Ebook Issues and trends in nursing (2/E): Part 2

UnitIII:ThePersonin
HealthCare
13AddressingPrimaryPreventionand
EducationinVulnerablePopulations
14CulturalDiversityandCare
15EthicalDecisionMakingandMoral
Choices:AFoundationforNursingPractice
16LegalIssuesinNursing
17HealthcarePolicyandAdvocacy


Chapter13:Addressing
PrimaryPreventionand
EducationinVulnerable
Populations

BrianW.Higgerson

LearningOutcomes
Afterreadingthischapteryouwillbeableto:
Definethetermvulnerablepopulation.
Identifywhatconstitutesahealthdisparity.
Discussatleastthreefactorsthatcontributeto
healthdisparities.
Understandhealthbehaviorsthatareclassified
asprimaryprevention.
Discusshowdietarypractices,lackofexercise,
andtobaccousemaycontributetoincreased
riskofdevelopingmajorchronicdiseasesinthe
UnitedStates.
Provideexamplesofhowhealthbehaviorsare

distributedinvulnerablepopulations.


Identifythreekeyapproachesforeducating
andmotivatingclientstoimprovetheirhealth
behaviors.
Discusschallengesforimprovinghealth
behaviorsinvulnerablepopulations.

Theeditorswishtoacknowledgethecontributionsof
DianeBaerWilsonandLisaS.Andersontothe
previouseditionofthischapter.

Introduction
KEYTERMVulnerablepopulations:Groupsof
individualswhoarelikelytohavecompromisedaccess
tohealthcareand,therefore,aremorelikelytohave
poorerhealthoutcomes,includinghighermortality
rates,comparedtolessvulnerablegroups.
Theincreasedprevalenceofchronicdiseasesinthe
UnitedStateshasawidespreadimpactonindividuals
aswellashealthcaredeliverysystems.Achronic
diseaseistypicallydefinedasdiseaseslastingmore
than3months—theyareassociatedwithdecreased
qualityoflife,increasedfinancialburdens,and
decreasedlifeexpectancy.Althoughchronicdiseases
areincreasinginnumbers,manyofthesechronic
conditionsarecompletelypreventable.Recentdata
suggestsapproximatelyonehalfofalladultslivingin

theUnitedStateshaveoneormorechronichealth
conditionsandoneinfouradultshastwoormore
chronicdiseases(Ward,Schiller,&Goodman,2014).
Heartdisease,cancer,anddiabetescontinuetorank
asthetopthreechronicdiseasesthatareestimatedto
resultin1.2milliondeathsayear(Centersfor
DiseaseControlandPrevention[CDC],2015a).
However,inlearningmoreaboutthepopulations
representedinthesestatistics,onemightbesurprised
atthedemographictrends.Researchrevealsthatpoor,
underserved,andminoritypopulationshavehigher
deathratesacrossallofthesediseases.Furthermore,
theseindividualsarealsolesslikelytohavehealth
insuranceandthus,theyfinditmoredifficulttoaccess
healthcareorreceivehigh-qualityhealthcarein
comparisonwithmoreaffluentgroups.
Chronicdisease:Along-lastingdiseasethat
typicallyremainswithapatientfromonsetto
endoflifeandrequiresmanagementof
symptoms.Chronicdiseasestypicallylast
longerthan3months.Examplesarecancer,
cardiovasculardisease,diabetes,and
cerebrovasculardisease.AccordingtotheU.S.
CentersforDiseaseControlandPrevention
(2015a),chronicdiseaseisresponsiblefor7out
of10deathsintheUnitedStates.


