Community-based Nutrition Interventions: Reaching Adolescents from Low-income Communities

Community-based Nutrition Interventions: Reaching Adolescents from Low-income Communities

ARNELL J. HINKLE“

California Adolescent Nutrition and Fitness Program 2140 Shattuck Avenue, Suite 61 0

Berkeley, California 94 704

INTRODUCTION

Several previous studies discussed the effects of poverty and ethnicity on the nutrient intake and fitness status of American children. ’ ‘ The mission of the California Adolescent Nutrition and Fitness (CANFit) Program-to improve the nutritional status, including physical fitness, of California’s low-income, African-American, Lati- no, Asian, and American Indian youth 10 to 14 years old-is based upon the results of an extensive needs assessment conducted in 1990 in California. The assessment revealed increased nutritional needs, yet lack of nutrition education and fitness programs for low-income multiethnic adolescents.’

This paper describes the evolution of the CANFit Program, and how it empowers community-based organizations to develop and implement nutrition education and physical activity programs for ethnic adolescents from low-income communities. CANFit engages these organizations in an active dialogue based on their vast experience in providing social and other services for this target population. Through this di- alogic process, the CANFit Program provides nutrition and physical activity information and resources to support organizations in developing their own ethnic-specific intervention strategies.

The first part of the paper relates the theoretical rationale for the program, draw- ing on data collected in a statewide needs assessment and the author’s previous experience working with low-income, ethnic communities. The second section demon- strates the relevance and importance of the CANFit Program strategy of working within the context of youth-serving organizations based in low-income, ethnic com- munitie s .

By means of a competitive funding mechanism, CANFit supports local projects that build community leadership and stimulate change at multiple levels, from indi- vidual behavior to policy, in the area of nutrition education and fitness. Currently, twenty-two organizations in California have received CANFit Program funding to plan or implement nutition educatiodphysical activity education projects. CANFit provides culturally, linguistically, and scientifically competent and appropriate technical assistance and training to grantee organizations.

“Tel.: (510) 644-1533; fax: (510) 644-1535; e-mail: [email protected].

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84 ANNALS NEW YORK ACADEMY OF SCIENCES

BACKGROUND

The California Adolescent Nutrition and Fitness Program resulted from a class- action lawsuit originally brought in 1977. The case, filed by Public Advocates, a non- profit law firm, on behalf of California’s low-income children, sued a children’s breakfast cereal manufacturer for alleged misleading advertisements that inferred their cereals were healthy when, in fact, they were more than 50% sugar.8 After more than 10 years of negotiations, with determination of the merits of the case still unre- solved, the parties agreed to the establishment of a nonperpetuating, $2 million trust fund to be used in the public’s interest.

In preparation for the settlement, consultants from the University of California, Berkeley’s School of Public Health, and the University of California, San Francisco’s Division of Adolescent Medicine conducted a needs assessment on the health and nutritional status of low-income, multiethnic adolescents-the class deemed most at risk of being misled by the advertisements when the case was originally filed.8

The assessment methodology included original research (i.e., 480 chart reviews, and 278 self-report surveys), a literature search, and consultation with over 30 experts representing a variety of nutrition and health fields, geographical areas, and ethnic group^.^ The central findings indicated that adolescents spent about 40% of the family food dollar, and prepared about 13 mealdweek for themselves and/or their families. Yet, many youths did not have the knowledge or skills needed to plan, buy, or prepare balanced meals. Adolescents were found to consume diets high in fat, sugar, cholesterol, sodium, and calories, and low in essential nutrients. There was frequent snacking, meal skipping, and eating away from home. Both the consumption of fruits and vegetables and instances of regular exercise were extremely low. Over 40% of the youth surveyed were overweight, only 2 1% of them met minimum fitness stan- dards, and over 28% had blood values consistent with iron-deficiency anemia.7

Another significant finding of the needs assessment was that there were few nutrition education and exercise programs designed exclusively to change the behavior of low-income or minority adolescents. Of the health and nutrition programs designed specifically for adolescents or teens, most included very small (if any) samples of low-income and/or ethnic youth in their initial pilots or demonstrations.’ This real- ization underscored a question that became a focal point for the CANFit Program- How do you design and implement effective nutrition and fitness interventions that deal with the cultural and economic realities facing adolescents from low-income communities?

