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Ideas and Opinions |

Cholesterol Control Beyond the Clinic: New York City's Trans Fat Restriction

Sonia Y. Angell, MD, MPH; Lynn Dee Silver, MD, MPH; Gail P. Goldstein, MPH; Christine M. Johnson, MBA; Deborah R. Deitcher, MPH; Thomas R. Frieden, MD, MPH; and Mary T. Bassett, MD, MPH
[+] Article and Author Information

From the New York City Department of Health and Mental Hygiene, New York, New York.


Acknowledgment: The authors thank Elliott Marcus, MSSW, and Robert Edman, BSc, of the Department's Bureau of Food Safety and Community Sanitation, as well as all the Bureau's directors and sanitarians for implementation of the work described here. They also thank Wilfredo Lopez, JD; Thomas Merrill, JD; Martha Robinson, JD; and Anna Caffarelli, MHS; the members of the New York City Board of Health; Walter Willett, MD, MPH, DrPH; Colin McCord, MD; and the other staff and interns of the Department whose work was critical to the success of this initiative.

Grant Support: By the City of New York. The American Heart Association provided an educational grant to support the Trans Fat Help Center.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Lynn Dee Silver, MD, MPH, New York City Health Department, 2 Lafayette Street, 20th Floor, CN-46, New York, NY 10007; e-mail, lsilver@health.nyc.gov.

Current Author Addresses: Drs. Angell and Silver, Ms. Goldstein, and Ms. Johnson: New York City Department of Health and Mental Hygiene, 2 Lafayette Street, 14th Floor, CN-46, New York, NY 10007.

Ms. Deitcher: New York City Department of Health and Mental Hygiene, 125 Worth Street, Room 345, CN-24, New York, NY 10013.

Dr. Frieden: Office of the Director, Centers for Disease Control and Prevention, 1600 Clifton Road, Northeast, Mailstop D-14, Atlanta, GA 30333.

Dr. Bassett: Doris Duke Charitable Foundation, 650 Fifth Avenue, 19th Floor, New York, NY 10019.


Ann Intern Med. 2009;151(2):129-134. doi:10.7326/0003-4819-151-2-200907210-00010
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Decades after key modifiable risk factors were identified, cardiovascular disease remains the leading cause of preventable death, and only one quarter of persons with high cholesterol levels have attained recommended levels of control. Cholesterol control efforts have focused on consumer education and medical treatment. A powerful, complementary approach is to change the makeup of food, a route the New York City Department of Health and Mental Hygiene took when it restricted artificial trans fat—a contributor to coronary heart disease—in restaurants. The Department first undertook a voluntary campaign, but this effort did not decrease the proportion of restaurants that used artificial trans fat. In December 2006, the Board of Health required that artificial trans fat be phased out of restaurant food. To support implementation, the Department provided technical assistance to restaurants. By November 2008, the restriction was in full effect in all New York City restaurants and estimated restaurant use of artificial trans fat for frying, baking, or cooking or in spreads had decreased from 50% to less than 2%. Preliminary analyses suggest that replacement of artificial trans fat has resulted in products with more healthful fatty acid profiles. For example, in major restaurant chains, total saturated fat plus trans fat in French fries decreased by more than 50%. At 2 years, dozens of national chains had removed artificial trans fat, and 13 jurisdictions, including California, had adopted similar laws. Public health efforts that change food content to make default choices healthier enable consumers to more successfully meet dietary recommendations and reduce their cardiovascular risk.

Figures

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Figure.
New York City restriction of artificial trans fat: reduction in use in frying, baking, or cooking or in spreads.

Data limited to use of artificial trans fat in oils, shortenings, and spreads (for which trans fat content could be determined) in New York City–licensed food service establishments by users of these products. Data from 2005 to 2007 are from surveys. July and November 2008 data are based on restaurant compliance data collected during regularly scheduled inspections. Compliance data are further adjusted to be consistent with survey denominator.

