Trans Fat Free by 2023 - CASE STUDIES in Trans Fat Elimination - NCD Alliance
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Trans Fat Free
by 2023
CASE STUDIES
in Trans Fat Elimination
YEARS
2009-2019
Edited by NCD Alliance, May 2019 Cover images and page 4, 22: © shutterstock Pages 8: © stock.adobe.com Page 16: Kim Jones Page 30: © REUTERS / Finbarr O’Reilly / stock.adobe.com Page 35: Paralela NCD Alliance | 31-33 Avenue Giuseppe Motta | 1202 Geneva, Switzerland www.ncdalliance.org
Table of contents Executive Summary 4 Background 4 Country-Specific Case Studies 5 Key Conclusions 6 Taking Action – What Needs to Happen 7 The NCD Alliance calls on governments to: 7 Introduction 8 Goals of the Report 8 Methodology 9 Background on Trans Fats and Policy Strategies 10 What Are TFAs? 10 Health Harms of TFA Consumption 10 World Health Organization Recommendations 11 Strategies to Reduce TFA Consumption 12 The First TFA Limit 12 Current Status of TFA Policies 12 Map of countries and territories that have enacted a TFA limit or PHO ban 14 Country-Specific Case Studies 16 Chile 16 Saudi Arabia 19 Slovenia 22 South Africa 25 Thailand 27 United States of America 29 Key Conclusions 32 Acknowledgements 36 Additional Information 38 References 39
Trans Fat Free by 2023
Case Studies in Trans Fat Elimination
Executive Summary
Background
Industrially-produced trans fatty acids (TFAs),a This report presents case studies of six countries
common in baked goods, pre-packaged foods in different regions of the world that have enacted
and some cooking oils, are a major contributor to policies to eliminate TFAs from their food supply,
cardiovascular diseases (CVD) and noncommunicable as recommended by WHO.4 The purpose of this
diseases (NCDs) worldwide,1 estimated to contribute report is to provide civil society organisations
to more than half a million deaths each year.2 TFAs (CSOs), including national and regional NCD
have no known health benefits and can be replaced alliances, and policy-makers around the world with
in foods without impacting their consistency or taste. examples of successful strategies for enacting and
implementing TFA policies, as well as an analysis
The elimination of TFAs from the global food supply of barriers, enablers and lessons learned based on
is a priority target of the World Health Organization’s the experience of policy-makers, advocates, and
(WHO) current strategic plan (GPW13 2019 – 2023)3 researchers involved in such efforts.
and is identified as an effective and cost-effective
policy measure to save lives. The elimination of TFAs The focus of the report is on industrially-produced
is part of the programmes being scaled up following TFAs in partially hydrogenated oils (PHOs), the most
global political commitment at the United Nations common type of industrially-produced TFA, and not
High-Level Meeting on NCDs held in September naturally-occurring TFAs present in some meats and
2018. Policies to eliminate TFAs can substantially dairy products.
contribute to achieving the global goal of reducing
premature deaths from NCDs by one-third by 2030
(compared with 2015) and WHO’s strategic priority
to deliver better health and well-being to one billion
people.
a Except where noted, the abbreviation TFA is used to refer to industrially-produced or artificial trans fats/ trans fatty acids, and does not include
ruminant or naturally-occurring TFAs present in some meat and dairy products.
4
Trans Fat Free by 2023
Case Studies in Trans Fat Elimination
Country-Specific Case Studies
The six countries profiled in the report include Chile, Saudi Arabia, Slovenia, South Africa, Thailand, and the
United States of America (USA). Each of these countries used a slightly different strategy for TFA reduction or
elimination, although some common themes emerged.
Chile used a two-step policy approach, first South Africa enacted a TFA limit in 2011 and is still
enacting a TFA labelling regulation followed by a the only country in Africa to have such a policy. The
TFA limit. The national TFA limit was supported by Ministry of Health had begun the process to issue
the concurrent establishment of regional targets for regulation on TFA labelling but decided to enact a
TFA reduction. Chile’s policy success was influenced TFA limit instead after a private member bill to ban
by factors including multi-stakeholder engagement, TFAs was introduced in Parliament. It is unclear
ensuring the TFA policy was part of a larger policy the extent to which South Africa’s TFA limit has
framework, and government capacity to implement been implemented, and data on the impact of the
the regulations. regulation is not available.
Saudi Arabia also enacted both a TFA labelling Thailand addressed TFAs through a ban on
requirement and TFA limit in 2015 in close sequence, PHOs enacted in 2018 to stop the production and
followed by a ban on PHOs in 2018 that is currently importation of Western-style foods high in PHOs.
being implemented. The country’s TFA policies The Thai government worked with the small number
were enacted as part of a broader Healthy Food of PHO producers in the country to change their
Strategy driven by the Minister of Health and other manufacturing process and cut off the supply chain to
government leadership. The Saudi government food manufacturers that used PHOs as ingredients.
collaborated with partners including the food and oil Factors important for successful policy enactment
industries, CSOs, and academia, and benefitted from and implementation included data collection on TFA
WHO resources and support in policy enactment levels, communication and collaboration among a
and implementation. range of stakeholders, and manufacturers’ readiness
for change.
Slovenia enacted a TFA limit primarily to address
the importation of TFA-laden products from other USA was the first country to restrict TFAs
European countries without TFA policies. The policy by prohibiting the use of PHOs and did so by
was passed, in part, as a result of researcher- determining that they are no longer “Generally
advocates conducting and publicising research on Recognized As Safe” for use in the food supply.
the levels of TFAs in Slovenian products and their The PHO determination was preceded by a federal
health harms. The policy process was delayed initially TFA labelling requirement and state and local TFA
while the European Commission was working to policies limiting TFAs in schools and food service,
develop a regional TFA limit; however, the Slovenian which provided proof of concept, evidence of policy
government ultimately decided to move forward in impact, and required or incentivised manufacturers
enacting its own national policy in 2018. to begin making changes to reduce or eliminate TFAs
from their products.
