Betel-quid (BQ) chewing, often referred to as “pan” in South Asia, is an ancient cultural practice that continues to be widely prevalent across India and much of Asia. Areca nut, the psychoactive ingredient in betel quid, is considered one of the most commonly used psychoactive substances after nicotine, alcohol and caffeine (Gunjal et al., 2020; Stokes et al., 2022). Betel-quid preparations typically combine areca nut with betel leaf, slaked lime and frequently tobacco, with regional variations in composition across countries (Gunjal et al., 2020).
       
Areca nut and betel-quid use are associated with substantial adverse health effects. Reviews of the systemic toxicity of areca nut describe effects spanning multiple organ systems, including hepatotoxic, neurotoxic and metabolic disturbances (Garg et al., 2014; Mahdavi Mortazavi et al., 2023). There is concern in the growing evidence linking habitual betel quid chewing to harmful cardiovascular outcomes and all-cause mortality, as revealed in a large cohort of Taiwanese men (Lin et al., 2008) and validated by a more recent systematic review (Itaki and Taufa, 2024; Siam et al., 2024).
       
Experiments conducted in rat models have shown that betel nut exposure is a risk marker for cardiovascular complications (Iqbal et al., 2012), while in vitro studies on 3T3-L1 adipocytes have revealed that betel nut extract hampers insulin signalling and disrupts normal lipid storage (Hsieh et al., 2011). Behavioural and psychosocial studies point out that betel-quid chewing is commonly initiated and sustained by deeply rooted social and cultural factors, making cessation hard (Rao et al., 2023; Lee et al., 2014).
       
Arecoline, structurally like acetylcholine, activates muscarinic and nicotinic receptors, triggering cholinergic and sympathomimetic effects that may strain the cardiovascular system independent of lipid changes (Huang et al., 2024). It may also drive dyslipidaemia through oxidative stress and disrupted hepatic lipid/energy metabolism via PI3K-Akt and PPARα/Acox-1 pathways (Cao et al., 2025; Huang et al., 2024; Khan et al., 2026). However, evidence is mixed some studies show lipid-lowering rather than lipid-raising effects (Xu et al., 2025) highlighting the need for further human studies.
       
This burden is especially relevant in Northeast India, where sustained betel-quid and areca nut use is deeply embedded in tribal cultural identity. Mizoram reports a remarkably high betel quid use rate of 56.1% (Zomawia et al., 2025), higher than the national average of 23.9% of adults who consume areca nut, with or without tobacco (Mishra et al., 2025; Singh et al., 2021). The specific characteristics of the tribe, together with healthcare disparities (Deb Roy et al., 2023) and strong cultural acceptance, embedded within broader tribal dietary and lifestyle traditions of the region (Chintu et al., 2024), lead to the rising burden of chronic diseases among tribal populations (Phukan et al., 2005; Joo et al., 2020).
       
Global health authorities have explicitly called for a coordinated research and policy agenda to address the health burden of betel-quid and areca nut use (Mehrtash et al., 2017). Indeed, most of the existing metabolic data linking betel-quid use to metabolic syndrome originate from  East Asian cohorts (Aung et al., 2023; Huang et al., 2022), leaving a significant evidence gap for Mizo tribal communities that exhibit high rates of betel-quid use. Given the rising number of non-communicable diseases and the unique sociocultural roots of betel-quid use in Mizo society, there is a crucial need to study this behaviour among betel-quid users in this population. The present study therefore aims to investigate the association between betel quid chewing habits and lipid parameters among the type 2 diabetes tribal population of Mizoram, with the goal of generating region-specific evidence to inform targeted public health interventions. We hypothesized that betel-quid chewing is independently associated with adverse lipid and glycemic profiles among tribal adults with T2DM in Mizoram, after adjustment for relevant covariates.

Study design and setting
 
A cross-sectional observational study was conducted at public and private diabetic clinics in Aizawl, Mizoram, India, between April and June 2023. Ethical approval was obtained from the Institutional Human Ethics Committee of Avinashilingam Institute for Home Science and Higher Education for Women (Approval No. AUW/IHEC/22-23/FSN-6) and Zoram Medical College No. F.20016/1/18-ZMC/IEC/97, Aizawl, Mizoram. As this is a cross-sectional design, exposure and outcome were assessed at a single time point; accordingly, the associations reported in this study should be interpreted as correlational rather than causal.