Through the wisdom of the courts, consultants, and litigants, a settlement was reached that acknowledged the need for significant behavioral and environmental change in order to improve the nutritional status of the target population. The court settlement agreement specified the type of interventions that would ultimately be supported and outlined the composition of an Administrative Board that would gov- em CANFit. The fact that the Administrative Board not only possesses expertise in nutrition, fitness, public health, and adolescent medicine, but also represents the ethnic and geographic diversity of California is the central reason why CANFit decided to approach nutrition and fitness in the way that it did.

Numerous cultural and economic realities challenge the nutritional status of ethnic adolescents from low-income communities. In school, at home, in their neighbor-

HINKLE: NUTRITION INTERVENTIONS 85

hoods, and in the surrounding environment there are ubiquitous images of abundance and affluence, and messages urging adolescents to consume plenty of soft drinks, fast food, and highly processed snacks. Yet the reality for low-income adolescents is very different from this image of abundance and affluence.

In developing the CANFit Program strategy, an effort was made to uncover and understand many of the environmental issues that had potential impact on the nutritional status of ethnic adolescents from low-income communities. The CANFit Pro- gram attempts to change the community context, so that adolescents have the decision-making skills and social support necessary for making healthy nutrition and fitness choices. This capacity-building model acknowledges the need for adolescent skills development by creating a statewide network of grassroots nutrition experts who have the access and ability to leverage community resources. Rather than be- coming experts on these issues, CANFit decided to provide a mechanism to support the resident experts, the youths themselves, in discovering strategies that would ame- liorate the nutrition and physical-activity conditions in their communities.

The CANFit Program strategy derives from health education theories that define empowerment as access to and control of valued resources-in this case culturally and linguistically appropriate information, materials, strategies, and opportunities that will enable the target population to improve their nutritional status9-’* By defin- ition, those who lack valued resources are disenfranchised or powerless. CANFit’s empowerment approach promotes participation of the disenfranchised (i.e., ethnic adolescents from low-income communities) in gaining control over one aspect of their lives, their nutritional status.

CANFit Program Components

In its second meeting after formation, the Administrative Board decided on the following strategies to widen the diversity of agencies providing nutrition education and physical activity programs to low-income, ethnic adolescents. They agreed to ( I ) fund innovative community-based interventions in nutrition education and fitness for targeted youth; (2) leverage existing resources by coordination with other organizations serving these youths; (3) evaluate and disseminate effective programs to low-income, multiethnic youths throughout the state; and (4) award scholarships to students from the target population pursuing degrees in nutrition, physical education, or public health. Each of these four strategic components is described below.

Community-based Funding Initiative

Because nutrition and physical activity behaviors are culture-bound, to be culturally sensitive and linguistically appropriate, any community-based nutrition intervention must arise from a knowledge of and respect for the culture of the target commu- nity9 Since the cultural diversity of California precludes any one organization from being an expert in all cultures, CANFit made the critical decision to seek out community-based organizations that represented the state’s ethnic, adolescent, and low-income constituencies. Over 400 organizations were identified and invited to submit letters of intent for funding.


Through its Community Based Funding Initiative, the CANFit Program provides two levels of grants, one level to support planning (up to $10,000), and the second level for intervention projects (up to $50,000). Only organizations actively involved in serving low-income youth are eligible to apply for funds, and all project plans must have youth actively involved in all aspects of planning and implementation.

An important part of the implementation of the CANFit Program was the realiza- tion that for lasting change to occur, there needed to be a constituency in low-income communities advocating for improved adolescent nutrition and physical activity. Suc- cessful planning and implementation of CANFit projects requires the participation and support of youth, parents, community members, and agencies providing services to youth and families. In order to build support for CANFit’s mission, and to cultivate the agencies’ ability to successfully implement multidimensional, community-based interventions, it is important to involve key community players in the process of planning how a CANFit intervention may operate in their community. By offering planning grants to community organizations, a critical mass of agencies becomes involved in assessing the nutritional status of low-income multiethnic youth in their community, and are able to benefit from CANFit’s technical assistance capability in planning appropriate community-based interventions.

