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Good fats: Bad fats II Progress on the fats agenda 2006 to 2009

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Scientic research into cardiac health

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Page 1: Good Fats Bad Fats

Good fats: Bad fats IIProgress on the fats agenda 2006 to 2009

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This update to the 2006 Good fats: Bad fats briefingpaper summarises the latest evidence and progresstowards supporting healthier fat intake in Cheshire& Merseyside, the UK and beyond. It makes a seriesof recommendations for further policy action tosupport the national fat goals.

Progress on the dietary fats agenda 2006 to 2009

Good fats: Bad fats II

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Dietary saturated fats powerfully influence bloodcholesterol levels. Dietary saturated fats are ‘bad’,they increase levels of ‘bad’ low density lipoprotein(LDL) cholesterol. The main sources of saturated fatsare butter, other full fat dairy products, processed foods,meat and meat products. It is generally recognisedthat current saturated fat intake levels in the UKpopulation are detrimental to cardiovascular health.

Industrial Trans Fatty Acids (TFAs) are particularlyharmful. Trans fats are artificially made by hydrogenationof vegetable oils. A small amount of trans fats occurnaturally in ruminant products, for example milk andcheese. Trans fats are considered to be ‘bad’ fats.Every 1% of our energy obtained from trans fatsincreases our CVD risk by 12%.

Polyunsaturated and monounsaturated fats are good.They reduce ‘bad’ LDL cholesterol and raise ‘good’ highdensity lipoprotein [HDL] cholesterol. Polyunsaturatedand monounsaturated fats are found in vegetables,nuts, avocados and vegetable oils including olive oil,rapeseed oil and sunflower oil.

Omega 3 oils and oily fish powerfully protect againstCVD through mechanisms which include reducingplaque formation and inflammation, and loweringblood pressure. The Food Standards Agency (FSA)recommends that everyone should eat at least twoportions of fish per week, one of which should be oily,such as trout, mackerel or salmon. Average UK intakesare currently much less. Plant sources of omega 3include flaxseeds, soya beans and walnuts.

Cardiovascular disease (CVD) includes heart attacks, angina, heart failure and stroke. Although many factors increase CVD risk, there are only three major risk factors whichcan be reduced: cholesterol, blood pressure and smoking. Dietary fats powerfully influence blood cholesterol, and also bloodpressure. The key target is to increase the intake of ‘good fats’ (whichlower blood cholesterol levels) and reduce the intake of ‘bad fats’(which increase blood cholesterol).

Summary

Plant sterols (and stanols) substantially lower LDLcholesterol levels in the blood. Clinical trials have shownthat daily consumption of 2–3g of plant sterols reducesblood cholesterol by about 10%. This will reduce therisk of coronary heart disease (CHD) by about 25%.Fortified margarines (e.g. Benecol, Flora pro.active)and yogurts (e.g. Danacol, Benecol) help meet the 2–3g per day recommendation for adults.

Blood cholesterol and coronary heart disease:Our bodies produce two types of cholesterol, high levelsof low density lipoproteins (LDL) are ‘bad’ cholesterolswhen levels in the blood are high. LDL cholesteroldamages the artery walls resulting in plaques(atherosclerosis) leading to heart attacks and strokes.High density lipoprotein (HDL) is ‘good’ cholesterol andis increased by exercise, moderate alcohol consumption,and oestrogens.

Successful population based approaches toreducing CVD: Switching from animal based saturatedfat sources to plant based mono and polyunsaturatedfat sources has been shown to be protective against CHDin several populations. Population based observationalstudies in Australia, Finland, Poland, Norway, Mauritiusand the US have all shown significant reductions in CHDmortality following the introduction of fiscal policieswhich resulted in a reduction in animal fat and anincrease in vegetable fat consumption.

