Systematic Review of Dietary Trans-Fat Reduction Interventions

SystematicSystematic reviews reviews

Systematic review of dietary trans-fat reduction interventions Lirije Hyseni,a Helen Bromley,a Chris Kypridemos,a Martin O’Flaherty,a Ffion Lloyd-Williams,a Maria Guzman- Castillo,a Jonathan Pearson-Stuttardb & Simon Capewella

Objective To systematically review published studies of interventions to reduce people’s intake of dietary trans-fatty acids (TFAs). Methods We searched online databases (CINAHL, the CRD Wider Public Health database, Cochrane Database of Systematic Reviews, Ovid®, MEDLINE®, Science Citation Index and Scopus) for studies evaluating TFA interventions between 1986 and 2017. Absolute decrease in TFA consumption (g/day) was the main outcome measure. We excluded studies reporting only on the TFA content in food products without a link to intake. We included trials, observational studies, meta-analyses and modelling studies. We conducted a narrative synthesis to interpret the data, grouping studies on a continuum ranging from interventions targeting individuals to population-wide, structural changes. Results After screening 1084 candidate papers, we included 23 papers: 12 empirical and 11 modelling studies. Multiple interventions in Denmark achieved a reduction in TFA consumption from 4.5 g/day in 1976 to 1.5 g/day in 1995 and then virtual elimination after legislation banning TFAs in manufactured food in 2004. Elsewhere, regulations mandating reformulation of food reduced TFA content by about 2.4 g/ day. Worksite interventions achieved reductions averaging 1.2 g/day. Food labelling and individual dietary counselling both showed reductions of around 0.8 g/day. Conclusion Multicomponent interventions including legislation to eliminate TFAs from food products were the most effective strategy. Reformulation of food products and other multicomponent interventions also achieved useful reductions in TFA intake. By contrast, interventions targeted at individuals consistently achieved smaller reductions. Future prevention strategies should consider this effectiveness hierarchy to achieve the largest reductions in TFA consumption.

Introduction A reduction in people’s intake of industrial TFA is thus a WHO policy priority.2 However, TFA intake in most countries Over two-thirds of the global burden of disability and death still exceeds the WHO target of 2 g/day, mainly reflecting is attributable to noncommunicable diseases. Diseases such as consumption of industrial TFAs in processed food.6 Further- cardiovascular diseases, common cancers, dementia, diabetes more, even as overall TFA consumption falls, intake is likely and respiratory disorders kill over 35 million people annu- to remain higher in poorer populations, who are more likely ally.1 The World Health Organization (WHO) priority areas to eat processed food products.7 Different strategies and policy for reducing noncommunicable diseases include tobacco, options, targeting different groups, have been proposed to alcohol, physical inactivity and poor diet. Poor diet generates meet these targets. These can be described as upstream or a larger burden of disease than the other three risk factors downstream interventions. Downstream interventions gener- combined. It accounts for an estimated 11.3 million deaths ally target individuals and involve behavioural approaches.8 annually, compared with 2.1 million for low physical activity, Intermediate interventions target subgroups in worksites, 6.1 million for tobacco smoke and 3.1 million for alcohol and schools or communities. Both downstream and intermediate drug use.1 The problem predominantly reflects an unhealthy interventions are dependent on the individual to respond. By global food environment dominated by processed foods high contrast, upstream interventions take place at the population in sugar, salt, saturated fats and, crucially, industrial trans- level and typically involve regulatory approaches, taxes or fatty acids (TFAs).1 subsidies. By creating a healthier environment, they avoid TFAs are found naturally in small amounts in some meat any dependence on an individual response.8 In alcohol and and dairy products produced by bacterial action in the stom- tobacco control policies, for instance, an effectiveness hierar- ach of ruminant animals.2 However, the majority of TFAs are chy of preventive interventions has been observed, whereby industrial, being manufactured by partial hydrogenation of population-wide policy interventions appear to be consistently edible vegetable oils, such as palm oil, cottonseed oil, soybean more powerful than interventions targeting individuals.9,10 oil or canola oil.3 Industrial TFAs are then added to processed Policy interventions to remove industrial TFAs from foods or packaged food, mainly to prolong shelf life and enhance have therefore been suggested as the most effective public taste and texture at a low cost.4 Since the 1990s, research evi- health approach for reducing TFA intake and decreasing the dence has accumulated demonstrating that TFA consumption burden of noncommunicable diseases.11 Some countries have substantially increases people’s risk of coronary heart disease.2,5 demonstrated that this is feasible. In Denmark, for example, It does this mainly by elevating harmful low-density lipopro- multicomponent interventions progressively reduced the tein cholesterol levels and decreasing protective high-density population’s TFA intake and a subsequent legislative ban lipoprotein cholesterol.2 TFAs may also increase the risk of virtually eliminated TFAs in margarines and vegetable short- Alzheimer’s disease and certain cancers,2 and worsen insulin enings.12 However, that success required substantial political sensitivity, thereby increasing the risk of type 2 diabetes.5 will sustained over a decade. Most other countries only have

a Department of Public Health and Policy, Whelan Building, University of Liverpool, Liverpool L69 3GB, England. b School of Public Health, Imperial College London, London, England. Correspondence to Lirije Hyseni (email: [email protected]). (Submitted: 14 December 2016 – Revised version received: 11 September 2017 – Accepted: 12 September 2017 – Published online: 19 October 2017 )

Bull World Health Organ 2017;95:821–830G | doi: http://dx.doi.org/10.2471/BLT.16.189795 821 Systematic reviews Dietary trans-fatty acid reduction policies Lirije Hyseni et al. achieved voluntary TFAs limits, reflect- Box 1. Search strategy used in the systematic review of dietary trans-fatty acid ing concerns about political feasibility reduction policies and generally lower levels of public pres- The following keywords were used in a search of CINAHL, the Centre for Reviews and sure for change.13 Dissemination Wider Public Health database, Cochrane Database of Systematic Reviews, Ovid®, The evidence supporting the most MEDLINE®, Science Citation Index and Scopus: effective policies for reducing TFA in- ((“Trans-fats” OR “trans-fats” OR “Trans-fat” OR “Dietary trans-fat” OR “Industrial trans-fat”) AND take remains unclear. To inform future (“Reformulation” OR “Regulation” OR “Self-regulation” OR “Labelling” OR “Limits” OR “Ban” OR prevention strategies we conducted a “Elimination” OR “Legislation” OR “Agreements” OR “Campaigns” OR “Tax” OR “Health promotion” systematic review of the evidence on the OR “Nutrition education” OR “Marketing control”)) effectiveness of interventions to reduce For Scopus, additional terms were used to narrow down the search: people’s TFA intake. We also hypoth- ((“Intake” OR “Consumption” OR “Composition” OR “Content” OR “Effect” OR “Effectiveness” OR esized that an effectiveness hierarchy “Cons-effectiveness”) AND (“Public policy” OR “Nutrition policy” OR “Health policy” OR “Policies” might exist. OR “Interventions” OR “Strategies” OR “Initiatives” OR “Policy options” OR “Actions”))

Methods Box 2. Inclusion and exclusion criteria for selecting studies for the systematic review of Data sources and searches dietary trans-fatty acid reduction policies We followed the Preferred Reporting Participants Items for Systematic Reviews and Meta- We included studies covering all age groups from all populations, from high-, middle- and low-income countries. Analyses guidelines.14 We carried out a We excluded studies on pregnant women, animals and cells. systematic search of online databases (CINAHL, the Centre for Reviews and Interventions Dissemination Wider Public Health da- We included primary studies and systematic reviews evaluating the effects of actions to promote tabase, Cochrane Database of Systematic TFA reduction by government policy or adopted in specific real or experimental settings. Reviews, Ovid®, MEDLINE®, Science We excluded studies evaluating the effect of a general or specific diet. Citation Index and Scopus) for stud- Comparators ies of interventions to reduce people’s We included studies where actions to promote TFA reduction were evaluated or compared. TFA intake, published between 1985 We excluded studies with no evaluation or comparison of actions to promote TFA reduction. and 24 August 2017. A combination Outcomes of relevant keywords, identified from We included primary outcome of interest was change in dietary TFA intake, reported as g/day. exemplar papers (including a systematic When TFA intake was reported as percentage of energy from total fat, values were converted review of policies for reducing dietary to g/day. Secondary outcomes included changes in clinical or physiological indicators related TFA),15 was used to construct the search to noncommunicable diseases and behaviours associated with a healthy diet. strategy (Box 1). All identified papers We excluded process evaluations reporting on implementation of interventions or policies were imported into a web-based data without any quantitative outcome data; feasibility or acceptability studies without an assessment management software (Zotero, version or primary outcomes (intake); studies on individuals as opposed to populations; data on cost 4.0.29, Roy Rosenzweig Center for His- only; reduction in product content only; body mass index studies. tory and New Media, Fairfax, United Study design States of America). We included primary studies, randomized controlled trials, systematic reviews, empirical One author conducted the searches observational studies, natural experiments,a secondary analysis, before and after interventions, and removed the duplicates. Two authors and modelling studies. then independently screened titles and We excluded commentary or opinion articles; purely qualitative evaluations with no quantitative abstracts for eligibility; if they deemed assessment. papers eligible, the full text was retrieved TFA: trans-fatty acid. and again screened independently. We a An empirical study whereby the exposure to the experimental and control groups are determined by also scanned reference lists of included nature or other factors outside the control of the researchers. studies for potential relevant papers. Note: Based on the population, intervention, comparison, outcome and study design14 inclusion and Any differences in screening outcomes exclusion criteria. were resolved either by consensus, or by involving the senior author. empirical studies. To be eligible, studies intake as a percentage of total energy Study selection had to include the effectiveness of spe- intake (E%), we converted the data to cific interventions on dietary TFA intake g/day using the conventional formula We included a wide range of study and have quantitative outcomes. Only below (1).16 designs including trials, observational studies published in English language studies, meta-analyses and modelling were included. We assessed retrieved g Trans fat intake ()= studies. Modelling studies added value studies by using the population, in- day by allowing the evaluation of certain tervention, comparison and outcomes (1) interventions using different scenarios study design approach (Box 2).14  Trans fat intake E%  2000 / 9 where empirical data are impractical or The primary outcome was dietary  100  lacking (e.g. food labelling). However, TFA intake in a population, reported we analysed them separately from the as g/day. For studies reporting TFA

822 Bull World Health Organ 2017;95:821–830G| doi: http://dx.doi.org/10.2471/BLT.16.189795 Systematic reviews Lirije Hyseni et al. Dietary trans-fatty acid reduction policies