Sample size determination
 
Calculation of the sample size was done using Daniel’s formula:

 
Where,
Z = 1.96 (95% confidence level).
P = 7.7% (prevalence of T2DM in Mizoram) According to ICMR-INDIAB-17 (Anjana et al., 2023).
d = 5% precision.
       
The minimum required sample size was 110 participants; however, 154 participants were enrolled during the study period of three months.
 
Study participants and eligibility criteria
 
Recruitment took place at the only two diabetic clinics, the only clinic available in Aizawl at the time of the study, Mizoram. Inclusion criteria were (1) receiving care at a diabetic clinic; (2) aged between 30 and 50 years; (3) HbA1c value between >6.5% and <10%; (4) willing to participate and (5) free of any critical illness at the time of recruitment.
 
Questionnaire construction
 
A structured questionnaire comprised three sections: the first included socio-demographic and clinical characteristics (age, sex, education, residence, treatment and years since diagnosis); the second comprised biochemical parameters (HbA1c, total cholesterol, triglycerides, HDL and LDL) and the third consisted of betel-quid consumption patterns (average daily frequency). Betel-quid consumption frequency was assessed using a single self-reported item on average daily quantity chewed, administered by trained interviewers as part of the structured questionnaire. This item was not independently validated against a biochemical marker of areca-nut exposure, nor was it formally pretested for reliability prior to use; frequency estimates therefore rely on participant recall and self-report, which may be subject to recall or social-desirability bias. The light (1-10), moderate (11-20) and heavy (>20 pieces/day) categories were derived from the observed distribution in this sample. No universally standardised cut-points exist for betel-quid quantity, but this tiering follows the general dose-band approach used in prior research, where comparable thresholds have been linked to graded increases in metabolic and pulmonary risk (e.g., Huang et al., 2021; Aung et al., 2023).
 
Biochemical data collection
 
Fasting blood parameters, including glycated haemoglobin (HbA1c) and serum lipid profile parameters (total cholesterol, triglycerides, HDL cholesterol and LDL cholesterol), were collected from patient records.  All biochemical assays for a given participant were performed in the diagnostic laboratory affiliated with the clinic at which they were recruited, complete standardisation across a single central laboratory could not be assured and this is acknowledged as a limitation.

Statistical analysis
 
Descriptive statistics were used to summarise the study variables. Normality was assessed using skewness, kurtosis, histograms and Q-Q plots, with no major violations of regression assumptions observed. Associations between betel-quid consumption and biochemical parameters were assessed using Pearson correlation. Hierarchical multiple linear regression was then performed for variables with significant correlations, adjusting for confounders (age, sex, education, years since diagnosis and treatment type), using IBM SPSS Statistics version 26.0. Betel-quid consumption was coded as an ordinal variable (0 = non-consumer, 1 = light, 2 = moderate, 3 = heavy) and entered as a single linear term in the regression model, reflecting an assumed dose-response relationship across categories. The variance inflation factor (VIF) was used to check for multicollinearity, with a significance level set at p<0.05.

Socio-demographic characteristics
 
The majority (61.7%) were in the age group 40-50 years, while 38.3% were aged 30-39 years. The distribution of gender was nearly equal, with 51.9% female and 48.1% male. 70.1% of the participants resided in urban areas, with the remaining 29.9% living in rural areas. Educational levels reveal that the largest proportion had completed intermediate schooling (31.2%), followed by graduate level (29.9%), high school (24.0%), primary (7.8%) and middle school (7.1%). Full socio-demographic details, including years since diabetes diagnosis and treatment type, are presented in Table 1.


 
Betel-quid chewing patterns
 
Among the 154 participants, 91 (59.0%) reported current betel-quid use, while 63 (41.0%) were non-consumers. The majority (68.0%, n = 62) consumed 1-10 betel-quids per day (light use); 26.0% (n = 24) consumed 11-20 betel-quids per day (moderate use); and 6.0% (n = 5) consumed more than 20 betel-quids per day (heavy use), as presented in Table 2.


