Editorial

Annals of Internal Medicine

New York City Trans Fat Ban: Improving the Default Option When
Purchasing Foods Prepared Outside of the Home

he adverse effects of trans fatty acid (trans fat) on cardiovascular health have been known for at least 2 decades (1). During that time, both the Dietary Guidelines
for Americans (2) and the Institute of Medicines Dietary
Reference Intake guidelines (3) have recommended restricting trans fat intake to the extent possible. To facilitate
adherence to this guidance, the U.S. Food and Drug Administration mandated in 2003 that trans fat content be
listed on the Nutrient Facts panel of packaged foods by
2006 (4). This ruling enabled consumers to make purchasing decisions based on the information provided, and it
incentivized food manufacturers to reformulate products to
reduce trans fat content. Recent data suggest that these
efforts have been successful. Between 2000 and 2009,
plasma trans fat levels in non-Hispanic white adults living
in the United States decreased by 50% (5). The U.S. Department of Agriculture documented a dramatic decrease
in the trans fat content of newly introduced foods and
an increase in the use of no trans fat claims on food
packaging between 2005 and 2010 (6). However, foods
prepared outside of the home are unaffected by the labeling requirements.
The major dietary sources of trans fat are ruminant fat
(from meat and dairy products) and partially hydrogenated
fat (from vegetable oils, vegetable shortenings, and traditional margarines). Although considerable effort has gone
into assessing potential biological differences between these
2 sources of trans fat, the results suggest that they are
similar, indicating that the intake of all sources of trans fat
should be minimized (7). With regard to ruminant fat,
adhering to the current dietary guidance of restricting saturated fat intake (primarily contributed by meat and dairy
fat) to reduce cardiovascular disease risk will likewise reduce trans fat intake (8, 9). With regard to partially hydrogenated fat, which in the early 2000s was the largest source
of trans fat in the U.S. diet (9), wise use of the information
provided on the Nutrient Facts panel could help limit
some sources of trans fat. However, because approximately
one third of the food that Americans eat is prepared outside of the home, trans fat content is unregulated and unlabeled in a large segment of the food supply (10). One
approach to effecting a secular decrease in trans fat intake is
to restrict the use of partially hydrogenated fat in commercially prepared foods.
In 2005, the New York City (NYC) Department of
Health and Mental Hygiene (DOHMH) took the bold
step of calling for a voluntary reduction in the use of partially hydrogenated fat by commercial food establishments
(11). Unfortunately, that approach did not succeed (12).
The following year, the DOHMH took the bolder step of
144 2012 American College of Physicians

mandating a 2-phase system to restrict the use of partially

hydrogenated fat in the preparation of foods sold by chain
restaurants in NYC that were under their jurisdiction. The
first phase required elimination of partially hydrogenated
fat from spreads and products used in frying, pan-frying
(sauteing), and grilling unless the product contained less
than 0.5 g of trans fat per serving. The second phase required that no food contain partially hydrogenated vegetable oil, shortening, or margarine with more than 0.5 g of
trans fat per serving. After several unsuccessful legal challenges (13), the first phase went into effect in July 2007
and the second phase in July 2008 (11). Concurrently, the
DOHMH provided technical assistance to facilitate compliance with the regulations; this was probably an important contributor to the success of the program. The assistance took the form of a trans fat training module in the
agencys food protection courses, informational brochures,
and a trans fat help center. The help center offered a telephone helpline; information on frying, baking, and purchasing prepared foods without partially hydrogenated fat;
Trans Fat 101 courses in English, Spanish, and Chinese;
and an extensive Web site containing critical information
on the topic (11).
In this issue, Angell and colleagues (14) provide a report on the effect of these regulatory efforts. They documented, on the basis of receipts collected in 2007 and
2009, a statistically significant decrease in the trans fat content and a much smaller increase in the saturated fat content of purchased foods, resulting in a statistically significant net decrease in both the trans and saturated fat
content of the purchases surveyed. The decrease was attributed to reformulation and new offerings (for example,
grilled chicken), rather than smaller portion sizes. Of
note, the effect was similar for restaurant patrons in highand low-income neighborhoods. Controlling for total calories purchased from the restaurant chains and sex of the
customer did not have a statistically significant effect on
the results.
Any time public health measures are introduced, it is
critical to anticipate and address potential impediments to
implementation and unintended consequences, both real
and perceived. Initial critics of the NYC DOHMH initiative (primarily the restaurant industry) voiced concerns
about an insufficient supply and higher cost of partially
hydrogenated fat alternatives, as well as less appealing food
products. In all cases assessed to date, these issues have not
materialized. Between 2006 and 2008, the proportion of
restaurants using partially hydrogenated fat decreased from
51% to 2% (12). Switching to trans fatfree frying oils has
been cost-neutral, and producers have expanded produc-