Papers only reporting on the reduc- was independently checked by other Data synthesis and analysis tion of TFA content in food products authors for the empirical and model- We conducted a narrative synthesis to without a link to intake were excluded. ling studies. interpret the data, grouping the studies Secondary outcomes included We used the National Heart, Lung according to intervention type. In ac- changes in clinical or physiological and Blood Institute quality assessment cordance with the McLaren continuum indicators related to noncommunicable tools to assess the quality of empirical of structural‒agentic interventions8 diseases (e.g. coronary heart disease studies.17 Two authors independently and the Nuffield ladder taxonomy,19 we deaths) and behaviours associated with assessed the methodological quality of defined downstream (agentic) inter- a healthy diet. each study as poor, fair or good. Model- ventions as those where the principal ling studies were independently assessed Data extraction and quality mechanism of action is dependent on by two modelling experts using an assessment individuals altering their consump- adapted version of a published quality tion behaviour. Conversely, we defined We used pre-designed and pre-piloted assessment tool.18 Quality was reported upstream (structural) interventions as data extraction forms to extract data as poor, fair or good. Any disagreements those creating changes that target an from all included studies. One author were resolved by consensus or with entire population ‒ not a subset, how- conducted the data extraction, which another author. ever large ‒ thus effectively eliminating individual agency. We then categorized Fig. 1. Interventions classified on the upstream–downstream continuum in the interventions according to their position systematic review of dietary trans-fatty acid reduction policies in the McLaren continuum (Fig. 1).8 We separately analysed multicomponent Upstream interventions. An unweighted median interventions • Legislation or mandatory reformulation regression model was fitted to the TFA of food products intake data from eight empirical studies • Taxation and subsidies and four modelling studies. • Voluntary reformulation of food products Results • Food labelling • Mass media campaigns The literature search identified 1785 • Community dietary counselling potentially relevant papers, and 22 ad- • Worksite dietary counselling ditional papers were identified through Downstream interventions • Individual dietary counselling screening reference lists. After removing 723 duplicates, we screened 1084 Note: Based on the McLaren continuum of interventions.8 publications by title and abstract, after which 70 full-text papers were assessed Fig. 2. Flowchart used for the systematic review of dietary trans-fatty acid reduction for eligibility. A total of 23 papers met policies the inclusion criteria (12 empirical stud- ies20–31 and 11 modelling studies;32–42 1785 records identified through database search 22 additional records identified through other sources Fig. 2). The interventions and their effect sizes are presented in Fig. 3. Table 1 summarizes the empirical 1084 records screened after studies and Table 2 summarizes model- duplicates removed ling studies included in this review (both tables available at: http://www.who.int/ 1014 records excluded bulletin/volumes/95/12/16-189795). Individual dietary counselling 70 full-text articles assessed 47 full-text articles excluded One study in 2007, rated as fair quality, for eligibility • 23 had no evaluation of TFA targeted Aboriginal families in Canada. interventions (descriptive) • 11 had no focus on TFAs or It investigated the effect of dietary TFA interventions counselling on dietary intake, includ- • 7 had focus on other outcomes ing TFA, using a 24-hour recall. The 29 • 2 studied the effect of TFA intervention households significantly reduction rather than effect of a policy reduced their consumption of TFA • 3 were opinion articles or (P = 0.02) from 0.6 to 0.5 g/day over conference abstracts 6 months, while the 28 control house- • 1 was a systematic review; studies holds increased consumption from 0.7 were included individually if they 23 studies included in to 1.3 g/day.20 qualitative synthesis met the criteria

Note: Based on the preferred reporting items for systematic reviews and meta-analyses guidelines.14

Bull World Health Organ 2017;95:821–830G| doi: http://dx.doi.org/10.2471/BLT.16.189795 823 Systematic reviews Dietary trans-fatty acid reduction policies Lirije Hyseni et al.

Food reformulation Fig. 3. Effectiveness of interventions to reduce trans-fatty acid intake in the systematic review of dietary reduction policies Empirical studies Two empirical studies examined the 5 effect of reformulating industrially produced foods. A good-quality study reported the results of a TFA monitoring y) 4 programme after voluntary reformulation limits for TFA content were put in place in Canada in 2005 on vegetable 3 oils and soft margarines and other prepackaged foods (< 2% and < 5% of total

A consumption (g/da fat, respectively). TFA intake, measured TF 2 using 24-hour food recalls in the general population (33 030 people), fell from tion in 4.9 g/day in 2004 to 3.4 g/day in 2008.22 1

Reduc The other study, rated as fair quality, conducted two meta-analyses of 0 North American and European data. Individual Worksite Food Reformulation Legislation Multi- Both analyses investigated the effect of dietary dietary labelling of food component TFA consumption on coronary heart counselling counselling products interventions disease risk factors (one included 13 Type of intervention randomized controlled trials and the Study of good quality Study of fair quality Study of poor quality other covered four prospective studies). TFA: trans-fatty acid. The researchers calculated the effect Notes: Plot of the reported reductions in TFA consumption (g/day) of the 12 empirical studies included in of reformulating the TFA content of this systematic review, by type of intervention. An unweighted median regression model was fitted to the partially hydrogenated vegetable oils data and is depicted by the grey line on the plot. We used the National Heart, Lung and Blood Institute with other fats. They found higher risk 17 quality assessment tools to assess the quality of empirical studies. reductions when reformulating oils with higher TFA content. The randomized Worksite dietary counselling estimated that labelling is at best only controlled trials reported an approxi- half as effective as a total ban on TFAs in mately 19% risk reduction, whereas the One poor-quality study in 2010 in the terms of health and socioeconomic ben- prospective studies found a 39% reduc- USA implemented a dietary counselling efits. Improved labelling might save ap- tion in coronary heart disease risk.23 programme at a worksite by educating proximately 3500 deaths from coronary participants on the use of a low-fat Modelling studies heart disease over the period 2015–2020 vegan diet. After 22 weeks, 3-day dietary (1.3%, 3500 of the total 273 000 deaths) One study of poor quality in 2011 mod- records showed that the 45 control and reduce socioeconomic inequalities elled the effect of reformulation of foods participants had increased their TFA by some 1500 deaths (from 20 400 to to reduce TFA in the Netherlands. TFA intake from 2.4 to 2.5 g/day over 22 18 900).32 Another modelling study in intake in the population of 750 partici- weeks, whereas the 68 participants in 2016 investigated the cost‒effectiveness pants aged 19–30 years was projected to the intervention group reduced their of mandatory labelling in products fall from 2.3 to 1.9 g/day after reformu- intake from 2.1 to 1.1 g/day (P ≤ 0.001).21 on sale in the European Union (EU) lating specific food groups (e.g. bread, Food labelling and projected that it may prevent 0.98 pastry, cakes and biscuits; meat snacks 37 Modelling studies million of the 1076 million disability- and salads; fat and margarines). An- adjusted life years (DALYs) attributed to other study of fair quality modelled the We found no empirical studies investi- coronary artery disease. However, com- effect of food reformulation on health gating the sole effect of labels showing pared with taking no action, this option outcomes in Denmark in 2016. The the TFA content of food products, but incurred greater costs than it saved, in researchers estimated reductions in car- we included five modelling studies (two terms of health-care costs, lost produc- diovascular disease deaths of 14.2 (from of good quality,32,33 two fair34,35 and one tivity and implementation costs.33 In a 441.5 to 427.3) per 100 000 population of poor quality36). In the Netherlands a similar approach to the Dutch study, re- over the years 2004‒2006 and coronary healthier choices logo for food packages searchers in Brazil investigated replacing heart disease deaths 26.5 per 100 000 was implemented in 2006. Replacing products with ones that complied with population.38 Finally, one good-quality all packaged products with those that a healthy choices logo.36 Estimated TFA modelling study of EU-level policy op- complied with a healthier choices logo intakes were 0.8 g/day (standard devia- tions investigated the cost‒effectiveness was projected to lead to a 0.8 g/day re- tion, SD: 1.0) for typical menus, 0.1 g/ of voluntary reformulation compared duction in TFA intake from 2.1 to 1.3 g/ day (SD: 0.2) for the choices menus and with no intervention. The study esti- day.34 Another Dutch study in 2013, 0.2 g/day (SD: 0.3) for energy-adjusted mated 2.19 of 1075 million DALYs could using a similar approach, projected a choices menus, i.e. the same as choices be averted from coronary artery disease higher reduction of 1.2 g/day (from 2.2 menu, but adjusted for energy of a typi- over the course of a person’s lifetime (85 to 1.0 g/day).35 A British study in 2015 cal menu. years). A projected 23 billion euros (€)