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A number of important developments haveoccurred on the saturated fat agenda since 2006.Among them:

•The European Commission introduced a flat rate schoolmilk subsidy in 2006 so schools are no longer financiallydisadvantaged for providing low fat milk

•New school food standards were published in England in 2006 with clear limits for saturated fat, and a ban on the provision of full fat milk

•Trans fats have risen up the political agenda. In 2007 the Secretary of State for Health requested the ScientificAdvisory Committee on Nutrition to undertake a rapid review of the evidence on trans fats, although it failed to recommend a national ban

•The Food Standards Agency (FSA) commenced its saturated fat and energy intake reduction programme in 2008 and launched a saturated fat campaign in 2009.The FSA also relaxed the rules allowing 1% milk to be marketed in the UK (1% milk is a new product that is halfway between semi-skimmed and skimmed milk; it contains 1% fat)

•More retailers have adopted the traffic light food labelling system. Traffic lights make it easier for consumers to spot foods high in saturated fat. Some have also eliminated trans fat from own brand products, and Sainsbury’s has introduced 1% fat milk

•Some food manufacturers have started to reformulate certain products to reduce the saturated fat content. However, this is a voluntary scheme and currently there are no government levies to promote improvements.

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Progress on fats 2006 to 2009

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Further actionneeded on fats

•The Common Agricultural Policy (CAP) needs further reform so expenditure reflects the Eatwell plate balance,i.e there is a shift from funding produce high in saturated fat such as beef and dairy, towards more spending on healthier foods such as fruit and vegetables

•The government should set a timetable for the complete eradication of industrial TFAs

•Urgent action is needed to clarify national nutrition guidelines for young children in relation to low fat milk and other dairy products and also the introduction of nutrient-based standards for food provided in pre-school nurseries

•The FSA should develop saturated fat targets for the food industry, as successfully done with salt. This would encourageproduct reformulation to replace saturated fat currently hidden in processed foods, with ‘good’ polyunsaturates

•The FSA should also set promotional targets for supermarketswhich reflect the balance of the Eatwell plate. The FSA should consider trans fats labels. Also for levels in cheap imported food products

•The Scientific Advisory Committee on Nutrition should urgently review the population saturated fat and nutritiontargets which were developed by its predecessor, the Committee on Medical Aspects of Food Policy. These were produced in 1991 and are now dated

•All sections of the food industry including manufacturers, retailers and the food service sector need to reformulate mainstream products to reduce saturated fat, provide responsible (i.e small) portion sizes for saturated fat ladenfoods such as cakes, pastries, crisps, chips etc, and adoptresponsible marketing practices which reflect the balanceof the Eatwell plate

•Everyone should switch to using unsaturated fats in cooking,using low fat dairy products, offering healthier snack alternatives such as nuts or chopped fruit and vegetables,and incorporating more foods of vegetable origin, e.g. nuts,beans, pasta, rice, couscous, into main dishes.

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However, excessive amounts of cholesterol in the bloodcause serious problems. Spare cholesterol is liable tooxidation. Oxidised cholesterol gets deposited on thewalls of the arteries. In response, the body’s inflammatorysystem attacks the cholesterol deposits in an effort toremove them. This results in scar and fatty tissue in theartery walls, known as plaques. These plaques silentlybuild up over the years, narrowing the arteries. Whenblood flow is seriously reduced, a heart attack orstroke could result.

Some individuals with CHD may experience pain inthe chest (angina). However for many people the firstsymptom of CHD is a heart attack or sudden death.This happens when an artery becomes completelyblocked, stopping blood from flowing to the heart.Around half of all heart attacks are fatal (see Figure 1)

Cholesterol levels are powerfully influenced by the type and amount of food we eat. Cholesterol is used in the formation of cell membranes, some hormones and in the production of vitamin D in our bodies.

Blood cholesterol and childhood obesityThe atheroma process begins in childhood. It worsenswith age and poor diet.1,2 An estimated 20% of obesechildren have raised blood cholesterol levels3 withmore advanced atherosclerosis.

Types of cholesterol‘Bad’ low density lipoproteins (LDL) transportcholesterol from the liver through the arteries to therest of the body. When LDL levels in the blood are high,the cholesterol sticks to the artery walls, creatingplaques (atherosclerosis).

‘Good’ high density lipoproteins (HDL) transportcholesterol from the blood to the liver, which thenremoves it from the body. High levels of HDL reducethe risk of plaque formation. HDL cholesterol is raisedby a healthy lifestyle (physical activity, moderate alcoholconsumption, not smoking and consumption of plantsterols /stanols).

