Betel nut (Areca catechu L.)
Natural Standard Bottom Line Monograph, Copyright © 2013 (www.naturalstandard.com). Commercial distribution prohibited. This monograph is intended for informational purposes only, and should not be interpreted as specific medical advice. You should consult with a qualified healthcare provider before making decisions about therapies and/or health conditions.
While some complementary and alternative techniques have been studied scientifically, high-quality data regarding safety, effectiveness, and mechanism of action are limited or controversial for most therapies. Whenever possible, it is recommended that practitioners be licensed by a recognized professional organization that adheres to clearly published standards. In addition, before starting a new technique or engaging a practitioner, it is recommended that patients speak with their primary healthcare provider(s). Potential benefits, risks (including financial costs), and alternatives should be carefully considered. The below monograph is designed to provide historical background and an overview of clinically-oriented research, and neither advocates for or against the use of a particular therapy.
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 Linn. (leaf of vine used to wrap betel nuts), pugua, ripe areca nut without husk, quid, Sting® (Tantric Corporation), supai, ugam.
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. Anecdotal reports have indicated that 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 the psychoactive effects to the alkaloids found in betel nuts.
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. There is little evidence to support the clinical use of betel nut, but the constituents have demonstrated pharmacological actions. The main active component, the alkaloid arecoline, has potent cholinergic activity.
Constituents of betel nut are potentially carcinogenic. Long-term use has been associated with oral submucous fibrosis (OSF), pre-cancerous oral lesions (mouth wounds), and squamous cell carcinoma (cancer). Acute effects of betel chewing include worsening of asthma, low blood pressure, and rapid heart beat.
These uses have been tested in humans or animals. Safety and effectiveness have not always been proven. Some of these conditions are potentially serious, and should be evaluated by a qualified healthcare provider.
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.
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. It is believed that small doses can lead to stimulant and euphoric effects, and betel nut chewing is popular due to these effects. Chronic use of betel nuts may increase the risk of some cancers, and immediate effects can include worsening of asthma, high or low blood pressure, and abnormal heart rate. 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.
*Key to grades:A: Strong scientific evidence for this use; B: Good scientific evidence for this use; C: Unclear scientific evidence for this use; D: Fair scientific evidence against this use (it may not work); F: Strong scientific evidence against this use (it likely does not work).
The below uses 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 health care professional.
Alcoholism, aphrodisiac, appetite stimulant, appetite suppressant, asthma, blindness from methanol poisoning, cough, dermatitis (used on the skin), 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).
The below doses are based on scientific research, publications, traditional use, or expert opinion. Many herbs and supplements have not been thoroughly tested, and safety and effectiveness may not be proven. Brands may be made differently, with variable ingredients, even within the same brand. The below doses may not apply to all products. You should read product labels, and discuss doses with a qualified healthcare provider before starting therapy.
Adults (18 years and older)
Betel nut can be chewed alone, but it is often chewed in combination with other ingredients (called a "quid") including calcium hydroxide, water, catechu gum, cardamom, cloves, anise seeds, cinnamon, tobacco, nutmeg, and gold or silver metal. These ingredients may be wrapped in a betel leaf, followed by sucking the combination in the side of the mouth. It is reported that ingestion of 8-30 grams of areca nut may be deadly.
Children (younger than 18 years)
Betel is not recommended in children due to risks of toxicity, including worsening symptoms of asthma, effects on the heart, and cancer.
The U.S. Food and Drug Administration does not strictly regulate herbs and supplements. There is no guarantee of strength, purity or safety of products, and effects may vary. You should always read product labels. If you have a medical condition, or are taking other drugs, herbs, or supplements, you should speak with a qualified healthcare provider before starting a new therapy. Consult a healthcare provider immediately if you experience side effects.
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.
Side Effects and Warnings
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.
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 ("milk alkali syndrome"), 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.
Most herbs and supplements have not been thoroughly tested for interactions with other herbs, supplements, drugs, or foods. The interactions listed below are based on reports in scientific publications, laboratory experiments, or traditional use. You should always read product labels. If you have a medical condition, or are taking other drugs, herbs, or supplements, you should speak with a qualified healthcare provider before starting a new therapy.