824 Bull World Health Organ 2017;95:821–830G| doi: http://dx.doi.org/10.2471/BLT.16.189795 Systematic reviews Lirije Hyseni et al. Dietary trans-fatty acid reduction policies could be saved due to reductions in socioeconomic inequalities in coronary including food labelling and voluntary direct health-care costs and in indirect heart disease mortality by approximately agreements with industry.38 One study costs linked to informal care, and these 3000 deaths.32 Two other British studies found that TFA intake dropped from outweighed the costs of implementing found that legislation to achieve a 0.5% 4.5 g/day to 1.5 g/day from 1976 to 1995. this policy.33 reduction in the total energy derived Intake from margarines and shortenings from dietary TFA could prevent 270039 virtually reduced to zero after legisla- Legislation or 3700 cardiovascular disease deaths tion to ban industrially produced TFA 40 31 Empirical studies annually. Another British study mod- in 2004. elled the effect of eliminating TFA from Modelling studies Analysing TFA g/purchase not TFA g/ industrially produced food and esti- day, one good-quality study investigated mated this could prevent around 1700 One modelling study of fair quality used the effect of regulations on TFA content coronary heart disease deaths and gain different scenarios to model the effect of food sold in New York city. Instituted some 15 000 life years annually over a of food labelling and reformulation of in 2007, the policy allowed takeaway decade. Eliminating both natural- and food products on health outcomes in food restaurants to sell only products industrial-derived TFAs may prevent Argentina. Based on changes in lipid with a ≤ 0.5 g TFA content per serving. some 3300 coronary heart disease profile, the combined intervention was The estimated mean TFA intake per deaths annually and gain approximately projected to avert 301 deaths, 1066 acute purchase, based on purchase receipts 30 000 life years.41 Finally, a study in coronary heart disease events, 5237 matched to products, decreased from 2016 modelled the cost‒effectiveness of DALYs and 17 million United States 2.9 g in 2007 (6969 purchases) to 0.5 g different EU policy options to reduce dollars in health-care costs annually in in 2009 (7885 purchases).24 the TFA intake of the population. Plac- the adult population.42 Another study of good quality anal- ing legal limits on the TFA content in ysed the impact of a upper limit of 0.5 g/ industrial foods was projected to avoid Discussion serving (commonly referred to as a TFA 3.73 DALYs and save € 51 billion from ban) on TFAs in all food-service estab- health-care costs and lost productivity Our systematic review suggests that lishments in the USA in 2016 and found in EU Member States.33 multicomponent interventions achieve a 4.5% reduction in cardiovascular the biggest reductions in TFA consump- disease mortality, from 13 per 100 000 Multicomponent interventions tion across an entire population, as 25 persons between 2010 and 2013. Empirical studies demonstrated in Denmark, Canada and Finally, a study of good quality in- Costa Rica. Systematic reformulation of vestigated the effect of TFA restrictions Four fair-quality empirical studies inves- products containing TFAs can also help, in restaurants in certain New York state tigated the combined effect of more than as observed in Canada and the USA. counties implemented in 2007, compar- one policy on TFA consumption.27–30 Interventions targeting individuals typi- ing hospital admissions for cardiovascu- One cross-sectional study evaluated the cally achieved smaller reductions in TFA lar events in counties with and without effect of both a public health education consumption. restrictions. Three or more years after programme and voluntary reformula- Several studies, in separate coun- the restrictions were implemented there tion of industrially produced TFAs in tries, investigated multicomponent were significantly fewer cardiovascular soybean oil in Costa Rica. Using 3-day interventions; all of them included food events in the intervention population food records the study found a 1.7 g/day reformulation, labelling and voluntary of 8.4 million adults compared with reduction in TFA intake among ado- limits on TFA content of industrial the reference population of 3.3 million, lescents from 4.5 g/day (276 people) in food. In Denmark, a progressive series after adjusting for temporal trends. 1996 to 2.8 g/day (133 people) in 2006.27 of interventions finally led to a legislative These changes applied when analysing Two other studies included both ban on TFA. This package achieved the myocardial infarction and stroke events labelling and voluntary reformulation largest observed reduction in TFA intake combined (change of −6.2%; 95% con- limits in Canada. Estimating TFA intake in the population over the period from fidence interval, CI: −9.2% to −3.2%) from breastmilk samples, they reported 1976 to 2005 (4.5 g/day).12,31 The USA is and myocardial infarction alone (−7.8%; reductions in TFA intake from 2.0 in now emulating this successful strategy.43 95% CI: −12.7% to −2.8%).26 2009 to 0.7 g/day in 2011 (639 people)29 Substantial, but smaller benefits were 28 Modelling studies and from 4.0 to 2.2 g/day (87 people). achieved by multi-intervention strate- An American cross-sectional pop- gies lacking a legislative component in Five modelling studies, all of good ulation-based study analysed blood Costa Rica27 and Canada.28,29 Multicom- quality, modelled the effect on health samples before and after introduction ponent strategies including upstream outcomes of legislation affecting TFA of food labelling and voluntary limits on policies, such as price regulations or consumption.32,33,39–41 One British study TFA in restaurants. A 58% reduction in legislation, consistently achieved greater projected that a ban on TFAs in sit-down TFA levels was found, from 93.1 µmol/L reductions in TFA intake than single and takeaway restaurants for the period (229 samples) in 2000 to 39.0 µmol/L interventions, particularly when these 2015‒2020 would save approximately (292 samples) in 2009, suggesting a were downstream approaches focused 1800 (0.7%) coronary heart disease substantial reduction in dietary intake on individuals. deaths annually in the population. A of TFAs over the period.30 Legislation to regulate TFA content total ban of TFAs in all products might From 1993 onwards, Denmark pro- in food achieved a 2.4 g/day reduction in achieve some 7200 (2.6%) fewer deaths gressively implemented multiple inter- intake of TFA in the city of New York.24 from coronary heart disease and reduce ventions to reduce dietary TFA intake, This success has now been extended

Bull World Health Organ 2017;95:821–830G| doi: http://dx.doi.org/10.2471/BLT.16.189795 825 Systematic reviews Dietary trans-fatty acid reduction policies Lirije Hyseni et al. nationwide by the United States Food understanding of labels, use of labels, compared with empirical evidence. Our and Drug Administration ruling in June food purchase and purchase-related review also had limitations. We were 2015 stating that partially hydrogenated behaviour rather than quantifying TFA unable to conduct a meta-analysis due oils are no longer generally recognized intake.50 The diverse labelling systems to the profound heterogeneity of the as safe for use in food.44 Following and claims currently generated by the studies and because several studies in- the Danish exemplar, several other industry may confuse many consumers, cluded multiple interventions. We only European countries have subsequently highlighting a need for package labels included studies in English. The primary introduced legislation, setting an upper that are easier to understand.48 outcome of this study was dietary intake limit for TFAs of 2 g per 100 g in fat or Dietary counselling interventions and we excluded studies considering oil.13 However, other countries still rely in different settings, such as commu- other components of dietary behav- on voluntary reformulation, which is nities, worksites, schools and homes, iour or changes in product content less effective.13,15 Legislation is routinely were sparse. One study in the home20 after reformulation. Generalization of opposed by the food industry, fearful of and another in worksites21 both sug- the results should be cautious because decreased profits or the additional costs gested that dietary counselling at an countries will vary in their baseline TFA of reformulating products.12,13,15 How- individual level could achieve TFA re- intake. Furthermore, we did not contact ever, the evidence is that such legislation ductions of 0.8 g/day20 and 1.2 g/day.21 authors for missing data. Publication has generally had minimal financial In practice, individuals may struggle to bias also remains possible, potentially impact on the food industry.12,31,45 adhere and comply with dietary advice overestimating the true effect of some Several evaluation studies have due to competing priorities or financial interventions. Finally, some interven- reported reductions in TFA content of constraints.51 tion benefits may have been overesti- margarines and industrially produced We found no studies of mass media mated due to underlying secular trends foods, particularly using mandatory campaigns focusing on TFA. Media among the public towards lower TFA reformulation.24,46 An early concern campaigns can achieve modest ben- consumption. that manufacturers would substitute eficial behaviour changes in nutrition, In conclusion, our results suggest an saturated fats such as palm oil for TFA physical activity and tobacco and al- effectiveness hierarchy similar to those has been dismissed. Both Canadian and cohol use ‒ in motivated individuals. previously demonstrated in salt, tobacco American studies of reformulation have However, the overall population benefits and alcohol control interventions.9,10,53 reported reductions in both TFA and tend to be more modest.52 Multicomponent interventions includ- saturated fats, and increases in unsatu- Taxation has been shown to be a ing a legislative ban on products appear rated fat,47 the preferred replacements potentially powerful tool for reducing the most effective strategy to reduce TFA for TFA.13 consumption of tobacco, alcohol or intake. By contrast, more downstream Food labelling has the potential to sugar sweetened beverages. However, interventions targeting individuals in help consumers make more informed we found no studies of taxation focusing domestic or work settings appear con- decisions48 and can also put pressure specifically on TFAs.13 sistently less effective. Future prevention on the food industry to reformulate Our systematic review has several strategies might consider this effective- products.49 We found no empirical stud- strengths. We did the screening, extrac- ness hierarchy to achieve the largest ies of the effects of food labelling alone. tion and analysis in duplicate, and all reductions in the consumption of TFAs However, several modelling studies es- the included studies were subjected to a or other harmful nutrients. ■ timated reductions in TFA consumption rigorous quality appraisal. Furthermore, ranging from 0.3 g/day to 1.2 g/day.32,34,35 modelling studies were included, but Competing interests: None declared. In contrast, most studies involving food considered separately, in recognition labelling have examined the public’s of their additional uncertainties when

ملخص مراجعة منهجية للتدخالت الرامية إىل خفض استهالك الدهون املتحولة يف النظام الغذائي الغرضإجراء مراجعة منهجية للدراسات التي سبق نرشها بشأن املتحولة دون ربط ذلك بالكمية املستهلكة. وتضمن البحث بعض التدخالت الرامية إىل خفض الكمية التي يستهلكها األفراد من التجارب، ودراسات رصدية، وحتليالت تلوية، ودراسات تعتمد TFA األمحاض الدهنية املتحولة ) ( يف النظام الغذائي. عىل النمذجة. كام اتبعنا ًاأسلوب ًاجتميعي ًارسدي لتفسري البيانات، مع بحثنا يفالطريقة قواعد البيانات املتاحة عرب اإلنرتنت تصنيف الدراسات يف جمموعات ضمن سلسلة تبدأ من التدخالت )CINAHL، وقاعدة بيانات CRD Wider Public التي تستهدف األفراد ً إىلوصوال التغيريات اهليكلية التي تتم عىل Cochrane Health ، وقاعدة بيانات للمراجعات املنهجية، مستوى السكان ًمجيعا. وOvid®، وMEDLINE®، وScience Citation Index، و النتائج بعد فرز 1084 دراسة من بني الدراسات البحثية املرشحة، Scopus ( عن الدراسات التي ّم تقيالتدخالت املتعلقة باألمحاض فقد أدرجنا 23 دراسة بحثية، بواقع 12 دراسة جتريبية و11 دراسة الدهنية املتحولة يف الفرتة بني عامي 1986 و2017. وكان املقياس تعتمد عىل النمذجة. وقد نجحت تدخالت متعددة يف الدانمرك يف الرئييس للنتائج يتمثل يف االنخفاض الكبري يف معدل استهالك خفض معدل استهالك األمحاض الدهنية املتحولة من 4.5 غم/ األمحاض الدهنية املتحولة )غم/يوم(. واستبعدنا الدراسات يوم يف عام 1976 ليصل إىل 1.5 غم/يوم يف عــام 1995، التي تسجل فقط احتواء املنتجات الغذائية عىل األمحاض الدهنية ونجحت ً ا أيضبعد ذلك يف حتقيق ما ُعد يشبه منع الستهالك

826 Bull World Health Organ 2017;95:821–830G| doi: http://dx.doi.org/10.2471/BLT.16.189795 Systematic reviews Lirije Hyseni et al. Dietary trans-fatty acid reduction policies

تلك األمحاض، وذلك عقب إصدار ترشيع يف عام 2004 حيظر إن االستنتاجالتدخالت متعددة العنارص والتي اشتملت عىل احتواء املأكوالت ُاملصنعة عىل األمحاض الدهنية املتحولة. وفيام الترشيع الذي حظر احتواء املنتجات الغذائية عىل األمحاض يتعلق بالبلدان األخرى، فقد نجحت اللوائح التنظيمية التي الدهنية املتحولة كانت أكثر االسرتاتيجيات فعالية. ونجح ألزمت بوضع أسلوب جديد إلعداد املأكوالت يف خفض معدل ًأيضااألسلوب اجلديد إلعداد املأكوالت وكذلك التدخالت استهالك األمحاض الدهنية املتحولة باملأكوالت بمقدار 2.4 غم/ األخرى متعددة العنارص يف حتقيق حاالت انخفاض يف استهالك يوم ًا. تقريبونجحت التدخالت املتعلقة بمواقع العمل يف خفض األمحاض الدهنية املتحولة. وعىل النقيض من ذلك، دائ ًام ما كانت معدل االستهالك بمتوسط يبلغ 1.2 غم/يوم. وظهرت حاالت التدخالت التي استهدفت األفراد حتقق معدالت انخفاض أقل انخفاض يف معدل االستهالك بمقدار 0.8 غم/يوم ًتقريبا نتيجة يف االستهالك. وجيب مراعاة هذا التدرج يف مستوى الفعالية عند امللصقات املوجودة عىل املأكوالت واالستشارات بشأن النظام وضع االسرتاتيجيات الوقائية املستقبلية، وذلك لتحقيق أقىص الغذائي لألفراد. معدالت خلفض استهالك األمحاض الدهنية املتحولة.