Blood cholesterol andcoronary heart disease

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CHD starts early, presents later Hanlon, Capewell et al SNAP 1997

Atheroma

Symptoms

Symptom threshold

Inflammation and thrombosisSource: Hanlon et al, 1998 4

Childhood Middle age Old age

No Symptoms (for survivors)

Secondary prevention

Natural course of CHD

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Figure 1: The natural progression of coronary heart disease

Table 1: Effects of different types of fats on cholesterol levels and cardiovascular disease

Adapted from: ‘Fats & Cholesterol: Nutrition Source’, Harvard School of Public Health.

Type of fat Major dietary sourcesEffect on bad LDLcholesterol

Effect on good HDLcholesterol

Effect on heartdisease incidence

Trans fat

Saturated fat

Junk foods including cakes,pastries, crisps, take-away foods,hard margarines, fried foods

Butter, milk, cheese, dairyproducts, beef, lamb, other redmeat, poultry fat and skin,biscuits, savoury snacks, friedfoods, processed foods.

Bad fats (generally solid at room temperature)

Good fats (generally liquid at room temperature)

Plant sterols

Polyunsaturated fat

Oily fish and omega 3 oilsOther benefits aremediated throughmechanisms other thancholesterol

Monounsaturated fat

Fortified soft margarines and yoghurts eg Benecol, Danacol and Flora pro.active; fruits andvegetables, nuts, seeds, cereals

Sunflower, corn oil, soya bean oil

Oily fish:Mackerel, sardines, herring,salmon, trout, fresh tuna (not tinned)

Plants: flaxseeds, soya beans, walnutsand their oils; green leafy vegetables.

Olive oil, rapeseed oil, nuts, avocado

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Saturated fats: the major problemConsuming excessive amounts of saturated fats raises LDL cholesterollevels, with a negative effect on cardiovascular health. Saturated fatsare the principle cause of elevated LDL levels in western diets. The mainsources are butter, ghee, cheese, full fat milk and yogurts, red meat,processed foods, cakes, pastries, biscuits, pizza, sausages, pies andother ‘junk’ food. (They are also found in palm oil and coconut oils.)

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Intake levels in the UK

Saturated fats are a major public health concern in the UK.

• Average intake levels for children (aged 2–18) are around 14% of food energy.5

• Average intake levels for adults are also high, averaging 14%.6

• These levels are well above the government maximum of 11%.7

• These levels are over double the much healthier 6% seen in Japan.

Food Standards Agency saturated fat campaignIn response to the high levels of saturated fat consumptionin the UK, the FSA launched a saturated fat campaignin 2009 to raise awareness of the dangers of saturatedfat, and advise individuals on how they can reduceconsumption. The FSA is also working with the foodindustry to encourage and support reformulation ofproducts to reduce saturated fat levels in foods.

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Some UK food manufacturers and distributors such as Marks & Spencer and Waitrose have already goneahead and banned trans fats in their own products.However, ‘value’ supermarkets that sell importedproducts are currently not covered by any trans fatreduction policies in the UK.16 Business among valuefood outlets is reported to be booming in the currenteconomic climate.17

European Food Safety Authority’s position on trans fatsIn 2004, the European Food Safety Authority’s (EFSA)Scientific Panel on Dietetic Products, Nutrition andAllergies published a position paper reviewing thescientific evidence around trans fats in the region.EFSA concluded that, ‘at equivalent dietary levels, the effect of trans fatty acids on heart health may begreater than that of saturated fatty acids.’ However,because many European countries have high intakesof saturated fats, EFSA failed to recommend a trans fat ban, on the basis that saturated fats represent agreater public health risk than trans fats.18

Trans fats are more stable and less expensive than saturated fats. They are used by the food industry to give products a longer shelf life.A recent large-scale meta-analysis of both randomised control trialsand cohort studies found that replacing just 1% of food energy fromtrans fats with plant-based unsaturated fats reduces CHD risk by 12%.8

Trans fats are unnecessary

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Trans fats raise the ‘bad’ LDL cholesterol and lower the‘good’ HDL cholesterol, and therefore damage health.Over 90% of dietary trans fat comes from processedfoods including hard margarines, cakes, biscuits,pastries, take-aways, fried food and ‘junk’ food.9

