Access pdf of Vivica Kraak's previous commentary here
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Trans fats are mainly in processed products like stick margarines (left), baked goods like cookies (biscuits), donuts (middle), and French fries (chips) (right)

Here are some of the consequences of people and entire populations consuming artificial, industrially-generated trans-fatty acids (trans fats) in processed food products:

Substantial increase in the risk of disease and death

• Consumption of trans fats, as contained in partially hydrogenated vegetable oils, are associated with an increased risk of heart diseases, including myocardial infarction and coronary artery disease.
• Consumption of trans fats is associated with a substantially higher risk of death and of myocardial infarction compared with other dietary constituents, notably including total fat and saturated fat.

Reasons for a global ban on trans fats

• A ban will cover the full range of processed food products in any country or region.
• A ban will benefit people who do not read food labels or who live in countries where trans fats are not labelled on processed food products.
• A ban will apply equally to all processed food products, whether domestic or imported from other countries.

Now is the time to act

• A coherent strategy is needed to ban trans fats from food environments.
• Trans-fat elimination is currently not included either among the World Health Organization's 'best buys' or among the nine voluntary targets to reach the '25 by 25' goal. However, reduction of partially hydrogenated vegetable oils from food supplies was suggested as one of 25 indicators for countries to measure progress to reduce premature chronic non-communicable disease mortality.
• Public health advocates, together with UN member states, have an unprecedented opportunity to respond to the WHO's consultation to develop a Global Action Plan to Prevent Non-Communicable Diseases for 2013-2020. Now is the time to advocate for a ban on trans fats from food environments, and to work toward the goal of creating a trans-fat free world by 2025.

Other products containing trans fats: packaged candies (confectionery) and packaged cakes (left, middle), and ready-made fried fast food products (right)

In 2009, a World Health Organization (WHO) scientific committee recommended the 'virtual elimination' of trans fats from all food supplies (1). This recommendation replaced the 2003 joint WHO and Food and UN Agriculture Organization (FAO) report recommendation that advised countries worldwide to limit their population intakes of industrially produced trans fatty acids (hereafter, referred to as trans fats) to less than 1 percent of total calories a person a day (2). (For the sources of trans fats, and the harmful effects of these type of fats on human health, see Boxes 1 and 2).

Many countries, including Denmark, Australia, Austria, Costa Rica, France, Germany, the United Kingdom (UK) and the United States (US) have made good progress to reduce trans fats in their national food supplies in order to approach a mean population intake target of less than 1 per cent of total daily calories. Certain regions have made promising progress.

In 2007, the Pan American Health Organization (PAHO)/WHO) convened a task force for the 'trans Fat Free Americas Initiative'. Its purpose was to evaluate the impact of trans fats on human nutrition and health; to find practical ways to phase out trans fats from the food supplies of Latin American and Caribbean countries using regulatory and voluntary actions; and to examine the feasibility of using healthier alternative fats.

But there is still much more to accomplish. There is limited information about the extent of trans fat consumption worldwide, and a lack of systematic information about national and regional work to eliminate it. There is a pressing need to collect this information to inform policies and actions, given the rapid rise in diet-related chronic non-communicable diseases, especially in low- and middle-income countries (3). It is estimated that a decrease of 4.5 grams of trans fats a person a day could prevent approximately 30,000 to 130,000 coronary heart disease events annually (4).

The 'best buy' concept

Over the course of 2012, WHO has requested input from countries to inform a global monitoring framework and indicators to prevent chronic non-communicable diseases. This will be finalised in 2013 (5). Surprisingly, a global ban on trans fats was not recommended as one of five 'best buys', which are defined as cost-effective, affordable, and feasible to implement in low- and middle-income countries (6). Nor was elimination of trans fats specified as one of the nine voluntary targets proposed to combat premature mortality. These include: taking action on reducing the harmful use of alcohol and tobacco use; reversing physical inactivity; reducing salt/sodium intake; addressing high blood pressure and type 2 diabetes; and promoting drug therapy and counselling, medicines and technology (7). The targets are set so as to reach the WHO's goal of reducing chronic non-communicable disease mortality by 25 per cent by 2025 ('25 by 25').