摘要降低膳食反式脂肪干预措施的系统评价目的旨在系统评价已发表的关于降低人类摄取膳食反丹麦的多项干预措施达到了将反式脂肪酸 (TFA) 消式脂肪酸 (TFA) 干预措施的研究。耗量从 1976 年的 4.5 克 / 天降低到 1995 年的 1.5 克方法我们调查了在线数据库（CINAHL、CRD Wider / 天的效果，2004 年禁止加工食品中含有反式脂肪 Public Health 数据库、Cochrane Database of Systematic 酸 (TFA) 的禁令颁布后，现已基本消除。在其他地 Reviews、Ovid®、MEDLINE®、Science Citation 方，强制重新制定食物配方的法规要求使得反式脂肪 Index 和 Scopus）中评估 1986 至 2017 年间膳食反式脂酸 (TFA) 含量降低约 2.4 克 / 天。工作场所干预措施肪酸 (TFA) 干预措施的研究。反式脂肪酸 (TFA) 消耗达到平均降低 1.2 克 / 天的效果。食物标签和个人饮量（克 / 天）的明显降低是主要的结果测量指标。我食辅导分别降低约 0.8 克 / 天。们排除了仅报告反式脂肪酸 (TFA) 在食品中的含量而结论包含立法要求的多元干预措施是最有效的消除与摄取量无关的研究。纳入了试验、观察性研究、元食品中反式脂肪酸 (TFA) 的策略。重新制定食品配方分析和建模研究。我们进行了叙述性汇总以解读数据，以及其他多元干预措施也达到了有效降低反式脂肪并且开展了范围从针对个人的干预到群体范围内的结酸 (TFA) 摄取量的效果。相比之下，针对个人的干预构变化的连续性小组研究。措施所达到的降低效果普遍偏低。未来的预防策略应结果在筛选了 1084 篇候选文章之后，我们收录当考虑这种效果层次，以达到最有效降低反式脂肪了 23 篇论文：12 份经验性研究和 11 份建模研究。在酸 (TFA) 消耗量的目的。

Résumé Revue systématique des interventions visant à réduire les acides gras trans alimentaires Objectif Effectuer une revue systématique des études publiées portant consommation d’acides gras trans de 4,5 g/jour en 1976 à 1,5 g/jour sur des interventions qui visent à réduire la consommation par les en 1995, jusqu’à une élimination virtuelle suite à l’adoption d’une loi individus d’acides gras trans alimentaires. en 2004 interdisant les acides gras trans dans les produits alimentaires Méthodes Nous avons recherché dans des bases de données en industriels. Dans d’autres pays, des réglementations imposant une ligne (CINAHL, The CRD Wider Public Health database, The Cochrane reformulation des aliments ont réduit la teneur en acides gras trans Database of Systematic Reviews, Ovid®, MEDLINE®, Science Citation d’environ 2,4 g/jour. Des interventions sur les lieux de travail ont induit Index et Scopus) des études évaluant les interventions relatives aux des baisses de 1,2 g/jour en moyenne. L’étiquetage des produits acides gras trans entre 1986 et 2017. Le principal critère d’évaluation alimentaires et la fourniture de conseils diététiques individualisés ont était la baisse absolue de la consommation d’acides gras trans (g/ quant à eux entraîné des diminutions d’environ 0,8 g/jour. jour). Nous avons exclu les études mentionnant uniquement la teneur Conclusion La stratégie la plus efficace consistait en des interventions en acides gras trans dans les produits alimentaires sans établir de lien à plusieurs composantes incluant une loi destinée à éliminer les acides avec leur consommation. Nous avons inclus des essais, des études gras trans des produits alimentaires. La reformulation des produits observationnelles, des méta-analyses et des études de modélisation. alimentaires et d’autres interventions à plusieurs composantes ont Nous avons réalisé une synthèse descriptive afin d’interpréter les également permis de réduire efficacement la consommation d’acides données en regroupant les études selon un continuum allant des gras trans. En revanche, les baisses induites par les interventions ciblant interventions ciblant des individus à des changements structurels au des individus étaient systématiquement moins importantes. Cette niveau de la population. hiérarchie de l’efficacité doit être prise en compte dans les futures Résultats Après avoir examiné 1084 études, nous en avons stratégies de prévention afin de réduire au maximum la consommation sélectionné 23: 12 études empiriques et 11 études de modélisation. d’acides gras trans. Au Danemark, de multiples interventions ont permis de faire passer la

Bull World Health Organ 2017;95:821–830G| doi: http://dx.doi.org/10.2471/BLT.16.189795 827 Systematic reviews Dietary trans-fatty acid reduction policies Lirije Hyseni et al.

Резюме Систематический обзор мероприятий по сокращению содержания трансжиров в пище Цель Проведение систематического обзора опубликованных исследований. Многочисленные мероприятия в Дании привели исследований мероприятий, направленных на сокращение к сокращению потребления ТИЖК с 4,5 г/сут в 1976 году до потребления с пищей транс-изомеров жирных кислот (ТИЖК). 1,5 г/сут в 1995 году, а затем к фактическому устранению ТИЖК Методы Был проделан поиск по базам данных в Интернете (CINAHL, из рациона в 2004 году после принятия законодательства, база данных CRD Wider Public Health, Cochrane Database of запрещающего присутствие ТИЖК в готовых продуктах питания. Systematic Reviews (Кокрановская база данных систематических В других местах правила, предусматривающие изменение состава обзоров), Ovid®, MEDLINE®, Science Citation Index (Индекс научного продуктов питания, способствуют снижению потребления цитирования) и Scopus) на предмет исследований, оценивающих TИЖК примерно на 2,4 г/сут. Мероприятия на рабочих местах мероприятия по сокращению потребления ТИЖК за период с привели к сокращению потребления ТИЖК в среднем на 1986 по 2017 год. Абсолютное снижение потребления ТИЖК (г/ 1,2 г/сут. Маркировка продуктов питания и индивидуальное сут) было основным критерием результата. Исследования, консультирование диетологов привели к снижению потребления сообщающие только о содержании ТИЖК в продуктах питания примерно на 0,8 г/сут. без указания количества потребления, были исключены. Вывод Наиболее эффективная стратегия — многокомпонентные В обзор также включались испытания, обсервационные мероприятия, в том числе введение в силу законов, запрещающих исследования, метаанализы и исследования с применением присутствие ТИЖК в продуктах питания. Изменение рецептуры моделирования. Исследователи провели нарративный синтез, продуктов питания и другие многокомпонентные мероприятия чтобы интерпретировать данные, группируя исследования по также привели к заметному сокращению потребления ТИЖК. континууму, начиная с мероприятий, направленных на отдельных Напротив, мероприятия, последовательно направленные на лиц, и заканчивая структурными изменениями, затрагивающими отдельных лиц, приводили к меньшему сокращению потребления. все слои населения. Стратегии будущей профилактики должны учитывать эту Результаты После отбора из 1084 статей-кандидатов в обзор иерархию эффективности для достижения максимального были включены 23 статьи: 12 эмпирических и 11 модельных сокращения потребления ТИЖК.

Resumen Revisión sistemática de las intervenciones dietéticas de reducción de grasas trans Objetivo Revisar de forma sistemática los estudios publicados sobre en el consumo de TFA de 4,5 g/día en 1976 a 1,5 g/día en 1995 y intervenciones para reducir la ingesta de ácidos grasos trans (TFA, por posteriormente la eliminación virtual tras la legislación de 2004 que sus siglas en inglés) en la dieta. prohibió los TFA en los alimentos manufacturados. En otros lugares, las Metodología En bases de datos en línea (CINAHL, la base de datos regulaciones que obligan a la reformulación de los alimentos redujeron de salud pública más amplia del CRD, la base de datos Cochrane sobre el contenido de TFA en unos 2,4 g/día. Las intervenciones en el lugar revisiones sistemáticas, Ovid®, MEDLINE®, Science Citation Index y de trabajo consiguieron reducciones con un promedio de 1,2 g/día. El Scopus), se buscaron estudios que evaluasen las intervenciones de TFA etiquetado de los alimentos y el asesoramiento alimenticio individual entre 1986 y 2017. El descenso absoluto del consumo de TFA (g/día) mostraron reducciones de alrededor de 0,8 g/día. fue la principal medida como resultado. Se excluyeron los estudios que Conclusión Las intervenciones de componentes múltiples, incluida la informan solo sobre el contenido de TFA en los productos alimenticios legislación para eliminar los TFA de los productos alimenticios, fueron la sin relacionarlos con la ingesta. Se incluyeron ensayos, estudios estrategia más efectiva. La reformulación de los productos alimenticios observacionales, metanálisis y estudios de modelación. Se llevó a cabo y otras intervenciones de componentes múltiples también lograron una síntesis narrativa para interpretar los datos, agrupando los estudios reducciones útiles en la ingesta de TFA. Por el contrario, las intervenciones en un continuo que va desde las intervenciones dirigidas a personas dirigidas a personas lograron sistemáticamente reducciones más hasta los cambios estructurales en toda la población. pequeñas. Las futuras estrategias de prevención deberían tener en Resultados Después de examinar 1084 documentos candidatos, se cuenta esta jerarquía de efectividad para conseguir la mayor reducción incluyeron 23 artículos: 12 estudios empíricos y 11 de modelación. posible en el consumo de TFA. Las múltiples intervenciones en Dinamarca lograron una reducción