 
Lipid profile, glycaemic parameters and pearson correlation
 
The mean biochemical values of the study participants, presented in Table 3, show mean total cholesterol (193.20±56.84 mg/dL), LDL cholesterol (97.63±33.36 mg/dL), HDL cholesterol (51.69±14.52 mg/dL) and triglycerides (216.50±96.54 mg/dL); the mean HbA1c was 8.62±2.08%.


       
The association between betel-quid consumption category (non-consumer, light, moderate and heavy use) and biochemical parameters was analysed using Pearson correlation, revealing statistically significant, small-to-moderate positive correlations with total cholesterol (r = 0.240, p = .003) and LDL cholesterol (r = 0.164, p = .043), suggesting an association with atherogenic lipid parameters across increasing levels of betel-quid exposure. Associations with HbA1c (r = 0.091, p = .267), HDL cholesterol (r = 0.128, p = .117) and triglycerides (r = 0.004, p = .965) were not significant. Hierarchical multiple linear regression analysis was further carried out for total cholesterol and LDL cholesterol.
 
Hierarchical multiple linear regression” of total cholesterol
 
To examine whether betel-quid consumption category independently predicted total cholesterol after controlling for age, sex, education, years since T2DM diagnosis and treatment type (Table 4a and 4b), hierarchical multiple linear regression was conducted. All 154 participants, including non-consumers, were included in this analysis. Model 1, comprising demographic and clinical covariates alone, was statistically significant (R² = .097, F (5,142) = 2.546, p = .023), explaining 9.7% of the variance in total cholesterol.




       
The addition of the betel-quid-consumption category in Model 2 produced a statistically significant increase in explained variance (ΔR² = .057, F (1,147) = 9.416, p = .003). The full model explained 15.4% of total variance (R² = .154; Adjusted R² = .112). Betel-quid consumption category emerged as a significant independent predictor of total cholesterol (B = 1.497, SE = 0.488, β = .244, t = 3.069, p = .003, 95% CI: 0.53–2.46), with each one-category increase in betel-quid consumption associated with a 1.497 mg/dL higher total cholesterol level, independent of the covariates examined. All VIF values were below 2.0, indicating no meaningful multicollinearity among predictors.
 
Hierarchical multiple linear regression of LDL cholesterol
 
Hierarchical multiple regression analysis was conducted to examine predictors of LDL cholesterol (mg/dL) as shown in Table 5a and 5b. In Model 1, socio-demographic and clinical variables (age, sex, education, duration of diabetes mellitus and treatment) explained 1.6% of the variance in LDL cholesterol (R² = 0.016; Adjusted R² = -0.025) and the model was not statistically significant (F = 0.395, p = 0.881).





In Model 2, betel-quid consumption frequency was added, resulting in a small increase in explained variance (R² = 0.039; Adjusted R² = -0.009). However, the change in R² was not significant (ΔR² = 0.023, p = 0.070). The overall model remained non-significant. None of the individual predictors were significantly associated with LDL cholesterol. Betel-quid consumption showed a positive but non-significant association (β = 0.155, p = 0.070). All VIF values indicated no multicollinearity concerns.
       
This cross-sectional study examined the association between betel quid chewing and biochemical markers of blood glucose and dyslipidaemia among 154 tribal patients with T2DM in Aizawl, Mizoram. The prevalence of current betel-quid use in this sample was 59.0%, consistent with the high regional burden of areca-based habits previously documented in Mizoram. Betel-quid consumption frequency was significantly and positively correlated with total cholesterol and LDL cholesterol at the bivariate level. After adjusting for age, sex, education, years since diagnosis and treatment type, betel-quid consumption category remained independently associated with total cholesterol, accounting for an additional 5.7% of variance beyond demographic and clinical covariates. The significant bivariate association with LDL cholesterol did not reach independent significance after adjusting for confounders.
       