New York City Trans Fat Ban

tion of acceptable fats to meet the increased demand (12).

In anticipation of a potential exchange of trans fat for saturated fat, the DOHMH crafted preventive explanatory
guidance. The results of the study by Angell and colleagues
(14) allay this concern.
Why is it important to document the effects of NYCs
partially hydrogenated fat restrictions? These data provide
a unique opportunity to study a new public health approach to altering secular dietary trends and, potentially,
health outcomes. Prior successful population-wide initiatives were designed to increase intake of specific nutrients
that were inadequately consumed in the U.S. dietfor
example, iodizing salt; fortifying fluid milk with vitamins A
and D; and enriching grains with thiamin, niacin, riboflavin, folate, and iron (15). We have entered a new era where
the focus is on limiting rather than maximizing intake.
Other population-wide approaches to changing dietary intake, primarily through recommendations and guidelines
(for example, in reducing calories, saturated fat, and sodium), have met with limited success (16, 17). New York
Citys restrictions on partially hydrogenated fat facilitated a
decrease in the trans fat content of food purchases, and
presumably trans fat intake, by making the default option
the healthier choice. Reaping this benefit is independent of
health literacy, awareness, motivation, or level of nutrition
knowledge. The regulation may serve as a model for future
successful public health initiatives.
What have we learned from NYCs trans fat ban? Public health measures work and, when well-planned and wellimplemented, do not result in adverse consequences. The
benefit seems to be widespread and not limited to subsets
of the population. Nevertheless, these new data represent a
sliver of the commercially prepared foods available from a
narrow segment of food outlets. Caution must be used
when interpreting the data.
What have we not learned from NYCs trans fat ban?
The major public health challenge in the United States is
excess energy intake, and the question remains about
whether the trans fatfree designation confers an undeserved health halo for foods that are high in energy and
low in nutrient density. Vigilance in this area is essential.
What NYCs trans fat ban has done is make the default
option for foods prepared outside of the home a bit healthier. The final assessment of this public health effort awaits
additional evaluation; however, the data so far suggest that
the mission has been accomplished.
Alice H. Lichtenstein, DSc
Tufts University
Boston, MA 02111
Potential Conflicts of Interest: None disclosed. Forms can be viewed at
www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum
M12-1321.

www.annals.org

Editorial

Requests for Single Reprints: Alice H. Lichtenstein, DSc, Tufts

University, 711 Washington Street, Boston, MA 02111; e-mail, alice
.lichtenstein@tufts.edu.

Ann Intern Med. 2012;157:144-145.