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Can J Public Health. 2007 Dec;98(6):447–52. PMID: 19039880 of non-transmissible chronic diseases. Food Chem. 2013 Oct 1;140(3):547– 21. Levin SM, Ferdowsian HR, Hoover VJ, Green AA, Barnard ND. A worksite 52. doi: http://dx.doi.org/10.1016/j.foodchem.2013.02.031 PMID: 23601405 programme significantly alters nutrient intakes. Public Health Nutr. 2010 37. Temme EHM, Millenaar IL, Van Donkersgoed G, Westenbrink S. Impact of Oct;13(10):1629–35. doi: http://dx.doi.org/10.1017/S136898000999303X fatty acid food reformulations on intake of Dutch young adults. Acta Cardiol. PMID: 20074388 2011 Dec;66(6):721–8. doi: http://dx.doi.org/10.1080/AC.66.6.2136955 22. Ratnayake WMN, L’Abbe MR, Farnworth S, Dumais L, Gagnon C, Lampi B, PMID: 22299382 et al. Trans fatty acids: current contents in Canadian foods and estimated 38. Restrepo BJ, Rieger M. Denmark’s policy on artificial trans fat and intake levels for the Canadian population. J AOAC Int. 2009 Sep- cardiovascular disease. Am J Prev Med. 2016 Jan;50(1):69–76. doi: http:// Oct;92(5):1258–76. PMID: 19916364 dx.doi.org/10.1016/j.amepre.2015.06.018 PMID: 26319518 23. Mozaffarian D, Clarke R. Quantitative effects on cardiovascular risk factors 39. Barton P, Andronis L, Briggs A, McPherson K, Capewell S. Effectiveness and coronary heart disease risk of replacing partially hydrogenated and cost effectiveness of cardiovascular disease prevention in whole vegetable oils with other fats and oils. Eur J Clin Nutr. 2009 May;63 Suppl populations: modelling study. BMJ. 2011 07 28;343 jul28 1:d4044. doi: 2:S22–33. doi: http://dx.doi.org/10.1038/sj.ejcn.1602976 PMID: 19424216 http://dx.doi.org/10.1136/bmj.d4044 PMID: 21798967 24. Angell SY, Cobb LK, Curtis CJ, Konty KJ, Silver LD. Change in trans fatty acid 40. O Flaherty M, Flores-Mateo G, Nnoaham K, Lloyd-Williams F, Capewell S. content of fast-food purchases associated with New York city’s restaurant Potential cardiovascular mortality reductions with stricter food policies regulation: a pre-post study. Ann Intern Med. 2012 Jul 17;157(2):81–6. in the United Kingdom of Great Britain and Northern Ireland. Bull World doi: http://dx.doi.org/10.7326/0003-4819-157-2-201207170-00004 PMID: Health Organ. 2012 Jul 1;90(7):522–31. doi: http://dx.doi.org/10.2471/ 22801670 BLT.11.092643 PMID: 22807598 25. Restrepo BJ, Rieger M. Trans fat and cardiovascular disease mortality: 41. Pearson-Stuttard J, Hooton W, Critchley J, Capewell S, Collins M, Mason Evidence from bans in restaurants in New York. J Health Econ. 2016 H, et al. Cost–effectiveness analysis of eliminating industrial and all trans Jan;45:176–96. doi: http://dx.doi.org/10.1016/j.jhealeco.2015.09.005 PMID: fats in England and Wales: modelling study. J Public Health (Oxf). 2017 26620830 Sept;39(3):574–82. doi: http://dx.doi.org/10.1093/pubmed/fwd095 PMID: 26. Brandt EJ, Myerson R, Perraillon MC, Polonsky TS. Hospital admissions 27613767 for myocardial infarction and stroke before and after the trans-fatty acid 42. Rubinstein A, Elorriaga N, Garay OU, Poggio R, Caporale J, Matta MG, et al. restrictions in New York. JAMA Cardiol. 2017 Jun 1;2(6):627–34. doi: http:// Eliminating artificial trans fatty acids in Argentina: estimated effects on the dx.doi.org/10.1001/jamacardio.2017.0491 PMID: 28403435 burden of coronary heart disease and costs. Bull World Health Organ. 2015 Sep 1;93(9):614–22. doi: http://dx.doi.org/10.2471/BLT.14.150516 PMID: 26478625

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43. Doell D, Folmer D, Lee H, Honigfort M, Carberry S. Updated estimate of 48. Campos S, Doxey J, Hammond D. Nutrition labels on pre-packaged foods: trans fat intake by the US population. Food Addit Contam Part A Chem Anal a systematic review. Public Health Nutr. 2011 Aug;14(08):1496–506. doi: Control Expo Risk Assess. 2012;29(6):861–74. doi: http://dx.doi.org/10.1080/ http://dx.doi.org/10.1017/S1368980010003290 PMID: 21241532 19440049.2012.664570 PMID: 22439632 49. Schleifer D. Categories count: trans fat labeling as a technique of corporate 44. United States Food and Drug Administration. Final determination regarding governance. Soc Stud Sci. 2013 Feb;43(1):54–77. doi: http://dx.doi. partially hydrogenated oils. Docket no. FDA-2013-N-1317. Federal Register. org/10.1177/0306312712461573 2015; 80(116). Washington DC: U.S. Government Publishing Office: 2015. 50. Hess S, Yanes M, Jourdan P, Edelstein S. Trans fat knowledge is related Available from: https://www.gpo.gov/fdsys/pkg/FR-2015-06-17/pdf/2015- to education level and nutrition facts label use in health-conscious 14883.pdf [cited 2016 Sep 17]. adults. Topics Clin Nutr. 2005 Apr;20(2):109–17. doi: http://dx.doi. 45. Skeaff CM. Feasibility of recommending certain replacement or alternative org/10.1097/00008486-200504000-00004 fats. Eur J Clin Nutr. 2009 May;63 Suppl 2:S34–49. doi: http://dx.doi. 51. Ashenden R, Silagy C, Weller D. A systematic review of the effectiveness org/10.1038/sj.ejcn.1602974 PMID: 19424217 of promoting lifestyle change in general practice. Fam Pract. 1997 46. Ricciuto L, Lin K, Tarasuk V. A comparison of the fat composition and prices Apr;14(2):160–76. doi: http://dx.doi.org/10.1093/fampra/14.2.160 PMID: of margarines between 2002 and 2006, when new Canadian labelling 9137956 regulations came into effect. Public Health Nutr. 2009 Aug;12(08):1270–5. 52. Wakefield MA, Loken B, Hornik RC. Use of mass media campaigns to change doi: http://dx.doi.org/10.1017/S1368980008003868 PMID: 18986592 health behaviour. Lancet. 2010 Oct 9;376(9748):1261–71. doi: http://dx.doi. 47. Ratnayake WMN, L’Abbe MR, Mozaffarian D. Nationwide product org/10.1016/S0140-6736(10)60809-4 PMID: 20933263 reformulations to reduce trans fatty acids in Canada: when trans fat goes 53. Hyseni L, Elliot-Green A, Lloyd-Williams F, Kypridemos C, O’Flaherty M, out, what goes in? Eur J Clin Nutr. 2009 Jun;63(6):808–11. doi: http://dx.doi. McGill R, et al. Systematic review of dietary salt reduction policies: Evidence org/10.1038/ejcn.2008.39 PMID: 18594558 for an effectiveness hierarchy? PLoS One. 2017 05 18;12(5):e0177535. doi: http://dx.doi.org/10.1371/journal.pone.0177535 PMID: 28542317

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Table 1. Empirical studies categorized according to type of intervention included in the systematic review of dietary trans-fatty acid reduction policies

Study Study Study aim Intervention Geographi- Participants and Methods Outcomes Comments Qualitya design analysed cal scope sample size Individual dietary counselling Anand et al., Randomized To determine Education about Canada 57 Aboriginal Families were recruited between May Intervention households decreased There may have been bias due to Fair 200720 open trial if a household- healthy lifestyles households (174 2004 and April 2005 and completed their consumption of TFAs self-reporting of lifestyle changes based lifestyle individuals) health assessment at baseline and from 0.6 to 0.5 g/day (–0.2 g/ and the 24-hour dietary recall. intervention 6 months after randomization to day versus +0.6 g/day, P = 0.02) The focus of the intervention was is effective at intervention or control groups. after 6 months compared with not TFA but many other dietary reducing energy Aboriginal health counsellors made non-intervention households who components as well as knowledge intake and regular home visits to assist families increased their consumption from and attitudes about healthy dietary increasing physical in setting their dietary and physical 0.7 to 1.3 g/day. practices activity among activity goals. Energy and nutrient Aboriginal families intake was measured using a 24-hour recall. The Food Processor program (ESHA Research, Salem, USA) was used for nutrient analysis Worksite dietary counselling Levin et al., Worksite- To examine whether Health promotion USA 109 participants (65 At weeks 0 and 22, participants In the intervention group, reported Nutrition intake was self-reported. Poor 201021 based dietary a worksite nutrition and nutrition intervention and 44 completed 3-day dietary records to intake of TFA, decreased significantly The study was non-randomized. intervention programme using a education control) assess energy and nutrient intake. (P ≤ 0.001) compared with the The trial was limited to 22 weeks. low-fat vegan diet At the intervention site, participants control group. The focus was on nutrition education could significantly were asked to follow a low-fat vegan TFA intakes in the intervention about a low-fat vegan diet not TFA improve nutritional diet and participate in weekly group group were: 2.1 g/day (SD: 0.1) at intake intake meetings that included instruction and baseline and 1.1 g/day (SD: 0.1) after group support (intervention group). At 22 weeks. Mean difference: –1.0 g/ the control site, participants received no day (SD: 0.2). instruction (control group) TFA intake in the control group was 2.4 g/day (SD: 0.1) at baseline and 2.5 g/day (SD: 0.2) after 22 weeks. Mean difference: +0.2 g/day (SD: 0.2). Mean effect size: –1.2 g/day (95% CI: –1.7 to –0.6). Food reformulation Ratnayake et Cross- To report the results Voluntary food Canada Over 33 000 The TFA programme was evaluated A previous study showed that the N/A Good al., 200922 sectional of a TFA monitoring reformulation respondents did between 2004 and 2008. Dietary estimated average intake of TFA programme and limits on a dietary recall, intake data for the estimations of TFA in Canada was 8.4 g/day in the TFA in food sold repeated by a subset and saturated fatty intake were from a mid-1990s. by retailers or of 10 000. 24-hour food recall survey performed This study showed that TFA intake in food service Respondents with in 2004 (Canadian Community Health 2004 dropped significantly to 4.9 g/ establishments null or invalid Survey, cycle 2.2). For the 2008 day and declined further to 3.4 g/ recalls, children estimation, the TFA and saturated fatty day in 2008. On average, there was a aged < 1 year and acid composition values were obtained 30% decrease in TFA intake between breastfeeding from the national TFA monitoring 2004 and 2008 children were programme excluded Mozaffarian Meta- To evaluate the Reformulation Unlimited 518 participants Three different partially hydrogenated For partially hydrogenated vegetable Estimates were based on isocaloric Fair and Clarke, analysis of effect on coronary of products vegetable oil formulations (containing oils with 20% TFA, replacement with replacement of 7.5% of energy from 200923 randomized heart disease risk containing fatty 20%, 35% or 45% TFA) were replaced butter would result in a small net partially hydrogenated vegetable controlled after reformulation acids with other fats or oils. decrease in coronary heart disease oil, but consumption of these oils trials of vegetable oils Effects on coronary heart disease risk risk (2.7%). while replacement with may be higher or lower in different to reduce TFA were estimated based on iso-caloric palm oil or lard would modestly populations. It is possible that consumption replacement of 7.5% of energy from decrease risk (by 7.6% and 6.0% saturated fatty acids of different partially hydrogenated vegetable oil in respectively). Replacement with chain lengths may have different an individual’s diet soybean, canola or high oleic effects on cardiovascular risk. sunflower oils would produce the Meta-analysis of randomized largest coronary heart disease risk controlled trials showed lower reductions (8.8–9.9%). For partially coronary heart disease risk reductions hydrogenated vegetable oil with 35% than the analysis of prospective TFA, risk reductions for replacement cohort studies in the same paper fats and oils ranged from 11.9% to 16.0%. Largest predicted declines in coronary heart disease risk were for replacement with vegetable oils. For partially hydrogenated vegetable oil with 45% TFA, predicted risk reductions were the highest, including risk reductions of 18.7% and 19.8% for replacement with soybean and canola oil, respectively Mozaffarian Meta- analysis To evaluate the Reformulation North America 4965 coronary Three different partially hydrogenated For partially hydrogenated vegetable The calculations based on cohort Good and Clarke, of prospective effect on coronary of products and Europe heart disease cases vegetable oil formulations (containing oil with 20% TFA, replacement studies are subject to residual 200923 cohort heart disease risk containing fatty prospectively 20%, 35% or 45% TFA) were replaced with butter would have little net confounding from other lifestyle studies after reformulation acids ascertained among with other fats or oils. Effects on effect on coronary heart disease factors and to measurement error in of vegetable oils 139 836 participants coronary heart disease risk were risk (0.5% higher risk), while assessment of dietary consumption to reduce TFA estimated based on iso-caloric replacement with palm oil or lard from questionnaires. consumption replacement of 7.5% of energy from would modestly decrease risk Meta-analysis of prospective cohort partially hydrogenated vegetable oil in (9.1% and 7.3%, respectively). studies showed higher coronary an individual’s diet Replacement with high oleic heart disease risk reductions than the sunflower oil would reduce risk analysis of randomized controlled by 15.9%, and replacement with trials in the same paper cottonseed, soybean or canola oils would produce the largest reductions in coronary heart disease risk (19.0–21.8%). For partially hydrogenated vegetable oil with 35% TFA, risk reductions for replacement fats and oils ranged from 14.4% to 33.4%, with the largest predicted declines in coronary heart disease risk for replacement with vegetable oils. For partially hydrogenated vegetable oil with 45% TFA, predicted risk reductions were the highest, including risk reductions of 39.6% and 38.6% for replacement with soybean and canola oil, respectively

