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The other Micronesians Chuukese, Palauan, and Yapese generally preferred the unripe nut with the betel leaf, lime, and tobacco. According to Staples and Bevacqua 37 , the alkaloid levels are highest in the unripe fruits, and thus they provide a better stimulating effect. The strength of the areca nut may be a contributing factor to its preference among certain ethnic groups.

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The women chewed the young nut, however, preference for a particular variety was not mentioned:. However, the betel quid recipes obtained from the focus groups included harmful ingredients such as tobacco, and recently, alcohol. Those who added alcohol claimed it enhanced the experience. Betel quid chewing can become a habitual practice where tolerance increases with habituation. The Yapese women believed that the addiction to betel quid chewing resulted from the addition of tobacco to the quid:. But when you chew it with cigarette you get the nicotine from it and you get addicted.

A few of the Non-Chamorro Micronesians added cardamom, ginger, and vodka to their betel quid. One Chuukese and one Yapese participant had developed a relatively new habit of spiking their ingredients, such as the tobacco or areca nut, with vodka to enhance the euphoric effects. Swallowing was generally not practiced among the other Micronesians, probably due to the complex mixture of ingredients used with the unripe nuts and the physical impossibility of swallowing the large masticated husk. Two classes of chewers were identified from the latent class analysis.

Information gathered from the focus groups and latent class analysis suggests that Chamorros are more likely to chew the ripe, red areca nut; and swallow the masticated wad and juice even if the betel leaf is added. The Chuukese, Palauans, and Yapese are more likely to chew the unripe, areca fruit nut and husk with betel leaf, lime, tobacco from cigarette , and other spices; and spit out the juice and betel quid.

These behavioral differences and the reasons for such differences should be taken into account when developing interventions targeted to Micronesian communities. Chewing practices among the Chamorros seems to have evolved over the years. Chamorros are believed to have originated from Southeast Asia 38 , 39 , where betel quid chewing is also believed to have originated.

If the ancient Chamorros chewed as their Southeast Asian ancestors did, a plausible suggestion based on anthropological evidence of betel stains in the teeth of the remains of ancient Chamorros 26 , 27 , 40 , then the chewing patterns of today reflect hundreds of years of cultural change and adaptation.

It would be useful to understand the factors that drive such changes. Effects of Western contact, and whether or not areca nut and betel quid use can be applied as a phenotypic marker for acculturation, are worth exploring. One hypothesis is that as the island adopted more Westernized thoughts, chewing became less attractive, and resulted in decreasing popularity. Modern simplification, or the removal of ingredients from the betel quid, as reflected in the practice of modern day Chamorros who chew only areca nut, may have been for convenience and the desire to be more attractive less obvious.

This may also explain the preference for swallowing. Other Micronesian islands remain less westernized than Guam, and may be less acculturated to Western customs. As Micronesians continue to migrate, they may also bring their practices with them. The effects of such migration on chewing practices and prevalence in other countries are areas for further research. If future research should include an intervention, the differences in chewing practices should be considered for the intervention to succeed.

For example, betel quid chewing cessation may be more successful in the Chuukese community, a relatively new group of chewers, than in the Chamorro, Palauan, and Yapese communities where chewing is culturally embedded. This study was supported by the National Cancer Institute grant no. Special thanks to Vickie Ramirez and Dr.


Patricia Tschida for assistance with the qualitative data , Dr. Alana Steffan and Dr. National Center for Biotechnology Information , U. Hawaii J Public Health. Author manuscript; available in PMC Feb Yvette C. Murphy , PhD, RD 5. Suzanne P. Author information Copyright and License information Disclaimer. Copyright notice. The publisher's final edited version of this article is available at Hawaii J Public Health. See other articles in PMC that cite the published article. Results Areca nut and betel quid recipes collected from the focus groups showed that Chamorros had a preference for the ripe nut and swallowed the nut, whereas, the Chuukese, Palauan, and Yapese groups preferred the unripe nut and did not swallow it.

Implication If future research should include an intervention, the differences in chewing practices among Micronesian populations should be taken into consideration to ensure programmatic success. Introduction Approximately million people worldwide 1 chew areca nut from the Areca catechu palm tree. Focus group methods The focus group script was pilot-tested with a group of university students to train the facilitator. Who or what encouraged you to chew betel nut? What kind variety of betel nut did you first start chewing? What other ingredients did you put on your betel nut?