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. 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 that betel nut may interact with 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.
This information is based on a systematic review of scientific literature edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).
Natural Standard developed the above evidence-based information based on a thorough systematic review of the available scientific articles. For comprehensive information about alternative and complementary therapies on the professional level, go to www.naturalstandard.com. Selected references are listed below.
Chitra S, Ashok L, Anand L, et al. Risk factors for esophageal cancer in Coimbatore, southern India: a hospital-based case-control study. Indian J Gastroenterol 2004;23(1):19-21. View Abstract
Deng JF, Ger J, Tsai WJ, et al. Acute toxicities of betel nut: rare but probably overlooked events. J Toxicol Clin Toxicol 2001;39(4):355-360. View Abstract
Huang Z, Xiao B, Wang X, et al. Betel nut indulgence as a cause of epilepsy. Seizure. 2003;12(6):406-408. View Abstract
Jeng JH, Chang MC, Hahn LJ. Role of areca nut in betel quid-associated chemical carcinogenesis: current awareness and future perspectives. Oral Oncol 2001;37(6):477-492. View Abstract
Kuruppuarachchi KA, Williams SS. Betel use and schizophrenia. Br.J.Psychiatry 2003;182:455. View Abstract
Lee CN, Jayanthi V, McDonald B, et al. Betel nut and smoking. Are they both protective in ulcerative colitis? A pilot study. Arq Gastroenterol 1996;33(1):3-5. View Abstract
Liao CT, Chen IH, Chang JT, et al. Lack of correlation of betel nut chewing, tobacco smoking, and alcohol consumption with telomerase activity and the severity of oral cancer. Chang Gung Med J 2003;26(9):637-645. View Abstract
Mannan N, Boucher BJ, Evans SJ. Increased waist size and weight in relation to consumption of Areca catechu (betel-nut); a risk factor for increased glycaemia in Asians in east London. Br J Nutr 2000;83(3):267-273. View Abstract
Shiu MN, Chen TH, Chang SH, et al. Risk factors for leukoplakia and malignant transformation to oral carcinoma: a leukoplakia cohort in Taiwan. Br J Cancer 2000;82(11):1871-1874. View Abstract
Stoopler ET, Parisi E, Sollecito TP. Betel quid-induced oral lichen planus: a case report. Cutis 2003;71(4):307-311. View Abstract
Sullivan RJ, Andres S, Otto C, et al. The effects of an indigenous muscarinic drug, Betel nut (Areca catechu), on the symptoms of schizophrenia: a longitudinal study in Palau, Micronesia. Am J Psychiatry 2007;164(4):670-673. View Abstract
Tsai JF, Chuang LY, Jeng JE, et al. Betel quid chewing as a risk factor for hepatocellular carcinoma: a case-control study. Br J Cancer 3-2-2001;84(5):709-713. View Abstract
Tung TH, Chiu YH, Chen LS, et al. A population-based study of the association between areca nut chewing and type 2 diabetes mellitus in men (Keelung Community-based Integrated Screening programme No. 2). Diabetologia 2004;47(10):1776-1781. View Abstract
Wu IC, Lu CY, Kuo FC, et al. Interaction between cigarette, alcohol and betel nut use on esophageal cancer risk in Taiwan. Eur J Clin Invest 2006;36(4):236-241. View Abstract
Yin XM, Peng JY, Gao YJ. [Clinical study on the relationship between tooth abrasion and the habits of chewing betel nut]. Hunan Yi Ke Da Xue Xue Bao 2003;28(2):171-173. View Abstract
Copyright © 2013 Natural Standard (www.naturalstandard.com)
The information in this monograph is intended for informational purposes only, and is meant to help users better understand health concerns. Information is based on review of scientific research data, historical practice patterns, and clinical experience. This information should not be interpreted as specific medical advice. Users should consult with a qualified healthcare provider for specific questions regarding therapies, diagnosis and/or health conditions, prior to making therapeutic decisions.
March 22, 2017