Fortunately, the replacement of partially hydrogenated vegetable oils, the main generator of trans fats in the food supplies, with polyunsaturated fats was suggested as one of the 25 indicators that countries should use to measure progress to reduce premature non-communicable disease mortality (7)

In our view, the evidence shows that if there ever was a 'best buy' for the public health community to unite around, it is a global ban on trans fats (8, 9).

This commentary explores several challenges implied by the WHO recommendation that countries achieve a 'virtual elimination' of trans fats from their food supplies. These include policy, operational, strategic and logistical challenges that must be addressed in order to eliminate trans fats, so as to help reach the '25 by 25' goal.

Here we build a case for public health and nutrition professionals, practitioners and advocates to play an active role to address these challenges. We can do this by working with governments, the food industry sector, private funders, other professionals and scientists, public interest non-governmental organisations and consumer advocates. Their purpose should be to support a global ban on trans fats, in order to remove this harmful substance from our food and eating environments.

This commentary proposes that we in the nutrition, public health and associated professions are now faced with challenges that need to be addressed now. The scale of the issue is substantial, and the prospect of success is palpable. The challenges specified below are addressed to us all in relevant professions and also to us as citizens and community and family members.

We must engage with our professional societies, regulatory agencies and the UN Codex Alimentarius system, to develop and disseminate an inclusive, comprehensive and uniform definition for industrially produced trans fats.

The first major challenge, is that countries do not have a standardised and comprehensive definition for industrially produced trans fats to help them achieve 'virtual elimination'. In some countries, the definition includes both industrial and ruminant trans fats. Within Latin American countries, the definitions used for trans fats are very diverse. In Denmark, the definition excludes the naturally occurring form in products.

The US and Canadian regulatory agencies define trans fats as'isomers of monounsaturated and polyunsaturated fats that contain one or more isolated or non-conjugated…double bonds in the trans configuration.' In other words, the hydrogen atoms linked to the carbon atoms on both sides of the double bond have an opposite position with respect to the double bond. This definition is consistent with the UN Codex Alimentarius definition of trans fats.

For the purpose of the Codex Guidelines on Nutrition Labelling and other related Codex standards and guidelines, trans fats are defined as 'all the geometrical isomers of monounsaturated and polyunsaturated fatty acids having non-conjugated, interrupted by at least one methylene group, carbon-carbon double bonds in the trans configuration.'In all these definitions, conjugated linoleic acid (CLA) is not included in the trans fat definition.

However, very remarkably the Codex Guidelines on Nutrition Labelling (CAC/GL 2-1985; adopted in 1985 and most recently amended in 2012) still does not include trans fats in the list of mandatory nutrients that must be declared in nutrition labelling. Instead, the guidelines state that 'countries where the level of intake of trans fats is a public health concern should consider the declaration of trans fats in nutrition labelling.' Such a voluntary recommendation for the labelling of trans fats does little to support trans-fat reduction efforts if only because many countries do not have trans-fat intake data.

The use of partially hydrogenated oil in food production and preparationstill remains on the US Food and Drug Administration (FDA) Generally Recognized as Safe (GRAS) list (10) despite requests that petitioned the FDA to remove it in 2010 (11). The Centers for Disease Control and Prevention has requested the food industry voluntarily to eliminate partially hydrogenated oils in all food production and preparation (12). This may stimulate FDA action to re-evaluate the trans-fat definition and its inclusion on the GRAS list.

In the US and some Latin American and Caribbean countries, a product labelled 'zero trans fat' or 'trans-fat free' should provide consumers with truthful and non-misleading information. However, these countries use the FDA definition whereby 'zero trans fat' allows anything for less than 0.5 grams trans fats per portion or serving to be labelled 'zero'. The reasoning for this decision is described below.

In 2010, the FDA acknowledged that trans fats occur naturally in animal-source food such as dairy products and meat from ruminants. Although data are limited, naturally occurring trans fats do not appear to have adverse human health effects. Because it is difficult to distinguish between ruminant sources and industrial sources produced by partially hydrogenated oils, and it would be impossible and undesirable to eliminate ruminant sources from the US food supply, the FDA concluded that 'consuming zero trans fats would require substantial adjustments to the diet that may have undesirable effects' (11). Based on this reasoning, the FDA set an industrially produced trans-fat threshold at less than 0.5 grams per serving as being equivalent to zero for labelling purposes. In contrast, in the Canadian food regulatory system, food products can only be declared 'trans-fat free' if the content is less than 0.2 grams a portion or serving, and the saturated fat content is less than 2.0 grams per reference amount or serving size.

