Cardiovascular disease is the leading cause of death in

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1 Aals of Iteral Medicie Origial Research Chage i Tras Fatty Acid Cotet of Fast-Food Purchases Associated With New York City s Restaurat Regulatio A Pre Post Study Soia Y. Agell, MD, MPH; Laura K. Cobb, MS; Christie J. Curtis, MBA; Kevi J. Koty, MS; ad Ly D. Silver, MD, MPH Backgroud: Dietary tras fat icreases risk for coroary heart disease. I 2006, New York City (NYC) passed the first regulatio i the Uited States restrictig tras fat use i restaurats. Objective: To assess the effect of the NYC regulatio o the tras ad saturated fat cotet of fast-food purchases. Desig: Cross-sectioal study that icluded purchase receipts matched to available utritioal iformatio ad brief surveys of adult luchtime restaurat customers coducted i 2007 ad 2009, before ad after implemetatio of the regulatio. Settig: 168 radomly selected NYC restaurat locatios of 11 fast-food chais. Participats: Adult restaurat customers iterviewed i 2007 ad Measuremets: Chage i mea grams of tras fat, saturated fat, tras plus saturated fat, ad tras fat per 1000 kcal per purchase, overall ad by chai type. Results: The fial sample icluded 6969 purchases i 2007 ad 7885 purchases i Overall, mea tras fat per purchase decreased by 2.4 g (95% CI, 2.8 to 2.0 g; P 0.001), whereas saturated fat showed a slight icrease of 0.55 g (CI, 0.1 to 1.0 g; P 0.011). Mea tras plus saturated fat cotet decreased by 1.9 g overall (CI, 2.5 to 1.2 g; P 0.001). Mea tras fat per 1000 kcal decreased by 2.7 g per 1000 kcal (CI, 3.1 to 2.3 g per 1000 kcal; P 0.001). Purchases with zero grams of tras fat icreased from 32% to 59%. I a multivariate aalysis, the poverty rate of the eighborhood i which the restaurat was located was ot associated with chages. Limitatio: Fast-food restaurats that were icluded may ot be represetative of all NYC restaurats. Coclusio: The itroductio of a local restaurat regulatio was associated with a substatial ad statistically sigificat decrease i the tras fat cotet of purchases at fast-food chais, without a commesurate icrease i saturated fat. Restaurat patros from high- ad low-poverty eighborhoods beefited equally. However, federal regulatio will be ecessary to fully elimiate populatio exposure to idustrial tras fat sources. Primary Fudig Source: City of New York ad the Robert Wood Johso Foudatio Healthy Eatig Research program. A Iter Med. 2012;157: For author affiliatios, see ed of text. Cardiovascular disease is the leadig cause of death i the Uited States, ad risk is icreased by poor diet. Tras fatty acid (tras fat) ad saturated fatty acid (saturated fat) itake egatively affect serum cholesterol profiles, thus icreasig risk for cardiovascular disease; however, the relative effect of tras fat is worse (1, 2). A icrease of just 2% of total eergy itake from tras fat icreases the icidece of coroary heart disease by as much as 23% (1). Dietary tras fat has both aturally occurrig ad idustrially produced sources. By the late 1990s i the Uited States, most tras fat i the diet (79%) came from processed oils ad fats, most commoly from partially hydrogeated vegetable oil (3). Because of the icreased risk for cardiovascular disease coferred by tras fat itake ad because idustrial sources of tras fat ca be replaced with more healthful alteratives, may coutries ad localities have recetly itroduced policies that decrease tras fat itake by promptig its removal from the food supply. I 2003, Demark became the first coutry to itroduce regulatory limits o the tras fat cotet of foods sold (4). I Caada ad the Uited States, utritioal labelig of tras fat cotet became required o packaged foods i 2005 ad 2006, respectively (5, 6). I 2006, New York City (NYC) became the first locality i the Uited States to pass a regulatory restrictio o the use of partially hydrogeated vegetable oil, targetig the restaurat eviromet. This latter approach is importat because more tha oe third of daily calorie itake i the Uited States is