A case study of the New York City trans-fat story for international application

Transcription

1 Original Article A case study of the New York City trans-fat story for international application Andy S.L. Tan a,b a Annenberg School for Communication at University of Pennsylvania, 3620 Walnut Street, Philadelphia, Pennsylvania 19104, USA. atan@asc.upenn.edu b Health Promotion Board, Singapore. Abstract Heart disease is the leading cause of death in New York City and contributes to significant burden of disease in the United States and internationally. Excessive intake of artificial trans-fatty acids has been causally associated with increased risk of heart disease. This article describes New York City s 2007 trans-fatty acids regulation, which was aimed at lowering the prevalence of heart disease among the city s residents by prohibiting the use of trans-fatty acids in the preparation of food in the city s food outlets. The author describes sequentially: (1) formulation, (2) public consultation, (3) implementation and (4) evaluation of the policy. He proposes a strategic framework for food policy development for international policymakers who are considering similar regulations. The framework includes four domains: (1) background research, (2) stakeholder support, (3) effective policy implementation and (4) evaluation and dissemination. Journal of Public Health Policy (2009) 30, doi: /jphp Keywords: trans-fatty acids; New York City; nutrition policy Introduction Heart disease is the number one cause of death in New York City (NYC) 1 and the United States, 2 killing New Yorkers and accounting for 44.7 per cent of total deaths in Although mortality has declined owing to improved treatment outcomes, 3 the burden of disease is still enormous, with 26 million Americans suffering from the disease. 4 In NYC, 6.7 per cent of residents reported symptoms of heart disease in Hospitalizations for heart disease rose from admissions in 1990 to r 2009 Palgrave Macmillan Journal of Public Health Policy Vol. 30, 1,

2 Tan in Apart from the well-studied health risk factors such as tobacco smoking, obesity, hypertension, and hypercholesterolemia, other socio-economic risk factors for developing heart disease were identified among New Yorkers. Males and blacks had the highest risks of dying from heart disease. 2 Higher risks of developing heart disease were found among males, American Indians/Alaska Natives, and people living in poverty, who were uninsured, had low education, and who lived in low-income families 4 or in neighborhoods in Brooklyn, Staten Island and Central Harlem. 6 Heart disease creates an economic burden for the United States. Total costs of coronary heart disease for United States were estimated at $151.6 billion in The State of New York spent $3.6 billion in 2000 on heart disease-related hospitalization costs, although total costs in 2002 amounted to $11.3 billion. 8 Globally, the impact of cardiovascular disease burden is equally staggering. On the basis of estimates from the World Health Organization, more than 7 million deaths occurred in 2002 owing to coronary heart disease. 9 Current projections indicate that the burden of coronary heart disease is likely to increase from around 47 million disability-adjusted life years (DALYs) in 1990 to 82 million DALYs in This global epidemic is not limited to high-income countries. In fact, low-income or transitional countries such as India, China, and Russia accounted for more than 2.9 million coronary heart disease deaths in As with the United States, direct and indirect economic costs of cardiovascular diseases constitute a major economic burden. One key nutrition-related risk factor for heart disease is excessive intake of artificial trans-fatty acids (hereafter referred to as transfat). Artificial trans-fats are found in partially hydrogenated vegetable oils commonly used in baked food products and deep frying. Large-scale cohort studies show that increased artificial trans-fat intake is causally associated with an increased risk of heart disease. 10,11 The medical and scientific communities are confident that the reduction, if not complete elimination of artificial trans-fat intake may lead to lower population risks of developing heart disease. In July 2007, the New York City Department of Health and Mental Hygiene (DOHMH) implemented a trans-fat regulation 4 r 2009 Palgrave Macmillan Journal of Public Health Policy Vol. 30, 1, 3 16

