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Calories, Fat and Salt: How NYC Helped Redefine Modern Food Safety July 7, 2015 Mary T. Bassett, MD, MPH Commissioner New York City Department of Health and Mental Hygiene CONFIDENTIAL AND PROPRIETARY Any use of this material without specific

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Calories, Fat and Salt:

How NYC Helped Redefine Modern Food Safety

July 7, 2015

Mary T. Bassett, MD, MPH

Commissioner New York City Department of Health and Mental Hygiene

CONFIDENTIAL AND PROPRIETARY Any use of this material without specific permission of DOHMH is strictly prohibited

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Overview

  • Status of NCD’s in U.S. and NYC
  • Policy Focus Areas

─Trans Fat Regulation ─Calorie Posting ─Sugary Drinks ─Sodium Warning Label

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US Life Expectancy is Too Low

Source: APHA Website - http://action.apha.org/site/MessageViewer?dlv_id=59346&em_id=54801.0

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US Mortality: Bottom of the Pack

Source: Woolf, S. H., & Aron, L. (Eds.). (2013). US Health in International Perspective:: Shorter Lives, Poorer Health. National Academies Press.

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Diabetes: Wrong Direction

Source: McKinlay, J., & Marceau, L. (2000). US public health and the 21st century: diabetes mellitus. The Lancet, 356(9231), 757-761.

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Obesity Trends* Among U.S. Adults BRFSS, 1986

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

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Obesity Trends* Among U.S. Adults BRFSS, 1987

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

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Obesity Trends* Among U.S. Adults BRFSS, 1988

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

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Obesity Trends* Among U.S. Adults BRFSS, 1989

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

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Obesity Trends* Among U.S. Adults BRFSS, 1990

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

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Obesity Trends* Among U.S. Adults BRFSS, 1991

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

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Obesity Trends* Among U.S. Adults BRFSS, 1992

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

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Obesity Trends* Among U.S. Adults BRFSS, 1993

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

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Obesity Trends* Among U.S. Adults BRFSS, 1994

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

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Obesity Trends* Among U.S. Adults BRFSS, 1995

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

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Obesity Trends* Among U.S. Adults BRFSS, 1996

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

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Obesity Trends* Among U.S. Adults BRFSS, 1996

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

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Obesity Trends* Among U.S. Adults BRFSS, 1997

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

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Obesity Trends* Among U.S. Adults BRFSS, 1998

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

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Obesity Trends* Among U.S. Adults BRFSS, 1999

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

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Obesity Trends* Among U.S. Adults BRFSS, 2000

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

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Obesity Trends* Among U.S. Adults BRFSS, 2001

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

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(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

Obesity Trends* Among U.S. Adults BRFSS, 2002

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Obesity Trends* Among U.S. Adults BRFSS, 2003

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

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Obesity Trends* Among U.S. Adults BRFSS, 2004

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

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Obesity Trends* Among U.S. Adults BRFSS, 2005

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

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Obesity Trends* Among U.S. Adults BRFSS, 2006

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

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Obesity Trends* Among U.S. Adults BRFSS, 2007

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

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Obesity Trends* Among U.S. Adults BRFSS, 2008

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

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Obesity Trends* Among U.S. Adults BRFSS, 2009

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

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Obesity Trends* Among U.S. Adults BRFSS, 2010

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

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Footprint of Obesity in NYC

44% 33% 23%

NYC Obesity and Overweight 2013

Under/normal weight Overweight but not obese Obese

Source: Bureau of Epi Services. 2013 Community Health Survey New York City Department of Health and Mental Hygiene

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Obesity and Diabetes in NYC

Source: Bureau of Vital Statistics New York City Department of Health and Mental Hygiene

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In New York City: Policy to Improve the Environment

Fresh fruits and vegetables Consumer-price index Sugar and sweets Carbonated drinks

Source: Brownell, K. D., & Frieden, T. R. (2009). Ounces of prevention—the public policy case for taxes on sugared beverages. New England Journal of Medicine, 360(18), 1805-1808.

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NYC DOHMH Food Regulation

  • Responsible for inspection of all food

service establishments (FSE) in NYC

  • Ensure FSE’s are in compliance with city

and state food safety regulations as

  • utlined in NYC health code
  • NYC implemented letter grades in 2010
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  • Oversees NYC Health Code
  • 11 members appointed by the

Mayor with consent of City Council

  • Board has enacted countless

measures to improve wellbeing

  • f New Yorkers:

– lead paint ban, window-guards,TB

control, calorie labeling, elimination

  • f trans fat

NYC Board of Health- 1865

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TRANS FAT REGULATION

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Trans Fat Timeline

Date Event February 1994 CSPI petitions the FDA to require trans fat to be listed on Nutrition Facts labels March 2003 Denmark bans artificial trans fat in all foods July 2003 FDA requires food manufacturers to list trans fat on Nutrition Facts labels by 2006 May & July 2004 CSPI petitions the FDA to prohibit use of PHOs and to require restaurants to immediately disclose use of PHOs August 2005 – May 2006 NYC DOHMH conducts educational campaign to reduce artificial trans fat use in food service establishments December 2006 NYC Board of Health passes restriction on use of artificial trans fat in NYC food service establishments

  • Numerous cities, counties and states enact similar restrictions

July 2008 NYC’s rule takes full effect in all food service establishments

  • Based on inspection results, an estimated 98% of restaurants were not

using artificial trans fats 6 months later June 2015 FDA determines that partially hydrogenated oils are no longer “Generally Recognized As Safe;” sets a compliance date of 3 years

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Trans Fat Regulation

  • Artificial trans fat poses a

substantial risk to heart health.

