Worldwide initiatives currently aim to reduce free sugar intakes, but success will depend on consumer attitudes towards sugar and the alternatives. This work aimed to explore attitudes towards sugar, sweeteners and sweet-tasting foods, towards consumption and related policies, in a sample of the general public of the UK. Focus groups and interviews were conducted with 34 adults . Thematic analysis identified six themes: ‘Value’ , ‘Angle’ , ‘Personal Relevance’ (to be concerned and/or change one’s own behavior), ‘Personal Responsibility’ (one has an active relationship with these food items), ‘Understanding’  and ‘It’s Not Up to Me’ . Both positive and negative attitudes towards sugar, sweeteners and sweet-tasting foods were expressed in all themes. Participants also reported varied engagement with and motivations towards all food items, with implications for intakes. Suggested challenges and potential strategies for reducing free sugar intakes highlighted the need for differing approaches. Future work should assess associations between attitudes and intakes. For greatest population benefit, evidence of the dominant attitudes in those in greatest need of reduced free sugar intakes would be of value. The World Health Organisation currently recommends reducing free sugar intakes to 10% daily energy intakes, with further benefits from a reduction to 5% daily energy intakes , cardiovPopulation levels of sugar consumption, however, lie above these recommendations. While free sugar intakes are difficult to accurately assess , total sConsumer food purchasing and consumption are determined by a range of factors from individual characteristics to environmental circumstances . Sugar oAttitudes to and associations with sugar consumption are also potentially confounded by attitudes to the alternatives to sugar consumption—namely the consumption of less sweet foods, or the consumption of other sweetening agents, such as low-calorie sweeteners. Humans have an innate liking for sweet taste  and prefLow- or no-calorie sweeteners (LNCS) may offer this desired sweet taste without the health implications of sugar. LNCS provide the pleasure of sweet taste without the energy content of sugar , and theDespite the lack of preferred alternatives, many individuals report concerns over sugar intakes ,31, and Given the limited existing research in this area and the current push to reduce free sugar intakes, further work exploring attitudes towards sugar, sweeteners and sweet foods is required. Considering the importance of differing policies toward sugar reduction for those attitudes, it is important furthermore, that this work is conducted in the context (time and location) of the intended policies. Increased understanding of current attitudes, both to the food items themselves and to relevant policies and suggestions for change would provide a strong basis for future work aiming to develop strategies for intervention and highlight areas of consumer concern. This research aimed to explore current attitudes towards sugar, sweeteners and sweet-tasting foods in a sample of the general public of the UK, including attitudes towards personal consumption and related policies.This was an exploratory qualitative study using focus groups and interviews in a sample of consumers living in the UK.Healthy adults, aged 18–65 years old and able to provide informed consent, were recruited from the south coast of England, through University contacts, community groups and flyers distributed in coffee shops and other public places. No further inclusion criteria were utilized. Minimal inclusion criteria and many recruitment strategies aimed to allow inclusion of volunteers from a range of backgrounds, providing a wide range of attitudes. Ethical approval for the study was granted by the Research Ethics Committee of Bournemouth University (ID: 29215) prior to commencement. All participants provided informed consent before participation and were compensated for their time.The study used a combination of focus groups, dyadic interviews and solo interviews to generate a wide range of perspectives and understandings. Topics for discussion were considered by the researchers to be non-sensitive, hence suitable for discussion in focus groups and dyadic interviews, and focus groups were used to elicit collective and personal opinions. Interviews were conducted only where participants were unable to attend a focus group session. Data collection was undertaken from January 2018 to March 2020. During this time (April 2018), a nationwide tax on soft drinks that contain at least five grams of sugar per 100 milliliters, the ‘Soft Drinks Industry Levy’ (SDIL) was implemented across the UK . Some foA moderator guide was used to structure all focus groups and interviews. Questions focused on participants’ beliefs about sugar and sweeteners, their preferences and rationales for consumption or avoidance, their attitudes towards different sweetener terms or categories, attitudes towards sugar intake versus sweet-tasting food intake and their opinions on current and potential strategies to reduce free sugar intakes. The open-ended moderator guide was piloted prior to use in six interviews, and refined to ensure the clarity, relevance and value of each question. The refined guide was then used for all focus groups and interviews. Visual materials were presented at various time-points during each session, with the purpose of generating more discussion. These included: pictures of the sugar content of several commercial beverages in sugar cubes, in relation to current Public Health England recommendations ,9; exampFocus groups and interviews were conducted using established methods ,36,37. AThematic analysis was selected for this exploratory work so as to not be theoretically-bound. Themes were identified using an inductive approach based on the explicit semantic content of the data . AlthougThematic analysis was performed based on Braun and Clarke’s six phases . ModeratTo address unitization, this study adopted a strategy that focused on meaning units rather than naturally given units. Initial codes were generated from each transcript by two researchers independently, and then agreed upon. This “negotiated agreement”  after sThe PI and all other researchers were female with lean body weight, and the majority were involved in other projects on dietary sweetness at the time of this study. Three researchers had backgrounds in eating behavior, nutrition and the drivers of food choice and intake, and one researcher had a history of eating disorders; all of which may have had an impact on the identification and definition of themes or subthemes.N = 11), from local workplaces, including the University (N = 9), among the parents of a local school (N = 5) and from the community, e.g., via coffee shops (N = 9). None of the participants reported being on a diet, having been diagnosed with diabetes or insulin resistance, or reported being intolerant or allergic to sugar, LNCS, wheat, gluten, rice, cereal or fruit. Three focus groups were undertaken from January–March 2018 before the implementation of the UK SDIL, one focus group was undertaken in July 2018 shortly after implementation of the UK SDIL, and three focus groups and all interviews were undertaken from January to March 2020.Twenty-nine participants  took part in seven focus groups, four participants took part in dyadic interviews  and one participant took part in a solo interview (1F). Seventeen participants were aged 18–30 years, four participants were aged 31–40 years, four participants were aged 41–50 years, four participants were aged 51–65 years, and age for five participants was not recorded. Participants were recruited from the University student population  To me, th-the life is too short, to do away with, good things in life.”