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from abuse to loss?

by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

pic1In Southeast Asia—Pakistan, India, Bangladesh, Thailand, Burma, Vietnam, and along the coast of China—and the Pacific Islands—from Indonesia, the Philippines, and east to Guam and Micronesia—a practice undertaken by about 600 million people is chewing betel nut, an activity akin to chewing Coca leaves as done in South America.  These are nuts of the tree Areca catechu, a type of palm tree that is believed to have originated in the area of the Philippines and Malaysia and was then cultivated over a wide region.  The nut (seed with the husk removed) is chewed with a pepper leaf (Piper betle) and a small amount of either lime (calcium oxide) or slaked lime (calcium hydroxide); various flavor ingredients, such as spices, can also be added, and tobacco might be included.  The pepper leaf, known as the betel leaf, wraps up the ingredients into a ball, commonly called a quid, that is chewed.  This practice is traced back at least 2,000 years in India, and appears to have been much older in some areas, based on archeological evidence of betel nuts in caves and remains of human teeth showing characteristic signs of the chewing.

pic2The main purpose of chewing the betel nut is to extract out the alkaloids, of which the dominant one is arecoline (related alkaloids present in smaller quantities are arecaidine, guvacoline, and guvacine) a process aided by the added lime (1).  Additionally, betel chewing is a distracting activity like chewing gum or smoking a cigarette, and it can also serve as a focal point for socializing.  The areca alkaloids are cholinergic agonists, which affect the nervous system functions via acetylcholine, and result in a stimulant action that increases capacity to work, and has euphoric effects with heightened alertness (as well as physical responses of increased salivation, warmth, and sweating).  Other natural cholinergic agonists are muscarine (from Amanita mushrooms) and nicotine (from tobacco); arecoline interacts preferentially with the muscarinic receptors, rather than those affected by nicotine (nicotinic receptors).  Muscarine is very toxic, arecoline is only mildly toxic. 

pic3If too much betel nut is used at one time, the symptoms of Amanita poisoning will result: intense discharges, including production of saliva, tears, and sweat; diarrhea and vomiting (accompanied by nausea and stomach cramps); and urinary incontinence; other symptoms can include fever and flushing, confusion, difficulty walking, memory lapse, and anxiety.   However, in ordinary amounts, chewing betel nut produces a desired response, which is a pleasant feeling.   The positive effects lead many to use betel nut habitually; the extent ranges from occasional to frequent.

Unfortunately, when people regularly chew betel nut, there can be adverse developments, particularly for the mouth, including inflammation (leukoplakia), fibrosis, and oral cancers (2).  Frequent use has the effect of turning the lips red and the mouth black (though that is reversible after ceasing its use), and the teeth can be damaged.  The carcinogenic agents in the betel quid are thought to be at least three of the constituents: arecoline, arecaidine, and safrole.   Safrole, from the pepper leaf, is the ingredient in original root beer that led to reformulation of the product without its key flavor ingredient: the safrole rich sassafras bark.   Arecoline and arecaidine from the nut may be promoters for other carcinogens (especially N-nitroso compounds with which they can combine); the areca alkaloids also contribute to changes in the oral mucosa that lead to the other detrimental oral effects.  The evidence for carcinogenicity in humans is primarily based on findings such as this one (3) relayed by the International Agency for Research on Cancer (IARC):

Oral cancers are more common in parts of the world where betel quid is chewed. Of the 390,000 oral and oro-pharyngeal cancers estimated to occur annually in the world, 228,000 (58%) occur in South and South-East Asia. In some parts of India, oral cancer is the most common cancer.  Striking evidence has emerged from Taiwan, where the incidence of oral cancer in men has tripled since the early 1980s, coinciding with a steep rise since the early 1970s and predominantly among men, in the practice of chewing betel quid. Tobacco generally is not added to the betel quid in that region.

The absence of tobacco in the Taiwanese quids, helps avoid the objection that it is inclusion of tobacco in the chewing material that is causing oral cancers.  In addition, it is suspected, though not proven, that regular chewing of betel nut also increases the occurrence of other cancers besides those of the mouth. 