Agencies selected for CANFit Planning Grants participate in training to learn focus-group techniques, the basics of adolescent nutrition and physical activity, techniques for assessing adolescent nutrition and fitness status, group facilitation, program planning, and evaluation. At the end of the planning period, each grantee is re- quired to produce a program plan for a nutrition educatiodfitness intervention that could be submitted to CANFit or other funding sources.

The CANFit Program benefits as well from this process because by the end of the trust fund’s existence there will be 20 to 30 community agencies throughout Califor- nia aware of the nutrition and physical activity needs of the youth in their communities. As a result of the planning process, youth and community members in the target area are mobilized for action, and a constituency has been created.

Organizations selected for CANFit intervention grants must demonstrate that they have gone through an assessment process and have involved target youths in design- ing a nutrition education and fitness project plan. Projects selected for funding “should attempt to alter the environment of the low-income, ethnic adolescent so that there is:

a) a wider variety of healthy and acceptable food choices available at school, convenience stores, vending machines, restaurants, and other settings that the targeted youth frequent, including out-of-home living situations;

b) improved access to adequate equipment and facilities to learn and practice regular aerobic exercise;

c) exposure to positive role models (peers, family, community leaders) that visi- bly practice healthy eating and exercise behaviors; and

d) a core group of youth leaders from the target population trained in sound nutrition and physical activity principles and practice^."'^

Through community-based funding, the CANFit Program has verified its suppo- sition that members of low-income communities are the experts in how to reach and work with youth from their communities, and that they only need resources (e.g.,


funding, guidance, training) to build capacity in adolescent nutrition and physical activity.

Leveraging Resources

Adolescents cannot assume full responsibility for creating a healthy environment that supports their nutritional status. Health professionals and other adults in leadership positions are often able to bring resources into disenfranchised communities and promote community capacity building. As a means of facilitating the larger nutrition and fitness community’s participation, the CANFit Program not only provides grants, but also makes resources available, in the form of people, either from its own staff, Administrative Board, or CANFit Consortium, who can provide technical assistance. An important aspect about technical assistance is that it be available close to the community. Another is that the “helpers” be trusted by the people who are going to call on them, and that they understand about building capacity rather than just going in and trying to do the work themselves. The proper role of the technical assistant is to help local people figure out what it is that needs to be done.

The CANFit Consortium comprises representatives from organizations that have developed programs, materials, or policies that favorably influence the nutrition and/or fitness status of low-income, multiethnic adolescents in California. The Con- sortium meets at least twice a year, once to network with other members and CANFit Program staff, and once with CANFitS grantees to share the latest developments from the field. In addition to the biannual meetings, Consortium members are invited to attend and participate in grantee trainings.

Besides these formal meetings, Consortium members play a vital role by being available to grantees and Program staff and agreeing to:

(a) Initiate cooperative efforts to develop nutritiodfitness-related messages, products, services, and materials for low-income, ethnic minority adolescents ( 10-1 4 years old);

(b) Identify exemplary nutrition and fitness materials and programs that could be adapted to specific adolescent target groups;

(c) Provide technical assistance to CANFit Program grantees in the area of program design, evaluation, and dissemination, as appropriate;

(d) Share the work and products of their organizations with CANFit grantees; (e) Identify products and services needed by their organizations and the target

(0 Learn about culturally appropriate nutrition education and fitness interven-

(8) Identify other funding sources to leverage CANFit’s $2 million trust fund.

populations;

tions;

Evaluation and Dissemination

The CANFit Program is actively engaged in conducting qualitative evaluations of grantee communities. In addition, an annual trend analysis survey is being adminis- tered to youth participating in CANFit interventions. These evaluation processes will result in a “how-to” guide that community organizations can use to learn from past


successes and mistakes. As the CANFit Program evaluates and analyzes the experience of our grantee communities, we will refine our grant-making.

Another form of resource leveraging is the postevaluation dissemination of proven effective nutrition education materials and products to a wider audience. This form of dissemination will also support the CANFit Program’s postgrantmaking evolution into a training, advocacy, and technical-assistance organization.

Scholarships

As a strategy to combat the shortage of multiethnic nutrition and physical activity professionals, and as another way of building capacity within low-income communities, CANFit created a scholarship program to provide financial aid to students enter- ing the fields of nutrition, physical education, or public health. Each year $10,000 is available for undergraduate and graduate education. Since its inception, twenty-three students have received financial assistance.

