proteinuria. This study investigated whether hyperuricemia is associated with betel nut chewing in men who participated in a health check-up program.

Methods

From hospital records, we identified a total of 11,991 men who participated in the health check-up program from 2003 to 2009. They were divided into hyperuricemic group and non-hyperuricemic group. Laboratory tests, medical history, and status of cigarette smoking, alcohol consumption, and betel nut chewing were compared between the 2 groups. We calculated odds ratio (OR) and 95% confidence interval (CI) of hyperuricemia in association with betel nut consumption and other factors.

Results

Compared with the non-hyperuricemic group, the hyperuricemic group was slightly older (59.4 vs. 58.6 years) but less prevalent with betel nut use (11.8 vs. 13.6%, p = 0.003). Multivariable logistic regression analysis showed that hyperuricemia was negatively associated with betel nut chewing (OR 0.75, 95% CI 0.66-0.84), older age (OR 0.84, 95% CI 0.77-0.93), and diabetes mellitus (OR 0.57, 95% CI 0.50-0.64). On the other hand, hyperuricemia was positively associated with body mass index (OR 1.75, 95% CI 1.62-1.90), drinking (OR 1.36, 95% CI 1.25-1.49), hypertension (OR 1.41, 95% CI 1.30-1.52), mixed hyperlipidemia (OR 1.84, 95% CI 1.33-2.54), chronic kidney disease (OR 3.28, 95% CI 2.94-3.65), and proteinuria (OR 1.22, 95% CI 1.08-1.38). Smoking, hypercholesterolemia, and hypertriglyceridemia had no significant association with hyperuricemia.

Conclusion

Our data suggest that betel nut chewing is negatively associated with hyperuricemia.

A prospective study of variability in systolic blood pressure and mortality in a rural Bangladeshi population cohort

OBJECTIVE

Limited studies suggest that blood pressure variability over time is a risk factor of long-term cardiovascular outcomes. However, most of these were in populations with pre-existing cardiovascular diseases (CVD) and studies in general population are lacking.

METHODS

The study included 11,153 participants in a population-based, prospective cohort study in Araihazar, Bangladesh. Resting blood pressure was measured at baseline and every two years thereafter. Participants were followed up for an average of 6.5 years (2002-2009).

RESULTS

Male gender, older age, baseline systolic blood pressure (SBP), and absence of betel leaf use were independently positively associated with greater SBP variability over time. There was a significant association between SBP variability and the risk of death from overall CVD, especially from major CVD events. The positive association with the risk of death from any cause and stroke in age- and sex-adjusted models was attenuated in fully-adjusted models. In addition, the hazard ratio (HR) of stroke mortality was greater for individuals with both high baseline and high SBP variability. Similar patterns of HRs were observed for all-cause and CVD mortalities.

CONCLUSION

In this rural Bangladeshi population, variability in SBP contributes to the risk of death from CVD and may further potentiate the increased mortality risk associated with high SBP.

Chewing betel quid and the risk of metabolic disease, cardiovascular disease, and all-cause mortality: a meta-analysis

Background

Betel nut (Areca nut) is the fruit of the Areca catechu tree. Approximately 700 million individuals regularly chew betel nut (or betel quid) worldwide and it is a known risk factor for oral cancer and esophageal cancer. We performed a meta-analysis to assess the influence of chewing betel quid on metabolic diseases, cardiovascular disease, and all-cause mortality.

Methodology/Principal Findings

We searched Medline, Cochrane Library, Web of Science, and Science Direct for pertinent articles (including the references) published between 1951 and 2013. The adjusted relative risk (RR) and 95% confidence interval were calculated using the random effect model. Sex was used as an independent category for comparison.

Results

Of 580 potentially relevant studies, 17 studies from Asia (5 cohort studies and 12 case-control studies) covering 388,134 subjects (range: 94 to 97,244) were selected. Seven studies (N = 121,585) showed significant dose-response relationships between betel quid consumption and the risk of events. According to pooled analysis, the adjusted RR of betel quid chewers vs. non-chewers was 1.47 (P<0.001) for obesity (N = 30,623), 1.51 (P = 0.01) for metabolic syndrome (N = 23,291), 1.47 (P<0.001) for diabetes (N = 51,412), 1.45 (P = 0.06) for hypertension (N = 89,051), 1.2 (P = 0.02) for cardiovascular disease (N = 201,488), and 1.21 (P = 0.02) for all-cause mortality (N = 179,582).

Conclusion/Significance

Betel quid chewing is associated with an increased risk of metabolic disease, cardiovascular disease, and all-cause mortality. Thus, in addition to preventing oral cancer, stopping betel quid use could be a valuable public health measure for metabolic diseases that are showing a rapid increase in South-East Asia and the Western Pacific.

Coronary artery disease in Bangladesh: a review

Coronary artery disease (CAD) is an increasingly important medical and public health problem, and is the leading cause of mortality in Bangladesh. Like other South Asians, Bangladeshis are unduly prone to develop CAD, which is often premature in onset, follows a rapidly progressive course and angiographically more severe. The underlying pathophysiology is poorly understood. Genetic predisposition, high prevalence of metabolic syndrome and conventional risk factors play important role. Lifestyle related factors, including poor dietary habits, excess saturated and trans fat, high salt intake, and low-level physical activity may be important as well. Some novel risk factors, including hypovitaminosis D, arsenic contamination in water and food-stuff, particulate matter air pollution may play unique role. At the advent of the new millennium, we know little about our real situation. Large scale epidemiological, genetic and clinical researches are needed to explore the different aspects of CAD in Bangladesh.

Hypertension in Bangladesh: a review

Hypertension (HTN) is an increasingly important medical and public health problem. In Bangladesh, approximately 20% of adult and 40-65% of elderly people suffer from HTN. High incidence of metabolic syndrome, and lifestyle-related factors like obesity, high salt intake, and less physical activity may play important role in the pathophysiology of HTN. The association of angiotensin-converting enzyme (ACE) gene polymorphism and low birth weight with blood pressure has been studied inadequately. Studies have found relationship between mass arsenic poisoning and HTN. Hypovitaminosis D presumably plays role in the aetiopathogenesis of HTN in Bangladeshi population. South Asians appear to respond to antihypertensive therapy in a similar manner to the Whites. The latest National Institute for Health and Clinical Excellence guideline advocates a calcium-channel blocker as step 1 antihypertensive treatment to people aged > 55 years and an ACE inhibitor or a low-cost angiotensin-II receptor blocker for the younger people. Calcium-channel blockers and beta-blockers have been found to be the most commonly prescribed antihypertensive drugs in Bangladesh. Non-adherence to the standard guidelines and irrational drug prescribing are likely to be important. On the other hand, non-adherence to antihypertensive treatment is quite high. At the advent of the new millennium, we are really unaware of our real situation. Large-scale, preferably, nation-wide survey and clinical research are needed to explore the different aspects of HTN in Bangladesh.