What’s in Your Shopping Cart?

Luis Gregorio Ruiz and Dr. Maureen Villasenor discuss his purchases in an Anaheim grocery store. Photo: Jazley Faith Sendjaja
Luis Gregorio Ruiz and Dr. Maureen Villasenor discuss his purchases in an Anaheim grocery store. Photo: Jazley Faith Sendjaja

Having just bought a dozen or so quart-bottles of sports drinks – a riot of reds, yellows and blues wedged in the front of his shopping cart — Luis Gregorio Ruiz almost made it out of an Anaheim grocery store on a recent morning.

But not quite.

Maureen Villasenor, a physician in a white coat with a friendly manner, hustled over to Ruiz and introduced herself to him to chat about healthy drink choices.

As it turns out, he thought the sports drink were benign. “The only problem is this drink has a ton of sugar,” Villasenor explained. Also, the carbs come from sugar rather than fiber, she said, holding up a bottle and pointing to the label.

Intrigued, he asked, “So what should I drink?” The answer: water or flavored water.

Ruiz good-naturedly answered some more questions. Yes, he had kids, four of them, and no, they didn’t eat a lot of vegetables. She made her pitch to go green. Mindful of his financial constraints, however, she didn’t advise ditching the sport drinks but recommended diluting them significantly.

After the amicable exchange, he walked out the sliding doors of Food 4 Less, and she was on to the next shopper.

Villasenor was taking part in the third annual “Shop With Your Doc” event, a public health campaign to bring doctors, nutritionists and medical assistants into numerous grocery stores in Orange County’s underserved communities to take blood pressure and offer nutrition education. The effort was sponsored by St. Joseph Hoag Health, the county’s largest health system.

“We want to focus on promoting health rather than waiting until people are sick,” explained Richard Afable, president and CEO of St. Joseph Hoag.

But is it paying off?

Shop With Your Doc is one of numerous outreach efforts led by county health officials, medical experts and community activists to combat obesity in Orange County.

Once seen as a bastion of all-white prosperity, the county is now more diverse in ethnicity and income, and vast health disparities have become standard.

In just one of many examples, 84 percent of seventh graders at the Thurston Middle School in wealthy Laguna Beach have a healthy body mass index, compared to 40 percent at Willard Intermediate in Santa Ana a half-hour away.

Outreach initiatives in response to disparities have included the deployment of Latino health promoters who are trained to talk to neighbors about better eating; diabetes support groups; in-school nutrition education to students and parents; community gardens; recipe exchanges and cooking demonstrations; and media and education campaigns like Rethink Your Drink, alongside fitness initiatives.

Still, several years into the work of promoting more healthful eating, experts don’t yet see obvious data points to indicate irreversible positive change.

Which is not to say the news is bad; the percent of Orange County fifth-graders with at-risk BMI dropped to 17.7 in 2014-15 from 18.3 the previous school year.

Such a decline is in line with the gradual leveling off in child obesity nationally and regionally after decades of growth.

“We didn’t get here over night. It’s going to take time,” said Amy Buch, manager of the Health Promotion Division at the Orange County Health Care Agency.

“Keeping it from getting worse is a sign of progress. There were a few years when it was a steady climb,” said Dareen Khatib, the manager of Nutrition and Wellness Services at the Orange County Department of Education. “We can impact it, but the great thing is prevention as early as you can get it.”

Lessons learned

Both Buch and Khatib say that progress in fighting obesity is not just measured in numbers but in learning what works and what doesn’t. A few key hard-won findings have emerged over the last several years, both say.

One of the biggest is that while early efforts toward nutrition awareness and individual choice-making are important, in recent years the goal has been to change the environment in which the individual makes choices.

“Knowledge alone doesn’t change behavior,” said Buch.

In the past, Khatib said, “We’d go into schools and do all this education, but the school still sold candy. There was still a junk food truck right outside the school, and classroom celebrations ended with sweets.”

The school environment has changed with the Healthy, Hunger-Free Kids Act and then the USDA’s Smart Snacks Guidelines, which both apply to public schools serving children receiving free or reduced lunches. The changes seek to lower sugar, sodium and fat in school lunches while requiring other foods on campus – such as in vending machines or at fundraisers – to be healthy.

Part of Khatib’s work with food service directors at schools with lower-income kids is going beyond providing the food to making it more appealing to students. This approach might entail offering a chili-lime seasoning called Tajin with fruit for the Mexican-American palate or arranging food in attractive presentations or promoting a restaurant-style “special of the day.” Scheduling lunch after recess instead of the reverse can increase appetite for healthier offerings.

Getting teachers and parents not to reward with sweets and to do fund-raisers that involve fitness rather than candy sales are another part of changing the environment to support health, Khatib said.

Schools are one way to reach large numbers of kids and they are an environment over which authorities have at least some control, compared to surrounding neighborhoods with numerous fast food restaurants and few parks.

The messenger, not just the message

Another key lesson that has emerged in fighting obesity is the importance of leadership from within communities targeted for outreach. In Orange County, the health care agency has participated in the statewide Champions for Change program to put health advocates from disadvantaged neighborhoods in the spotlight.

But this year the agency added something new: training citizens from lower-income cities to press the case for healthier environments in their communities and the political sphere. This spring, 13 residents underwent the agency’s Leadership Academy, with more training planned.

Since then, some participants have begun going door to door in their neighborhoods to talk about wellness, focusing on community safety and walkability through improved sidewalks, bike lanes and crosswalks.

“It’s all pretty organic, and we hope to sustain it,” said Buch. “Bringing in community folks to embody and exemplify change: we value that very much – that local wisdom…we all want to hear from people who are like us and whose experience we can identify with.”

Back at the Anaheim Food 4 Less, Villasenor is one such leader with whom the shoppers nearby can identify; she’s a Latina pediatrician with relatable community roots. She grew up one of 12 kids in the largely immigrant city of Santa Ana next door, and she believes in meeting people where they are. So if a parent arrives home too late to fix a home-cooked meal, she will advise him or her to modify the diet in practical ways, such as reducing the calorie count in a fast food order. Also, it’s better to use frozen or canned vegetables than none.

“You cannot cook everything from scratch. It’s not realistic in this day and age,” says Villasenor, herself a busy mother of three. But she adds that eating more healthfully “is doable with limited resources.”

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