Progress in Denmark and the USADenmark banned all artificial trans fats in food in 2004.Industry adapted overnight.10 Switzerland and severalcities in the US have banned the use of trans fats inrestaurants including New York City, Seattle, Philadelphiaand California.11,12 The US government has slowlyintroduced legislation making it compulsory for foodlabels to show trans fat content from 2006. However,foods with 0.5g trans fat per serving or less can still belabelled as free from trans fats.9

Procrastination in the UKThe UK Government still recommends trans fat intakeup to 2% of total energy.13 Worse still, some socio-economic groups are eating much more than that:

• Although average intake levels for UK adults are 1.0% of energy,14 a minority of low income adults consume over 2.9% per day in some groups.15

• Average intake levels are also higher among childrenfrom the North of England compared to the South.5

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Situation in the UKAs a guide, the American Heart Association recommendsup to 10% of dietary energy from omega 6 PUFAs andup to 1.2% of dietary energy from omega 3 PUFAs.19

Even the dated UK COMA report cautiously recommendsthat 6.5% of total energy should come from omega 3and omega 6 oils.7 Intake levels in the UK populationare below these levels, averaging 5.8% of energy inadults and children.15

Polyunsaturated oils

Omega 6 oilsPlant based omega 6 oils are highly protective againstCHD by reducing total and LDL cholesterol levels. A largebody of evidence supports the health impact of linoleicacid (the principle omega 6 oil) including meta analysesof clinical trials, and long-term prospective cohort studiessuch as the nurses’ health study in the US.19

Dietary sources of omega 6 oils include seeds andoils from the following plants: pumpkin, sunflower, corn,soya and wheatgerm. Vegetables, fruits, nuts andgrains are also good sources.

Oily fish and Omega 3 oilsOily fish and some plant based foods are rich dietarysources of omega 3 polyunsaturated fatty acids(omega 3 oils). Their health benefits include:

• Protecting against CVD through a number of mechanisms including reducing plaque formation and inflammation, regulating heartbeat and lowering blood pressure.20

• Development of an infant’s central nervous system including brain and vision during pregnancy and lactation. Infants with higher intake levels of fish oils have better vision at three years.

Oily fish include: salmon, trout, mackerel, herring,sardines, pilchards, kipper, anchovies and fresh tuna(the process of canning tuna eliminates the fat content).

Mozaffarian (2008) undertook a review of observationalstudies, randomised control trials (RCTs) andexperimental studies looking at the effect of fish andfish oil consumption on prevention of fatal CHD andsudden cardiac death. Among the findings, a meta-analysis of over 15 cohort studies and RCTs found a 35%lower risk of CHD death in those who ate an averageof 250mgs per day of omega 3 fish oils comparedwith those who did not eat any omega 3 fish oils.(250mgs per day is equivalent to one to two servingsper week of oily fish.) 21

Evidence for the CVD protective benefits of fish isabundant. In cohort studies, fish eaters have a muchlower CHD risk. The bigger the dose, the larger thebenefit. Clinical trials in high risk patients have alsodemonstrated improvements in CVD risk and bloodlipid profile from consumption of omega 3 oils.Benefits can occur within two months.22

Recommended intake levels for fishUK intakes average about one third of a portion of oily fish per week per person. The FSA recommendsthat everyone in the population should eat at leasttwo portions of fish per week, one of which should be oily.20

• Men, boys and women past childbearing age, or those who will not be having children can safely eat up to four portions of oily fish per week

• Girls and women who might become pregnant can safely eat up to two portions.

Toxins in fishIn a small proportion of sensitive individuals, exceedingthe recommended intake levels over a prolongedperiod (i.e. several months or years) could be harmfuldue to the accumulation of fat soluble chemicalpollutants which are present in marine environments.20

Plant based sources of omega 3 oils include flaxseeds,soya beans, walnuts and their oils. Green leafyvegetables including brussel sprouts, spinach, kaleand salad dressings made from non-hydrogenatedsoya bean oil.22

Good FatsGood fats should replace saturated fats in the diet. The different typesof good fats and their contributions to health are outlined below.