Since then, why did you decide to continue chewing betel nut? What other ingredients do you add? How much of each ingredient? Describe what you do with the betel nut mixture. Do you swallow the betel nut or do you spit it out? Do you now chew betel nut? How often do you chew betel nut? Do you include lime when you chew betel nut? Do you include tobacco when chewing betel nut? Tobacco can be twist tobacco, cigarettes, or canned tobacco. Do you include pupulu or pepper leaf when chewing betel nut? What variety of betel nut do you most often chew? Do you ingest swallow your chew?

Open in a separate window. Analysis Focus groups Focus group sessions were transcribed immediately after each session. Results Areca nut and betel quid preferences Recipes that were collected from the focus groups revealed differences in chewing patterns among ethnic groups Table 2.

Table 2 Summary of areca betel nut recipes submitted by focus group participants.

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Ethnic group Number of Participants Ingredients reported Swallow quid Comments Chamorro 18 Nut, red variety, ripe Betel leaf Yes One male used areca nut white, soft variety , lime calcium hydroxide , and tobacco from cigarette. Chuukese 11 Nut, white variety, unripe Betel leaf Lime Tobacco from cigarette not smoked No One male did not use tobacco. Two males added ginger. One female added ginger and cardamom. Two males added vodka. Yapese 10 Nut, unripe Betel leaf Lime Tobacco from cigarette not smoked No One female sometimes swallowed the betel quid.

Two males added cardamom. One male added vodka. Note: One participant refused to submit a recipe. Figure 1. Themes of areca betel nut chewing in Micronesian populations. Practices Areca nut chewing practice among the Chamorros was distinct from the other Micronesians Chuukese, Palauan, and Yapese. Acknowledgments This study was supported by the National Cancer Institute grant no. References 1. Gupta PC, Warnakulasuriya S.

Global epidemiology of areca nut usage. Addict Biol. World Health Organization. Betel-quid and areca-nut chewing and some areca-nut-derived nitrosamines. Lyon: International Agency for Research on Cancer; Pyridine and Piperidine Alkaloids. In: Brossi A, editor.

The Alkaloids.

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New York: Academic Press; A prospective community-population-registry-based cohort study of the association between betel-quid chewing and cardiovascular disease in men in Taiwan KCIS no. Betel-quid use is associated with heart disease in women. Am J Clin Nutr.

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J Occup Environ Med. Betel nut chewing and other risk factors associated with obesity among Taiwanese male adults. Int J Obes. Am J Epidemiol. The Guam Website-Hafa Adai. United States Census Bureau. Office of the Governor of Guam. Hagatna: Bureau of Statistics and Plans; Paulino YC. Describing and measuring variability of Areca catechu betel nut chewing in Micronesian populations in Guam.

Bernard HR. Research methods in anthropology: qualitative and quantitative approaches. Walnut Creek: AltaMira Press; Krueger RA. Focus groups: A practical guide for applied research. Newbury Park: Sage Publications; Centers for Disease Control and Prevention. Behavioral risk factor surveillance system operational and user's guide. Atlanta: Centers for Disease Control and Prevention; The discovery of grounded theory: strategies for qualitative research.

New York: Aldine Publishing Company; McCutcheon AL. Latent class analysis. Muthen B. Latent variable mixture modeling. New developments and techniques in structural equation modeling.

Affected countries

New Jersey: Lawrence Erlbaum Associates; Huyser-Honig J. Community or cash? Winstock A. Areca nut-abuse liability, dependence and public health. The FSM international trade publication release. Palikir: FSM; Government of the Federated States of Micronesia. Tobacco smoke and involuntary smoking. Tobacco habits other than smoking; betel-quid and areca-nut chewing; and some related nitrosamines.

Kennedy D. Skeletal biology of Apurguan: A precontact Chamorro site on Guam. A J Phys Anthropol. An assessment of health and disease in the prehistoric inhabitants of the Mariana Islands. Howden GF. The cariostatic effect of betel nut chewing. PNG Med J. The relation between betel chewing and dental caries. Scand J Dent Res. Hornung RS. Observations on the effects of betel-nut chewing. Agana: Guam Recorder; The oral characteristics of Guamanians including the effects of betel chewing on the oral tissues: part I. Oral Surgery. Relationship between quid additives and established periodontitis among Bangladeshi subjects.