The positive association between betel-quid consumption and total cholesterol is consistent with previous studies linking betel-quid chewing to cardiometabolic risk. Additionally, meta-analyses have reported elevated cardiovascular disease risk among betel-quid users (Itaki and Taufa, 2024) and a study of a Myanmar community similarly found that risk increases with the dose of betel-quid consumption (Aung et al., 2023). In contrast, the present study did not find a significant association with HbA1c, which diverges from prior reports of higher glucose levels among chewers (Hasan et al., 2020). This difference may reflect differences in population characteristics and betel-quid composition. As HbA1c reflects longer-term glycaemia, the absence of an association may also be due to a temporal mismatch, since exposure was evaluated at a single time point. Future studies should consider more comprehensive, longitudinal measures and additional glycaemic markers.
       
Several aspects merit discussion. First, the LDL association attenuated after adjustment (bivariate r = .164, p = .043; adjusted β = .155, p = .070), suggesting the crude association partly reflected covariates like age and education, though lower power for LDL, its stronger dependence on dietary fat and hepatic/genetic factors, or a more direct effect of betel-quid on total cholesterol specifically could also explain the pattern. Given the modest sample (n = 154), p = .070 is better read as an underpowered trend than a confirmed null. Second, residual confounding cannot be excluded. Dietary intake, alcohol use, smoking, BMI, physical activity and socioeconomic status were unmeasured. Since these behaviours often cluster with betel-quid use, including within tribal Mizo communities where chewing is embedded in broader lifestyle patterns (Rao et al., 2023), the observed associations may partly reflect unmeasured lifestyle factors rather than a direct effect of betel-quid itself. Third, Indian data remain scarce. A study linking areca-nut chewing to cardiovascular risk via hs-CRP (Vasanthi et al., 2022) and a Tamil Nadu study reporting higher total cholesterol/triglycerides and lower HDL among chewers (Ramya and Anuradha, 2015, non-diabetic sample) offer some support for biological plausibility, though few Indian studies examine lipid outcomes directly. Given the cross-sectional design and unmeasured confounders, these findings should not be interpreted as evidence of a causal effect of betel quid on lipid parameters.

This study provides one of the first quantitative examinations of the association between betel quid use and cardiometabolic markers in a specific region of the Northeast Indian tribal population. However, several limitations should be noted. The cross-sectional design precludes causal inference: because exposure and outcome were measured at the same time point, reverse causation cannot be ruled out and these findings should be read as associational, not causal. Betel-quid exposure was self-reported, which may introduce recall or social-desirability bias. The lack of data on tobacco content within betel-quid and unmeasured confounders such as diet and physical activity may also have shaped the findings. In addition, the restricted 30-50-year age range and recruitment from only two clinics in a single city limit the generalisability of these findings to the broader and typically older, T2DM population of Mizoram.
       
After adjusting for demographic and clinical covariates, betel-quid use was independently associated with elevated total cholesterol among tribal T2DM patients in Mizoram. These findings reveal an urgent need for culturally sensitive public health interventions targeting betel-quid cessation as part of comprehensive cardiometabolic risk management in communities with high rates of betel-quid consumption. Longitudinal studies integrating quid composition, diet and lifestyle covariates are further needed to clarify the causal pathways linking betel quid to lipid dysregulation.

The authors thank the participating diabetic clinics, healthcare staff and study participants in Aizawl, Mizoram, for their cooperation.
 
Disclaimers
 
The views and conclusions expressed in this article are solely those of the authors and do not necessarily represent the views of their affiliated institutions. The authors are responsible for the accuracy and completeness of the information provided but do not accept any liability for any direct or indirect losses resulting from the use of this content.
 
Informed consent
 
Ethical approval was obtained from the Institutional Human Ethics Committee of Avinashilingam Institute for Home Science and Higher Education for Women (Approval No. AUW/IHEC/22-23/FSN-6) and the Institutional Ethics Committee of Zoram Medical College (Approval No. F.20016/1/18-ZMC/IEC/97). Verbal informed consent was obtained from all participants prior to enrolment.

The authors declare that there are no conflicts of interest regarding the publication of this article. No funding or sponsorship influenced the design of the study, data collection, analysis, decision to publish, or preparation of the manuscript.