“Yeah like I don’t really mind, I would rather be a bit curvy and happy and enjoy what I eat rather than obsessively worry all the time and restrict myself of things that I want.”Examples quotes from this theme are::: Negativity surrounding sugar, sweeteners and sweet-tasting foods.Contrary to the positive nature of the ‘Value’ theme, the theme ‘Angle’ referred to more negative perceptions of sugars, sweeteners and sweet-tasting foods. The subtheme ‘Disinterest’ alluded to indifference. Comments suggested that some participants did not specifically include or exclude sugar, sweeteners or sweet-tasting foods in their diets, adding that concerns about sugar intake can be excessive and consuming sugar is ‘not a big deal’. Disinterest in sweeteners was related to the view that “artificial” or “synthetic” LNCS need not be deemed as worse than “natural” sweeteners.Stronger negative feelings were grouped under the subtheme ‘Disapproval’. Comments included concerns about the short- and long-term health implications of sugar and LNCS. Sugar was perceived as non-nutritious and unnecessary in the diet, hence avoiding it was seen as a good decision, while LCNS were viewed as artificial chemicals that came from laboratories, and were potentially carcinogenic. Under this subtheme, several participants believed that sugar, LNCS and sweet-tasting foods are physically addictive, and that reducing their intake would lead to withdrawal symptoms, viewing consumption as synonymous with vices such as drug-taking.The subtheme ‘Relativity’ contained comparative considerations. Sugar and sweeteners were viewed not in isolation, but in relation to each other, or other food components such as fat or salt. Comments suggested the concept of the ‘lesser of two evils’. For example, LNCS may be unhealthy chemicals, but at least they provide sweet taste without the detrimental health effects of sugar. On the other hand, sugar may contribute to weight gain, but at least it does not cause cancer.“To me, eating sweet things, is just, quite normal! Um I-I don’t necessarily look upon it as a treat. It’s like I fancy something sweet, I’m gonna have that.”“The reason I don’t pick diet is because I heard about aspartame and I’ve heard people get tumours. It might be a myth thing but both options are bad and it’s better to do better the devil I know than I don’t.”Examples quotes from this theme are::: To be concerned personally and/or to change one’s own behavior.While the themes ‘Value’ and ‘Angle’ were generic in nature, many concepts were considered to affect different individuals in dissimilar ways, including the idea that some concepts were relevant to “me”, while other concepts were more relevant to other people. Many reasons were given for an individual to be personally concerned with sugar, sweeteners and sweet-tasting foods, and individuals could view these food items negatively, but did not see themselves as needing to reduce their intakes. Alternatively, some participants identified themselves as people who needed to change and thus viewed intake modifications as relevant to them. In this theme, attitudes towards sugar reduction strategies focused on specific population groups: the young, old, children, parents, pregnant women, people of lower socioeconomic status or people with obesity or diabetes. There was general consensus that the effectiveness of strategies would largely depend on the target audience and that appropriate intakes differ across individuals; hence strategies should be personalized.Personal relevance was described in relation to a number of specific characteristics. The ‘Health and Body Image’ subtheme included references to how a person thought he or she looked in terms of body size and skin, and how healthy a person thought he or she was. Comments under the ‘Generation and Age’ subtheme reflected beliefs that taste preferences change with time and age, such that as one ages one might prefer and desire sweet-tasting foods less, rendering intake reduction irrelevant to those of older ages. Personal relevance in terms of ‘Socio-Economic Status’ referred to perceptions of economic and social class in relation to others, as a combination of income, education and occupation.More individualized involvement and interest in consuming sugar, sweeteners and sweet-tasting foods were reflected in the subtheme ‘Stake’. Some individuals felt that they had higher tendencies than others to crave sweet or sugary foods, associated intake with socially desirable traits or saw sweet-tasting foods as staples, hence they had a greater investment when taking action towards consumption. Conversely, some participants expressed that sugar reduction was less of a priority when they were faced with a myriad of challenges, such as a heavy workload or family commitments.“Although there are a notable amount of people now who are kinda you know driving the healthy lifestyle, there is still a lot of people who are, you know, probably more in line with where I am, and slightly beyond, which is like pffttt! Yeah, if you make it easy for me, maybe, but I’ve got other fish I need to fry right now and I’m not gonna get there.”An example quote from this theme is::: One has an active relationship with sugar, sweeteners and sweet-tasting foods.Related to ‘Personal Relevance’, the theme ‘Personal Responsibility’ revolved around the idea that individuals have an active relationship with sugar, sweeteners and sweet-tasting foods and their consumption. Showing the greatest degree of responsibility, the subtheme ‘Informed Choice’ demonstrated complete choice over food consumption as an individual. Comments suggested that individuals valued the ability to understand and make their own decisions; they do not like to merely be told what to do, but instead want to be educated on foods, on their health implications and the rationales behind interventions. Consumption of sugar or sweeteners would depend on one’s knowledge and familiarity with each food item. Poor health was viewed as the fault of an individual for making poor decisions. Awareness and education could bring about behavioral changes, but individuals were responsible for their consumption, so there are boundaries that regulations should not cross. Some participants viewed sugar taxes as helpful in raising awareness of the high sugar content of some foods, and driving consumers to reduce intakes, suggesting even that consumers should share the cost of sugar taxes as a way of taking responsibility. However, sugar taxes were also considered unfair to consumers who keep their intakes within healthy ranges, hence any levy should be placed on overconsumption instead of consumption per se. Tactics or regulations similar to those for cigarettes such as packaging with graphic imaging, were also viewed as helpful to allow clearer identification of high-sugar products, with the recognition that this packaging could also be ignored. Furthermore, such tactics were seen as extreme and would require gradual introduction to the public. Some comments suggested that labels and guidelines, such as the traffic light rating system, were not helpful or clear enough and still require effort on the part of consumers.An active relationship with sugar, sweeteners and sweet-tasting foods might also include ‘Self-Regulation’, a subtheme defined as managing one’s own intake of these food items. Comments suggested that some participants actively avoid or reduce sugar by rationing consumption, reducing frequency of consumption, removing any foods from the immediate environment and by preparing their own sweet-tasting foods to include less sugar. Taste preferences were also believed to be modifiable; changing preferences was a matter of habit and of getting used to new tastes. This subtheme also included the concept of balancing out one’s sugar or sweet food intake with foods or behaviors that are perceived as healthier, such as the use of sweet-tasting rewards only after intense exercise.The idea of balance was also found in the subtheme ‘Internal Conflict’, although here the focus was more on the struggle to balance different opposing motives. Comments implied that participants struggle with motives of health versus enjoyment, resulting in the use of words such as ‘devil’, ‘naughty’, ‘demon’, ‘indulgence’ and ‘guilt’ in association with sugar and sweet-tasting food consumption. Participants expressed an “all or nothing” mentality and were unable to halt intake at times and while preferences for sugar and sweet-tasting foods were considered to be acquired and not innate, habits were also considered difficult to break. Sugar reduction was related to restraint and deprivation.