5
Trans Fat Free by 2023
Case Studies in Trans Fat Elimination
Key Conclusions
Several key conclusions emerge from the case a broader, coordinated approach to improve diet and
studies. Importantly, these profiles show that nutrition and reduce NCDs.
reducing or eliminating TFAs from the food supply is
both politically and technically feasible. Mandatory Following enactment of the policy, guidance and
TFA policies have now been enacted by 55 countries technical assistance for manufacturers and importers
and territories in all WHO regions, 31 of which have can help to support successful implementation. Small
implemented these policies, while the other 24 will and mid-size companies are likely to face the greatest
bring them into force in the next few years. challenges with compliance, but companies may be
able to learn from each other. In addition, providing
Nearly all of the cases show that collaborating guidance on TFA replacements and monitoring policy
across sectors, both within and outside of impact may help to ensure that the TFA policy does
government, is important for successful policy not inadvertently increase consumption of unhealthy
enactment and implementation. Key agencies saturated fats/saturated fatty acids (SFAs), reducing
within government include those with jurisdiction its health benefits.
over health, agriculture and commerce. Key external
stakeholders include CSOs, academia, and industry. In many countries, more research is needed to
CSOs – including, but not limited to, disease-specific determine the effects of TFA policies on the levels
organisations, medical associations, public health of various fats in the food supply, their consumption,
advocacy groups and consumer organisations – can overall dietary impact, and effects on CVD
play an important role in mobilising awareness and prevalence and deaths in the short and long-term.
support for policy enactment, implementation, and Policy leadership and advocacy is also needed to
enforcement. Academia can also play an important spur further enactment and implementation of best
role in conducting and publicising research, serving practice TFA policies across the globe.
as an expert resource for government, convening
stakeholders, and supporting policy evaluation.
In countries considering TFA policies, research on
the extent of the problem and major sources of
TFAs in the food supply is important for making the
case for the policy and identifying policy targets.
However, given the robust international experience,
lack of local data should not be an excuse to justify
policy inaction. In addition, the impact of TFA policies
on NCDs will be even greater if the policy is part of
6Trans Fat Free by 2023
Case Studies in Trans Fat Elimination
Taking Action – What Needs to Happen
The NCD Alliance calls on governments to:
Follow WHO recommendations to enact a mandatory 2 per cent limit on industrially-produced
TFAs in foods or to ban PHOs. The WHO’s REPLACE action package and technical support in-
country should be leveraged by policy-makers to protect their populations from the health
harms of TFAs.
Embed TFA elimination in a broader, coordinated approach to improve diet and nutrition and
reduce NCDs to maximise the impact of TFA policies on NCDs.
Collaborate across sectors within and outside of government to ensure successful enactment
and implementation of the chosen TFA elimination policy. A multi-stakeholder approach is
essential while being mindful of conflicts of interest.
Involve civil society, such as national and regional NCD alliances, to reach local communities,
leverage the media to build public awareness, advocate for systematic change, ensure
accountability and support monitoring and compliance with TFA policies.
Learn from the international experience and evidence – lack of local data should not be an
excuse to justify inaction on TFA elimination.
Fund local research on TFA sources and consumption and its impact on CVD prevalence and
mortality to tailor the policy choice to the local context, add to the existing body of research, and
provide a baseline for policy evaluation after implementation.
Provide technical assistance and guidance on replacement fats to food manufacturers,
particularly small and mid-sized producers, to ensure successful implementation of the TFA
policy.
Budget and plan for monitoring and evaluation of the TFA policy from the beginning.
7Trans Fat Free by 2023 Case Studies in Trans Fat Elimination Introduction Goals of the Report This report presents case studies of six countries in different regions of the world that have enacted policies to eliminate TFAs from their food supply, as recommended by WHO.5 The report is intended to provide CSOs and policy-makers around the world with examples of successful strategies for enacting and implementing TFA policies. The report also provides best practices, lessons learned, and recommendations based on the experience of policy-makers, advocates, and researchers involved in such efforts. Countries highlighted in this report are diverse geographically, economically, and politically, have enacted different TFA policies, used varied strategies for enacting and implementing them, and are at different stages in the implementation process. This diversity demonstrates that there are many potential policy paths to reducing or eliminating TFAs from the food supply. 8
Trans Fat Free by 2023
Case Studies in Trans Fat Elimination
Methodology
The information in this report was obtained directly Interviewees were asked questions regarding
through interviews or written correspondence with eight topic areas:
government, CSO, and research stakeholders and
experts in the case study countries. Information 1. Rationale for TFA policy action
was also compiled through researching the peer-
reviewed literature, media, and reputable CSO 2. Policy type
and government websites. Criteria for selection of
countries profiled in the report include geographic, 3. Overarching strategy
political, and economic diversity, diversity in policy
strategy and approach, and lack of existing reports 4. Supporters and opponents
or case studies that tell the country’s story. Only
countries that had enacted policies in line with 5. Advocacy strategies and messages
WHO recommendations as of December 2018 were
considered for inclusion. 6. Implementation and enforcement
Semi-structured phone interviews were conducted 7. Evaluation
with 10 stakeholders/experts in the case study
countries, including one stakeholder within 8. Best practices and lessons learned.
government and one outside of government in
most cases. Four additional stakeholders provided All interviews were conducted in English except
responses to questions in writing. In one country, where noted. All interviews were recorded and
information obtained from a webinar on the country’s transcribed with the interviewee’s permission
TFA policy organised by the project funder was using GoToMeeting. The full list of interviewees is
utilised in lieu of an interview. Interviewees were included as an appendix. Exceptions are noted in the
identified through internet research and consultation footnote.b
with other TFA, nutrition, and CVD policy experts in
the country or region.
b Chile: Interviews with Senator Dr. Guido Girardi, Dr. Tito Pizarro Quevedo, and Dr. Lorena Rodriguez were conducted in Spanish. Key takeaways and
quotations were then translated into English.
South Africa: Penny Campbell, Antoinette Booyzen and Malose Matlala from the South Africa Department of Health provided responses to interview
questions in writing. We were unable to speak with a non-government stakeholder or expert.
Thailand: Information provided by Dr. Visith Chavasit on a webinar hosted by LINKS (https://www.linkscommunity.org/), an online community for
cardiovascular health and collaborative program of WHO, the U.S. Centers for Disease Control and Prevention, CDC Foundation, and Resolve to
Save Lives, was utilised in lieu of an interview with Dr. Chavasit.
USA: Responses from the U.S. FDA were provided in writing by an authorised representative and are attributed to the U.S. FDA.
