Sugar Sweetened Beverages and Tooth Decay in the YK Delta

09/09/14, Bethel, Alaska: Sugar sweetened beverage consumption in the YK is implicated as the driving force in the Alaska Native childhood tooth decay epidemic. Sugar sweetened beverages include instant Tang, Kool Aid, Sunny Delight, energy drinks, and soda. Tap water is either unavailable or tastes bad in the YK.

Sugar sweetened beverages are relatively inexpensive and abundantly available in village grocery stores. In addition, while it is well known that soda pop contains high concentrations of sugar, many parents are unaware of the amount of hidden sugars present in juices and other sugared beverages.

Our research team, consisting of collaborators from UW, UAF, and YKHC, received pilot funding from the UW Royalty Research Fund. Our goal was to use a novel biomarker to measure sugar sweetened beverage (added sugar) consumption in childrens' diets and to develop a community-based intervention aimed at reducing added sugar intake by targeting sugar sweetened beverage intake.

In January 2014, we traveled to Bethel and spent about 2 weeks enrolling study participants. We enrolled 54 children and adolescents ages 6 to 17 into our study. We spent the next few months processing and analyzing data. Our findings indicate that YK children consume the equivalent of 5 cans of Coke each day. This is over 16 times the maximum amount of added sugars recommended for children. Parents and community members were stunned.

During our 2-day stay in Bethel, we presented study findings to parents of participants, disseminated study findings to YKHC health providers and community stakeholders, recruited members of a Community Planning Group (CPG), and convened our first CPG meeting to generate a series of community-based interventions.

The trip was very successful and we generated a preliminary intervention. In the next few months, we will work with our CPG and YKHC partners to fine tune our intervention and apply for NIH research funding.

Sour dock and tundra

06/10/14, Chefornak, Alaska: After a productive day in clinic, I met the Dental Assistant and her two sisters, niece, nephew, and Golden Retriever puppy (Zola) near the local store so we could take a walk on the Alaksa tundra. Our goal was to look for and pick sour dock – a redish-greenish leaf that grows wild near ponds in the summer. When we got close to one of the many large ponds, I saw sour dock growing in small patches. As I picked the leaves, I tried a few and found that it is sour (thus the name) and really tasty. It would a great addition to a leafy summer salad. We picked two large bags of sour dock and quickly began walking back to town – it was extremely wind and about 42 degrees.

Sour dock is chopped into small pieces and boiled for a few minutes.It is then frozen and used in sour dock agudak, an Alaska Native dessert that consists of instant potato flakes (a binder), hot water, Crisco (or seal oil), and sugar. The Dental Assistant’s mother made a special batch of sour dock agudak and brought it to the clinic. I was only able to take a few bites before heading to the airport. It was a super interesting treat. Two nights ago, when I went over to the Assistant's home for dinner, I had a large serving of homemade blackberry agudak. It was awesome.

As we walked back, I quickly learned that it’s easy to lose your footing. The tundra is soft and soggy. There were berry blossoms all over and a rich moss that looked like wood shavings.

Half-way point - fish, fish, fish

06/07/14, Chefornak, Alaska: It’s the start of day 6 of 12. During the long summer days, Alaskan villagers are busy catching and preparing fish, picking berries, and hunting – all in preparation for the nose-hair-freezing winter. Subsistence fishing/farming/hunting help Alaska Natives survive the long winter. Currently, it’s the height of the fishing season. Later in the summer will be berry picking and hunting. Of course, the specific harvested goods vary from community to community.

I walked to the local grocery store on day 3 to explore Chefornak and get some exercise. Throughout Chefornak, you can see fish hanging on outdoor wooden structures and drying on boards matressing the Alaskan tundra. From the village boardwalk, you can smell fish, which reminded me of my childhood and early 20s – wonderfully familiar scents that wafted through mom's kitchen on weekend mornings and during trips I’d take to old villages in Korea. Each household has a slightly different wooden structure constructed for drying fish in the Alaskan summer heat. Though it was cold when we first arrived, it’s been warm the past few days and the sunshine has been intense.