RELEVANCE AND IMPORTANCE

Grantee Projects

CANFit support mobilizes low-income communities and gives them the resources to assess and address adolescent nutrition and physical activity in culturally appropriate ways. In the first year of grant making, over 3000 adolescents were served by CANFit Program projects. These projects worked with urban and rural African- American, Latino, Korean, Filipino, Southeast-Asian, and American Indian adolescents throughout California. Refer to Table 1.

Examples of CANFit Grantees ’ Work

In San Leandro, Girls Inc. developed a 10-week Afro-centric curriculum that focuses on self-esteem, body image, healthy eating, cooking, and physical activity (hip-hop dance). Girls attend the after-school program three times a week. During the second year of funding, girls successfully advocated their local school to have hip-hop dancing become a physical education class option. The Korean Health Education and Information Resource (WEIR) Center developed a nutrition and physical activity program for youth and their parents attending Saturday Korean Language Schools in Los Angeles. Latino youth in the Colton Soccer League created a peer-driven club that works with local health department staff to train team coaches and parents in sports nutrition. Middle school students in rural Monterey County are actively involved in de- ciding how nutrition and physical activity are going to be incorporated into their new school-based community center. Cooking classes, regular dances, and a new sports league are being considered. Kalasugan Community Services and the Santa Paula Health Action Coalition worked with youth and community members to convince school officials to

HINKLE: NUTRITION INTERVENTIONS

TABLE 1. CANFit-Funded Projects

89

Grantee Organization Location Target Population

Intervention Escondido Community

Health Center

Girls, Inc. of Alameda Kalusugan Community

Korean Health, Education, Services

Information and Referral Center

Dept.

Health Dept.

Dept.

Monterey County Health

San Bernardino County

Ventura County Health

Planning Avalon Carver Community

Boys & Girls Club of the

City of Paso Robles Community Leadership

Development Institute El Concilio del Condado

de Ventura Girls After School Academy Hispanos Unidos

Center

Peninsula

Kids in Sports

Pacific Institute for Women’s

RiversideBan Bernardino Co.

St. Mary Medical Center

Stanislaus County Health

Telegraph Hill

Viejas Indian School West County Public

Education Fund

Health

Indian Health

Foundation

Dept.

Neighborhood Center

Pauma Reservation and migrant education sites, San Diego County

After school, Oakland Middle school, Chula Vista

Saturday Korean language school, Los Angeles

Rural middle school,

Soccer league, Colton Greenfield

Middle school, Santa Paula

Community center and middle

Redwood City school, Los Angeles

Parks and Recreation Dept. Public housing, Richmond

Public housing, Oxnard

Public housing, San Francisco After school and urban middle

school, Menlo Park Neighborhood sports leagues,

Los Angeles Urban school health clinic,

Culver City A consortium of eight Indian

reservations, Banning After school, Long Beach

Rural middle school. Modesto

After school, San Francisco

Indian reservation, Alpine Urban middle school. San Pablo

American Indian and Latino

African-American girls Filipino

Korean

Latino children of farm

Latino workers

Latino

African-American and

African-American and

Latino African-American

Latino

Latino

Latino

African-American girls Latino

Multiethnic

Multiethnic girls

American Indian

Southeast Asian

Multiethnic

Asian and

American Indian Multiethnic

African-American


provide more ethnically appropriate activities as physical education class options. In Chula Vista, youths are learning traditional Filipino stick dances and games, while in Santa Paula a quebradita dance and nutrition class is now taught three times a week. American Indian adolescents living on the Pauma Reservation in rural San Diego County are working with tribal elders to learn traditional North Ameri- can Indian games. The youth sponsor a booth at community pow-wow cere- monies where games are played and fresh fruit and water provide an alternative snack to the omnipresent fry bread.

Findings

In the first two years of program operation, eighteen organizations have received grants to conduct nutrition and physical activity assessments of their local youth. Grantees are encouraged to use qualitative research (focus groups, community map- ping, ethnographic interviews) to determine the adolescents’ cultural belief systems surrounding nutrition, eating, and physical activity.