To translate these food limits into reduced population intakes of trans fat, the Task Force for a trans Fat Free America Initiative recommended that countries adopt a limit of less than 2 per cent of total fat as trans fat in vegetable oils, soft margarines and spreads, and less than 5 per cent for all other foods, as well as to encourage complementary measures such as nutrition labelling.

Finalising a uniform definition for trans fat is crucial to advise countries on product labelling, to ensure that consumers understand nutrition labels across international borders, to accelerate healthy product reformulation by industry, and ultimately to eliminate trans fats from the global food system.

This is a timely issue that the Codex Alimentarius Commission should address when it convenes in Germany this month, early December 2012. Its purpose is to develop a more comprehensive definition for countries to standardise food product labelling within and across international borders while harmonising these issues with existing free-trade agreements (13, 14).Until Codex approves a more comprehensive definition, regulatory agencies such as the FDA cannot assure consumers that this type of fat will be removed from products labelled 'zero trans fat' or 'trans-fat free.' Other countries may encounter a similar situation because they must work through their national regulatory agencies. Therefore, it is essential that Codex standardises analytical methods to identify and quantify trans fats, and provides an inclusive definition for trans fats and trans-fat free, to enable consistent labelling and monitoring across countries.

We must work with governments to prioritise trans-fat elimination on policy agendas.

The second challenge is political. Specifically, it requires bold leadership and a political commitment by national governments to prioritise trans-fats elimination on their national policy agendas, and to use all possible policy tools to eliminate trans fats from their food environments. These tools include 'hard' policy approaches (meaning, enacting comprehensive mandatory legislation, empowering regulatory agencies, institutionalising a monitoring system, litigating to protect public health).They also can be combined with 'soft' policy approaches (such as investment in education awareness and behavioural change campaigns and supporting voluntary partnerships that produce specific outcomes) (15, 16, 17).

Mandatory food labelling is important legislation for governments to enact because this raises consumers' awareness about the health risks of substantial trans-fats consumption, and may accelerate food industry-wide product reformulation and product disclosures faster than would occur through only voluntary measures.

National governments should lead the effort to phase out trans fats in the global food supply. As public health, nutrition or allied professionals, we must work with governments to facilitate this goal. It requires that governments promote a phased plan for food-sector businesses of all sizes to eliminate trans fats and substitute healthier oils and fat alternatives in their products. A global ban on trans fats may be financially painful for transnational corporations and national and small companies alike. Changes must be coordinated among all industry sub-sectors including suppliers, manufacturers, caterers and retailers, for all product categories.

Industry has reformulated products in countries where regulations have been established and enforced. The costs of labelling changes, surveillance of population intakes and monitoring changes in food environments should be shared by government and industry, to ensure that reformulated products meet healthy dietary guidelines. The mass media plays a key role in framing issues and alerting citizens about the various roles that the government, food industry, civil society organisations and consumers have in responding to the problem (18). Heightened consumer and citizen awareness about the risks and harmful effects of trans fats can help to facilitate the removal of trans in food products (8).

Therefore, designing comprehensive public health communications campaigns must be a priority for governments and for public health professionals with expertise in these areas. Campaigns will need to be adequately planned with multi-level strategies (for example, raising awareness at hospitals, conveying messages to children in schools, influencing food preparation in schools and in government facilities). These campaigns and programmes will need to be sustained for several years to change purchasing and eating behaviours. Such campaigns can be funded with public as well as private funds, and educational activities will require joint planning between many relevant actors.

Governments and civil society groups need to build public support for a global ban on trans fats, which may include sensitising consumers to the rationale for the ban, anticipating societal responses, and preparing for resistance and regulatory backlash (8, 9, 19). Government agencies and institutions can show leadership by establishing institutional policies that support trans-fat elimination, providing clear criteria and a timeline for food vendors and caterers to eliminate trans fats, and communicating with and educating staff about their expectations (20).

We must encourage and support governments to measure and monitor the trans-fat intake in populations with the assistance of research institutions, the food industry, and public-interest non-government organisations.

