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Betel-quid dependence and oral potentially malignant disorders in six Asian countries

  • Chien-Hung Lee (a1), Albert Min-Shan Ko (a2), Cheng-Fang Yen (a3), Koung-Shing Chu (a4), Yi-Jun Gao (a5), Saman Warnakulasuriya (a6), Sunarjo (a7), Salah Osman Ibrahim (a8), Rosnah Binti Zain (a9), Walter K. Patrick (a10) and Ying-Chin Ko (a11)...
Abstract
Background

Despite gradual understanding of the multidimensional health consequences of betel-quid chewing, information on the effects of dependent use is scant.

Aims

To investigate the 12-month prevalence patterns of betel-quid dependence in six Asian populations and the impact of this dependence on oral potentially malignant disorders (OPMD).

Method

A multistage random sample of 8922 participants was recruited from Taiwan, mainland China, Indonesia, Malaysia, Sri Lanka and Nepal. Participants were evaluated for betel-quid dependency using DSM-IV and ICD-10 criteria and assessed clinically for oral mucosal lesions.

Results

The 12-month prevalence of dependence was 2.8-39.2% across the six Asian samples, and 20.9-99.6% of those who chewed betel-quid were betel-quid dependent. Men dominated the prevalence among the east Asian samples and women dominated the prevalence in south-east Asian samples. ‘Time spent chewing’ and ‘craving’ were the central dependence domains endorsed by the Chinese and southern/south-east Asian samples respectively, whereas the Nepalese samples endorsed ‘tolerance’ and ‘withdrawal’. Dependency was linked to age, gender, schooling years, drinking, smoking, tobacco-added betel-quid use and environmental accessibility of betel-quid. Compared with non-users, those with betel-quid dependency had higher pre-neoplastic risks (adjusted odds ratios 8.0-51.3) than people with non-dependent betel-quid use (adjusted odds ratio 4.5-5.9) in the six Asian populations.

Conclusions

By elucidating differences in domain-level symptoms of betel-quid dependency and individual and environmental factors, this study draws attention to the population-level psychiatric problems of betel-quid chewing that undermine health consequences for OPMD in six Asian communities.

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Copyright
Corresponding author
Professor Ying-Chin Ko, Centre of Excellence for Environmental Medicine, Kaohsiung Medical University, 100 Shih-Chuan First Road, Kaohsiung 807, Taiwan. Email: ycko@kmu.edu.tw
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Declaration of interest

None.

Footnotes
References
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Betel-quid dependence and oral potentially malignant disorders in six Asian countries

  • Chien-Hung Lee (a1), Albert Min-Shan Ko (a2), Cheng-Fang Yen (a3), Koung-Shing Chu (a4), Yi-Jun Gao (a5), Saman Warnakulasuriya (a6), Sunarjo (a7), Salah Osman Ibrahim (a8), Rosnah Binti Zain (a9), Walter K. Patrick (a10) and Ying-Chin Ko (a11)...
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eLetters

Betel Chewing and Psychiatry

K.A.L.A. Kuruppuarachchi, Professor of Psychiatry
13 February 2013

The article on Betel- quid dependence and oral potentially malignant disorders in six Asian countries (Lee et al. 2012)has been read with interest.

There is ample evidence that betel leaf has been chewed for centuriesin eastern countries and in fact it has been valued as having medicinal properties. It has also been widely used in various cultural and religiousoccasions such as in traditional wedding ceremonies, new year ceremonies,when worshiping the clergy /the elders / the teachers and inviting guests for an important event. Crushed piper betel trunk has been used as a substitute for tooth-brush to clean the teeth since ancient times in countries like Sri Lanka.

On the other hand many chew " adulterated betel quid" at present withother substances such as lime, areca nut and tobacco. This practice has been observed over the last few centuries. Alcohol and tobacco have been regarded as a taboo whereas betel chewing is socially acceptable amongst many. So much so many women also tend to chew betel quid without any hesitation. Many like to observe the reddish discolouration of the stuff and the saliva produced after chewing the betel quid in addition to its stimulating properties.

In fact the medicinal properties of the betel leaf(piper betel) has been documented and also its potential beneficial effects such as anti-carcinogenic, anti-mutagenic, anti-oxidant , anti-inflammatory and anti-bacterial properties have been mentioned. The influence of solvents with different polarities on the anti-inflammatory and anti-oxidant properties of piper betel leaf extracts has been studied(Pin et al. 2010) and concluded water as the most suitable and effective solvent to obtain betel leaf extracts. Unfortunately the current practice of chewing betel leaf with carcinogenic substances such as areca nut and tobacco is commonly seen.

Betel chewing is widely encountered amongst the people living between the east coast of Africa and the western Pacific.

It is note worthy that many patients with psychiatric disorders also tend to chew betel quid due to a variety of reasons perhaps in the hope ofalleviating some psychotropic induced side effects like akathisia as well as due to its stimulating properties. A study done with regard to effects of betel nut(Areca catechu) chewing on the symptoms of people with schizophrenia in Micronesia has shown that betel chewing was associated with milder symptomatology and significantly lower on the positive and negative symptom sub-scales of the PANSS amongst the chewersthan the non-chewers and postulated the beneficial effects of the compounds found in areca nut on the symptoms and suggested the need for further studies. Avoidance of more harmful recreational drugs amongst the betel chewers has also been observed(Sullivan et al. 2000). A study done in the North Colombo Teaching Hospital, Ragama, Sri Lanka demonstrated that patients with schizophrenia chewed betel more often than the controls ( Kuruppuarachchi & Williams 2003). On the other hand many working women from lower socio- economic classes in countries like Sri Lanka for example those employed in the tea estates and many rural women chew betel quid routinely. Those women have other vulnerability factors such as poor nutritional state to cause adverse pregnancy outcomes also.

As mentioned in the article this is a common problem yet in adequately addressed in our part of the world. Clinicians including psychiatrists must be aware of this important area and it's co-occurrenceand "co-morbidity " with other psychiatric disorders such as schizophreniaand even mood disorders.

We should initiate more research work with regard to the prevalence and dependence of betel chewing and its contribution to psychiatric disorders. Obviously we need to pay attention to its carcinogenic properties as well.

References;

Lee C-H, Ko A M-S, Yen C-F, Chu K-S, Gao Y-J et al. Betel - quid dependence and oral potentially malignant disorders in six Asian countries. British Journal of Psychiatry 2012; 201: 383 - 391.

Pin KY, Chuah AL, Rashih AA, Mazura MP, Fadzureena J, Vimala S, Rasadah MA. ANTIOXIDANT AND ANTI-INFLAMMATORY ACTIVITIES OF EXTRACTS OF BETEL LEAVES (PIPER BETEL) FROM SOLVENTS WITH DIFFERENT POLARITIES. Journal of Tropical Forest Science 2010; 22(4): 448- 455.

Sullivan RJ, Allen JS, Otto C, Tiobech J, Nero K. Effects of chewing betel nut (Areca catechu) on the symptoms of people with schizophrenia inPalau; Micronesia. British Journal of Psychiatry 2000; 177: 174 - 178.

Kuruppuarachchi KALA, Williams SS. Betel use and schizophrenia. British Journal of Psychiatry 2003; 182; 455.

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Conflict of interest: None declared

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