Challenging Dogma


...Using social sciences to improve the practice of public health

Wednesday, April 25, 2007

The wrong focus: Too much attention on banning trans fat will not solve the heart disease epidemic - Kelly Ho

Over the past two decades, much effort has been spent on eliminating trans fat from the American diet. Studies have shown that the consumption of trans fat has a linear relationship with the incidence of heart disease (1). So, what is trans fat? Why is it so bad for you? Trans fat is bad for you because it increases your LDL (bad) cholesterol and also lowers your HDL (good) cholesterol, which together increase your risk of having heart disease (2).

Proctor and Gamble was the first company that used trans fat to make the hydrogenated shortening “Crisco” in 1909 (3). In 1960, there was a significant increase in the use of trans fat in the food industry due to lower costs and in response to health concerns in using saturated fat in food production, such as lard and beef fats (3). Later, trans fats started to grab attention in 1988, when scientific studies suggested they could be related to the large increase in the incidence of coronary heart disease (3). From this point onwards, there have been interventions attempting to ban the use of trans fats in food production.

One of the pioneers was a California organization that launched a lawsuit in 2003 asking Kraft Food Inc. to stop selling Oreos to children in California because Oreos contain trans fat (3). In 2006, the FDA required manufacturers to list trans fat content on nutrition labels and by 2008 all restaurants in New York will have to limit their use of trans fat in spreading fats or frying to below 0.5 g per serving (3). However, banning trans fat is not an effective public health intervention to alleviate the cardiovascular disease epidemic. It is detracting our attention from the more critical and broader issues that could prevent the disease, such as increasing the accessibility to a healthy diet, changing the dietary behavior of Americans, and undermining the public’s awareness of trans fat. Without addressing all of these issues, banning trans fat alone is a flawed public health intervention.

Ignoring factors that are related to the accessibility to a healthy diet

The goal for banning trans fat is to offer a healthier diet environment to Americans in order to prevent heart disease (4). Until now, the only two things that have been done are to restrict and label the trans fat content of the food sold in supermarkets, as well as to limit the amount of trans fat that can be used in cooking and as spreads in the restaurant industry. Apart from limiting the amount of trans fat, a healthy diet should also contain fresh produce such as fruits and vegetables. These two things are crucial as a part of a healthy diet. In 2000, the average daily fruit and vegetable consumption was only 1.4 servings and 3.8 servings, respectively (5). Without the adequate supply of fruits and vegetables, the goal of offering a healthy diet would not be fulfilled. The banning of trans fat ignore the importance of addressing this issue.

Often, people who live in low income areas are more unlikely to have access to fresh fruits and vegetables (6). According to USDA Supermarket Characteristics and Operating Cost in Low-Income Areas, the prices of food sold in the supermarkets located in the low income area are usually higher (7). This may due to a higher operating cost of supermarkets located in the low-income area due to lower operation efficiency (7). Also, because food availability is usually associated with ZIP code, fresh fruits and vegetables are less readily available in low income areas (7). With limited economic resources, residents of low income areas cannot afford the high prices of the fresh fruits and vegetables (6).Their diets tend to contain more low cost, energy dense foods which are mostly made of refined grains, added sugar, or fats. Studies have shown that early onset of obesity can result from a low quality diet (6). Energy dense foods diminish feelings of fullness and promote over-consumption, which then leads to higher energy intake (6).

Dietary behavior of Americans

Banning trans fat does not alter people’s fundamental dietary behavior. Such a ban may convey the wrong message to people that it is now safe to eat as many baked goods, cookies, or French fries as they like because these foods no longer contain trans fat. These foods have other non-nutritious ingredients, such as saturated fats and added sugar, which could contribute to becoming overweight or obese if too much is consumed. It is not only about what Americans eat – the amount they consume and the choices they make also matter. Average Americans are now consuming 300 calories more per day compared to 1985 (5).

According to Nutrition Well Being A-Z, 60% of Americans eat snack food regularly (8). Living in a fast pace and time crunched society like the US, Americans adopt a convenient lifestyle, often meaning they do not cook their own meals (9). In fact, 25% of adults skip breakfast either due to the fact that they have no time to prepare or they are afraid of excess weight gain (8, 10). But these individuals might be eating snack such as Oreo cookies and other calories-dense food later on the day (8). What is more worrying is that they might just buy some ready-made food or eat at restaurants (9). Foods that are ready to eat and restaurant meals are usually higher in calories and fat, compared to food prepared at home (9).

The second reason why Americans consume snack foods might be because Americans love to socialize (9). Fun and food seems to go hand in hand when it comes to a social event like watching the Super bowl. Having an ample amount of snack food while watching the game is always a part of the experience. Americans consume 30.4 million pounds of snack foods during Super Bowl (11). If Americans do not change these habits, banning trans fat alone would definitely not be helpful to the heart disease epidemic.