  • Amendment to New York

City’s health code (2006)

  • Prohibits restaurants from

the following

– Storing, using or serving foods containing partially hydrogenated vegetable oils, shortenings, margarines – if 0.5 grams or more artificial trans fat per serving.

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Evaluations Show Decrease in Trans Fat Consumption

  • Study examining consumption before (2007) and

after (2009) trans fat regulation showed:

– A significant decrease in mean trans fat content per

purchase (by 2.4 grams)

– An increase in purchases with 0 grams of trans fat

increased from 32% to 59%

  • Post ban (2008), use of artificial trans for frying,

baking, or cooking decreased from 50% to less than 2%

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Trans Fat Regulation - Impact

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Trans Fat National Policy

  • FDA will give manufacturers three years to

remove artificial trans fat from national food supply

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CALORIE POSTING

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Fight for Calorie Labeling in NYC

  • 2006 – NYC BOH adopts calorie labeling rule,

making NYC the first locality to require chain FSEs to post calorie information on menus

  • 2007 – First lawsuit against BOH in attempt to stop

calorie labeling

  • 2008 – NYC BOH adopts revised calorie labeling

rule, implementation begins

  • 2009 – Calorie labeling rule is upheld by US Court
  • f Appeals, Second Circuit, creating a legal

framework for others to follow

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Menu Labeling becomes National Trend

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Calorie Labeling Becomes a National Model

  • 2009 – Seattle requires calorie labeling on

restaurant menus

  • 2010 – Menu labeling requirements included in

the Affordable Care Act

  • 2014 – Federal regulations issued requiring all

chain restaurants/retailers to post calorie information

  • 2015 – Federal regulation effective December 1
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Calorie Labels Increase Awareness

  • Labels increase

awareness

– Exposure to calorie

labels is critical to educating consumers about calorie content

  • Studies have shown

customers using labels purchase fewer calories

– Patrons who used calorie

information purchased > 100 fewer calories

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Calorie Awareness Campaign

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Majority of New Yorkers Find Calorie Labeling Useful

Useful, 79% Not Useful, 19% Don't Know/ No Answer, 2%

2011: Do you think the New York City law requiring fast-food restaurants to post calorie information is useful or not useful?

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Corporations respond to Sticker Shock

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Proposed Amendments Applicability to Retail Food Establishments

  • Chain Retail Food Establishments

–Federal regulation covers chain

supermarkets, convenience stores, other food retailers

–Sale of prepared, restaurant-type food –Chains 20+ locations nationwide

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Proposed Amendments Nutrition Statements, Information

  • Federal regulation newly requires

nutritional statements, information

  • Nutrition statements

–Every menu, menu board

  • ―2,000 calories a day is used for general

nutrition advice, but calorie needs vary.‖

  • ―Additional nutritional information is

available upon request‖

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SUGARY DRINKS

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Condiments, Gravies, Spreads, Salad Dressings, 2.0% Snacks and Sweets, 31.2% Dairy, 3.8% Fruits + Fruit Juice, 0.8% Mixed Dishes, 5.8% Protein Foods, 0.6% Vegetables, 1.1% Grains, 7.8% , 0

Soft Drinks, 25.1% Fruit Drinks, 10.6%

Sport + Energy Drinks, 2.6%

Coffee + Tea, 6.7% Other: Waters, Flavored

  • r Carbonated Water,

Nutritional Beverages, 0.6% Alcoholic Beverages, 0.8%

Beverages (not incl. milk

  • r 100% juice),

46.4% Sources of added sugars in the diets of US children and adults ages 2 and

  • lder9

Source: NHANES 2009-10, as presented to the 2015 DGAC

Sugary Drinks are Making Us Sick

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New Yorkers are Paying with Their Bodies

33.1% 65.5% 12.8% 30% 66.9% 15.2% 14.8% 49.1% 7.1% 20 40 60 Sugary Drink Consumption (1+ Drinks/Day) Obesity & Overweight Diabetes % Adult New Yorkers14 Non-Hispanic Black Hispanic Non-Hispanic White

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  • Children ages 2-11 see an average of 13 food

and beverage ads per day

  • Children of color are targeted:

– In 2013, black youth saw more than twice as many

ads for sugary drinks than white youth

– In 2013, Hispanic youth were 93% more likely to visit

all beverage company websites compared to all youth

– Sugary drink advertising spending on Spanish-

language TV increased by 44% in 2013 vs. 2010

Youth are Vulnerable to Industry Tactics

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Portion Rule Regulation

  • Caps sugary drink

portion size at 16

  • unces
  • Portion size influences

consumption

  • Evidence suggests that

the policy will decrease calorie intake from sugary drinks

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Portion Rule Regulation - Response

  • Extensive coverage in TV and

print media.

