By Gilbert Ross, M.D.
Posted: Tuesday, February 2, 2010

LETTER
Publication Date: February 2, 2010

The February 2, 2010 issue of Annals of Internal Medicine features this retort to Dr. Marcia Angell and colleagues on New York City's trans fat ban, along with the original authors' reply:

TO THE EDITOR:

Angell and colleagues (1) want to be congratulated for finding that their own regulatory approach has succeeded -- according to them. The New York City Department of Health and Mental Hygiene passed a regulation restricting the use of trans fatty acids (TFAs) in chain restaurants, and the authors have discovered that -- lo and behold! -- this law is being obeyed. But what have they accomplished in terms of public health? That is a difficult question to answer.

The amount of TFAs in one's diet is repeatedly referred to as a "recognized risk factor" for heart disease. However, this assessment is based entirely on observational dietary studies -- and diet is not listed among the main coronary risk factors. Furthermore, on the basis of my twenty-plus years of practicing internal medicine, I can attest to how hard it is to significantly reduce lipid levels through diet, despite all the stringent diet programs we so assiduously distributed to our at-risk patients. Now, at last, the authors assert that they have found the culprit: TFAs. They say that by eliminating these heart-attack generators, we can relax and throw away those statins.

Not so fast. Is there a shred of evidence that decreasing TFA intake actually lowers lipid levels -- much less reduces the toll of cardiovascular disease? No. So why are the authors trumpeting how their new regulations have led to restaurant food with "healthier fatty acid profiles"?

Health issues aside, where will such measures lead us? In the accompanying editorial (2), Gerberding says, "Unfortunately, relying on consumers alone to make healthy choices about food intake is a strategy that has not worked, as our growing obesity epidemic demonstrates." Since when is "allowing" Americans to choose their own food a public health strategy? And what does TFA intake have to do with the obesity epidemic? Not a thing, as I'm sure Gerberding knows.

If the authors are allowed to merely declare that their government regulatory program on TFAs is a success, there are in all likelihood more such strategies for "guiding" consumer health choices coming down the pike, to your local pharmacies and restaurants, and your kitchens. The authors apparently believe that we cannot be trusted to figure out our own diet choices regarding our health, and they nominate the New York Department of Health and Mental Hygiene to be the food arbiter of first resort. This would be a bad idea for health and for personal responsibility.


Gilbert L. Ross, M.D.
American Council on Science and Health
New York, NY 10023


References

1. Panel on Macronutrients. Letter report on dietary reference intakes for trans fatty acids. In: Institute of Medicine. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Washington, DC: National Academies Pr; 2002.

2. Mensink RP, Zock PL, Kester AD, Katan MB. Effects of dietary fatty acids and carbohydrates on the ratio of serum total to HDL cholesterol and on serum lipids and apolipoproteins: a meta-analysis of 60 controlled trials. Am J Clin Nutr. 2003;77: 1146-55. [PMID: 12716665] extension. A practical solution would use bootstrap estimation (4), which is also useful for bias correction (as also suggested by Cook and Ridker). Ewout W. Steyerberg, PhD Erasmus MC University Medical Center Rotterdam Rotterdam 3015, the Netherlands.