One afternoon, I was chatting with the Chefornak health clinic receptionist, who mentioned that she was keeping busy outside of clinic hours preparing fish for the winter. Mothers of children I’d been treating in clinic talked about similarly busy summer schedules. In the village, men and boys take their boats and fish on the river, bringing back gunny sacks filled with halibut, salmon, anchovies, herring, white fish, and other river delicacies. Women and girls clean, prepare, and hang the fish to be dried. It’s a time sensitive process (to prevent spoiling of fish and to take optimal advantage of weather conditions to dry the fish properly).

There are apparently dozens of ways to prepare fish. Some fish are dried and then frozen – and eaten like jerky except that it is dipped into seal oil, which helps villagers keep warm in the winter. Other preparations include fermentation and drying, salt curing, and drying then soaking fish in seal oil. I asked the receptionist if we could stop by after work to watch her prepare fish and she warmly welcomed us to her home on the river. I was able to watch her and her three daughters prepare semi-dried fish to be soaked in seal oil. It was an amazing experience.

 We also got to see families braid anchovies onto beautifully crafted ropes made of dried tundra grass.

Most of the fish will be ready to consume in the late fall and early winter. The food preparation activities require intense family effort. I’m not sure how many families involve children in these activities, but from an outsider’s perspective, it seems like most do - and what a great way for children to contribute to the household and stay busy during the long summer days.

The little things in life

06/02/14, Chefornak, Alaska: Day 1. This is my third clinic trip to a Yukon Kuskokwim village (first trip was to Kipuk in August 2013 and second was to Chevak in October 2013). I arrived into Bethel on June 1 at 8:30PM. The first thing I noticed after landing was how bright it was outside – and then it struck me that I had entered the land of the Midnight Sun. It wasn’t sunny but it was super bright most of the evening. I woke up early to pick up my travel bag from the YKHC dental clinic and arrived the next morning at the Era Airlines counter in Bethel at 8:00 AM, about an hour before my flight to Chefornak. I met the super friendly Dental Assistant who had been assigned to this village trip along with 3 or 4 YKHC social workers who were getting ready to travel out to different villages in the YK. I had 3 requisite cups of very strong Folgers coffee (compliments of the airport). We walked onto the tarmac about 30 minutes after our scheduled departure time to allow for some time for the morning clouds to lift.

Riding aboard a 7-passenger place Cessna is a really cool experience. It's small enough where you have you crouch to get to your seat. You can hear everything - the engines, the propellers, all of the other machinery. Earplugs are a must - I forgot to grab a pair during check in at the Era Airlines counter.

We flew for about an hour and landed in Kipnuk to drop off a few passengers and then continued onto Chefornak, which took about 20 minutes from the Kipnuk airport. When we landed in Chefornak, we were greeted by a Primary Dental Health Aide (PDHA) with whom I had worked during my first village trip to Kipnuk. PDHAs are an integral member of the dental care delivery system in rural Alaska and provide preventive dental care services to villagers. The PDHA met us on her sparkling red 4x4 (all terrain vehicle). After loading our personal belongings onto a second 4x4 with a wooden trailer in tote, we hopped onto the back of the red ATV and rode to the dental clinic.

Once we arrived to the Denali clinic (the name of pre-fabricated structures that serve as health care centers in the YK Delta), we unpacked our dental supplies and started setting up the clinic. Denali clinics are really nice – they contain primary care medical care examination room, an emergency room, and a dental clinic. There is also a room set aside for itinerant health care providers that contains 2 bunk beds and a kitchen with a sink, a small fridge, and microwave. There is also water treatment equipment used to produce drinking water.

After setting up the clinic, I unpacked my large “immigrant suitcase” I had stored in Bethel with one of the dentists. I bought this abnormally large suitcase back in the early 2000s when world travelers were allowed to pack bags that weighed 75 pounds (and sometimes, in my case of jetsetting between Seattle and Seoul, 100+ pounds) unlike today where the strict limit is 50 pounds. The bag contained a portable air mattress, sleeping bag, a small stash of non-perishable snacks, and other random items needed for village trips.

