Nej Mp 078058

7/30/2019 Nej Mp 078058

1/5

Perspective

TheNEW ENGLAND JOURNAL ofMEDICINE

may 17, 2007

n engl j med 356;20 www.nejm.org may 17, 20072017

nature pastries: cheesecake andcannoli. Like other cooks in thecitys restaurants, bakeries, andfast-food outlets, Canciello facesan impending deadline for con-forming to an unusual mandatefrom the New York City Board ofHealth. Beginning July 1, 2007,most foods prepared in the citys22,000 restaurants will no longerbe permitted to contain more thanhalf a gram per serving of arti-ficial trans fats a type of fat,

found chiefly in partially hydrog-enated vegetable oils used for fry-ing and baking, in shortenings,and in margarines, that has moreunhealthy effects on blood lipidsthan any other kind. Bakers, aswell as purveyors of deep-friedcake or dough products such asdoughnuts, for whom finding asuitable alternative is particularlychallenging, have until July 1,

2008, to stop using such ingre-dients. Faced with predictions thatbanishing artificial trans fats fromrestaurant foods would reduce therate of heart attacks and save thelives of several hundred New York-ers annually, the powerful boardof health voted unanimously lastDecember to eliminate what healthcommissioner Thomas Friedencalls a hazardous substancefrom the citys cuisine. The sweetspot of public health, Frieden told

me, is when you do somethingthat makes the default setting ahealthy choice.

The ingredient that Canciellohas decided to substitute palmoil is a highly saturated fat andby no means healthful, but hesays he needs a fat that is semi-solid at room temperature to frythe crisp pastry tubes for hisricotta-filled cannoli and bake the

firm base of his cheesecake. Youcant fry in an unsaturated fat,said Canciello, who began work-ing in the caf three decades ago,when he was 14. The food in-dustry is a constant cycle, he said.Twenty years ago, I baked withsaturated fat, so Im just going togo back.

Cooks and managers at otherManhattan eateries offered variedresponses to the new rules. Atthe Tick Tock Diner near Madi-son Square Garden (motto: EatHeavy), manager Tommy Lazara-kis said his cooks would complybut added, I dont know what theoil will be whatever the boardof health wants. At Papaya Dog

on West 4th Street, the two cookson duty gave me blank looks whenasked whether they would beswitching to a new oil for fryingfrench fries. At the upscale Mag-nolia Bakery on Bleecker Street,popular for cupcakes, a managersaid, Thank God, it doesnt affectus, because we only use butter.

The health department will of-fer education and technical assis-

New York to Trans Fats: Youre Out!Susan Okie, M.D.

Ferrara Caf in Manhattans Little Italy is a cen-tury-old bakery steeped in tradition, but execu-tive pastry chef Dennis Canciello has recently beentinkering with the recipes of two of the cafs sig-

The New England Journal of Medicine

Downloaded from nejm.org on March 20, 2012. For personal use only. No other uses without permission.

Copyright 2007 Massachusetts Medical Society. All rights reserved.

7/30/2019 Nej Mp 078058

2/5

PERSPECTIVE


tance to cooks to encourage themto switch to polyunsaturated ormonounsaturated oils, and res-taurant inspectors will be trainedto enforce the rules by examiningingredient lists on oil and short-ening labels. Frieden says he isnt

worried that a large-scale increasein the use of saturated fats willnegate the beneficial effects of re-ducing trans fat intake. Of coursewe want people to change tohealthier oils, and its easy, formost food items, to convert toalternatives like canola oil, oliveoil, or soy oil, he said. But transfat is clearly worse than saturat-ed. Even if you switch to suet, youdo better.

New York is not the first ju-risdiction to legally limit the useof artificial trans fats Den-mark did so in 2004 (see time-line) but the citys move hasalready had a national impact: itsdeadline lit a fire under the coun-trys two largest restaurant chains,McDonalds and Burger King,which had been moving slowly ontheir promise to eliminate artifi-cial trans fats from their menus.McDonalds spokesman Walt Ri-ker confirmed that, for frying, the

company will switch to a blend ofnonhydrogenated soybean, corn,and canola oils in its New YorkCity locations by July 1 and that ithopes to complete a nationwidechangeover to eliminate oil andshortening containing artificial

trans fats in its 13,000 restau-rants by the end of 2008. As ofmid-March, about 3500 had al-ready made the switch.

New York is critical, said Mi-chael Jacobson, executive directorof the Center for Science in thePublic Interest (CSPI), a Washing-ton-based advocacy group that hasbeen urging restaurants and man-ufacturers to eschew artificialtrans fats since the early 1990s.

What [the restaurant chains] doin New York, theyre going to dothroughout the United States.New York, home to 3% of the U.S.population, is also an economicand cultural trendsetter. The healthboards decision has receivedwidespread media coverage andspawned similar efforts in othercities, counties, and states.