‘Motivation’ was also associated with personal responsibility. While some participants viewed themselves as responsible for their own intake, they lacked the willpower, self-care or time to change their behaviors. Other participants felt driven to make changes. Comments suggested that on top of education and modifying food products, strategies should target behaviors, such as focusing on empowerment and positive reinforcement to effect and maintain sugar reduction.“I’ll just go ‘oh okay, that meal is mostly red for sugar [on the traffic light rating system] so I’ll make sure the other meals are not red in other areas’ so I make sure it’s like lower, a different colour for anything else I buy, and that they don’t add up. I could be buying four […] things in the red zone and be like ‘oh yeah that’s fine cause I’ve had like seven things in the orange or green’.”An example quote for this theme is::: Acquiring, comprehending and applying insights on sugar, sweeteners and sweet-tasting foods.The theme ‘Understanding’ encompassed sub-themes associated with ‘Delivery of Information’, ‘Awareness’, ‘Perceptions’, ‘Proficiency’ and ‘Reasoning’. The subtheme ‘Delivery of Information’ focused on how information on sugar, sweeteners and sweet-tasting foods is disseminated and received. Channels included celebrities or influencers, doctors, documentaries, films, friends, social media platforms, newspapers, television programmes, the internet and hearsay and all channels were considered both reliable and unreliable. Opposing views also suggested that education and awareness was sufficient and health guidelines and promotions were aplenty, while other comments indicated that information was not widely accessible and suggested a need for education in workplaces, schools, hospitals or other organizations. Technologies such as mobile phone applications and visual cues such as labelling and advertising were seen as impactful aids in sugar reduction strategies.The subtheme ‘Awareness’ summed knowledge and being conscious of issues related to sugar, sweeteners and sweet-tasting foods. While some participants were conscious of their intakes, were aware of concepts such as “hidden sugars” in food products and attended to the health implications and guidelines related to sugar, sweeteners and sweet-tasting foods, other participants were not mindful of these, and were unclear on the reasons behind recommendations or the origins of their opinions. When prompted specifically about the UK SDIL, some participants expressed confusion or surprise, were unaware as to whether the tax had been implemented and suggested poor awareness of the details of the scheme.The subtheme ‘Perception’ referred to the way in which one interprets or regards information related to sugar, sweeteners and sweet-tasting foods. Perceptions included concepts of “healthy” versus “unhealthy” sugars, the suggestion that natural sugars, such as fruit sugars and honey, were healthier than artificial  sweeteners and that brown sugar was more natural and so healthier than white sugar. Participants generally viewed fruit as a healthy source of sweet taste, but suggested confusion in relation to fruit juices, fruit drinks and concentrates. The terms ‘fresh’, ‘natural’ and ‘organic’ were interpreted positively. The term “sweeteners” was generally used to refer to LNCS, and these were treated separately from “natural” sweetening agents such as honey. Low-fat or fat-free products were considered to include a high sugar content, while low-sugar or sugar-free products were considered to be high in LNCS.‘Proficiency’ was defined as a deeper knowledge and proficiency in matters related to sugar, sweeteners and sweet-tasting foods. There were concerns that current sugar-reduction campaigns focused on sugar cubes and carbonated beverages, and hence the public may only view these items as unhealthy. There was general consensus regarding a lack of proper understanding of LNCS, and how to replace sugar with LNCS, for example, in baking or cooking. There were suggestions consequently for education on sources of sugar, sweeteners and sweet taste, and on how to prepare sweet-tasting foods with reduced sugar at home.The subtheme ‘Reasoning’ covered how an individual applies logic while processing information in order to form inferences. Participants reported being unable to interpret the large range of available marketing, nutrition and health information, such that they were unsure whether to consume sugar or LNCS as a source of sweet taste. Responses indicated support for LNCS use for weight loss, hyperactivity, diabetes or other medical conditions. In addressing whether LNCS should replace sugar, some participants supported the use of LNCS as a short-term strategy to reduce dietary sugar, while others did not see the need for LNCS and supported sugar reduction alone. There were suggestions also that LNCS could include added health benefits such as vitamins, instead of simply providing fewer calories. With the knowledge that LNCS could provide sweet taste without the energy content of sugar, there were also concerns that guidelines may have detrimental side effects, such as reductions in physical activity when individuals switched from sugar to LNCS because they are consuming less calories, or that some strategies, such as graphic imaging on packaging, may be equally applicable to other food items, such as those high in fat or salt. There was general consensus that sugar reduction would require a holistic approach, involving government legislation, food product reformulation, education and motivation.“But brown rice is better for you, so surely brown sugar is.”“I think a lot has been done to educate people on sugar, but there seems to be no education on sweeteners and what they are.”“I think my concern would be if people, mis-interpreted the message that said sweeteners are okay, and sugars are less okay. People might think, well I won’t bother exercising now and they think then if if I just turn to sweeteners.”Example quotes for this theme are::: One takes a passive approach towards sugar, sweeteners and sweet-tasting foods, because intake is subject to other factors.Contrary to the active involvement of the individual in the above three themes, the theme ‘It’s not up to me’ detailed a passive approach to sugar, sweetener and sweet food consumption. Food intake was considered to be ‘Beyond Individual Control’, to be determined instead by ‘Strategies and Regulations’ or ‘Deception’. The subtheme ‘Beyond Individual Control’ referred to factors that individuals felt unable to control. Food choice and intake were considered to be determined by the availability and accessibility of sugar, sweeteners and sweet-tasting foods and the social and cultural environment, including family, friends and peers. Some participants suggested that the normalization of obesity could increase sugar consumption, as high sugar intake was seen as acceptable or typical, while others suggested that society is becoming healthier and that lower sugar consumption is more acceptable. The sugar content of foods was seen as unnecessarily high, a fault of food manufacturers, and advertising and marketing strategies were considered to be aggressive. Sugar reduction strategies were also considered to compete with these influences. One reason that was given for failing to notice the SDIL, for example, was that large price fluctuations in the economy may mask small tax-related increases in prices. For some participants, sugar reduction was also beyond one’s control because the addiction to sugar was difficult to overcome and would require professional help.The subtheme ‘Strategies and Regulations’ referred to official legislation and large-scale measures. Comments implied that healthy food consumption was the responsibility of the government. Sugar taxes and the promotion of reduced-sugar foods as default options were viewed as beneficial for driving manufacturers to lower the sugar content of foods, but there were concerns that implementation was dependent on individual manufacturers, and that the food industry could choose to reject measures such as sugar labelling or graphic imaging. Current government dietary recommendations, such as keeping below 30 g of free sugars per day, were also seen as possibly unrealistic.Finally, the subtheme ‘Deception’ incorporated ideas of traps and tricks used by food manufacturers and distrust of the food industry. The food industry was considered to be corrupt, to intentionally load sugar or sweeteners into foods, and to mislead consumers with unclear labels; there were suggestions that consumers were pitted against food manufacturers and the tactics of the latter would triumph. Comments also reflected distrust of current food labels and of the information produced by health professionals and scientific researchers.