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Consumption of trans fats and estimated effects on coronary heart disease in Iran

Abstract

Objective:

To investigate the consumption of industrial trans-fatty acids (TFAs) in Iranian homes and the proportion of coronary heart disease (CHD) events in Iran attributable to such intake.

Design, setting and participants:

The consumption of industrial TFAs was determined using (1) detailed in-home assessments of dietary intake among 7158 urban and rural households containing 35 924 individuals and (2) gas chromatography to determine TFA contents of the most commonly consumed partially hydrogenated oils. The population-attributable risk for CHD owing to TFA consumption was calculated on the basis of (1) documented effects of TFAs on total:high-density lipoprotein (HDL) cholesterol in randomized controlled dietary trials and (2) relationships of TFA intake with incidence of CHD in prospective observational studies.

Results:

Partially hydrogenated oils were used extensively for cooking in Iranian homes with average per-person intake of 14 g/1000 kcal. TFAs accounted for 33% of fatty acids in these products, or 4.2% of all calories consumed (12.3 g/day). On the basis of total:HDL cholesterol effects alone, 9% of CHD events would be prevented by replacement of TFA in Iranian homes with cis-unsaturated fats (8% by replacement with saturated fats). On the basis of relationships of TFA intake with CHD incidence in prospective studies, 39% of CHD events would be prevented by replacement of TFA with cis-unsaturated fats (31% by replacement with saturated fats). These population-attributable risks may be overestimates owing to competing risks and because not all the fat used for cooking might actually be consumed. If actual TFA consumption were only half as large, the estimated proportion of CHD events prevented by TFA elimination would be 5% on the basis of total:HDL cholesterol effects and replacement with cis-unsaturated (4% for replacement with saturated fats), and 22% on the basis of prospective studies and replacement with cis-unsaturated fats (17% for replacement with saturated fats). These estimates do not include possible additional benefits derived from replacing TFAs with vegetable oils containing n-3 fatty acids.

Conclusions:

Intake of TFAs is high in Iranian homes and contributes to a sizeable proportion of CHD events. Replacement of partially hydrogenated oils with unhydrogenated oils would likely produce substantial reductions in CHD incidence.

Sponsorship:

National Heart, Lung and Blood Institute, National Institutes of Health, USA. National Nutrition & Food Technology Research Institute, Tehran, Iran.

Introduction

Trans-fatty acids (TFAs), unsaturated fats with at least one double bond in the trans configuration, are formed during the partial hydrogenation of vegetable oils. This process facilitates conversion of vegetable oils to solid or semi-solid products for use in margarines, deep frying and food manufacturing. Partially hydrogenated oils may contain up to 30–50% TFAs, resulting in significant TFA intake in many populations (Allison et al., 1999; Hulshof et al., 1999). Substantial evidence indicates that consumption of TFAs increases the risk of coronary heart disease (CHD) (Willett et al., 1993; Mozaffarian et al., 2006), which may be related to adverse effects on serum lipids and lipoproteins (Ascherio et al., 1999; Mauger et al., 2003; Mensink et al., 2003; Mozaffarian et al., 2006), systemic inflammation (Han et al., 2002; Baer et al., 2004; Mozaffarian et al., 2004a, 2004b; Lopez-Garcia et al., 2005) and endothelial function (Kummerow et al., 1999; de Roos et al., 2001; Baer et al., 2004; Lopez-Garcia et al., 2005). TFA consumption may also increase the incidence of sudden death (Lemaitre et al., 2002, 2005) and diabetes mellitus (Hu et al., 2001). Consumption of TFAs may therefore contribute to a substantial burden of cardiovascular disease.

The intake and potential adverse health effects of TFAs in Western countries have received considerable attention (Allison et al., 1999; Hulshof et al., 1999; Dietary Guidelines Advisory Committee, 2005; New York City Department of Health and Mental Hygiene, 2005), with resulting legislation to increase awareness of and/or limit TFA consumption in these populations (Health Canada, 2005; Leth et al., 2005; US Food and Drug Administration, 2005). However, little is known regarding TFA intake in many other regions. Data are particularly sparse for countries in the Middle East, a populous region that generally receives less attention in CHD research. We determined the consumption of TFAs from partially hydrogenated oils in Iran and calculated the health impact of this TFA intake on CHD risk in Iran.

