Challenging Dogma - Fall 2007

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

Tuesday, December 11, 2007

Banning Trans Fats: A Flawed Public Health Approach - Alicia Lazzaro

There is no doubt that trans fats are unhealthful and confer an increased risk of coronary heart disease, however, banning trans fats is a flawed public health approach. The current trend of banning trans fats is counterproductive as it facilitates foods being deemed as healthy while masking their inherent unhealthfulness, thus deceiving the public. The problem lies in the communication of the “trans fat-free” message. Trans fat bans fail because of the way the issue is framed. Secondly, public health's use of the media has led to the distribution of incomplete information about trans fats. Finally, public health's use of the power-coercive approach is not appropriate with respect to trans fats and does not serve the public's best interest.  

Trans fats are unsaturated fatty acids with at least one double bond and are formed through the partial hydrogenation of vegetable oils. Hydrogenation converts vegetable oils into semi-solid fats that can be used in margarines, shortenings, commercial cooking/baking, and food manufacturing. Trans fats, also known as partially hydrogenated vegetable oils, are stable for deep-frying, have a long shelf life, and improve the palatability of baked goods (1). In addition to the production of artificial trans fats, a small amount of trans fat is also formed in the gastrointestinal tract of cattle, causing low levels of naturally occurring trans fat to be present in dairy and beef fat (2). The vast majority of trans fats consumed are via artificial trans fats, which are present in foods containing stick margarine or vegetable shortening. The major sources of trans fats in the United States (U.S.) food supply are deep-fried fast foods, bakery products, packaged snack foods, and margarines (1).

Commercial production of trans fats commenced in the early 20th century. Production progressively increased through the 1960’s and partially hydrogenated vegetable fats gradually took the place of animal fats in the diets of Americans. The initial driving force for using trans fats was lower cost, however health benefits were later claimed for margarine as a substitute for butter (2). Before the 1980’s, in general there was very little concern regarding the trend of increased intake of partially hydrogenated fat in the American diet, particularly when the trans fats replaced fats high in saturated fatty acids in the diet. During the 1980’s, research studies in animals demonstrated a hypercholesterolemic effect of trans fats and starting in the 1990’s, there was increased attention paid to the topic of trans fat intake in human diets (3). Consumption of trans fats is now known to increase the risk of coronary heart disease. Research indicates that a two percent increase in calories consumed from trans fats is associated with a 23% increase in the incidence of coronary heart disease (1). Trans fats have a marked adverse effect on serum lipids by raising levels of low-density lipoprotein cholesterol (“bad cholesterol”) and decreasing levels of high-density lipoprotein cholesterol (“good cholesterol”) (2).

One of the key recommendations in the U.S. Department of Agriculture’s Dietary Guidelines for Americans issued in 2005 is to limit trans fat intake by keeping trans fat consumption as low as possible (4). On January 1, 2006, the U.S. Food and Drug Administration (FDA) began requiring that nutrition labels for foods indicate the content of trans fat (1). However, foods that contain less than 0.5 grams of trans fat per serving can list the content of trans fat as zero by means of rounding. Additionally, the FDA’s mandatory labeling of trans fats does not apply to food served in restaurants, unless nutrient claims are made for a food product such as “low fat” or “low sodium” (5).

On December 5, 2006, the New York City (NYC) Board of Health ratified an amendment to phase-out artificial trans fat in all NYC restaurants (over 20,000). This amendment requires by July 1, 2008, that all foods served in NYC restaurants must have less than 0.5 grams of trans fat per serving if they have any artificial trans fat (6). The passing of the nation’s first municipal ban of artificial trans fats in NYC has kicked off the trend towards banning trans fat in cities nationwide (7). Philadelphia has followed NYC’s lead and has banned trans fats, as did Seattle, WA and Brookline, MA, and Chicago has a proposed ban of trans fats. The list goes on of cities across the U.S. that are considering banning trans fat in restaurants (8).

Trans Fats Are Framed in a Misleading Fashion
Framing theory can be invoked to partially explain why trans fat bans are a flawed approach. A frame is defined as a conceptual structure involved with thinking and framing is a process of having selective influence over an individual’s perception of the meaning attributed to words or phrases (9-10). The way an issue is framed can encourage a certain interpretation of a concept and discourage other interpretations. Trans fat bans fail because of the way this issue is framed. The information about trans fats that is being put forth by various boards of health, city governments, and the media is stated, or framed, in such a way that indicates trans fats are a single bad nutrient and if removed the healthfulness of a food is dramatically improved. However, the issue has not been framed to include the idea that by removing one unhealthy aspect, the trans fat in this case, food does not necessarily become healthy.

