Betel nut use refers to a combination of three ingredients: the nut of the betel palm (Areca catechu), part of the Piper betel vine, and lime. According to anecdotal reports, small doses generally lead to euphoria and increased flow of energy while large doses often result in sedation. Although all three ingredients may contribute to these effects, most experts attribute these effects to the alkaloid chemicals found in betel nuts. (Alkaloid chemicals are nitrogen containing compounds found primarily in plants; these chemicals may be medicinal or poisonous. Examples of alkaloids include nicotine, quinine, cocaine, strychnine, codeine, caffeine and morphine.)
Betel nut is reportedly used by a substantial portion of the world's population as a recreational drug due to its stimulant activity. Found originally in tropical southern Asia, betel nut has been introduced to the communities of east Africa, Madagascar, and the West Indies.
Amaska, Areca catechu, areca quid, areca nut, arecoline, arequier, betal, betel quid, betelnusspalme, chavica etal, gutkha, hmarg, maag, marg, mava, mawa, paan, Palmaceae (family), pan, pan masala, pan parag, pinang, pinlang, Piper betel (leaf of vine used to wrap betel nuts), pugua, ripe areca nut without husk, quid, supai, ugam.
Why It Is Used
The uses listed below are based on tradition or scientific theories. They often have not been thoroughly tested in humans, and safety and effectiveness have not always been proven. Some of these conditions are potentially serious, and should be evaluated by a qualified healthcare provider.
Alcoholism, aphrodisiac, appetite stimulant, appetite suppressant, asthma, blindness from methanol poisoning, cough, dermatitis (skin inflammation), digestive aid, diphtheria, diuretic, ear infection, excessive menstrual flow, excessive thirst, fainting, gas, glaucoma, impotence, intestinal worms, joint pain/swelling, leprosy, respiratory stimulant, toothache, veterinary uses (intestinal worms).
What the Science Says
There is little evidence to support the clinical use of betel nut. The chemicals in betel nut have demonstrated pharmacological actions. The main active component, the alkaloid arecoline, has potent cholinergic activity. Cholinergic chemicals increase vegetative functions; hence they slow the heart rate, stimulate digestive secretions, constrict the pupils and dilate blood vessels.
Early poor-quality research reports that betel nut chewing may lessen anemia in pregnant women. Reasons for this finding are not clear, and betel nut chewing may be unsafe during pregnancy.
Due to the known toxicities of betel nut use and the availability of other proven products for dental hygiene, the risks of betel nut may outweigh potential benefits.
Betel nut chewing may increase salivation. However, it is not clear if this is helpful for any specific health condition. Due to known toxicities from betel nut use, the risks may outweigh any potential benefits.
Preliminary poor-quality studies in humans suggest improvements in symptoms of schizophrenia with betel nut chewing. However, side effects such as tremors and stiffness have been reported. More research is necessary before a firm conclusion can be drawn.
It is believed that small doses can lead to stimulant and euphoric effects, and betel nut chewing is popular due to these effects. Based on the known toxicities of betel nut use, the risks may outweigh any potential benefits.
Several poor-quality studies report the use of betel nut taken by mouth in patients recovering from stroke. In light of the potential toxicities of betel nut, additional evidence is needed in this area before a recommendation can be made.
Currently, there is a lack of satisfactory evidence to recommend the use of betel nut for ulcerative colitis. Based on the known toxicities of betel nut use, the risks may outweigh any potential benefits.
Safety, Side Effects and Warnings
Breathing problems with betel nut use have been reported, although no allergic reactions are noted in the available scientific literature. Caution is warranted in people with allergies to other members of the Palmaceae family.
Betel nut cannot be considered safe for human use by mouth. This is due to toxic effects associated with short or long-term chewing or eating of betel nut. Constituents of betel nut are potentially carcinogenic. Long-term use has been associated with oral submucous fibrosis (OSF), pre-cancerous oral lesions, and squamous cell carcinoma (cancer). Acute effects of betel chewing include worsening of asthma, low blood pressure, and rapid heart beat.
Betel nut and chemicals in betel leaves may cause skin color changes, dilated pupils, blurred vision, wheezing/difficulty breathing, and increased breathing rate. Tremors, slow movements, and stiffness have been reported in people also taking anti-psychotic medications. Worsening of spasmodic movements has occurred in patients with Huntington's disease. Seizure has been reported with high doses.
Cholinergic toxicity symptoms from betel use may include salivation, increased tearing, lack of urinary control (incontinence), sweating, diarrhea, and fever. Other problems may include confusion, problems with eye movement, psychosis, amnesia, stimulant effects, and a feeling of euphoria. Long-term users may form a dependence on the effects of betel, and discontinuing use may cause signs of withdrawal, such as anxiety or memory lapse.
Chewing betel nuts can also cause nausea, vomiting, diarrhea, stomach cramps, chest pain, high or low blood pressure, and irregular heart beats. A heart attack occurred in a man immediately after chewing betel nut. It is not clear if betel was the cause.
Betel chewing has been shown to have a harmful effect on the gums. The nut may cause the teeth, mouth, lips, and stool to become red stained. Burning and dryness of mouth may occur.
