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Betel Nut Chewing Is Associated with Hypertension in Taiwanese Type 2 Diabetic Patients

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Betel Nut Chewing Is Associated with Hypertension in Taiwanese Type 2 Diabetic Patients 417 Hypertens Res Vol.31 (2008) No.3 p.417-423 Original Article Betel Nut Chewing Is Associated with Hypertension in Taiwanese Type 2 Diabetic Patients Chin-Hsiao TSENG1)-5) Betel nut chewing is associated with oral cancers and diabetes. This study investigated whether betel nut chewing could be associated with hypertension in Taiwanese patients with type 2 diabetes mellitus (T2DM). The data of a total of 81,226 (37,226 men and 44,000 women) patients with T2DM obtained from a cross-sec- tional telephone survey in a national sample of diabetic patients in Taiwan were analyzed. Hypertension was defined by a positive history or reported systolic blood pressure ≥140 mmHg and/or diastolic blood pres- sure ≥90 mmHg. Analyses were performed in separate sexes with consideration paid to the potential con- founding effects of age, diabetic duration, body mass index and smoking. The prevalences of betel nut chewing in men and women were 20.4% and 1.1%, respectively. Betel nut chewing was more common in the younger age groups of the male sex. The multivariate-adjusted odds ratios for hypertension in chewers vs. non-chewers were 1.067 (1.007–1.131) and 1.897 (1.534–2.346) for men and women, respectively. In mul- tiple linear regression, although no adjustment was made for the use of antihypertensive agents, betel nut chewing was significantly associated with blood pressure, with regression coefficients of 0.958±0.163 (SEM) for systolic and 0.441±0.108 for diastolic blood pressure in men; and the respective values for women were 1.805±0.618 and 1.198±0.393. In conclusion, betel nut chewing was significantly associated with hyperten- sion in Taiwanese patients with T2DM and the association was stronger in women. (Hypertens Res 2008; 31: 417–423) Key Words: betel nut chewing, smoking, hypertension, type 2 diabetes mellitus, Taiwan 600 million people who chew betel nuts worldwide (3). It is a Introduction common habit and is a means of social interaction in Asia, particularly the South Pacific islands, Southeast Asia, Papua The areca nut is the seed of the palm tree Areca catechu, and New Guinea, Bangladesh, Pakistan and India (1–4). Chewing is the fourth most commonly used psychoactive substance, of betel nuts was forbidden in Taiwan during the Japanese after caffeine, nicotine and alcohol (1). Because areca nuts are reign more than 60 years ago (4), but the habit has become always consumed with the leaves of the Piper betle, the chew- popular in Taiwan over the past several decades, and in 1997 ing of areca nuts has always been referred to as “betel nut it was estimated that about 2.4 million, or 11.4%, of the total chewing” in the English literature (2). There are an estimated population engaged in betel nut chewing (5). Moreover, the From the 1)Department of Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan; 2)Division of Endocrinology and Metab- olism, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; 3)Department of Medical Research and Development, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin, Taiwan; 4)School of Public Health, Taipei Medical University, Taipei, Taiwan; and 5)Division of Environmental Health and Occupational Medicine of the National Health Research Institutes, Taipei, Taiwan. This study was partly supported by grants from the Department of Health (DOH89-TD-1035), the National Taiwan University Hospital Yun-Lin Branch (NTUHYL96.G001) and the National Science Council (NSC-86-2314-B-002-326, NSC-87-2314-B-002-245, NSC88-2621-B-002-030, NSC89-2320- B002-125, NSC-90-2320-B-002-197, NSC-92-2320-B-002-156, NSC-93-2320-B-002-071, NSC-94-2314-B-002-142, NSC-95-2314-B-002-311 and NSC-96-2314-B-002-061-MY2), Taiwan. Address for Reprints: Chin-Hsiao Tseng, M.D., Ph.D., Department of Internal Medicine, National Taiwan University Hospital, No. 7 Chung-Shan South Road, Taipei, Taiwan. E-mail: [email protected] Received March 13, 2007; Accepted in revised form September 27, 2007. 