Trans fats fats containingfatty acids with at least one dou-ble bond in the trans configura-tion (see diagram) make up

2.6% of the average Americansdaily calorie intake, or about 6 gdaily for a person consuming2000 calories per day. About 80%of calories from trans fats comefrom partially hydrogenated veg-etable oils and 20% from naturally

occurring trans fats in dairy prod-ucts and meats (see bar graph).Partially hydrogenated vegetableoils were developed early in the20th century as a cheaper alterna-tive to animal fats; they are stableduring frying, have a long shelflife, and can be used to make mar-garine or shortening with a con-sistency, melting point, andmouth feel similar to those ofbutter. In the 1980s, doctors and

nutrition experts concerned aboutthe role of dietary saturated fat inincreasing cardiac risk urged con-sumers to switch from butter andanimal fat to margarine, and CSPIled a successful campaign to getMcDonalds to switch from beeftallow to vegetable oil for fryingits french fries.

Meanwhile, however, studiesbegan to raise concerns about thehealth effects of artificial transfats, and by the 1990s, both con-trolled feeding trials and prospec-

New York to Trans Fats: Youre Out!

1957

First data on health effects ofdifferent types of fats published

by Ancel Keys.

1961

Keys et al. show that partiallyhydrogenated fats modestlyelevate cholesterol.

1972Unilever labs confirm

Keyss findings.

1975

Procter & Gamble studyshows no effect of partiallyhydrogenated fats oncholesterol.

1985

FDA-commissionedreport concludes that

artificial trans fats affectserum cholesterol

levels similarly to themonosaturated

fat oleic acid

Information from Harvard School of Public Health and Korver and Katan.1

1903

Wilhelm Normann files British patent onProcess for Converting UnsaturatedFatty Acids or Their Glycerides into Saturated Compounds.

1950 1960 1970 19801900




7/30/2019 Nej Mp 078058

3/5


PERSPECTIVE

2019

tive epidemiologic studies hadimplicated them in causing un-desirable changes in blood lipidlevels and raising cardiac risk. In-creasing the dietary intake of ei-ther trans fats or saturated fatsraises the serum level of low-den-

sity lipoprotein (LDL) cholesterol but increasing trans fat intakealso reduces the serum level ofhigh-density lipoprotein (HDL)cholesterol, resulting in a biggerincrease in the LDL:HDL ratio.On the basis of this effect alone,trans fat intake has been estimat-ed to cause about 6% of coronaryevents in the United States, in-cluding about 27,000 deaths peryear nationwide and about 1400

per year in New York City. SinceNew Yorkers, like other Americans,get roughly one third of their dai-ly calories from restaurant food,Frieden estimates that eliminatingartificial trans fats from the citysmenus should save between 200and 500 lives per year, dependingon the mix of fats that are sub-stituted.

The benefits could be consid-erably greater. Prospective cohortstudies suggest that a high transfat intake is associated with a

much greater increase in heartdisease rates than would be ex-pected from the fats effect on se-rum lipids alone, and trans fatsare thought to contribute to the

development of heart disease byadditional mechanisms, such aspromoting inflammation and pro-ducing endothelial-cell dysfunc-tion. It was recently estimated thatcompletely replacing artificialtrans fats with more healthful un-saturated fats might avert 12 to22% of myocardial infarctions anddeaths due to coronary disease.2

In New York, Frieden and hisstaff will attempt to study the ef-

fects of the new trans fat rules bykeeping track of the fats that res-taurants are substituting and pos-sibly chemically analyzing somemenu items to measure their transfat levels. They may also measurelevels of trans fatty acids in the

serum of volunteers and comparethem with levels in stored serumsamples from a 2004 New YorkCity Health and Nutrition Exam-ination Survey. Because the transfat content of supermarket foodsis being reduced as well, howev-er, it will be hard to assess howmuch change is attributable tothe restaurant rules.

Given such developments in thefood industry, some nutrition ex-

perts believe that artificial transfats could be nearly eliminatedfrom the average American diet.After an Institute of Medicine pan-el recommended that trans fattyacid consumption be kept as lowas possible,3 the Food and DrugAdministration (FDA) announcedin 2003 that it would require trans-fat content to be listed on nutri-tion labeling of packaged foodsbeginning in 2006 thoughfoods containing less than 0.5 gof trans fat per serving may claim


1990

Human trial shows trans fats increaseLDL cholesterol and decrease HDL

cholesterol.

1990U.S. Nutrition Labeling and Education Actrequires manufacturers to show amountsof saturated and unsaturated fats andcholesterol in food products.

1994

Unilever announces it willremove trans fats frommargarines and spreads.