9Trans Fat Free by 2023
Case Studies in Trans Fat Elimination
Background on Trans Fats and Policy
Strategies
What Are TFAs?
TFAs are a type of unsaturated fatty acids that
occur naturally in meat and dairy products or can be
Health Harms of TFA
industrially-produced through partial hydrogenation of Consumption
vegetable oils. The process of partial hydrogenation TFAs were once touted as a healthier replacement
increases the solidity and stability of the fat.6 for SFAs when the health harms of SFAs, including
Modifications to the partial hydrogenation process increased blood cholesterol and CVD risk,13 became
result in different products used for deep frying and known. However, evidence has become clear that
baking, such as oils, margarines, and shortenings.7 TFAs provide no nutritional benefits and are even
In meat and dairy products, naturally-occurring TFAs more harmful than SFAs in increasing CVD risk.14
(ruminant TFAs), do not exceed 6 per cent of total TFAs increase CVD risk by increasing the ratio of
fatty acids.8 However, in partially-hydrogenated oils “bad” LDL cholesterol to “good” HDL cholesterol,
(PHOs), up to 60 per cent of total fatty acids may be promoting inflammation, and causing dysfunction in
TFAs.9 the lining of the heart and blood vessels.15 In fact,
consumption of 5 grams of TFAs per day has been
PHOs were first introduced into the food supply in the shown to increase the risk of CVD by 29 per cent.16
late 19th or early 20th centuries as a replacement for Globally, more than 500,000 deaths each year are
fats such as butter and lard.10,11 Given the properties due to consumption of TFAs.17 TFAs have shown to
of PHOs and that they are more shelf stable and cause health harms even when they comprise only
often cheaper, PHOs were commonly used in 1-3 per cent of total calories.18
margarines, vegetable shortenings, packaged snacks
and baked goods, and fried foods.12 While sources
of industrially-produced TFAs vary by country, some
common sources are included in the graphic below.
The focus of this report is on industrially-produced
TFAs in PHOs and food products containing PHOs as
an ingredient.
Common Dietary Sources of Industrial Trans Fats
Margarine, Baked goods Fried foods Restaurant
vanaspati ghee, (biscuits, pies, crackers, buns, (French fries, chicken nuggets, and street foods
vegetable shortening cakes, pastries, sweet rolls) doughnuts) that are baked or fried
10Trans Fat Free by 2023
Case Studies in Trans Fat Elimination
World Health Organization WH O / N M H / N H D / 1 8 . 6
Recommendations
In 2007, WHO undertook a scientific update on TFAs intake of SFAs and TFAs to reduce the risk of CVD.
as part of the implementation of its Global Strategy The draft guidelines recommend limiting total TFAs
on Diet, Physical Activity and Health. (industrially-produced and ruminant) to no more than
1 per cent of total energy for both adults and children,
The WHO Scientific Update on TFA concludes that or 2.2g per day for a 2,000-calorie diet.20 As of the
AN ACTION
restaurants and food PACK AGE TO should
manufacturers ELIMINATE
avoid INDUSTRIALLY-PRODUCED
date of publication of this report, the draft guidelines
TRANS
using FAT
industrially FROM
derived TFA THE GLOBAL
in food FOOD SUPPLY
products and are in the process of being finalised and the WHO
continues to recommend a 1 per cent limit for TFAs.
TRANS FAT FREE BY 2023
that governments should take steps to support
alternative fats or oils for TFA replacement. The
evidence on the effects of TFA and disease outcomes In May 2018, WHO also released the REPLACE
Industrially-produced trans fat is a man-made harmful compound foundpackage,
action in foods, fats and oils.
a step-by-step guide for eliminating
strongly supports the need to remove [PHOs] from the
human food
Trans fatsupply. The result
clogs arteries, would be
and increases thea risk
substantial TFAs from
of coronary heart disease.
the global food supply by 2023. REPLACE
health gain for the population at large, with greatest provides governments with six strategic action areas.
Trans fat is responsible for more than a half million deaths around
health benefits obtained when replacement oils are In May 2019,
the world WHO
every year released
from heart the REPLACE modules
disease.
rich inEliminating
[unsaturated and additional resources to facilitate implementation
transfatty acids] . supply and replacing it with healthier
19
fat from the food alternatives is feasible
and is happening in many high-income countries. of the policies and measures at a national level.
In May 2018, WHO released for public consultation
The WHO REPLACE action package provides governments with a strategy to achieve the prompt, complete, and
draft guidelines on SFA and TFA intake for adults
sustained elimination of industrially-produced trans fat from their national food supplies including six action areas.
and children to provide recommendations on the
RE P L A C E
THE SIX ACTION AREAS ARE:
REVIEW PROMOTE LEGISLATE ASSESS CREATE ENFORCE
dietary sources of industrially- the replacement or enact and monitor awareness compliance
produced trans fat and the of industrially- regulatory trans fat content of the negative with policies
landscape for required policy produced trans actions to in the food health impact and regulations
change fat with healthier eliminate supply and of trans fat
fats and oils industrially changes in trans among policy-
-produced fat consumption makers,
trans fat in the population producers,
suppliers,
and the public
Source: WHO, https://www.who.int/docs/default-source/documents/replace-transfats/replace-information-sheet.
Eliminating industrially-produced trans fat from the world food supply and replacing them with healthier oils
pdf?Status=Temp&sfvrsn=f6effd4f_2
could save more than 500,000 lives per year.
The REPLACE action package provides countries with proven tools that will help them eliminate 11
industrially-produced trans fat from their food supplies by the global target date – TRANS FAT FREE BY 2023!Trans Fat Free by 2023
Case Studies in Trans Fat Elimination
Strategies to Reduce TFA
Consumption
Informed by well-established research on the health
harms of TFAs, governments at multiple levels across In partially-hydrogenated
the globe have taken actions to reduce TFAs in the
food supply and inform consumers about their risks. oils (PHOs)
Policy strategies have included:
• Voluntary agreements with industry to reduce or
remove TFAs from their products;
60% of total
• Requirements to add TFA content to nutrition
fatty acids may
labels;
be TFAs
• Limits on TFA content in fats/oils and in all foods;
• Bans on the use of PHOs.