418 Hypertens Res Vol. 31, No. 3 (2008) Table 1. Characteristics of Study Subjects by Betel Nut Chewing and by Sex Current or Characteristics Total Non-chewers p ex-chewers Men n (%) 37,226 (100.0) 7,585 (20.4) 29,641 (79.6) Age, years 61.3±11.9 57.3±11.0 62.4±11.9 <0.001 Diabetic duration, years 6.8±6.4 6.1±5.5 7.0±6.6 <0.001 Body mass index, kg/m2 24.5±3.4 24.7±3.5 24.4±3.4 <0.001 Hypertension, % 53.0 50.9 53.6 <0.001 Smoking, % 62.4 92.7 54.8 <0.001 SBP, mmHg 133.2±12.0 133.5±11.2 133.2±12.2 0.057 DBP, mmHg 79.4±7.9 79.6±7.7 79.3±8.0 <0.01 Women n (%) 44,000 (100.0) 471 (1.1) 43,529 (98.9) Age, years 63.0±10.9 61.2±10.9 63.1±10.9 <0.001 Diabetic duration, years 7.3±6.4 6.6±5.7 7.3±6.4 0.017 Body mass index, kg/m2 24.7±3.8 25.7±4.6 24.7±3.8 <0.001 Hypertension, % 54.9 69.6 54.7 <0.001 Smoking, % 3.2 42.0 2.8 <0.001 SBP, mmHg 132.6±13.3 134.9±14.6 132.6±13.3 <0.001 DBP, mmHg 79.0±8.4 80.7±7.9 79.0±8.4 <0.001 Data are mean±SD or %. chewing population continues to increase in Taiwan, espe- be needed to investigate the pathogenetic mechanisms, it may cially among younger males (6, 7). In Taiwan, unripe areca prove highly difficult to reach satisfactory conclusions on the nuts are commonly chewed with a mixture of lime and the associations between betel nut chewing and clinical diseases, leaves or flowers of the Piper betle, but without tobacco (4). due to the complex constituents of the nuts and leaves and the Betel nut chewing has been linked to a variety of health interactions among various active compounds that occur dur- problems, including oral lesions of leukoplakia, submucosal ing chewing. Moreover, any immediate effects observed fol- fibrosis, squamous cell carcinoma and periodontal disease (8, lowing betel nut chewing would not necessarily impact 9), albuminuria in diabetic patients (10), disruption of gastric human health over the long-term. For this reason, epidemio- mucosal barriers (11), aggravation of asthma (12), induction logic studies are needed to evaluate the link between betel nut of extrapyramidal syndrome (13), milk-alkali syndrome (14), chewing and medical conditions. To the best of our knowl- induction of uterine cervical dysplasia (15), cancers of the edge, there has not been any previous epidemiologic study esophagus (16) and liver (17), and low birth weight of babies evaluating the effect of betel nut chewing on hypertension born to mothers chewing betel nut (18). In more recent popu- status. The purpose of this study was to evaluate whether lation-based studies in Taiwan, betel nut chewing has also betel nut chewing in patients with T2DM could be associated been associated with a higher risk of type 2 diabetes mellitus with the prevalence of hypertension by analyzing the data (T2DM) (19) and total and cerebrovascular deaths (20). obtained in a national cohort of diabetic patients in Taiwan. Studies on the cardiovascular effects of betel nut chewing are rare, and there has not been any population-based epide- Methods miologic study evaluating this aspect of the habit. In an earlier study evaluating the cardiovascular response associated with Study Subjects betel nut chewing in a group of subjects in Taiwan, Chu found that betel nut chewing was associated with an elevated sys- The study was approved and supported by the ethics commit- tolic blood pressure (SBP) in fresh chewers but not in habitual tee of the Department of Health of Taiwan and conducted fol- chewers (21). However, a more recent study by the same lowing the local regulations. All subjects who submitted to group did not confirm this effect (7), but rather showed a sig- the telephone interview were first informed of the purpose of nificant drop of diastolic blood pressure (DBP) and an insig- the study and gave their consent to participate. Because more nificant increase of SBP in 30 healthy men (7). The small than 96% (after exemption of persons involved in military number of cases and the use of exclusively healthy subjects in services and those subject to criminal sanction, etc.) of the the later study could have been responsible for the discrep- total population of Taiwan has been covered by the compul- ancy in the observations. Although experimental studies will sory and universal National Health Insurance (NHI) plan Tseng: Betel Nut Chewing and Hypertension 419 Table 2. Distribution of Case Number by Betel Nut Chewing and by Age and Sex n (%) Age, years n p* Current chewers Ex-chewers Non-chewers Men <40 1,474 327 (22.2) 88 (6.0) 1,059 (71.8) <0.001 40–49 5,231 1,064 (20.3) 497 (9.5) 3,670 (70.2) 50–59 8,447 1,366 (16.2) 869 (10.3) 6,212 (73.5) 60–69 11,891 1,142 (9.6) 1,218 (10.2) 9,531 (80.2) ≥70 10,183 395 (3.9) 619 (6.1) 9,169 (90.0) Total 37,226 4,294 (11.5) 3,291 (8.8) 29,641 (79.6) Women <40 1,077 14 (1.3) 1 (0.1) 1,062 (98.6) <0.001 40–49 3,952 43 (1.1) 8 (0.2) 3,901 (98.7) 50–59 10,177 101 (1.0) 31 (0.3) 10,045 (98.7) 60–69 15,934 122 (0.8) 45 (0.3) 15,767 (99.0) ≥70 12,860 61 (0.5) 45 (0.3) 12,754 (99.2) Total 44,000 341 (0.8) 130 (0.3) 43,529 (98.9) *χ2 test.
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