The ethics of betel nut consumption in Taiwan

Epidemiology of Oral Cancer in Taiwan: A Population-Based Cancer Registry Study

Oral cancer (OC) is one of the most common cancers worldwide, and its incidence has regional differences. In this study, the cancer registry database obtained from 1980 to 2019 was used to analyze the characteristic of incidence of OC by average annual percentage change (AAPC) and an age–period–cohort model. Spearman’s correlation was used to analyze the relationship between the age-standard incidence rates (ASR) of OC and related risk factors. Our results showed that the ASR of OC increased from 4.19 to 27.19 per 100,000 population with an AAPC of 5.1% (95% CI = 3.9–6.3, p value < 0.001) in men and from 1.16 to 2.8 per 100,000 population with an AAPC of 3.1% (95% CI = 2.6–3.6, p value < 0.001) in women between 1980–1984 and 2015–2019. The age–period–cohort model reported a trend of rising then declining for the rate ratio in men, with peaks occurring in the 1975 cohort, with a rate ratio of 6.80. The trend of incidence of oral cancer was related to changes in the consumption of cigarettes and alcohol and production of betel quid, with r values of 0.952, 0.979 and 0.963, respectively (all p values < 0.001). We strongly suggest avoiding these risk factors in order to prevent OC.

Cumulative Betel Quid Chewing and the Risk of Significant Liver Fibrosis in Subjects With and Without Metabolic Syndrome

Background

Betel quid chewing is associated with metabolic disorders, oral cancer, cardiovascular disease, and chronic liver diseases. Metabolic syndrome (MetS) is also a factor associated with liver fibrosis, cirrhosis, and hepatocellular carcinoma (HCC). However, studies on the relationship between betel quid and liver fibrosis while also considering MetS are lacking. The aim of this study was thus to investigate the association of betel quid chewing and liver fibrosis with MetS.

Methods

A total of 9,221 subjects were enrolled after excluding subjects <18 years of age, with past history of chronic liver diseases, cancer, significant alcohol consumption, and incomplete data. Betel nut chewing habit was classified into three groups: none, former-chewing, and current-chewing, and cumulative exposure was calculated by multiplying the duration with the quantity. Liver fibrosis was evaluated based on the NAFLD fibrosis score (NFS), which is a composite score of age, hyperglycemia, BMI, platelet count, albumin, and the AST/ALT ratio. Significant liver fibrosis was defined as NFS ≥-1.455.

Results

After adjusting for other variables, MetS was positively associated with significant liver fibrosis. Subjects with both MetS and betel quid chewing had a higher associated risk of significant liver fibrosis than those with neither MetS nor betel quid chewing (adjusted OR: 3.03, 95% CI: 2.04–4.50, p < 0.001). Betel quid chewing was associated with significant liver fibrosis (adjusted OR: 2.00, 95% CI: 1.14–3.49, p = 0.015) in subjects with MetS, but not in subjects without.

Conclusion

Metabolic syndrome increased the associated risk of significant liver fibrosis. Cumulative betel quid exposure increased the associated risk of significant liver fibrosis in subjects with MetS, but not in subjects without.

Betel Nut Chewing Decreased Calcaneus Ultrasound T-Score in a Large Taiwanese Population Follow-Up Study

Chewing betel nut is common in Taiwan. Although previous studies have shown that chewing betel nuts is associated with adverse health effects, findings about the impact on bone density have been inconsistent. Therefore, the aim of this study was to investigate the correlation between betel nut chewing and calcaneus ultrasound T-score in a longitudinal study of 118,856 participants from the Taiwan Biobank. Of these participants, 27,002 were followed up with for a median of 4 years. The T-score of the calcaneus was measured in the non-dominant foot using ultrasound. Multivariable analysis showed that a history of chewing betel nut (coefficient β = -0.232; p < 0.001) was significantly associated with low baseline T-score in all participants (n = 118,856). In addition, a long duration of betel nut chewing (per 1 year; coefficient β = -0.003; p = 0.022) was significantly associated with a low baseline T-score in the participants with a history of chewing betel nut (n = 7210). Further, a long duration of betel nut chewing (per 1 year; coefficient β = -0.004; p = 0.039) was significantly associated with a low ΔT-score in the participants with a history of chewing betel nut (n = 1778) after 4 years of follow-up. In conclusion, our results showed that betel nut chewing was associated with a decrease in calcaneus ultrasound T-score, and thus, it is important to stop chewing betel nut to help prevent an increased risk of osteoporosis in the Taiwanese population.