“I think people need professional help! You know for sugar? Cause of the fact that I’ve I- I- y-yeah. I think she’s right. It is a drug (pause) and when I when I need, I need it.”“But, at the end of the day, you know, if that doesn’t work, is like people are children you know, [authorities have] to tell them off and the only way is punishment! Isn’t it?”“I think it’s sneaky how much they put in stuff, it can be hard to stick to your plan or keep things in moderation when companies load things with sugar and fat.”Example quotes for this theme are:This work aimed to explore attitudes towards sugar, sweeteners and sweet-tasting foods in a sample of the general public of the UK. A combination of seven focus groups, two dyadic and one solo interview was conducted to elicit a wide range of attitudes. Attitudes were grouped into six main themes: ‘Value’, ‘Angle’, ‘Personal Relevance’, ‘Personal Responsibility’, ‘Understanding’ and ‘It’s Not Up to Me’. Both positive and negative attitudes towards sugar, sweeteners and sweet-tasting foods were expressed across these six themes, largely dependent on the individual.Attitudes captured by the theme ‘Value’ demonstrated a range of advantages to using and consuming sugar, LNCS and sweet-tasting foods, from food preservation, energy provision and reduction, to pleasure and enjoyment, while less positive attitudes were grouped into the theme ‘Angle’. Comments in this theme demonstrated attitudes that were negative, uninterested or dependent on competing alternatives. Perceived benefits are common reasons for consuming foods ,43, and Compared to the straightforward nature of the themes ‘Value’ and ‘Angle’, the theme ‘Personal Relevance’ focused on more complex ideas that some people may be or may need to be more concerned with sugar, sweeteners or sweet-tasting food consumption than others. Differences between individuals were recognized based on demographic characteristics such as gender, age and socioeconomic status, on personal interests such as the importance of health or appearance to each individual, or personal situation. The importance of personal relevance for influencing dietary behaviors has been previously detailed elsewhere ,49,50,51The ideas of individual differences and individual motivations were also noticeable in the theme ‘Personal Responsibility’. This theme centered around the idea that one has an active relationship with sugar, sweeteners and sweet-tasting foods. Participants liked to be fully informed over the advantages and disadvantages of food ingredients, such that they can make their own choices, and regulate their intake for themselves. This idea of personal choice and personal control is apparent elsewhere in the literature relating to sugar and LNCS use ,17,31, aLinked to ideas of personal choice, and the need for information to enable this, the theme ‘Understanding’ specifically considered the means by which consumers gain and process information. Subthemes recognized the importance of both conventional and novel types of information and information channels, the value of awareness for informing and changing intakes, the importance of diverse perceptions and the use of wide-ranging and assorted justifications to rationalize sugar, sweetener and sweet food intakes. Information is repeatedly requested in response to dietary challenges ,20,23,30Contrary to the active engagement in themes ‘Personal Responsibility’ and ‘Understanding’, the theme ‘It’s not up to me’ allowed individuals to take a passive approach towards sugar, sweeteners and sweet-tasting foods, and recognized that intake is subject to other factors. The influence of external influences, such as the food supply and the social and cultural environment, in dietary intakes is well recognized ,18,19,20Clear attitudes towards policies and strategies for reduction were also expressed, and attitudes within each of the themes had clear implications for reducing sugar intakes. Clear benefits and disadvantages of sugar, sweeteners and sweet-tasting foods, plus the importance of personal relevance suggest a need for individualized and personalized strategies. The active engagement demonstrated under the themes of ‘Personal Responsibility’ and ‘Understanding’ suggests a need for greater awareness, education and the many independent ideas in the theme ‘Understanding’ suggest the potential need for a range of distinct types of information or education for instigating dietary change. The media portrayal of scientific publications and policy discussions has been shown to influence consumer perceptions of sugars and sweeteners .The need for personal relevance, and the possible differing attitudes based on population group, however also suggest that information may be more acceptable and more effective when tailored to specific perceptions and motivations. Similar concerns over acceptability, use and effect have also been suggested in the literature on sugar, sweeteners and sweet foods ,14,16,19The need for ‘Personal Relevance’ may make it hard to make changes to intakes on a population-wide basis. An absence of evidence for the prevalence of different attitudes and distinct consumer groups, furthermore, makes prioritization of certain approaches or strategies difficult. Evidence of the dominant attitudes in those in greatest need of change would be of value. Arguably, those in greatest need of reduced sugar intakes are those who are consuming large amounts of sugar, and those who are likely to be differentially affected by these intakes—those already experiencing or likely to experience related health conditions, such as dental caries, cardiovascular disease, Type II diabetes, overweight and obesity . Future The study was limited by its qualitative nature, allowing inclusion of a limited number of participants, however, recruitment was undertaken across a range of venues and minimal inclusion criteria were used to gain a range of individuals with a range of attitudes. Bias in the participants who volunteered and participated may have led to the demonstration of certain attitudes more than others, but we think it is unlikely that any important concepts have been missed. Discussions were also contextual and will reflect the prevalent attitudes and sugar-related policies in the UK at the time the study was undertaken. New legislations on advertisements and the labeling of foods high in sugar may shape consumer attitudes in the future . The anaThis study identified six themes to describe attitudes to sugar, sweeteners and sweet-tasting foods in a sample of UK consumers: ‘Value’, ‘Angle’, ‘Personal Relevance’, ‘Personal Responsibility’, ‘Understanding’ and ‘It’s Not Up to Me’. Individuals held indifferent, positive or negative perceptions of sugar, sweeteners and sweet-tasting foods, which could be influenced by their perceived competing alternatives. Individuals also reported varied engagement with intakes of these foods, taking either an active or passive approach to modifying their intakes. Potential strategies for reducing free sugar intakes were reported, but differing perceptions of likely value were also suggested. The existence of individual differences in perceptions, motivations and priorities may indicate a benefit for differing approaches. For the greatest population benefit, evidence of the dominant attitudes in those of greatest need of reduced free sugar intakes would be of value. Future work will investigate attitudes in a large representative sample of UK consumers, the dominant attitudes in specific population groups, and investigate the associations between these attitudes and free sugar intakes.