(continues. . .)

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(. . .continued)

Study Study Study aim Intervention Geographi- Participants and Methods Outcomes Comments Qualitya design analysed cal scope sample size Legislation Angell et al., Pre–post test To assess the effect Food USA Adult restaurant Brief surveys of adult lunchtime Overall, mean TFA per purchase The fast-food restaurants included Good 201224 of the New York city reformulationand customers. restaurant customers were conducted decreased by from 2.91 g to 0.51 g may not have be representative of all regulations on the restriction 168 randomly in 2007 and 2009, before and after (change –2.4 g; 95% CI: –2.8 to –2.0) New York city restaurants. TFA and saturated fat selected NYC implementation of the regulation. from 2007 to 2009. Mean TFA per Non-chain restaurants were not content of fast-food restaurant locations Purchase receipts were matched to 1000 kcal decreased from 3.16 g to included in the survey sample purchases of 11 fast-food- available nutritional information. 0.51 g (change –2.7 g per 1000 kcal because they were not covered by chains. Measurements included change in (95% CI: –3.1 to –2.3) existing regulations requiring public Final sample was mean grams of TFA, saturated fat, trans disclosure of nutritional information. 6969 purchases in plus saturated fat together and TFA per The study design was cross-sectional, 2007 and 7885 in 1000 kcal per purchase, overall and by and therefore causation could not be 2009 type of restaurant decisively attributed. Restrepo and Pre–post test To analyse the TFA ban USA All 66 New York Between 2007 and 2011, a ban on After the ban on TFA in restaurants The regression estimate captured Good Rieger, 201625 impact of TFA bans state counties; 898 TFA in restaurants was implemented a 4.5% reduction in cardiovascular the impact of a TFA ban on mortality in restaurants on samples. by the health departments of six New disease mortality rates was found, caused by heart disease that cardiovascular TFA ban York city counties and New York. Data or 13 fewer cardiovascular disease may operate through a variety of disease mortality implemented over on annual mortality rates over the deaths per 100 000 persons per year channels, not only through reduced rates study: 11 counties; period 1999–2013 were obtained for over 2010–2013. The deaths averted TFA intake from food eaten away 165 samples. all counties of New York state from a were valued at about US$ 3.9 million from home. TFA ban not publicly available national database. per 100 000 persons annually. Changes in the amount artificial implemented Comparable data was obtained for the Deaths attributed to heart disease TFA in fast-food-chain purchases over study period: New York metropolitan area. Effective decreased by about 11 per 100 000 after bans may not have been 51 counties; 733 dates of bans for each county were persons, and the corresponding representative of other areas of samples obtained from the state department of estimated reduction in deaths the state or of all food service health. Panel regression models were attributed to strokes was about 2 establishments in the counties. used to evaluate the effect of the bans per 100 000 persons Medical evidence was used to estimate mortality was based on risk factors such as increasing cholesterol levels and inflammation. Thus, the USA Food and Drug Administration’s estimate of the mortality impact of a reduction in TFA intake may underestimate the total impact of TFA intake on heart disease mortality Brandt et al., Retrospective To determine TFA restrictions New York 11 counties with TFA restrictions were implemented in Three or more years after the The study was unable to assess Good 201726 observational the effect of TFA state, USA TFA restrictions in 2007. intervention, myocardial infarction population-level changes in TFA pre–post restrictions in and 25 counties Annual hospital admissions for and stroke events combined consumption. Race and ethnicity test New York state without TFA myocardial infarction and stroke in all (–6.2%; 95% CI: –9.2 to ––3.2) was poorly reported in the state’s counties on restrictions were counties were tracked from January were significantly lower in in the data reporting system and therefore hospital admissions included. In 2006, 2002 to December 2013, using central population with TFA restrictions, the results were not adjusted for it for myocardial the year before the government national monitoring data. after adjusting for temporal trends. or stratified by race and ethnicity. infarction and first restrictions Admission rates were calculated by This was equivalent to 43 events Myocardial infarction and stroke stroke were implemented, year, age, sex and county of residence. averted per 100 000 people. events that did not result in hospital there were 8.4 A difference-in-differences regression There were also significant admission within the state were million adults aged design was used to compare additional decreases in myocardial not captured. The study controlled 45– > 65 years admission rates in populations infarction (–7.8%; 95% CI: –12.7 for linear trends over time on the in highly urban with and without TFA restrictions. to –2.8) and a nonsignificant county level. However, additional counties with TFA Restrictions on TFA content in decline in stroke (–3.6%; 95% CI: differences between counties could restrictions and food products in restaurants were –7.6 to 0.4) compared with the have developed over time that were 3.3 million adults only implemented in highly urban non-restriction population, after not accounted for in the analysis in highly urban counties. Non-restriction counties adjusting for temporal trends counties without of similar urbanicity were chosen as restrictions a comparison population. Temporal trends and county characteristics were accounted for using fixed effects by county and year, as well as linear time trends by county. Results were adjusted for age, sex and commuting between restriction and non- restriction counties Multi-component interventions Leth et al., Pre–post To assess the TFA ban Denmark 253 food samples A ban on TFA was introduced in 2003. TFA intake decreased from 4.5 g/ There was no clear structure to Fair 200631 test effectiveness of before ban; 148 Food samples were collected before day in 1976 to 1.5 g/day in 1995. the paper or clear introduction or Denmark’s ban on after ban (between end of 2002 and early TFAs were virtually eliminated from method section. TFA in industrial 2003) and after the ban (between margarines and shortenings in There was also only a brief results food products November 2004 and February 2005). 2005 after the ban section TFA content was analysed in both imported and domestically produced food products. Categories included chocolate and confectionary products, sweets, industrial baking products (e.g. cookies) and French fries Monge-Rojas Pre–post To identify how Public health Costa Rica 276 adolescents TFA interventions were implemented In 2006, 68% of adolescents Demographically similar groups Fair et al., 201327 test dietary intake and education (aged 12–17 years) from 1996 to 2006. Cross-sectional exceeded the upper limit on TFA were used in 2006 compared with food sources of campaign in 1996; 133 in comparisons used data from intake (> 1% of total energy), with 1996. saturated- and cis- and voluntary 2006 measured food records adolescents intakes ranging mostly around The focus was on soybean oil but polyunsaturated reformulation of surveyed in 1996 and a similar 1% to 2% and 2% to 3% of total not on products generally eaten by fatty acids and TFA soybean oil group of adolescents surveyed in energy. This was an improvement adolescents, e.g. biscuits with cream in the diet of Costa 2006. Values obtained in 1996 and from 1996, when 100% of filling or hard chocolate coating, Rican adolescents 2006 were compared with the latest teenagers reported TFA intakes which contribute the largest % of changed during a WHO guidelines for chronic disease > 1% of total energy, mostly industrial TFAs in adolescents’ diets period with several prevention around > 4% of total energy. public health TFA intake in 1996 was 2.1% of nutrition changes total energy (SD: 0.9) and in 2006 was 1.3% of total energy (SD: 0.5). Energy-adjusted intake of TFA in 1996 was 4.52 g/day (SD: 0.74) and in 2006 was 2.80 g/day (SD: 1.04; P = 0.003) Friesen and Pre‒post To determine Food labelling and Canada 103 breastmilk TFA labelling was introduced in 2003. Mean concentration of total TFA TFA intake was calculated by the Fair Innis, 200628 test whether voluntary limits samples in 1998; Samples of breastmilk (60–100 mL) in milk collected in 1998 was authors themselves using TFA introduction of 87 samples in were collected at 1-month postpartum 7.1 g/100 g milk fatty acids (range: content in human breastmilk. labelling of TFA 2004‒2006 during the course of a feeding. 2.2–18.7). Mean values for milk Participants in 1998 were not the content in retail Samples in 1998 were compared with collected and analysed in three same ones as in 2004–2006. foods and removal samples from 2004 to 2006 consecutive 5-month periods Baseline data came from 1998 not or reduction of TFAs from November 2004 to January from 2003 when food labelling was from vegetable oils 2006 were 6.2 g/100 g milk fatty introduced in many foods was acids (range: 3.4–13.7), 5.3 g/100 g accompanied by a (range: 3.0–14.5) and 4.6 g/100 g decline in the TFA (range: 2.2–12.2), respectively. concentration of Estimated mean intake of TFA by human milk women were 4.0 g/day (range: 0.5–12.3) in 1998 and 3.4 (range: 1.4–8.7), 2.7 (range: 1.1–9.3) and 2.2 g/day (range: 0.6–7.7) in three consecutive 5-month periods from November 2004 to January 2006, respectively (continues. . .)

