Khat consumption and undernutrition among adult population in Ethiopia: A systematic review and meta-analysis

BACKGROUND

In Ethiopia, malnutrition is a public health threat causing a significant burden of morbidity, mortality, and economic crisis. Simultaneously, khat consumption is alarmingly increasing among adults, yet it might contribute to the existing burden of malnutrition, where the current evidence is inconclusive. Hence, this review was to estimate the association between khat consumption and undernutrition among adults in Ethiopia.

METHODS

A comprehensive search for Google, Google Scholar, and PubMed, coupled with a thorough manual search of the literature, was done up to date, October 18, 2023, using relevant search terms: "impact," "effects," "khat chewing," "khat consumption," "Ethiopia," "nutritional status," and "undernutrition." An updated PRISMA guideline was used to select relevant literature. The extracted data was summarized in narrative summaries, descriptions, and meta-analyses. The risk of bias was assessed. The results are presented in forest plots and funnel plots to assess publication bias. A pooled effect size (odds ratio) with a 95% certainty level was reported.

RESULTS

While a total of 17 articles (n = 45,679) were included in the narrative review, only 15 articles were included in the quantitative meta-analysis. The majority of studies had a low and moderate risk of bias (based on risk of bias assessment tool), mainly due to unclear exposure assessment and high study heterogeneity. A total of 11 studies were cross-sectional studies (71%), three were comparative studies (17.4%), and three were case control studies (17.4%). There is a higher risk of publication bias as evidenced by the funnel plot. Overall, five studies were from the Oromia region, and three studies were conducted at the national level. Overall, chewing had been shown to significantly increase the risk of undernutrition by 53% (pooled OR = 1.53; 95% CI: 1.09-2.16) under a random effect model. Under the fixed effect model, higher weight was given to national-level studies with higher samples, where chewing contributed to a 12% increased risk of undernutrition (AOR = 1.12; 95% CI: 1.01-2.23). Hence, khat chewing could raise the odds of undernutrition by 12-53%.

CONCLUSION

There is evidence of an association between khat chewing and an increased risk of undernutrition among adults in Ethiopia, which highlights the need for public health interventions to address the potential adverse effects of khat chewing on nutritional status.

Determinants of undernutrition among khat chewing and non-khat chewing male adults in Addis Ababa, Ethiopia: a comparative cross-sectional study

Khat chewing is a deep-rooted socio-cultural tradition that affects appetite, gastric emptying, and food intake, ultimately influencing nutritional status. Moreover, there is significant variation in lifestyles and ways of living among khat chewing and non-chewing people. However, there is limited evidence on the disaggregated determinants of undernutrition among khat chewers and non-chewers in Ethiopia. A community-based comparative cross-sectional study was conducted with 253 Khat-chewing and 249 non-chewing male adults in Addis Ababa, Ethiopia. Weight and height were measured under standard procedure and used to calculate the body mass index (BMI < 18.5 kg/m2 indicates undernutrition). Variables with p-values below 0.25 in the bi-variable analysis were entered into a multivariable logistic regression model to identify factors associated with undernutrition and to control confounding respectively. An adjusted odds ratio with 95% confidence interval was used to declare the presence and the strength of association between the independent and outcome variable. Statistical significance was declared at a p value of 0.05. In this study, a total of 138 (27.5%: 23.6-31.6%) adult males were undernourished; among them, 78 (32.0%) were khat chewers and 60 (23.9%) were non chewers. Christian religion (AOR = 1.49; 1.02-2.30), vegetable consumption (AOR = 1.69; 95% CI 1.12-2.55) and khat chewing (AOR = 1.60; 1.04-2.45) were independent risk factors for undernutrition. However, none of the above factors showed a statistically significant association among non-khat chewer male adults. In conclusion, undernutrition was a public health concern in male adults in the study area. Frequent consumption of fruits, vegetables and family size of the households were the independent predictors of undernutrition. The practical implication of identifying risk factors of undernutrition among chewers and non-chewers could be helpful in depicting the relevant risk factors by exposure category and helping to further refine intervention packages. In addition, focusing on interventions which can increase the availability and accessibility of fruits and vegetables are important to improve the nutritional status of adult male populations.

The effect of possible mediators on the association between chewing khat during pregnancy and fetal growth and newborn size at birth in Eastern Ethiopia

INTRODUCTION

Restriction in the growth of the fetus is a leading cause of stillbirth, neonatal mortality, and short- and long-term morbidity. Documented existing scientific evidence have shown the effects of maternal drugs use, alcohol drinking, tobacco smoking, cocaine use and heroin use on fetal growth restriction. However, data is lacking on the effects of khat chewing during pregnancy on fetal growth status and newborn size at birth. Therefore, the aim of the present study was to measure the effect of chewing khat during pregnancy on fetal growth and size at birth in eastern Ethiopia.

METHOD

A cohort study was conducted in selected health institutions in eastern Ethiopia. All pregnant women fulfilled the eligibility criteria in the selected health institutions was the source population. The calculated sample size of exposed and unexposed groups included in the study, in total, was 344. Data collection was performed prospectively by interviewers administered questionnaires, and anthropometric, clinical and ultrasound measurements. Data was analyzed using SPSS version 27 and STATA version 16 software. The survival analysis (cox proportional hazards model) and generalized linear model (GLM) for the binomial family analysis were performed to estimate the crude and adjusted relative risk and attributable risk (AR) with corresponding 95% CI of chewing khat on fetal growth restriction. The mediation effect has been examined through Generalized Structural Equation Modeling (GSEM) analysis using the Stata 'gsem' command. Statistically significant association was declared at p-value less than 5%.

RESULTS

In the present study, the incidence of fetal growth restriction (FGR) among the study cohorts was 95 (29.7%); of this, 81 (85.3%) were among khat chewer cohorts. The relative risk of fetal growth restriction among khat chewer cohort mothers was significantly higher (aRR = 4.32; 95%CI 2.62-7.12). Moreover, the incidence of small for gestational age at birth among the present study cohorts was 100 (31.3%); 84 (84%) were from khat chewer cohorts' deliveries. More importantly, in the present study, 98.95% of the ultrasound-identified fetuses with FGR were found to be SGA at birth. Hence, in the current study, FGR was highly associated with SGA at birth. In additional analysis, the regression coefficient of khat chewing during pregnancy on fetal growth restriction has been decreased in size from path o, β = 0.43, p < 0.001 to path o', β = 0.32, p < 0.001, after adjusting for gestational hypertension and maternal anemia.

CONCLUSION

In sum, the present study showed khat chewing during pregnancy is not simply affected the mothers, but it also affected the unborn fetuses. Therefore, the health workers as well as the local community and religious leaders should give high emphasis on provision of health education regarding the damage of chewing khat by pregnant mothers, with especial focus of the effects on their fetuses.

Epidemiology of Khat (Catha edulis) Chewing in Ethiopia: A Systematic Review and meta-analysis

In several countries, including Ethiopia, the shrub Catha edulis (khat) leaves are chewed for their stimulant properties. The present review summarizes evidence on the prevalence of khat use in Ethiopia and forwards recommendations for future action. PubMed, Embase, and Scopus were searched for studies examining the prevalence of Khat chewing among adolescent and/or adult populations in Ethiopia. A random-effects model was employed to estimate the pooled prevalence of khat chewing. Of the 568 articles identified, 26 were included in the review. The pooled prevalence of current and lifetime khat use was 19.55% (95% CI 14.62-25.64) and 26.14% (CI 17.66-36.87), respectively. The current prevalence of khat use was higher in men, 23.72% (CI 13.42-38.41), than in women 8.45% (CI 4.94-14.08). Lifetime prevalence of khat use was higher in men, 29.8% (CI: 22.80-37.99) than in women 13.02% (CI 8.96-18.56). The results of the meta-analysis demonstrated a higher odds of current (OR = 4.00, CI 2.80-5.73) and lifetime (OR = 2.84, CI 2.50-3.23) khat use in men than in women. Our review found a high prevalence of current (19.55%) and lifetime (26.14%) khat chewing in Ethiopia and demonstrated higher odds of current and lifetime khat use in men than in women. Awareness creation and integrated management of khat use problems at the primary health-care level is highly recommended.