Thepurposeofthischapteristoidentifyvulnerable

populationsandprovideadiscussiononwhythese
frequentlyoverlookedpopulationsareatgreaterriskfor
poorhealthoutcomescomparedtootherpopulations.
Inaddition,thischapterexplorestheroleofdisease
preventionorriskreductionofchronicdisease.Three
categoriesofpreventionareaimedatreducinghealth
riskoutcomes:primaryprevention,secondary
prevention,andtertiaryprevention.Primary
preventionreferstomodifyinghealthbehaviorssuch
asdiet,sedentarybehavior,ortobaccousetoreduce
one’sriskofdevelopingchronicdiseasessuchasheart
disease,stroke,cancer,anddiabetes.Secondary
preventionfocusesonearlydetectionofdisease
usuallydetectedthroughearlyassessmentfindingsor
diagnostictestsorprocedures,suchasaprostatespecificantigen(PSA)testforprostatecanceror
mammographytodetectbreastcancer.Thegoalof
tertiarypreventionistoimplementstrategiesthatwill
slowdiseaseprogression,limitdisabilityfroma
disease,andrestoreindividualstotheiroptimallevelof
functioning(Nies&McEwen,2014).Examplesof
tertiarypreventionstrategiesincludecardiac
rehabilitationservicesfollowingamyocardialinfarction
orasupportgroupfornewlydiagnoseddiabeticclients.
Primaryprevention:Actionstakentomodify
healthbehaviorssuchasdiet,sedentary
behavior,orsmokingtowardpreventingor


managingachronicconditionsuchasheart
diseaseorcancer.Anexampleisreducing

one’sdietaryfatintaketohelplowercholesterol
levelsandpreventonefromexceedingthe
recommendedcholesterolguidelines.
Secondaryprevention:Interventionsfocused
onearlydetectionandscreeningofdisease,
suchastuberculosisskintesting.
Tertiaryprevention:Strategiesthatwillslow
diseaseprogression,limitdisabilityfroma
disease,andrestoreindividualstotheiroptimal
leveloffunctioning.

Thefinalpartofthischapterdetailsthenurse’sroleas
anadvocateforindividualswithinthesevulnerable
populations.Througheducationandsupport,nurses
canplayaninstrumentalroleinencouragingvulnerable
populationstoparticipateinhealthylifestylechoices
andultimatelyreducechronicconditions.

DefiningVulnerablePopulation
Althoughawiderangeoffactorsandincome
categoriesmaybeusedtodefinepoverty,abroad
definitionforpovertyiswhenanindividualorgroupof
individualslackshumanneedsbecausetheysimply
cannotaffordtomeettheseneeds(Short,2016).An
unfortunatecommonconsequenceofpovertyis


inadequatehealthcareoraccesstohealthcare
services.Socioeconomicstatusandpovertyrateshave
moreofanimpactonhealthstatusandmortalityrates

thananyspecificraceorculture.Overtime,datahave
demonstratedthatsocioeconomicstatusisastrong
andpersistentpredictorofhealthstatus.Forexample,
adultslivinginpovertyreporthigherincidenceof
diabetes,kidneydisease,liverdisease,andchronic
jointpainscomparedtoadultswhowerenotpoor.
Moreover,ahigherpercentageofadultslivingin
povertyreportedmorefeelingsofbeinghopeless,sad,
orworthlesscomparedtononpooradults(Blackwell,
Lucas,&Clarke,2014).Alandmarkstudy,published
in1967,examinedthisissueintheUnitedStatesand
Europetracingbacktothe17thcenturyandreported
betterhealthandlowermortalityrateswere
consistentlyassociatedwithhigherincomeandhigher
levelsofeducation(Antonovsky,1967).Ifonelooksat
anyofseveralmeasures,theresultsareconsistentin
therelationshipbetweensocioeconomicstatusand
mortalityrates.Forexample,lifeexpectancyin2013
was52yearsinAngola,whichisaverypoorcountry,
comparedto79yearsintheUnitedStates,ahighly
developedcountry(WorldHealthOrganization
[WHO],2015a).
Poverty:Whenanindividualorgroupof
individualslackshumanneedsbecausethey
simplycannotaffordtomeettheseneeds.