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Monounsaturated fats

Rich sources of monounsaturated fats include olive oil;also avocados and nuts. Monounsaturated fats lowerLDL cholesterol levels, reducing risk of CHD. Diets richin monounsaturated fats e.g. the ‘Mediterranean diet’reduce CHD risk.

NutsWalnuts, peanuts and almonds are rich sources ofpolyunsaturated monounsaturated fats. Large-scalecohort studies have all consistently demonstratedbenefits of nut consumption protecting against CHDmortality.23,24 Randomised-controlled trials (the scientific‘gold’ standard) show that nut consumption lowers LDLcholesterol. Consumption of a handful of nuts a day(around 40g) reduces LDL cholesterol levels by around4%.25,26 The effects of nut consumption reflect the dose.

Nuts also contain arginine and nitric oxide, which alsoprotect against CHD: 24 (Warning: Macademia nuts aredifferent. They are harmful, containing mainlysaturated fats.)

Plant sterols and stanolsPlant sterols (and stanols) resemble cholesterol molecules.Around 90% of sterols are simply not absorbed. Theylower blood cholesterol levels by competing withcholesterol in the gut. Consuming between 2–3g perday of sterols greatly reduce LDL cholesterol levels by10% to 30%. It has been demonstrated that this reducesCHD risk by about 25%.27

Adults need to consume fortified products to reach the2–3g/d target. In the UK these include Flora pro.activeand Benecol products including margarines, milk and yogurts.

Consumption of margarines with added sterols or stanolscost up to £2.50 per person per week. In patients withCHD they provide an additive effect to that of LDLcholesterol reduction with statins. Statins lower cholesterollevels more than fortified margarines but may cost moreand can also have various side effects.28

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ObesityObesity levels in the UK have been rising at worryingrates. All fats are high in calories and excess consumptionof dietary fats can significantly contribute to obesity.The optimum diet should therefore contain no morethan 25% to 35% of energy from total fat. This shouldmainly consist of poly and monounsaturated fats.

As previously stated, the UK population is substantiallyexceeding the maximum recommended intakes of‘bad’ saturated fats. The key population goal shouldtherefore be to replace saturated fats in the diet withpoly and monounsaturated fats. Options for making thispossible at a population and individual level areoutlined below.

Population based approaches to reducing CVDSwitching from animal based saturated fat sources to plant based polyunsaturated fat sources has been shown to be protective against CHD in severalpopulations. Population based observational studiesin Australia, Finland, Mauritius, Poland, Norway andthe US reported substantial reductions in CHD mortalityfollowing the introduction of fiscal policies whichreduced animal fat and increased vegetable fat consumption.29–31

For example, in Poland between 1990 and 1999, CHD mortality rates fell sharply by 26%, reversing the previous steady rises.29 This reflected markedreductions in animal fat and butter consumption and sharp increases in polyunsaturated margarineand vegetable cooking oil consumption. Subsidiesfor dairy and meat products were cut in the late 1980sleading to price rises compounded by increasedavailability of cheaper rapeseed and soya beanbased margarines. The resulting replacement ofdietary saturated fats with polyunsaturated fats wasthe only marked change in CHD risk factors whichcould convincingly explain the CHD fall.29,32

Actions needed to replace dietary saturated fatwith mono and polyunsaturated fat Heart of Mersey is working with partners to reduce the population’s intake of saturated fat in Merseyside,Cheshire and beyond. A number of developmentshave occurred since publication of the original GoodFats, Bad Fats briefing paper in 2006. However, muchmore needs to be done if we are to achieve long-termbeneficial changes in the population.

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The Common Agricultural Policy (CAP), originallyintended to prevent post-war food shortages fromever re-occurring, has led to over-production and thesaturated-fat laden beef and butter mountains in theEuropean Union. The resulting excess consumption ofsaturated fat is estimated to have contributed to over10,000 deaths from CVD each year in the EU.33 Recentreforms have included the decoupling of paymentsfrom production quantities; revision of subsidies for the disposal of full fat milk in schools and hospitals tosupport low fat milk in 2007; while in 2008, £90m Euros(around 0.3% of the budget) was made available tosupport an EU school fruit and vegetable scheme.