Governments must measure and monitor the trans-fat intakes of the general population, as well as of at-risk sub-groups who are more likely to eat foods prepared with cheaper partially hydrogenated oils (1, 12). Some countries have conducted cross-sectional studies or have monitored the trans-fat consumption trends for populations. trans-fat intake can vary widely, ranging from 0.1-0.6 grams a person a day in Korea and Japan (21), to 12.3 grams a person a day in Iran (22) and 2.6 grams a person a day in Costa Rica (23).

However, there is still limited information about the extent of trans-fat consumption worldwide such as in South Asian countries(for example, Sri Lanka, Malaysia, Indonesia and the Philippines)where the use of hydrogenated and partially hydrogenated vegetable oils for cooking traditional dishes is common (24). There have been efforts to understand barriers, such as a lack of intersectoral collaboration, to monitor population intakes and trans-fats changes in the food supply in middle-income countries such as Mexico (25) and Costa Rica (26).

While there is awareness about the importance of monitoring more than the mean population's trans-fat intake, many countries do not have adequate resources or the expertise to conduct rigorous and systematic surveillance (1, 15, 16).Our role as health professionals, working with allies in associated fields, should be to find creative and sustainable ways to help governments monitor trans-fats consumption.

The WHO regional offices for Africa, Southeast Asia, the Americas, Europe, Eastern Mediterranean, and the Western Pacific should compile the mean trans-fat intakes of populations in countries where data exist, and identify countries where information is needed. This effort started in the PAHO/WHO regional office of the Americas in 2007.

We must call for all food industry sectors to eliminate trans fats across many product categories, while also reducing total fat in products, and by replacing unhealthy fats (saturated. and trans from partially hydrogenated oils)with healthy fats (non hydrogenated monounsaturated and polyunsaturated).

While trans-fats sources vary by region and country, one of the most common contributors of trans fats is partially hydrogenated oils as used in margarines, spreads and shortenings and in highly processed products such as fried and baked pre-prepared products, and also the partially hydrogenated oils used to fry foods at home and by street vendors, most of all when the oils are re-heated at high temperatures and re-used (15, 16, 27).

So the fourth challenge is for all industry sectors to configure the appropriate amounts of zero-trans replacement fats in processed foods, while at the same time reducing total and saturated fat, and also increasing cis-unsaturated fats (including monounsaturated fats) in reformulated products. Unsaturated fats may not be currently available for all food manufacturers and retailers, as the way to replace partially hydrogenated vegetable oils with these healthier oils (27). However, farmers and oil processors appear to be responding to the increased demand for healthier fats and oils (16).

These product changes must be complemented with a strong advocacy push and communications campaign for consumers also to reduce their overall consumption of processed foods that contain high amounts of saturated fat, added sugars and salt. These actions will accelerate the pace at which companies reformulate entire product categories, rather than making changes based on a food category-by-category basis. It will also stimulate governments to work across borders rather than to make progress on a country-by-country basis. Reliance on primarily voluntary approaches to change food environments would likely take several decades.

We must hold governments accountable for coordinating, funding, measuring and monitoring the effects of trans-fat elimination policies on food and eating environments, and support actions that should include the monitoring of trans fats into the forthcoming Global Action Plan to Prevent Non-Communicable Disease for 2013-2020.

National governments must enact legislation and allocate adequate funds to support regulatory actions affecting all relevant food industry sectors. A systematic and random monitoring of food and eating environments over time is needed to ensure that highly saturated animal fats and tropical oils are not used to replace inexpensive partially hydrogenated vegetable oils, after legislation has been implemented (1, 27).

Available evidence for how governments have dealt with these challenges varies between countries. In Eastern Europe (for example, Hungary, Poland and the Czech Republic) where voluntary-only labelling or limited reformulation has occurred, trans fats remain unacceptably high in many processed products and quick-serve restaurant meals, compared with acceptable levels in Denmark and Austria where trans-fat bans and regulations have been implemented (28). Other western European Union countries (for example, France, Germany, the Netherlands, and the UK) have succeeded in reducing trans fats in many processed products and in the overall food supplies, by implementing more assertive industry-wide measures, and raising consumer awareness about its harmful effects (28).