Areca Nut in Chinese Medicine

Chinese herbalists have used betel nut for centuries in herbal decoctions and pills.  The inner portion (areca seed; binglang) is the same as the part chewed; the husk (areca peel, dafupi) is the part that is usually stripped off.  Both are used as qi-regulating diuretic agents and the seed is also used for antiparasitic therapies.  The excessive betel nut chewing, leading to a finding of elevated oral cancer incidence, has threatened these uses of the herb in Chinese formulas, even though there is no evidence that such use is carcinogenic.

In California, voters approved a measure in 1986 known as Proposition 65. The California Environmental Protection Agency issued a notice on February 3, 2006, listing areca nut as a carcinogen subject to the Prop 65 rules (4, 5).  They stated the basis for its addition to the Prop 65 list was the IARC monograph mentioned above that concluded: “Areca nut is carcinogenic to humans.”  The notices usually allow for a year before enforcement begins.

Although there may be no cancer risk (or no significant cancer risk) from using binglang or dafupi in herbal formulas, several herb companies are likely to remove this ingredient (or not include it in new formulations) rather than risk legal trouble in California or being compelled to label their products as containing carcinogens (though some are labeling all their products that way, realizing that customers eventually ignore the warnings).  A Prop 65 listing primarily affects companies that are based in California (as many Chinese herb companies are) and those who utilize California distributors of the product, but anyone selling to California is subject to its rules.  It is very difficult to prove that an herb is safe; it is much easier to suggest it could be harmful (such as from abuse of betel chewing). 


Areca seed and husk are not frequently used in the modern practice of Chinese medicine, so removing them from products will only have a limited effect.  However, it is worth reviewing what areca seed is used for to fully appreciate the impact of its absence.  When taken as a tea or pill, any stimulant properties experienced with betel nut chewing are very mild or absent, but the herb is considered a remarkable remedy for accumulations of moisture and phlegm.

The primary use of areca seed and husk are for alleviating fluid retention that is associated with qi stagnation.  The herb specialist Jiao Shude (6) makes a direct comparison of the two medicinals: “areca seed disperses hard accumulations, downbears qi, and moves phlegm; areca husk dissipates formless qi stagnation, disperses distention, and disinhibits water.” Put another way, the seed is for firm swellings with uprising qi, and the husk is for diffuse accumulations. 

There are many Chinese herbs for eliminating accumulated fluids, perhaps the most widely used are hoelen and atractylodes, neither of which disperse accumulations (citrus, magnolia bark, saussurea, and other dispersing herbs would be added for that purpose).  Areca seed has a reputation of getting rid of fluids that are stubbornly retained and that may adversely affect emotions (draining excess fluids as a means of treating spirit disorders was described in detail elsewhere; see the ITM booklet Towards a Spirit at Peace). 

Japanese physicians, more so than their Chinese counterparts, refer frequently to shuidu (water toxin) and lishui (hidden water), the concept that accumulated fluids can have a corrupt nature when they accumulate, leading to production of bizarre symptoms.  A key herb that they rely on for treating this condition is areca seed, which is understood to penetrate the hidden water and flush it out.  Areca seed is described in detail in the Shiwu Bencao (1571 A.D.), translated by Paul Unschuld (7):

Binglang.  Taste: acrid; nature: warm; no poison.  It promotes the digestion of grains and eliminates water.  It removes mucous congestions.  It relieves sensations of repletion [fullness], breaks through obstructions in the flow of qi and drains obstructions in the zangfu.  It is added to all medications meant to descend in the body.  It kills the three worms and the tapeworm.  If areca seed is consumed in large amounts, it damages the original qi.

The text goes on to describe the process of chewing areca seed (betel nut) which was a practice in the southern provinces of China at that time.  The reference to damaging original qi if areca seed is used in large amounts is consistent with the set of symptoms experienced by those who take betel nut chewing to excess.

Areca seed was described in another Chinese book, Yaoxing Bencao Yueyun, published around the same time, that described it this way (7):

Binglang. Taste: acrid-bitter; Nature: warm; no poison.  The drug belongs to the category yin within yang.  It descends in the body.  It penetrates the chest and abdomen and breaks through obstructions in the flow of qi; it cannot be stopped.  It penetrates the intestines and the stomach, removes mucous congestions and moves directly downward.  In all medications that are supposed to fall through [moving downward], this one shows itself to possess the properties of a piece of iron or of a stone.  After treatment, a powerful success occurs.  As quickly as a running horse, this herb penetrates the hand- and foot-yang brilliance conduits....This herb is even better than green-peeled zhishi.