  • ~38,000 public comments

– Roughly 32,000 in support of regulation

  • 55 testimonies presented at

public hearing.

– 28 supporters including academics, local community leaders, elected officials, private citizens

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Industry Strikes Back

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Portion Cap Timeline

Date Event June 2012 Proposal introduced at New York City’s Board of Health meeting July 2012 Public hearing September 2012 Board of Health votes to approve proposal; rule was to take effect March 2013 October 2012 American Beverage Association and other groups file petition in New York State court to overturn rule March 2013 New York State Court rules Portion Cap Rule violates separation of power July 2013 NYC appeals; higher court affirms lower court’s decision June 2014 NYC appeals; New York State’s highest court affirms lower court’s decision

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35.9% 32.6% 31.6% 30.3% 29.9% 28.2% 23.3%

20% 25% 30% 35% 40%

2007 2008 2009 2010 2011 2012 2013

Percent of New York City adults consuming 1 or more sugary drinks per day

Hard hitting media campaigns Community

  • utreach;

Food standards for city agencies Sugary drinks restricted in child care centers Portion cap Food standards for city agency vending machines

^Sugar sweetened beverage includes soda and other sweetened drinks like iced tea, sports drinks, fruit punch/other fruit –flavored drinks. *Youth Risk Behavior Survey (YRBS) data includes soda only. NYC Community Health Survey included adults with landline phones since 2002 and, starting in 2009, also has included adults who can be reached only by cell-phone. 2007 is baseline for Take Care New York 2012.

Some Success:

35% decline in sugary drink consumption among NYC adults, 2007-2013

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SODIUM WARNING

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Heart Disease is a Leading Killer Nationally and in NYC

  • 1 in 3 deaths are due to heart disease1
  • 36% of Black adults have been told by a health professional that they

have high blood pressure, nearly 50% more than Whites (36.1% vs. 24.8%)2

Nationally: In NYC:

Centers for Disease Control and Prevention

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  • Poor awareness of sodium recommendations

and major sources of dietary sodium

– > 80% of adults in NYC consume more sodium daily

than the recommended limit

– Black New Yorkers consume more sodium daily

than White New Yorkers

  • Too few consumers understand that high

sodium intake is a serious health hazard

– Limited awareness of link between sodium and heart

disease/stroke7

Warnings about Sources of Excess Sodium Can Help New Yorkers

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Why Restaurants? Sources of Sodium

  • Restaurant/processed

food makes up majority of dietary sodium intake

  • Restaurant food is

more sodium dense than food prepared at home

Restaurant / processed foods, 77%

Home cooking, 5% While eating, 6% Naturally

  • ccurring,

12%

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Why Warning Labels?

  • Evidence suggests that health warnings

↑ knowledge and can ↓ purchase and consumption of certain products

  • Labels facilitate education

–

Can inform customers of the risks of consuming certain products

–

More than 1 million New Yorkers see calorie labels daily in restaurants

  • Consumers find labels helpful

–

Nearly 80% of New Yorkers find calorie labels ―useful‖

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Proposed Amendment to Article 81 of the Health Code: Sodium Warning Labels

  • Identify high sodium items

– Icon on menu/menu boards identifies items

containing ≥ 2,300 mg of sodium

  • Warning Statement at point of purchase

– Warning:

indicates that the sodium (salt) content in this item is higher than the total daily recommended limit (2,300 mg). High sodium intake can increase blood pressure and risk of heart disease and stroke.

  • Affects chain restaurants (≥ 15 locations

nationwide)

– 1/3 of all restaurant traffic in NYC

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Do Something, Do More, Do Better

  • Do Something

– Push back on Big Food – Educate public on health

consequences

  • Do More

– Create policies to

regulate Big Food

  • Do Better

– Work with communities to

advocate for policies changes

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Questions

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Food Deserts

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NYC Food Standards

Sodium

  • Require all individual items contain ≤ 480 mg sodium

per serving,5 not including specific items stated

  • Recommend purchasing ―low sodium‖ (≤ 140 mg

sodium per serving) whenever feasible. Beverages

  • Require ≤ 25 calories per 8 oz for all beverages other

than 100% fruit juice or milk.6

  • If purchasing juice, require 100% fruit juice.
  • Require milk be 1% or non-fat, and unsweetened.7,8
  • Require fluid milk substitutes (e.g. soymilk) be

unflavored

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NYC Board of Health's new, stricter rules for day cares limit how much juice kids can drink

  • New regulations adopted April 2014
  • No juice under age 2
  • Serving size limited to 4 oz
  • Television watching limited to 30

minutes/day

–Only for >2 years

  • No more than 30 minutes sedentary