Christine J. Curtis

Change in Trans Fatty Acid Content of Fast-Food Purchases Associated With New York City's Restaurant Regulation: A Pre–Post Study

BACKGROUND Dietary trans fat increases risk for coronary heart disease. In 2006, New York City (NYC) passed the first regulation in the United States restricting trans fat use in restaurants. OBJECTIVE To assess the effect of the NYC regulation on the trans and saturated fat content of fast-food purchases. DESIGN Cross-sectional study that included purchase receipts matched to available nutritional information and brief surveys of adult lunchtime restaurant customers conducted in 2007 and 2009, before and after implementation of the regulation. SETTING 168 randomly selected NYC restaurant locations of 11 fast-food chains. PARTICIPANTS Adult restaurant customers interviewed in 2007 and 2009. MEASUREMENTS Change in mean grams of trans fat, saturated fat, trans plus saturated fat, and trans fat per 1000 kcal per purchase, overall and by chain type. RESULTS The final sample included 6969 purchases in 2007 and 7885 purchases in 2009. Overall, mean trans fat per purchase decreased by 2.4 g (95% CI, -2.8 to -2.0 g; P < 0.001), whereas saturated fat showed a slight increase of 0.55 g (CI, 0.1 to 1.0 g; P = 0.011). Mean trans plus saturated fat content decreased by 1.9 g overall (CI, -2.5 to -1.2 g; P < 0.001). Mean trans fat per 1000 kcal decreased by 2.7 g per 1000 kcal (CI, -3.1 to -2.3 g per 1000 kcal; P < 0.001). Purchases with zero grams of trans fat increased from 32% to 59%. In a multivariate analysis, the poverty rate of the neighborhood in which the restaurant was located was not associated with changes. LIMITATION Fast-food restaurants that were included may not be representative of all NYC restaurants. CONCLUSION The introduction of a local restaurant regulation was associated with a substantial and statistically significant decrease in the trans fat content of purchases at fast-food chains, without a commensurate increase in saturated fat. Restaurant patrons from high- and low-poverty neighborhoods benefited equally. However, federal regulation will be necessary to fully eliminate population exposure to industrial trans fat sources. PRIMARY FUNDING SOURCE City of New York and the Robert Wood Johnson Foundation Healthy Eating Research program.

Sodium Intake in a Cross-Sectional, Representative Sample of New York City Adults

OBJECTIVES We estimated sodium intake, which is associated with elevated blood pressure, a major risk factor for cardiovascular disease, and assessed its association with related variables among New York City adults. METHODS In 2010 we conducted a cross-sectional, population-based survey of 1656 adults, the Heart Follow-Up Study, that collected self-reported health information, measured blood pressure, and obtained sodium, potassium, and creatinine values from 24-hour urine collections. RESULTS Mean daily sodium intake was 3239 milligrams per day; 81% of participants exceeded their recommended limit. Sodium intake was higher in non-Hispanic Blacks (3477 mg/d) and Hispanics (3395 mg/d) than in non-Hispanic Whites (3066 mg/d; both P < .05). Higher sodium intake was associated with higher blood pressure in adjusted models, and this association varied by race/ethnicity. CONCLUSIONS Higher sodium intake among non-Hispanic Blacks and Hispanics than among Whites was not previously documented in population surveys relying on self-report. These results demonstrate the feasibility of 24-hour urine collection for the purposes of research, surveillance, and program evaluation.

Progress toward sodium reduction in the United States

The average adult in the United States of America consumes well above the recommended daily limit of sodium. Average sodium intake is about 3 463 mg/day, as compared to the 2010 dietary guidelines for Americans recommendation of < 2 300 mg/day. A further reduction to 1 500 mg/day is advised for people 51 years or older; African Americans; and people with high blood pressure, diabetes, or chronic kidney disease. In the United States of America, the problem of excess sodium intake is related to the food supply. Most sodium consumed comes from packaged, processed, and restaurant foods and therefore is in the product at the time of purchase. This paper describes sodium reduction policies and programs in the United States at the federal, state, and local levels; efforts to monitor the health impact of sodium reduction; ways to assess consumer knowledge, attitudes, and behavior; and how these activities depend on and inform global efforts to reduce sodium intake. Reducing excess sodium intake is a public health opportunity that can save lives and health care dollars in the United States and globally. Future efforts, including sharing successes achieved and barriers identified in the United States and globally, may quicken and enhance progress.