1993

Willett et al.publish data

showingtrans fats

increase riskof coronary

heart disease.

2002

Institute of Medicinerecommends mini-

mizing trans fat intake. 2003FDA announces requirement that food labels show trans fat content beginning January 1, 2006.

2004

Trans fat ban goes intoeffect in Denmark.

2004

Research suggests trans fats affect coronary risk more than expectedfrom effect on LDL and HDL. Inflammatory processes might contribute.

2000 2020 20301990 2010

2005

USDA and DHHS issue guidelines recommending minimizingtrans fat consumption and call on food industry to decrease trans fat content.

2006 FDA trans fat labeling requirements go into effect.

2006

American Heart Association recommends limiting trans fat intake to 1% of dailycalorie consumption, suggests food manufacturers and restaurants switch to other fats.

2006

New York City Board of Health announces trans fat ban in restaurants.

2007

Most foods in New York City restaurants may not have more than 0.5 g of trans fat per serving.

2008 New York City baked goods and products containing deep-friedbatter may not contain more than 0.5 g of trans fats.

Cis double

bond

Oleic Acid

Trans double

bond

Elaidic Acid

Carbon

Hydrogen

Oxygen

il ll

i

i l

i

I

I

i

l l

Cis and Trans Double Bonds.Not all hydrogens are shown.




7/30/2019 Nej Mp 078058

4/5

PERSPECTIVE


to have 0 g on their nutrition

facts panel. According to WalterWillett, a professor of nutritionscience and policy at the HarvardSchool of Public Health, compa-nies did marketing research andfound that most Americans hadheard of trans fats and knewthey were considered unhealthful,so the labeling requirement mo-tivated them to get rid of them.Fear of lawsuits was probably an-other motivation. Beginning in2003, manufacturers such as Frito-Lay, Kraft, and Campbells refor-mulated popular brands of chips,cookies, and crackers, and in 2004,some restaurant chains announcedthat they had stopped cookingwith partially hydrogenated veg-etable oils. In a recent CSPI sur-vey of the 50 largest U.S. restau-rant chains, 33 reported either thatthey had already stopped using

the oils or that they were in theprocess of switching to alterna-tives for some or all menu items.

The rush to remove trans fatsfrom foods has boosted demandfor new varieties of oil, includingsoybean oil low in linolenic acid(a fatty acid vulnerable to oxida-tion, which can change the tasteand reduce the shelf life of ordi-

nary soybean oil). Walter Fehr, a

plant breeder and geneticist atIowa State University who spentdecades developing an ultra-low-linolenic soybean strain, said foodcompanies showed no interest inhis beans until the FDA announcedthat it would require trans fat la-beling. Now, theres a market foras much low-linolenic soybean oilas processors can produce, whichdepends on how many acres of thespecial soybean strains U.S. farm-ers decide to grow. Theres beena major effort under way to signup as many acres as possible,Fehr said.

Despite the eagerness for transfatfree oils, however, not every-one is equally optimistic about thelikely effect on rates of illness andmortality. I think any time wevefocused on one single dietarycomponent, weve been disap-

pointed, said Alice Lichtenstein,a professor of nutrition scienceand policy at Tufts University.Its one part of overall dietarymodifications that we need tomake. Faced with national epi-demics of obesity and diabetes,said Lichtenstein, we have to lookat the big gorilla in the room,which is total calories and to re-

duce saturated fat intake as well.Marion Nestle, a professor of nu-trition, food studies, and publichealth at New York University,agrees and she worries thatmanufacturers aggressive mar-keting of products that contain

0 grams trans fat leads con-sumers to think that they can eatthem with impunity. Most peoplehave no clue that this has noth-ing to do with calories, saidNestle. Guess what? Nobodysgoing to lose weight.

Frieden has a strategy for ad-dressing that problem, too. LastDecember, his board of healthalso approved new rules requiringrestaurants that voluntarily pub-

lish calorie information (on Websites or tray liners, for example)to post it alongside menu pricesso that its visible at the time ofpurchase. These rules, also sched-uled to go into effect July 1, 2007,will apply only to restaurants withstandardized menus that alreadyprovide calorie data somewhere only about 10% of the citysrestaurants. Some evidence sug-gests that providing such infor-mation can change behavior:about half of Americans reportthat reading food labels haschanged their buying habits. Arecent study found that restau-rant customers grossly underes-timate the calorie and fat contentof menu items and that offeringpoint-of-purchase nutrition infor-mation significantly influencedconsumer choice.4

Nestle believes that the calo-rie rules could have a greater ef-fect on public health than thetrans fat rules but the restau-rant industry is fighting themharder. Wendys removed calorieinformation from its Web sitebefore the March 1 deadline toavoid having to post it on menus.As of late March, the New York


40

21

17

8

5

4

3

1

1

l

Animal products

Cakes, cookies, crackers, pies,bread, etc.