This study aimed to describe the connotation of respect for community elders in daily situations, and discuss the elderly’s views on respect for healthcare services. A qualitative research design was conducted to interview elders from a non-urban area in Changhua, Taiwan. Study sites were Lukang and Ershui. A total of 52 people were interviewed, with an average age of 75 years old. Based on Grounded theory, the thematic analysis method was used to analyze data. This study found that respect from the perspective of the elderly can be divided into three categories: (1) verbal expression, (2) non-verbal behavior, and (3) behavior combined with appropriate language. We found that elders use the performance of healthcare service providers to discuss respect in the field of healthcare services. Respect can also be shown in the physical environment in healthcare settings. This study found that, for the community elders, respect is an individual’s subjective feelings regarding the process of interpersonal interaction. Compared to daily life, the respect of the elderly for the healthcare setting has increased the element of the environment. In addition, it was found that elderly people have lower expectations and requirements for respect in healthcare settings. As the proportion of older people increases globally, the development of an environment that meets the aspirations and needs of older people has become a major concern for society and public policy. Therefore, the World Health Organization has proposed age-friendly cities as a policy guideline for countries and pointed out that “respect” is the key to planning age-friendly cities. For policymakers, the essence of respect should be based on the viewpoint of the elderly, not just the professional perspective.“Respect” is the foundation of human interaction  and one The number of elders over 65 in Taiwan is increasing steadily and reached 16.2% of the population by the end of January 2021 . The NatRespect is not only a topic of daily life but a subject that medical and health service providers should pay attention to. As indicated by Beach: Respect is fundamental to all human interactions and especially important in healthcare, where its presence allows for some levels of patient dependency without fear of mistreatment or abuse . PreviouUnderstanding the elderly’s views, experiences, and feelings of respect is an important subject but missing evidence-based support. Respect is a noun frequently used and heard nowadays, however, it is an abstract concept due to its vague definition. It would be appropriate to adopt a qualitative study design to examine an abstract concept because it can directly and deeply reveal the opinion and feelings of study participants. This study, therefore, adopts qualitative interviews to verify and compare the perspective of respect of the elderly from both daily life and healthcare settings.Based on Grounded Theory, we conducted a face-to-face, in-depth qualitative interview to depict the elders’ perceptions of respect.2. On the other hand, agriculture is the major industry in Ershui since it was developed late and with a lower population density of 1174/km2 Main Question:We all know that it is very important for people torespect each other, but we don’t know what our elders think about respect. So could you please tell us what do you think respect means?would like to ask you or anyone else you know if they have ever experienced not being respected. Please describe the time and place of this experience. [Healthcare Settings]Main QuestionWhat do you think is respectful in a healthcare setting ?ContinuedIs there a specific behavior that shows respect?ContinuedHave you ever experienced being disrespected in a medical setting? Why?The interviewers received training one month before the interview launched. The training not only emphasized the accordance of interview technique but detailed every possible scenario and their solutions during the interview. Before the formal interview, the four interviewers conducted a pilot interview at the research site after the interview training and research ethics course to practice their interviewing skills and to test the applicability of the interview outline. A total of four elderly people who met the inclusion criteria were interviewed for this pilot study and were not included in the formal study sample.The interview time varied due to the differences in response and answers of the elderly; it ranged from fifteen to sixty-five minutes with an average of thirty-three minutes.This study passed the requirement set by the Institutional Review Board (IRB) of Chung Shan Medical University Hospital . Before the interview, the purpose of study, study contents and all related right issues, and the reason for tape-recording of the interview were fully explained to all interviewees. Interviewees also signed two copies of the letter of agreement, participants and researchers each retaining one.This study was based on Grounded Theory  combinedAll of the following descriptions of respect are based on what the elders described. The inquiry did not specifically refer to elders, but rather to the broader concept of respect.Participant:…soft voice and lower volume when speaking (L07M71)Respect is a way of verbal expression, for example, “gentle tone”, and “smile when speaking”.Participant: Respect is…understanding each other, each other, right? Right, understand each other, it would be fine as long as we perceive what he thinks (U01F72).Participant: Respect! It means do not interfere with other people. Other people do not interfere with us either (U27F70).Participant: Respect for the view is mutual, you care about me and I will care about you so, should be mutual (U15M77).Participant: Respect is…nothing particular, just be polite, with courtesy …(U24M71).Participant:…they do respect me; two kids, one works at a railway station and the other takes care the store,  Participant: Yes, yes! (U06F80).Respect is a non-verbal behavior including “listening”, “fairness”, “comprehending other people”, “do not cross the line”, “good rapport”, support”, “politeness”, and “filial piety”.Participant: Respect is…(a short pause)…There were responses after you spoke (L12F75).Participant: Respect means do not argue, do not quarrel (U08M75), do not offend other people, everyone should have mutual affection (L19F67).Participant: Everyone respects me. ……I told them that you are much older than I am, you cannot call me as “elder sister”…(L26F750).Respect is a behavior combined with appropriate language including “responsiveness”, “conflict avoiding”, “praise”, and “greeting according to seniority in the family”.When asking the elderly “What do you think respect means?”. When analyzing the general view of respect of the elderly, we found that the majority of seniors do not convey subjectively how respect should be expressed during the interaction, and there was no “I” appearing in their responses. Less often taking himself/herself or a specific person as an example. The responses could be categorized in three dimensions after thematic analysis:The results of this section are based on the elders’responses to the second question of the Qualitative Interview Outline, i.e., “What do you think is respectful in a healthcare setting?”.Participant: …It was OK! (Interviewer: Can you tell me why it was OK?) Participant: The tone of healthcare providers was acceptable! (L07M71).Participant: respect me?…I felt he was kind when he spoke (L07M71),…Ya, both doctors and nurses spoke in a very nice way (L11F75).In terms of respect in healthcare settings, the statement of the elderly mainly involves the professional services of medical care providers. It indistinctly suggests that most elderly think healthcare services are medical services. As for respect in such a setting, it ranged from a broader and abstract concept of “overall service attitude” and “listening to the elderly” to “care services other than healthcare services”, and “attitude when offering healthcare services”. Furthermore, elders more directly use medical care outcomes as an indicator of respect, such as “providing expected medical care services” and “obtaining final health results”. In terms of non-verbal behaviors of respect, it is clear that the elderly have specific and diverse expectations of respect in healthcare settings, as opposed to verbal expressions of respect.Participant: I felt that everybody is very kind, with very good service, that’s it, this is the way to show respect to me (L25F68).Participant: The doctor is more polite, more respectful of what you say, will listen to what you say, and will listen to whatever you want to say (U14M84).Participant: They are very good, so they are very respectful. I had my tooth extracted, they were afraid that I would fall and would like to escort me to the station …the doctor asked a nurse to take me to a bus station (U22F73).Participant: There is respect… that was a nurse, he was doing an ultrasound, when there was an issue, he said “let’s do it again, let’s do it again”, he would re-scan the spot thoroughly or ask you to come back another time (U24M71).Participant: being respected… he would check what discomfort I described, prescribing medication for me (L17M84).Participant: …cure me, that’s it…that’s respect…we wouldn’t visit again if he didn’t cure us, that’s impossible (U19M82)?The study found the following in the current dimension: the elderly felt being treated with respect when healthcare providers offered services combined with appropriate language including “looking after”, “caring and greeting the elderly himself/herself”, “reminding and explaining during the process of healthcare services”, and “describing and explaining healthcare services”. We found that language was an important medium to convey respect to the elderly. Even for behavior, it needs to go along with language to show respect. As for the contents of language, the elderly stressed