AccordingtotheU.S.CensusBureau(2014),the
nation’spovertyratein2014was14.8percent,which
translatestoapproximately46.7millionpeoplelivingin

poverty.Afurtherexaminationofthedatarevealsthe
disproportionateprevalenceofpovertyamongracial
groups.MoreAfricanAmericans(26.2percent)and
Hispanics(23.6percent)livebelowthepovertyline
thanCaucasians(10.1percent).Likewise,accordingto
the2014CensusBureaudata,moreAfricanAmericans
(11.8percent)andHispanics(19.9percent)arewithout
medicalinsurancecomparedwithCaucasians(7.6
percent).
Alarmingly,thehighestpercentageofgroupof
individualslivinginpovertyintheUnitedStatesare
childrenunderage18(21.1percent),followedby
adultsages18to64years(13.5percent)andolder
adultsovertheageof64(10percent;DeNavas-Walt
&Proctor,2015).Approximately6percentofchildren
intheUnitedStatesundertheageof19arewithout
healthinsurance(Smith&Medalia,2015).

PeoplewithDisabilities
Vulnerablepopulationsmayincludepeoplein
additionalgroups,suchasindividualswithadisability.
Althoughmanypeoplewithdisabilitiesarefully
functional,maintainemployment,andhaveahigh
qualityoflife,somedisabilitiescanmakeitmore


difficultfortheindividualtofindemploymentormay
limitsomeactivitiesofdailyliving.Inaddition,some
disabilitiesmayplaceindividualsatgreaterriskfor
developingcomorbidities.Forexample,anindividual

withdiabeteswhodoesnotcontrolbloodsugarlevels
isatgreaterriskfordevelopinginfection,havingpoor
circulation,anddevelopingheartdisease.Thus,people
withdiabetesserveasanotherexampleofapotentially
vulnerablepopulation.
Disability:Physicalormentalimpairmentthat
substantiallylimitsapersonfromcompleting
activitiesofdailyliving.

ElderlyandYoungChildren
Ageisalsoafactorthatcanbeassociatedwithpoor
healthoutcomes.Bothsocioeconomicfactorsand
physiologicalissuescontributetothesegroupsbeing
moreatriskforpoorhealththanindividualsinother
agegroups.Elderlypeopleareoftenonafixedincome
andmaynothavehealthinsurancetosupplement
governmentalhealthplans;thustheymaynotbeable
toaffordmedicalproceduresormedicationsthatare
notcoveredbyMedicare.Childrenareparticularlyat
riskiftheyeitherareuninsuredorhaveinsufficient
coverageformedicalcarebecausethelackof
resourcesmayleadtoinadequateaccesstomedical
care.Childrenwithhealthinsurancecoveragehavea


higherpercentageoftheirhealthcareneedsmet.
Insuredchildrenaremorelikelytoreceivetimely
diagnosesofseriousorchronichealthconditionsand
thushavefeweravoidablehospitalizations(Price,
Khubchandani,McKinney,&Braun,2013).

Physiologicaldifferencesalsocontributeto
vulnerabilities.Olderpeople,particularlythosewith
lessbodymass,aswellasveryyoungchildren,donot
tolerateextremeheatorcoldtemperatures.For
example,thesetwoagegroupsaretargetedinextreme
heatwarningsinthesummerbecausetheyaremore
pronetodehydrationandheatstroke.Overall,
however,individualsintheseagecategoriestendto
haveaweakerimmuneresponseandtheyareoften
prioritizedforpublichealthinitiativessuchasinfluenza
vaccinationdistribution,usuallygiveninfallmonths.