Reducing Sugary Drink Consumption: New York City’s Approach

Studies have linked the consumption of sugary drinks to weight gain, obesity, and type 2 diabetes. Since 2006, New York City has taken several actions to reduce consumption. Nutrition standards limited sugary drinks served by city agencies. Mass media campaigns educated New Yorkers on the added sugars in sugary drinks and their health impact. Policy proposals included an excise tax, a restriction on use of Supplemental Nutrition Assistance Program benefits, and a cap on sugary drink portion sizes in food service establishments. These initiatives were accompanied by a 35% decrease in the number of New York City adults consuming one or more sugary drinks a day and a 27% decrease in public high school students doing so from 2007 to 2013.

US Food Industry Progress During the National Salt Reduction Initiative: 2009–2014

OBJECTIVES To assess the US packaged food industrys progress from 2009 to 2014, when the National Salt Reduction Initiative had voluntary, category-specific sodium targets with the goal of reducing sodium in packaged and restaurant foods by 25% over 5 years. METHODS Using the National Salt Reduction Initiative Packaged Food Database, we assessed target achievement and change in sales-weighted mean sodium density in top-selling products in 61 food categories in 2009 (n = 6336), 2012 (n = 6898), and 2014 (n = 7396). RESULTS In 2009, when the targets were established, no categories met National Salt Reduction Initiative 2012 or 2014 targets. By 2014, 26% of categories met 2012 targets and 3% met 2014 targets. From 2009 to 2014, the sales-weighted mean sodium density declined significantly in almost half of all food categories (43%; 26/61 categories). Overall, sales-weighted mean sodium density declined significantly (by 6.8%; P < .001). CONCLUSIONS National target setting with monitoring through a partnership of local, state, and national health organizations proved feasible, but industry progress was modest. PUBLIC HEALTH IMPLICATIONS The US Food and Drug Administrations proposed voluntary targets will be an important step in achieving more substantial sodium reductions.

Highlighting the ratio of sodium to potassium in population-level dietary assessments: cross-sectional data from New York City, USA.

OBJECTIVE To contrast mean values of Na:K with Na and K mean intakes by demographic factors, and to calculate the prevalence of New York City (NYC) adults meeting the WHO guideline for optimal Na:K (<1 mmol/mmol, i.e. <0·59 mg/mg) using 24 h urinary values. DESIGN Data were from the 2010 Community Health Survey Heart Follow-Up Study, a population-based, representative study including data from 24 h urine collections. SETTING Participants were interviewed using a dual-frame sample design consisting of random-digit dial telephone exchanges that cover NYC. Data were weighted to be representative of NYC adults as a whole. SUBJECTS The final sample of 1656 adults provided 24 h urine collections and self-reported health data. RESULTS Mean Na:K in NYC adults was 1·7 mg/mg. Elevated Na:K was observed in young, minority, low-education and high-poverty adults. Only 5·2 % of NYC adults had Na:K in the optimal range. CONCLUSIONS Na intake is high and K intake is low in NYC adults, leading to high Na:K. Na:K is a useful marker and its inclusion for nutrition surveillance in populations, in addition to Na and K intakes, is indicated.

Potassium and fruit and vegetable intakes in relation to social determinants and access to produce in New York City