more of the personal caring aspect rather than an explanation of disease and services.Participant: respect…they would say ”sir, sit here and wait for a while”, that’s it, this is what I need. This is respect, what would it be otherwise? (L01F70). Participant: respect me…doctors are very nice nowadays when I entered, he invited me to sit near him, they all very kind (L03F74).Participant: respect in this environment, they were nice to us, asked you “Did you eat This morning?...You need to pay attention when going out.” It made me feel this doctor is very nice (L15F73).Participant: respect…doctors were very nice, currently, he knew how to treat me, “Hey, don’t eat sweet stuff!” He made fun of me, “You will get a needle if you eat sweet stuff again!” (Smiling), harassing me (L20F81).Participant: Respect…what to say…the doctor pointed out the issue and how to treat it (U23M65).The study found that respect in healthcare settings is not only conveyed by healthcare providers, humans, it can also be delivered through the environment, such as “the distance between the elderly and healthcare providers” and “the privacy concern when receiving services”.Participant: Being respected… doctor sat closer to you, discussed the inner issue with you, a doctor sat across the table and the nurse was beside him/her, it felt like being examined (L04M76).Participant: Respect for patients who come to see the doctor….you should offer privacy when they need it, not just open to everybody (U13F71).Participant: respect me?…I felt he was kind when he spoke (L07M71),…Ya, both doctors and nurses spoke in a very nice way (L11F75). On the contrary, the elderly in Ershui are more concerned with “listening to the elderly”. For example, The doctor is more polite, more respectful of what you say, and will listen to what you say, and will listen to whatever you want to say (U14M84).Area difference: The elderly in Lukang care more about the verbal expression of healthcare providers. For example, Participant: there is respect… that was a nurse, he was doing an ultrasound, when there was an issue, he said “let’s do it again, let’s do it again”, he would re-scan the spot thoroughly or ask you to come back another time (U24M71). Respect…they would say ”sir, sit here and wait for a while”, that’s it, this is what I need. This is respect, what would it be otherwise? (L01F70). Males, however, payed more attention to “obtaining final health results” such as “Participant: …cure me, that’s it…that’s respect…we wouldn’t visit again if he didn’t cure us, that’s impossible (U19M82)?”.Gender difference: Females stressed “offering care services other than healthcare services” and “being looked after”. For example, After stratifying by sociodemographics, it is found the majority view of the elderly toward “respect in healthcare settings” was coherent in dimensions, but some examples in the dimension varied as follows:Further analysis revealed that general daily life situations can be subdivided into family and community. Therefore, the following comparison of respect in different contexts is presented as (1) interactions with family members, (2) interactions with community groups, and (3) interactions in healthcare settings  sufficient explanation, such as reminding and explaining during the process of healthcare services, or describing and explaining the contents of healthcare services, (2) meeting expectations, such as providing expected medical care services; and (3) health outcomes, that is a cure or control for the disease. The respect for “beyond medical treatment” in healthcare settings can be further divided into two subcategories: the physical environment and the attitude of the practitioner. The respect related to the physical environment includes “privacy” (the privacy concern when receiving services) and “distance” . The respect element related to the attitude of the practitioner, which reflects seniors’ requests and expectations of the practitioner’s service attitude, was ranked from low to high: (1) not mean and not harsh; (2) kind or friendly; (3) looking after, such as arranging and greeting the elderly to be seated actively; and (4) caring for and greeting the elderly, such as reminding the elderly of traffic safety when leaving.This paper used the question “What do you think respect means?” to interview elders to understand their perspectives on respect. The qualitative analysis was used to construct the connotation of respect from the elder’s perspective. Some elders gave examples to illustrate their views on respect, and these examples included their own experiences and their observations. Therefore, respect in the eyes of the elders is a feeling of interpersonal interaction, which implies how they should behave when interacting with each other, and also includes self-requirement and expectation of the behavior of others. Furthermore, elders’ subjective perceptions of respect are influenced by the culture and traditions of the region in which they live. Therefore, the results of this study are not only the elders’ experiences of respect but also the elders’ overall perceptions of the concept of respect.In terms of respect in daily life, this study found that the elderly are familiar with it and they do possess their way of thinking, which is congruent with previous studies. In terms of respect in daily life, this study found that the elders were familiar with the term respect and had their ideas about it, which is consistent with Ronzi’s studies . OverallIn terms of respect in health services, it can be summarized as “For the elderly, respect in healthcare settings is a subjective evaluation of the process, the provider, and the environment in which the service is provided, and is composed of verbal expressions, nonverbal behaviors, behaviors combined with appropriate language, and the physical environment of the healthcare setting.” The attitudes and behaviors of health service providers mentioned by the elderly in various aspects were similar to previous studies. Take the study in Finland as an example, admitted elders believe the following are ways to show respect: nurses should respond to patients’ questions/requests, listen to the elderly, and offer healthcare information . Beach’s3.Compared to general situations, it is easier to present a clearer and different perspective on a specific situation. A healthcare setting is not only a more specific context for the seniors but also a place to treat their health problems. Interpersonal interactions in this setting include both general and therapeutic levels. In addition to interpersonal interaction, it also includes the perception of environmental arrangements. From the elderly’s statement, the expectation of respect for the healthcare setting is implied: I am not just a health problem to be treated, but a person.4.The elderly believe subconsciously that respect in healthcare settings contain his/her expectation in utilizing healthcare services including space planning. The closer spatial distance seems to make the elderly feel more respected. This result is consistent with the psychological view that spatial distance reflects psychological distance, and that psychological distance can be reduced by shortening spatial distance .The issue of respect in the environment of healthcare settings has not been found in daily life. The elderly think “ensuring privacy” in healthcare settings is a way of respect, which corresponds to an England study: elders believe “maintaining privacy” is the main factor of care with dignity . This stIs respect in the eyes of the elders respect for others or being respected? We found that: (1) In daily life, respecting others and being respected are two sides of the same coin, and (2) seniors are more concerned about “being respected” in the healthcare setting. The discussion is as follows.We found that respect in the eyes of the elders manifested itself in the interactions of daily life. Although respect can theoretically be divided into active and passive aspects, the elders seemed to view respect for others and being respected as two sides of the same coin. The elders usually discussed it without a subject word or outlined it as “mutual”. For example, responding to each other in conversation. Or a polite interaction in which “everyone is polite”. Or “don’t cross the line” to describe respect for each other.Ingersoll-Dayton  used aduUnlike respect in everyday life, we found that seniors’ perception of respect in healthcare settings is unidirectional. All of the narratives in our findings were about respect of the delivery of healthcare services, and none of them mentioned the respect that patients have for the healthcare setting or the provider. In terms of respect, healthcare providers are contributors and the elderly are receivers. This result is consistent with previous studies in other countries. Past research on respect in healthcare settings has focused on the respect of healthcare providers for their patients. For example, in a study in South Africa, it was found that the elders perceived the negative attitude of the medical staff  or lack This study found some slight area differences in the perceptions of respect in health service settings among the elderly. (1) Those who perceived respect as a verbal expression were all from the respondents in Lugang. These seniors seemed to have lower expectations or standards of respect in healthcare settings compared to respect in general situations. (2) Those who thought that listening to patients was a form of respect were the respondents from Ershui. Ershui’s seniors could provide real examples to express what they consider to be respectful of healthcare. For example, the kind greetings from doctors, the care for the elderly in their daily lives outside of medical treatment, etc.This could be attributed to different interviewing locations: a community care station in Lukang and the gym in a health station in Ershui. When being asked about “respect in healthcare settings”, the majority of the elderly in Ershui replied “The director in the health station is very nice” in the beginning. They replied more once the interviewer asked deeper. The elderly in Lukang shared their previous experiences instead of their impression of specific healthcare provided. The elders mentioned that the respect of healthcare providers is shown through careful examination during treatment. It could be due to the variation of care-seeking location, health station for Ershui’s elders, and hospitals or clinics for the elderly in Lukang.There are differences between male and female seniors toward the view of respect in the healthcare setting. Female elders felt being respected through “offering care services other than healthcare services”  and “looking after” by healthcare providers (behavior combining with appropriate language). For example, while waiting for a consultation, the nurse asks if the patient needs a drink of water or to sit down for a break. During the consultation, the doctor will take care of the elderly’s daily life, such as whether they have eaten breakfast or not. After the visit, the doctor will ask a nurse or volunteer to accompany the elder to the station. Male elders, however, believed that respect is “obtaining final health results” . For example, curing a disease is respect.From the above interpretation, it seems that female elders are more process-oriented, while male elders are more outcome-oriented. Compared to males, females’ perception of respect originates through multiple sources including language and behavior. Previous studies of respect concentrated on females and very few of them focused on males. In Janevic’s study, women hesitated to seek care because they did not feel they were being treated respectfully and thought they were discriminated against . In KujaThe elders think gentle tone, responding, and listening are ways of showing respect in both daily life and healthcare settings. The elders seem to have a lower requirement for respect in healthcare settings in that respect is expressed in a manner of acceptable, not mean, or not harsh tone. In healthcare services utilization, some elders raised the view that respect with no excess expression is an acceptable tone for providers.It can be seen that the elders possess a similar view of respect in both daily life and healthcare settings. They play a passive receiver role in healthcare settings and pay less attention and care to respect. In the process of medical sociology development, the roles of medicine and society evolve constantly. Medicine is not merely a science, it can sculpt a society or vice versa . This inThe possible explanation could be due to the gap between patients and healthcare professionals and the latter plays an active role most of the time. The doctor–patient relationship produces an asymmetrical power structure due to the capability gap and makes users ask for less in healthcare services . It coulBased on the above discussion, healthcare practitioners and health policies have recently attempted to develop and promote measures to facilitate physician–patient communication, such as shared decision-making. The literature  suggestsSome of the respondents were brief in expressing abstract concepts . Therefore, this study was conducted through constant encouragement and gentle probing by the interviewers to obtain richer information. However, to understand the perceptions of respect among the elderly without any specific orientation, the interview protocol was not pre-designed to include any specific orientation. For example, respect in everyday life was not specifically asked about, such as family or community groups. Similarly, when the elderly were asked about respect in health services, they were only asked about their perceptions of respect in a broad sense, without specifically including environmental factors and interpersonal interactions, which may have prevented them from giving focused responses. Therefore, the various aspects of respect and the conceptual framework found in the findings of this study all emerged from the information provided by the elderly interviewees. If future research would like to know the perceptions of elders about specific dimensions of respect, it is recommended to ask more specific questions, such as: “What are the things that the elderly feel respected for in the healthcare setting? Do they respect each other during interactions with healthcare providers?”Firstly, because the elderly are more accustomed to community care stations and trust them more, the participants were introduced by community care stations. Therefore, elderly people who were not involved in community care stations were less likely to be participants in this study. Secondly, because qualitative interviews require informative participants and ethical considerations of informed consent, this study invited people to participate in the study through the assistance of a community care station. This recruitment channel may have biased the study results in terms of health effects: that is, seniors who participated in community activities are healthier than those who do not. The elderly who participate in the community care station may have different perceptions of respect. The generalizability of the results is limited by this group of community care center participants. Furthermore, since social and cultural backgrounds may have an impact on the elderly’s perceptions of respect, this study invited the elderly from the same county as the research subjects, whose living environment and cultural backgrounds may be similar, so the results of this study cannot be inference. Therefore, in the future, it is necessary to invite the elderly from different backgrounds as research subjects to explore the perceptions of respect among elders from different social and cultural backgrounds. In addition, there are local variations in healthcare resources and healthcare systems, which may affect the use of health services for the elderly, and these experiences of use may also affect their perceptions of respect. Therefore, it is suggested that health system factors could be taken into account in future studies.The World Health Organization (WHO) advocates for the promotion of age-friendly cities  around tThis study found two characteristics of elderly people’s perceptions of respect in healthcare settings that are worth highlighting: (1) Compared to respect in general life situations, respect in healthcare settings seems to be passively received by the elderly. (2) Respect in healthcare settings is perceived by the elderly to include many non-therapeutic components. It seems to be implied that (1) in their role as patients, the elderly seem to take their respect for healthcare providers for granted and do not need to say so specifically. (2) The elderly seem to want to be seen as a person and not just a disease to be dealt with. Therefore, based on the findings of this study, it is recommended that healthcare providers should view the patient as a whole person, not as a health problem to be remediated.For this study, in-depth personal interviews were used to collect qualitative data to avoid interference from others and privacy concerns. It is suggested that future research could be conducted in focus groups, for example, because of the difference in responses between individual interviews and group interactions.The elderly respondents were recruited through the assistance of the community care station, which may have resulted in a lack of elderly who did not participate in community activities. Therefore, it is suggested that future studies may target those who did not participate in any community activities to find out whether they have different views on respect.This study attempted to understand the elderly’s perceptions of respect through broader, non-induced interviews. Not only was it found that the meaning of respect was illustrated in different contexts, but the perceptions of respect also varied from scenario to scenario. Therefore, future studies may design more follow-up questions to obtain more specific perceptions of respect according to the researcher’s concerns. For example, respect in a healthcare setting can be subdivided into questions about people , procedures , and the physical environment .Finally, to understand the distribution of elderly people’s perceptions of respect, we recommend designing a structured questionnaire based on the findings of this study and conducting a quantitative survey with a larger representative sample.This study found that, through in-depth interviews, for the community elders, respect is the individual’s subjective perception regarding the process of interpersonal interaction. It is shaped by verbal expression, non-verbal behavior, and behavior combined with appropriate language. When inquiring more about respect in healthcare settings, the elderly believe respect in healthcare settings is a subjective assessment of healthcare providers while offering healthcare services. It is achieved through healthcare providers’ verbal expression, non-verbal behavior, behavior combined with appropriate language, and the physical environment of healthcare settings. Respect can be perceived differently depending on the person and situation with whom you are dealing. The ways of showing respect can range from active to passive. In this study, it was found that gentle tone and listening are the core concepts of respect in all three contexts . In conclusion, the perceptions of respect vary along with scenarios and controllability. At the same time, these results could offer healthcare practitioners a useful hint to provide more respectful services which fit the elders’ implicit expectations. In addition, the results of this study will help one to understand the elderly and promote intergenerational communication as well as a more harmonious doctor–patient relationship.