Magnitude and associated factors of chewing khat during pregnancy in Eastern Ethiopia, 2022: a mixed method cross-sectional study

Introduction

khat (Catha edulis Forsk), is an evergreen flowering tree or shrub widely produced and consumed in East Africa and the Arabian Peninsula. In Ethiopia, it is largely produced, freely marketed and consumed by almost all segments of the population. This is more pronounced in the Eastern part of the country. However, there exists little scientific information on the level and associated factors of khat use among pregnant women in Ethiopia, despite a few available evidences indicated its adverse effect on pregnancy outcomes. Moreover, the perceived reasons for chewing khat during pregnancy were not yet explored qualitatively to triangulate the quantitative findings. Hence, the aim of the present study was to determine the magnitude and associated factors of chewing khat during pregnancy in Eastern Ethiopia, 2022, in a Mixed Method study approach.

Methods

an institution-based cross-sectional study was conducted from August 1st to 14th, 2022 using both quantitative and qualitative methods. Two hundred forty-two pregnant mothers on Antenatal care (ANC) were included in the study. Moreover, 18 purposively selected pregnant mothers on ANC were also considered for qualitative data. Analysis of quantitative data was performed on Statistical Package for the Social Sciences (SPSS) version 27 and thematic framework analysis was performed for qualitative data. Univariable and multivariable logistic regression analysis was performed to identify variables which are significantly associated with khat chewing during pregnancy and to estimate the variable's crude and adjusted odds' ratio with corresponding 95% CI. The statistically significant association was declared at p-value of less than 5.

Results

the overall magnitude of chewing khat during pregnancy in the present study was 27.4% (95% CI: 22.2-33.0). Variables which significantly associated with chewing khat during pregnancy in this study were being >26 years [adjusted odds' ratio (AOR)=2.81 95% CI: 1.19-6.59], being a rural resident (AOR=2.82 95% CI: 1.19-6.69), being illiterate (AOR=4.31 95% CI: 1.02-18.20), participants having chewer husbands (AOR=3.51 95% CI: 1.33-9.24) and respondents having other chewer family members (AOR=3.05 95% CI: 1.19-7.77). In addition, the perceived reasons for chewing khat explored through in-depth interviews were for socialization, to obey tradition, to be happy with friends, husbands and families, to be free from tensioned situations, to be effective in performing daily activities, and due to lack of knowledge of its harm.

Conclusion

in the present study, a relatively higher proportion of mothers chewed khat during their current pregnancy. Being older age, living in rural areas, being illiterate, having khat chewer husbands and other family members were statistically significant variables associated with khat chewing during pregnancy. Moreover, pregnant mothers are practicing chewing of khat in the current study area due to deep-rooted sociocultural issues. Hence, creation of awareness on possible harm of chewing khat during pregnancy especially for those found to be at significantly increased risk of consumption in this study is highly recommended during their antenatal care visits. In addition, creation of awareness out of health institutions, at household and community level, is highly recommended, probably using community volunteers (health development armies) in the present study area. At last, we highly also recommend the local government and religious leaders to work on how to stop the chewing practice especially during pregnancy. For example, the local government and religious leaders can work on averting consideration of chewing by the community as culturally accepted practices.

Perceived harms and protective behavioural strategies among khat chewers: a qualitative study in Jimma, Ethiopia

BACKGROUND

While there have been many previous studies focusing on the adverse effects of khat chewing, attempts to investigate the protective behavioural strategies (PBS) employed by the khat using population are rare. PBS are strategies that substance users employ to minimize or alleviate the possible negative consequences related to the behaviour. This study focuses on the harms that chewers associate with khat use, and the behavioural strategies they practise to prevent or minimize these harms.

METHODS

A community-based qualitative study was conducted using a snowball sampling technique to recruit a diverse sample of khat chewing participants (N = 102) in Jimma city, Ethiopia. Face-to-face in-depth interviews were carried out with the participants.

RESULTS

Participants identified a variety of harms likely to result from chewing khat. These include impacts on their finances, work, social life and health. The PBS that participants employed to avoid or minimize the risks were classified into four themes based on their temporal sequence with khat chewing sessions: prior to chewing, during chewing, after chewing and general PBS covering the whole of their khat chewing career. The PBS enable khat chewers to prevent or minimize the adverse health consequences of chewing, socialize and work without or with fewer difficulties and manage their economy successfully.

CONCLUSION

The study participants believe that khat-related harms are avoidable if khat users implement appropriate strategies prior to, during and after chewing, and if they apply PBS to khat-related factors (e.g. type, amount and frequency), set factors (e.g. reason for using and health behaviour) and setting factors (e.g. place of use, when used, with whom used and social norms) covering the whole of their khat chewing career.

Association of Khat Use Disorder and Antisocial Personality Disorder Among Inmates in Ethiopia: A Cross-Sectional Study

Objective: To examine the relationship between khat use disorder and antisocial personality disorder in newly admitted inmates in a correctional facility in Ethiopia.

Methods: A cross-sectional study using successive sampling was conducted among 411 new inmates from April 20 to July 19, 2019. The Alcohol, Smoking, and Substance Involvement Screening Test was utilized to measure khat use. DSM-5 diagnostic criteria were used to identify antisocial personality disorder. Environmental, criminal, and clinical backgrounds of the inmates were also evaluated.

Results: The prevalence of current khat use and khat use disorder was 49.4% and 37%, respectively. The prevalence of khat use disorder among inmates with antisocial personality disorder was 76%. Inmates with antisocial personality disorder were twice as likely as those without antisocial personality disorder to have khat use disorder (adjusted odds ratio [AOR] = 2; 95% CI, 1.2-3.4). Punishment for misconduct in prior imprisonment (AOR = 3; 95% CI, 1.6-5.3), family history of alcohol use (AOR = 2; 95% CI, 1.3-3.5), and chronic physical illness (AOR = 5.3; 95% CI, 2.4-11.8) were significantly associated with khat use disorder.

Conclusions: The prevalence of khat use disorder was higher among inmates with antisocial personality disorder, and antisocial personality disorder is linked to khat use disorder. The findings of this study suggest the need for the establishment of a mental health system in all prison institutions in Ethiopia to enhance early screening for underlying medical conditions, history of substance use, and antisocial personality disorder. Those inmates with identified substance use need detoxification therapy and motivational interviews after prison admission.

Prim Care Companion CNS Disord 2023;25(5):22m03470.

Author affiliations are listed at the end of this article.

Parental khat use and early childhood growth status in Eastern Ethiopia

BACKGROUND

Adult chewing of the stimulant plant khat (Catha edulis) has an unclear relationship with child growth outcomes. Contradictory study conclusions because habitual khat chewing covary with increased household income from khat production.

AIM

Disentangling the association of parental khat use, household khat production, and child nutritional status and growth markers.

METHODS

Bayesian analysis was applied to survey data for 2340 households containing 2760 children aged 24-60 months in a population-representative geographic sampling of two districts in Eastern Ethiopia, a khat chewing and producing region.

RESULTS

Stunting effects were more evident than wasting; the negative child growth effect of khat chewing persisted regardless of household khat production; maternal chewing particularly mattered for child growth delays.

CONCLUSIONS

This exploratory analysis suggests that future studies should target the interactions of khat chewing practices with gendered performances of child care/feeding responsibilities.

Task-specific oromandibular dystonia secondary to chewing Khat (Catha edulis)- A series of 35 cases

BACKGROUND

The leaves of "Khat" (Catha edulis), an indigenous shrub of Yemen and Arabian Peninsula are habitually chewed by the inhabitants for psychostimulant properties.

OBJECTIVE

To describe a unique task specific Oro-mandibular dystonia (OMD) in Yemenese men, with a temporal association with chewing "Khat".

METHODS

Multicentric, retrospective analysis (2009-2020) of patients with OMD associated with "Khat" chewing, evaluating clinical features and response to Onabotulinum toxin A.

RESULTS

35 Yemenese men with a negative family history, normal neuroimaging mean age of 44.31(±3.21) years and prolonged (20.31 ± 3.27 years) history of chewing Khat, around 5.16(±0.80) hours/day presented with OMD-20 jaw opening, 13 jaw closing and 2 mixed affecting chewing (n = 6), speech (n = 3), or both (n = 26). Additional lingual dystonia was seen in five.

CONCLUSIONS

Chewing of khat is a repetitive task involving the jaw musculature and may be one of the causative factors of this task specific OMD. Recognition can prevent disability in these regions.

Exploring the perception of key stakeholders toward khat policy approaches in Ethiopia: a qualitative study

BACKGROUND

Khat is an amphetamine-like plant, produced and commonly chewed in Ethiopia by a large group of the population. Although significant multidimensional harms of khat use have been reported, currently, there are no policies or organized activities against khat use in Ethiopia. Therefore, the current study aimed to explore the perception of key stakeholders toward khat policy approaches for Ethiopia.