Which brings me to the reason I titled this blog post (the little things in life). First, all of my food for the 2 weeks fit into the small fridge. The dental assistant and I had to play a little bit of “fridge puzzle” but it all fit. SCORE! I can’t believe what a relief it is to know that your perishable foods will stay cold the whole 2 week trip. During past village trips, I’d spend the first few days nervously and voraciously consuming food that wouldn’t fit into the fridge, which is really stressful. Second, when I opened up the front zipper of the immigrant suitcase, I found 2 items that were icing on this wonderful day: a stash of Tazo teabags and a set of Krogers toenail clippers. It felt like Christmas. I can’t describe how unbelievably happy I was to rediscover these precious items I had left in Alaska after my last village trip.

In terms of clinic, it was wonderful to keep busy. We saw 15 patients on day 1 for exams and cleanings and have a full day of patients scheduled for day 2. It helps tremendously to work with a local PDHA who knows the families and is able to call households for same day dental appointments. It’s summer in the YK and the school kids have been on vacation since May 15, which can make it hard to schedule children.

After work, I reheated a bowl of Basmati rice along with General Tso’s Fish and Kung Pao Tofu from my favorite Chinese restaurant in Seattle – a place called Sichuanese Cuisine Restaurant. I took a lukewarm shower, which was wonderful. There have been times in the past when an-end-of-clinic-day shower wasn’t possible (e.g., sewer was backed up, water was turned off, water was ice cold, gym lockers were locked). Also, this trip I brought with me a cordless 1.7L hot water kettle - one the best ways to ensure easy access to cuppa. The planned kettle coupled with a fistful of surprise Tazo teabags are the perfect pairing.

Lesson reinforced on day 1: enjoy the little things in life. Teabags, toenail clippers, and the ability to shower – I feel like the luckiest itinerant village dentist in the world!

Rest in Peace, Lyle

I met Lyle during third year of dental school at UW in 2004. At our first appointment, we learned that we had both studied government as college students and hit it off immediately. Over the  next year, we spent many hours together in clinic - sometimes working on his teeth - mostly talking about politics, the state of the country, single payer health care systems, his work as an advocate for the vulnerable and disenfranchised, and public health.

We kept in touch throughout dental school. I'd go over to his house for dinner (he and his wife Bobby lived down the street from me) and I went to my first peace march with the Mercers at the Seattle Center during fourth year. As a dental school graduation gift, he and Bobby took me to the Pink Door in the Pike Place Market. We had an awesome dinner - I remember Lyle and I sharing an enormous tray of raw oysters.

After I moved to Iowa for residency training, Lyle kept in touch and sent me postcards, letters, and health-related newspaper clippings. When I moved back to Seattle in 2009, we reconnected. Life got super busy and I didn't get to see Lyle and Bobby as often as I should have. Two weeks ago, after giving a lecture in which I had recalled working with Lyle in dental school, I called Lyle and Bobby to make dinner plans. This is when I learned of Lyle's death.

Lyle led an amazingly rich life and fought tirelessly for progressive political causes as an upstanding U.S. citizen. He helped keep me on track during a professionally vulnerable time in my career. I started off as his student dentist and we quickly became friends. Rest in peace, Lyle.

Food Glorious Food

Peruvian food is AMAZING. The last time I was in Arequipa and Lima (November 2013), I gained 5kg in 6 days. Even as a devout pescatarian, I will admit that there are lots of wonderful land proteins served in Peru. There is no shortage of wonderful food options in Peru. The seafood (especially ceviche), fruit, pasteries, chifa (Chinese food), Inca Kola – I love it all. One of my favorite things to do in Peru is to visit the local market and look around at the food stalls.

The fruit stalls are my favorite – so much fruit I’d never seen, heard of, or tasted before visiting Peru. Most of the fruit is trucked in from nearby farms.

Within hours of arriving into Arequipa, we drove to the market and brought back a ton of fruit (and carrots) to our hotel.

During my last trip to Arequipa, I tried 5 new fruits. This time, I’ve added a few more to the list. I can never remember names. One of my favorites is granadilla, which looks and feels like a hollowed out orange. Cut it in half and there are tons of edible seeds swimming in a mass of gooey and sweet fruit.

