Sunday, December 17, 2006

The Singular Focus on Trans-fats Obscures the Important Role of Balanced Nutrition in Managing the Obesity Epidemic – Ellen Klein

The singular public health focus on the elimination of trans-fats has obscured the importance of other food related problems such as poor nutrition and vitamin intake. Interventions that concentrate solely on removing trans-fats from food overlook the problem of nutritional deficiencies. The obesity epidemic would be more effectively managed if a more comprehensive public health approach was to be implemented which includes overall nutritional awareness building and vitamin screenings.

The problem with the current approach to eliminate trans-fats as the singular solution to the obesity has been twofold. Firstly, by exclusively concentrating on the removal of trans-fats, the public receives the erroneous message that weight issues can be solved by simply eliminating trans-fats from our diets. Foods that are high in trans-fats are often unhealthy for other reasons, so the public can get a false sense of security that the removal of the trans-fats now renders this food healthy. Weight loss cannot be maintained if proper nutrition is neglected. Secondly, public health awareness of the benefits of maintaining adequate vitamin intake and nutritional balance is not achieved. Public health providers need to include the message of adequate nutrition in the campaign to decrease obesity.

What are trans-fats? Trans unsaturated fatty acids, (“trans fats”), are solid fats produced artificially by heating liquid vegetable oils in the presence of metal catalysts and hydrogen. (1) This process, partial hydrogenation, causes carbon atoms to bond in a straight configuration and remain in a solid state at room temperature. Naturally-occurring unsaturated fatty acids have carbon atoms that line up in a bent shape, resulting in a liquid state at room temperature. Trans fats are produced commercially in large quantities to harden vegetable oils into shortening and margarine. The oils used to cook French fries and other fast foods are usually this kind of partially hydrogenated oil, containing trans fats. Commercial baked goods frequently include trans fats to protect against spoilage and to add crispness to foods. They raise both total cholesterol and LDL, the "bad" cholesterol, levels while lowering levels of beneficial, HDL cholesterol in the body.

Commercial production of partially hydrogenated fats began in the early 20th century and increased steadily until about the 1960s as processed vegetable fats displaced animal fats in the diets of the U.S. and other Western countries. Lower cost was the initial motivation, but health benefits were later claimed for margarine as a replacement for butter. (2)

So, what changes are needed to improve the current public health approach to the obesity epidemic? First, the epidemic could be better managed if it were integrated with nutrition education. Overall nutritional education is a vital part of the message. A balanced diet of adequate nutrients and caloric needs must be maintained to ensure proper health. The USDA’s 2005 Dietary Guidelines for Americans recommends “a variety of nutrient-dense foods and beverages within and among the basic food groups while choosing foods that limit the intake of saturated and trans fats, cholesterol, added sugars, salt, and alcohol.” (3)

Second, obesity screening interventions could be combined with vitamin blood level screenings. In almost every public health setting, combined screenings are often more effective than screenings of one disease alone. Many people have deficient levels of vitamin in their blood, but are not aware of it. The efficacy of individual public health screening interventions is often improved when integrated with another screening intervention program. For example, safe sex campaigns integrated with STD and HIV screenings improve the success rate of both projects. A site that provides flu shot vaccines could benefit from being combined with tuberculosis screenings. Mammograms could be done on female partners accompanying men undergoing prostate screenings. Hearing & eye tests could be done at the same time as depression screenings. These are just a few examples of how public health goals can be met more easily through synergistic integration. This same approach could be made with obesity interventions and vitamin level screenings.

In the United Kingdom, an integrated approach has already begun. Encouraging are recent requests for dieticians to “take on a wider role in health promotion” A survey of readers subscribed to Network Health Dietitians magazine revealed that professional dieticians in the UK wish to more actively participate in other public health issues. Eighty one percent of the dieticians surveyed expressed desire to expand their roles into a “holistic approach, increasing media presence and offering exercise and smoking cessation advice.” The dieticians also expressed frustration of their profession’s lack of visibility. They believe their skills and training could be utilized in a more interdisciplinary manner to promote other public health issues. (4)

Vitamin screenings could become a “Standard of Care” for patients being treated for obesity. Results from the screenings would have two useful purposes. First, the screening results would provide important health information to both the patient and care provider. Patients would discover information about their own vitamin levels and be able to take action to correct these deficiencies. Vitamin deficiencies are the main reason for many health problems, as discussed further in this paper.

Second, if providers were required to submit results of vitamin serum level screenings, a database could be formed that would reveal trends in vitamin deficiencies for a particular community or region. These screenings could be enforced by Department of Public Health, the same way they mandate the reporting of certain infectious diseases.

Obese adults are chronically vitamin deficient of the fat soluble vitamins: A, D, E and K. Excess layers of adipose tissue position fat soluble vitamins out of reach from blood vessels which would ordinarily resorb the vitamins from fat storage. An observational clinical trial revealed that obese subjects had significantly lower basal vitamin D concentrations and higher parathyroid hormone concentrations.