TheInterplayofEconomic,Social,and
CulturalIssuesonHealthStatus
Howlivinginpovertyactuallyaffectshealthandhealth
statusturnsouttobeacomplexissue.Overthelast
decade,thinkinghasshiftedfromaprimaryfocuson
povertyastheprimefactorrelatedtohealthstatustoa
broaderfocus.Inreality,thereisnoonereasonthat
explainswhythosewholiveinpovertyaremorelikely
tobecomeill,sufferfromchronicconditions,andmore
likelytodieprematurely.Manyfactorsbeyondincome


statusarecontributorytohealthstatusandchronic
disease.Factorssuchasthestateofourliving
environment,genetics,educationalbackground,and
oursocialsupportsystemsallhaveaconsiderable
impactonouroverallhealthstatus(WHO,2015b).The
mechanismsbywhicheconomic,social,andcultural

issuesareoperationalandaffecthealtharenotwidely
known,whichopensresearchopportunitiesforsocial
scientists,publichealthepidemiologists,aswellas
healthcareproviderssuchasnurses,physicians,
psychologists,andalliedhealthprofessionalsto
explorethesecontextualvariables.Social
determinantsofhealth(seeFigure13-1)include
broadfactorsthatcancontributetoanindividual’s
overallhealthstatus.Thesefactorsmayincludesocialeconomicaspects,physicalenvironment,and
individualbehaviorsorcharacteristics(WHO,2015b).
TheschemashowninFigure13-1depictsawidely
adoptedrainbowmodelofdeterminantsofhealth,
demonstratingthelayeredconnectivityamong
individuallifestylefactorsandvariablessuchassocial
networksandcultural-environmentalinfluences
(Dahlgren&White-head,1991).
Socialdeterminantsofhealth:Factorsthat
cancontributetoanindividual’soverallhealth
status.Thesefactorsmayincludesocialeconomicaspects,physicalenvironment,and
individualbehaviorsorcharacteristics.


Figure13-1Socialdeterminantsofhealth.

HealthDisparities
Onceevidencewasfoundthatoverallmortalityrates
variedbyeducationandsocioeconomicstatus,more
studywasgiventoexaminechronicdiseaseratesin
ordertodeterminewhethermortalityratesalso
reflecteddifferencesacrossgroupsofindividuals.

Populationhealthreferstotheaggregationof
healthcareoutcomeswithinspecifiedgroupsof
individualsandthedistributionofoutcomesamong
thesegroups.Thetermhealthdisparitiesisusedto
describegroupsthathaveadisproportionateamountof
diseasecomparedtotheproportionofrepresentation
inthepopulation(seeContemporaryPractice


Highlight13-1).Whenwelookatthemajorchronic
diseaseswesee,forexample,thatAfricanAmerican
menaremorelikelytodevelopprostatecancerand
haveahighermortalityratefromthediseasecompared
toCaucasianmen.Moreover,AfricanAmericanwomen
areapproximately9percentmorelikelytodiefrom
breastcancerthanCaucasianwomen(U.S.Cancer
StatisticsWorkingGroup,2015).Althoughoverall
deathsfromcancerhavedeclinedintheUnitedStates
overthepastdecades,from1999–2012,thecancer
deathrateswerehigheramongAfricanAmericanmen
andwomencomparedtootherethnic/racialgroups
(U.S.CancerStatisticsWorkingGroup,2015;see
Figure13-2).Hypertensionisalsoaconcernamong
chronicdiseasesbecauseofthedetrimental
consequencesofcardiovasculardiseaseandstroke.
AfricanAmericanshavethehighestoccurrenceof
hypertensionandidentifiedasaracialgroupmost
likelytodevelophighbloodpressureatayoungage
(Mozaffarianetal.,2015).
Populationhealth:Theaggregationof

healthcareoutcomeswithinspecifiedgroupsof
individualsandthedistributionofoutcomes
amongthesegroups.
Healthdisparities:Differencesinthe
incidence,prevalence,mortality,andburdenof
diseaseandotheradversehealthconditions
thatexistamongspecificpopulationgroups.