Materials and methods

Assessment of dietary intake in Iran

A national Food Consumption Survey was used to determine dietary intakes in Iran. A systematic stratified sampling design was used to select a nationally representative sample of urban and rural households from the 28 Iranian provinces. Between March 2001 and November 2003, in-home interviews were performed by trained nutritionists of the member of each household most responsible for food preparation and cooking. Dietary habits of the household were assessed using three consecutive 24-h dietary recalls, including information on types, quantities and sources of food items; cooking methods; recipes and ingredients. Quantities were reported in units of foods as they were brought into the household from the store, garden or farm. To increase the accuracy of the reported quantities, a Soehnle kitchen weighing scale (with accuracy of 5 g) was used to weigh regularly used foods. Consumption of foods representing major contributors to energy intake (breads, fats and oils, and sugars) was further evaluated using 2 days of weighed diet records. To account for seasonal variation in food intake, one-quarter of the households in each province were interviewed in each season. A major food purchase list for the past year was also completed for each household. All data were computerized, and a food composition table modified for Iranian diets was used to determine the average nutrient intakes of the individuals in the household.

Assessment of TFA intake

The dietary data were used to determine the average consumption of partially hydrogenated oils in Iranian homes. We determined the national market share of brands of partially hydrogenated oils consumed in Iran (Zandi, 2004) and analyzed the fatty acid content of the most commonly consumed partially hydrogenated oils. Fatty acid contents were determined by gas chromatography with a nonbonded, biscyanopropyl polysiloxane column as described previously (Baylin et al., 2002). Peak retention times and area percentages of total fatty acids were identified by injecting known standards (NuCheck Prep, Elysium, MN, USA), and analyzed with computer software (Agilent Technologies ChemStation A.08.03, Santa Clara, CA, USA). The TFA contents of the most commonly consumed partially hydrogenated oils were averaged, weighted by market share and multiplied by the mean per-person intake of partially hydrogenated oils to determine the average TFA consumption.

Estimation of impact on CHD risk

We calculated the proportion of CHD events in Iran attributable to intake of TFAs in partially hydrogenated oils. The population-attributable risk percent was calculated as Pe(RR−1)/(Pe(RR−1)+1), where Pe is the prevalence of exposure to TFAs in the population and RR is the relative risk of CHD associated with TFA intake. TFA intake was assumed to be equally distributed in the population; other distributions resulted in similar or higher population-attributable risk percents (if some individuals were less exposed, others would be more exposed to produce the observed per capita TFA intake). Two estimates of the health impact were calculated. The first estimate was on the basis of documented effects of TFAs on the total:high-density lipoprotein (HDL) cholesterol ratio in a meta-analysis of randomized controlled dietary trials (Mozaffarian et al., 2006), coupled with established relationships of this ratio to CHD risk (Stampfer et al., 1991). Because TFAs affect many other risk factors beyond total and HDL cholesterol concentrations (Mozaffarian et al., 2006), this would likely underestimate the full health impact. The second estimate was on the basis of associations of TFA intake with incidence of CHD events in a meta-analysis of prospective cohort studies (Mozaffarian et al., 2006). For each estimate, effects were calculated for the replacement of TFAs with (1) cis monounsaturated and n-6 polyunsaturated fats (the averaged effect) and (2) saturated fats. In practice, partially hydrogenated oils are most commonly replaced with a combination of cis monounsaturated and polyunsaturated fats from unhydrogenated sunflower, canola and soybean oils, with the relative proportions depending on market prices and specific product reformulations. Because population-attributable risks may be overestimates owing to competing risks and because not all the fat used for cooking might actually be consumed, we also repeated the estimates of health impact assuming that actual TFA consumption were only half as large as observed.