The penetrating quality of areca is here emphasized, along with its ability to drain downward.  This means that if there is inhibition of urination or defecation it will resolve it.  It will also counteract flushing up of qi.  The reference to superiority of areca seed to chih-shih (green peeled zhishi) is made because the chih-shih is one of the most commonly used herbs for promoting the downward flow of qi and dispersing of accumulations.  Areca seed and chih-shih are the sole ingredients of Tongge Wan (Diaphragm Clearing Pill) for qi stagnation and dampness retention causing pressure in the diaphragm.  Jiao Shude makes this comparison:

Chih-shih has greater power than areca seed to abduct and disperse accumulation and stagnation and to eliminate glomus [mass] and fullness.  Areca seed has greater power than chih-shih to downbear qi and in addition it kills worms.

The accumulated fluids are often associated with feelings of pressure, swelling, lumps, and unusual symptoms.  The application of herbs for this type of condition is described by Noburo Muramoto, a Japanese herbalist; he recommended Areca Seed Combination (Jui Bing Wu Fu Tang) to be used “experimentally to treat strange and unrelated symptoms that do not lead to a clear diagnosis (8).”

Areca Seed Combination includes herbs used for treating neurotic syndromes, such as magnolia bark, perilla leaf, and hoelen. The formula also includes evodia, which contains alkaloids that may have some nervous system effects.  The other ingredients are cinnamon twig, rhubarb, and citrus.  The original formula name refers to its content of areca seed (binglang), evodia (wuzhuyu), and hoelen (fuling) as key components.   The formula is used for a large number of diverse symptoms and disorders.  According to Commonly Used Herb Formulas (9) the indications include rapid heartbeat due to anxiety, hypertension, gastroenteritis, multiple neuritis, rheumatism, fatigue, and climacteric disorders.  The primary indication, however, is “emotional distress.” 

Other formulas that contain areca seed as an ingredient and have similar applications, used mainly in Japanese practice of herbal medicine, are:

Most of the formulas have one or more citrus materials (citrus, chih-ko, chih-shih, aurantium): these components contribute essential oils that penetrate areas of obstruction, resolve phlegm, and disperse stagnated qi, and also contain the alkaloid synephrine, which has effects on the nervous system (if given in high enough dosage).  Several of the formulas contain the areca peel along with the seed.  

There are additional prescriptions of similar design that are mentioned in Chinese medical texts but are not relied upon by Japanese physicians (who have focused on applying the formulas for strange symptoms, undiagnosable masses, and various kinds of edematous swellings).  These other formulas (10), including Tiantai Wuyao San, Tiaogan Yin, Da Sanwan San, Liume Tang, Jiawei Wuyao Tang, Jiuqi Niantong Wan, and Kaixiong Shunqi Wan, all contain areca seed and saussurea.  The formulas are mainly used for discomfort or pain in the region of the chest and abdomen and for irregular menstruation.

Areca Seed in ITM Formulary

Areca seed has been included in three ITM formulas (11).  One is designed to help get rid of fluid accumulation causing prolonged problems that may be hard to diagnosis, called “Diagnostic Tablets.”  Another is Omphalia 11, which utilizes areca seed as an antiparasitic herb.  The third is a formula for digestive disorders, Huo Xiang Zheng Qi Pian. Areca seed is present in the amount of 12%, 15%, and 5% respectively.  In Diagnostic Tablets, areca seed can be removed, and the proportions of the remaining ingredients in the formula increased to take its place; the formula contains a number of other herbs for regulating qi and fluids, such as magnolia bark, aurantium, perilla leaf, and saussurea.  In Omphalia 11, areca seed is used to inhibit intestinal worms; it functions by affecting their nervous system, which is sensitive to the areca alkaloids, leading to their paralysis and detachment.  This herb can be replaced by sophora root, which recent studies show to be one of the more effective broad-spectrum anti-parasitic agents which also has this type of effect on intestinal worms (12).   In Huo Xiang Zheng Qi Pian, areca seed can be replaced by hoelen extract to boost the amount of that ingredient already in the formula, benefiting the digestive system.














painting showing Areca palms

July 2006