The way trans fats have been framed has misled the public because of the approach that has been taken, which has been to highlight just trans fat content and not emphasize other undesirable nutrients or ingredients in food such as saturated fat, sodium, cholesterol, refined grains, or added sugar. Michael Bloomberg, Mayor of NYC and proponent of the recent ban of trans fats in NYC is quoted as saying, “Nobody wants to take away your French fries and hamburgers – I love those things, too. But, if you can make them with something that is less damaging to your health, we should do that” (11). The message being conveyed here is that once the trans fat is removed from food, this is a license to eat anything you want without consequence. Additionally, cities that have banned trans fat are not heavily publicizing the fact that foods may be deemed trans fat-free even though they still contain a small amount of artificial trans fat (less than 0.5 grams). If a person consumes many servings of a product that contains 0.45 grams trans fat per serving, they will still be taking in a considerable amount of trans fat.

BanTransFat.org is the organization that claims to have started the national campaign to ban trans fat by suing Kraft Foods Inc. in 2003 to eliminate trans fats from Oreos. In a question and answer portion of their website, BanTransFat.org is quick to mention that, “Every food that is on the market today, including French fries, fried chicken, fried fish, and yes – donuts, will continue to be just as available as they are today” (8). Another section of their website praises a bakery and a funnel cake factory for not using trans fats and then shows a picture of donuts with the following statement directly below it: “Fried in trans fat-free, low saturated fat canola oil and just perfect” (8). While canola oil is a healthier fat than partially hydrogenated vegetable oil, this does not mean donuts are a healthy food. An article in the Boston Globe notes that trans fat is the “bad boy of the fat world” (but has no mention of saturated fat and its adverse effect on blood lipids) and quotes a chef as saying “now that we got rid of the trans fat, people won’t feel guilty about eating French fries” (12). Dr. Dariush Mozaffarian, a professor in the Department of Epidemiology at Harvard School of Public Health is quoted as saying that trans fats are "the most dangerous ingredient in our diet" (13). This portrayal of trans fats ignores the fact that a healthy eating pattern must consider much more than just one factor. You cannot just eliminate trans fats and make a donut or French fries healthy, however this is how BanTransFat.org, various media outlets, elected officials, and even public health professionals have framed the issue.

Public Health's Use of the Media Has Led to the Distribution of Incomplete Information About Trans Fats
According to the Agenda Setting Theory, mass media determines what is perceived as important and delivers topics they deem newsworthy. This focus on particular issues by dedicating a lot of time and space in the news media makes certain issues more accessible to the public (14). The passing of NYC’s ban in December 2006 propelled trans fats to front-page news at a national level. Public health took advantage of being in the media spotlight, but the message they provided about trans fat was limited and focused solely on getting rid of trans fat in restaurants. This perpetuated the misconception of trans fats in the media by sending a message that foods free of trans fats are healthy. The media’s focus on trans fat further boosts the issue onto the public agenda. However, the material provided and emphasized by public health authorities and presented by media outlets has resulted in the public not receiving the full story on trans fats. Therefore, trans fat bans fail because public health has provided incomplete information to the media outlets, resulting in erroneous conclusions being drawn by the public. Consequently, the public falsely equates eating trans fat-free foods with being healthy.

According to the Agenda Setting Theory, the media does not reflect reality, they filter and shape it (14). Public health doesn’t provide the media and subsequently the public with enough information to understand that the types of foods in which trans fats are found are often not healthy choices for reasons aside from their trans fat content. This causes the public to wrongly conclude that trans fat-free products are healthier and less caloric. In actuality, if the trans fat in a product is replaced with the same amount of a different type of fat, even a healthier unsaturated fat, it will still have the same amount of fat and calories. Misinformation about trans fats may actually lead an individual to consume more calories and/or saturated fat. An article in the San Diego Union Tribune reports on Starbucks’ plan to eliminate trans fats from its baked goods (15). Starbucks is being praised here for eliminating trans fats, which in turn may cause the public to go to Starbucks and eat more pastries than they may have in the past now that these foods are free of trans fat. A Washington Post article quotes a NYC doctor who urges people to avoid fried foods and order fruit for dessert when eating out “until that law takes effect” (referring to the ban on trans fats in NYC) (16). Here, the message conveyed is that once trans fats are not present, people can go back to eating high calorie, high fat desserts and fried foods.

Agenda Setting Theory also suggests that media concentration on a few issues and subjects leads the public to perceive those issues as more important than other issues (14). Public health uses the media to focus on trans fat, rather than healthy eating in general. In NYC’s Department of Health and Mental Hygiene proceedings posted on their Internet site, it states, “eliminating artificial trans fat from the menus of New York City's restaurants is necessary to protect diners from this hazardous substance and reduce their risk for cardiovascular disease” (17). Here only trans fats are pinpointed as a risk factor for heart disease. Statements in the media that single out trans fats as a major contributor to heart disease can cause the public to overlook other important risk factors for heart disease such as obesity, hypertension, smoking, and consumption of saturated fats (18).