* Phase 1 of the regulation only covered fats used for frying or as a spread. Phase 2 covered all other foods and ingredients.

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References

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Benefits of NYC Trans-fat Ban Are Unclear
Posted on July 21, 2009
Gilbert L. Ross
Medical Director, The American Council on Science and Health
Conflict of Interest: None Declared

To the Editor:

The authors of the Perspective piece "Cholesterol Control Beyond the Clinic: New York City's Trans Fat Restriction" (Annals' July 21 issue) want to be congratulated for finding that their own regulatory approach has succeeded"” according to them. The NYC Dept. of Health passed a regulation restricting the use of trans-fats (TFAs) in chain restaurants, and the authors have discovered that--lo and behold!--this law is being obeyed.

But what have they accomplished in terms of public health? That is a difficult question to answer.

The amount of TFAs in one's diet is repeatedly referred to as a "recognized risk factor" for heart disease. However, this assessment is based entirely on observational dietary studies--and diet is not listed among the main coronary risk factors. Further, based upon my twenty-plus years practicing internal medicine, I can attest to how devilishly hard it is to significantly reduce lipid levels through diet, despite all the stringent diet programs we so assiduously distributed to our at-risk patients. Now, at last, the authors assert that they have found the culprit: TFAs! By eliminating these heart attack generators, so goes their story, we can relax and throw away those statins.

Not so fast. Is there a shred of evidence that manipulating TFA intake in this manner will actually lower lipid levels--much less reduce the toll of cardiovascular disease? No. So why are the authors trumpeting how their new regulations have led to restaurant food with "healthier fatty acid profiles?"

Health issues aside, where will such measures lead us? In the editorial, Dr. Geberding says, "Unfortunately, relying on consumers alone to make healthy choices about food intake is a strategy that has not worked, as our growing obesity epidemic demonstrates." Since when is "allowing" Americans to choose their own food a public health strategy? And what does TFA intake have to do with the obesity epidemic? Not a thing, as I'm sure Dr. Geberding well knows.

If the authors are allowed to merely declare that their government regulatory program on TFAs is a "success", there are in all likelihood more such strategies for "guiding" consumer health choices coming down the pike, to your local pharmacies, restaurants--and your kitchens. The authors apparently believe that we cannot be trusted to figure out our own diet choices regarding our health, while they nominate the NYC Dept. of Health to be our food arbiter of first resort. This would be a bad idea, for health and for personal responsibility.

Conflict of Interest:

The American Council on Science and Health, a non- profit consumer education organization, accepts no- strings-attached donations from corporations, individuals, and foundations. Food-related companies have contributed well under 2% of our budget.

Re: Benefits of NYC Trans-fat Ban Are Unclear
Posted on July 23, 2009
Morton Satin
Salt Institute
Conflict of Interest: None Declared

What the authors of this article could not say was how this initiative actually helped the citizens of New York. The presumption is that ridding the food supply of trans fats will definitely improve the cholesterol levels of millions of people. Improving the cholesterol levels should result in reduced cardiovascular disease, but has it? Since most New Yorkers eat in restaurants, often several times a week, there should be a significant decrease in the number of people that will have heart attacks and die - right? That is what everyone is after - n'est pas? And certainly with all the modern statistical tools we have available and with a precise knowledge of the exact date that the trans fat ban went into effect, we must be able to demonstrate the health benefits that accrued from the New York ban. Surely we can be spared the lame "cardiovascular disease is multifactorial, therefore we can't really tell if the ban worked" excuse. There are no metrics in place to measure what should have been the primary goal of the ban. The people behind the ban felt they could dispense with the trivialities of actually determining if their initiative really accomplished anything. The journey is more important than the destination, they say. The fact is there is nothing in place to "Show me the money!"

For 1500 years, the world believed in 'spontaneous generation' simply because the Greek philosophers said it was so. Francis Bacon, often referred to as the father of the scientific method, didn't buy it and effectively said, "Show me the money!" Credibility has to be based upon experimentally derived evidence.

