Several specific population interventions that achieved a Class I or IIa recommendation with grade A or B evidence were identified , providing a set of specific evidence -based strategies that deserve close attention and prioritization for wider implementation .
Effective interventions included specific approaches in all 6 domains evaluated for improving diet , increasing activity , and reducing tobacco use .
The writing group also identified several specific interventions in each of these domains for which current evidence was less robust , as well as other inconsistencies and evidence gaps , informing the need for further rigorous and interdisciplinary approaches to evaluate population programs and policies .
This systematic review identified and grade d the evidence for a range of population -based strategies to promote lifestyle change .
BACKGROUND Poor lifestyle behaviors , including suboptimal diet , physical inactivity , and tobacco use , are leading causes of preventable diseases globally .
Although even modest population shifts in risk substantially alter health outcomes , the optimal population -level approaches to improve lifestyle are not well established .
Cholesterol Control Beyond the Clinic: New York City's Trans Fat Restriction
Although blood cholesterol levels in the United States have decreased slightly since the late 1980s ( 1 ) , consumption of saturated and trans fats remains above recommended maximum levels ( 2 , 3 ) , and only one quarter of U.S. adults with high cholesterol have it under control ( 4 ) . Some 24 million U.S. adults report taking cholesterol-lowering medications ( 5 ) . Changing a person 's nutrition-related behavior to improve cholesterol control is challenging ( 6 ) and a source of frustration for clinicians ( 7 ) . Public health action can complement health care provider efforts . The New York City Department of Health and Mental Hygiene adopted such a strategy when it restricted the use of artificial trans fat in restaurant food . We describe the rationale and process that led to this New York City Health Code amendment and the Department 's experience implementing the rule . Artificial trans fat is an unnecessary ingredient that poses a substantial risk to heart health . Although no r and omized , controlled trials have assessed the effect of trans fat consumption on cardiovascular events , evidence from experimental studies , dietary trials , and prospect i ve observational studies ( 3 , 8) demonstrates that consumption of trans fatty acids provides no apparent nutritional benefit and has considerable potential for harm . The Institute of Medicine ( 3 ) concluded that a positive linear trend exists between  trans fatty acid intake and low-density lipoprotein cholesterol level , which increases the risk for coronary heart disease . Unlike saturated fat , trans fat also decreases high-density lipoprotein cholesterol levels ( 3 , 8 , 9 ) . Trans fat intake has a large effect on cardiovascular health : A mere 2 % increase in energy intake from trans fat may increase the risk for a coronary event by up to 23 % ( 8) . Other potential adverse effects have been noted , such as affecting insulin sensitivity and increasing systemic inflammation , which raises additional public health concerns ( 8 , 10 ) . Each year , 6 % to 19 % of coronary heart disease events and 30000 or more premature deaths are estimated to occur in the United States because of trans fat consumption ( 8 , 11 ) . The Institute of Medicine , the American Heart Association , the U.S. Department of Agriculture , and other leading health organizations recommend minimizing trans fat intake ( 3 , 1215 ) . To achieve this , health care providers are asked to counsel patients ( 12 ) . However , such advice is unlikely to be broadly effectivemillions of Americans would need to routinely study package labels on groceries and actively seek information on trans fat in restaurant foods , where a growing proportion of calories are now consumed . Health would be better served by making the use of safer fats the default in food preparation . The Emergence of Artificial Trans Fat and Recognition of Its Risks Trans fats occur naturally in small amounts in some meat and dairy products ( 3 ) ; however , these sources make up only 21 % of total trans fat intake ( 16 ) . The remaining trans fat in the U.S. diet is artificial , produced by partial hydrogenation of vegetable oils and found mostly in processed foodsespecially baked and fried goods and spreads . Partial hydrogenation was patented in 1903 . Eight years later , Crisco ( J.M. Smucker , Orrville , Ohio ) became the first such product widely marketed in the United States ( 17 ) . These chemically modified oils , like several food ingredients in the 20th century , entered the food supply without a full evaluation of human health effects and were generally recognized as safe on the basis of experience ( 18 ) . Industrial advantages , such as extended product shelf life and fry oil stability , led to increased use in the 1950s . In the 1970s , margarine made from partially hydrogenated oil was promoted as a healthier alternative to butter ( 19 ) . However , by the 1990s , studies began to identify trans fat as a health hazard ( 9 ) . In 2003 , the U.S. Food and Drug Administration ( FDA ) required that all packaged goods display information on trans fat content by 2006 ( 20 ) . The regulation allows products that contain less than 0.5 grams of trans fat per serving to be labeled zero grams trans fat . This prompted a widespread industry response of reformulating products to declare zero grams trans fat on front-of-package labeling ( 2123 ) , although such products may still contain trans fat in small amounts , which can add up . The nutrition facts labeling allowed attentive consumers to avoid trans fat in packaged foods ; however , restaurantswhich provide one third of daily caloric intake (24)generally do not disclose nutritional information , leaving consumers no practical way to avoid trans fat . At the time of the FDA action , only Denmark limited trans fat in its entire food supply ( 25 ) . Although local health departments do not commonly regulate packaged goods , inspecting , licensing , and regulating restaurants and retail food outlets are core local public health functions ( 26 ) . Building on its food safety infrastructure , the Department trained restaurant inspectors in May 2005 to assess the presence of artificial trans fat in products used for frying , baking , or cooking or in spreads by means of food label inspection . Because inspection visits are scheduled each year on the basis of original restaurant licensing date and compliance records , a survey fielded during regularly scheduled inspections approximates a r and om sample of these establishments . In May and June 2005 , inspectors assessed the use of trans fat in oils , shortenings , and spreads used for frying , baking , or cooking or in spreads in 529 restaurants . Of the 478 restaurants that used fats for any of these purpose s and for which complete data were collected , trans fat presence could not be determined in one third . Where it could be assessed , 50 % of restaurants used artificial trans fat to prepare food . Educational Campaign In August 2005 , the Department launched an educational campaign to reduce restaurant artificial trans fat use . Information was sent to the 30000 licensed food outlets in the city , 15000 suppliers and supermarkets , and hundreds of thous and s of consumers . Mailings urged restaurants to remove artificial trans fat from food , suppliers to promote 0-grams trans fat products , and patrons to inquire about oils used . Press coverage was extensive ( 2729 ) . More than 7800 restaurant operators received training on the issue during the m and atory food protection course . Nearly a year later , inspectors surveyed 1021 restaurants in April and May 2006 by following the same methodology as the previous year . Despite the educational campaign , prevalence of artificial trans fat use remained virtually unchanged at 51 % in places where it could be assessed . Given survey findings of a wide range of restaurants that cooked without artificial trans fat , successful reformulation of packaged foods , and the Danish experience , the Department concluded that food choice and quality would be unaffected by replacing artificial trans fat and proposed using its regulatory authority to reduce artificial trans fat use ( 26 ) . Crafting Regulation Department clinical staff , food safety experts , and lawyers considered a range of regulatory options , from disclosure-only requirements to content restrictions . Labeling trans fat would benefit only consumers who were aware of and would act on the dangers of trans fat and would be difficult to enforce . A restriction , however , would benefit all New Yorkers , regardless of language , literacy , level of health awareness , or age . Protecting children , who consume French fries and other quick-service foods that are common sources of artificial trans fat ( 30 ) , was particularly important . Because artificial trans fat is both harmful and fully replaceable , allowing continued use , even with disclosure , could not be justified . Similarly , restricting trans fat in cooking oils and spreads onlyalthough easier to achievewould be insufficient because baked goods are the largest dietary source of trans fat ( 16 ) . Given that an estimated one third of calories comes from away-from-home sources , removing most trans fat from restaurants could be expected to reduce trans fatassociated deaths proportionately . The Department drafted a broad proposal to restrict artificial trans fat use in fry oils ; spreads ; and all other ingredients and products , including baked goods . For the regulation to be clear and enforceable , the Department adopted the FDA threshold used for labeling of up to 0.5 grams of trans fat per serving for products containing any trans fat ( 20 ) . The regulation would apply to all licensed food establishments , including restaurants , school cafeterias , caterers , senior centers , and street-food vendors . It intentionally did not affect products that contained only natural trans fat . The Department design ed enforcement to rely on existing infrastructure . Inspectors check product labels , which restaurants now must maintain , during their regular annual inspections . The rule included a 6-month phase-out period for artificial trans fat in fry oils and spreads and 18 months for all other items , to give restaurants time to identify alternatives and reformulate ( 31 ) . Fines for violations range from $ 200 to $ 2000 . From Concept to Action The regulation was proposed as an amendment to the city 's Health Code , approvable by the Board of Health . Nearly 2300 public comments were received , with supporters outnumbering opponents 31 to 1 . Local , regional , and national organizations and professional medical associations made statements of support . Opposition came primarily from industry associations , including the National Restaurant Association and its state affiliate and the Grocery Manufacturers Association ( 32 ) . The restaurant industry , which often opposes regulation on principle , alleged that the elimination of artificial trans fat would result in more expensive and less flavorful food and also cl aim ed that the supply of alternative oils was insufficient and the regulatory timeline
Several specific population interventions that achieved a Class I or IIa recommendation with grade A or B evidence were identified , providing a set of specific evidence -based strategies that deserve close attention and prioritization for wider implementation .
Effective interventions included specific approaches in all 6 domains evaluated for improving diet , increasing activity , and reducing tobacco use .
The writing group also identified several specific interventions in each of these domains for which current evidence was less robust , as well as other inconsistencies and evidence gaps , informing the need for further rigorous and interdisciplinary approaches to evaluate population programs and policies .
This systematic review identified and grade d the evidence for a range of population -based strategies to promote lifestyle change .
BACKGROUND Poor lifestyle behaviors , including suboptimal diet , physical inactivity , and tobacco use , are leading causes of preventable diseases globally .
Although even modest population shifts in risk substantially alter health outcomes , the optimal population -level approaches to improve lifestyle are not well established .