The Power-Coercive Approach Utilized with Trans Fats is Inappropriate and Undesirable
The power-coercive approach relies on influencing individuals and systems to change through legislation (19-20). This approach forces the public to adopt a change, rather than educating them on why a change is needed. The power-coercive approach does not communicate a message that educates the public about appropriate alternatives to trans fats. While trans fat bans help to decrease the public’s intake of trans fats, bans of trans fats may actually increase intake of saturated fats and total calories, which could contribute to higher rates of heart disease and obesity (21).

Trans fat bans put food service establishments in an ill-prepared position to make appropriate decisions in choosing healthy alternatives to trans fats. In an effort to comply with the ban, a restaurant may switch to a different type of fat which also has unhealthful effects (e.g. saturated fats) (22). The trans fat bans in place now in the U.S. do not mandate that healthy alternatives (those low in saturated fat) be used to replace trans fat. In the NYC ban, there is no provision requiring trans fat to be replaced with a healthier alternative; in fact, butter or lard are allowable substitutes (23). With a ban come deadlines by which restaurants need to rid themselves of trans fats. The pressure to comply with bans by a certain deadline date and desire to avoid fines and citations, may not allow the restaurant ample time to fully understand the reasoning for the ban. There is a disincentive to finding an appropriate healthful solution when a deadline is pending. In addition to choosing an unhealthy alternative to trans fat, in order to comply with a trans fat ban, a bakery, for example, may reduce the portion size of a cookie (or other food) so that it contains less than a 0.5 grams of trans fat per serving, without changing the ingredient content of that cookie (24). Here, people would likely eat more of the smaller cookies and would unknowingly consume the same, if not more trans fat depending on how many cookies they consume.

Since a trans fat ban does not educate the public, individuals can’t translate the purpose of the ban into their everyday life. The bans of trans fats that have been passed do not apply to grocery stores. While foods on grocery store shelves must be labeled to indicate trans fat content, if the public is uneducated on how to know if there is trans fat in a product, or how to read a nutrition label or ingredient list to look for trans fat, or why they should even care, a person will not be able to apply the goals of the ban to their life outside the walls of a restaurant. Even if a consumer does know how to read a nutrition label, if they are not fully educated on why they should avoid trans fats, they may not base their decisions on the information provided on the nutrition label (1). The trans fat ban that Chicago is considering would apply only to large restaurants (those that gross $20 million or more per year) and is specifically targeted at fast-food and other chain restaurants (11,25). In this case, although consumers may eat less trans fats while at large restaurants and fast-food outlets, without education, customers won’t know how to go to a smaller restaurant and avoid foods that contain trans fat.

The power-coercive approach does not serve the public’s best interest, as establishing laws to ban trans fats does not wholly educate consumers to the purpose of the ban and does not help to promote healthier alternatives to trans fats. Therefore, a rational-empirical approach, one which strives to change public behavior through education, would be more appropriate in communicating the desired message regarding trans fats and suitable alternatives. There are some cities that have decided to take a rational-empirical approach to trans fats by educating the public about this topic (19-20). For example, in November 2006, Cambridge, MA decided not to regulate trans fat use, but rather to use a rational-empirical approach to the issue by developing an education program aimed at educating restaurant owners and staff about trans fats and alternatives to trans fats that are unsaturated for use in cooking, frying, and baking. Cambridge strives to incorporate education of trans fats into the city’s overall obesity prevention strategy. The city of Cambridge also views this as an opportunity to work with the restaurant community to build a lasting relationship (26). The rational-empirical approach used here is more suitable to providing information to the public about trans fat. Educating the public, as opposed to imposing a law, is more likely to facilitate a more complete and accurate transmission of information about trans fats.

Implications and Recommendations for Future Public Health Programs
Any public health initiative must be tailored to the needs of those within its target audience. Information must be accurately portrayed and distributed to the public in a manner that carefully conveys the intended message. As seen with trans fat bans, misinformation can lead to poor health decisions. Ultimately, this leads to not meeting the goal intended for the trans fat bans, which was to decrease consumption of unhealthy fat in order to prevent heart disease.
Mandated bans are not appropriate for certain public health issues. Chin and Benne state that “some of the difficulty with the use of political institutions to effect changes arises from an overestimation by change agents of the capability of political action to effect change in practice” (19). With trans fat bans, city officials supporting and passing the bans have overestimated the ability of such a ban to lead the public to consume healthier alternatives. While trans fat bans bar trans fat from restaurants this does not necessarily guarantee that the public will consume a healthier diet.