Findings from the first year’s planning grantees paint a vivid portrait of some of the relevant issues facing youths involved in CANFit projects, and underscore the level of disenfranchisement they face. The majority of these youths have been as- sessed by some outside group (e.g., university, health department) and determined to be “at-risk’’ by nature of their family income, ethnicity, or ZIP code. Many are deal- ing with issues of abandonment, fear, and cynicism from having to live in an environment where the dominant culture does not support their education, cultural norms, values, or safety. Most are bicultural (and often bilingual), meaning that they are able to navigate between at least two different worlds, that of the culture of authority (e.g., school), and that of their specific ethnic culture (e.g., family, friends, neighborhood); they know how to survive in each, yet usually feel more comfortable in one or the other world. Images of people who look like them are usually associated with crime, drugs, welfare, and substance abuse, not with eating sensibly and exercising.

In most communities, fear of crime is a major concern, and the adolescents fear that they may not be alive long enough to develop a chronic disease. This fear for their own physical safety restricts their ability to walk, bike, or play in their neighborhoods, and results in sedentary behaviors and decreased opportunities to engage in physical activity. One of the most common forms of physical activity is going to the neighborhood convenience store for a snack or soft drink.

Many youths from low-income communities must rely on food assistance programs and school meals to supply an adequate diet. Most of them quality for free or reduced-price school meals. However, school meals, especially in large city districts where most low-income children attend, are often prepackaged, “cook-chilled- warmed affairs, trucked out to satellite cafeterias and distributed in disposable units. Some schools have simply contracted directly to fast-food chains and airline-food service companies for their meals. While the schools increasingly cave in and begin serving the equivalent of fast foods (“that’s what kids want, why should we fight it?”), the food served in cafeterias does not model the few nutrition messages that woefully underfunded nutrition education curricula in schools attempt to reenforce.


Therefore, there is “cognitive dissonance” between what is preached and what is practiced in most schools.

There are few, if any, computers to use for interactive games and CD-ROMs, either in school or at home. Literacy levels are disturbingly low, hindering youths’ ability to complete survey questionnaires. Declining wages and increasing numbers of single-parent families mean that many parents work long hours, sometimes at two or three jobs. The decreased parental presence means that adolescents are often left to fend for themselves in terms of meal preparation. Meal skipping is common, especially breakfast, and often adolescents are responsible for preparing family meals, which usually translates into frying or microwaving food.

In this environment, daily recreational activities usually consist of activities that are affordable and safe, for example, watching television and eating. Fast-food restaurants may be one of the few clean, brightly lit, and safe places in a young per- son’s neighborhood; and an important source of enjoyment and recreation is hanging out with a group of friends at a fast-food restaurant and sharing inexpensive, special combination meals. The very activities and behaviors that are life-affirming and sus- taining to these youths are the same ones that health professionals want to alter.

As part of the planning grant process, adolescents were encouraged to identify both healthy, positive attributes of their neighborhoods as well as negative and un- healthy influences in their community; share their food and fitness experiences; ana- lyze the root causes of these experiences; and pose alternatives for themselves, their peers, and communities. Initially both youth and health professionals had a difficult time trusting the information-gathering process. Some adolescents did not believe that their opinions were truly valued, but as trust developed and youths were repeat- edly queried for “their” opinion, the youths blossomed. By the end of the planning process, the youths themselves were able to conceive of the solutions that would improve their food and fitness environment.

CONCLUSIONS

The overarching conclusion from grantee work to date has been the imperative to change the environment of low-income communities by improving access to healthier food choices and safe, affordable physical activity opportunities. In terms of food choices, this access can take the form of better food selection in stores; affordable prices; local farmers’ markets; serving healthy food at meetings, programs, events; faith institutions that provide healthier entrees at events; neighborhood schools with healthier vending machine food, school meals that meet the U.S. Dietary Guidelines, and policies limiting sales of candy bars, and the like for fund-raising; and community gardens. Physical activity opportunities include accessible neighborhood centers; ethnic dance classes; walking clubs; groomed playgrounds and recreation fields; and more culturally appropriate physical education class options (e.g., hip-hop dance, salsa, traditional games). Initial observations from our grantees’ experience lead us to consider how we might facilitate more policy and organizational change at the local, state, and national levels to improve adolescent nutrition and physical activity opportunities for our target population.