In 2011, the South African Department of Health enacted legislation to limit the industrial trans-fat content of all oils or fats in foods to a maximum of 2 per cent of total calories (29). In Costa Rica (26), the majority of trans fats in processed products were replaced by a healthier oil (palm olein) that appears to have a better fatty acid profile than highly saturated palm oil. In Brazil (30) and Canada (31), trans fats have been replaced with unhealthy saturated fats in some products, and reductions have been claimed for specific brands and food categories.

Ongoing progress needs to be checked

The Canadian government passed mandatory product labelling in 2002, which included mandatory labelling of trans fat levels, followed by a trans Fat Task Force report in 2006, which recommended regulatory limits on trans fats (31). However, instead of regulating the food industry, the Canadian government requested food manufacturers voluntarily to reduce trans fats and instituted a trans-fat monitoring program that was subsequently cancelled in 2009. Results of voluntary efforts are mixed. While reductions have occurred within many food categories, there is a need to further reduce trans fats in commonly consumed processed products, notably fried and baked goods and tub margarines (32). Another Canadian study conducted after the labelling regulations, but before the trans Fat Task Force report was released, found that only higher-priced margarines rather than the entire product category benefited from these voluntary labelling changes, which would disadvantage low-income Canadian consumers who already are at higher risk of coronary heart disease (33).

Voluntary-only policy measures have made limited progress in several Latin American and Caribbean countries. Requests have been made through the PAHO/WHO transFat Free America Initiative (34), to obtain data from industry sectors (notably manufacturers and restaurants) for reformulated product categories following calls for voluntary trans-fat reductions. Some companies did not provide the requested data to researchers so that their claims could be verified (34). Evaluations so far show that voluntary reduction of trans fats in selected Latin American countries, independent of mandatory labelling, has not lead to substantial reductions in trans fats in these countries' food supplies (34).

US food supply monitoring has suggested that several combined interventions (including mandatory labelling) have increased consumer education and awareness. Voluntary industry product reformulation may have led to a reduction in trans-fat intake from a mean of 4.6 grams a person a day to 1.3 grams a person a day by 2009. These data assume that consumption of the same products remained steady from 2003-2006 until 2009(35). While these findings are encouraging, regular monitoring of trends in various food industry sub-sectors, while essential, is not happening in most countries worldwide.

Evaluations have shown that some US-headquartered snack food manufacturers have substituted healthy fats for trans fats in chips (crisps) but not all types of cookies (biscuits)(36). The pre- and post-monitoring of trans fats in restaurant chain meals in New York City, where trans fats were banned to less than 0.5 grams a serving in 2006, showed substantial declines (37, 38) compared with other US cities where no bans or legislation were enacted. Many national quick-serve and full-serve chain restaurants did not even report trans fats for adult and child meals before the mandatory US restaurant labelling law was passed in 2010(39). Additionally, trans-fat labelling will remain voluntary despite mandatory calorie reporting that will start in 2013.

Coordinating and monitoring the effects of trans fat elimination will require a discussion of what has worked effectively elsewhere. As public health professionals, it is our role to initiate and facilitate these discussions and translate them into policies and action.

We must learn from advocacy work and apply insights from successful social and public health movements.

Placing a trans-fat ban onto the WHO agenda is an important first step in making progress. WHO has initiated a consultation to develop a Global Action Plan to Prevent Non-Communicable Diseases for 2013-2020 (40) and has requested public input to identify 'best buys' to reduce mortality 25 per cent by 2025 (the '25 by 25' goal).

So, many groups, including the public health and nutrition communities, have an extraordinary window of opportunity to develop and implement a coherent strategy (harmonised with other relevant strategies and monitoring frameworks) to work toward a trans-fat free world by 2025.The revised first draft to the WHO 'Zero Draft Action Plan' (40) will be submitted to the WHO Executive Board next month, in January 2013, and there will be an informal online consultation during 2013.

Once the issue is on the global agenda, there needs to be a strong organisation to advocate for and coordinate efforts of many groups within and across countries. This is an issue that the World Public Health Nutrition Association could spearhead, to engage and mobilise its members, and its networks, to implement successful strategies to eliminate trans fats by adopting or adapting approaches such as those used in Denmark and Austria(28) and New York City (37, 38, 41).

The process of persuading decision-makers and policy-makers to support a course of action for specific policies and actions will involve strategic organising, raising funding and in-kind resources, building a power base, and applying a range of skills to support concerted actions. A strong public health movement that encourages many groups working in a coordinated and systematic way is needed to support a global ban on trans fats on national and regional policy agendas.

