The principal finding

The findings of this study clearly demonstrate that in 2014, I-TF was still present in high concentrations in many different brands of popular foods in each of the six countries in South–eastern Europe, and the number of different packages with high amounts of I-TF has increased considerably since 2012 (figure 1). The voluntary reduction in the amount of I-TF in foods by food producers appears to work well in some European countries but not—as demonstrated here—in others.7 With altogether 23 different producers of prepackaged biscuits/cakes/wafers with high amounts of I-TF in 2012 and with an increase to 33 different producers in 2014 (figure 3) and a competitive market, the possibility of an effective voluntary reduction in I-TF is probably slim.

Strengths and weaknesses of the study

A strength of this study is that the same procedure to obtain popular foods found in large supermarkets in six European capitals in 2012 was followed in the same supermarkets in 2014, and that the products were analysed for I-TF in the same laboratory. The study demonstrates that I-TF is used in the prepackaged foods that were analysed and that the presence of these foods has increased considerably in just 2 years. I-TF was not measured in products collected in 2012 and in 2014 that did not meet the inclusion criteria. It leaves the theoretical possibility that more products contained I-TF in 2012 than appears from the measurements (but there is also the possibility that more products contained I-TF in 2014 than was observed in this study). The suggestion about an increase in the presence of foods with high amounts of I-TF from 2012 to 2014 rests on the assumption that the number of foods with appreciable amounts of I-TF but without partially hydrogenated fat or similar term in the list of ingredients is small in 2012 and in 2014 compared with the number of foods that fulfil the inclusion criteria. The assumption seems justified, first of all, because it is illegal in most European countries to omit labelling if partly hydrogenated fat is present in prepackaged food. Many of the prepacked biscuits/cakes/wafers on the shelves in the supermarkets in the six countries have in the list of ingredients several other languages such as English, German or French in addition to the local language and the language of the country of origin. This means that the products were also meant for export. It seems unlikely that food producers would risk an export to a big market because of misleading information that public food or health authorities in any country could easily reveal.

A considerable number of products had less than 2% of total fat as I-TF in spite of the term partly hydrogenated fat or similar term in the list of ingredients. This may be due to the consideration of some food producers that a mixture of cis unsaturated fat and fully hydrogenated fat without I-TF is understood to be partially hydrogenated fat. An additional explanation is an effort of the producer to empty stores of old package material after a change of the recipe to fat without I-TF even if the recipe is permanently changed. If the recipe only is temporarily changed due to favourite prices for non-hydrogenated fat, the producer may find it better to maintain the term partly hydrogenated fat even though the food temporarily is without I-TF. The increase in number of these packages, together with an increase in number of packages containing foods with more than 2% of the fat as I-TF, suggests an increase in sale of all biscuits/cakes/wafers. The competition of shelf space in supermarkets is usually fierce. If products do not sell, they are rapidly replaced by other products.

It is unknown why there has been such a large increase in the availability of these foods with high amounts of I-TF in all of these six European countries between 2012 and 2014. One possibility is aggressive marketing efforts by the relatively few large producers in these countries (figure 1). Another possibility is that the economic downturn that all of these countries experienced in 2013 and 2014 created financial constraints and led consumer demand for cheap candy-like food such as prepackaged biscuits/cakes/wafers to increase.

The presence of high concentrations of I-TF in biscuits/cakes/wafers may be a sign that I-TF is used in other foods as well. This is supported by the high concentrations recently reported in certain brands of Serbian margarine.9 Other internationally published reports about I-TF in other foods in these countries are non-existent.

A limitation of this study is that no other food groups (such as shortenings and margarines) and no unpackaged foods (such as baked goods, sweet rolls, pastries and buns) were investigated. Another limitation is that the average daily intake of I-TF was not measured in any subgroup of the populations but instead was inferred from the availability of popular foods with high amounts of I-TF in large supermarkets. A relevant subgroup would be the consumers who buy biscuits/cakes/wafers.

Voluntary reduction of I-TF in foods

Each of the top 10 producers in 2012 of biscuits/cakes/wafers except one—producer A—has increased the number of different foods with high I-TF in 2014 compared with 2012 (figure 3). It suggests that the intake of I-TF increased during this period. A considerable increase or reduction in the concentration of I-TF in a given product appeared when products obtained in 2014 were compared with products obtained in 2012 with the same barcode number and the same selling name (figure 2, right panel in the middle). This variation suggests that the recipe for some of the products do not require the same I-TF concentration from batch to batch. The I-TF concentration apparently depends on the price and availability of the fat used for the production of the product, considerations that seem to outweigh the recommendation to minimise the use of I-TF in human food. If a producer removed I-TF from a product between 2012 and 2014 and, at the same time, removed the term partially hydrogenated fat from the list of ingredients, the product will not appear in our 2014 purchase, since it did not fulfil the inclusion criteria. This may explain the disappearance of at least some of the 49 products between 2012 and 2014 (figure 2 lowest panel to the left).

When voluntary reduction of I-TF in foods does not work, labelling of prepackaged foods with the contents of I-TF is an alternative. This method has been used in the USA since 2006 but will be eliminated when the new regulation fully takes effect in 2018.5 Although labelling prepackaged foods in Europe with I-TF content may further reduce the mean intake of I-TF, such labelling still allows for the intake of high amounts because unpacked foods and foods in restaurants are not labelled, and also because consumers might not pay attention to or understand the labels.10 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. 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.