CONTEMPORARYPRACTICEHIGHLIGHT
13-1
HEALTHDISPARITIESACROSSTHECANCER
CONTINUUMOFCARE
ThemodelshowninFigure13-1depictsthe
multifactorialaspectsthatmaybecontributoryto
anindividual’shealthstatus.Dahlgren&
Whitehead(1991)presenttheinterrelatednessof
individualfactors,environmental,social,and
culturalinfluencesthattogetherplaceindividuals
atgreaterriskforhavingadisproportionateburden
ofpoorhealthcareacrossthecontinuumofcare
andpotentiallysuboptimalhealthoutcomes.This
modelisparticularlyrelevantforhealthcare
practitionersbecauseitemphasizesthesynergy
createdbytheintersectionofmultiplefactors.
Disparitiesindiseaseoutcomesmaybeginwith
differencesineachoftheareasofcare;thus,
healthcarepractitionersmustbediligentin
completingthoroughhistoryassessmentsoftheir
clientsandfamilies.Byobtainingacomprehensive

healthhistory,thehealthcarepractitionercan
developacomprehensiveunderstandingofthe
client’ssocialdeterminantsofhealthand
potentiallyidentifyfuturerisksforchronicdisease.


Figure13-2Deathratesbyraceandethnicityforall
cancersitescombined,UnitedStates,1999–2013.A.
Male.B.Female.


Figure13-3Ratesofdiagnoseddiabetes.

Otherracialandethnicgroupssufferdisproportionately
fromchronicdiseasessuchasdiabetes.IntheUnited
States,approximately25.8millionindividualshave
diabetesandanestimated7millionoftheseindividuals
areundiagnosed(Spanakis&Golden,2013).
AccordingtotheAmericanDiabetesAssociation
(2016),theprevalenceofdiabetesishighestamong
AmericanIndians/AlaskanNatives(15.9percent)and
lowestamongnon-HispanicCaucasians(7.6percent;
seeFigure13-3).

SummaryofVulnerablePopulations
Overall,thereisevidencethatacombinationofseveral
factorsincludingpoverty,culture,andsocialissues
contributestoindividualsbeingatriskforpoorhealth
outcomesincludingchronicdiseaseandlowerlife
expectancy.Thissectiondiscussedminorities,people

withdisabilities,andveryyoungandelderlypersonsas


examplesofgroupsthatcanbeconsideredvulnerable
forinadequatemedicalcareandthus,more
susceptibletopoorerhealthoutcomes.

IndividualHealthBehaviors:
PrimaryPrevention
Evidencedemonstratesadirectlinkbetweenhealth
behaviorsandillness.Behaviorssuchasdietary
practices,activitylevels,useoftobaccoproducts,or
consumptionofalcoholmayincreaseourriskof
developingthemostprevalentchronicdiseasesinthe
UnitedStates(WHO,2013).Infact,thetopthree
chronicdiseasesintheUnitedStates—heartdisease,
stroke,andcancer—areallfueledbyobesityandby
beingphysicallyinactive.Inotherwords,ifpeople
wouldreducetheirfoodintakeandexerciseinorderto
reachabodymassindex(BMI)of18–25kg/m2,many
heartattacks,strokes,andcancerdiagnoseswould
likelybeaverted.Researchsuggeststhatdietary
intake,regularexercise,andstressreductionmay
contributetolowerrisksorimprovedoutcomesof
chronicconditions,suchasprostatecancer(Hebertet
al.,2013).
Obesity:Havingexcessbodyfat.Obesityis
clinicallydeterminedbybodymassindex(BMI),
whichiscalculatedbydividingaperson’sweight
inkilogramsbyheightinmeterssquared

2


(kg/m2).ApersonwithaBMIof30.0ormoreis
definedasobese.

Inthissectionofthechapterwediscussthetop
preventablecausesofdeathintheUnitedStatesand
howtheyaredistributedinvulnerablepopulations(see
ContemporaryPracticeHighlight13-2).Preventable
causesofdeathhavealsobeenquantifiedtoshow
howmuchtheycontributetothetopdiseasesthat
accountforthemostdeathsintheUnitedStates.