Five components are essential for civil society groups and public health advocates to build a successful movement (42). These are:

• Organise an authentic support base
• Cultivate strong leadership
• Develop a clear vision
• Build and support strategic alliances and social networks
• Develop and sustain an advocacy infrastructure

It will also be important to assess the national and global advocacy capacity and the potential policy impact of a movement that is specifically focused on a global ban on transfats, and to evaluate the impact of advocacy. Finally, applying insights from other movements that have successfully banned substances harmful to human health is critical. These include national and international agreements and treaties that have been used to support bans on tobacco (43) and pesticides (44).

We recommend that governments work together to enact national and global trans-fats bans, rather than accepting voluntary approaches, in order effectively to eliminate trans fats in all processed foods. As stated in the key points above, the rationale for this approach is that a ban will:

• Cover the full range of food products in a country or region;
• Benefit people who do not read food labels or who live in countries where trans fats are not labelled on food products; and
• Apply equally to all food products, whether domestic or imported from other countries.

Importantly, some food products with higher trans-fat content are likely to remain unchanged in the absence of a regulated limit. Examples are inexpensive products; highly palatable, indulgent foods consumed for reasons other than nutritional value, such as cakes and pastries; and foods for which nutritional information is not available, such as in poorly-regulated low- and middle-income countries and everywhere for food sold in local restaurants or by street vendors.

Planning and implementing a coordinated strategy must include a uniform definition for trans fats and clear language articulating the elimination of trans fat in the WHO's global monitoring framework and indicators. These steps will help all relevant sectors within countries to establish an elimination goal and a strategy to achieve it, as well as governments across regions to prioritise trans-fat elimination as part of the WHO's '25 by 25' to reduce chronic non-communicable disease mortality 25 per cent by 2025.

Needed: vision and determination

With vision and focused determination, it is possible to mobilise available resources to coalesce around a global ban on trans fats. The public health and nutrition communities throughout the world can address the challenges associated with the WHO and PAHO transFat Free Americas Initiative that countries achieve a 'virtual elimination' of trans fats from their food supplies.

This commentary presents a case for public health professionals, practitioners, academics, industry and government representatives, funders, public-interest non-governmental organisations and consumer advocates, to collaborate to support a global trans-fat ban. Coordinated actions to remove this harmful substance from our food and eating environments will be able to contribute to reducing chronic non-communicable disease mortality by 2025.

Deliberation about a global ban will take time. But we must still address the following challenges and play an active role in the resolution of each one of them. Here is how we can make progress:

Prominent nutrition and public health organisations should petition their own countries' regulatory agencies, and the FAO/WHO Codex Alimentarius Commission, to develop and disseminate an updated, inclusive and comprehensive definition of trans fats that clearly identifies partially hydrogenated vegetable oils and includes trans fat in the list of mandatory nutrients for nutrition labelling.

The bottom lines

We in the public health and nutrition communities also need to press for the following six actions:

• Definition. We must engage with our professional societies, regulatory agencies and the UN Codex Alimentarius system, to develop and disseminate an inclusive, comprehensive and uniform definition for industrially produced trans fats.
• Priority. We must work with governments to prioritise trans-fat elimination on policy agendas.
• Knowledge. We must encourage and support governments to measure and monitor the trans-fat intake in populations with the assistance of research institutions, the food industry, and public-interest non-government organisations.
• Manufacturers. We must call for all food industry sectors to eliminate trans fats across many product categories, while also reducing total fat in products, and by replacing unhealthy fats (saturated, partially hydrogenated and trans) with healthy fats (monounsaturated and polyunsaturated).
• Accountability. We must hold governments accountable for coordinating, funding, measuring and monitoring the effects of trans-fat elimination policies on food and eating environments, and support actions that should include the monitoring of trans fats into the forthcoming Global Action Plan to Prevent Non-Communicable Disease for 2013-2020.
• Action: We must learn from advocacy work and apply insights from other successful social and public health movements.

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Please cite as: Kraak V, Colon-Ramos U, Monge-Rojas R. Legislation: Trans fats. Case for a global ban[Commentary].World Nutrition, December 2012, 3, 12, 570-591. Obtainable at www.wphna.org.