Researchers had estimated that 50,000 Danes were
Strategies used have varied by the level of at risk for CVD as a result of their TFA consumption.31
government at which they are implemented and by
country and region of the world. Denmark’s TFA policy has been shown to be effective
in reducing TFAs in the food supply and reducing
Research has shown that all of these strategies deaths from CVD. A study showed that in the two
are effective in reducing TFAs in the food supply.21 years after Denmark’s TFA policy took effect, TFA
However, a systematic analysis of 32 studies content was reduced or removed from products
examining TFA policies showed that TFA limits or with high TFA content originally, including French
bans are more effective than voluntary policies or fries, microwave popcorn, and bakery products, to
TFA labelling.22 TFA limits or bans virtually eliminate the point that TFAs no longer posed a health risk.32
TFA from the food supply and are likely to have the Denmark’s TFA policy has effectively removed TFAs
greatest impact with regard to reducing CVD risk.23 from the country’s food supply. While TFAs should be
replaced with healthier oils containing unsaturated
The First TFA Limit fats to maximise health benefits of their removal,
research showed that in Denmark, SFAs were used
In 2003, Denmark became the first country to enact in approximately two-thirds of products.33 Despite
a regulation limiting TFAs. Denmark’s policy limits this, during the three years after Denmark’s TFA
TFAs to 2 grams TFA per 100 grams of total fats and policy was enacted, CVD mortality dropped faster in
oils, excluding naturally occurring TFAs, in all foods comparison to reference countries as a result of the
sold to consumers.24 Denmark’s policy was enacted TFA policy.34 In fact, the 70 per cent decline in heart
in March 2003 and took effect on 1 June 2003 with a disease mortality rates that occurred in Denmark
phase-in period from 1 June to 31 December 2003, between 1980 and 2009, likely at least partly due
during which the TFA limit was 5 grams TFA per 100 to the country’s efforts to address multiple CVD risk
grams of total fats.25 factors, including TFA intake, was the largest in the
European Union (EU).35
Denmark’s TFA policy was part of a package of
policies to address the high rates of CVD in the
country that also included tobacco control laws, new Current Status of TFA Policies
guidelines and improved treatment of hypertension, Since 2003, countries on five continents have
and policies and partnerships to improve the followed Denmark’s lead and enacted policies to
nutritional quality of the food supply.26 Denmark’s TFA limit TFAs or ban PHOs. The number of countries
policy was precipitated by a study first published in and territories with TFA policies in effect has grown
1993 by Dr. Walter Willett and colleagues at Harvard significantly in recent years, from one in 2004
University in the USA on the impact of TFAs on heart (Denmark) to three in 2009 (Denmark, Switzerland,
disease risk.27, 28 and Chile)36 to 31 as of March 2019.37 The majority
of countries to enact TFA policies thus far have been
This was followed by widely-publicised research high and upper-middle income countries.38 However,
about the health impact of TFAs in Denmark and low- and middle-income countries bear up to 90 per
recommendations by the Danish Nutrition Council cent of the global CVD burden,39 underscoring the
that TFA content be limited through legislation.29, 30 need to extend TFA elimination strategies globally.
12Trans Fat Free by 2023
Case Studies in Trans Fat Elimination
The map on the next page shows countries and territories
that have enacted a TFA limit or PHO ban.
Countries with a TFA limit of 2 per cent Countries with a TFA limit of 2 per cent for
for all foods fats/oils and 5 per cent for all other foods
Austria Argentina
Belgiumc Colombia
Bulgariac Iran
Chile (page 16)
Countries with a TFA limit of 2 per cent for
Croatiac
fats/oils only
Czech Republicc
Armenia
Denmark
Belarus
Estoniac
Ecuador
Finlandc
Georgiaf
Francec
Germanyc Kazakhstan
Greecec Kyrgyzstan
Hungary Russia
Iceland Singapore
Irelandc Switzerland
Italyc Countries with a TFA limit of 5 per cent for
Latvia fats/oils only
Lithuaniac India
Luxembourgc
Maltac Countries with a TFA limit of 4 per cent for
Netherlandsc foods with a total fat content ofTrans Fat Free by 2023
Case Studies in Trans Fat Elimination
Map of countries and
territories that have enacted
a TFA limit or PHO ban
Canada
United States
Countries with a TFA limit of 2 per cent
for all foods
Implemented
Not yet implemented
Countries with a TFA limit of 2 per cent for fats/oils Colombia
and 5 per cent for all other foods
Ecuador
Countries with a TFA limit of 2 per cent
for fats/oils only
Peru
Countries with a TFA limit of 5 per cent
for fats/oils only
Countries with an implemented TFA limit of
4 per cent for foods with a total fat content of ChileTrans Fat Free by 2023
Case Studies in Trans Fat Elimination
Finland
Sweden
Norway
Denmark
Iceland
Russia
Netherlands
UK
Estonia
Latvia
Belgium
Lithuania
Ireland Belarus Czech Republic
Germany Poland
Slovakia Austria
Luxembourg Kazakhstan
France Hungary
Romania
Bulgaria Georgia
Uzbekistan Kyrgyzstan
Spain Armenia
Portugal Italy
Greece
Malta Republic
of Cyprus
Switzerland Iran
Croatia
Slovenia
Chinese Taipei
Saudi Arabia
India
Northern Mariana
Islands
Thailand Guam
Singapore
South Africa
15Trans Fat Free by 2023
Case Studies in Trans Fat Elimination
Country-Specific Case Studies
Chile
KEY POINTS
Chile used a two-step policy approach, first
enacting a TFA labelling regulation in 2006
followed by a TFA limit in 2009 of 2 per
cent of total fat in all foods, a best practice
policy.
Chile’s enactment of a national TFA
limit was supported by the concurrent
passage of the regional Trans Fat
Americas Declaration, which was signed
by stakeholders across the Americas
and established regional targets for TFA
reduction.
