Products with industrial TF in supermarkets

In each of 20 European capitals, three large supermarkets were visited in 2012–2013, and in five of the capitals and in Malmö, Sweden, an additional three ethnic shops were visited. A total of 598 packages containing biscuits/cakes/wafers were bought and analysed for TF content, and 396 of these products contained high amounts of I-TF (more than 2 g/100 g of fat). In 25 different products, the I-TF content was higher than 40/100 g of fat. Similarly high values of I-TF in foods bought in Poland and in Serbia have also been reported in Polish and Serbian studies.22 ,23 The findings clearly demonstrate that I-TF is still present in 2013 in high concentrations in popular foods in many countries in Europe (figures 1 and 2).

Some foods with partially hydrogenated fat or a similar term in the list of ingredients did not contain significant amounts of TF based on a chemical analysis. A mixture of cis unsaturated fat and fully hydrogenated fat without TF is understood by some food producers to be partially hydrogenated fat.

In all 20 countries except for Denmark and Austria, it is legal to use as much I-TF in foods as technically possible without providing the quantity on the list of ingredients. Governments and consumer associations strive to follow the recommendations of the WHO. The voluntary reduction in the amount of I-TF in foods by food producers appears to work well in some countries, but not in others. Food producers in a given country or in neighbouring countries may remove I-TF from their products, but importing products with high I-TF content from more distant countries may counteract the initiatives, as demonstrated in the supermarkets in southern Sweden (figure 1, panel 4). Based on previous measurements, the I-TF content in biscuits/cakes/wafers from supermarkets in Germany, France and the UK was nearly eliminated between 2005 and 2009,19 and no products with significant amounts of TF were found in 2013 (figure 1). This result contrasts with the situation in Poland, Bulgaria and Romania, where there were no obvious changes in the presence of I-TF in foods between 2006 and 2013 (figure 3). The products in these countries were primarily from local food producers. Hungary and, especially, the Czech Republic showed a decline in high-I-TF foods during the same period.

Products with industrial TF in ethnic shops

Although the number of consumers who regularly buy food in ethnic shops may be lower than the number of consumers who purchase food in large supermarkets, the harmful effect of I-TF is still present. Studies from Sweden suggest that mortality due to heart disease among immigrants exceeds the mortality rate in the indigenous population.24–26 Using the same internet procedure that was used to identify shops with Balkan foods in other countries, three ethnic shops where prepackaged biscuits/cakes/wafers with high amounts I-TF were available were found in Copenhagen. These sales are illegal and can be stopped immediately by the food authorities, if they desire.27

In Southern Sweden, biscuits/cakes/wafers with high amounts of I-TF are present not only in small ethnic shops (figure 2) but also in large supermarkets (figure 1). This type of product has spread from the small ethnic shops to large supermarkets, suggesting considerable sales of these products, which remain legal in Sweden. The Swedish parliament decided in 2011 that Sweden should adopt the same I-TF legislation as Denmark, but the Swedish government decided to postpone the implementation on the advice of the Swedish food authorities because they found that all of the large food suppliers in Sweden, Norway and Denmark had removed I-TF from products sold in Sweden.13 They did not take into account the free flow of goods across borders in Europe. Many products with high amounts of I-TF have ingredient lists in more than 10 different languages, suggesting that they are potentially exported to many different countries. Retailers distributing these foods are present in Sweden and in other European countries, and the majority of products with high amounts of I-TF can be bought on the Internet, which is legal for private consumption only. Although foods with high amounts of I-TF were not found in large supermarkets in other Western countries, the Swedish story may repeat elsewhere.