Tiefer highlights key steps in the "creation" of a new diagnosis, female sexual dysfunction, and of the campaign to challenge its reductionist approach to women's sexual problems. The creation and promotion of “female sexual dysfunction” (FSD) is a textbook case of disease mongering by the pharmaceutical industry and by other agents of medicalization, such as health and science journalists, healthcare professionals, public relations and advertising firms, contract research organizations, and others in the “medicalization industry.” Whether one relies on Lynn Payer's original definition of disease mongering , her chEach physical condition or life event that has been subject to disease-mongering tactics has its own unique history. Sexual life has become vulnerable to disease mongering for two main reasons. First, a long history of social and political control of sexual expression created reservoirs of shame and ignorance that make it difficult for many people to understand sexual satisfaction or cope with sexual problems in rational ways. Second, popular culture has greatly inflated public expectations about sexual function and the importance of sex to personal and relationship satisfaction.Thus the public is led to want and expect high rewards from sexual life without having tools to achieve these rewards. People fed a myth that sex is “natural”—that is, a matter of automatic and unlearned biological function—at the same time as they expect high levels of performance and enduring pleasure, are likely to look for simple solutions. This sets the stage for disease mongering, a process that encourages the conversion of socially created anxiety into medical diagnoses suitable for pharmacological treatment.In this essay, I begin by examining sexual attitudes in the 20th century that were crucial in setting the scene for the creation of FSD. I then highlight key steps in the history of FSD and of the campaign to challenge its reductionist approach to women's sexual problems.In the early 20th century, sexual life and interest were stimulated by intensive urbanization and immigration that disrupted old community-based patterns of sexual regulation ,4. SexuDramatic liberalization occurred after World War II as purity campaigns failed to hold back the sex-promoting impact of changes in longevity, leisure, employment and childrearing, new technology, and mass media . EffectiBeginning in the 1970s, along with the increasing sexual explicitness in popular culture, there were two competing academic theories of sexuality. In the social sciences and humanities, a social-constructionist perspective emphasized political, economic, and social determinants of sexual life . It tendIn the 1980s, the nature of sex research and expertise began to shift as a new “sexual medicine” focused on function was created by urologists, insurance reimbursement programs, diagnostic technologies, science and medicine journalists, and, then, the pharmaceutical industry .Urologists looked to new opportunities in genitourinary sexual medicine as their surgical careers were limited by the new (1984) kidney stone lithotripsy and by effective medications for benign prostate disease. Insurance-based reimbursement for sex-problem treatments (including psychotherapy) became linked to a diagnostic classification system that recognized only discrete sexual “dysfunctions” such as low desire, inadequate arousal/erection, and premature or delayed orgasm/ejaculation. Technologies for measuring genital blood flow and nerve function were widely used to substantiate dysfunction diagnoses. Taking advantage of post-1980s deregulatory policies, the pharmaceutical industry began to redirect its pipeline to new “lifestyle drugs” and its marketing to consumer advertising. Science and medicine journalists played key roles in whetting the public's appetite for medical news about sex by breathlessly covering each new discovery and treatment.PLoS Medicine  as a deficiency disease or disease of hormonal imbalance” (p. 93)“Getting the right spin doctors” (p. 93)“Framing the issues in a particular way” (p. 94)“Selective use of statistics to exaggerate the benefits of treatment” (p. 95)“Using the wrong end point” (p. 96)“Promoting technology as risk-free magic” (p. 96)“Taking a common symptom that could mean anything and making it sound as if it is a sign of a serious disease” (p. 98)


With our increased awareness of the need to understand human–environment interactions, it is more critical than ever to spark and nourish children’s interest in science. Now an NIEHS-sponsored program at the Baylor College of Medicine Center for Educational Outreach is responding to this educational challenge by offering the ECOS (Environment as a Context for Opportunities in Schools) project, a teacher professional development and curriculum implementation project with an integrative approach that focuses on strengthening science teaching and learning at the elementary school level.Over the Hedge.Established in 2000, the ECOS project was created by a team of educators, scientists, and health specialists to connect environmental health science with health, reading/language arts, mathematics, and social studies for Houston-area elementary schools. Two distinct educational series for grades K–2 and 3–5, developed previously with funding from the NIEHS and the National Center for Research Resources, were first implemented in six schools. Later, a charter school and four more elementary schools were added to the project. Both series of curriculum materials include interactive class lessons and engaging adventure storybooks illustrated by T. Lewis, co-creator of the syndicated comic strip and animated movie “My World and Me,” the module developed for students in grades K–2, contains two units, “Living Things and Their Needs” and “Resources and the Environment,” each with 10 sequential series of lessons, an illustrated storybook for each student that teaches science and health concepts while relating the adventures of Tillena Lou Turtle, and a “read aloud” big book for classroom use. An accompanying teacher’s guide to hands-on activities stresses inquiry-based lessons such as observing an earthworm, identifying its needs, and building an appropriate habitat in a terrarium made of a plastic soda bottle.Explorations mini-magazine for each student to share with family members, an activity guide for teachers, and supplements (for reading/language arts and mathematics) related to the storybook. Typical language arts activities include “finding the main idea” and writing about cause-and-effect relationships. Math activities focus on developing basic skills using science information related to a specific unit—for example, estimating metric measures, solving number puzzles, and creating and using graphs.The “My World”  series has four units on integrative topics for students in grades 3–5: “Air,” “Water,” “Global Resources,” and “Food.” Each unit includes a story-book featuring the adventures of squirrels Riff and Rosie, an The program also provides support and training for teachers to help maximize the effectiveness of the curriculum. New teacher enrollees receive two days of professional development including an overview of the curriculum content, a complete package of instructions, classroom activity kits, and training in conducting the different activities in the classroom units. Those already participating in the program receive additional training in enrichment activities scheduled several times throughout the academic year.Both series are designed to be flexible and accommodate a variety of teaching methods and styles; the program designers note that schools have begun customizing unit activities to fit their own educational needs and priorities. Nancy Moreno, associate director of the Center for Educational Outreach and the ECOS project principal investigator, says customization shows that teachers are actively involved in the planning process for the project’s implementation in their schools, and are intellectually invested in it. For example, she describes how the “Water” unit, initially designed for use in 2nd grade to meet science standards for that grade level, is now being used in 4th-grade classes in some schools because it better fits requirements for that grade level. “Since the materials are not grade level–specific, teachers can adjust them up or down by using suggestions and extensions that are provided in the teacher’s guide,” she explains.ECOS project participation is also having a positive impact on overall science learning for both students and teachers. The program developers have measured student knowledge using tools such as pre- and post-tests and essay assignments, and have observed a noticeable increase in student performance, especially among Spanish-speaking students, at all grade levels. Participating teachers have also shown gains in content knowledge when taking similar types of assessments.“The ECOS project is an example of how scientific research institutions can collaborate effectively with local schools to improve science teaching and learning,” says Moreno. “Shortcuts do not work. However, when scientists, science educators, school administrators, and classroom teachers work together, the nature of science instruction received by students changes profoundly. The payoffs from this approach are beginning to be visible in the ECOS project.”http://www.ccit.bcm.tmc.edu/ceo/. The project, which has received such honors as finalist status for the State of Texas Environmental Excellence Award, is developing new units to integrate science inquiry into schoolwork. Coming up in the next school year is a unit for 5th graders that focuses on alcohol as a chemical that can interact with the human body.More information on the project, including ordering information, is available at


I read with horror the article “Pesticides and Parkinson Disease” by Renee To set the record straight, rotenone is not commonly used in organic agriculture. Rotenone that has been naturally derived is listed as a “restricted substance” by the Organic Materials Review Institute (OMRI 2004) and may be used only in special circumstances with designated limitations. Meanwhile, rotenone’s synergist, piperonyl butoxide, is prohibited from use in organic agriculture.The premise of organic agriculture is to fortify the soil through wholesome, nontoxic means, thereby strengthening the ability of plants to defy diseases and pests.It is the hope of the hardworking pioneers in the organic movement that the instance of Parkinson disease, cancer, and many environmentally related illnesses will diminish exponentially with the conversion of acreage to organic cultivation.Editor’s response: As DiMatteo implies, rotenone is, or should be, used only as a last resort in organic gardening and farming. It should be noted, however, that this pesticide is commonly marketed and sold under the rubric “organic gardening supplies.”