The scientific integrity of this country and its great institutions is declining because we are associating credibility with institutions rather than with evidence. We accept notions without demanding proof. It may well be that there is spontaneous generation and that New York's citizens have actually benefitted from the trans fat ban, but until there is objectively-obtained evidence to confirm this, the only ones who have really benefitted are those individuals and institutions who have garnered unwarranted praise and free publicity. Consumers should be served a lot better than that!

Conflict of Interest:

None declared

Response from Authors
Posted on September 15, 2009
Lynn D.
New York City Department of Health
Conflict of Interest: None Declared

Response to 1st Letter: Morton Satin, MSc, Salt Institute and 2nd Letter: Gilbert L. Ross, M.D. Medical Director, The American Council on Science and Health

Regarding Dr. Ross's comment, evidence supporting restriction of trans fat use is not limited to observational studies. A multitude of controlled feeding trials have assessed the impact of trans fatty acids on serum lipid profiles (1). Meta-analyses of up to 60 of these trials demonstrate a relative increase in LDL and decrease in HDL when trans fatty acids are consumed as compared with saturated or cis unsaturated fats (2,3). As Dr. Gerberding states in her accompanying commentary, the science for eliminating exposure is "rock solid" (4).

In his letter, Mr. Satin (of the Salt Institute) expresses frustration that measuring the isolated impact of trans fat restrictions may not be possible even with "modern statistical tools." Unlike biomedical research, evaluation of population level health interventions does not always allow for randomized controlled trials. Once there is scientific consensus that the exposure of interest is dangerous, such as lead-based paint, a pesticide or trans fat, such trials may also be unethical. That said, evaluation is integral to good public health practice and the best possible methods should be employed to assess interventions.

Evaluations underway include assessment of a) replacement products, b) changes in food fatty acid composition and c) CHD mortality. We are exploring assessing changes in CHD risk and in markers of trans fatty acid intake by repeating New York City's 2004 Health and Nutrition Examination Survey (NYCHANES). NYCHANES included a representative sample of sera in repository which can provide a pre-intervention baseline.

In her commentary, Dr. Gerberding endorses the substantial public health risk associated with artificial trans fat but raises concern that healthier oil supplies are not sufficient for replacement at the national level (4). Similar arguments were raised in 2005 at the time of our proposal. All failed to materialize as practical obstacles. No shortages of safer replacement products have been reported and saturated fat use has declined in at least some areas. Indeed, the food industry proved efficient when faced with a clear imperative and an appropriate timeline.

Lastly, Dr. Ross remarks that restricting trans fat use reduces consumer choice. We beg to differ. Artificial trans fat was added to restaurant meals unbeknownst to consumers; menus never offered a choice of French Fries with or without artificial trans fat. Industry chose to use artificial trans fat because of practical industrial advantages. As its dangers are now apparent, there is no reason not to remove it from our food.

References

1. Panel on Macronutrients. Letter report on dietary reference intakes for trans fatty acids. In: Institute of Medicine. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Washington, DC: Institute of Medicine; 2002.

2. Mensink RP, Zock PL, Kester ADM, Katan MB. Effect of dietary fatty acids and carbohydrates on the ratio of serum total to HDL cholesterol and on serum lipids and apolipoproteins: a meta-analysis of 60 controlled trials. Am J of Clin Nutrition 2003;77:1146"“1155

3. Mozaffarian D, Katan MB, Ascherio A, Stampfer MJ, Willett WC. Trans fatty acids and cardiovascular disease. N Engl J Med. 2006;354:1601-13. [PMID: 16611951]

4. Gerberding JL. Safer Fats for Healthier Hearts: The Case for Eliminating Dietary Artificial Trans Fat Intake. Ann Intern Med. July 21, 2009;151(2):137-138.

Conflict of Interest:

None declared

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