U.S. Food Regulators’ Perceptions of Areca Nut as Food and Religious Exemption
Allen L. Mozek, MPH
IFPTI 2012 Fellow
New York State Department of Agriculture
Division of Food Safety & Inspection
Abstract
This study examines U.S. food regulators’ perceptions of areca nut as food and religious exemption of adulterated food. Areca nut is the processed edible seed kernel of the Areca catechu fruiting palm tree. Areca nut is the fourth most commonly used addictive psychoactive substance in the world after tobacco, alcohol, and caffeine-containing beverages (IARC, 2004). Areca nut itself has been classified as a Group 1 carcinogen (carcinogenic to humans) by the International Agency for Research on Cancer (IARC, 2004)). Areca nut consumption causes an unconventional chronic foodborne disease called oral submucous fibrosis (OSF) and other precancerous lesions and conditions. Ancient areca nut chewing culture is practiced by 600 million people on the Indian subcontinent and in Southeast Asia (Gupta & Warnakulasuriya, 2002; Sullivan & Hagen, 2002). The number of U.S. immigrants and refugees from these regions has increased from 2000 to 2010 faster than the general population (U.S Census, 2010). Asian immigrants and refugees have access to areca nut in South Asian and Southeast Asian food stores and restaurants in New York City (Changrani et al, 2006) and other U.S. metro areas with large Asian populations. An electronic survey was conducted of 19 food regulators to gauge perception of areca (betel) nut and paan as food and as a religious exemption. Survey results revealed a lack of awareness and uncertainty among the regulators. Additional studies are warranted, especially in metro areas with large Asian populations.
Background
The sale and use (chewing and consumption) of areca nut, which is a definitive cause of oral submucous fibrosis (OSF) (Aziz, 2010), is not regulated as either a food or drug in the United States; however, the availability of areca nut is increasing due to demand from growing Asian immigrant and refugee populations. The use of areca nut and common food combinations called paan (betel quid) can be defined by four main categories: social acceptability, religious beliefs, perceived health benefits, and addiction (IARC, 2004).
Areca nut is commonly and incorrectly referred to as ‘betel nut’ through association with the betel leaf (Piper betel). Areca catechu fruit is akin to stone fruits such as peaches, apricots, and cherries. The mature fruit is the size of a mango and is a mottled orange in appearance. Areca fruit is usually listed as an edible fruit and is therefore normally sold as a food, although the food value is uncertain (IARC, 2004). The areca fruit is most valuable for the seed kernel or “nut”, which is processed overseas by de-husking, boiling, sun drying, roasting, and fermenting. The result is a very hard nut, the size of a small egg, with a tan exterior and a mottled whitish or reddish colored interior.
Asian immigrants and refugees in the United States and other Western countries retain areca nut chewing culture (Auluck et al., 2009). Asian immigrant populations that practice areca nut chewing culture are increasing in the U.S. faster than the general population. The Asian Indian population grew 24.6% between 2000 and 2010 in New York State, and 12.5% in New York City during the same period (U.S. Census, 2010). According to the 2010 Census, there are 3.2 million Asian Indians in the U.S. OSF is predominantly affecting Asian Indians.
There is a concern that the habit of spitting out some of the contents of paan (betel quid) has changed and more of the contents are now being swallowed in Western countries. This change in habit may increase the risk of hypopharyngeal and esophageal cancer (Nandakumar et al., 1996). South Asian communities are generally not aware that areca nut chewing can cause oral cancer and that ceasing its use would reduce the likelihood of developing oral cancer. Reports also suggest that many shopkeepers selling these chewing products are not aware of any health risks (IARC, 2004).
Dry areca nut imported into the U.S. is a processed, ready-to-eat food and not a raw agricultural commodity. The nut is imported whole, sliced, crushed, or shredded and has been reported to be adulterated and misbranded by the U.S. Food & Drug Administration (FDA) and the New York State Department of Agriculture. Areca nut is offered for sale in New York State and New York City via Asian Indian restaurants and South Asian food stores in the form of freshly prepared paan (betel quid) and bulk packages of sliced areca nut. Many Asian Indian restaurants and Asian Indian video stores in New York City prepare fresh paan for sale for about one U.S. dollar (Stanley, 2010; Changrani et al, 2006).