REFERENCES
1. Mozaffarian D, Katan M, Ascherio A, Stampfer M, & Willett W. Trans fatty acids and cardiovascular heart disease. N Engl J Med 2006; 354:1601-1613.
2. 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.
3. Institute of Medicine of the National Academies. Letter report on dietary reference intakes for trans fatty acids. Washington, DC: Institute of Medicine of the National Academies. http://www.iom.edu/Object.File/Master/13/083/TransFattyAcids.pdf.
4. U.S. Department of Health and Human Services & U.S. Department of Agriculture. Dietary guidelines for Americans 2005: Chapter 6 Fats. Washington, DC: U.S. Department of Health and Human Services & U.S. Department of Agriculture. http://www.health.gov/dietaryguidelines/dga2005/.
5. U.S. Food and Drug Administration. Questions and answers about trans fat nutrition labeling. Washington, DC: U.S. Food and Drug Administration. http://www.cfsan.fda.gov/~dms/qatrans2.html#s2ql.
6. New York City Department of Health and Mental Hygiene. Take the trans fat out of New York. New York, NY: Department of Health and Mental Hygiene. http://www.nyc.gov/html/doh/html/cardio/cardio-transfat.shtml.
7. Lueck T, & Severson K. New York bans most trans fats in restaurants. New York City, NY: The New York Times. http://www.nytimes.com/2006/12/06/nyregion/06fat.html?ex=1188619200&en=729d56519a787a7b&ei=5070.
8. BanTransFats.com, Inc. Ban trans fats. California: BanTransFats.com, Inc. http://www.bantransfats.com/index.html.
9. Chua K. Introduction to framing. Reston, VA: American Medical Student Association. http://www.amsa.org/uhc/FramingIntro.pdf.
10. Wikipedia. Framing (social sciences). St. Petersburg, FL: Wikimedia Foundation Inc. http://en.wikipedia.org/wiki/Framing_(communication_theory).
11. MSNBC. New York City passes trans fat ban. New York, NY: MSNBC. http://www.msnbc.msn.com/id/16051436/.
12. Stephen S. Trimming the trans fat. Boston, MA: The Boston Globe. http://www.boston.com/news/local/articles/2007/06/17/trimming_the_trans_fat/.
13. Whelan E. Trans fats: Anatomy of a scare. New York, NY: American Council on Science and Health. http://www.acsh.org/healthissues/newsID.1427/healthissue_detail.asp.
14. Wikipedia. Agenda-setting theory. St. Petersburg, FL: Wikimedia Foundation Inc. http://en.wikipedia.org/wiki/Agenda-setting_theory.
15. Davies J. Starbucks to eliminate trans fat from baked goods, pastries. San Diego, CA: The San Diego Union-Tribune. http://www.signonsandiego.com/news/nation/20070103-9999-1n3starbucks.html.
16. Gordon S. High trans fat intake triples heart disease risk. Washington, DC: Washington Post. http://www.washingtonpost.com/wp-dyn/content/article/2007/03/27/AR2007032701075_2.html.
17. New York City Department of Health & Mental Hygiene, Bureau of Intergovernmental Affairs. Intro 517: In relation to prohibiting the use of artificial trans fat by food service establishments and mobile food unit commissaries. New York, NY. New York City Department of Health & Mental Hygiene, Bureau of Intergovernmental Affairs. http://www.nyc.gov/html/doh/html/testi/testi20070301.shtml.
18. Whelan E. Demonizing trans fats. Chicago, IL: The Heartland Institute. http://www.heartland.org/Article.cfm?artId=12780.
19. Chin R, & Benne K. General strategies for effective change in human systems (pp. 22-45). In: Bennis W et al., eds. The Planning of Change (3rd edition). New York, NY: Holt, Rinehart and Winston, 1976.
20. Southwest Educational Development Laboratory. Approaches to change. Austin, TX: Southwest Educational Development Laboratory. http://www.sedl.org/change/facilitate/approaches.html#early2.
21. Levin B. Central regulation of energy homeostasis intelligent design: How to build the perfect survivor. Obesity 2006; 14:192S-196S.
22. Tarrago-Trani M, Phillips K, Lemar L, & Holden J. New and existing oils and fats used in products with reduced trans-fatty acid content. Journal of the American Dietetic Association 2006; 106:867-880.
23. Trans Fat Help Center. Summary of the regulation. New York, NY: New York City College of Technology.
http://www.citytech.cuny.edu/notransfatnyc/english/faqs.html.
24. Severson K. Trans fat fight claims butter as a victim. New York, NY: The New York Times. http://www.nytimes.com/2007/03/07/dining/07tran.html?_r=1&oref=slogin.
25. Public Broadcasting Service. Chicago City Council proposes anti-trans fats ordinance. Arlington, VA: Public Broadcasting Service. http://www.pbs.org/newshour/bb/health/july-dec06/transfats_08-16.html.
26. Cambridge Public Health Department. Response to Policy Order #17. Cambridge, MA: Cambridge Public Health Department, 2006. http://www.cambridgepublichealth.org/news/TransFat111506.pdf.

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