Factors that influenced Chile’s policy
success include its engagement of key
external stakeholders throughout the
process, such as well-respected academic
and industry leaders, multi-stakeholder The Need for Policy
coordination within government, situating The Chilean government’s policy efforts to reduce
the TFA policy within a larger healthy consumption of TFAs began in 2006, driven by new
eating policy framework, and government research linking TFA consumption with CVD and its
capacity to implement the policy. rising prevalence in the country. A 2003 National
Health Survey found that deaths from heart attacks
had increased in the two decades prior and heart
disease had become the leading cause of death
in the country.40 At that time, 41 per cent of the
population had two or more major CVD risk factors
and 55 per cent had a global CVD risk classified
as “high” or “very high”.41 The Ministry of Health
determined that the primary reasons for Chile’s CVD
burden were unhealthy diets and lack of physical
activity and decided to focus on improving the poor
nutritional quality of the food.
Chile’s TFA Labelling and TFA Limit
Regulations
The Ministry of Health began to work closely with
academia, including Prof. Ricardo Uauy of the
University of Chile, consumer representatives, and
the food industry to identify strategies to limit TFA
16Trans Fat Free by 2023
Case Studies in Trans Fat Elimination
TFA products to use in their recipes. Once oils
and margarines that met the new TFA limits were
available, producers of other foods that used these
products as ingredients had time to reformulate
their recipes before the five-year deadline. Given
the small number of oil and margarine producers
in Chile, focusing on them was an effective way
to improve the whole food supply. This approach
was proposed by the Ministry of Health following
consultation with expert academics and food
manufacturers.
The Ministry of Health’s regulatory activities on
TFAs formed part of a larger framework called
the Comprehensive Strategy Against Obesity
(Estrategia Global Contra la Obesidad or EGO
Chile)43 as well as Vida Chile, a national health
promotion programme including healthy eating,
which provided the context for comprehensive food
policy actions.
International Influence
Chile’s TFA limit was informed by international
efforts, both within the Americas and globally.
consumption. In 2006, the Chilean government Evaluations of local TFA policies in the USA and
enacted a TFA labelling regulation, which required the national regulation in Denmark showed policy
that the amount of TFA be declared on the nutrition strategies to be effective, and their results were
label. While this regulation had some loopholes (e.g., taken to mean that a TFA regulation in Chile would
it did not require TFA labelling for foods with a total have similar impacts. TFA experts from the Chilean
fat content below a particular threshold and allowed Ministry of Health also met with representatives
foods with small amounts of TFA to be labelled as from regulatory agencies in Canada and Argentina,
having none),42 it was an important first step in a who were also exploring strategies to reduce TFA
broader strategy to reduce TFAs in the food supply. consumption nationally.
According to Dr. Lorena Rodriguez, an advisor in the
Food and Nutrition Department at the Ministry of In 2008, the Pan American Health Organization
Health at the time, the Chilean government already (PAHO) convened government and non-government
had an eye toward the future when enacting the experts within the Americas, including food and
TFA labelling requirement. As she explained, “if we oil producers, to discuss the need for country-
identify TFA clearly on the label, it would be very level actions to reduce TFAs in the food supply.
easy to introduce a regulatory restriction or a limit.” The result of this meeting was the 2008 Trans Fat
Free Americas Declaration,44 which expressed that
Chile followed their TFA labelling regulation with TFAs should be limited to no more than 2 per cent
a limit on TFAs of 2 per cent of total fat in 2009. of total fats in oils and margarines and no more
The limit applied to all foods but used a two-phase than 5 per cent of total fats in processed foods,
approach to implementation: the TFA limit took effect and that unsaturated fats were the recommended
two years after enactment for oils and margarines, replacement for TFAs. Dr. Tito Pizarro Quevedo,
and five years after enactment for all other foods. Head of the Food and Nutrition Department at
A shorter timeline was applied for fats and oils so the Chilean Ministry of Health at the time, who
that producers of other foods would have the lower attended the meeting convened by PAHO on behalf
17Trans Fat Free by 2023
Case Studies in Trans Fat Elimination
of the Chilean Government, noted “this type of A per centage of products are then tested in a
leadership from PAHO was very important to boost laboratory by the Institute of Public Health of the
the work that Chile was doing…. That PAHO was Ministry of Health to ensure the labels are correct.
working on TFA was, of course, an impetus and a While adherence to the TFA limit is strong, variability
support to continue developing [Chile’s] regulation.” in food production and technology limitations have
prevented 100 per cent compliance. Evaluation of
the impact of the regulation on TFA consumption is
Stakeholder Engagement and Policy also limited, as Chile only conducted one national
Implementation consumption survey in 2010. However, Dr. Rodriguez
believes that evaluation is important not only for the
The Chilean Ministry of Health engaged multiple
TFA regulation, but also for other food policies in Chile.
stakeholders in developing the regulation. Chile has
a multi-stakeholder standing committee dealing with
food issues, the Committee for the Modification TFA Policy Best Practices
of the Sanitary Regulation of Food (Comisión Para
la Modificación del Reglamento Sanitario de los Dr. Pizzarro Quevedo attributes the success of Chile’s
Alimentos). It is comprised of several ministries, policy to two factors: it was part of a larger framework,
including health, agriculture, and foreign relations; Chile’s Comprehensive Strategy Against Obesity,
industry players; consumer organisations; and and a national, efficient health governance structure
academia. However, as it deals with a large number capable of implementing mandatory public policies.
of food-related issues, the Committee decided to Dr. Rodriguez believes an additional factor is the multi-
form a parallel multi-stakeholder commission on sectoral approach Chile uses in food regulation.
TFAs to advance regulation more quickly.
The food industry pushed back initially, but finally
came around when nutrition scientist Dr. Gastón
“The participation of all [stakeholders]
Rosselot, who worked with the food industry, took does not mean that they all have the
leadership and explained in a commission meeting
to industry and government that reducing TFAs in same weight, because otherwise one
food was possible. As an industry representative and would never advance – some would pull
expert on fats and nutrition, Dr. Rosselot’s statement
carried weight and paved the way for industry’s
in one direction and the others in another
collaboration with the Ministry of Health.45 The direction. But it is very important to have
Ministry of Health did not know if the price for food everyone at the table.”
products would increase as a result of a TFA limit, as
Dr. Lorena Rodriguez, former Head and Advisor, Department
feared by industry. Consequently, they did not refute
of Nutrition and Food, Chilean Ministry of Health
nor discuss this argument, but focused on the health
care costs resulting from TFA consumption.46
Academia’s involvement in the commission was also Next Steps
essential. The Ministry of Health lacked the technical Chilean Senator Dr. Guido Girardi, the leading
expertise in oil processing and could leverage champion of Chile’s recent, internationally-known
the expertise of Prof. Uauy to demonstrate that food labelling and advertising law, is considering
replacement of TFAs with healthy oils was possible, introducing legislation to take the country’s TFA
refuting industry arguments claiming that TFAs could limit one step further and completely ban the use
only be replaced with SFAs, also detrimental to of PHOs.48 He expects pushback from the food
health.47 industry, but that there will ultimately be compliance.