from food prepared away from home (7). The NYC regulatio was phased i startig i July 2007 ad was fully i effect by July It restricts all food service establishmets, icludig both chai ad ochai restaurats, from usig, storig, or servig food that cotais partially hydrogeated vegetable oil ad has a total of 0.5 g or more tras fat per servig. Tras fat restrictios for restaurats have sice bee adopted by at least 15 additioal local ad state jurisdictios (8). These policies represet importat public health iovatios with broadscale potetial to eable patiets to achieve complicated dietary chages, such as avoidig tras fat itake, commoly recommeded by health care providers. Evaluatig the effect of these policies o tras fat cotet ad itake is paramout, especially as coutries ad jurisdictios aroud the world cotiue to itroduce similar actios (9, 10). Such a assessmet should address See also: Prit Editorial commet America College of Physicias 81

2 Origial Research Chage i Tras Fatty Acid Cotet of Fast-Food Purchases i New York City Cotext A restrictio o restaurat sale of foods cotaiig tras fats wet ito effect i New York City i Cotributio I 2007 ad 2009, receipts were obtaied from adult customers exitig fast-food chai restaurats i New York City ad matched to published utritioal iformatio. Betwee these 2 periods, there was a substatial decrease i the amout of tras fat purchased per meal, without a commesurate icrease i saturated fat. Results did ot differ accordig to the poverty rate of the eighborhood i which the restaurat was located. Cautio Oly atioal chai restaurats were studied. Implicatio Regulatio ca result i positive dietary chage at the populatio level. The Editors cocers that restrictig tras fat use could lead to replacig saturated fat at a amout that offsets the beefit of tras fat reductio (11). Sice the itroductio of tras fat labelig i Caada ad food cotet restrictios i Demark, studies of chages i total tras plus saturated fat or tras fat cotet i packaged food thus far have bee geerally favorable (4, 12). I NYC, statistically sigificat decreases i tras fat ad tras plus saturated fat cotet i Frech fries were foud at chai restaurats after full implemetatio of the restaurat restrictio (97.9% ad 54.2% decreases, respectively) (13). A aalysis of 83 major brad-ame U.S. supermarket ad restaurat foods, which were reformulated to reduce tras fat cotet, foud that saturated fat levels were lower tha or similar to prereformulatio levels i 65% of supermarket products ad 90% of restaurat products assessed (14). These studies of marketplace product availability are importat because they assess chages i cosumer optios. However, a more complete assessmet of itake would cosider both product availability, as prepared for cosumptio, ad cosumer choice. Although restaurats would provide a ideal settig to coduct such a evaluatio, to our kowledge o studies to date have cosidered the chage i tras fat cotet of restaurat purchases as a result of tras fat regulatios. To evaluate the effect of the NYC restaurat tras fat regulatio o tras fat itake as reflected by food purchases, we used a uique survey data set of customers of luchtime chai restaurats fielded before ad after full implemetatio of the tras fat regulatio. The data set was iitially collected to assess NYC s calorie-labelig regulatio, but it icluded iformatio o utriets i additio to calories (15, 16). We aimed to describe ad compare tras fat, saturated fat, ad tras plus saturated fat cotet i luchtime purchases iteded for idividual cosumptio before ad after implemetatio of the regulatio, icludig cosideratio of the effect of associated sociodemographic variables. We hypothesized that the tras fat ad tras plus saturated fat cotet of luchtime purchases would decrease after the NYC regulatio that restricted the use of tras fat i restaurats was implemeted. METHODS Study Desig I 2007, we radomly sampled 300 locatios from all 1625 NYC licesed restaurat locatios of 13 chais. These 13 chais represeted almost 90% of all eligible restaurats, defied