METHODS

A qualitative study was conducted using focus group discussion (FGD) and in-depth interview (IDI). Ten stakeholders participated in the IDIs, and another 15 individuals participated in the FGDs. Key stakeholders were appropriately mapped and purposively selected based on their experience related to khat use and khat harm reduction. Interviews and FGDs were led by the study authors and were audio-recorded. The audio-recorded data were transcribed verbatim and then translated into English language. The data were analyzed using thematic analysis approach.

RESULTS

Participants preferred prevention and law regulation measures for khat policy approaches for Ethiopia. Proposed prevention and law regulation measures included regulating the transportation of khat, limiting the minimum age to buy and sell khat, prohibiting khat use at some public places, banning khat advertising and promotion, and imposing excise tax. Individual level khat harm reduction strategies were also proposed to be useful. However, the participants asserted that total khat ban in Ethiopia is not likely to be feasible and acceptable.

CONCLUSION

Prevention, treatment or care for individuals with problematic khat use, law regulation, and harm reduction were preferred approaches by stakeholders for khat policy in Ethiopia instead of total banning.

Prevalence and risk factors for tobacco, khat, and alcohol consumption among high school students in Ethiopia

BACKGROUND

Tobacco, khat, alcohol, and marijuana are the main risk factors for non-communicable diseases. There are limited studies on substance use in Ethiopia, especially among secondary school students. This study aims to determine the epidemiology of substance use among secondary school students in Ethiopia.

METHODS

This cross-sectional study was conducted in March 2020 in four large regions of Ethiopia and the capital Addis Ababa. We collected data from 3,355 grade 9 and grade 10 students in 36 randomly selected high schools. Data were collected on tobacco, khat, alcohol and other substances. Mixed effect logistic regression models were fitted to determine the predictors of cigarette smoking.

RESULTS

157 (4.7%) of the participants ever smoked cigarettes and 81 (2.4%) were current smokers. 106 (3.2%) ever used smokeless tobacco, 1,342 (41.8%) had ever drunk alcohol, 290 (8.7%) ever used khat, 137 (4.8%) chewed khat regularly and 76 (2.3%) ever used marijuana. There was a significant regional variation in substance use patterns; cigarette and khat use was the highest in southern regions, whereas alcohol use was highest in the northern areas. Availability of cigarette and khat shops within a 100-meter radius of the school compound was reported by 1,229 (37.5%) and 816 (25%) students, respectively. Three hundred fifty-four (10.9%) students had ever seen someone smoking a cigarette in the school compound. Ever use of smokeless tobacco (Adjusted Odds Ratio (AOR) = 9.4, 95%CI: 4.9-17.9), ever use of shisha (AOR = 8, 95% CI: 3.9-16.3), ever use of khat (AOR = 4.1, 95%CI: 2.5-6.8), ever use of alcohol (AOR = 2.3, 95%CI: 1.4-3.7), having a friend who smoked a cigarette (AOR = 2, 95%CI: 1.2-3.5), and ever seen someone smoking a cigarette in the school compound (AOR = 1.9, 95%CI: 1.1-3.4) were associated with ever use of cigarettes.

CONCLUSION

Substance use prevalence in Ethiopia has regional variations and prevention strategies should be tailored to the needs of the regions. Although this study reported a lower prevalence of cigarette smoking, students could access cigarettes and khat in nearby school areas. The existing tobacco control laws that prohibit selling tobacco products to children and adolescents under 21 years of age and ban establishing tobacco shops close to school compounds should be enforced.

The effects of khat use during pregnancy on perinatal and maternal outcomes: a meta-analysis

Chewing khat during pregnancy adversely affects maternal and fetal health, but available studies are scarce and inconsistent, and it is difficult to conclude the relationship between khat consumption and perinatal outcomes. We aimed to investigate the available studies on the effect of khat use during pregnancy on perinatal and maternal outcomes. For this meta-analysis, we conducted a thorough search of articles published in PubMed, Embase, Scopus, and Web of Science up to the date this search was undertaken (03.01.2022). We used random effect model with the Mantel-Haenszel method to calculate the pooled odds ratio and mean difference. We found that khat use during pregnancy was significantly associated with increased odds of low birth weight (OR:2.51; 95% CI: 1.60 to 3.94), congenital anomalies (OR:3.17; 95% CI: 1.30 to 7.73), premature rupture of membrane (OR: 1.99; 95% CI: 1.59 to 2.50), perinatal mortality (OR: 1.95; 95% CI: 1.26 to 3.03), and lower APGAR scores at the fifth minute (MD: -1.7; 95% CI: -2.32 to -1.07). Also, increased odds for developing maternal psychological stress and anemia were reported in women using khat during pregnancy. There were no statistically significant differences in stillbirth and preterm birth between women using khat during pregnancy and their counterparts. Since prenatal khat use is associated with adverse perinatal and maternal outcomes, we strongly recommend equitable and easily accessible health services through the implementation of integrated addiction treatment with maternity services to address khat use during pregnancy and encourage the practice of healthy behavior of women.

Exploring the association between khat use and psychiatric symptoms: a systematic review

OBJECTIVES

Consumption of the drug khat is high across East Africa and the South-Western Arabian Peninsula despite evidence for its adverse psychiatric effects. This systematic review aims to explore cross-sectional research in the field to determine the strength of the association between khat use and psychiatric symptoms METHODS: Six databases were searched in October 2021-Ovid Medline, Embase, APA PsycINFO, CINAHL, Scopus and Proquest-using the following search terms: "khat" OR "qat" OR "qaad" OR "catha" OR "miraa" OR "mairungi" AND "depression" OR "anxiety" OR "mania" OR "psych*" OR "schiz*" OR "mental" OR "hallucinations" OR "delusions" OR "bipolar". Eligible studies were cross-sectional studies of any population or setting comparing the prevalence of psychiatric symptoms in long term or dependent khat users with non-users. The quality of each study was appraised by the Newcastle-Ottawa scale. A meta-analysis was planned using a random effects model to produce an OR with 95% CIs-using the Mantel-Haenszel method-alongside an I² statistic to represent heterogeneity. The quality of this meta-analysis was appraised using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) scoring system.

RESULTS

35 studies were eligible for inclusion (total participants=31 893), spanning 5 countries (Ethiopia, Somalia, Kenya, Saudi Arabia, UK). Meta-analysis suggests that khat use is associated with an 122% increased prevalence of psychiatric symptoms (OR 2.22, 95% CIs 1.76 to 2.79, p<0.00001, GRADE score: 'very low').

CONCLUSIONS

The high heterogeneity of the meta-analysis is likely due to the wide variation between the studies within the evidence base. To perform a more accurate systematic review, further primary studies are needed with standardised measurements of variables, particularly khat consumption.

PROSPERO REGISTRATION NUMBER

CRD42020224510.

Validation of the Problematic Khat Use Screening Test: A Cross-Sectional Study

AIM

The study aimed to evaluate the psychometric properties of the Problematic Khat Use Screening Test (PKUST-17) in Ethiopia.

METHODS

A validation study of PKUST-17 was carried out among 510 khat users, using a house-to-house survey. Confirmatory factor analysis and 2-parametric item response theory (IRT) were used to evaluate the construct validity of PKUST-17. We also used Spearman's rank-order correlation coefficient and other test statistics to assess the convergent validity of PKUST-17 with depression symptoms, functional impairment, and other characteristics of participants. We generated latent classes of problematic khat use using latent profile analysis (LPA) and validated the classes using multinomial logistic regression.

RESULTS

The data confirm the unidimensional model of the PKUST-17. The internal consistency of PKUST-17 was excellent (Cronbach's alpha = 0.93). IRT discrimination parameters indicated that each item had a strong ability to distinguish participants across the spectrum of problematic khat use (α thresholds range from 1.02 to 2.9). The items were fairly or moderately severe to be endorsed by participants (β thresholds vary from 1.43 to 5.57). The LPA identified three latent classes which have severity differences: mild (34%), moderate (34%), and severe (32%) problematic khat use. Depression symptoms, functional impairment, and other khat use patterns were also associated with moderate and severe problematic khat use class membership compared to mild problematic khat use class.

CONCLUSION

We found that the PKUST-17 is a culturally appropriate, brief, easy to use, and psychometrically sound screening test. PKUST-17 can be used to screen khat users with different levels of risk for providing stepped care at different healthcare levels, including integration of services in primary care. Future studies need to test the predictive capacity of the PKUST-17 for khat-related harms.

Oral cancer among Khat users: finding evidence from DNA analysis of nine cancer-related gene mutations

BACKGROUND

Khat leaves contain the alkaloid cathinone. Research shows that khat might provoke toxicity, mutagenicity, as well as carcinogenicity.

