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Misconceptions related to the areca nut chewing habits of Mainland China
Oral Oncology (2007) 43, 958– 959
available at www.sciencedirect.com
journal homepage: http://intl.elsevierhealth.com/journals/oron/
EDITORIAL
Misconceptions related to the areca nut chewing habits of Mainland China A recent evaluation of the English and Chinese literature on betel quid chewing (BQC) and/or areca nut chewing (ANC) in Mainland China has revealed new and until now unknown aspects of these habits.1 The patterns of areca chewing habits uncovered in our travels in Mainland China and in recent pilot surveys are outlined below: 1. the BQC/ANC habits are prevalent in only a few provinces of Mainland China and not, as has been described in the literature, in ‘‘China’’. 2. the BQC/ANC habits in Hunan province where they are mainly prevalent are different from the rest of Southand Southeast Asia. 3. the terminology used to describe areca nut vs. fruit among the constituents used for chewing by Chinese is misleading. Ad 1. In contrast to the literature on BQC/ANC the geographic prevalence of these habits in Mainland China seems to be restricted to only some southern provinces particularly Hunan Province. In a publication by Norton2 a map of distribution of ‘‘betel use’’ was shown which included China south of the Yangtsekiang river. Older maps often show the entire coast line of Mainland China to be an area where the BQC/ANC habits are prevalent, a concept which should be revised. In this context it has to be considered where in Mainland China the Areca catechu L. palm actually may be grown. In Hunan province where this habit is prevalent areca is not grown and fruits have to be imported from Hainan province or from Thailand. Ad 2. Areca husk is the main constituent of betel quid used by Chinese.1 Tang et al., however, referred to this as the ‘‘nut’’.3 Generally, areca nut is defined as the seed of the fruit of the oriental palm Areca catechu L.4 It is the basic ingredient of a variety of widely used chewed products. Use of the term ‘‘betel nut’’ is botanically incorrect; it has caused considerable confusion in the scientific literature and should be avoided.4
The misconception concerning the Chinese chewing pattern obviously occurred when other authors referred to the article by Tang et al.3 assuming that their description of the ‘‘nut’’ corresponded to the seed and not to the husk.5 This erroneous concept of terminology, therefore, has resulted in misinterpretation of scientific results of studies on epidemiology and associated oral lesions. In addition, this also brings up the issue of applicability of data from laboratory research reported on the nut (seed) rather than on the husk to Chinese people. Most laboratory studies so far have analysed alkaloids and metals in nut extracts rather than the fruit.6,7 In fact, the Monograph 85 of the IARC did not refer to the husk of the areca fruit as chewing substance at all.4 Further of interest was that in Hunan province the areca fruit products are available as commercial preparations which are produced on a large scale. Until now commercial preparations have only been known to exist as Pan Parag, Guthka and others in South Asia. Ad 3. In Hunan province the husk of the areca fruit is the main constituent of the quid. When Tang et al.3 described the habit, they referred to areca nut: ‘‘. . .In kiosks one areca nut is cut into two (each piece is approximately 2 g of weight) or four pieces and the kernel is taken out. The nut is chewed either alone or with additives. The additives include bittern, cassia twig oil, and kernel of the areca nut.’’ This description is rather confusing from two points of view: 1. The authors state that on the one hand the kernel (representing the seed) is removed but that on the other hand kernel of the areca nut is added as an additive. 2. The term ‘‘areca nut’’ is used although the main constituent is husk. Inquiries about the Hunan BQC/ANC habits have revealed three variants of the ‘‘quid’’:
1368-8375/$ - see front matter c 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.oraloncology.2007.01.020
Misconceptions related to the areca nut chewing habits of Mainland China 1. husk without areca nut (kernel, seed, endosperm) 2. husk with other substances e.g. dried grape 3. husk with areca nut The most common practice is variant 1 as most people chew the areca husk. Variant 3 is uncommon.
References 1. Zhang X, Reichart PA. A review of betel quid chewing, oral cancer and precancer in Mainland China. Oral Oncol 2007;43: 424–30. 2. Norton SA. Betel: consumption and consequences. J Am Acad Dermatol 1997;37:81–8. 3. Tang JG, Jian XF, Ling TY, Zhang KH. An epidemiological survey of oral submucous fibrosis in Xiangtan City, Hunan province, China. Community Dent Oral Epidemiol 1997;25:177–80. 4. IARC Monograph on the evaluation of carcinogenic risks to humans. Volume 85: Betel-quid and areca-nut derived nitrosamines, Lyon, France; 2004. 5. Gupta PC, Warnakulasuriya S. Global epidemiology of areca nut use. Areca nut symposium. Addict Biol 2002;7:77–83.
959
6. Lord GA, Lim CK, Warnakulasuriya S, Peters TJ. Chemical and analytical aspects of areca nut. Areca nut symposium. Addict Biol 2002;7:99–102. 7. Trivedy C, Baldwin D, Warnakulasuriya S, Johnson N, Peters T. Copper content in Areca catechu (betel nut) products and oral submucous fibrosis letter. Lancet 1997;349:1447.
