Shelley Wood

September 27, 2013

BARCELONA, SPAIN — Chewing betel quid (also known as areca nut or paan) is associated with significant increases in all-cause death, diabetes, cardiovascular disease, and a range of other metabolic conditions, according to the largest meta-analysis to address this subject.

The study, while epidemiological, highlights the need for better education on the harms of this popular stimulant in a part of the world where both the habit and diabetes are on the rise, Dr Tomohide Yamada (University of Tokyo, Japan) told heartwire . While the habit of chewing betel quid is confined to Asian and Western Pacific countries, the authors estimate that as many as 600 million people chew betel quid on a regular basis.

"This is a very big issue for public health in these countries," Yamada told heartwire .

The study was presented this week at the European Association for the Study of Diabetes (EASD) 2013 Meeting .

Dr Tomohide Yamada

Yamada and colleagues conducted literature searchers looking for Betel or Areca nut and a range of cardiovascular and metabolic risk factors, ultimately winnowing down 675 studies to 21 cohort or case-controlled studies that included relevant data. In all, more than 434 000 subjects were included in the analysis.

In adjusted analyses, the relative risks associated with betel-quid chewing as compared with nonuse were significantly increased for cardiovascular disease, all-cause mortality, obesity, metabolic syndrome, diabetes, hypertension, hypertriglyceridemia, and chronic kidney disease.

Risks Associated With Betel Quid vs Nonuse

End point Relative risk p
All-cause mortality 1.21 0.02
CVD 1.20 0.02
Obesity 1.47 <0.001
Metabolic syndrome 1.51 0.01
Diabetes 1.47 <0.001
Hypertension 1.45 0.06
Hypertriglyceridemia 1.63 0.04
Chronic kidney disease 1.55 0.004

Betel/areca nut contains four arecal alkaloids, and their nitrosated compounds are known to be carcinogenic; the World Health Organization has deemed betel-quid chewing a risk factor for oral and esophageal cancer.

To heartwire , Yamada noted that there are a range of potential mechanisms.

Betel nut contains substances that appear to increase the release of inflammatory mediators and reactive oxygen species that have the potential to cause chronic inflammation, hypothesized to play a role in the development of both diabetes and coronary disease.

Arecoline, found in betel quid, may promote appetite and potentially alter insulin secretion. Other neurological effects have also been proposed, linking betel-quid use to increases in heart rate and altered hemodynamics.

All of these potential mechanisms need to be studied in more detail, Yamada stressed. "This is just an epidemiological study" and subject to the many problems of combining large data sets collected in different populations at different points in time.

But the habit of chewing betel quid is actually on the rise, he continued, in part because it is cheap and considered to be somewhat "natural." It's particularly popular among undereducated populations—many of the same ones at risk for developing diabetes in these countries.

Asia, he points out, already has 60% of the world's diabetic population, and rates of the disease are growing faster in Asian and South Asian countries than anywhere else in the world.

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