METHODS

Two groups were identified as khat abusers and were categorized by abuse time and diagnosis of oral squamous cell carcinoma (OSCC). Here, 41 participants from Group 2 were short-term khat users, and 42 participants were long-term khat users. The control group included 30 healthy individuals. The coding exons included nine cancer-related genes and were analysed. The histopathological research was conducted with H&E staining along with the TP53 protein expression by implementing immunohistochemical analyses.

RESULTS

Here, 41 short-term khat users carried seven somatic mutations in four out of nine cancer-related genes: 29/41(70.73%) ARID1A, 24/41(58.53%) MLH1, 34/41(82.92%) PIK3CA and 36/41(87.80%) TP53. The 42 long-term khat users incorporated nine somatic mutations in five out of nin ecancer-related genes: 40/42(95.23%) ARID1A, 36/42(85.71%) ARID2, 29/42(69.04%) PIK3CA, 27/42(64.28%) MLH1, and 35/42(83.33%) TP53. Every khat user had somatic mutations related to OSCC affecting the gingiva and the lower lip. TP53 protein expression was confirmed in all immunohistochemical oral tests. Carcinoma was also positive in the histopathological analysis.

CONCLUSIONS

Khat is a mutagenic and carcinogenic plant that provoked OSCC among short-term khat users (<15 years of use) and long-term users (>15 years of use).

Heavy khat (Catha edulis) chewing and dyslipidemia as modifiable hypertensive risk factors among patients in Southwest, Ethiopia: Unmatched case-control study

BACKGROUND

The burden of hypertension is more devastating in low-and middle-income countries, including sub-Saharan Africa than in high-income countries. Among the modifiable risk factors, dyslipidemia and khat chewing were expanding at an alarming rate in Ethiopia but were still underestimated. Thus, this study aimed to assess heavy khat (Catha edulis) chewing and dyslipidemia as modifiable hypertensive risk factors among patients in the southwest, Ethiopia.

METHODS

A facility-based case-control study was conducted among 136 cases and 270 controls from May 15 to July 30, 2017. A consecutive sampling technique was used in this study. Epi data version 3.1.1 and SPSS version 21 were used for data entry and analysis. Descriptive statistics and bivariate and multivariate logistic regression analyses were performed. Both crude and adjusted odds ratios and 95% confidence intervals were reported.

RESULTS

The majority of the cases had a total cholesterol to high-density lipoprotein ratio of >5 (72.1%). The odds of hypertension increased among participants who had attended no formal education [AOR = 2.25, 95% CI: (1.05-4.82)], history of alcohol consumption [AOR = 5.93,95% CI:(3.11-11.30)], moderate khat chewing [AOR = 3.68, 95% CI:(1.69,8.01)], heavy khat chewing [AOR = 18.18, 95% CI: (3.56-92.89)], mild intensity physical activity [AOR = 3.01, 95% CI: (1.66-5.47)], type of oil used for food preparation [AOR = 2.81, 95% CI: (1.49-5.28)], and dyslipidemia [AOR = 6.68, 95% CI: (2.93-15.23)].

CONCLUSION

The study showed that modifiable risk factors were the major factors associated with the development of hypertension. The findings of this study highlighted that health education is needed to focus on physical exercise, quitting excess alcohol consumption, quitting khat chewing by giving special emphasis to those who had no formal education. In addition, consideration should be given to a healthy diet free of cholesterol and unhealthy behavior.

Khat and neurobehavioral functions: A systematic review

Background

Khat is a plant that is used for its amphetamine-like stimulant properties. However, although khat is very popular in Eastern Africa, Arabian Peninsula, and the Middle East, there is still a lack of studies researching the possible neurobehavioral impairment derived from khat use.

Methods

A systematic review was conducted to identify studies that assessed the effects of khat use on neurobehavioral functions. MedLine, Scopus, Cochrane, Web of Science and Open Grey literature were searched for relevant publications from inception to December 2020. Search terms included (a) khat and (b) several cognitive domains. References from relevant publications and grey literature were also reviewed to identify additional citations for inclusion.

Results

A total of 142 articles were reviewed, 14 of which met the inclusion criteria (nine human and five rodent studies). Available human studies suggest that long term khat use is associated with significant deficits in several cognitive domains, including learning, motor speed/coordination, set-shifting/response inhibition functions, cognitive flexibility, short term/working memory, and conflict resolution. In addition, rodent studies indicated daily administration of khat extract resulted in dose-related impairments in behavior such as motor hyperactivity and decreased cognition, mainly learning and memory.

Conclusions

The findings presented in this review indicates that long-term khat use may be contributing to an impairment of neurobehavioral functions. However, gaps in literature were detected that future studies could potentially address to better understand the health consequences of khat use.

Khat chewing leads to increase in glycaemic parameters in patients with type 2 diabetes mellitus in Jazan region, Saudi Arabia and Yemen

BACKGROUND

Khat is known to have a stimulating effect on the sympathetic nervous system by producing a temporary sensation of activeness and happiness, along with mood disturbance and anxiety. Despite growing evidence of the association between khat chewing and glycaemic control in patients with diabetes, the position of khat chewing in DM is not fully recognised.

AIM

To evaluate the association of khat chewing with the risk of elevated blood glucose levels among patients with type 2 diabetes mellitus.

METHOD

A web-based literature search was performed using the electronic databases PubMed, EMBASE and Google Scholar. Databases were searched for studies published about khat chewing and diabetes mellitus in the Jazan region, Saudi Arabia and Yemen.

RESULT

Twenty-five published articles studying the relation between khat chewing and diabetes mellitus were identified, but only 10 studies reported an association between khat chewing and blood glucose levels and were included.

CONCLUSION

Khat chewing increases fasting blood glucose, post-prandial blood glucose and HbA1c levels in patients with diabetes in the Jazan region, Saudi Arabia and Yemen.

Khat Chewing Effect on the International Normalized Ratio in Patients with Mechanical Heart Valves under Warfarin Therapy

BACKGROUND AND OBJECTIVE

Khat is a plant that contains the alkaloids cathine and cathinone which have some amphetamine-like properties. It is cultivated and it's leaves chewed for their euphoric effect. This study intended to elucidate the effect of khat chewing on blood coagulation by using the International Normalized Ratio (INR) value as a calculable benchmark.

MATERIALS AND METHODS

In this cohort study, 146 patients with Mechanical Heart Valves (MHV) were assessed for two consecutive visits at one-month intervals. For each visit, the date of surgery, the patient's compliance, the dose of warfarin and the INR reading were assessed by the researcher.

RESULTS

Out of 146 patients with MHV, the mean age was 33.72±12.43 years (range, 14-65 years); 82 (56.2%) were female and 64 (43.8%) were male. The results revealed that the mean of absolute INR readings was lower in khat-chewers than non-chewers by average 0.2 on the first and second visits (p = 0.038 and 0.002, respectively).

CONCLUSION

Khat chewing has a significant coagulant effect. There was a significant decrease in the value of INR for khat chewers patients with MHV when compared to non-khat chewers.

Exploring the concept of problematic khat use in the Gurage community, South Central Ethiopia: a qualitative study

OBJECTIVE

This study aimed to explore how problematic khat use is characterised in the Gurage community in South Central Ethiopia.

DESIGN

Qualitative study.

SETTING

Gurage community in South Central Ethiopia.

PARTICIPANTS

We conducted indepth interviews with 14 khat users and 5 non-khat users, and three focus group discussions with khat users.

METHODS

All participants were selected purposively based on their exposure to khat or khat use. We used an interview guide to explore the perceptions of participants about khat use and problematic khat use. We analysed the data thematically using OpenCode V.4.03 software. We used iterative data collection and analysis, triangulation of methods, and respondent validation to ensure scientific rigour.

FINDINGS

We identified three major themes: sociocultural khat use, khat suse (khat addiction) and negative consequences of khat use. Sociocultural khat use included a broad range of contexts and patterns, including use of khat for functional, social, cultural and religious reasons. Khat addiction was mainly explained in terms of associated khat withdrawal experiences, including harara/craving and inability to quit. We identified mental health, sexual life, physical health, social and financial negative consequences of khat use. The local idiom jezba was used to label a subgroup of individuals with khat suse (khat addiction).

CONCLUSION

The study has identified what constitutes normative and problematic khat use in the Gurage community in South Central Ethiopia. Problematic khat use is a broad concept which includes frequency, reasons, contexts, negative consequences and addiction to khat. Insights generated can be used to inform future studies on the development of tools to measure problematic khat use.