Obesity
Beingoverweightorobeseisoneofourmost
concerningpublichealthissuestodayandtheratesof
obesityareincreasingatalarmingrates(seeBox131).ThemajorityofAmericansareoverweight;more
than69percentoftheadultpopulationhasaBMI
greaterthan25kg/m2(CDC,2015b).In2003,U.S.
SurgeonGeneralRichardCarmona,MD,MPH,said
“Aswelooktothefutureandwherechildhoodobesity
willbein20years,itiseverybitasthreateningtousas
isthethreatofterrorism.Obesityisthethreatfrom
within”(Ornish,2007).Dr.Carmonawasrespondingto
thefactthatanobesityepidemicisaseriousandcostly
issueintheUnitedStates,basedonthesignificant
increasesintheprevalenceofobesity.Ratesof
overweightandobesityareincreasingnotonlyinthe

adultpopulationintheUnitedStatesbutamong
childrenaswell.In2011–2012,approximately17
percentofchildrenandteenagerswereobeseand31
percentwereeitheroverweightorobese.Racialand
ethnicinequitiesexistrelatedtoobesityinchildren.
AccordingtoOgden,Carroll,Kitt,andFlegal(2014),
22percentofLatinochildrenand20percentofAfrican
Americanchildrenareestimatedtobeobese
comparedtoonly14percentofCaucasian,non-Latino
children.
Overweight:Havinganexcessofbodyweight
thatincludesfat,muscle,bone,andwater.
OverweightisclinicallydeterminedbyBMI,
whichiscalculatedbydividingaperson’sweight
inkilometersbyheightinmeterssquared
(kg/m2).ApersonwithaBMIrangingbetween
25.0and29.9isdefinedasoverweight.

CausesofObesity
Manyfactorscontributetobecomingoverweight,but
beingoverweightresultsfromconsumingmorecalories
thanareburnedeachday.Eatingtoomuchandbeing
lessphysicallyactivearehallmarksofwealthynations,
wherefoodisaffordable,heavilymarketed,andreadily
available.Inaddition,aswealthincreasesinasociety,
mundanephysicaltasksarebecomingmore
automatedandrequirelessphysicallabor;withthe

prospectofroboticsinthefuture,thesepatternswill
onlyincrease.

CONTEMPORARYPRACTICEHIGHLIGHT
13-2
QUANTIFYINGTHECONTRIBUTIONOF
UNHEALTHYLIFESTYLEBEHAVIORSIN
CAUSESOFDEATHINAMERICANS
Figure13-4quantifiesandrankstheleading
causesofdeathintheUnitedStates.Smoking,
highbloodpressure,andbeingoverweightarethe
leadingcontributingfactorstoprematuredeath.
Heartattacks,stroke,cancer,anddiabetes,and
otherphysicalconditionsarelinkedtotheserisk
factors.Healthbehaviorsaretheonlyknown
nonpharmaceuticalmodifiablefactorsforreducing
riskofchronicdisease.Thus,thereisgreater
focusontheseissuesbythehealthcareindustry,
foodmanufacturersandmarketers,businesses,
andorganizationsatalllevelsofoursocietyto
supportindividualsindiseasepreventionand
promotinghealthylifestylesthroughsmoking
cessation,healthierdiets,andmorephysical
activity.


Figure13-4Causesofdeath.

BOX13-1THEOBESITYEPIDEMIC
Beingoverweightandobesityhavesignificantly

increasedamongbothadultsandyouthinthe
UnitedStates,andtheratescontinuetoincrease
asillustratedinFigure13-5.Beingoverweightor
obeseisariskfactorfordiabetes,heartdisease,
stroke,andmanytypesofcancerincludingbreast
cancer.Ethnicandracialinequitiesinweight
statusexistamongparticulargroups.Forexample,
beingoverweightorobeseaffectsmorethanthree
outofeveryfourHispanicorAfricanAmerican