However, despite a number of reforms, the majority of the CAP budget still supports the production of beefand dairy products. Much less is spent on healthierproduce such as fruit, vegetables and cereals forhuman consumption. The CAP therefore needs to beradically reformed to encourage and support farmersto switch production from animal fat to healthier foods.

National policyThe Scientific Advisory Committee on Nutrition(SACN) urgently needs to undertake a revision of thedated 1991 COMA dietary reference values for the UK population. Revision of the recommendations onsaturated fats is long overdue. Furthermore, thesetargets should also be extended to children over two as in other countries such as the US and Finland.SACN undertook a rapid review of trans fats in the UK in 2007 but failed to recommend a UK ban on transfats owing to reported pressure by the UK food industry.Also, the growing sectors of imported value foods andtakeaway foods are not covered. SACN should thereforeurgently undertake a more considered review on trans fats in the UK.

Urgent action is needed to clarify national nutritionguidelines for young children. In 2006 the School MealsReview Panel introduced saturated fat limits for schoolmeals, and restricted the use of full fat milk and dairyproducts in schools as part of the mandatory nutrient-based standards to improve children’s nutrition.34

However, there are currently no nutrient-based guidelinesfor food provided in nurseries. The nutritional guidelinesfor young children aged two to five are ambiguous inrelation to the use of semi-skimmed milk and low fatdairy products for this age group.35 Given the worryingrise in overweight and obesity levels among youngchildren, together with the evidence that the processof atherosclerosis begins in childhood, action toaddress this gap should proceed without delay.

The Food Standards Agency embarked on its saturatedfat reduction programme in 2008. Activities haveincluded working with industry on voluntary productreformulation, reducing portion sizes, and increasingavailability of healthier options.36 In 2009 the FSAlaunched a national saturated fat campaign to raiseawareness of the effects among consumers. However,further actions by the agency should include:

• Setting targets for saturated fat reductions in everyday products by food manufacturers, as they have successfully done with salt levels. The existing processed food nutrient standards for schools could be used as a starting point

• Setting and monitoring promotional targets for supermarkets which reflect the recommended proportions of the Eatwell plate 37

• Recommending compulsory labelling of trans fats

• Reconsidering the introduction of action to ban trans fats alongside SACN

• Clarifying saturated fat recommendations for young children.

European agriculture policy reform

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Happily, retailers are increasingly giving consumersinformation on healthier cooking methods. Someretailers, such as Sainsbury’s, have led the way inintroducing new 1% milk to the market. However,both retailers and manufacturers need to undertakefurther reformulation of mainstream products,especially processed ‘own label’ foods, given thegrowth of this sector. They should begin to provideresponsible (i.e. small) portion sizes for saturated fatladen foods such as cakes, pastries, crisps, chips etc.They should increasingly stock healthier alternativesto products which are high in saturated fats e.g.unsaturated cooking oils, low fat dairy products, fish, lean meats, nuts and seeds, pulses, fruit and vegetables.

A recent report on in-store supermarket promotionsfound that there was a significant increase between2005 and 2006. However, across retailers, only12% of promotions featured fruit and vegetables,compared to the Eatwell plate recommendedproportion of a third.37 It is essential that supermarketssystematically adopt responsible in-store promotionse.g. no junk food snacks at checkouts, and reduceproportion of promotions on fatty and sugary foods.37

Finally, all retailers should adopt the easily understoodtraffic lights labelling system to help consumerschoose the healthier option. It is encouraging that 50% of retailers including The Co-operative,Sainsbury’s, Waitrose and more recently, ASDAhave already done so.

Food providers and individualsAll food providers and individuals need to greatlyreduce the saturated fat content of foods theyprepare, replacing these with unsaturated fats.They should also provide responsible (i.e. small)portion sizes. Food providers include the foodservice sector in schools, hospitals, workplacecanteens, restaurants, pubs etc.

