Knowledge Brief Health, Nutrition and Population Global Practice TRANS FAT ELIMINATION Bethany Warren & Kate Mandeville September 2022 KEY MESSAGES: Why eliminate trans fats? Trans-fatty acids (trans fats) are harmful to human health • Artificial trans fats are toxic, unnecessary and an unnecessary ingredient that provide no nutritional chemicals that increase the risk of heart attack value. Their consumption is estimated to cause more than and death. Consumption causes 540,000 500,000 deaths every year globally – most of which are in deaths each year globally, similar in magnitude low- and middle-income countries (Figure 1). This annual to deaths from malaria and HIV/AIDS burden is similar in magnitude to deaths from malaria and • Trans fats are added to processed foods for HIV/AIDS. Trans fat consumption increases the risk of heart attack and death. They raise LDL (bad) cholesterol commercial benefit (e.g., to extend shelf life) and lower (HDL) good cholesterol. Eliminating artificial and commonly found in baked and fried foods, trans fats is also cost effective –it is a simple intervention snack food products, and cooking oils and that saves lives, money, and scarce health resources, spreads boosting countries’ human capital and productivity. • It is feasible to eliminate artificial trans fats by replacing them with healthier alternatives BOX 1. WHAT ARE TRANS FATS? without altering taste or increasing cost, and many countries have done so Artificial trans fats are unnecessary artificial • 2/3 of the world’s population is not yet covered compounds in processed foods. They are industrially- by effective policy. Albeit 94% of policies produced, meaning they are man-made compounds enacted have been in high- and upper-middle that are added during processing for commercial income countries, some low- and middle- benefit (e.g., cost savings, longer shelf life). Artificial income countries are starting to consider it, trans fats were first introduced in the early 20th century as a replacement for butter and lard. especially given 80% of annual deaths from trans fats occur in low- and middle-income Partially hydrogenated oils are the main source of countries artificial trans fats. These are created through a • Implementing this cost effective, relatively process that adds hydrogen to liquid vegetable oils to straightforward policy intervention globally make them more solid. would save 17.5 million lives and healthcare Artificial trans fats are commonly found in baked and costs, boosting countries’ human capital and fried foods (e.g., biscuits, pies, french fries, chicken productivity nuggets, donuts), snack food products, and cooking oils and spreads (e.g., ghee, margarine, vegetable shortening). Page 1 HNP GP Knowledge Brief • Figure 1. Low- and middle-income countries account for 80% monounsaturated fatty-acids is also helpful for health of annual deaths due to trans fat intake (e.g., canola oil, peanut oil). WITHIN A COUNTRY Countries can use the REPLACE action framework (Review, Promote, Legislate, Assess, Create, Enforce). This is a roadmap to implement the complete and sustained elimination of industrially produced trans fats from the food supply. It provides practical, step-by-step implementation guidance to support governments, such as how to: ‒ Develop and implement best-practice policies to set mandatory limits for industrially produced trans fats to 2% of oils and fats in all foods or to ban partially hydrogenated oils ‒ Invest in mechanisms to measure and monitor trans fats in foods (e.g., lab capacity) ‒ Advocate for regional or sub-regional regulations ‒ Handle the challenges of enforcement– especially in countries with large informal food sectors and how reformulation of available products and Source: Resolve to Save Lives, adapted from Wang et al., 2016. monitoring can help ‒ Provide government support to: (i) industry to What does it mean to eliminate trans support reformulation; and (ii) to scale suitable replacements (which are country-specific) fats? Global recommendations suggest that trans fat intake should be limited to less than 1% of total energy intake – BOX 2. WHY MANDATORY APPROACHES? which is less than 2.2 g/day with a 2,000-calorie diet. Voluntary efforts and labelling approaches can lead to There are two best practice policies for countries to adopt reductions– but are not impactful enough. For and implement to eliminate industrially-produced trans example, in New York City, voluntary efforts to reduce fats from the food supply. The first is to institute a trans fat exposure by asking restaurants to use other mandatory national limit of 2 grams of industrial trans fats products had no impact after a one-year intervention, per 100 grams of total fat in all fats, oils, and foods. The and regulatory action to ban