The strength of this study is that it provides up-to-date data about the availability of popular foods containing high amounts of I-TF in 20 European countries. One weakness of the study is that the average daily intake of I-TF was not measured in subgroups of the population in the various countries but instead was inferred from the presence of biscuits/cakes/wafers with high amounts of I-TF in large supermarkets. The following assumptions led to the conclusion that these products have harmful effects: (1) the analysed brands of biscuits/cakes/wafers were stocked at the supermarkets because they are sold in considerable amounts; (2) the majority of these foods are regularly bought and consumed by the same subgroups of consumers and (3) the findings in the supermarkets in each capital are representative of the country. In addition, it is likely that the presence of I-TF in biscuits/cakes/wafers is a marker of a more widespread use of I-TF in other foods, including products that are not sold in a prepackaged form suggesting a higher intake of I-TF than that from biscuits/cakes/wafers. Another weakness of the study is that the foods were only bought in large supermarkets or in small ethnic shops with foods from the Balkans. The I-TF content in other foods sold by small, privately owned shops or street vendors was not examined. High amounts of I-TF prolong the shelf life of foods, and it is reasonable to assume that this factor is even more important for small shops than it is for larger supermarkets. The selective pattern of purchasing in the present study may thus have led to an underestimation of the amounts of I-TF consumed by subgroups of the population, such as truck and taxi drivers, manual labourers and members of minority ethnic groups, who already have an increased risk of coronary heart disease partly because of lifestyle factors such as smoking, poor diet and metabolic syndrome.28

A legislative limit of industrial TF in foods or a voluntary reduction?

EU countries, with the exceptions of Austria and Denmark, legally allow foods with a high amount of I-TF as a percentage of the total fat content (up to 60%) to be sold without notice as long as the food is unpackaged, as it is in restaurants and fast food outlets. If the food is prepackaged, the law requires the presence of I-TF to be noted only by the term ‘partially hydrogenated fat’ on the list of ingredients. Most consumers do not recognise the hazard concealed therein and will have difficulties in, or not attempt to decipher the often illegible text in the list of ingredients.29–31

Societal pressure on food producers has undoubtedly resulted in a reduction in the population-level mean intake of I-TF from 2005 to 2013, especially in Western EU countries19 but high intake of I-TF is still possible in Eastern Europe and South-eastern European countries, with no obvious downward trend in the availability of these foods from 2006 to 2013 in three of the countries (figure 3). High intake of I-TF in subgroups will continue as long as popular foods with a high concentration of I-TF are available. Although labelling foods with I-TF content may further reduce the mean intake of I-TF, such labelling still allows for the intake of high amounts because fast food in restaurants is not labelled and because consumers might not pay attention to or understand the labels.31 An important advantage of a legislative limit on the I-TF content of food is that it does not require that the population learn about the health risks of I-TF or pay attention to the labels of food products. Furthermore, it is simpler and less expensive to monitor the presence of I-TF in foods at the sales level than to monitor the actual intake of I-TF at the individual level in at-risk subgroups of the population.

Because many of the biscuits/cakes/wafers in the supermarkets that were visited did not contain I-TF, a legislative I-TF limit would not affect the supply of these foods and would most likely moderately affect the production of most food producers. It has been shown that I-TF in cakes, cookies and microwave popcorn can be replaced by a mixture of saturated, monounsaturated and polyunsaturated fat, which is a healthier fat composition than a one-to-one substitution of I-TF with saturated fat.32 A reduction in I-TF content without a commensurate increase in saturated fats was found in fast food purchases in New York City's restaurants after legislative restriction of I-TF in restaurants.33 The regulations in Austria, Denmark, Switzerland, Norway and Iceland have shown that the health risks of high intake of I-TF can be eliminated for the entire population without any noticeable side effects for consumers. The extent to which the difference in the presence of I-TF in popular foods in Eastern and Western Europe contributes to the much higher mortality from coronary heart disease in Eastern Europe than in Western Europe remains to be determined.34 It also needs to be determined to which extent the approximate 70% reduction (the highest reduction in the EU from 1980 to 2009) in coronary mortality among Danish men and women is actually due to a minimal intake of I-TF in all subgroups in Denmark during the latter part of this period.34

The effectiveness of policies for reducing dietary TF was recently assessed based on studies published between 2005 and 2012.17 It was found that ‘bans were most effective in eliminating TF from the food supply, whereas mandatory TF labelling and voluntary TF limits had a varying degree of success’. This statement is strongly supported by the findings in the present study concerning the current availability of popular foods with high amounts of I-TF in Europe, thus lending support to a legislative TF restriction by the EU. This is a low hanging fruit to pick in the prevention of coronary heart disease among 500 million EU citizens.