BACKGROUND Potassium-rich diets are inversely associated with blood pressure. Potassium intake before this study had not been objectively measured by using potassium excretion in a population-based sample in the United States. OBJECTIVES The objectives of the analysis were to 1) report mean potassium excretion in a diverse urban population by using 24-h urine collections, 2) corroborate potassium excretion by using self-reported fruit and vegetable consumption, and 3) characterize associations between potassium excretion and socioeconomic indicators and access to produce. DESIGN Participants were from the 2010 Community Health Survey Heart Follow-Up Study-a population-based study including data from 24-h urine collections. The final sample of 1656 adults was weighted to be representative of New York City (NYC) adults as a whole. RESULTS Mean urinary potassium excretion was 2180 mg/d, and mean self-reported fruit and vegetable intake was 2.5 servings/d. Adjusted urinary potassium excretion was 21% lower in blacks than in whites (P < 0.001), 13% lower in non-college graduates than in college graduates (P < 0.001), and 9% lower in the lowest-income than in the highest-income group (P = 0.03). Potassium excretion was correlated with fruit and vegetable intake. Most NYC residents reported a <10-min walk to fresh fruit and vegetables; this indicator of access was not associated with potassium excretion or fruit and vegetable intake. CONCLUSIONS Potassium intake is low in NYC adults, especially in lower socioeconomic groups. Innovative programs that increase fruit and vegetable intake may help increase dietary potassium and reduce hypertension-related disease. This trial is registered at clinicaltrials.gov as NCT01889589.

Use of Sodium Information on the Nutrition Facts Label in New York City Adults with Hypertension

The Nutrition Facts (NF) label was established to help individuals monitor their nutrient intake and select healthier foods. This tool is particularly useful for individuals for whom dietary improvements are recommended, such as those with hypertension. Study objectives were to examine the independent association between hypertension and frequency of use of the NF label for sodium information and determine whether frequent use in individuals with hypertension was associated with differences in mean sodium intake assessed through 24-hour urine samples. Data came from the New York City Community Health Survey Heart Follow-Up Study, a cross-sectional study conducted in 2010 in a representative sample of New York City adults (n=1,656). Participants were asked questions regarding frequency of checking the NF label and also had 24-hour urine samples collected to assess actual sodium intake. Results indicated that hypertension was associated with frequent use of the NF label for sodium information (adjusted odds ratio 1.71, 95% CI 1.07 to 2.73). In individuals with hypertension, sodium intake did not differ between frequent vs nonfrequent use of the NF label for sodium information (3,084 mg/day vs 3,059 mg/day; P=0.92). Although individuals with hypertension compared to those with no hypertension had 71% higher odds of frequently using the NF label for sodium information, suggesting they may be interested in decreasing sodium intake, sodium intake did not differ by frequency of NF label use among those with hypertension. Future research should explore strategies to ensure that when nutrition information is used, it is translated into meaningful results, especially in individuals with health concerns such as hypertension.

Availability of potassium on the nutrition facts panel of US packaged foods.

cine, Department of Health and Human Services. Drs Ross and Krumholz receive support from Medtronic Inc and from the Centers of Medicare & Medicaid Services to develop and maintain performance measures that are used for public reporting. Dr Ross is supported by the National Institute on Aging (K08 AG032886) and by the American Federation for Aging Research through the Paul B. Beeson Career Development Award Program. Dr Tse is supported by the Intramural Research Program of the National Institutes of Health, National Library of Medicine. Dr Krumholz is supported by a National Heart Lung Blood Institute Cardiovascular Outcomes Center Award (1U01HL105270-02). Disclaimer: The ideas and opinions expressed are the authors’ own. The content of this publication does not necessarily reflect the views or policies of the US National Institutes of Health, Public Health Service, or Department of Health and Human Services. The authors assume full responsibility for the accuracy and completeness of the ideas presented. Online-Only Material: The eFigure is available at http: //www.jamainternalmed.com. Additional Contributions: Deborah A. Zarin, MD, of the Lister Hill National Center for Biomedical Communications, National Library of Medicine, National Institutes of Health,providedcomments onanearlyversionof the manuscript. Dr Zarin received no compensation for her review.

Prevalence of partially hydrogenated oils in US packaged foods, 2012.

Although there is evidence that consumption of trans fat has declined in the United States, limited documentation exists on current levels of industrial trans fat in foods. We estimated the prevalence of partially hydrogenated oils in 4,340 top-selling US packaged foods. Nine percent of products in the sample contained partially hydrogenated oils; 84% of these products listed “0 grams” of trans fat per serving, potentially leading consumers to underestimate their trans fat consumption. Government efforts to eliminate partially hydrogenated oils from packaged foods will substantially reduce exposure to this known cardiovascular disease risk factor.