Results

Participant characteristics

A total of 7158 urban and rural households, representing 35 924 individuals, were evaluated (Table 1). Consistent with the demographics of modern Iran, 41% of the population were at or below 18 years of age and 88% were at or below 50 years of age. Educational attainment was highly variable with nearly one-quarter of the heads of households having no formal education and an additional one-quarter having graduated from high school or attended college.

Table 1 Characterisitics of participants in the Food Consumption Survey, Iran 2001–2003

Dietary intakes

The overall dietary results are shown in Table 2. Total energy intake was consistent with estimated energy requirements on the basis of weight and occupation of adults and predicted basal metabolic rate and age- and sex-specific estimated physical activity in children (Schofield, 1985; James and Schofield, 1990). Partially hydrogenated oils were commonly used for cooking in Iranian homes, with average per-person intake of 14 g/1000 kcal, representing 12.5% of all calories. On the basis of total market sales of partially hydrogenated fats (retail and commercial), the per capita intake would be 19 g/1000 kcal (Nowrouzi and Samimi, 2002). This latter value is likely the result of additional intake of partially hydrogenated oils outside the home, such as in restaurants, universities, ministries, prisons, military bases, etc. We used the more conservative value (14 g/1000 kcal) for these analyses.

Table 2 Dietary consumption in the home, Iran 2001–2003

The TFA content of the most commonly consumed partially hydrogenated oils in Iran ranged from 23 to 36% (Table 3). Weighted by their market share, TFAs accounted for 33% of all fatty acids in these partially hydrogenated oils. This can be compared to 5% TFAs in sunflower oil (likely owing to deodorization) and <1% TFAs in unhydrogenated soybean or olive oil. Thus, with partially hydrogenated oils accounting for 12.5% of all calories consumed and TFAs representing 33% of all fatty acids in these oils, TFAs accounted for 4.2% of all calories consumed per capita in the home (12.3 g/day for the average diet). This is approximately double the per capita TFA intake from partially hydrogenated oils in the United States (Allison et al., 1999), and does not account for additional TFAs that might be consumed outside the home in Iran.

Table 3 Fatty acid composition of the most commonly consumed partially hydrogenated oils in Iran and, for comparison, of unhydrogenated soybean and olive oils

Impact of TFA intake on CHD incidence in Iran

We calculated the proportion of CHD events in Iran that might be prevented by eliminating TFA consumption from partially hydrogenated oils in Iranian homes (Figure 1). On the basis of changes in the total:HDL cholesterol ratio alone, 9% of CHD events would be prevented if TFAs were replaced with cis-unsaturated fats (8% if TFAs were replaced with saturated fats). This likely underestimates the full health impact as TFAs influence other cardiovascular risk factors beyond total and HDL cholesterol levels, including triglyceride concentrations (Mensink et al., 2003), lipoprotein(a) levels (Ascherio et al., 1999), low-density lipoprotein (LDL) particle size (Mauger et al., 2003), systemic inflammation (Han et al., 2002; Baer et al., 2004; Mozaffarian et al., 2004a, 2004b; Lopez-Garcia et al., 2005), endothelial function (de Roos et al., 2001; Baer et al., 2004; Lopez-Garcia et al., 2005), and possibly abdominal adiposity and insulin resistance (Koh-Banerjee et al., 2003; Kavanagh et al., 2006). On the basis of relationships of TFA intake with CHD incidence seen in prospective studies, which may better account for the total effects, 39% of CHD events would be prevented by replacement of TFAs with cis-unsaturated fats (31% by replacement with saturated fats).

Figure 1
figure1

Estimated impact of TFA consumption on CHD events in Iran. The proportion of CHD events that would be prevented by eliminating TFA consumption from partially hydrogenated oils in Iranian homes was calculated based on (1) the effects of isocaloric replacement of TFAs with cis-unsaturated fats or saturated fats on the total cholesterol (TC):HDL ratio in a meta-analysis of randomized controlled dietary trials (Mozaffarian et al., 2006) and the relationships of this ratio with CHD incidence (Stampfer et al., 1991) and (2) the relationships of TFA intake with CHD incidence in a meta-analysis of prospective observational studies (Mozaffarian et al., 2006).