Cancer, rickets, poor eyesight, and immune disorders are caused by deficient levels of fat soluble vitamins. (5) “PubMed database search yielded 63 observational studies of vitamin D status in relation to cancer risk, including 30 of colon, 13 of breast, 26 of prostate, and 7 of ovarian cancer, and several that assessed the association of vitamin D receptor genotype with cancer risk.” (6) Much research is being done now to find the link between Prostate cancer and vitamin D deficiency. A biological link has been discovered, and epidemiologic data need to be researched to support this link. (7)

A problematic result of the current public health approach, which solely focuses on trans-fats elimination, is the escalation of lawsuits against fast food companies and food manufacturers. “…there are public health groups that are trying to pursue such an approach. For example, the Public Health Advocacy Institute states that: "Tobacco litigation focused on the tobacco industry's behaviors that interfered with the consumer's ability to make a free and informed choice. As in tobacco, there is a similar concern with the food industry." (8)

These legal claims serve to reinforce the erroneous idea that trans-fats are the sole culprit of obesity. The group sued Kraft Foods, Inc. in 2003 to eliminate trans-fat in Oreo cookies. Kraft eliminated trans-fat from Oreos and reduced or eliminated it in about 650 other products. Also, in 2003, prevailed in a lawsuit against McDonald’s. McDonald’s agreed to pay $7 million to the American Heart Association to fund a trans-fat program. It is important to note that even though these foods are trans fat free they are still very unhealthy. A single serving of Oreos (34g or roughly three Oreos) contains 7 grams of fat, which represents 11% of the USDA daily recommended intake of fat based on a 2,000 calorie diet, while being totally devoid of vitamins. (9) A large order of McDonald’s French fries contains 30g of fat, or 47% of the recommended daily intake based on the same guidelines. (10) It is clear that even without trans fats, the over consumption of these foods can still lead to obesity. The success of these two suits against Kraft and McDonald’s reinforces the message that trans-fats are the holy grail of obesity and serves to eclipse importance of balanced nutritional intake. (11)

A hyperbolized focus on trans-fats communicates fear and negativity, which is an ineffective and often maladaptive mode of communication. Guided by the Extended Parallel Process Model (EPPM) investigators Cho and Witte discuss fear and health risks: “ …if an audience is already frightened by a threat and feel hopeless, further heightening of threat perceptions may promote self-defeating actions, instead of self-protective actions.” When people feel they have some control, ‘high self efficacy’ over a solution, they are more likely to engage in steps toward the solution. Alternatively, when they perceive the solution has ‘low self efficacy’, they engage in defensive denial and avoidance. (12) After all why should we worry about things we have no control over? Furthermore, by creating an inordinate fear of a small part of a much larger problem can lead people to feel that the danger has past once the small piece is removed. People are so frightened of trans fat in particular that they either give up on trying to eat healthy, since trans fats are in many convenience foods, or they work to have it removed by legal or legislative action. In either case, once the trans fat is gone the public believes that the risk is gone with it. They then shift their attention to other matters and can lose sight of the big picture. By focusing on the tree that is trans fat, the public can miss the forest.

This week, the Board of Health of New York City passed the first citywide ban on trans-fats in restaurant cooking. Some believe that a new standard has been set in Public Health. While it is definitely a step in the right direction, the long-term beneficial effect toward managing the obesity epidemic will be realized only if the messages for balanced nutritional diets are also emphasized. Banning trans-fats is an excellent and important intervention, though it will not be successful without additional interventions such as nutritional education and vitamin screenings.
Focusing solely on the elimination of trans-fats as the ultimate solution to reducing obesity is a strategy, which provides a misleading public health message, while doing nothing to reduce the obesity epidemic. The use of fear and legal action reduces self-efficacy and reinforces the message that no other intervention is necessary for weight loss. An integrated approach including nutrition education, vitamin screening, and overall nutritional balance would improve the management of the obesity epidemic.

1.) Katan MB, Mensink RP, Zock PL. Trans fatty acids and their effect on lipoproteins in humans. Annu Rev Nutr 1995; 15:473-493.
2.) Herman, R. (Nov 15, 1999) Transfatty acids and Coronary Heart Disease. Retrieved Nov 22, 2006.
3.) USDA Dept of Health and Human Services (Jan 12, 2005) New Dietary Guidelines will Help Americans Make Better Food Choices and Live Healthier Lives Retrieved Nov 20, 2006
4.) No author cited. (Nov 10, 2006) 98% Of UK Dietitians Want Wider Role In Public Health. Medical News Today.
5.) American Journal of Clinical Nutrition, Vol. 72, No. 3, 690-693, September 2000.
6.) Holick,MF.Am Journal Public Health Am J Public Health. 2006 Feb;96(2):252-61. Epub 2005 Dec 27.
7.) Schwartz, GG. Cancer Causes Control. 2005 Mar;16(2):83-95.
8.) Siegel, M (July 11, 2005) Obesity Lawsuits Tryiing to Follow Tabacoo Model . Retrieved June 13, 2006.
9.) (2006) Oreo Sandwich Cookie Nutritional Info, Retrieved December 6, 2006.
10.) (Nov 12, 2006) McDonald’s USA Nutritional Facts for Popular Menu Items. Retrieved Dec 6, 2006.
11.) (Feb 11, 2005) The Campaign to Ban Partially Hydrogenated Oils. Retrieved Nov 15, 2006.
12.) Cho, H. & Witte, K. (Oct 2005) Managing Fear in Public Health Campaigns: A Theory-Based Formative Evaluation Process. Health Promot Practice 6(6(4):482-90.


Blogger Michael Siegel said...

This is a very strong critique, and extremely timely in light of New York City's decision just this past week to ban trans-fats in restaurants. I think you should share this critique with public health officials and policy makers in NYC. I think it is an important paper, and needs to be seen by all public health practitioners who might have input into these types of regulations in the future.

5:00 PM  
Anonymous Anonymous said...

The recommendation of pairing screenings with eduational programs is a great idea. It seems that the trans-fat obsession while good intentioned was limited but could be salvaged if accompanied by an educational campaign?

5:59 PM  
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Anonymous Hill Park said...

Thanks for this post, I have been wondering about how fast food joints would deal with all of the discoveries about the dangers of trans fat in processed foods.

8:58 AM  

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