Studies of Asian populations have linked pre-cancer conditions of the mouth and esophagus to betel use (oral submucous fibrosis). There may be a higher risk of cancers of the liver, mouth, stomach, prostate, cervix, and lung with regular betel use.
In animals, a chemical in betel nut alters blood sugar levels. Although human study is lacking in this area, caution is advised in people with diabetes or glucose intolerance, and in those taking drugs, herbs, or supplements that affect blood sugar. Serum glucose levels may need to be monitored by a healthcare provider, and medication adjustments may be necessary. Betel nut chewers may have a higher risk of developing type 2 diabetes. Animal studies show mixed effects on thyroid function and increased skin temperature. Other problems can include increased blood calcium levels and kidney disease, possibly due to calcium carbonate paste sometimes used for preparing betel nuts for chewing.
Some betel nuts may be contaminated with harmful substances, including aflatoxin (a toxin produced by mold) or lead. Betel nut may cause metabolic syndrome, immunosuppression, and liver toxicity.
Pregnancy and Breastfeeding
Betel nut is not recommended during pregnancy and breastfeeding due to the risk of birth defects or spontaneous abortion.
Interactions with Drugs
The effects of anticholinergic drugs may decrease when used in combination with betel nut or its constituent arecoline. Use with cholinergic drugs may cause toxicity (salivation, increased tearing, incontinence, sweating, diarrhea, vomiting, or fever). Betel nut may slow or raise the heart rate and could alter the effects of drugs that slow the heart, such as beta-blockers, calcium channel blockers, or digoxin.
Betel nut may alter blood sugar levels. Caution is advised when using medications that may also alter blood sugar. Patients taking drugs for diabetes by mouth or using insulin should be monitored closely by a qualified healthcare provider. Medication adjustments may be necessary.
Betel nut may increase the effects of monoamine oxidase inhibitors (MAOIs), angiotensin-converting enzyme (ACE) inhibitors, phenothiazines, cholesterol-lowering drugs, stimulant drugs, and thyroid drugs. Betel may increase or decrease the effects of anti-glaucoma eye drops. Reliable human study is lacking in these areas.
Other medications that betel nut may interact with include: antibiotics, medications that alter blood pressure, anti-inflammatory medications, or medications taken for cancer or immunosuppression. Patients taking anti-psychotic drugs should use cautiously due to reports of increased side effects. Based on the way betel nut is processed in the body, there may be interactions when taken with muscarinic antagonists. (Muscarinic drugs block cholinergic effects.) Furthermore, chronic use of betel nut and alcohol may lead to an increased risk of oral cancer.
Interactions with Herbs and Dietary Supplements
Taking betel with other cholinergic herbs may cause toxicity (salivation, tearing, urinary incontinence, sweating, diarrhea, vomiting, facial flushing, and fever) due to the chemical arecoline. Examples of cholinergic herbs include: American hellebore, jaborandi, lobelia, pulsatilla, and snakeroot. Betel may reduce the effects of herbs with possible anticholinergic properties, such as belladonna, henbane, hyoscyamine, and Swertia japonica Makino.
Betel may alter blood sugar levels. Caution is advised when using herbs or supplements that may also alter blood sugar. Blood glucose levels may require monitoring, and doses may need adjustment.
Betel may inhibit monoamine oxidase and therefore may increase the effects of herbs and supplements that may also inhibit monoamine oxidase. Betel nut may also interact with cardioactive agents, such as hawthorn or oleander, or agents that effect thyroid levels, such as bladderwrack.
Betel nut extracts may lower blood cholesterol levels and may increase the effects of agents that lower cholesterol levels, such as fish oil, garlic, guggul, and niacin.
Betel may cause stimulant and euphoric effects and add to the effects of stimulants such as caffeine, guarana, or ephedra (ma huang).
Betel has been reported to deplete an essential vitamin (thiamine) and theoretically may cause neurologic damage including Wernicke-Korsakoff syndrome (confusion, poor muscle coordination, eye movement problems, and amnesia). Based on human study, chewing betel nut may aggravate the effects of vitamin D deficiency. Theoretically, simultaneous long-term use of betel and alcohol may lead to an increased risk of mouth cancer.
Other herbs or supplements with which betel nut may interact include antibacterials, agents that alter blood pressure, anti-inflammatory agents, or agents taken for cancer or immunosuppression. Patients taking herbs with antipsychotic effects should use cautiously due to reports of increased side effects. Based on the way betel nut is processed in the body, there may be interactions when taken with herbs with muscarinic antagonists effects as well.
The FDA does not have the authority to test or approve the safety of herbal products before they are available for your consumption. Since the FDA does not regulate betel nut products, there is no guarantee of the strength, purity or safety of betel nut products; so effects may vary.
Just because an herbal product is labeled "natural" does not mean it is safe. Herbal supplements and remedies may have harmful effects and can interact with prescription and over-the-counter medications to cause severe side effects and complications.
Read product labels. Speak with your doctor before using any herbal remedy or supplement. Tell your doctor about any herbal remedies you already use and about any complementary and alternative practices you use. Give him/her a full picture of what you do to manage your health. This will help ensure coordinated and safe care. Call your doctor if you experience side effects.
The content of this posting is based on information from the National Institutes of Health.
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Deborah White, MD, MBA