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Allen L. Mozek, MPHIFPTI 2012-13 Fellow

New York State Department of AgricultureDivision of Food Safety & Inspection

U.S. Food Regulators’ Perceptions of ArecaNut as Food and Religious Exemption

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• Processed edible seed kernel

Areca catechu

• Fruiting palm tree

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• Areca nut• Betel leaf• Slaked lime (calcium

hydroxide)

Triune of Paan (Betel Quid)

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Food Condiments and Tobacco Are Optional

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Religious Ritual (puja) Non-Food Item in Hinduism, Buddhism, and Animism

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Background

• Areca nut and betel quid (with and without tobacco)cause oral cancer, oral submucous fibrosis (OSF) andother precancerous lesions. (WHO InternationalAgency for Research on Cancer, 2004).

• OSF is an unconventional chronic foodborne disease.

• OSF has a 7 to 30% malignant transfer rate.

• Areca nut is only etiologic agent for OSF.

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Constant irritation causes chronic inflammation;Alkaloid absorption in the mouth causes fibrosis

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OSF is observable—scarlet stained teeth and restrictive mouth opening (trismus)

Role of areca alkaloids in OSF (Ghom & Mhaske, 2008).

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• 600 million people (10 – 20 % of the world’spopulation) practice areca nut chewing culture on thesubcontinent of India and in South East Asia—including immigrants and refugees in the U.S.

• Areca nut (with natural alkaloids including arecoline) isthe fourth most common addictive substance in theworld after; alcohol, tobacco, and caffeine.

Background (continued)

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• U.S. food regulators may not be aware of areca nut orpaan.

• May not consider areca nut or paan as food.

• May not consider areca nut exempt from adulteration iflabeled: For Religious Purposes Only – Not ForHuman Consumption.

Problem Statement

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Methodology

• Food regulators in 20 metro areas (22 states) withlargest Asian populations surveyed.

• (19 of 108 (17.6%) responded).

Questions:• Have you heard of betel nut (areca nut)?• Have you heard of paan (betel quid)?• Do you consider betel nut a food?• Do you consider paan a food?• Would you consider a religious exemption?

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Heard of Betel Nut/Paan? Are They Food? (%)

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Religious Exemption if Labeled?

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• There is a lack of awareness amongst U.S. foodregulators regarding areca nut and paan (betel quid).

• Regulators are unsure if areca nut and paan are food.

• Only 10.5% of regulators would consider a religiousexemption.

Conclusions

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• Provide food regulators with evidence of the seriousharm caused by areca nut chewing; with and withouttobacco.

• Examine oral submucous fibrosis (OSF) as anunconventional chronic foodborne disease caused byconsumption of areca nut.

• Educate immigrants and refugees concerning thehealth effects from consuming areca nut products.

Recommendations

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• Inform health providers, serving at risk populations,about the likelihood of diagnosing OSF and otherprecancerous lesions and conditions.

• Regulate areca nut as an adulterated food.

• Exempt whole areca nut for religious worship whenpackaged and labeled; Not For HumanConsumption – Religious Purposes Only.

Recommendations (continued)

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• Cultural anthropology meets food safety.• The definition of food is challenged.• Religious exemption is unique.• Areca nut addiction (betelmania) meets tobacco

addiction.• U.S. food regulators can mitigate oral cancer and oral

sub mucous fibrosis (OSF) disease worldwide insofaras U.S. policy has a ripple effect worldwide.

Ancient Areca Nut (Betel Nut) Chewing Culture is where…

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1. Auluck, A., Hislop, G., Poh, C., Zhang, L., & Rosin, M. P. (2009).Areca nut and betel quid chewing among South Asianimmigrants to western countries and its implications for oralcancer screening. Rural Remote Health, 9,1118–1125.

2. Awang, M. N. (1986). Estimation of arecoline contents incommercial areca (betel) nuts and its relation to oralprecancerous lesions. Singapore Medical Journal, 27, 317-320.

3. Aziz, S. R. (2010). Coming to America: Betel nut and oralsubmucous fibrosis. Journal of the American Dental Association,141(4), 423-428.

4. Changrani, J., Gany, F. M., Cruz, G., Kerr, R., & Katz, R. (2006).Paan and gutka use in the United States: A pilot study inBangladeshi and Indian-Gujarati immigrants in New York City.Journal of Immigrant & Refugee Studies, 4(1), 99-109.

References

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5. Gupta, P. C. & Warnakulasuriya, S. (2002). Global epidemiologyof areca nut usage. Addiction Biology, 7, 77-83.

6. International Agency for Research on Cancer. (2004). Betel-quidand areca-nut chewing and some areca nut relatednitrosamines. IARC Monograph, 85, 1-334.

7. Stanley, J. (2010). Confessions of a white, middle-aged paaneater. Retrieved from http://nypress.com/confessions-of-a-white-middle-aged-paan-eater/

8. Sullivan, R. J. & Hagen, E. H. (2002). Psychotropic substance-seeking: Evolutionary pathology or adaptation? Addiction, 97,389-400.

9. U.S. Census Bureau. (2012). The Asian population: 2010. Retrieved from http://www.census.gov/prod/cen2010/briefs/c2010br-11.pdf

References (continued)

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• IFPTI mentors; James Sevchik, Dr. Preston Hicks, andJoseph Corby

• Erin Sawyer, NYS Department of Agriculture,Division of Food Safety and Inspection

• Dr. Ross Kerr, Director, Oral Mucosal DiseaseService, NYU College of Dentistry

• Prakash C. Gupta, Director, Healis – SekhsariaInstitute for Public Health, Navi, Mumbai, India

• Dr Pankaj Chaturvedi, Head and Neck Surgeon, TataMemorial Hospital, Parel, Mumbai, India

Acknowledgements

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Questions?