The areca nut natural alkaloid toxins, principally arecoline, are similar to other toxic plant alkaloids. Mushroom poisoning is an example of a natural plant poison and foodborne disease. Areca nut consumption is the definitive cause of oral submucous fibrosis (OSF) (Aziz, 2010) – an unconventional chronic foodborne disease. OSF is a chronic disorder characterized by fibrosis of the lining mucosa of the upper digestive tract involving the oral cavity, oro-and hypopharynx and the upper third of the esophagus. The fibrosis involves the lamina propria mucosa and the submucosa and may often extend into the underlying musculature, resulting in the deposition of dense fibrous bands. These bands give rise to the limited mouth opening called trismus, which is a hallmark of this disorder (IARC, 2004).
The United States Federal Food, Drug, and Cosmetic Act defines “food” as (1) articles used as food or drink for man or other animals, (2) chewing gum, and (3) articles used for components of any such articles. Areca nut is a component of paan (betel quid) which, in turn, contains conventional foods. Tobacco ingredient in conventional foods is not considered generally recognized as safe (GRAS) by the FDA. The addition of tobacco to conventional foods in the U.S. deems that food adulterated.
Areca nut is considered an adulterated food under Sections 402 and 801 of the U.S. Federal Food, Drug, and Cosmetic (FD&C) Act according to the FDA and the New York State Department of Agriculture (Stanley, 2010). In fact, the FDA provided Congressional testimony in 2000 opposing a measure (HR.2462) to exempt betel nuts from being adulterated under the FD&C Act. The FDA testimony claimed that exempting an unsafe food like betel nuts undermined the important public health provisions of the FD&C Act.
Problem Statement
South Asian and South East Asian immigrant and refugee populations practicing areca nut chewing culture have an increased risk of OSF and oral cancer due to consuming areca nut. The level of U.S. regulatory food safety professionals’ knowledge of areca (betel) nut and paan (betel quid) and their perception of either as a food is unknown. Additionally, regulatory food safety professionals’ perception of a religious exemption for non-food use of an adulterated food is also unknown.
Research Questions
What are U.S. regulatory food safety professionals’ perceptions of areca (betel) nut and paan (betel quid) as food? What are regulatory food safety professionals’ perceptions of a religious exemption for an adulterated food if labeled: For Religious Purposes Only – Not for Human Consumption?
Methodology
A survey was conducted of 108 food regulators in 22 States via email (Survey Monkey). The email addresses were obtained from the Association of Food and Drug Officials (AFDO) - Directory of State and Local Officials (DSLO). The States were chosen that correspond to the top 5 Asian Groups in 20 Metro Areas with the largest Asian populations per the 2010 U.S. Census. Regulatory food safety professionals from Health Departments, Departments of Agriculture, and State Epidemiologists were surveyed. No background explanation was provided for the questions. The questions were;
Have you heard of betel nut (areca nut)?
Have you heard of paan (betel quid)?
Do you consider betel nut a food (betel nut is a processed edible seed kernel that is chewed)?
Do you consider paan a food (paan is betel nut with edible limestone paste wrapped in a betel leaf with optional condiments that is chewed)?
Would you consider a religious exemption for an adulterated food if labeled: For Religious Purposes Only – Not for Human Consumption?
Results
Nineteen of 108 regulators responded to the survey (17.6%). Figure 1 shows the percentage of respondents who had heard of betel nut or paan and considered betel nut or paan a food. Approximately fifty-eight percent (57.9 %) of respondents had heard of betel nut, and a little over twenty-six percent (26.3%) of respondents had heard of paan. Approximately forty-two percent (42.1%) considered betel nut a food, 10.5% did not consider betel nut a food, and 47.4% were unsure. Just over thirty-one percent (31.6%) considered paan a food, 10.5% did not consider paan a food, and 57.9% were unsure (Figure 1).
Approximately ten percent (10.5%) of respondents would consider a religious exemption for an adulterated food if labeled: For Religious Purposes Only – Not for Human Consumption; 42.1% would not consider a religious exemption, and 47.4% were unsure (Figure 2).
Conclusions
This survey reveals a lack of awareness amongst the respondents of both areca (betel) nut and paan (betel quid), and uncertainty as to whether betel nut or paan are food. The results also reveal uncertainty as to whether a religious exemption applies to an adulterated food if labeled: For Religious Purposes Only – Not For Human Consumption. The exclusive use of this product by Asian immigrants and refugees and the foreign cultural practice of chewing, consumption, and religious worship may account for the lack of investigation, enforcement, and awareness. The small sample size of respondents may reflect the reluctance of the respondents to comment about a subject they are not familiar with. Additional studies are warranted regarding areca nut and paan (betel quid) use patterns in metro areas with large Asian populations. Research should be conducted involving health care providers (especially oral surgeons and dentists) serving at-risk populations (people who practice areca nut chewing culture) regarding the prevalence of diagnosing OSF and oral cancer in relation to the general population.