3 New York City s trans-fat story intended to reduce the intake of trans-fat among its residents and prevent heart disease. The trans-fat regulation was intended to phase out the use of artificial trans-fat in all food outlets in the city. From 1 July 2008, all food outlets were prohibited from using partially hydrogenated vegetable oils, shortenings, or margarines containing trans-fat to prepare foods, except foods containing less than 0.5 g of artificial trans-fat per serving. 12 The regulation did not apply to prepackaged foods such as crackers or chips sold in food outlets. Violators of the regulation were to be assessed fines of $ and be listed on the department s inspection website. Violations of this regulation were to have no bearing on a food outlet s hygiene certification. To the author s knowledge, there is no previously published account of the NYC experience implementing this public health nutrition policy. This paper describes the policy processes underlying NYC s trans-fat regulations, identifies pitfalls and critical success factors encountered by the city officials, discusses the benefits and ramifications of the trans-fat policy, and offers practical policy recommendations for public health agencies in other countries considering similar food policies. The main focus of the case study is four key processes of the trans-fat policy development in NYC: (1) policy formulation, (2) public consultation, (3) implementation, and (4) evaluation. Chronology of Events Table 1 summarizes a timeline of significant events leading up to the introduction of the trans-fat regulation in NYC. The events are important for understanding the scientific, consumer, behavioral, political, and economic contexts within which NYC implemented its trans-fat regulation. Scientific As early as the 1990s, trans-fat was linked to increased risks of coronary heart disease among women. 14 A meta-analysis of four prospective cohort studies showed that a 2 per cent increase in energy intake from trans-fat was associated with an aggregate increase in the incidence of heart disease of 23 per cent. 15 There is currently r 2009 Palgrave Macmillan Journal of Public Health Policy Vol. 30, 1,

4 Tan Table 1: Chronology of events for New York City trans-fat regulations 1990 Nutrition labeling for saturated and unsaturated fats and cholesterol content in food products required under the US Nutrition Labeling and Education Act Trans-fats shown to increase low-density lipoprotein (LDL) cholesterol and decrease high-density lipoprotein (HDL) cholesterol in humans 1993 Willet et al. publishes data showing that the intake of trans-fatty acids increases the risk of coronary heart disease among women 2002 Institute of Medicine links trans-fat to coronary heart disease and recommends reduced intake of trans-fat 2003 Denmark limits artificial trans-fat content in manufactured foods to below 2 per cent of total-fat 2004 Trans-fats shown to affect coronary risk more than expected from the effect on LDL and HDL 2005 US Department of Agriculture dietary guidelines recommend lowering trans-fat intake in the American diet Kraft removes trans-fat across seven categories of products in the United States and globally 2006 Federal Drug Administration trans-fat labeling act comes into effect for food labels American Heart Association recommends lowering trans-fat intake to less than 1 per cent of caloric intake Evidence that reduction of transfat can reduce risk of coronary heart disease published by Mozaffarian et al. New York City (NYC) launches trans-fat education campaign to encourage restaurant owners to voluntarily use trans-fat free oils; evaluation of this campaign showed that voluntary substitution is not effective in NYC Public hearing in NYC regarding the proposed trans-fat regulation NYC issues intention to amend Article District judge rules against menu labeling in NYC restaurants Trans-fat regulations partially implemented in NYC 2008 District judge rules in favor of revised menu-labeling regulation in NYC which takes effect on 31 March Trans-fat regulations fully implemented in NYC on 1 July California announces ban of trans-fat from restaurant products beginning in 2010, and from all retail baked goods by 2011 San Francisco announce menu-labeling regulations to include calorie, saturated fat, carbohydrates and sodium information Adapted from Okie r 2009 Palgrave Macmillan Journal of Public Health Policy Vol. 30, 1, 3 16

5 New York City s trans-fat story strong scientific consensus that the intake of artificial trans-fat should be minimized, if not entirely eliminated from the diet. 16 These studies and expert recommendations provided the scientific rationale behind the DOHMH s trans-fat regulations. Consumer Consumers in the United States had become increasingly aware of the harmful effects of trans-fat. This was important to the success of DOHMH s trans-fat regulations. Increased awareness may have been due to a combination of public education by government agencies, lobbying efforts from health advocacy and consumer interests groups, media coverage, increased marketing efforts by food manufacturers of low trans-fat foods, several high-profile lawsuits against food manufacturers including Kraft and McDonald s for their use of trans-fats in their products. Also, a few took notice of Denmark s successful 2003 trans-fat regulations. 17 Consumer surveys indicate that 68 per cent of American households were aware of the health risks of trans-fat 18 and 40 per cent of shoppers regularly checked food labeling for trans-fat content. 19 Nutrition intake In 1999, Americans consumed an average of 2.6 per cent of their total daily energy intake as trans-fat. In 2000, Americans consumed a calorie diet that translates to about 5.8 g of trans-fat per day. 20,21 Most of the consumption of trans-fat in the American diet is from artificial trans-fat used in processed foods (80 per cent), such as margarine, baked goods, and snacks. The remaining 20 per cent consists of naturally occurring trans-fatty acids in animal products such as dairy, lamb, and beef. 21 Americans consumed more than onethird of their caloric intake from foods outside of their homes. 22 This means that food outlets were significant sources of trans-fat in the American diet. Targeting these sources of trans-fat could, it seemed, achieve significant reductions in trans-fat intake in NYC. However, the regulation exempted packaged or manufactured foods because these products fell under the jurisdiction of the Federal Food and Drug Administration (FDA). The impact of the NYC trans-fat regulation might therefore achieve less than the Danish example. 23 r 2009 Palgrave Macmillan Journal of Public Health Policy Vol. 30, 1,