P.A. Reichart ´, Department of Oral Surgery and Dental Radiology, Charite ¨tsmedizin Berlin, Campus Virchow Klinikum, Universita Augustenburger Platz 1, D-13353 Berlin, Germany Tel.: +49 30 450 56 26 02; fax: +49 30 450 56 29 01 E-mail address: [email protected] X. Zhang School and Hospital of Stomatology, Peking University, Beijing 100081, China E-mail address: [email protected] Available online 7 September 2007
available at www.sciencedirect.com
journal homepage: http://intl.elsevierhealth.com/journals/oron/
EDITORIAL
Misconceptions related to the areca nut chewing habits of Mainland China A recent evaluation of the English and Chinese literature on betel quid chewing (BQC) and/or areca nut chewing (ANC) in Mainland China has revealed new and until now unknown aspects of these habits.1 The patterns of areca chewing habits uncovered in our travels in Mainland China and in recent pilot surveys are outlined below: 1. the BQC/ANC habits are prevalent in only a few provinces of Mainland China and not, as has been described in the literature, in ‘‘China’’. 2. the BQC/ANC habits in Hunan province where they are mainly prevalent are different from the rest of Southand Southeast Asia. 3. the terminology used to describe areca nut vs. fruit among the constituents used for chewing by Chinese is misleading. Ad 1. In contrast to the literature on BQC/ANC the geographic prevalence of these habits in Mainland China seems to be restricted to only some southern provinces particularly Hunan Province. In a publication by Norton2 a map of distribution of ‘‘betel use’’ was shown which included China south of the Yangtsekiang river. Older maps often show the entire coast line of Mainland China to be an area where the BQC/ANC habits are prevalent, a concept which should be revised. In this context it has to be considered where in Mainland China the Areca catechu L. palm actually may be grown. In Hunan province where this habit is prevalent areca is not grown and fruits have to be imported from Hainan province or from Thailand. Ad 2. Areca husk is the main constituent of betel quid used by Chinese.1 Tang et al., however, referred to this as the ‘‘nut’’.3 Generally, areca nut is defined as the seed of the fruit of the oriental palm Areca catechu L.4 It is the basic ingredient of a variety of widely used chewed products. Use of the term ‘‘betel nut’’ is botanically incorrect; it has caused considerable confusion in the scientific literature and should be avoided.4
The misconception concerning the Chinese chewing pattern obviously occurred when other authors referred to the article by Tang et al.3 assuming that their description of the ‘‘nut’’ corresponded to the seed and not to the husk.5 This erroneous concept of terminology, therefore, has resulted in misinterpretation of scientific results of studies on epidemiology and associated oral lesions. In addition, this also brings up the issue of applicability of data from laboratory research reported on the nut (seed) rather than on the husk to Chinese people. Most laboratory studies so far have analysed alkaloids and metals in nut extracts rather than the fruit.6,7 In fact, the Monograph 85 of the IARC did not refer to the husk of the areca fruit as chewing substance at all.4 Further of interest was that in Hunan province the areca fruit products are available as commercial preparations which are produced on a large scale. Until now commercial preparations have only been known to exist as Pan Parag, Guthka and others in South Asia. Ad 3. In Hunan province the husk of the areca fruit is the main constituent of the quid. When Tang et al.3 described the habit, they referred to areca nut: ‘‘. . .In kiosks one areca nut is cut into two (each piece is approximately 2 g of weight) or four pieces and the kernel is taken out. The nut is chewed either alone or with additives. The additives include bittern, cassia twig oil, and kernel of the areca nut.’’ This description is rather confusing from two points of view: 1. The authors state that on the one hand the kernel (representing the seed) is removed but that on the other hand kernel of the areca nut is added as an additive. 2. The term ‘‘areca nut’’ is used although the main constituent is husk. Inquiries about the Hunan BQC/ANC habits have revealed three variants of the ‘‘quid’’:
1368-8375/$ - see front matter c 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.oraloncology.2007.01.020
Misconceptions related to the areca nut chewing habits of Mainland China 1. husk without areca nut (kernel, seed, endosperm) 2. husk with other substances e.g. dried grape 3. husk with areca nut The most common practice is variant 1 as most people chew the areca husk. Variant 3 is uncommon.
References 1. Zhang X, Reichart PA. A review of betel quid chewing, oral cancer and precancer in Mainland China. Oral Oncol 2007;43: 424–30. 2. Norton SA. Betel: consumption and consequences. J Am Acad Dermatol 1997;37:81–8. 3. Tang JG, Jian XF, Ling TY, Zhang KH. An epidemiological survey of oral submucous fibrosis in Xiangtan City, Hunan province, China. Community Dent Oral Epidemiol 1997;25:177–80. 4. IARC Monograph on the evaluation of carcinogenic risks to humans. Volume 85: Betel-quid and areca-nut derived nitrosamines, Lyon, France; 2004. 5. Gupta PC, Warnakulasuriya S. Global epidemiology of areca nut use. Areca nut symposium. Addict Biol 2002;7:77–83.
959
6. Lord GA, Lim CK, Warnakulasuriya S, Peters TJ. Chemical and analytical aspects of areca nut. Areca nut symposium. Addict Biol 2002;7:99–102. 7. Trivedy C, Baldwin D, Warnakulasuriya S, Johnson N, Peters T. Copper content in Areca catechu (betel nut) products and oral submucous fibrosis letter. Lancet 1997;349:1447.
P.A. Reichart ´, Department of Oral Surgery and Dental Radiology, Charite ¨tsmedizin Berlin, Campus Virchow Klinikum, Universita Augustenburger Platz 1, D-13353 Berlin, Germany Tel.: +49 30 450 56 26 02; fax: +49 30 450 56 29 01 E-mail address: [email protected] X. Zhang School and Hospital of Stomatology, Peking University, Beijing 100081, China E-mail address: [email protected] Available online 7 September 2007