adults.Moreover,atrendingincreaseinobesity
amongchildrenextendstoadolescentsinthe
UnitedStates.TheseincreasespromptedtheU.S.
governmenttoidentifyanobesityepidemictoraise
thepublic’sawarenessofthehealth
consequencesandsuggestsolutionsacross
multipledomainssuchasbusiness,healthcare,
marketing,schools,churches,andindividuals’
healthbehaviorchoices.Healthpolicyandfederal
fundinghasalsoincreasedtobattletheobesity
epidemic.TheHealthy,Hunger-FreeKidsActof
2010authorizesfundingandestablishes
guidelinesforschoolbreakfastandlunch
programstoimprovenutritionalstandardsfor
school-agedchildren(U.S.Departmentof
AgricultureFoodandNutritionService[USDA],
2014).

Figure13-5Overweight/obeseadultsestimated
percentagesbyrace/ethnicity.

FoodConsumptionPatterns
Changingpatternsinsocietyandthemarketplacehave
contributedtopeopleconsumingmorecalories.
Consumptionoffastandtakeawayfoodcontinuesto
beaprevalentpatternintheUnitedStatesandis
particularlywidespreadamongchildrenand


adolescents(Jaworowska,Blackham,Davies,&
Stevenson,2013).Frequentconsumptionoffast-food
itemsthatarehighinfat,sodium,andsugarcanlead
topoordietaryquality,increasingaperson’sriskfor
chronicdiseases.
AccordingtoarecentGalluppoll,approximately28
percentofAmericansreportedeatingfastfoodatleast
onceaweekand16percentreportedtoconsumefast
foodseveraltimesaweek(Dugan,2013).Fewer
peoplecookathome,whereitiseasiertohavecontrol
overportionsizesandtheingredientsusedincooking.
Eatingoutoftentranslatesintoeatinglargerportions
andconsuminghigherlevelsoffatandsugar.Fast
foodisnotonlyconvenient,itisrelativelyinexpensive,
makingiteasyforworkingfamiliestogotothedrivethroughtopickupfastfoodontheridehomefrom
work.
FoodAdvertising
Themarketingoffoodisahugepartofthefood
industry.Foodadvertisingissosophisticatedthatit

targetsspecificgender,age,andethnicgroups.
Companiesplaceasignificantfocusonconducting
marketresearchsotheyspecificallylearnwhatappeals
tovariousgroups.Cerealmanufacturersareagood
example.Theyareverysuccessfulatmarketingcereal
productstokidsthroughSaturdaymorningcartoonson
television,somuchsothatthesepracticescameunder


scrutinybyfederalregulators.Inadditiontofederal
regulation,privategroupshaveacted.In2007,the
Kellogg’scompanyannounceditwouldphaseoutads
targetingchildrenunder12aswellasdiscontinuingthe
useofwell-knownchildren’scharactersortoysto
promoteproductsthatdidnotmeetcertainnutritional
guidelines(Martin,2007).Theguidelineswerebased
onthecalorie,sugar,fat,andsodiumcontentof
primarilybreakfastfoods.Kellogg’smadeitsdecision
becauseofthethreatofalawsuitbytwoadvocacy
groupsandprivatecitizenswhowantedtoeliminate
thepromotionoflesshealthyfooditemstoyoung
children(CenterforScienceinthePublicInterest,
2007).
Colabeveragecompaniesrepresentanothermarket
segmentthatcompetessoheavilythattheyaresaidto
have“advertisingwars.”Theyareknownforstate-ofthe-artadcampaignsthatappealtonearlyallagesbut
targetteensandyoungadults.Afewcompaniesdo
usehealthtotargetcertaingroups,suchasthelean
microwavedinnersthatappealtomenandwomenwho
arehealthandfitnessconsciousordieterswithgoals

oflosingweight.
BeverageConsumption
TherehavebeenhugeshiftsintheU.S.consumption
patternsofbeveragesoverthepastseveraldecades.
Whereasmilkusedtobethetopconsumedbeverage