References
1. Mensink RP, Katan MB. Effect of dietary trans fatty acids on high-density and
low-density lipoprotein cholesterol levels in healthy subjects. N Engl J Med.
1990;323:439-45. [PMID: 2374566]
2. Center for Nutrition Policy and Promotion. Dietary Guidelines for Americans. Alexandria, VA: U.S. Department of Agriculture; 2000. Accessed at www
.cnpp.usda.gov/DGAs2000Guidelines.htm on 4 June 2012.
3. Institute of Medicine. Dietary Reference Intakes. Energy, carbohydrate, fiber,
fat, fatty acids, cholesterol, protein and amino acids. Washington, DC: National
Academy of Sciences; 2005.
4. Food and Drug Administration, HHS. Food labeling: trans fatty acids in
nutrition labeling, nutrient content claims, and health claims. Final rule. Fed
Regist. 2003;68:41433-1506. [PMID: 12856667]
5. Vesper HW, Kuiper HC, Mirel LB, Johnson CL, Pirkle JL. Levels of plasma
trans-fatty acids in non-Hispanic white adults in the United States in 2000 and
2009. JAMA. 2012;307:562-3. [PMID: 22318273]
6. Rahkovsky I, Martinez S, Kuchler F. New Food Choices Free of Trans Fats
Better Align U.S. Diets With Health Recommendations. Economic Information
Bulletin no. 95. Washington, DC: U.S. Department of Agriculture Economic
Research Service; 2012.
7. Brouwer IA, Wanders AJ, Katan MB. Effect of animal and industrial trans
fatty acids on HDL and LDL cholesterol levels in humansa quantitative review.
PLoS One. 2010;5:e9434. [PMID: 20209147]
8. Lichtenstein AH, Appel LJ, Brands M, Carnethon M, Daniels S, Franch
HA, et al; American Heart Association Nutrition Committee. Diet and
lifestyle recommendations revision 2006: a scientific statement from the
American Heart Association Nutrition Committee. Circulation. 2006;114:
82-96. [PMID: 16785338]
9. Center for Nutrition Policy and Promotion. Dietary Guidelines for Americans. Alexandria, VA: U.S. Department of Agriculture; 2010. Accessed at www
.cnpp.usda.gov/DGAs2010-DGACReport.htm on 4 June 2012.
10. Agricultural Research Service. Away from Home: Percentages of Selected
Nutrients Contributed by Foods Eaten Away from Home, by Gender and Age.
What We Eat in America, NHANES 2007-2008. Washington, DC: U.S. Department of Agriculture; 2010. Accessed at www.ars.usda.gov/SP2UserFiles/Place
/12355000/pdf/0708/Table_9_AWY_GEN_07.pdf on 4 June 2012.
11. New York City Department of Health and Mental Hygiene. Cardiovascular
Disease Prevention. New York: New York City Department of Health and
Mental Hygiene; 2012. Accessed at http://home2.nyc.gov/html/doh/html/cardio
/cardio-transfat-rest-food-info.shtml on 4 June 2012.
12. Angell SY, Silver LD, Goldstein GP, Johnson CM, Deitcher DR, Frieden
TR, et al. Cholesterol control beyond the clinic: New York Citys trans fat
restriction. Ann Intern Med. 2009;151:129-34. [PMID: 19620165]
13. Silver LD, Angell SY. Results of Public Hearing and Comments Received
Regarding Amendment of Article 81 of the New York City Health Code Adding
a New Section 81.08 to Limit the Use of Artificial Trans Fat in NYC Food
Service Establishments (FSEs). New York: New York City Department of Health
and Mental Hygiene; 2006.
14. Angell SY, Cobb LK, Curtis CJ, Konty KJ, Silver LD. Change in trans fatty
acid content of fast-food purchases associated with New York Citys restaurant
regulation. A prepost study. Ann Intern Med. 2012;157:81-6.
15. Fulgoni VL 3rd, Keast DR, Bailey RL, Dwyer J. Foods, fortificants, and
supplements: where do Americans get their nutrients? J Nutr. 2011;141:1847-54.
[PMID: 21865568]
16. Astrup A, Dyerberg J, Elwood P, Hermansen K, Hu FB, Jakobsen MU,
et al. The role of reducing intakes of saturated fat in the prevention of cardiovascular disease: where does the evidence stand in 2010? Am J Clin Nutr. 2011;93:
684-8. [PMID: 21270379]
17. Appel LJ, Angell SY, Cobb LK, Limper HM, Nelson DE, Samet JM, et al.
Population-wide sodium reduction: the bumpy road from evidence to policy.
Ann Epidemiol. 2012;22:417-25. [PMID: 22626000]

17 July 2012 Annals of Internal Medicine Volume 157 Number 2 145