830B Bull World Health Organ 2017;95:822–830G| doi: http://dx.doi.org/10.2471/BLT.16.189795 Systematic reviews Lirije Hyseni et al. Dietary trans-fatty acid reduction policies

(. . .continued)

Study Study Study aim Intervention Geographi- Participants and Methods Outcomes Comments Qualitya design analysed cal scope sample size Ratnayake et Pre–post To assess the Food labelling and Canada 153 breastmilk Mandatory labelling came into force Mean TFA content of breastmilk Breastmilk values were estimated Fair al., 201429 test impact of labelling voluntary limits samples in 2009; in 2005 with were 2.7% (SD: 0.9; range: as % of total energy and converted and voluntary 309 samples in voluntary limits agreed with the food 1.4–7.2%), 2.2% (SD: 0.7%; range: to g/day. limits on the 2010; 177 samples industry in 2007. 1.0–6.8%) and 1.9% (SD: 0.5; The TFA intake of mothers were concentration of in 2011 Samples were collected from range: 0.9–3.4%) of total milk lower than the WHO’s maximum TFAs in human breastfeeding mothers in 10 major fat for samples collected in 2009 recommended TFA intake of 1% of breastmilk samples cities across Canada. TFA content of (n = 152), 2010 (n = 309) and total energy for a healthy diet human milk was estimated using 2011 (n = 177), respectively. These a previously established linear values were considerably lower correlation between the percentage than the value of 7.2% (SD: 3.0; of TFAs in the diet and human milk fat, range: 0.1–17.2%) (n = 198) found and assuming that 30% of the energy previously for Canadian human of a lactating mother’s diet is derived milk in 1992. from fat Estimated TFA intake of Canadian breastfeeding mothers was 0.9% (2 g/day), 0.5% (1.1 g/day), and 0.3% (0.7 g/day) of total energy in 2009, 2010 and 2011, respectively Vesper et al., Cross- To determine Food labelling and USA 229 participants TFA content of foods was to be Levels of TFAs were detectable The study was only reported as a Fair 201230 sectional plasma limits in 2000 and 292 declared on the nutrition label after in all samples. Levels of vaccenic research letter. concentrations of in 2009 2003. Some community and state acid decreased by 56% from 43.7 The study measured percentage TFAs in a subset departments required restaurants to µmol/L in 2000 to 19.4 µmol/L in decreases of TFAs in blood samples of non-Hispanic limit TFA content in food products. 2009 (difference of 24.3 µmol/L; rather than g/day white adults after Data were from the National Health 95% CI: 19.6 to 29.0). Similar labelling TFA and Nutrition Examination Surveys in changes were seen in elaidic acid, content of foods 2000 and 2009. palmitelaidic acid and linoelaidic and voluntary Participants were selected if they had acid. limits on TFA in morning fasting blood samples. Weighted geometric mean of the restaurants were Four TFAs (elaidic acid, vaccenic acid, difference for the sum of all four introduced linoelaidic acid and palmitelaidic acid) TFAs was 54.1 µmol/L (95% CI: 43.4 were measured in plasma to 64.7 µmol/L) or 58% lower in samples from 2009 (39.0 µmol/L) than from 2000 (93.1 µmol/L) CI: confidence interval; DALYs: disability-adjusted life years; EU: European Union; N/A: not applicable; SD: standard deviation; TFA: trans-fatty acid; US$: United States dollars; WHO: World Health Organization. a We used the National Heart, Lung and Blood Institute quality assessment tools to assess the quality of empirical studies.17

Bull World Health Organ 2017;95:822–830G| doi: http://dx.doi.org/10.2471/BLT.16.189795 830C Systematic reviews Dietary trans-fatty acid reduction policies Lirije Hyseni et al.

Table 2. Modelling studies included in the systematic review of dietary trans-fatty acid reduction policies

Study Study aim Policy analysed Geographical scope Participants and Methods Outcomes Comments Qualitya sample size Allen et al., 201532 To determine the (i) Total ban on England Adults aged ≥ 25 For policies aimed at A total ban on TFAs in processed The health outcomes Good health and equity TFAs in processed years reducing consumption, foods: might prevent or analysis assumed benefits and cost– foods; (ii) improved (numbers not health benefits and cost postpone about 7200 (2.6%) continuing declines effectiveness of labelling of TFAs; stated) outcomes were calculated of the 273 000 total deaths in incidence of and policies to reduce (iii) bans on TFAs for 2015–2020 in England from coronary heart disease mortality from coronary or eliminate TFAs in sit-down and only. from 2015–2020 and reduce heart disease. from processed takeaway restaurants Government national socioeconomic inequality in The study used an foods, compared data and health mortality from coronary heart area-based measure of with consumption economic data from disease by about 3000 of socioeconomic status. remaining at most other published studies 20 400 deaths (14.7%). Policies Within an area there recent levels in were used for the model. to improve labelling: could will be individuals England Adults were stratified by save 3500 (1.3%) of 273 000 of higher and lower fifths of socioeconomic total deaths from coronary socioeconomic status. circumstances heart disease and reduce Therefore, the study inequalities by 1500 (7.4%) of could not make firm 20 400 deaths, thus making conclusions about them at best half as effective individuals. as a ban. Policies to simply As the effect of remove TFAs from restaurants or TFAs operated on a fast-foods: could save between percentage basis (food 1800 (0.7%) and 2600 (1.0%) energy from TFAs of the 273 000 total deaths divided by total food from coronary heart disease energy), differences and reduce inequalities by 600 between surveys (2.9%) to 1200 (5.9%) of the could only affect the 20 400 deaths. results if consumption A total ban would have the were substantially greatest net cost savings misreported in the of about £ 265 million, surveys used excluding reformulation costs, or £ 64 million if substantial reformulation costs are incurred Martin-Saborido To assess the (i) Status quo; EU EU population A computer-simulated The model estimated that Major sources of Fair et al., 201633 added value of (ii) impose (numbers not model was developed, imposing an EU-level legal potential errors were EU-level action by mandatory stated) using effect sizes limit would avoid the loss of the estimated current estimating the cost– TFA labelling of from different studies, 3.73 of 1073 million DALYs TFA intake; the wide effectiveness of three prepackaged food; complemented with due to coronary artery disease variability observed possible EU-level (iii) seek voluntary results from a survey of EU over the course of a person’s for many variables policy measures to agreements with Member States. The model lifetime (85 years), and making between EU countries; reduce population food industry and considered three types of voluntary agreements would and the lack of data in dietary TFA intake retailers towards cost: (i) health care costs, avoid 2.19 of 1076 million some instances, e.g. further reducing (ii) non-health care costs DALYs. Imposing EU-level legal lack of data on number industrially produced and (iii) costs of policy- limits: would save an estimated of coronary artery TFA content in food; associated measures € 51 billion of € 10 723 635 disease events per (iv) impose a million in total costs when year (coronary artery legislative limit for compared with the reference disease-related hospital industrially produced situation and voluntary discharges were used TFA in foods agreements would save € 23 instead). billion (of € 10 752 032 million). The results should Implementing mandatory TFA be interpreted as a labelling: could also avoid the comparison between loss of 0.98 of 1076 million different policy options DALYs, but this option incurred rather than considering greater costs (€ +95 billion) absolute costs, DALYs or than it saved compared with deaths per option the reference option Vyth et al., 201234 To investigate the Food labelling Netherlands Dutch adult The healthier choices Replacing non-complying The study was based Poor potential impact on population (aged logo for food packages products with products that on theoretical food cholesterol levels 18–70 years) was implemented in complied with the label’s criteria: replacements not of consuming a (n = 4336) 2006. National food median intakes of TFA (as a % people’s actual diet consisting of consumption and food of total energy intake) would practices. products that comply composition data were fall from the reference value The study assumed with the criteria for a used to estimate the of 0.95% (2.1 g/day) to 0.80% that people would eat healthier choice logo nutrient intake of the (1.8 g/day), 0.70% (1.6 g/ the same amounts of Dutch adult population day) and 0.57% (1.3 g/day) replacement foods as before and after replacing in the minimum, medium their traditional choice, foods that did not comply and maximum scenarios, whereas people may with the choices criteria. respectively eat high amounts of Four different scenarios products they perceive were modelled: to be healthier. (i) reference; The minimum scenario (ii) minimum, if 24% of was based on a single the population replaced study that may not be their food products which representative of the complied with the label general population. criteria; (iii) medium, if The available national 48% replaced their food representative food products which complied consumption data with the label criteria; used were based on (iv) maximum, if 100% self-reports, and were replaced their food outdated products which complied with the label criteria. The difference in cholesterol levels in the Dutch population was assessed before and after replacement by means of equations from meta- analyses that calculated how blood lipids change when diet composition changes

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830D Bull World Health Organ 2017;95:822–830G| doi: http://dx.doi.org/10.2471/BLT.16.189795 Systematic reviews Lirije Hyseni et al. Dietary trans-fatty acid reduction policies