6 Tan Political will The city administration led by Mayor Michael Bloomberg and DOHMH led by health commissioner Dr Thomas Frieden acted proactively and championed public health issues. The presence of strong political leadership was an important factor leading to the successful implementation of the trans-fat regulation. The political will for addressing public health issues had been evident since 2002 when NYC led the nation in implementing aggressive public health policies a smoking ban in public places in and stricter gun control policies in In 2006, DOHMH proposed a regulation requiring that restaurants publish the number of calories for items on menus and menu boards. 26 The New York State Restaurant Association (NYSRA) opposed this rule and sued DOHMH. In September 2007, a Federal District Court ruled in favor of the NYSRA, stating that such regulation was preempted by federal laws. Despite the setback, DOHMH demonstrated political will and persistence. It proposed a revised menu-labeling regulation and in the ensuing legal battle with the NYSRA, DOHMH successfully implemented a regulation in March National developments aided the City. In 2003, the FDA announced it would promulgate by 2006 regulations requiring that trans-fat content information appear on all food labels. 21 This FDA policy and the presence of strong political will in NYC were crucial to NYC s successful implementation of the trans-fat regulation. Economic Ten of the fourteen major US food manufacturers (71per cent) in a survey by consumer interest group Center for Science in the Public Interest either reformulated some or all of their products to eliminate trans-fats or were in the process of doing so by Several large food outlet chains have also voluntarily removed trans-fat from their offerings nationally since These companies did not suffer any earnings loss and one, in fact, reported an increase in revenues after reducing trans-fat in its products. 31 For food companies, many alternatives to oils containing artificial trans-fat were available at comparable prices and tastes. 32 Industry showed that the technology is readily available for food businesses to replace trans-fat with 8 r 2009 Palgrave Macmillan Journal of Public Health Policy Vol. 30, 1, 3 16

7 New York City s trans-fat story healthier options with minimal negative impact for cost or revenue. Since 1993, food manufacturers in Denmark substituted trans-fat with alternatives voluntarily, almost a decade before the Danish trans-fat ban came into effect in The Danish experience strengthened a sense that changes were economically feasible and did not affect the quality or cost of the foods. 33 Processes Involved in NYC s Trans-Fat Regulations Policy formulation DOHMH was well prepared with the scientific rationale for its policy. The department carefully assembled the evidence of the population health impact of trans-fat intake, sought recommendations about reducing trans-fat intake from independent committees such as the Institute of Medicine, and the American Heart Association, and gathered international evidence about the effectiveness of such policies from the Danish experience. DOHMH also considered practical issues such as the feasibility of switching from trans-fat to healthier alternatives and the department s capacity to enforce the ban. Armed with the above information, DOHMH was able to present the proposed policy to the public and industry. Justification for the proposal was soundly grounded in science. Public consultation To obtain political and public support before proposing the regulation, New Yorkers and representatives of the food industry were invited to comment on the proposal. DOHMH recorded potential objections (especially from the food industry) and addressed and countered them in press releases following the implementation of the policy. The public response was overwhelmingly supportive. More than 96per cent of comments supported the regulations. 34 DOHMH remained flexible and open to requests from food businesses to modify its policy. For instance, DOHMH recognized the difficulties faced by businesses that served baked goods how to make the transition to non-trans-fat ingredients. The department extended the deadline to 1 July 2008 for these businesses and to allow food r 2009 Palgrave Macmillan Journal of Public Health Policy Vol. 30, 1,