Prevalence of hypertension and associated factors among adult residents in Arba Minch Health and Demographic Surveillance Site, Southern Ethiopia

Hypertension is the leading risk factor for mortality and it is also one of the major risk factors for other non-communicable diseases (NCDs). The objective of the study was to assess the prevalence of hypertension and its associated factors among adults residing in Arba Minch health and demographic surveillance site (HDSS), Southern Ethiopia. A community-based cross-sectional survey was conducted in 2017 on the estimated sample size of 3,368 adults at Arba Minch Health and Demographic Surveillance site (HDSS). Data were collected using the WHO STEPS survey tools. Bivariate analysis was done to detect candidate variables at P-value less than 0.25 and entered into the final model to identify the independent predictors of hypertension. The prevalence of hypertension was 18.92% (95% CI: 17.63-20.28). The magnitude increase among respondents in the older age group [AOR 1.39 (95%CI: 1.05-1.84), 1.68 (95% CI: 1.26-2.23) and 2.67 (95%CI: 2.01-3.56) for age group 35-44, 45-54 and 55-64, respectively, compared to 25-34 years old group] and those with the higher wealth index [AOR 1.86 (95%CI: 1.33-2.59), 2.68 (95% CI: 1.91-3.75) and 2.97 (95%CI: 2.08-4.25) for 3rd quantile, 4th quantile and 5th quantile, respectively, compared to 1st quantile]. The odds of hypertension reduce among married participants (AOR 0.66, 95%CI: 0.51-0.85). Respondents with overweight (AOR 1.44, 95%CI: 1.02-2.02), khat chewing (AOR3.31, 95%CI: 1.94-5.64), low fruit and/or vegetable consumption (AOR 1.27, 95%CI: 1.05-1.53) and those who do not use coffee and tea (AOR 1.52, 95%CI: 1.03-2.24) had significantly higher likelihood of hypertension. Nearly one out of five participants have hypertension in this population. As hypertension is one of the silent killers, it is advisable to develop a system for enabling early detection and monitoring in the older age groups and overweight individuals.

Impact of Khat (<i>Catha edulis</i>) Chewing on Carotid Intima-media Thickness

BACKGROUND AND OBJECTIVE

Khat has severe adverse socio-economic consequences. It causes serious cardiovascular, neurological and psychiatric problems. The study aimed to evaluate the effect of chewing khat on intima-media thickness (IMT) of the common carotid arteries.

MATERIALS AND METHODS

This was a descriptive case-control cross-sectional study. A total of 50 participants of chronic regular khat chewers were investigated. B-mode ultrasound 7-10 MHz linear transducers used for assessment of common carotid arteries according to the standard carotid sonography protocol. The IMT was measured and the presence of plaques was assessed.

RESULTS

The carotid IMT was significantly increased in regular khat chewers more than the controls (p-value = 0.016). The common carotid IMT increased in smokers more than non-smokers among khat chewers (0.6710±0.20687 vs. 0.5789±0.16859 mm). Significant correlations existed between the duration of chewing khat and age with the presence of plaque (p-values = 0.013 and 0.002, respectively).

CONCLUSION

There is a significant correlation between carotid plaque and longtime khat chewing. Khat is a contributory factor for increasing carotid intima-media thickness and formation of carotid plaques. A combination of khat and smoking produce more thickening of carotid intima-media.

Effects of Khat on Surface Roughness and Color of Feldspathic and Zirconia Porcelain Materials under Simulated Oral Cavity Conditions

Background and Objectives: Khat chewing is considered as a daily habit that is practiced by more than five million people globally. The effect of khat chewing on the surface roughness and the color stability of natural teeth and the material used in the fabrication of dental prosthesis remains unknown. This study was conducted to explore and compare the effect of khat homogenate (KH) on the surface roughness (Ra) and the average color changes (ΔE*) amongst natural teeth and selected shades from different porcelain types, namely, feldspathic metal ceramic (MC) VM13, computer-aided design/computer assisted manufacture (CAD/CAM) feldspathic (Vitablocs Mark II), and multilayer zirconia (Ceramill Zolid PS) porcelains. Materials and Methods: Seventy samples were prepared from natural teeth, feldspathic MC, CAD/CAM Vitablocs Mark II, and zirconia porcelain. The Ra values were measured using a profilometer and expressed in micrometers, whereas the ΔE* values were measured using VITA Easyshade^® V spectrophotometer for all samples before and after frequent immersion and thermocycling in KH for 30 days. The surface topography was used to assess the materials surfaces (glazed or polished) after KH immersion by using a white light interferometry machine. Results: Results revealed that the Ra and the ΔE* values of the different types of tested porcelain were influenced by KH. The order of surface roughness values was glazed or polished MC > polished Zircon > polished Vitablocs Mark II > natural teeth. The lowest ΔE* values were recorded for glazed Vitablocs Mark II and MC, and the values could be arranged as polished zircon > natural teeth > glazed zircon > polished MC > polished Vitablocs Mark II. P values were significantly varied (<0.001) among all the tested groups, except the zircon group (>0.05) for both Ra and ΔE*. Conclusions: KH significantly affected both surface parameter and color of glazed or polished porcelain materials and natural teeth.

Khat chewing prevalence and correlates among university staff in Ethiopia: a cross-sectional study

OBJECTIVES

Khat is an herbal cultivated plant growing mainly in Eastern Africa and Arabians. Chronic khat chewing leads to the development of liver toxicity, cardiovascular disease, sleeping disorder, psychosis, memory impairment, poor academic performance and variety of social and economic problems affecting the consumers and their families. Therefore, this study aimed to determine the prevalence of khat chewing and associated factors among Jimma university staff. An institution-based cross-sectional study was employed on 354 university staff. A self-administered questionnaire was used to collect the data. The analysis was done using Stata 14. A multivariable logistic regression model was used to identify associated factors of khat chewing among university staff. p ≤ 0.05 was employed to declare statistically significant factors.

RESULTS

The lifetime prevalence of khat chewing among university staff was 41.0% (95% CI 35.9-46.1%). The odds of khat chewing was higher among males (AOR = 2.66 95%, CI 1.52-4.68), participants who had khat chewer friends (AOR = 2.15 95% CI 1.18-3.93), alcohol users (AOR = 9.02, 95% CI 4.96-16.42) and participants who had khat chewer family member (AOR = 4.03, 95% CI 1.16-13.99). Since a significant proportion of staff chew khat, appropriate measures need to be taken to reduce its prevalence and adverse social and health consequences.

Prevalence and associated factors of khat chewing among students in Ethiopia: a protocol for systematic review and meta-analysis

INTRODUCTION

These days, in Ethiopia, khat chewing is one of the widely spreading public health problems affecting the most productive segment of the population. The health implications of khat chewing among students are strongly linked with poor mental, physical and social performances. However, the national magnitude of khat chewing and the associated factors among Ethiopian students are unknown. Therefore, this systematic review and meta-analysis will answer the national prevalence of khat chewing and the associated factors among students in Ethiopia.

METHODS

Published primary relevant articles will be accessed using various databases, such as Medline, PubMed, EMBASE and Scopus. Other electronic search engines, for instance, Google Scholar and Google, will be used. Furthermore, additional studies will be collected by communicating with the author(s) and following the references of relevant articles. To select eligible studies, the Joanna Briggs Institute quality appraisal checklist will be used. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist will be followed to keep the scientific rigour of the study. Heterogeneity between studies will be examined through forest plot and I² heterogeneity tests. To identify influential studies, sensitivity analysis will be done. For substantial heterogeneity (I²>50%), the DerSimonian and Laird random-effects model will be employed. Subgroup analyses will be conducted using the random-effect model. Moreover, small studies' publication bias will be checked by funnel plots and objectively by Egger's regression test. If in case Egger's test was found to be statistically significant (p<0.05), trim and fill (Duval and Tweedie) analysis will be performed. The presence of association will be declared using p≤0.05 and OR with corresponding 95% CI.

ETHICS AND DISSEMINATION

Since the intention of the study is to describe earlier primary studies qualitatively and pool the results of those articles, ethical clearance will not be a concern. The results of the study will be published in a reputable peer-reviewed journal and presented at different scientific research conferences. It will also be disseminated to academic as well as other concerned institutions.

PROSPERO REGISTRATION NUMBER

CRD-42,017,081,886.