He said, “The industry can argue, but once [the law
Following the deadline for full implementation of is] enacted, they have to comply…. Implementation
the TFA limit in 2014, compliance is assumed to works.” Senator Girardi believes that the best strategy
be high, although resources for enforcement are for holding companies accountable is using the
limited. Dr. Rodriguez noted that small producers media. The legislature successfully works with the
of pastry products had the greatest challenges with regulatory agencies to bring visibility to compliance
implementation. Inspections of production facilities issues. He claimed, “The biggest punishment for a
are conducted periodically by the Health Authority. company is making it public that they are damaging
the health of the population illegally.”
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Saudi Arabia
Commitment to NCD Prevention
KEY POINTS The government of Saudi Arabia has committed to
addressing the country’s high prevalence of CVD and
Saudi Arabia enacted both a TFA labelling other NCDs. In 2016, approximately 37 per cent of
requirement and TFA limit of 2 per cent for deaths in Saudi Arabia were due to CVD.49 In the past
fats and oils and 5 per cent for all other four decades, the dietary fat in the food supply has
foods in 2015, the second country in the more than doubled from 33 grams per person per day
region to limit TFAs through regulation. in 1969-71 to 82 grams per person per day in 2014 (the
A ban on PHOs was then enacted in most recent data available), falling from a peak of 96
December 2018 to align with international grams per person per day in 2011.50 The recent decline
best practices. was hypothesized to be due to increased awareness
about the importance of a healthy diet.51 Committed
The country’s TFA policies were enacted to addressing the country’s diet-related NCDs, the
as part of a broader Healthy Food Strategy Saudi Food & Drug Authority (SFDA) developed its
driven by the Minister of Health and other Healthy Food Strategy, which is part of the country’s
government leadership. broader Vision 2030. According to Meshal Almotairi,
Standards Department Manager with SFDA, “In 2015
The Saudi government used a multi- our management asked us to have a healthy food
sectoral approach to policy development strategy…. We want to take all the actions that are
and implementation, collaborating with needed to reduce obesity and to reduce CVD.” He
the food and oil industries, CSOs, and noted that in response to this directive, SFDA has
academia. Small manufacturers that were taken regulatory action on nutrition labelling, including
more likely to experience challenges in TFA labelling, and limits on TFAs in the food supply.
complying with the regulations were given
opportunities to learn from larger ones that
already made the necessary changes.
Policy Development Process:
TFA Labelling and Limit Regulations
WHO was another particularly important While Saudi Arabia has both a requirement for
partner and provided resources and TFA labelling and a TFA limit, these policies were
support, including tools, guidelines, developed separately. In 2015, SFDA updated its
and training, to the Saudi government food labelling regulations to require labelling of TFAs
to facilitate policy enactment and on food packages. This regulation took effect just
implementation. over one year later.
Also in 2015, the SFDA Board of Directors approved
a regional Gulf Cooperation Council (GCC) standard
limiting TFAs to 2 per cent for fats and oils and 5
per cent for other foods,52 making Saudi Arabia the
second country in the region to limit TFAs, after Iran.
Prior to its adoption, the draft GCC standard was
circulated to the World Trade Organization (WTO) and
food manufacturers for comment. The standard was
largely based on the experience in other countries,
including prior voluntary TFA guidelines in Canada
preceding its PHO ban,53 and developed with input
from WHO’s Eastern Mediterranean Regional Office
(WHO EMRO). The TFA limit took effect in November
2017, two years after enactment, in order to give food
manufacturers time to reformulate their products.
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With the aim of strengthening its TFA regulations to in other countries including the USA and Canada.
align with international best practices, in December Mr. Almotairi noted that the major food companies
2018 the SFDA updated its TFA limit to prohibit the had told SFDA that they would stop using PHOs
use of PHOs by 1 January 2020.54 This new PHO when the TFA limits of 2 and 5 per cent for fats and
ban is unique to Saudi Arabia and not based on a oils and all other foods, respectively, took effect,
regional GCC standard. However, the country was so a national PHO ban was not expected to pose a
informed by the experience of recent PHO bans significant additional burden.