J Clin Periodontol. Effects of chewing a mixture of areca nut and tobacco on periodontal tissues and oral hygiene status. The manner in which the people have arranged over the landscape varies from disbursed settlement to neatly clustered, but not overcrowded, villages. Special importance is attached to land in Micronesia both because of its short supply and its traditional importance.

Many parcels of land are held by families or clans. Still, visitors are able to access areas of interest in the country, and along the way they are afforded a glimpse into the daily activities of the people of the country. English is the official language of the government and of commerce. Many elderly people are fluent in Japanese. Some common phrases for each of the main languages are available below:. They are actually a heterogeneous mixture with different customs and traditions bound together by recent history and common aspiration. The cultural diversity is typified by the existence of eight major indigenous languages, although English remains the official language of commerce.

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The cultural similarities are indicated by the importance of traditional extended family and clan systems found on each island. Each of the State has developed unique cultural characteristics which are important to the potential outsiders especially those interested in visiting or investing in the islands. In Kosrae State, the Congregational Church plays an extremely important role in everyday life while in Chuuk, clan relationships remain an important factor. Yap continues as the most traditional society in the FSM with a strong caste system.

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Over the last 15 years Pohnpei has rapidly developed as the most westernized state in the nation. This results in large part because the national government is located here. At the same time, traditional leadership continues to play an important role.

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The people of the FSM are culturally and linguistically Micronesian, with a small number of Polynesians living primarily on Nukuoro and Kapingamarangi atolls of Pohnpei State. The influence of European and Japanese contacts is also seen. It can be said that each of the four States exhibits its own distinct culture and tradition, but there are also common cultural and economic bonds that are centuries old.

For example, cultural similarities are evidenced in the importance of the traditional extended family and clan systems found on each island. Although united as a country, the people are actually a heterogeneous mixture with different customs and traditions bound together by recent history and common aspirations. The cultural diversity is typified by the existence of eight major indigenous languages, and its peoples continue to maintain strong traditions, folklore and legends.

The four states of the FSM are separated by large expanses of water. Prior to Western contact, this isolation led to the development of unique traditions, customs and language on each of the islands. There is a rich oral history. Part of this history is a unique musical heritage. The traditional music is carried forward from generation to generation, although upon tuning into the local radio station the visitor is far more likely to hear the distinctive sounds of Micronesian pop music, which has also developed its own character from state to state. Influenced obviously by traditional music, the FSM's pop music also draws from influences as diverse as American country and western, reggae, and modern europop.

The basic subsistence economy is based on cultivation of tree crops primarily breadfruit, banana, coconut and citrus and root crops primarily taro and yam supplemented by fishing. Small scale agriculture and various traditional fishing practices continue today. Sharing, communal work, and the offering of tributes to the traditional leaders are fundamental to the subsistence economic system and the culture of the island societies of the FSM.

The basic economic unit is the household, which consists primarily of extended families. Larger solitary social groups found on most of the FSM islands are matrilineal clans. Traditional political systems, such as the Nahmwarki Political System on Pohnpei and the Council of Pilung on Yap, continue to play an important role in the lives of the people of the FSM today. The FSM has a rich history dating back several thousand years. The islands were originally settled by ancient people sailing east from Asia and north from Polynesia.

Later discoverers and settlers included the Spanish, Germans, and Japanese and evidence of their former presence is found throughout the islands. Following the trusteeship under U. II, the FSM is now independent and self-governing. Most linguistic and archaeological evidence indicates that the islands were first discovered and settled between two and three thousand years ago. The first settlers are often described as Austronesian speakers possessing horticultural skills and highly sophisticated maritime knowledge. These first settlers are thought to have migrated eastward from Southeast Asia to Yap.

The oral histories of the Micronesian people indicate close affiliations and interactions in the past among the members of the island societies comprising the present-day FSM. Spanish expeditions later made the first European contact with the rest of the Caroline Islands. Spain established its colonial government on Yap and claimed sovereignty over the Caroline Islands until At that time, Spain withdrew from its Pacific insular areas and sold its interests to Germany, except for Guam which became a U.

German administration encouraged the development of trade and production of copra. In German administration ended when the Japanese navy took military possession of the Marshall, Caroline and Northern Mariana Islands. Japan began its formal administration under a League of Nations mandated in During this period, extensive settlement resulted in a Japanese population of over , throughout Micronesia.

The indigenous population was then about 40, Sugar cane, mining, fishing and tropical agriculture became the major industries.