8 Tan businesses to get accustomed to the regulation gradually provided a grace period of 3 months where violators would not be assessed fines. The sensitivity shown by DOHMH was important for avoiding serious backlash from the public or industry. Implementation DOHMH was well-equipped to implement and enforce the policy. DOHMH translated the regulation into a comprehensive package of activities to ensure that the objectives were met. These activities included: (1) consumer education, (2) food business owners education and technical support, (3) capacity building for health department inspectors and (4) food outlet inspection for violations. The department conducted consumer and business owner education through mass media, direct mail, and dedicated internet websites. With a grant from the American Heart Association, DOHMH and the City University of New York established a Trans-Fat Help Center for restaurant personnel with dedicated telephone hotlines, training classes, and resources on preparing foods without ingredients containing trans-fat. 35 The main messages were simple to understand, demonstrated the rationale for the policy, and allayed fears that the policy would affect dining experiences. Evaluation The evaluation for the trans-fat regulation s first phase of implementation was primarily a process evaluation. Between July and September 2007, DOHMH conducted inspections of 3300 restaurants and found that 94 per cent of restaurants were in compliance with the first phase of trans-fat regulation. This compares with compliance rates of 50 per cent before the policy was announced and 80 per cent in June A second round of evaluation in May 2008 showed that 95 per cent of restaurants inspected were in compliance with the regulations. 37 The results validated the department s assumption that it was relatively easy to replace ingredients containing trans-fat in the city s food outlets. The city health department inspectors conducted the evaluations as part of the routine hygiene inspections. No additional workforce resources were required. 10 r 2009 Palgrave Macmillan Journal of Public Health Policy Vol. 30, 1, 3 16

9 New York City s trans-fat story Discussion and Recommendations This case study of the NYC trans-fat regulation illustrates successful implementation of a nutrition policy to achieve public health benefits. The strengths of DOHMH s experience included having clear objectives, setting realistic requirements for food outlets, assembling robust background research, using a strategic political process, reducing barriers to implementing the switch to alternatives, and maintaining the momentum to approve the regulation. On the basis of this case study, DOHMH demonstrated a remarkably strategic execution formulating, implementing, and following through. NYC s experience has served as a useful model for other cities and regions in the United States that have implemented similar policies to reduce the usage of trans-fat or to regulate menu labeling. In July 2008, California became the first state in the United States to pass a law that will phase out the use of trans-fat in all restaurants and baked goods, statewide beginning in California has paved the way for similar policy actions by other state governments. The city of San Francisco also announced a menu-labeling regulation requiring restaurants to post nutrient information calories, saturated fat, carbohydrates, and sodium. 42 San Francisco requirements go beyond NYC s menu-labeling regulation, which required only calorie information. But will additional nutrient information benefit consumers in their food-purchasing decisions and health outcomes? The California Restaurant Association sued San Francisco about the menu-labeling regulation 43 and the outcome may hinge on DOHMH/NYSRA precedents. Critics have also questioned the health impact of NYC s trans-fat policy as NYC s baseline intake of trans-fat was modest compared to the total fat intake of Americans, and moreover manufactured foods containing trans-fat were not covered in the policy. Popular press coverage now reports that the vast majority of food outlets in NYC replaced oils containing artificial trans-fat with natural atherosclerosis-causing saturated fats such as butter or palm oil. Gains in reduced trans-fat intake may be negated by trans-fat in manufactured foods and a concurrent increase in natural saturated fat intake. Another unintended consequence of this policy could be a false sense of security among consumers who may actually increase their overall food intake, resulting in increased of obesity, neutralizing the r 2009 Palgrave Macmillan Journal of Public Health Policy Vol. 30, 1,

10 Tan impact of the policy. Describing limiting trans-fat intake as low lying fruit, some lamented that perhaps greater health impact may be achieved by focusing on reducing other heart disease risk factors such as smoking, obesity, total fat intake, lack of physical activity, and sodium intake. DOHMH s menu-labeling regulation was part of a broad-based strategy to provide consumers with caloric information about foods at the point-of-purchase; encouraging consumers to make informed food choices. Research suggested that menu labeling was effective in reducing the calories of food purchased by consumers. 44 A recent consumer survey of New Yorkers by a private consulting firm (Technomics Inc.) found that most (80 per cent) of 299 respondents were aware of the menu-labeling regulation and 75 per cent thought that the nutritional information on menus is helpful when ordering. Of 192 respondents who went to a restaurant that posted menu labels, 84 per cent used the nutrition information. The trans-fat regulations and menu labeling are complementary policies aimed at reducing the overall risk of cardiovascular disease in the population. It is still too early to observe changes in health outcomes or risk factors arising from the trans-fat or menu-labeling regulations. It remains to be seen if these policies will indeed effectively prevent heart disease and lower mortality among New Yorkers. Danish experience following the 2003 trans-fat ban suggests that a broadbased ban of artificial trans-fat in foods (manufactured and prepared foods) significantly lowered the population intake of trans-fat. 23 NYC should therefore continue its surveillance of the burden of heart disease, early behavioral indicators, and consumers food choices to measure the impact of its policies. The experience of Denmark which implemented similar trans-fat regulations in 2003 was not unlike NYC s, with differences. The differences should be carefully studied by public health agencies. In Denmark s case, successful implementation was largely attributed to sustained pressure on the food industry through media exposure, alliances with key politicians in the Ministry of Food and Agriculture, and scientific integrity of the Danish Nutrition Council. 45 Similar widespread media coverage of NYC s announced trans-fat regulations may have contributed to greater public support for the regulations. It was, however, less evident that federal agencies or national interest groups played significant roles in NYC. 12 r 2009 Palgrave Macmillan Journal of Public Health Policy Vol. 30, 1, 3 16