as chai restaurats that have more tha 15 locatios atioally, have available utritioal iformatio, ad are ot ice cream chais. Of the 300 idetified restaurat locatios, 25 were excluded because they had closed or were i a airport or a shoppig mall. For 9 weeks from March through Jue 2007, we recruited patros exitig the 275 sampled fast-food locatios for participatio i the study. They were asked to provide their receipts after exitig ad to take a brief survey to describe their purchase, cofirm that it was for oly 1 perso, ad aswer a few additioal questios. Durig the same time frame i 2009, we approached the same restaurat locatios for a repeated survey of patros. Of the origial 275 locatios, 22 had either closed or would ot allow data collectio ad were therefore replaced i our sample by outlets of the same chai i the same eighborhood or a eighborig ZIP code. The NYC Departmet of Health ad Metal Hygiee Istitutioal Review Board determied the study to be exempt from review. Study Populatio Study participats icluded adults eterig sampled fast-food chais betwee oo ad 2:00 p.m. durig the survey time frames. We offered a sigle-ride MetroCard as a icetive. We based the patro sample size calculatio for the origial calorie study o the assumptios of a coefficiet of variatio of 38% i purchased calories ad a desig effect of 4. The study therefore required at least 3600 people per year for a 80% power to detect a 5% chage i calories betwee 2007 ad To allow for stratified aalyses of that study, we set a goal of customer receipts for each study period. Samplig ad data collectio methodology have bee published previously (15). Because this study aimed to assess luchtime purchases, we excluded data from patros of the 2 coffee chais i the origial list of 13 chais. Our aalysis therefore icluded purchases from patros of 168 locatios of 11 fast-food chais i NYC. These iclude hamburger chais (McDoald s, Burger Kig, Wedy s), sadwich chais (Subway, Au Bo Pai), fried chicke chais (KFC, July 2012 Aals of Iteral Medicie Volume 157 Number 2

3 Chage i Tras Fatty Acid Cotet of Fast-Food Purchases i New York City Origial Research Popeyes), pizza chais (Domio s, Pizza Hut, Papa Joh s), ad a Mexica food chai (Taco Bell). Data Set The fial data set icluded items purchased plus modificatios made to each item at the customer s request, the sex of the customer, ad the customer s itetio for idividual cosumptio. We matched baselie receipts from 2007 ad receipts collected i 2009 after the regulatio was implemeted to utritioal iformatio posted o compay Web sites o 1 March 2007 ad 1 March 2009, respectively. Of ote, federal regulatios allow products that cotai up to 0.5 g of tras fat to be labeled as cotaiig zero grams of tras fat. Receipts were deemed ieligible for iclusio if the purchase was for more tha 1 perso, the customer s order could ot be determied, or the customer did ot order a food item. We also excluded receipts with missig calorie, tras fat, or saturated fat iformatio for at least 1 food item. Statistical Aalysis Our aalysis compared purchases made i 2007 ad 2009 that were iteded for idividual cosumptio ad cotaied at least 1 food item. Usig the SURVEYMEANS procedure i SAS, versio 9 (SAS Istitute, Cary, North Carolia), to accout for the clustered sample desig, we calculated descriptive statistics (mea [ SE] ad rage) for the umber of grams of tras fat, saturated fat, tras plus saturated fat, ad tras fat per 1000 kcal for purchases (overall ad by chai type) for both years. We performed hypothesis testig separately for each measure of fat purchased by usig the SURVEYREG procedure (a regressio procedure that accouts for complex survey desig) i SAS. We estimated the uadjusted differeces i mea saturated ad tras fat per purchase betwee 2007 ad 2009 ad tested them agaist the ull hypothesis of o chage. Multiple liear regressio modelig estimated the adjusted chage i mea grams of tras fat per purchase from 2007 to 2009, cotrollig for customer sex, the poverty rate of the eighborhood i which the restaurat