Population-attributable risks may overestimate the true effect of eliminating a risk factor owing to the principle of competing risks: when one risk factor is removed from the environment, a proportion of the events that would have been caused by that risk factor may still occur as a result of other unrelated (competing) risk factors. Additionally, most TFA intake in Iranian homes were owing to use of cooking oils, and not all the fat used for cooking might actually be consumed. To account for such potential uncertainties, we performed sensitivity analyses assuming that actual TFA consumption were only half as large as observed. In this case, the proportion of CHD events prevented by TFA elimination would be 5% on the basis of total and HDL cholesterol effects alone and replacement with cis-unsaturated fats (4% for replacement with saturated fats), and 22% on the basis of prospective studies and replacement with cis-unsaturated fats (17% for replacement with saturated fats).

We did not consider the potential effects of naturally occurring ruminant TFAs from dairy or meat sources. We estimated that TFA intake from these sources totaled 0.5% energy, considerably less than the consumption of industrially produced TFAs from partially hydrogenated oils. Consumption of naturally occurring TFAs has not been associated with higher CHD risk, which may be related to the much lower levels of intake, possible different biologic effects of ruminant vs industrial TFAs (which share some but not all isomers), or the presence of other factors in dairy and meat products which balance any effects of the small amount of TFAs (Mozaffarian et al., 2006).

Nearly 350 000 deaths occur annually in Iran (Unicef, 2005), and 70 000 of these (20.5%) are owing to CHD (on the basis of death rate statistics from 18 provinces; Dr M Janghorbani, personal communication, 24 October 2004). On the basis of health impact of TFAs (Figure 1), the near elimination of TFA consumption from partially hydrogenated oils in Iranian homes would prevent between 5600 (8%) and 27 300 (39%) CHD deaths annually. These estimated benefits do not include corresponding reductions in other CHD events, which would likely be reduced by decreased TFA consumption, including nonfatal myocardial infarctions, acute coronary syndromes and coronary revascularization procedures. These estimates also do not include possible additional benefits of replacing TFAs with vegetable oils containing n-3 fatty acids.

Discussion

TFA intake from partially hydrogenated oils in Iranian homes is very high, approximately twice as high as in the United States and much higher than many European countries. This intake likely contributes to a significant proportion of CHD events in Iran: between 8 and 39% of CHD events might be due to consumption of TFAs. The upper range may be an overestimate if the observed associations between TFA intake and CHD risk in prospective studies were partly due to residual confounding from unmeasured lifestyle or dietary habits. Conversely, the lower range likely underestimates the health impact because it is based only on total and HDL cholesterol effects, and TFAs affect many other risk factors (Mozaffarian et al., 2006). Nevertheless, even this lower estimate represents a substantial proportion of CHD events in Iran.

We did not account for potential additional benefits of using replacement oils containing α-linolenic acid (ALA, 18:3 n-3), the plant-derived n-3 fatty acid. In Iran, consumption of fish, and therefore seafood-derived n-3 fatty acids, is very low (Table 2). Thus, plant sources (vegetable oils) represent the major potential source of n-3 fatty acid intake. ALA is destroyed by partial hydrogenation, so that partially hydrogenated oils contain <1% ALA, compared with 7–9% ALA in unhydrogenated soybean or canola oil (Table 3). Although cardiovascular benefits of ALA are not conclusively established (Mozaffarian, 2005), the replacement of partially hydrogenated oils with unhydrogenated oils containing ALA (such as soybean or canola oil) would possibly reduce the risk further. Because intake of n-3 fatty acids is already low in Iran, the destruction of ALA in vegetable oils by partial hydrogenation may be as significant a problem as the creation of TFAs. Rapid reductions in CHD mortality – within months – were seen with a dietary intervention that included increased ALA intake in the Lyon Heart Study trial (de Lorgeril et al., 1999) and also in Poland after increases in vegetable oil consumption, mainly as canola oil, in the early 1990s (Zatonski et al., 1998). Thus, replacement of partially hydrogenated oils with unhydrogenated oils that include ALA might reduce CHD incidence in Iran within months, with additional benefits in ensuing years.