A Modeling Application for GHG Fluxes Estimates in Betel Nuts Plantations in Taiwan

Perennial woody crops could have a positive impact on carbon balance, absorbing carbon during growing season and storing it for several years, whereas annual crops do not have this particular effect. Usually, techniques for GHG (greenhouse gases) flux measurements have limited spatial representativeness, with some difficulties to extend leaf measurements to field scale. Models, especially if supported by remote sensing data, allow for upscaling the monitoring of these fluxes. The aim of this work was to evaluate the carbon fluxes (gross primary production, GPP; net ecosystem production, NEP) of the betel nut cultivars in Taiwan by a vegetation photosynthesis model (VPM). The model permitted estimating seasonal dynamics of GPP in a moist tropical evergreen forest. These plantations are very common in Taiwan and their role could be significant in environmental and development policies even though, until now, the consumption of the fruit of this tree is at the center of controversy due to their use and effects on the population. To obtain estimates of carbon fluxes on a large area that would appreciate its spatial variability, a model based on physiological processes was used. This model incorporated a series of procedures and monthly mean meteorological data, light use efficiency, and satellite enhanced vegetation index (EVI) were used as inputs. An additional purpose of this work was to compare the carbon uptake of different cultivars in Taiwan and Italy. Using a different model, always based on light use efficiency, a similar project was carried on Italian vineyards, with other climate conditions and different agricultural practices.

The Effectiveness of Betel Quid Cessation among Workers through the Adoption of the Five Action Areas of the Ottawa Charter

This study aimed to increase workers' awareness of betel quid cessation. Methods: Using community and workplace resources, a workplace health promotion program was developed in accordance with the five action areas of the Ottawa Charter. Questionnaires were administered to examine the changes in the knowledge and attitudes of 714 workers in different occupations before and three months after the intervention. Results: Regardless of subjects' pre-intervention chewing status, their knowledge and attitude scores relating to betel quid cessation increased significantly after the intervention. The effect of occupation was significant on the post-intervention knowledge and attitude scores among chewers. Furthermore, 16 (11.6%) of the 138 study subjects who chewed betel quid before the intervention and had no willingness to quit, did quit betel quid chewing following the intervention. The factors contributing to an unwillingness to quit among chewers with no intention to quit before the intervention were examined. Workers in the electronic material manufacturing industry had a greater willingness to quit compared to those in the metal, machinery, and related trades (odds ratio [OR] = 0.15; 95% confidence interval [CI] = 0.02-0.94). Travel attendants, tour guides, cleaners, and helpers were the least willing to quit (OR = 21.29; 95% CI = 2.51-180.81). Conclusions: This study promoted workers' awareness of betel quid cessation by adopting the five action areas of the Ottawa Charter framework, the effectiveness of the intervention varied in different occupations. Workers with a high-income and better education level had a higher awareness of betel quid cessation.

Sex Differences in the Heterogeneous Dynamic Incidence of Oral Cancer: A Comparison between Taiwan and Thailand

Background

This study aims at investigating differences in oral cancer (OC) incidence trends between two populations in Taiwan and Thailand.

Methods

We used the population-based cancer registry data from Taiwan (1979-2016) and Khon Kaen (KK), Thailand (1985-2016). We performed joinpoint analyses to detect the trend change points for the OC incidence and to quantify the time trends in both sexes and regions. Age-period-cohort curves were plotted to explain the incidence trends.

Results

In Taiwan, the estimated annual increases in OC were approximately 6.0% in males, although the increase slowed after 2009, and 2.6% in females. In KK, the OC incidence steadily decreased by -2.5% per year in females, but there was no obvious change in males. A strong period effect observed in those aged 45-69 years in Taiwanese males resulted in a peak incidence in the middle age group. Decreased period and cohort effects were observed in females in KK.

Conclusions

Taiwanese males are the predominant sex affected by OC in Taiwan, and the trend has decelerated since 2009. Age, period, and cohort effects were different between males and females in the two regions.

Clinical characteristics and treatment outcome of oropharyngeal squamous cell carcinoma in an endemic betel quid region

The clinical characteristics of oropharyngeal squamous cell carcinoma (OPSCC) may be different between endemic and non-endemic regions of betel nut chewing. The impact of combined alcohol drinking/betel quid chewing/cigarette smoking (ABC) exposure on the survival of OPSCC remains unclear. We reviewed the medical records of OPSCC patients between 1999 and 2013. Immunohistochemical staining of p16 and HPV genotype detection by DNA Polymerase chain reaction were both performed for each tumor. A total of 300 eligible patients including 74 HPV+ OPSCC patients and 226 HPV− OPSCC patients were enrolled. The 5-year disease-free survival rates for the HPV−, HPV+ OPSCC with and without ABC patients were 49.8%, 58.4% and 94%, respectively. The 5-year overall survival rates for the patients with HPV−, HPV+ OPSCC with and without ABC patients were 46%, 57.4% and 86%, respectively. Advanced locoregionally disease (T3/T4, N2/N3), HPV- OPSCC, combined 2 or all ABC exposure were the independent adverse prognostic factors for disease-free and overall survival. Therefore, our data suggest that in an endemic region of betel quid chewing, HPV− OPSCC comprises the majority of OPSCC and has a worse survival. Combined 2 or all ABC exposure had a significant negative impact on disease-free and overall survival.

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.