Individual and Integrated Effects of Potential Risk Factors for Oral Squamous Cell Carcinoma: A Hospital-Based Case-Control Study in Jazan, Saudi Arabia

Background: Oral cancer is the sixth most common cancer in the world, with a high prevalence reported in Jazan province of Saudi Arabia. The objectives of this study were to check individual and integrated effects of potential risk factors for oral squamous cell carcinoma. Materials and methods: A case control study was designed with a sample of 210 subjects, in which histopathologically confirmed incident cases (n=70) and controls (n=140) matched for age, gender and referral route, were recruited. Differences in exposure to potential risk factors between cases and controls were assessed using chi-square and McNemar analyses. A logistic regression model with interactions was applied to check individual and integrated effects. Results: Mean age of the sample was 55 years (+ 20 years). Shammah (O.R = 33.01; C.I = 3.22 – 39.88), shisha (O.R = 3.96; C.I = 0.24 – 63.38), and cigarette (O.R = 1.58; C.I = 0.13, 2.50) consumption was significantly associated (P<0.05) with oral squamous cell carcinoma development. In contrast, Khat chewing (O.R = 0.67; C.I = 0.19-2.36) was without significant effect. An increase in odds ratios was observed when combinations of shammah and shisha (O.R = 35.03; C.I = 11.50-65.66), shisha and cigarettes (O.R = 10.52; C.I = 1.03 – 33.90) or shamma and cigarettes (O.R = 10.10; C.I = 0.50 - 20.40) were used. Conclusion: Combined exposure to risk-factors has serious implications and policies on oral cancer prevention should be designed with attention to this aspect.

[Tranylcypromine and khat: a potentially fatal combination]

It is well known that the use of tranylcypromine in combination with amphetamines may induce a potentially lethal hypertensive crisis. That such a complication may also occur when tranylcypromine is combined with khat, however, is less known. We describe the case of a young patient who received a low dose of tranylcypromine combined with a small amount of khat, subsequently developing a subarachnoid hemorrhage.

'Khatatonia' - cathinone-induced hypertensive encephalopathy

Khat consumption is an under-recognised cause of hypertensive encephalopathy and intraparenchymal brain haemorrhage. We report the radiological findings of extensive periventricular, subcortical and brain stem white matter pathology of a patient who had consumed excessive amounts of Khat. The Khat plant contains cathinone, an amphetamine-like alkaloid which has been associated with chronic hypertensive end-organ damage, but is seldom considered a cause of cerebrovascular events in northern Europe.

Correlates of khat use during pregnancy: A cross-sectional study

OBJECTIVES

Khat is widely used in East African countries including Ethiopia. A growing body of evidence indicates that long-term khat use is associated with various health consequences. The aim of this study was to examine the magnitude and correlates of khat use in pregnant women.

METHODS

This study used a cross-sectional, face-to-face interview design that included 642 pregnant women receiving antenatal care services at primary care centers in Ethiopia. A series of chi-square tests and regression models were conducted to examine whether khat use status (i.e., 123 current khat users, 41 former khat users, and 478 non-users) was associated with socio-demographic, mental distress, and substance use measures.

RESULTS

As compared with non-users, current and former khat users had higher levels of depressive symptoms and distress. Khat users minimized potential health risks associated with khat use. Social and motivational factors related to khat use were different between current and former khat users.

CONCLUSIONS

Findings of this study suggest a substantial prevalence of khat use among pregnant women in Ethiopia and highlight the role of socio-demographic and cultural influences on khat use during pregnancy. Health care professionals in the region where khat is available are encouraged to ask their female patients about khat use and encourage them to refrain from use while they are pregnant. The positive link between khat and mental distress warrants further research focusing on biological, psychological, and social mechanisms of this relationship.

Qat use and esophageal cancer in Ethiopia: A pilot case-control study

BACKGROUND

Qat (Catha edulis) chewing is reported to induce lesions in the buccal mucosa, irritation of the esophagus, and esophageal reflux. Case series suggest a possible etiological role in oral and esophageal cancers. This pilot study aimed to generate preliminary estimates of the magnitude and direction of the association between qat use and esophageal cancer (EC) risk and to inform the logistics required to conduct a multi-center case-control study.

METHODS

Between May 2012 and May 2013, 73 EC cases (including 12 gastro-esophageal junction cases) and 133 controls matched individually on sex, age, and residence were enrolled at two endoscopy clinics and a cancer treatment hospital in Addis Ababa. A face-to-face structured questionnaire was administered. Qat use was defined as ever having chewed qat once a week or more frequently for at least one year. Odds ratios were calculated using conditional logistic regression.

RESULTS

Only 8% of cases resided in Addis Ababa. Qat use was more frequent in cases (36%) than in controls (26%). A 2-fold elevation in EC risk was observed in ever qat chewers compared with never users in unadjusted conditional logistic regression (OR = 2.12; 95% CI = 0.94, 4.74), an association that disappeared after adjusting for differences in tobacco use, consumption of alcohol and green vegetables, education level, and religion (OR = 0.95; 0.22, 4.22). Among never tobacco users, however, a non-significant increase in EC risk was suggested in ever qat users also after adjustment. Increases in EC risk were observed with ever tobacco use, alcohol consumption, low consumption of green vegetables, a salty diet, illiteracy, and among Muslims; the four latter associations were significant.

CONCLUSIONS

This pilot study generated EC risk estimates in association with a habit practiced by millions of people and never before studied in a case-control design. Results must be interpreted cautiously in light of possible selection bias, with some demographics such as education level and religion differing between cases and controls. A large case-control study with enrolment of EC cases and carefully matched controls at health facilities from high-risk areas in the countryside, where the majority of cases occur, is needed to further investigate the association between qat use and EC.

Patterns of Restorative Failure among Khat and Shammah Users in Jazan City, Kingdom of Saudi Arabia: A Cross-sectional Survey

INTRODUCTION

The effect of Khat and Shammah habits, with the parafunctional jaw activities that accompany them, on the integrity of the natural dentition, dental restorations, and prostheses has not yet been investigated. This study is the first attempt to identify the patterns of restorative failure among Khat chewers and Shammah users in Jazan City, Kingdom of Saudi Arabia.

MATERIALS AND METHODS

A cross-sectional study was conducted in 294 recruits among dental clinics in Jazan City, Kingdom of Saudi Arabia, from October 1, 2015, to April 30, 2016. The patients were surveyed and examined to identify the type of restorations/prosthesis they had and their failures. Bivariate analysis was conducted to investigate the association of the restorative failure with the demographic variables. General linear model was performed to investigate the association between restorations/prostheses failure and Khat/Shammah use with the controlling factors of age and gender as independent variables.

RESULTS

Khat/Shammah use was statistically significantly associated with restorative failure (p < 0.05) relative to amalgam, composite, crowns, fixed partial dentures, removable partial dentures, and complete dentures. In addition, a significant association of restorative failure was observed with gender, education, and brushing.

CONCLUSION

Consumption of Khat/Shammah may be attributed as one of the reasons associated with restorative failure among the Saudi population.

Prevalence and Severity of Temporomandibular Disorders among Undergraduate Medical Students in Association with Khat Chewing

INTRODUCTION

The aim of this study was to assess the prevalence and severity of temporomandibular joint disorders (TMDs) among undergraduate medical students in the presence of khat chewing over a period of time.

MATERIALS AND METHODS

Totally, 186 medical college students (age < 20 years) were randomly selected for the present study. The study subjects were divided into two groups according to age, under 20 and above 20 years. The study was based on Fonseca's anamnestic index and its questionnaire, which is composed of 10 questions and classifies the severity of TMDs. The obtained data were coded and entered into Statistical Package for the Social Sciences (SPSS) program for analysis using chi-square test at significance level of 5%.

RESULTS

Most of the participants were male (68.8%) students and older than 20 years (63%). Those who reported with khat chewing comprised 31.7%. From the total samples, only 38.0% was classified as having mild TMD and 0.50% were classified as having severe TMD. Poor dental articulation, grinding of teeth, headaches, tense personalities, and temporomandibular joint (TMJ) clicking were the most common clinical findings. The mean scores showed no significant difference among gender (p < 0.29) and the khat chewing (p < 0.531) groups for the 10 questions. However, it showed significant difference among age groups (p < 0.025).

CONCLUSION

The majority of subjects complained of mild TMD, while only a few cases showed a moderate TMD among different age groups. The most frequently reported dysfunctions were related to poor dental articulation and grinding of the teeth, frequent headaches, the clicking of joint, and tense personalities. No significant difference was found between gender and khat and nonkhat chewing groups.

CLINICAL SIGNIFICANCE

Khat chewing is a parafunctional habit and affects dental occlusion (especially cuspal wear) in terms of anterior guidance. Such alterations in occlusion are known to be one of the causative (predisposing) factors of TMD.