Intake of I-TF in subgroups

Certain subgroups, such as patients with severe atherosclerotic heart disease, have been told by their physicians or have read in the lay press since 1994 that I-TF is bad for the heart; many will thus avoid this type of food and have a low intake of I-TF. This may explain the very low TF concentrations found in the red blood cells of patients admitted to a tertiary heart centre in Germany between 1997 and 2001 for coronary angiography due to chest pain or other signs of myocardial ischaemia.11 The TF concentrations in red blood cells reflect the intake of TF of only several weeks.12 Even people who accept to be enrolled in studies concerning diet and health may comprise a relatively health-conscious subgroup with a low intake of I-TF.13 The low contents of TF in the blood in health-conscious subgroups of the population thus do not preclude the existence of other subgroups with a much higher intake of I-TF. A recent study from 9 EU countries reports that in spite of a low average daily intake of TF, specific subgroups exist with average intake values above the WHO maximum recommended level of 1 energy % of total TF.14 A vicious cycle apparently occurs: as long as foods with high amounts of I-TF are present in the shops, some consumers will buy them, and as long as they are bought, the foods will be available.

Since many of the biscuits/cakes/wafers in the 18 supermarkets that were visited and revisited in this study did not have the words partially hydrogenated fat or hydrogenated fat on the label, a legislative I-TF limit would not affect the supply of these foods. Even a one-to-one replacement of I-TF with saturated fat may confer a health benefit.15

WHO-Europe recently investigated the various ways to reduce I-TF in foods and concluded that establishing a legal limit for the content of I-TF in foods is potentially the only available option that reduces the risks associated with I-TF faced by all consumers, and doing so may contribute to reducing inequalities. Such a policy is unique in its combination of efficacy, cost-effectiveness and low potential for negative impact. Removing I-TF from the food supply is possibly one of the most straightforward public health interventions for reducing risk of CHD.16

I-TF legislation and CHD

Danish males and females appear to have had the highest reduction in CHD mortality in the European Union from 2000 to 2009.17 This was further investigated by comparing the decline in CHD mortality in a so-called synthetic Denmark, consisting of a composite group of OECD countries, with the observed decline in Denmark. The composite group simulated the observed decline in Denmark from 1990 to 2004, but from 2004 to 2007 the CHD mortality observed was lower than in the synthetic Denmark, corresponding to 14.2 fewer deaths per 100 000 inhabitants per year.18 The authors ascribe this reduction to the Danish I-TF legislation implemented in 2004, 3 years before the Danish antismoking legislation. Owing to reports in 1994, 2001 and 2003 from the Danish Nutrition Council about the harmful effects of I-TF in foods and subsequent media interest, most health-conscious Danes did not consume products with potentially high amounts of I-TF several years before the I-TF legislation in 2004. The extra decline in CHD mortality after the 2004 I-TF legislation in Denmark may have been due to the effect on less health-conscious consumers in particular and thereby helped reduce health inequalities. This observation supports the hypothesis that healthy environments appear to promote health more than healthy choices, as suggested by a British study quantifying the socioeconomic benefits of reducing I-TF in foods.19 Findings based on ecological data should be interpreted with care. A change in treatment guidelines for CHD in Denmark in 2003 and 2004 was therefore scrutinised. Late in 2003, acute PCI (percutaneous coronary intervention) was introduced in Denmark as the recommended treatment for acute myocardial infarct with ST-segment-elevation in the ECG (STEMI). Patients with STEMI were transported to the nearest of five centres for acute PCI. This plan was based on the findings that acute PCI at the nearest heart centre was superior to fibrinolysis, the usual treatment at the local hospital.20 Although there was a significant reduction in the composite end point consisting of death and reinfarction in the group from the referral hospital receiving acute PCI compared with the group receiving the usual fibrinolytic treatment, there was no significant difference in coronary mortality. After a 7.8 years follow-up period, the cumulative coronary death rate in the group from the referral hospital that received acute PCI was 12.4% versus 15.6% (p=0.06) in the group that received fibrinolysis at the local hospital.21 The national change in treatment of STEMI may thus have added only marginally to the reduction in coronary death in 2004 and the following years.

An investigation of the effect on CHD mortality of a legislative TF limit in some counties in New York State compared with counties that did not have this limit suggests that the policy reduced the CHD mortality to the same extent as was observed in Denmark.22

Unanswered questions and future research

It is of considerable interest if coronary mortality did change after introduction of trans fat legislation in countries such as Iceland, Switzerland, Austria and Hungary and if it will change in Norway, Latvia and Georgia,23 countries that more recently have introduced legislation that restricts the use of I-TF.

If reduction of I-TF in foods reduces CHD, as seems likely, it follows that increased I-TF in foods increases CHD. It is of interest to discover the extent to which the increasing intake of I-TF contributed to the increase in CHD in the Western hemisphere from 1950 until its peak in 1970 to 1980 and to what extent the decline in intake of I-TF has contributed to the subsequent decline in CHD.

Globally, CHD is still the leading cause of death in spite of the recent decline in several countries. On the basis of data from 2009 to 2011, there is a 10-fold difference in age-standardised mortality rates of CHD between some countries within WHO-Europe, with countries in Central Europe, Eastern Europe and Central Asia having the highest rates.24 It is unknown why, when taken together, these countries had only a 2.8% reduction in CHD mortality between 1990 and 2010, in contrast to the global reduction of 19.5% and the more than 40% reduction in several Western European countries during the same period.25 It seems obvious to investigate the presence of I-TF in popular foods in these countries with excessively high CHD mortality.

Finally, it will be interesting to investigate the reasons for the resistance to implementing a legal limit for I-TF in foods in the European Union for more than 10 years now in spite of the facts that such a legislation has already been introduced in several European countries, is strongly recommended by various scientific organisations, and has been found by the WHO to be the cheapest and most effective way to reduce CHD.26