Saudi Arabia’s TFA Policy Timeline55
2015 2016 2017 2018
June September November February
TFA labelling requirement TFA labelling TFA limit of 2 per cent SFDA inspection campaign found that
enacted requirement took effect for fats and oils and 94 per cent of products met the 2 per
5 per cent for all other cent and 5 per cent TFA limits
5 November foods took effect
Board of Directors of the September
GCC Standardization SFDA Healthy Food Strategy rolled
Organization (GSO) approved out and voluntary agreements with
Standard GSO 2483/2015 industry signed
limiting TFAs to 2 per cent for
fats and oils and 5 per cent for December
all other foods
PHO ban enacted
25 November
nder voluntary agreement,
U
SFDA Board of Directors
deadline for large multinational
approved the GCC Standard
companies to limit PHOs to less than
GSO 2483/2015, thus enacting
1 per cent by weight
the GCC TFA limits nationally
2020
1 January 2020
PHO ban takes effect
Partnerships to Support Policy
Implementation
According to Mr. Almotairi, initially the food industry and sodium and stop marketing unhealthy foods to
was opposed to the TFA policies and asked for more children.56 As part of that agreement, the companies
time to comply. However, now they are on board. To agreed to limit PHOs to no more than 1 per cent
strengthen its partnership with industry and support of the product by weight by the end of 2018, one
implementation of policies to improve nutrition, year before the PHO ban takes effect.57 The pledge
including removal of PHOs from the food supply, was announced in conjunction with the release of
in September 2018 the President of SFDA signed SFDA’s Healthy Food Strategy. It was noted in the
a voluntary agreement with nine multinational food media that many of the companies that signed the
companies that are members of the International pledges already had plans to reformulate and launch
Food & Beverage Alliance to reduce TFAs, sugars, new products to meet their commitments.58
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SFDA is also working to support small and mid- Evaluation and Lessons Learned
size food manufacturers in implementing the TFA
requirements by helping them learn from the An inspection campaign conducted in February 2018
experience of larger multinational companies. Mr. by the SFDA found that 94 per cent of the more
Almotairi noted that SFDA hosted a workshop for than 400 food products sampled complied with the
food manufacturers on TFA policy implementation current TFA limits.59 The SFDA is planning another
that brought together companies of all sizes and inspection campaign for early 2020 to monitor
allowed the small and mid-size manufacturers to compliance with the PHO ban. Mr. Almotairi noted
benefit from the experience of the larger ones that that their greatest challenge is likely to be monitoring
had already reformulated to remove TFAs from compliance, given that a test for PHOs does not
their products in other countries. This strategy exist. SFDA will look to other countries such as the
was successful in helping the small and mid-size USA and Canada with similar policies for guidance
manufacturers comply with the policy. SFDA also on best practices.60 While Saudi Arabia also intends
makes guidance available on its website on how to to develop a plan for evaluating the health impact of
reduce TFAs in products and replace sources of TFAs the policy, Mr. Almotairi believes that the impact on
with healthier fats. CVD outcomes would be maximised if the TFA policy
was combined with other measures for improving
CSOs, academia, and WHO are also important nutrition to reduce NCDs, which is why the country
partners. Mr. Almotairi explained that representatives is enacting multiple policies as part of its Healthy
from CSOs and academia participated in a specialised Food Strategy. In addition to limiting TFAs, the
committee that was involved in the development of Healthy Food Strategy includes reducing sugar, salt,
the regulations. CSOs and academia also provide and fat in food products, requiring calorie labelling
support through advocacy and communications, in restaurants and cafes, and improving nutrition
materials on healthy diets, including websites, surveillance through both regulation and voluntary
tools, campaigns, and workshops, and conducting measures.61
research and evaluation. Dr. Ayoub Al-Jawaldeh,
Regional Advisor for Nutrition at WHO EMRO, Overall, Saudi Arabia’s enablers to enacting and
confirmed that WHO has been a valuable partner implementing TFA policies included political will,
in providing resources and technical support to the vision, targets, multi-sectoral coordination, and
Saudi government. Dr. Al-Jawaldeh explained that capacity building. As Dr. Al-Jawaldeh explained, “In
WHO EMRO works with Saudi Arabia and other Saudi Arabia, they have a strong FDA; they have
governments in the region to enhance the technical Vision 2030; there is political will from the Minister
capacity at the regional and country levels and build of Health to implement [policies]. There is also proper
capacity through networking and partnership to coordination between all sectors,… participation
promote research and evidence generation. Dr. Al- from academia, [and a] good working relationship
Jawaldeh noted, “Saudi Arabia is an active member between WHO and the government in Saudi Arabia.”
of the WHO region…. WHO has tools, guidelines,
training, [etc,....that ] have helped Saudi Arabia and all Saudi Arabia’s case may serve as a model for other
countries in the region to expedite implementation” countries to follow in the EMRO region and elsewhere.
of evidence-based TFA and other policies.
Dr. Al-Jawaldeh stated that Saudi agencies across
government, including the SFDA and the Ministers “Saudi Arabia is doing a great job in
responsible for health, trade, education, and
information, are committed to implementing the terms of addressing obesity and NCDs.
TFA policies. He also added, “Saudi Arabia is a good They are moving forward with many
example where we can see harmony and proper
coordination within government with different interventions…. With this current
sectors and also with research institutions and with momentum they are really helping other
civil society.”
countries learn from their success story.”
Dr. Ayoub Al-Jawaldeh, Regional Advisor for Nutrition,
WHO EMRO
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Slovenia
KEY POINTS
Slovenia enacted a TFA limit of 2 grams per
100 grams fats and oils in 2018 to address
the importation of TFA-laden products
from other European countries without TFA
policies, particularly Balkan countries, and
to reduce TFAs in foods produced locally
by small manufacturers, such as bakeries
and pastry shops.
Researcher-advocates played a key role in
making the case for policy by conducting
and publicising research on the levels
of TFAs in Slovenian products and their
health harms.
The potential for regional EU policy
delayed the Slovenian national policy The Need for Policy
initially, while they waited for the EU
to act. While Slovenia moved forward Many of the first countries to enact TFA limits were
with enacting and implementing its own in Europe, including Denmark, Austria, Hungary,
national policy, the government still Iceland, Norway and Switzerland, and they were
called for regional policy enactment and seen as leaders on TFA policy from 2003 to 2014.62
implementation. While the level of TFAs in the food supply had
declined during that time period in many European
countries, research63 – including a 2014 study led by
Danish researcher Prof. Steen Stender64 – showed
that these declines were not being experienced in
all European countries. While deaths from CVD as
a share of total deaths was lower in Slovenia than
the EU average in 2011,65 this status was at risk
without policy action. Prof. Stender’s pivotal study
found that biscuits, cakes, and cookies purchased
from several Western European countries contained
no TFAs, but that was not the case for other Central,
Eastern, and South-Eastern European countries,
including Slovenia.66 The researchers found that in
these countries, TFA levels in pre-packaged biscuits,
cakes, and wafers had not dropped meaningfully
since the mid-2000s, in contrast to other, mostly
Western European countries where TFA levels had
dropped to nearly zero.67 A number of products
the researchers purchased in Slovenia contained
TFAs, with concentrations of up to 9 per cent.68 In
fact, a follow-up study showed that levels of TFA
as a per centage of total fat in biscuits, cakes, and
wafers in Slovenia further increased between 2012
and 2014, up to 17.9 per cent.69 The majority of
the products in Slovenia with high levels of TFAs
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“A legal limit on TFAs in foods is the
most effective way to protect the entire
population, especially vulnerable groups
such as children and pregnant women,…
and especially those population groups
with the highest consumption of such
foods. In addition, consumers who have
not reached awareness of presence of
TFAs would also be protected.”