11 New York City s trans-fat story Background research Burden of disease Scientific consensus International experience Industry response Potential alternatives Health impact Economic burden Technical feasibility Operational capacity Stakeholder support Political leadership Public Industry Academia Health organizations Other government agencies Lobby groups Media Funding support Implementation of policy Pre-testing Public education Assist food business owners Access to substitutes Staff training Enforcement Evaluation and Dissemination Obtain feedback Process measures Outcomes measures* Share experience* Create a movement* Refine policy if necessary* Figure 1: Framework of trans-fat regulation formulation processes. Note: *These were not performed by the Department of Health and Mental Hygiene (DOHMH) but were included as possible activities which would be appropriate for evaluation and dissemination. How will the NYC experience benefit other public health agencies within the United States or around the world that are considering similar trans-fat policies? On the basis of NYC s approach to introducing its trans-fat regulations, a strategic framework might illustrate the policy processes involved (Figure 1). The policy process may be broadly organized into four main categories: (1) background research, (2) stakeholder support, (3) implementation and (4) evaluation and dissemination. These are to be underpinned by clear objectives to achieve reductions in risk factors for heart disease. Key factors identified in NYC s example are also included in the proposed strategic framework. With this descriptive case study of NYC s critical success factors and the proposed framework, other public health agencies may be able to shorten the process for implementing similar trans-fat policies. Acknowledgement I acknowledge and thank Professor Marion Nestle, PhD, New York University, for her insightful comments and suggestions, for which she received no compensation. r 2009 Palgrave Macmillan Journal of Public Health Policy Vol. 30, 1,

12 Tan About the Author Dr Andy Tan, MBBS, MPH, MBA is a public health physician specializing in health promotion and health communication in Singapore. He is currently a doctoral candidate and research fellow at the Annenberg School for Communication at the University of Pennsylvania. References 1. New York City Department of Health and Mental Hygiene. (2005) Summary of vital statistics 2004: The city of New York, sum.pdf, accessed 25 September Minino, A., Heron, M.P., Murphy, S.L., Kochanek, K.D. and Centers for Disease Control and Prevention National Center for Health Statistics National Vital Statistics System (2007) Deaths: Final data for National Vital Statistics Reports: From the Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System 55(19): Ford, E. et al. (2007) Explaining the decrease in U.S. deaths from coronary disease, The NEJM 356(23): Pleis, J. and Lethbridge-Cejku, M. (2006) Summary health statistics for U.S. adults: National Health Interview Survey, Vital and Health Statistics 10(232): New York State Department of Health. Bureau of Chronic Disease, Epidemiology and Surveillance. (2005) BRFSS brief: Cardiovascular disease New York state adults, (no. 0702), accessed 25 September Office of the New York City Comptroller. (2007) Health and wealth: Assessing and addressing income disparities in the health of New Yorkers, gov/bureaus/opm/reports/ _health-wealth-report.pdf, accessed 25 September Rosamond, W. et al. (2007) Heart disease and stroke statistics 2007 update: A report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 115(5): e69 e New York State Department of Health. Bureau of Chronic Disease, Epidemiology and Surveillance and Bureau of Health Risk Reduction. (2002) The burden of cardiovascular disease in New York: Mortality, prevalence, risk factors, costs, and selected populations, accessed 25 September Mackay, J. and Mensah, G. (2004) The Atlas of Heart Disease and Stroke. Geneva: World Health Organization. 10. Ascherio, A., Rimm, E.B., Giovannucci, E.L., Spiegelman, D., Stampfer, M. and Willett, W.C. (1996) Dietary fat and risk of coronary heart disease in men: Cohort follow up study in the United States. BMJ (Clinical Research Education) 313(7049): Sun, Q. et al. (2007) A prospective study of trans fatty acids in erythrocytes and risk of coronary heart disease. Circulation 115(14): New York City Department of Health and Mental Hygiene. (2006) Notice of adoption of an amendment (y81.08) to Article 81 of the New York City Health Code, 14 r 2009 Palgrave Macmillan Journal of Public Health Policy Vol. 30, 1, 3 16

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