To chew or not to chew: that's the question

A 25-year-old Somalian man was referred to the department of internal medicine because of nausea, vomiting and jaundice of recent onset. On physical examination, he was frankly icteric without clinical signs of chronic liver disease. Laboratory data showed evidence of acute hepatitis. Viral serologic tests for hepatitis A, B, C and E were negative. Antinuclear antibodies (ANA) were positive (titre 1 : 1280; speckled pattern, NV < 1 : 40) as well anti-actin antibodies (titre 75 UA, NV < 20). A liver biopsy was performed and showed a feature compatible with toxic hepatitis. On further questioning, the patient admitted to daily chew Khat when he was living in Somalia. We concluded to Khat-induced toxic hepatitis together with high-titre anti-nuclear antibody mimicking serologic patterns of auto-immune hepatitis.

[Hepatitis after chewing of khat leaves]

Chewing of leaves from the Catha edulis (khat) plant has amphetamine-like, stimulating effects and is used in rituals among East African men. In recent years, a possible liver-toxic effect has been observed in Somali immigrants in Western countries and has in severe cases led to death or liver transplantation. It is discussed whether the liver insufficiency represents a severe ethnic variant of autoimmune hepatitis, or a khat-induced hepatitis with autoimmune features. We describe six patients with Somalian background and possibly khat-induced toxic hepatitis.

Bibliometric analysis on global Catha edulis (khat) research production during the period of 1952-2014

BACKGROUND

Publication of scientific articles related to khat (Catha edulis) in peer-reviewed journals is considered a measure of research productivity. The principal objectives of this study were to quantify the research contribution related to khat at the global level, as well as to determine its relative growth rate, collaborative measures taken, productivity at the institutional level, and the most prolific journals publishing on the topic.

METHODS

On the basis of title words related to khat, publications were identified for all data in Scopus bibliographic database's history up to December 31, 2014. The research productivity for the top 10 countries was evaluated in relation to the population size and gross domestic product (GDP) in 2013.

RESULTS

The criteria were met by 651documents published in 51 countries. The largest number of articles associated with khat was from the UK (15.2 %), followed by Yemen (10.3 %), the USA (9.7 %) and Ethiopia (9.1 %). Ethiopia, Yemen, and Kenya had the highest productivity of publications after standardization by population size and GDP. Furthermore, Yemen achieved the highest number of collaborations, by having researchers from 19 countries. Ethiopia followed, having researchers from 16 countries.

CONCLUSIONS

This bibliometric study provides a demonstration for the worldwide research activity regarding khat. The number of articles related to khat has increased rapidly over the last 10 years. The present study is a good starting point to evaluate research activity in the field of khat. Although the data shows a promising increase in the research activity, the quantity of khat-related research is still too little compared to the massive use of khat in certain countries.

Qat Chewing and Risk of Potentially Malignant and Malignant Oral Disorders: A Systematic Review

BACKGROUND

Qat (also known as Khat, Kat and Miraa) is a green-leaved plant (Catha edulis). It is a shrub indigenous to Yemen and certain parts of eastern Africa. Chewing the leaves, which have sympathomimetic and euphoric effects, has been documented in many countries and increased with worldwide migration. The effect of long-term chewing Qat on the oral cavity is unknown.

OBJECTIVE

A systematic review was performed to identify any associations between Qat chewing and the occurrence of potentially malignant and malignant oral disorders.

METHODS

Medline and the Web of Science were searched for articles published before May 2014 without limits with regard to publication date and language.

RESULTS

From a total of 890 papers identified, 17 English papers reported potentially malignant or malignant oral disorders and Qat chewing. One additional paper in Arabic language was identified from reviewing the list of references of eligible papers. It was found that exposure to Qat may be associated with potentially malignant and malignant oral disorders, but methodological issues, such as inadequate study design, sample size, selection of study subjects, clinical evaluations of outcome and limited adjustment for confounders, limit the strength of the evidence base in this area.

CONCLUSION

The association between Qat chewing and potentially malignant and malignant oral disorders remains debatable and requires further investigations.

Concurrent tobacco and khat use is associated with blunted cardiovascular stress response and enhanced negative mood: a cross-sectional investigation

OBJECTIVES

Khat (Catha edulis), an amphetamine-like plant, is widely used in East Africa and the Arabian Peninsula and is becoming a growing problem in other parts of the world. The concurrent use of tobacco and khat is highly prevalent and represents a public health challenge. We examined for the first time associations of the concurrent use of tobacco and khat with psychophysiological responses to acute stress in two sites in Yemen.

METHODS

Participants (N = 308; 135 women) included three groups: users of khat and tobacco, users of khat alone, and a control group (nonsmokers/nonusers of khat). These individuals completed a laboratory session in which blood pressures (BP), heart rate, and mood measures were assessed during rest and in response to acute stress.

RESULTS

Concurrent use of khat and tobacco was associated with attenuated systolic BP, diastolic BP, and heart rate responses to laboratory stress (ps < 0.05) and with increased negative affect relative to the control group (ps < 0.05).

CONCLUSIONS

Results demonstrated blunted cardiovascular responses to stress and enhanced negative affect in concurrent khat and tobacco users. These findings extend previous studies with other substances and suggest that adverse effects of khat use may lie in its association with the use of tobacco.

Subacute administration of crude khat (Catha edulis F.) extract induces mild to moderate nephrotoxicity in rats

BACKGROUND

Although various studies have been conducted to shed light on the pharmacological actions of khat, little or no data are available regarding khat's effect on the renal redox system. The aim of this study was therefore to investigate the potential of nephrotoxicity associated with khat exposure in rats.

METHODS

Sprague Dawely rats were randomly assigned into eight experimental groups. Animals were treated with Tween80, gentamicin 100 mg/kg and khat at various doses (100, 200 and 400 mg/kg) alone or in combination with gentamicin for ten days. The animals were then sacrificed to obtain blood and renal tissues for subsequent analysis. Renal markers, including creatinine, blood urea nitrogen, antioxidant enzymes as well as markers for lipid peroxidation were determined using established protocols. In addition, histopathological changes were evaluated with hematoxilin and-eosin staining technique.

RESULTS

Lower and moderate doses of khat did not alter the measured parameters compared to controls. By contrast, higher dose (400 mg/kg) of khat not only increased levels of serum creatinine and blood urea nitrogen (p < 0.001) but also levels of malondialdehyde (p < 0.01). Moreover, 400 mg/kg of khat significantly decreased enzymatic activities of superoxide dismutase (p < 0.01) and catalase (p < 0.001). When khat was administered with gentamicin, it was again the higher dose that significantly accentuated gentamicin-induced alterations in the renal system.

CONCLUSIONS

Khat treatment at high dose is demonstrated to induce mild to moderate renal damage. Moreover, it creates synergy when combined with nephrotoxic drugs such as gentamicin.

Khat chewing and restrictive dietary behaviors are associated with anemia among pregnant women in high prevalence rural communities in eastern Ethiopia

Background

Anemia affects a high proportion of pregnant women in the developing countries. Factors associated with it vary in context. This study aimed to determine the prevalence and predictors of anemia among pregnant women in the rural eastern Ethiopia.

Methods

A community-based cross-sectional study was done on 1678 pregnant women who were selected by a cluster random sampling technique. A pregnant woman was identified as anemic if her hemoglobin concentration was <11 g/dl. Data were collected in a community-based setting. Multilevel mixed effect logistic regression was used to determine the adjusted odds ratios (AOR) with 95% confidence intervals (CI) for the predictors of anemia.

Results

Anemia was observed among 737(43.9%) of the 1678 pregnant women studied (95% CI 41.5%–46.3%). After controlling for the confounders, the risk of anemia was 29% higher in the women who chewed khat daily than those who sometimes or never did so (AOR, 1.29; 95% CI, 1.02–1.62). The study subjects with restrictive dietary behavior (reduced either meal size or frequency) had a 39% higher risk of anemia compared to those without restrictive dietary behavior (AOR, 1.39; 95% CI, 1.02–1.88). The risk of anemia was increased by 68% (AOR, 1.68; 95% CI, 1.15–2.47), and 60% (AOR, 1.60; 95% CI, 1.08–2.37) in parity levels of 2 births and 3 births, respectively. Compared to the first trimester, the risk of anemia was higher by two-fold (AOR, 2.09; 95% CI, 1.46–3.00) in the second trimester and by four-fold (AOR, 4.23; 95% CI, 2.97–6.02) in the third trimester.