Between the design of the “cadillac” community nutrition intervention and the re-


ality of life in a low-income community lies the need for a pragmatic method of reaching adolescents from low-income communities and inspiring them to improve their nutrition and exercise habits. The CANFit Program’s premise is that projects must be created that, from the start, work with the resources and the constraints of specific, low-income, ethnic communities. Successful projects construct a unique program plan by incorporating the following elements into their design. They (1) in- tegrate the cultural, linguistic, social, and demographic characteristics of youth; (2) identi@ and incorporate into the intervention the ethnic-specific messages likely to motivate behavior change; (3) address the multiple influences (e.g., mass media, environment, peers, family, etc.) affecting adolescent dietary and exercise behaviors; (4) employ individuals who are highly credible and respected to deliver the program; and (5) involve youth in significant ways in the planning and implementation.

ACKNOWLEDGMENTS

The author gratefully acknowledges Lewis Martin King, Leslie Mikkelsen, Laurie True, and John Wolfe for their comments on earlier drafts of this manuscript. The author would also like to express her sincere appreciation for the dedication and leadership exhibited by CANFit Program Administrative Board members Lucy B. Adams, Cheme Boyer, Carmela Castellano, Nicolette Collins, Gail Frank, Felicia Hodge, Virginia Jang, Karen Kamachi, Lewis Martin King (Chair), Patricia Lozada-Santone, Helen Magnuson, Michael Mudd, John Payne, Lois Salisbury, and Sarah E. Samuels.

REFERENCES

1. TROIANO, R. P., K. M. FLECAL, R. J. KUCZMARSKI, S. M. CAMPBELL & C. L. JOHNSON. 1995. Overweight prevalence and trends for children and adolescents. Arch. Pediatr. Adolesc. Med. 149: 1085-1091.

ing nutrient intakes of children by sociodemographic factors. Public Health Rep. 109: 414420.

3. MURPHY, S. P., R. 0. CASTIILO, R. MARTORELL & F. S. MENDOZA. 1990. An evaluation of food group intakes by Mexican-American children. 1 Am. Diet Assoc. 90(3): 388-393.

ERICK & Z. I. SABRY. 1995. The effects of race, household income and parental education on nutrient intakes of 9- and 10-year old girls: NHLBI growth and health study. Ann. Epidemiol. 5(5): 360-368.

5 . DESMOND, S. M., .I. H. PRICE, R. S . LOCK, D. SMITH & F! W. STEWART. 1990. Urban black and white adolescents’ physical fitness status and perceptions of exercise. J. Sch. Health 60(5): 22Cb-226.

6. MCPHERSON, R. S., D. H. MONTGOMERY & M. Z. NICHMAN. 1995. Nutritional status of children: What do we know? J. Nutr. Ed. 27(5): 225-234.

7. ADAMS, L. B. & D. D. DISBROW. 1990. The California Adolescent Nutrition and Fitness Program: Needs Assessment and Recommendations. CANFit Program, 2 I40 Shattuck Ave., Suite 610, Berkeley, CA 94704. Unpublished.

8. ASHE, M. 1995. Alternative dispute resolution and public interest settlements. National In- stitute for Dispute Resolution Forum. Summer(28): 25-27.

2. JOHNSON, R. K., H. A. GUTHRIE, H. SMICIKLAS-WRIGHr & M. Q. WANG. 1994. Characteriz-

4. CRAWFORD, F! B., E. OBAIUANEK, G. B. SCHREIBER, P. BARRIER, S. GOLDMAN, M. M. FRED-


9. BRAITHWAITE, R. L., F. MURPHY, N. LYTHCOTT & D. S. BLUMENTHAL. 1989. Community organization and development for health promotion within an urban black community: A conceptual model. Health Educ. 20(5): 5660 .

10. WALLERSTEIN, N. & E. BERNSTEIN. 1988. Empowerment education: Freire’s ideas adapted to health education. Health Educ. Q. lS(4): 379-394.

1 I . JSATZ, R. 1984. Empowerment and synergy: Expanding the community’s healing resources. In Studies in Empowerment: 201-225. Haworth Press. Binghamton, N.Y.

12. FREIRE, I? 1968. Pedagogy of the Oppressed. Searbury Press. New York. 13. COMMITTEE ON CHILDREN’S TELEVISION, INC., et al. 1992. Revised Settlement Agreement:

Guidelines for Program Content, Case No. CA 00429, May 7.

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Community-based Nutrition Interventions: Reaching Adolescents from Low-income Communities