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Effectiveness of the TFA elimination policy in disease control cannot be ignored

October 01, 2023


housands of patients visit various hospitals specialising in cardiology-related care in Pakistan daily. As healthcare providers we aim to provide quality services to our patients.

With the increasing number of patients daily, my concerns have grown manifold.

Pakistan is one of the few countries in the world where people consume fats beyond safe limits. That the most injurious forms of fats, which contain trans-fatty acids (TFAs), are consumed way above the WHO-recommended limits is alarming.

This trend has serious implications for community health and healthcare system. Immediate action is required from policymakers, food regulatory bodies and civil society organisations in this regard.

Medical research has shown that the availability and intake of excessive trans-fats is a major dietary risk factor associated with many non-communicable diseases such as diabetes, cancers, obesity and various cardiovascular diseases.

Due to the high intake of TFAs and other unhealthy food ingredients, the country has more than 33 million diabetic patients, making Pakistanis the third highest disease carrying population in the world. The disease killed 400,000 people in 2021. Many of those could have been saved.

According to a WHO estimate, six out of ten deaths in Pakistan are ascribed to non-communicable diseases. A secondary analysis of national diabetes survey in 2017 concluded that generalised obesity in children has increased to 58 percent. This means that these children have the potential to develop chronic diseases in the future.

Seeing the problems associated with TFAs and their health and economic impacts in 2018, the WHO called for global elimination of industrially produced TFA by 2023 through the REPLACE action framework.

The framework was designed as a roadmap for countries to implement prompt, complete and sustained elimination of industrially produced TFA from food supply.

Many countries have eliminated TFAs and shown improvements in cardiovascular health of their citizens.

Scientific evidence published in peer-reviewed journals has shown that TFA eliminating policies are well suited to reduce heart disease across populations, and that such policies are effective in controlling TFA consumption.

Medical literature provides sufficient evidence that TFA policy interventions play a significant role in reduction of obesity, diabetes and premature cardiovascular deaths. Several studies have indicated that eliminating industrially produced TFAs (iTFAs) from the food supply reduces the risk of heart disease, diabetes, stroke and cancer. It helps socioeconomically disadvantaged populations the most by saving their hospital expenditure.

An interesting aspect of many researches is that socioeconomically disadvantaged groups outside major cities could potentially have the greatest health gains from such policy and legislative actions.

Due to the high intake of TFAs and other unhealthy food ingredients, the country has more than 33 million diabetic patients, making Pakistanis the third highest disease carrying population in the world.

A paper from Denmark tells a success story of irrefutable benefits of a complete ban on TFA. The study showed that a de facto ban on TFAs implemented in 2001 prevented 33 age-standardised deaths per 100,000 population in Denmark over a period of 15 years.

Another much larger study has suggested that a de facto TFA policy intervention can prevent 19 cardiovascular deaths per 100,000 population over a period of three years.

The impact of TFA policy intervention on reduction of obesity is similarly impressive. The reduction in the mortality rate tends to amplify in the long run. Another paper, The Impact of Policies to Reduce Trans-fats Consumption: A Systematic Review of the Evidence, shows that “policies aimed at reducing TFAs in the food supply are effective and will reduce the burden of diet-related disease, particularly among the most vulnerable socioeconomic groups. A simple extrapolation of the data suggests that if a similar TFA policy intervention is implemented in Pakistan, 38,000 people will be saved from premature cardiovascular deaths by the end of 2026.

The central conclusion of evidence-based policy effect as well as predictive models is that TFA reduction has a positive impact on cardiovascular health of the population and improves not only public health but also health equity. The best practice in this intervention area is to eliminate industrially-produced TFA by setting a two percent limit of iTFA of total fats in all foods and/ or banning partially hydrogenated oils.

The consumption of iTFAs can be eliminated through proper regulations.

An encouraging development is that advocacy efforts have been started by civil society organisations like Centre for Peace and Development Initiative, Pakistan Youth Change Advocates and Heartfile. These organisations are advocating enactment of policies that can eliminate trans-fats from the food supply and save thousands of lives in Pakistan every year.

The country has recently made a downward revision of trans-fats limits in vanaspati ghee, shortenings, bakery fats, bakery ware, rusk and breads. This may represent positive progress, but considering the lesson learnt from other countries, Pakistan should consider adopting improved policy practices by enacting a regulation to cover all foods with no more than two percent of iTFAs limit of the total fats and ban partially hydrogenated oils.

Such regulations have been adopted by several countries, and the evidence suggests that cardiovascular diseases have reduced significantly.

Denmark is one such example. India and Bangladesh have also recently enacted similar regulations. Pakistan’s national regulatory body, the Pakistan Standards and Quality Control Authority, should consider expediting progress on this front. So should provincial food authorities.

The author, a cardiac surgeon, has headed many leading institutes of cardiology. He is currently the executive director of Punjab Institute of Cardiology, Lahore and dean of the Faculty of Cardiac Surgery at College of Physicians and Surgeons, Pakistan