Retailers and Manufacturers

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Simple tips

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•Replace meat and incorporate more vegetable sources of protein into main dishes, including nuts, pulses, and beans

•Eat oily fish instead of meat, especially sardines, mackerel, salmon and trout

•Choose non-dairy sources of calcium e.g. tofu, sardines with bones, kale, soya beans, sesame seeds, tahini (sesame seed paste), almonds, dried apricots, hummus

•Switch to low fat dairy products such as skimmed milk, low fat yoghurt and reduced fat cheese

•Use fat-free cooking methods or small amounts of unsaturated fats in cooking e.g. olive or sunflower oil

•Replace cakes, biscuits, crisps and junk food snacks with nuts, dried fruit, chopped fruit and vegetables

•Cut down on processed foods and choose foods labelled as low in saturated fat

•Add (sprinkle) seeds (e.g. sunflower, pumpkin or sesame) to salads, soups, smoothies, breakfast cereals and bread

•Use salad dressings that are based on unsaturated oils e.g. olive and soya oils

•Avoid traditional mayonnaise or use varieties that are low fat or mainly polyunsaturated fat

•Choose foods containing plant-sterols e.g. margarines and yoghurts like Benecol, Danacol and Flora pro.active

•Choose lean meat, remove skin and visible fat from meat and poultry.

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Resources on healthier eating and practical tips on switching to healthier fats

British Heart Foundation, Cutting down on saturated fat www.bhf.org.uk

Food Standards Agency, Good fats? Bad fats?www.eatwell.gov.uk

American Heart Association, Face the Fats www.americanheart.org

Author and contact details

This paper was prepared by Modi Mwatsama, Food and Health Programme Manager for Heart of Mersey.(From February 2004 until May 2009)

The author wishes to thank all those who commented on the first edition of Good fats: Bad fats including: Christopher Birt, Simon Capewell, Phil Baines, Mary Bownes, Helen Brack, Tony Brand, Lucy Elas, Geraldine Foster, Alison Nelson and Robin Ireland.

The author also wishes to thank all those who commented on this second editionincluding: Christopher Birt, Simon Capewell, Robin Ireland, Angela Cockburn, Julie Macklin and Nicola Evans who succeeds Modi Mwatsama as Heart of Mersey’s Food and Nutrition Programme Manager.

All correspondence to [email protected] For further information about Heart of Mersey visit www.heartofmersey.org.uk

Further information

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2 Berenson GS, Srinivasan SR, Bao W, Newman WP,3rd,Tracy RE, Wattigney WA. Association between multiplecardiovascular risk factors and atherosclerosis in children and young adults. The Bogalusa Heart Study.N.Engl.J.Med. 1998 Jun 4;338(23):1650–1656.

3 Lobstein T, Jackson-Leach R. Estimated burden of paediatric obesity and co-morbidities in Europe. Part 2. Numbers of children with indicators of obesity-related disease. International journal of pediatric obesity 2006;1(1):33–41.

4 Hanlon P, Venters G, Burns H, Capewell S, McWhirter M, Tannahill C. SNAP: Coronary Heart Disease. Scottish Needs Assessment Programme. 1998.

5 Gregory J, Lowe S. National Diet & Nutrition Survey: Young people aged 4 to 18 years 2000.

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7 Department of Health. Dietary Reference Values of Food Energy and Nutrients for the United Kingdom. 1991.

8 Mozaffarian D, Clarke R. Quantitative effects on cardiovascular risk factors and coronary heart diseaserisk of replacing partially hydrogenated vegetable oils with other fats and oils. European Journal of ClinicalNutrition 2009;In press.

9 Food and Drug Administration U. Revealing Trans Fats. 2005.

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11 Food Standards Agency. Trans fatty acids. Board paper 7/12/07. 2007.

12 California State U. Assembly Bill No. 97 (trans fats section). 2008.

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19 Harris WS, Mozaffarian D, Rimm E, Kris-Etherton P, Rudel LL, Appel LJ, et al. Omega-6 Fatty Acids and Risk for Cardiovascular Disease: A Science Advisory From the American Heart Association Nutrition Subcommittee of the Council on Nutrition, Physical Activity, and Metabolism; Council on CardiovascularNursing; and Council on Epidemiology and Prevention.Circulation 2009 Feb 17;119(6):902–907.

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26 Sabate J, Haddad E, Tanzman JS, Jambazian P, Rajaram S. Serum lipid response to the graduated enrichment of a Step I diet with almonds: a randomized feeding trial. Am.J.Clin.Nutr. 2003 Jun;77(6):1379–1384.

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