trans fats resulted in rapid second is to have a mandatory national ban on the and near-complete elimination. Research in six production or use of partially-hydrogenated oil as an European countries that had introduced voluntary ingredient in all foods. trans fat reductions (Slovenia, Croatia, Serbia, Bosnia, How can trans fats be eliminated? and Herzegovina) found high concentrations of industrially-produced trans fats still present in many WITHIN A FOOD different brands of biscuits, cakes and wafers after two Healthier alternatives to artificial trans fats exist that do years (Stender et. al, 2016). Mandatory limits and not affect taste or cost of food. Experience from food bans are best practice and are most effective policies manufacturing shows that is possible to eliminate artificial for trans fat elimination. trans fats, although it may take two to three years for certain foods. See Box 3 for more detail on how Thailand Where have trans fats been eliminated to pursued mandatory elimination of trans fats. date? The greatest health benefit to eliminating artificial trans There has been progress globally, but 2/3 of the world’s fats is obtained when they are replaced by oils rich in population is not yet covered (Figure 2). 94% of policies healthier polyunsaturated fatty acids (e.g. sunflower oil, have been implemented in high- and upper-middle- safflower oil, soybean oil, walnuts). Replacement with income countries, particularly in the Americas and Europe (Figure 3). Page 2 HNP P Knowledge Brief Figure 2. Number of countries that passed best practice elimination policies – 2/3 of the world’s population is not yet covered Source: https://extranet.who.int/nutrition/gina/en/scorecard/TFA; Resolve to Save Lives Only three low- and middle-income countries have Figure 3. Countries with mandatory partially hydrogenated mandatory policies – Thailand, South Africa, and India. oil bans or trans fat limits passed or in effect, by income Yet 80% of annual deaths from trans fats occur in low- level and middle-income countries. WHO maintains a map of trans fat elimination policy progress. 40 What is the evidence? 35 38 HEALTH BENEFITS 30 Elimination of artificial trans fats has substantial health 25 benefits – ranging from reducing LDL (bad) cholesterol, increasing HDL (good) cholesterol to reducing 20 cardiovascular disease events and deaths. For example, in Denmark, eliminating artificial trans fats from food 15 reduced deaths from cardiovascular disease by 6% in 10 men and 5% in women between 2004 and 2006. It also 13 averted 75 deaths for every 100,000 people aged 55 or 5 older (Restrepo and Rieger, 2016). In New York State, 3 0 people living in counties with artificial trans fat restrictions 0 in restaurant food had a 6% greater decrease in hospital HIC UMIC LMIC LIC admissions from heart attacks and strokes than people in Source: https://extranet.who.int/nutrition/gina/en/scorecard/TFA; counties without restrictions three years after Resolve to Save Lives implementation (Brandt et al., 2017). COST EFFECTIVENESS effectiveness of trans fat elimination policies as well. A Elimination of artificial trans fats has substantial health ban on trans fats in Australia was estimated to prevent Elimination of artificial trans fats is also cost effective – around 40,000 deaths, gain 100,000 health-adjusted life saving lives, money, and scarce health care resources. In years, and be cost saving or highly cost-effective Argentina, restricting artificial trans fats to 2% of fats and (Marklund et al., 2020). In the United Kingdom, reducing oils saved between 300 to 1,500 lives and averted industrial trans fats from 0.8% to 0.4% of daily energy between 1,100 to 5,300 heart attacks and related intake was estimated to result in GBP 100 million (US$ episodes (1.3 to 6% of total coronary heart disease 147 million) saved in direct health care costs (which events) and saved US$17 to 84 million in health care doubled when eliminating all trans fats; Pearson-Stuttard expenses (Rubinstein et al., 2015). Modeling studies in et al., 2016). Results from both countries demonstrated Australia and the United Kingdom demonstrated the cost reductions in health inequities. Page 3 HNP GP Knowledge Brief • Medicine,157(2):81-6. BOX 3. CASE STUDY: TRANS FAT ELIINATION Brandt, Myerson, et al., 2017. Hospital admissions for myocardial SUCCESS IN THAILAND infarction and stroke before and after the trans-fatty acid restrictions in New York. JAMA Cardiol, 2(6): 627-634. Brownell and Pomeranz, 2014. The Trans-fat ban—food regulation and In 2018, Thailand enacted a ban on partially long-term health. New England Journal of Medicine, 370:1773- hydrogenated oils to stop the production and importation 1775. of foods with high levels. To do so, Thailand focused on Downs et al., 2013. The