Recommendations
Provide U.S regulatory food safety professionals with evidence of the serious harm caused by areca nut and betel quid consumption.
Examine oral sub mucous fibrosis (OSF) as an unconventional chronic food borne disease caused by consumption of areca nut.
Educate immigrants and refugees concerning the health effects from consuming areca nut products.
Inform health providers serving at risk populations about the likelihood of diagnosing oral sub mucuou fibrosis (OSF) and other precancerous lesions and conditions.
Regulate areca nut as an adulterated food.
Exempt whole areca nut for religious worship when packaged and labeled: Not for Human Consumption – Religious Purposes Only.
Build collaborations between medical centers, academia, health providers, and food regulatory agencies in the U.S. and India regarding education and measured enforcement based on thoughtful regulatory policy.
Re-examine regulatory policy when areca nut is combined, in any formulation, with tobacco.
Acknowledgements
I would like to thank my IFPTI mentors: James Sevchik, Dr. Preston Hicks, and Joseph Corby; Erin Sawyer of the NYS Department of Agriculture, Division of Food Safety and Inspection; Dr. Ross Kerr, Director of the Oral Mucosal Disease Service at the NYU College of Dentistry; and Dr. Prakash C. Gupta, Director of the Healis – Sekhsaria Institute for Public Health in Navi Mumbai, India.
References
Auluck A, Hislop G, Poh C, Zhang L, Rosin MP. (2009). Areca nut and betel quid chewing among South Asian immigrants to Western countries and its implications for oral cancer screening. Rural Remote Health. 9,1118–1125.
Awang, MN. (1986). Estimation of arecoline contents in commercial areca (betel) nuts and its relation to oral precancerous lesions. Singapore Medical Journal, 27, 317-320.
Aziz, SR. (2010). Coming to America: Betel nut and oral submucous fibrosis. Journal of the American Dental Association 141(4), 423-428.
Bunning V.K., Lindsay J.A., Archer D.L. (1997) Rapport Trimestrial de Statistiques Mondiales. World Health Statistics Quarterly, 50(1-2), 51-56.
Changrani J, Gany FM, Cruz G, Kerr R Katz R. (2006) Paan and Gutka Use in the United States: A Pilot Study in Bangladeshi and Indian-Gujarati Immigrants in New York City. Journal of Immigrant & Refugee Studies 4(1), 99-109.
Gupta MK, Mhaske S, Ragavendra, Raja, Imtiyaz. (2008). Oral submucous fibrosis – Current Concepts in Etiopathogensis. People’s Journal of Scientific Research, 1, 39-44.
Gupta PC & Warnakulasuriya S. (2002). Global epidemiology of areca nut usage. Addiction Biology 7, 77-83.
Gupta, PC, Ray CS. (2004).Epidemiology of Betel Quid Usage. Academy of Medicine Singapore; 33(Supplement), 31S-36S.
International Agency for Research on Cancer. (2004). Betel-quid and areca-nut chewing and some areca nut related nitrosamines. IARC Monographs 85, 1-334.
Lindsay JA. (1997) Chronic Sequelae of Foodborne Disease. Emerging Infectious Diseases, 3(4), 443-452.
Murti PR, Bhonsle RB, Gupta PC, Daftary DK,Pindborg JJ, Metha FS. (1995). Aetiology of oral submucous fibrosis with special reference to the role of areca nut chewing. Journal of Oral Pathology & Medicine, 24, 145–152.
Nandakumar A, Thimmasetty KT, Sreeramareddy NM, Venugopal TC, Rajanna, Vinutha AT, Srinivas, Bhargava MK. (1990). A population-based case-control investigation on cancers of the oral cavity in Bangalore, India. British Journal of Cancer, 62(5), 847–851.
Pickwell SM, Schimelpfening S, Palinkas LA. (1994) ‘Betelmania’. Betel quid chewing by Cambodian women in the United States and its potential health effects. Western Journal of Medicine, 160, 326–330.
Shah N, Sharma PP. (1998). Role of chewing and smoking habits in the aetiology of oral submucous fibrosis (OSF): a case control study. Journal of Oral Pathology & Medicine, 27, 475-479.
Stanley J. (2010). Confessions of a White, Middle-Aged Paan Eater. Retrieved from http://nypress.com/confessions-of-a-white-middle-aged-paan-eater/.
Sullivan RJ & Hagen EH. (2002) Psychotropic substance-seeking: Evolutionary pathology or adaptation? Addiction 97, 389-400.
U.S. Census Bureau. (2012). The Asian Population: 2010. Retrieved from http://www.census.gov/prod/cen2010/briefs/c2010br-11.pdf.