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Study Study aim Policy analysed Geographical scope Participants and Methods Outcomes Comments Qualitya sample size Roodenburg et al., To describe a Food labelling Netherlands 750 Young Dutch Data from the 2003 Dutch An estimated reduction of Replacements chosen Fair 201335 nutrient intake adults (aged 19–30 food consumption survey –62% for TFA intake was found may be susceptible to modelling method years) in young adults and the when foods complied with the some subjectivity and to evaluate the Dutch food composition choices labelling programme bias. choices programme tables were combined compared with the actual Product acceptability – a nutrition profiling into a Monte-Carlo risk scenario. was not taken into system with nutrition assessment model. Three TFA intakes in the different consideration. The same criteria for TFAs, SFAs, scenarios were calculated: scenarios were 2.2 g/day for replacement food was sodium, added sugar (i) actual intakes; the actual scenario; 0.8 g/ used for a large number and product groups (ii) intakes when all foods day for the choices labelling of snacks. Snacks by investigating the that did not comply programme and 1.0 g/day are usually eaten for potential effect on with the healthy choices for the choices labelling indulgence; therefore it nutrient intakes criteria were replaced programme, adjusted for is unrealistic to assume by similar foods that did energy. TFA intakes were 1.3 g/ that consumers will comply; (iii) intakes when day and 1.4 g/day, when snacks replace all snacks with food replacements were were partially replaced or not the same healthier adjusted for the difference replaced, respectively alternative in energy density between the original and replacement food. Another two scenarios were calculated where snacks were not replaced or partially replaced De Menezes et al., To evaluate the Food labelling Brazil 1720 food products Data on industrialized Replacement of typical The study compared Good 201336 impact of introducing in the Brazilian diet and packaged products products by those meeting the the typical menu with products in available in the market choices criteria was estimated the choices criteria to agreement with the in São Paulo state were to cause a decrease in the see how the intake of choices labelling collected in 2011. The intake of TFAs of 92%. Estimated dietary components criteria for TFAs, sources of nutritional TFA intakes were: 0.8 g/day (SD: might change. There saturated fatty acids, information were product 1.0) for typical menus; 0.1 g/day was no specific focus sodium and added labels or websites. (SD: 0.2) for choices menus; and on TFA sugar in the typical To evaluate the impact 0.2 g/day (SD: 0.3) for energy- Brazilian diet of the consumption of adjusted choices menus, i.e. products aligned with the the same as choices menu, but choices criteria, ingestion adjusted for energy of typical of key compounds was menu estimated based on theoretical menus. Typical menus consumed by the Brazilian population were compared with the choices menu (and with the choices menu with energy adjustment). The estimated menus were based on data from a Brazilian household budget survey carried out between 2008 and 2009 Temme et al., To estimate the Food reformulation Netherlands 750 young adults Intakes of TFA were Average TFA intake decreased Composition data Poor 201137 impact of recent (aged 19–30 years): estimated before significantly from 2.3 g/day provided by members reformulations of 352 men, 398 reformulation (started (95% CI: 2.2 to 2.5) to 1.9 g/ of the Dutch task force food groups in the women in 2003), using national day (95% CI: 1.8 to 2.0) in for the improvement of Netherlands on food composition data of the reformulation scenario. fatty acid composition median intake of TFA 2001 as a reference and Pastry, cakes and biscuits, and was purchasing data and saturated fatty including most recent snacks contributed most to the not actual intake data. acids TFA composition of decrease of TFA than potato, Therefore it was not foods. Food composition bread, fats and margarines. always possible to link of other foods and Median TFA intakes were 2.3 g/ this information with food consumption was day (95% CI: 2.2 to 2.5) in the food consumption data assumed to be unchanged reference scenario and 1.9 g/ day (95% CI: 1.8 to 2.0) in the reformulation scenario. Estimated reduction in TFA intake was 0.4 g/day (–0.2 of total energy) Restrepo and To assess whether Mandatory food Denmark Danish population A policy restricting the In the period before the policy The study investigated Good Rieger, 201638 Denmark’s TFA reformulation (number not stated) content of artificial TFA in (1990–2003), the mean annual what would have policy reduced certain food ingredients number of deaths per 100 000 happened if mandatory deaths caused was implemented in 2004. people in Denmark were 441.5 reformulation had by cardiovascular Annual mortality rates in and in the synthetic control not been applied in disease OECD and development group were 442.7. In the Denmark. countries from 1990 3 years after the policy was The paper focuses on to 2012 were used to implemented (2004–2006), 2004–2006 before the estimate the effect of mortality attributable to anti-smoking law was Denmark’s food policy cardiovascular disease implemented. on cardiovascular disease decreased on average by 14.2 mortality rates. A synthetic deaths per 100 000 people per control group was year in Denmark relative to the composed of a weighted synthetic control group. average of other OECD The policy reduced male and countries that did not female cardiovascular disease implement the policy. deaths by 24.4 per 100 000 Analyses were conducted and 14.3 per 100 000 per year in 2015 over the 2004–2006 period, respectively. For coronary heart disease, the estimated reduction over the 2004–2006 period was 26.5 deaths per 100 000 people per year

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Bull World Health Organ 2017;95:822–830G| doi: http://dx.doi.org/10.2471/BLT.16.189795 830E Systematic reviews Dietary trans-fatty acid reduction policies Lirije Hyseni et al. (. . .continued)

Study Study aim Policy analysed Geographical scope Participants and Methods Outcomes Comments Qualitya sample size Barton et al., To estimate the Legislation to ban England and Wales Entire population A spreadsheet model Legislation to reduce intake of The study made no Good 201139 potential cost– industrially produced aged 40–79 years was used, with a range industrial TFA by approximately attempt to consider effectiveness of a TFA (about 50 million) of possible interventions 0.5% (from 0.8% to 0.3%) of recurrent events or population-wide to quantify the reduction total energy content could subsequent deaths. risk factor reduction in cardiovascular disease prevent approximately 2700 The estimates of programme aimed over a decade, assuming deaths annually and thus gain deaths avoided, life at preventing the benefits applied 570 000 life years and generate years gained and cost cardiovascular consistently for men and savings to the national health savings were thus likely disease women across age and service worth at least £ 230 to be underestimates, risk groups million a year making the analysis conservative. The study only modelled a 10-year timeframe; reduction in cardiovascular disease would clearly be greater over a lifetime. The analysis was pragmatically limited to people aged between 40 and 79 years at the time of the intervention. This initial modelling lacked a full probabilistic sensitivity analysis O’Flaherty et al., To estimate how (i) Target of 0.5% United Kingdom Adults aged 25–84 Potential reductions in In the conservative scenario: The study did not Good 201240 much more decrease in the years (number not cardiovascular disease reducing the TFA intake by 0.5% explicitly model lag cardiovascular fraction of total stated) mortality in the United in total energy, approximately times. disease mortality energy derived Kingdom between 2006 3500 of the 12 500 total The study assumed could be reduced from TFA by 2015; (baseline) and 2015 were cardiovascular disease deaths that the effects of food in the United (ii) legislative ban estimated by synthesizing would be prevented. In the policies on dietary Kingdom through data on population, diet aggressive scenario: effectively intake in the United more progressive and mortality. The effect eliminating the consumption Kingdom would be nutritional targets of specific dietary changes of TFA (to reach 0% of total quantitatively similar to on cardiovascular disease energy) could result in those in other countries, mortality was obtained approximately 4700 of the without explicitly from recent meta- 29 900 fewer cardiovascular considering political, analyses. The potential disease deaths (range: commercial, cultural reduction in cardiovascular 2500–8800) per year and socioeconomic disease deaths was differences or whether then estimated for countries’ baseline two dietary policy dietary values were scenarios: (i) conservative high or low. scenario, with modest The study assumed improvements (assuming commercial vested recent trends would interests could be continue until 2015); minimized (ii) aggressive scenario. with more substantial, but feasible reductions (already seen in several countries) in saturated fats, industrial TFAs and salt consumption, plus increased fruit and vegetable intake. A probabilistic sensitivity analysis was conducted Pearson-Stuttard To quantify the (i) Elimination England and Wales England and Wales The study extended a Elimination of all TFA resulted The model assumed Good et al., 201641 potential health of industrial TFA; population stratified previously validated in the largest gains in mortality immediate health effects and costs and (ii) elimination of by age, sex and model to estimate the and life years, with slightly benefits. However, rapid benefits of the United both industrial and socioeconomic potential effects on larger gains when modelling improvements might Kingdom-wide natural TFA status (number not health and economic unequal baseline TFA by reasonably be expected. policies to eliminate stated) outcomes of mandatory socioeconomic status. The study assumed dietary intake of TFA reformulation or a Scenario 1 (elimination of equal mortality gains complete ban on dietary industrial TFA only) from elimination of TFA in manufactured Annual deaths prevented: natural and industrial products in England and 1700. Annual life-years gained: TFAs Wales from 2011 to 2020. 15 000. Annual hospital Two policy scenarios were admissions averted: 4400. modelled: (i) elimination Hospital admissions averted of industrial TFA over 10 years: 38 000 consumption from 0.8% Scenario 2 (elimination of all TFA) to 0.4% daily energy; Annual deaths prevented: (ii) elimination of all TFA 3300. Annual life-years gained: consumption from 0.8% 29 000. Annual hospital to 0% admissions averted: 8400. Hospital admissions averted over 10 years: 72 000

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830F Bull World Health Organ 2017;95:822–830G| doi: http://dx.doi.org/10.2471/BLT.16.189795 Systematic reviews Lirije Hyseni et al. Dietary trans-fatty acid reduction policies

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Study Study aim Policy analysed Geographical scope Participants and Methods Outcomes Comments Qualitya sample size Rubinstein et al., To estimate the Reformulation Argentina Adults aged 34+ Baseline intake of Baseline number of deaths The cardiovascular risk Fair 201542 impact of policies (voluntary and years (number not TFA before 2004 was were: 24 875 for coronary heart calculator used was to reduce TFA on mandatory) and stated) estimated to be 1.5% disease and 17 942 for acute based on equations coronary heart mandatory food of total energy intake. A myocardial infarction. Baseline developed a couple disease, DALYs labelling policy model was built costs were: US$ 6416 per acute decades before when and associated including baseline intake coronary syndrome, US$ 5765 the coronary heart health-care costs in of TFA, the oils and fats per acute myocardial infarction, disease incidence was Argentina used to replace artificial US$ 1199 per follow-up and higher in Argentina. TFAs, the clinical effect of treatment, and US$: 129 001 for The study used global reducing artificial TFAs and programmatic costs. percentage estimates the costs and DALYs saved The proportion of CHD events to adjust for under- due to the coronary heart averted by the modelled reporting of mortality disease events averted. TFA reduction policy in 2014 from coronary heart To calculate the ranged from 1.3% (scenario disease. percentage reduction 1) to 6.4% (scenario 3) of the The study only looked of risk, coronary total. The estimated reductions at cost from a health heart disease risks in coronary heart disease system perspective and were calculated on were sensitive to the assumed not at the cost for the a population-based baseline TFA intake in 2004. industry to reformulate. sample before and after Based on projected changes The study did not have implementation of the in plasma lipid profiles: an precise data on baseline intervention. estimated 301 coronary heart TFA and the level of this The effect of the disease deaths, 572 acute would influence the policies was modelled myocardial infarctions, 1066 results in three ways, based on acute coronary heart disease (i) projected changes events and 5237 DALYs would in plasma lipid profiles; be annually averted after 2014. (ii) projected changes in This is calculated compared lipid and inflammatory with the expected events biomarkers; and (iii) the if the policy had not been results of prospective implemented. In addition, more cohort studies. than US$ 17 million would be The current economic saved annually due to acute value of DALYs and coronary heart disease events associated health-care averted and lower costs of costs of coronary heart chronic treatment and follow- disease averted were also up. estimated Based on projected changes in lipid and inflammatory biomarkers: using the baseline estimate of 1.5% energy intake from TFA, a total of 3109 acute coronary heart disease events, 15 271 DALYs and more than US$ 50 million in costs would be annually averted after 2014. Based on the results of prospective cohort studies (baseline): an estimated 1517 coronary heart disease deaths, 2884 acute myocardial infarctions, 5373 acute coronary heart disease events and 26 394 DALYs would be averted, resulting in estimated savings of $US 87 million CI: confidence interval; DALYs: disability-adjusted life years; EU: European Union; OECD: Organisation for Economic Co-operation; £: Pounds sterling; SD: standard deviation; TFA: trans-fatty acid; US$: United States dollars; WHO: World Health Organization. a We used adapted version of a published quality assessment tool by Fattore et al..18

Bull World Health Organ 2017;95:822–830G| doi: http://dx.doi.org/10.2471/BLT.16.189795 830G