Gigantic Peruvian corn with kernels 5 or 6 times as large as kernels of U.S. corn. Peruvian corn isn't sweet like American corn.

Avocado and cheese sandwiches made with Pan de Tres Puntas (or Three Points Bread), a puffy pita-like bread that originated in Arequipa. Bought a few of these from a very nice woman at a sandwich stand for 1.2 soles (<$0.50 apiece).

Inca Kola, the best-selling carbonated beverage in Peru. It's everywhere. This is the famous stuff that looks like a yellow-hued Mt. Dew and tastes like bubble gum. I’ve been told that Inca Kola had historically outstripped Coke and Pepsi in terms of sales and popularity. Coke had tried to compete, but it gave up and ended up buying Inca Kola. After toying around with the formula, which resulted in massive consumer protests, Coke reverted to the original Inca Kola formula and hasn’t touched it since. Not sure if the popularity of Inca Kola is generational. Most of the young children I've seen in Peru seem to prefer other types of carbonated drinks. I'll ask around and report back later.

Speaking of Inca Kola. I agree with my Peruvian friends that it is the perfect accoutrement to chifa, the Peruvian version of Chinese food. Haven’t seen General Tso’s Fish yet, but I’m on the prowl.

I’ve managed to walk over 10,000 steps each day (tracked using my handy FuelBand), which has helped me to keep my weight down this trip. So far, my belt notch suggests that I haven’t gained any weight. In fact, I think I’ve dropped a couple pounds. Last trip, I was walking less than 2,000 steps per day, which in conjunction with heavy, non-stop eating might explain the flash weight gain. I have an embarrassingly large collection of food photos. I will continue posting new AMAZING food photos throughout the week.

Hello, Arequipa!

The last three months, I have been busy running around town preparing for a clinical trial funded by the International Association of Dental Research. We are working with our long-time friends and colleagues in Peru to test whether adding xylitol to milk prevents tooth decay in Peruvian school children. Xylitol is a natural sweetener found in birch trees and other agricultural byproducts that has been shown to prevent tooth decay. There is an interesting story that led to the development of our study. All low-income children in Peru are given a glass of milk each day as part of Peru's Programa del Vaso de Leche, a national nutrition program designed to improve the health of vulnerable populations. Peruvian children, like most children worldwide, don’t like the taste of  milk. To enhance uptake by children, local schools add sucrose (table sugar) to milk. Adding sweeteners like table sugar or honey to milk is common practice by milk manufacturers in Latin America. Notice the honey bees on the Gloria milk can label. The rest of the world isn't innocent. We do this in the U.S. with chocolate and strawberry milk and in Korea with banana milk. The public health problem is that exposing low-income children to fermentable carbohydrates via sweetened milk can increase tooth decay risk among these already vulnerable children.

Before we left Seattle, I visited the Peruvian Consulate in North Seattle to seek approval to transport our microbiological supplies to Peru. The Consul, Miguel Angel Velasquez, was very friendly and helped moved the process along quickly. The Consulate is located in a neighborhood off Bothell Way.

We flew to Atlanta and arrived in Lima at 1:00 AM. After a few hours of sleep, we were back at the Lima airport to catch our morning flight to Arequipa, the second largest city in Peru (after Lima, the capitol).

After nearly 22 hours of non-continuous travel that started at SeaTac Airport, we made it to Arequipa, Peru. We were greeted by at least 100 parents and family members of local high school students who were returning from studying abroad in Europe. Each family member was holding balloons and screaming as each passenger entered the airport. I felt like a K-pop star.

Our team will be in Arequipa for the next 11 days. The weather today was sunny, dry, and warm. Rain is in the forecast, which is an obvious feature of the rainy season that typically lasts from January to March.

12th Man in Alaska

Had a great time supporting the Seahawks from Bethel. Went to a house party hosted by a YKHC optometrist and her husband. Ten of the twelve people in attendance were Seattle fans, including Emily, a very fashionable and mild mannered Chihuahua. Go Seahawks!