Experiences in several European countries demonstrate that the use of partially hydrogenated oils can be reduced without increases in food cost or reductions in availability or palatability (Jensen, 2005; Aro, 2006; Leth et al., 2006; Nielsen, 2006). TFA consumption in Iran could be reduced by recognition and avoidance of partially hydrogenated oils by consumers, voluntary reductions in their use by restaurants and food manufacturers, or governmental intervention to limit use. In Iran, each individual is entitled to an annual ration of inexpensive (i.e., heavily subsidized) cooking oil, currently fulfilled by sales of partially hydrogenated oils. Nonhydrogenated oils are also available, but are unsubsidized and thus much more expensive. Thus, governmental legislation to subsidize unhydrogenated rather than partially hydrogenated oils would likely produce rapid and substantial reductions in TFA consumption.

Several limitations are worth noting. The well-defined effects of TFA intake on LDL and HDL cholesterol have not been proven to affect CHD risk; however, other interventions that affect LDL or HDL cholesterol result in changes in CHD risk as large or larger than predicted (Robins et al., 2001; Baigent et al., 2005). Our estimates were confined to in-home consumption of TFAs, which likely underestimates total TFA intake in the population; estimated benefits would be greater if consumption of TFAs outside the home was also reduced. The estimates of benefit also did not account for potential effects of TFAs on risk of sudden death (Lemaitre et al., 2002; Lemaitre et al., 2005) or diabetes mellitus (Hu et al., 2001), the incidence of which may also be lowered by reductions in TFA intake.

Reducing the intake of partially hydrogenated oils in Iran through governmental intervention is feasible and would likely result in substantial health benefits, and little justification exists for not doing so. The incidence of CHD in Iran has been increasing, and such increases are likely to continue unless other underlying causes are also addressed, including smoking, overweight, low levels of physical activity and other unhealthy dietary habits in addition to intake of partially hydrogenated oils. If ongoing increases in these other causes of heart disease are not addressed, the reductions in rates of CHD over time may be less than estimated. Thus, the importance of reducing TFA intake should not, and need not, distract from other CHD prevention efforts. Nevertheless, we believe that a comprehensive strategy to replace partially hydrogenated oils with unhydrogenated oils in Iran would have dramatic health benefits, substantially reducing the incidence of CHD.

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Acknowledgements

Dr Mozaffarian was supported by funding from the National Heart, Lung and Blood Institute, National Institutes of Health (K08-HL-075628). We thank Dr Mohsen Janghorbani for providing cause-specific mortality data from Iran and the investigators of the Nutrition Research Department, National Nutrition & Food Technology Research Institute, who collaborated in the conduction of the Iranian Food Consumption Survey.

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Contributors: DM participated in the conception and design, statistical analysis and data interpretation, manuscript drafting, critical revision of the manuscript for important intellectual content and approval of the final manuscript for submission.MA participated in the collection of data, critical revision of the manuscript for important intellectual content, and approval of the final manuscript for submission.HC participated in the collection of data, critical revision of the manuscript for important intellectual content, and approval of the final manuscript for submission.AH participated in the collection of data, critical revision of the manuscript for important intellectual content, and approval of the final manuscript for submission.WW participated in the conception and design, data collection and interpretation, critical revision of the manuscript for important intellectual content, and approval of the final manuscript for submission.

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Mozaffarian, D., Abdollahi, M., Campos, H. et al. Consumption of trans fats and estimated effects on coronary heart disease in Iran. Eur J Clin Nutr 61, 1004–1010 (2007). https://doi.org/10.1038/sj.ejcn.1602608

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Keywords

  • trans-fatty acids
  • coronary heart disease
  • diet

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