Margarine

Fried potatoes

Household shortening

Salad dressing

Candy

Potato chips, corn chips,

popcorn

Breakfast cereal

0 5 10 15 20 25 30 35 40 45

Percent of Dietary Trans Fats

Sources of Trans Fat in the U.S. Diet.

Data are from the FDA.




7/30/2019 Nej Mp 078058

5/5


PERSPECTIVE

2021

City Council was preparing toconsider a restaurant industrysupported bill that would over-turn the calorie rules.5 Friedenpredicted that the industry mightalso challenge the rules in court.

Nonetheless, calorie counts on

menus may be the wave of thefuture. Even the savviest consum-ers probably need frequent remind-ers that trans fats arent the onlyobstacles to steering a healthycourse through the U.S. diet.Frieden himself is a case in point:to celebrate the approval of thetrans fat regulations, the lean and

fit health commissioner ordereddoughnuts for his staff fromDoughnut Planet, which has elim-inated trans fat from its confec-tions. Oh, wow, those doughnutsare delicious, he recalled wistful-ly. They were so good I couldnt

stop eating them.

An interview with Dr. Thomas Frie-

den, commissioner of the New York

City Department of Health, can be

heard at www.nejm.org.

Dr. Okie is a contributing editor of theJournal.

Korver O, Katan MB. The elimination oftrans fats from spreads: how science helped1.

to turn an industry around. Nutr Rev 2006;64:275-9.

Mozaffarian D, Katan MB, Ascherio A,Stampfer MJ, Willett WC. Trans fatty acidsand cardiovascular disease. N Engl J Med2006;354:1601-13.

Letter report on dietary reference intakesfor trans fatty acids. In: Institute of Medicine.Report on dietary reference intakes for ener-

gy, carbohydrate, fiber, fat, fatty acids, cho-lesterol, protein, and amino acids. 2002.Washington, DC: National Acadamies Press,2002:14.

Burton S, Creyer EH, Kees J, Huggins K.Attacking the obesity epidemic: the potentialhealth benefits of providing nutrition infor-mation in restaurants. Am J Public Health2006;96:1669-75.

Rivera R. City council may rewrite calorierules. New York Times. February 26, 2007:B1.

Copyright 2007 Massachusetts Medical Society.

2.

3.

4.

5.


Prohibiting Genetic DiscriminationKathy L. Hudson, Ph.D.

Even before the sequencing ofthe human genome began inearnest, Americans started worry-ing about how information abouttheir genetic makeup might beused in harmful ways, and policy-makers began considering legis-lation to prevent misuses of ge-netic information. The GeneticInformation NondiscriminationAct, which would prohibit healthinsurers and employers from ask-ing or requiring a person to takea genetic test and from using ge-netic information in setting insur-ance rates or making employmentdecisions, passed unanimously inthe Senate in 2003 and again in2005. The bill remained stalled

in the House of Representatives,however, apparently because theHouse leadership was sympathet-ic to the few employer and busi-ness groups that oppose the bill.This year, with its new Democrat-ic majority in place, Congress hastaken up the bill once again.

Enactment of this law wouldsubstantially enhance the current,

limited protections against the useof genetic information in healthinsurance and the workplace. TheHealth Insurance Portability andAccountability Act (HIPAA) of 1996imposed some restrictions on theuse of health-related informationby group health insurers in de-termining eligibility for benefitsand setting premiums. Congressspecifically listed genetic infor-mation as protected health infor-mation and explicitly stated thata genetic risk factor for diseasecould not be considered a preex-isting condition. Subsequently, inpromulgating privacy regulationscalled for by HIPAA, the Depart-ment of Health and Human Ser-

vices made clear that access to anddisclosure of genetic informationare protected. But though HIPAArestricted the ability of insurers tocharge different premiums to per-sons within a group on the basisof genetic information, it did notlimit their ability to use such in-formation to raise the rates forthe entire group. HIPAA also did

not address the use of geneticinformation for underwriting inthe individual-insurance market.

As for the workplace, theEqual Employment OpportunityCommission has interpreted theAmericans with Disabilities Act(ADA) as providing some protec-tions against the use of geneticinformation by employers, but theextent of those protections is un-clear and largely untested. TheADA prevents workplace discrim-ination based on a disability, thehistory of a disability, or a per-ceived disability. However, legalexperts have concluded that ad-ditional clarification is needed toensure that genetic information

cannot be used to discriminate inemployment decisions such as hir-ing, firing, job assignments, andpromotions.1

Many states have taken stepsto limit the misuse of genetic in-formation. Currently, 35 stateshave laws against genetic discrimi-nation in employment, and 47 havelaws against genetic discrimina-




Documents

Nej Mp 078058