Ms. Mojca Triler, Senior Advisor,
Ministry of Health, Slovenia
Researchers and advocates, including the Slovenian
Consumers Association, developed educational
campaigns about the harms of TFAs and collaborated
on a television program “Tarca”,72 produced by
Slovenia national television, to educate policy-
makers and consumers about Slovenia’s exposure
were imported from Balkan countries without TFA to imported foods high in TFAs. In early 2016, Prof.
policies, including Bosnia & Herzegovina, Croatia, Pravst and colleagues received funding from the
Montenegro, North Macedonia, and Serbia.70 In the Slovenian government to carry out research on TFAs
absence of a TFA policy, products containing TFAs and presented preliminary findings at an October
were being imported to and distributed in Slovenia, 2016 press conference. The research is ongoing,
whereas those products by law could not be sold in and further results have been presented to the
other European countries with TFA policies in place. government through publications and additional
International researchers presented this information public forums. The research found that the proportion
to the Slovenian government, which Mojca Triler, a of products with PHOs in categories that previously
senior advisor with the Slovenian Ministry of Health, had high levels of PHOs, including vegetable cream
said was “quite shocking”. In response, the Ministry substitutes, soups, biscuits, crisps, and snacks,
of Health and Slovenian Research Agency funded a decreased considerably between 2015 and 2017.
national research study to identify the main sources However, PHO content remained high in some foods,
of TFAs in the food supply and levels of TFA intake including cakes, muffins, pastries, and biscuits.73
in both the general population and key population Additionally, packaged margarines in food stores
groups in Slovenia.71 were found to mostly contain minimal levels of TFAs,
while a considerable proportion of food operators
(primarily bakeries) still used PHOs.74 About a quarter
The Path to Policy of sampled products that were used by food service
When data on the high levels of TFAs in some providers contained more than 2 per cent TFAs, with
foods in Slovenia emerged in 2014, researchers some having TFA levels as high as 11 per cent of total
and advocates sought to identify how to use the fats.75 The researchers concluded that previous food
data to spur action. Slovenian researcher Prof. Igor policy involving voluntary guidelines76 and regular
Pravst with the Nutrition Institute explained that his public communication of the risks related to the TFA
organisation planned educational events, including consumption had a considerable effect on the food
a scientific conference and a press conference, to supply, but had not resulted in sufficient removal of
educate Slovenian policy-makers and other key PHOs.77
stakeholders about the country’s TFA problem.
International researchers, including Prof. Stender, Given that the majority of products high in TFAs
presented their data, which generated substantial were imports,78 the Slovenian government realised
media attention. that commitment from national industry was not
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enough to solve Slovenia’s TFA problem. They create a harmonised approach to limiting TFAs.
learned that producers in Balkan countries that Slovenia delayed issuing its own decree for a year
were importing their products into Slovenia were in anticipation of a European Commission report on
unable or unwilling to make their products without TFAs in the EU, but the Commission delayed their
TFAs because of lack of raw materials, technology, project. Prof. Pravst believes that one reason the
or pricing considerations. Ms. Triler explained the EU TFA policy wasn’t a priority was because TFA
government’s conclusion, “A legal limit on TFAs exposure was no longer a problem in many Western
in foods is the most effective way to protect the European countries. However, the EU delay was
entire population, especially vulnerable groups putting Slovenian consumers at risk, so the national
such as children and pregnant women,… and government ultimately decided to take action. The
especially those population groups with the highest European Commission released a draft regulation to
consumption of such foods. In addition, consumers limit TFAs to 2 grams per 100 grams of fat in October
who have not reached awareness of presence of 2018 and adopted the regulation on 24 April 2019.79
TFAs would also be protected.” The regulation is directly applicable in all EU Member
States and has a compliance deadline of 1 April 2021.
Once the Slovenian government decided to move
forward with policy, engagement across sectors was Even though Slovenia has enacted its own policy,
needed for enactment. The Ministry of Health began Ms. Triler believes that a regional EU policy would
by drafting a proposed decree, which went through still be beneficial, given that the majority of products
the public consultation process with multiple in Slovenia that are high in TFAs are imported from
stakeholders, including the Chambers of Commerce, countries without TFA policies, both within and
Agriculture, and Food. The decree followed the outside of the EU. An EU regulation would also
Danish model of limiting TFAs to 2 grams per 100 likely have an additional benefit of incentivising food
grams total fat but was broader in applying the TFA producers in the wider European region, including
limit to all foods, including foods used as ingredients Russia and Turkey, for example, to reformulate their
that were not sold directly to consumers. products to meet the EU regulation so they can
export their products into the EU. Therefore, an EU
In October 2017, the European Commission was regulation could be expected to reduce TFA content
notified of the harmonised draft decree, as required beyond EU borders.
by EU procedures for technical regulations. A
temporary suspension period of three months was Effective Messages and Tactics
established to give the European Commission and
other EU member states time to comment and Ms. Triler and Prof. Pravst agree that concerns about
propose amendments, as is required when national the health effects of TFAs and the high levels of TFAs
measures could have an impact on EU trade and in Slovenian products were the strongest arguments
free movement of goods. During that time, Slovenia for the policy. Ms. Triler explained, “We had a strong
received a request for supplementary information argument that limiting TFAs was important to protect
from the European Commission and comments from consumer health.” The Slovenian government had
the Austrian government. After the comment period been pressured to take action primarily as a result
closed on 22 January 2018, national interministerial of the research, education, and media campaigns by
coordination took place, and the Ministry of researchers and advocates with CSOs including the
Agriculture, Forestry, and Food, which has authority Nutrition Institute, the National Institute for Public
over food regulation, adopted the decree. The decree Health, and the Slovenian Consumers Association.
was officially published on 20 March 2018, and press She noted that the relevant national industries were
conferences were held by the Ministry of Health and on board because the majority of their products
other supporters to announce the policy, which took already complied with the decree; however, this
effect 15 days later in April 2018. Food products on was not the case for small food enterprises like
the market were required to be in compliance with pastry shops. Given this, Ms. Triler believes that
the TFA limit by 7 April 2019. the policy is important and should improve the
situation. The Ministry of Agriculture, Forestry, and
Food will be responsible for monitoring compliance,
Regional Policy Interplay and the Ministry of Health plans to develop a plan
The Slovenian government almost did not move for evaluating the impact of the policy on health
forward with the national TFA policy because they outcomes over time.
were informed that the European Commission was
planning to develop an EU regional policy that would
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