effectiveness of policies for reducing dietary the supply chain and worked with the small number of trans fat: a systematic review of the evidence. Bull World Health Organ, 91(4): 262-269H. partially hydrogenated oil producers in the country to NCD Alliance, Trans fat free by 2023: Case studies in trans fat adapt their manufacturing processes and find elimination. Available at: replacements. https://ncdalliance.org/printpdf/resources/transfatfree2023report [Accessed June 22, 2022]. Key factors important for policy enactment and Restrepo and Rieger, 2016. Denmark's policy on artificial trans fat and cardiovascular disease. Am J Prev Med, 50(1): 69-76. implementation included: (i) accurate data collection of Rubinstein et al., 2015. Eliminating artificial trans fatty acids in trans fats in the food supply; (ii) continuous Argentina: estimated effects on the burden of coronary heart communication among stakeholders including the disease and costs. Bull World Health Organ, 93(9): 614-622. Perason-Stuttard et al., 2017. Cost-effectiveness of eliminating industrial government, food and oil producers and importers, and and all trans fats in England and Wales: modelling study. J researchers; and (iii) food companies’ readiness for Public Health, 39(3):574-582. change. For further detail on this case study or other Marklund et al., 2020. Estimated health benefits, costs, and cost- examples in Chile, Saudi Arabia, Slovenia, South Africa, effectiveness of eliminating industrial trans-fatty acids in Australia: a modelling study. Plos Medicine, 17(11):e1003407. and the United States of America, please see the full NCD Alliance. Trans fats elimination. Available at: case study report published by the NCD Alliance. https://ncdalliance.org/why-ncds/risk-factors-prevention/trans- fats- Conclusion elimination#:~:text=Global%20elimination%20of%20iTFA%20wi ll,people%20from%20this%20toxic%20substance [Accessed Implementing this cost effective, relatively straightforward September 28, 2022] policy intervention will save lives and healthcare costs, Stender et al., 2016. Artificial trans fat in population foods in 2012 and 2014: a market basket investigation in six European countries. boosting productivity and human capital. BMJ Open, 6(3):e010673. UNAIDS, Global HIV & AIDS statistics—fact sheet. Available at: https://www.unaids.org/en/resources/fact-sheet [Accessed June Acknowledgements 22, 2022]. Wang, A., et al., 2016. Impact of nonoptimal intakes of saturated, polyunsaturated, and trans fat on global burdens of coronary heart disease. Journal of the American Heart Association, 5(1). World Health Organization, Countdown to 2023: WHO Report on global trans fat elimination 2019. Available at: https://resolvetosavelives.org/assets/Resources/REPLACE- Adapted in part from materials developed by Resolve to Global-Progress-Report.pdf [Accessed June 22, 2022]. Save Lives, a not-for-profit organization partnering with World Health Organization, Replace: Trans fat free by 2023. Available countries, communities, and organizations to prevent 100 at: https://www.who.int/teams/nutrition-and-food-safety/replace- trans-fat [Accessed June 22, 2022]. million deaths from cardiovascular disease and make the World Health Organization, Replace trans fat – frequently asked world safer from epidemics. To found out more, visit questions. Available at: https://resolvetosavelives.org or Twitter @ResolveTSL. https://resolvetosavelives.org/assets/Resources/REPLACE_FA Qs.pdf [Accessed June 22, 2022]. This brief was funded by the World Bank Group’s Tackling World Health Organization, TFA country score card. Available at: https://extranet.who.int/nutrition/gina/en/scorecard/TFA of Non-Communicable Diseases Challenges in Low- and [Accessed June 22, 2022]. Middle-Income Countries Multi-Donor Trust Fund (Trust World Health Organization, World malaria report 2021. Available at: Fund No. 072759), supported by Access Accelerated, and https://www.who.int/publications/i/item/9789240040496 the Nutrition Global Solutions Group. [Accessed June 22, 2022]. References American Heart Association, Trans fats. Available at: https://www.heart.org/en/healthy-living/healthy-eating/eat- smart/fats/trans-fat [Accessed June 22, 20222]. Angell, et al., 2012. Change in trans fatty acid content of fast-food purchases associated with New York City’s restaurant regulation: a pre-post study. Annals of Internal The Health, Nutrition and Population Knowledge Briefs of the World Bank are a quick reference on the essentials of specific HNP-related topics summarizing new findings and information. These may highlight an issue and key interventions proven to be effective in improving health, or disseminate new findings and lessons learned from the regions. For more information on this topic, go to: www.worldbank.org/health. Page 4