Decrease in public awareness

Trans fat bans in restaurants also decrease public awareness about trans fat. This might send the wrong message to the general public that the problem is being solved and that they do not have to worry about the heart disease problem anymore as long as they are eating trans fat free product. Even if trans fat are banned in restaurants, there are still other sources of trans fat in convenient stores or grocery stores. For example, numerous popular snacks, such as Barum’s Animal cracker, Premium Crackers’ Saltine Crackers, Teddy Grahams’ Graham Snacks, Snackwell’s Cookies Crème sandwich, Ritz bits cracker’ Sandwich Cheese Now all contain partially hydrogenated cotton seed oil – a kind of trans fat. However, the trans fat category in the nutrition label is labeled as 0g trans fat because the amount of trans fat in these crackers might be less than 0.5 g per serving. But how many people are actually aware of this? If a person does not read the nutrition label carefully or does not know how to read it, it is hard for them to choose which product does not contain any trans fat.

Nothing has been done in the banning of trans fat to teach the general public how to read the new nutrition label. Moreover, it was estimated that 90 million Americans do not have the skills to interpret basic health information, such as the nutrition label, in order to make a healthy choice (12). Studies have shown that men, young teens, the elderly, people with an education level of high school or below, and people who are under federal food assistance are less likely to read the food labels correctly (13). This may due to the fact that men do not care as much about nutrition as women. What they really care about is food taste (9). Young teens do not usually connect their food choices with long-term health consequences such as heart disease (14). For the elderly and people with a high school education or less, the information in the nutrition label might be too hard to comprehend or the words might be too small to read (15). For the people who are under federal food assistance, they might not understand the nutrition label due to the language barrier (16). This can result, for example, in an uninformed individual from any of these groups snacking on three Oreo cookies without knowing he or she has already consumed the recommended daily amount of saturated and total fat. Putting the content of trans fat on food packaging is like giving a tool to the general public to make healthy choice without educating them on how to use the tool.

Conclusion

There is no one simple solution to solve the heart disease epidemic. Banning trans fat alone is not enough to curb the problem of heart disease in the United States. Several other public health interventions are needed in order to see a change. Rather than focus only on trans fat, the public should approach the heart disease epidemic using several different tools. Interventions should help disadvantaged populations overcome barriers in order to achieve a desired health outcome. Also, improving dietary habits is not only a matter of what Americans eat, but the amount they consume and the choices they make. If Americans do not change their dietary behaviors, heart disease will continue to rank as the leading cause of death in the US. Effective and easy to understand education on dietary behaviors are needed. Together, there is a chance for us to win our first victory against the war of heart disease epidemic.

REFERENCES

1. Harvard School of Public Health. Trans Fatty Acids and Coronary Heart Disease. Boston, MA: Harvard School of Public Health. http://www.hsph.harvard.edu/reviews/transfats.html.

2. Food and nutrition board, institute of medicine of the national academies. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (Macronutrients). National Academies Press 2005 , 504. .

3. Cincinnati Enquirer. The Rise and Fall of Trans Fat. Cincinnati Enquirer.

http://news.enquirer.com/apps/pbcs.dll/article?AID=/20070327/LIFE01/703270316/-1/all.

4. U.S Food and Drug Administration. Federal Register Final Rule. Trans fatty acid in Nutrition Labeling, Nutrient Content Claims and Health Claims. U.S Food and Drug Administration. http://www.cfsan.fda.gov/~lrd/fr03711a.html

5. Putnam, J., J. Allshouse, L.S. Kantor. US per capita food supply trends: More calories, refined carbohydrates, and fats. USDA, Economic Research Service. Food Review 2002. 25: 2-15.

6. Drewnowski A, Specter. Poverty and obesity: the role of energy density and energy costs. Am. J. Clinical Nutrition 2004; 79: 6 - 16.

7. United States Department of Agriculture. Supermarket Characteristics and Operating Costs in Low-Income Areas. Economic Research Service, 2004.

8. Nutrition and Well Being A-Z. Dietary Trends, American- Dietary patterns, Sweet, quick, and easy, Nutrition Adequacy. http://www.faqs.org/nutrition/Diab-Em/Dietary-Trends-American.html.

9. Leap D. America’s War With Obesity. theTRUMPET.com. 2001. http://www.thetrumpet.com/print.php?id=543.

10. Cho S, Dietrich M, Brown C, Clark C, Block G. The Effect of Breakfast Type on Total Daily Energy Intake and Body Mass Index: Results from the Third National Health and Nutrition Examination Survey (NHANES III). Journal of the American College of Nutrition . 2003; Vol. 22 :No. 4, 296-302.

11. Snock C. Snack Attack: Taming The Urge To Overeat!. L&T Health and Fitness.

http://www.ltwell.com/healthy_eating.htm

12. Blackburn GL. Teaching, learning, doing: best practices in education. American Journal of Clinical Nutrition. 2005; 82(1 Suppl):218S-221S.

13. Satia A, Galanko J, Neuhouser M. Food Nutrition Label Use Is Associate with Demographic, Behavioral, and Pyschosocial Factors and Dietary Intake among African Americans in North Carolina. Journal of the American Dietetic Association. 2005; Vol 105(3): 392-402.

14. International Food Information Council. Label Matters: Teaching Teens About the New Food Label. http://www.ific.org/publications/other/tnfloverview.cfm?renderforprint=1.

15. Kristal AR. Levy L. Patterson RE. Li SS. White E. Trends in food label use associated with new nutrition labeling regulations. American Journal of Public Health. 1998; 88(8):1212-5.

16. Boehl T. Linguistic Issues and Literacy Barriers in Nutrition. Journal of the American Dietetic Association. 2007; Vol. 107: Issue 3, Page 380,383.

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