Conclusion

In this study, two out of five women were anemic. Chewing khat and restrictive dietary habits that are associated with anemia in the setting should be addressed through public education programs. Interventions should also focus on the women at higher parity levels and those who are in advanced stages of pregnancy.

Khat dependence syndrome: a cross sectional preliminary evaluation amongst UK-resident Yemeni khat chewers

ETHNOPHARMACOLOGICAL RELEVANCE

Khat is a natural psychostimulant that has pharmacological effects similar to that of amphetamine. The behaviour of khat chewing is embedded within a cultural context. Meanwhile khat chewing is associated with psychological and physiologically burden, as a 'dependence producing' substance.

AIMS OF THE STUDY

To assess the applicability of the construct of substance dependence syndrome (DSM-IV, 1994) to khat chewing and to examine psychosocial and behavioural correlates of this syndrome including tobacco use.

MATERIALS AND METHODS

A sample of 204 khat chewers was recruited during random visits to khat sale outlets. A face to face interview that assessed socio-demographic, psychosocial dependence, substance dependence syndrome and behavioural characteristics was conducted. Descriptive, exploratory psychometric and multivariate analyses were employed.

RESULTS

Approximately a third (31%) of khat chewers reported symptoms consistent with dependence syndrome including increased khat chewing (13%) and cessation attempts (19%) while 17% reported withdrawal symptoms including depression (61%), increase in appetite (74%) and interrupted sleep (58%). Thirty-eight percent reported continued khat chewing despite impacts on their health. Psychometric assessment of the DSM-IV criteria for khat chewing dependence identified two factors; factor 1 consisted of bio-behavioural items and factor 2 withdrawal items, accounting for 67% of the variance and Cronbach's alpha coefficient at 0.78. In multivariate logistic regression modelling, there was an association between intensity of psychological khat dependence (SDS-Khat) and nicotine dependence with the likelihood of exhibiting khat chewing dependence syndrome (p=0.0005, OR=1.51, 95%CI=1.33-1.71; p=0.043, OR=2.87, 95%CI=1.03-7.98, respectively).

CONCLUSIONS

The substance dependence syndrome criteria are applicable to khat chewing and associated with increased intensity of nicotine and psychological khat dependence. The applicability of khat dependence syndrome and exploration of its dimensions and associated factors should be extended in future research. Concurrent validation of these findings using specific objective measures for self-report khat chewing is also recommended.

Chewing over the future: khat consumption, anxiety, depression, and time among young men in Jimma, Ethiopia

This article draws on qualitative and quantitative research to examine the relationship between the consumption of khat, symptoms of depression and anxiety and the experience of time among young men in urban Ethiopia. Young men claim that khat, a mild stimulant, both causes and alleviates symptoms of depression and anxiety. However, our quantitative data indicate that there is not a direct relationship between khat and symptoms of depression and anxiety. We analyze this apparent contradiction in terms of young men's experiences of time. Long-term ethnographic research indicates that khat consumption and mental distress have a close relationship with young men's temporal problems. In a context of high urban unemployment, young men struggle to negotiate overabundant amounts of unstructured time in the present and place themselves within a narrative in which they are progressing toward future aspirations. These temporal struggles generate symptoms of depression and anxiety. For young men, khat consumption functions to reposition them in relation to time, both in the present and the future. Ultimately, we argue that the relationship between khat and time has implications for the economic issues that underlie young people's symptoms of depression and anxiety.

Validation of self-reported khat chewing amongst khat chewers: an exploratory study

ETHNOPHARMACOLOGICAL RELEVANCE

Khat chewing amongst the UK communities originating from Yemen and the East African coast is suggested to create dependency through its main stimulant components (cathinone, norephedrine and norpseudoephedrine) on the central nervous system.

AIMS OF THE STUDY

To validate self-reported khat chewing behaviours by measuring levels of cathinone, norephedrine and norpseudoephedrine in saliva and to explore their associations with self-reported khat chewing dependency.

MATERIALS AND METHODS

Face-to-face interviews were conducted amongst 30 male UK-resident khat chewers. Saliva samples were collected from each participant and high-performance liquid chromatography (HPLC) employed to extract and quantify the levels of the biomarkers.

RESULTS

The mean (SD) for cathinone and the composite norephedrine and norpseudoephedrine levels were 33.93 (±39.20) and 29.28 (±26.32)μg/mL respectively. These biomarkers were significantly associated (p≤0.05) with khat chewing dependency.

CONCLUSIONS

Validation of self-reported khat chewing is possible. Khat chewing dependency correlates significantly with biomarker levels in saliva. Replication is required.

Subchronic administration of Catha edulis F. (khat) extract is marked by elevation of cardiac biomarkers and subendocardial necrosis besides blood pressure alteration in rats

ETHNPHARMACOLOGICAL RELEVANCE: Khat is a widely chewed herb for its stimulant effect, however, its effects on the cardiovascular system are a source of growing concern, as prevalence of chewing is increasing and susceptible individuals may experience cardiovascular episodes. This study attempted to evaluate cardiovascular substrates that predispose individuals to these episodes by using both biochemical and morphologic-pathologic studies.

MATERIALS AND METHODS

Rats were treated with either Tween 80 (2% in distilled water) (CON), or khat extract (100mg/kg, K100; 200mg/kg, K200; or 400mg/kg, K400 doses) orally for 6 weeks. Blood pressure (BP) in each group was measured before dosing and 1, 2 and 3h after-dose as well as weekly for 6 weeks using Tail cuff method. On day 45, blood was drawn for assessment of cardiac biomarkers and animals were sacrificed, and histological examination was undertaken for any overt damage on the myocardium.

RESULTS

K400 was the only dose that significantly increased BP at 2 (p<0.05) and 3h (p<0.001) postdose compared to predose level. Likewise, the 3h postdose BP of each week was significantly greater (p<0.001) than baseline BP only at 400mg/kg. However, when the weekly values were compared among themselves, the difference was not statistically significant and a progressive change in postdose BP had not been observed. On the other hand, predose systolic BP of K400 rats tended to decline at week 3 and significantly decreased (p<0.05) beyond week 4 compared to baseline values, but the decline was not significant for the rest of the doses. Biomarker assessments revealed that whereas levels of total creatine kinase were found to be elevated significantly for K100 (p<0.05), K200 and K400 (p<0.001 in both cases); aspartate aminotransferease was increased in K200 (p<0.01) and K400 (p<0.001) compared to CON rats. By contrast, levels of cardiac troponin T was significantly increased (p<0.001) only in K400 rats. Heart tissues of CON and K100 rats were normal, while those from K200 showed signs of focal lesions but normal architecture of the myocardium was maintained. K400 rats, however, displayed fragmentation and segmentation of fibers, edema and mottled staining.

CONCLUSIONS

These findings collectively indicate that the high dose of crude khat extract modulated most of the hemodynamic, biochemical and histopathological parameters in rats and hence chronic use of khat at higher dose and for longer sessions bear a significant risk for cardiovascular morbidities.

The ambiguity of khat in Somaliland

AIM OF THE STUDY

This article presents an analysis of the economic, political and socio-cultural significance of khat in Somaliland, highlighting both its positive and negative effects.

MATERIALS AND METHODS

Thirteen months of anthropological fieldwork in Somaliland, two months of anthropological fieldwork among Somalis in London, four months experience from the Somalia Joint Needs Assessment working as a development specialist on khat, as well as available and relevant literature.

RESULTS

The recent growth in khat consumption in Somaliland is linked to dispersal, unemployment, socio-cultural changes caused by the civil war, and the massive inflow of remittances. Consumption takes place because of an encouraging socio-cultural environment, few opportunities for education and employment, lack of care and support from parents, as well as widespread availability. Khat represents a significant economic drain on the Somaliland economy, but is also an important source of income for the state and an employment opportunity for thousands. The consumption of khat among government employees challenges the efficiency of state institutions, but also provides a participatory and peaceful political environment that is vital to the democratic transformation of Somaliland. Khat causes the breakdown of families and seriously challenges Somali socio-cultural identities, values and practices. However, khat also strengthens male networks, communities and senses of belonging to Somaliland.

CONCLUSION

The article argues that khat has both negative and positive effects on Somaliland society. Comparing the role of khat in Somaliland with khat in Puntland and South-central Somalia it is clear that khat in itself does not determine if it contributes to state building and peace, or state failure and violence. Rather, it is the socio-cultural, political and historical context in which it is consumed that determines its larger societal effects. A nuanced analysis of the positive and negative aspects of khat that builds on local perceptions and practices is necessary in order to work with khat from a regulatory and developmental perspective.