was located, calories purchased, ad idividual chai. For this model, purchases with missig data i ay variable were excluded. We icluded calories i the model to cotrol for chages i the size of meu items betwee the 2 study periods. We cotrolled for the variatio i the umber of customers by chai betwee 2007 ad 2009 by icludig idicator (dummy) variables for each chai. Neighborhood poverty rate was based o the restaurat s ZIP code ad is the percetage of households below 200% of the atioal poverty level. All aalyses were coducted by usig SAS, versio 9. Role of the Fudig Source The 2007 baselie data collectio was fuded by the City of New York. The follow-up data collectio was fuded by the City of New York ad the Robert Wood Johso Foudatio Healthy Eatig Research Program to examie the effectiveess of calorie labelig. Staff supervisig ad aalyzig the study of tras fat cotet were employees of the NYC Departmet of Health ad Metal Hygiee. RESULTS Luchtime receipts ad surveys totaled 7750 i 2007 ad 8730 i We excluded 589 receipts from 2007 because of ieligibility ad 192 because of missig calorie or fat iformatio i a food item; for 2009, we excluded 557 ad 288, respectively. Foods missig calorie or fat iformatio were geerally limited-time offers, rather tha items o the regular meu. Our fial aalytic sample totaled purchases (6969 from 2007 ad 7885 from 2009). I both years, customers were evely split betwee me ad wome. The distributio of customers by chai type also remaied similar, with 53% from hamburger chais, 28% from sadwich chais, 12% from fried chicke chais, ad approximately 4% each from pizza ad Mexica food chais. Betwee 2007 ad 2009, mea tras fat cotet per purchase decreased by 2.4 g (2.9 vs. 0.5 g; 95% CI, 2.8 to 2.0g[P 0.001]) (Table 1). Tras fat cotet per purchase showed a statistically sigificat decrease from 2007 to 2009 i 3 of the 5 chai types ad a icrease i 1. The greatest absolute decrease per purchase (3.8 g) was observed i hamburger chais (4.5 vs. 0.7 g; CI, 4.2 to 3.5g[P 0.001]), followed by Mexica food ad fried Table 1. Chage i Tras Fat Cotet i Luchtime Purchases at New York City Fast-Food Chais Chai Type Mea Tras Fat Cotet (±SE), g Chage (95% CI), g P Value Mea Tras Fat Cotet (±SE), g/1000 kcal Chage (95% CI), g/1000 kcal P Value All receipts ( 2.78 to 2.02) ( 3.06 to 2.25) Hamburger ( 4.15 to 3.47) ( 4.55 to 3.79) Sadwich (0.04 to 0.12) ( 0.04 to 0.07) 0.65 Fried chicke ( 3.82 to 1.48) ( 3.95 to 1.54) Pizza ( 0.60 to 0.04) ( 0.35 to 0.04) Mexica food ( 2.93 to 2.37) ( 3.68 to 3.24) July 2012 Aals of Iteral Medicie Volume 157 Number 2 83

4 Origial Research Chage i Tras Fatty Acid Cotet of Fast-Food Purchases i New York City Table 2. Chage i Saturated Fat Cotet i Luchtime Purchases at New York City Fast-Food Chais Chai Type Chage (95% CI), g P Value Mea Saturated Fat Cotet (±SE), g Mea Saturated Fat Cotet (±SE), g All receipts (0.13 to 0.96) Hamburger ( 0.89 to 0.16) Sadwich (1.46 to 2.45) Fried chicke (0.56 to 3.32) Pizza ( 3.80 to 0.49) Mexica food ( 2.27 to 0.21) chicke chais. Tras fat cotet per 1000 kcal also decreased across the sample by 2.7 g per 1000 kcal (CI, 3.1 to 2.3 g per 1000 kcal [P 0.001]). However, at sadwich chais, tras fat cotet per purchase icreased by 0.1 g (0.2 vs. 0.3 g; CI, 0.0 to 0.1 g [P 0.001]), whereas tras fat cotet per 1000 kcal, already low i 2007, remaied costat. Overall mea saturated fat cotet per purchase icreased by 0.6 g (CI, 0.1 to 1.0 g [P 0.011]) (Table 2), whereas mea tras plus saturated fat decreased by 1.9 g (13.8 vs g; CI, 2.5 to 1.2g[P 0.001]) (Table 3). Mea saturated fat icreased by 2.0 g at sadwich chais (CI, 1.5 to 2.5 g [P 0.001]) ad by 1.9 g at fried chicke chais (CI, 0.6 to 3.3 g [P 0.006]). Mea tras plus saturated fat decreased at 2 chai types ad icreased i 1. The reductio was greatest i hamburger chais (4.2 g; CI, 4.9 to 3.5g[P 0.001]) ad Mexica food chais (3.7 g; CI, 5.2 to 2.2g[P 0.001]). Sadwich chais showed a icrease of 2.0 g (8.6 vs. 10.6; CI, 1.5 to 2.6 g [P 0.001]). I our liear regressio aalysis, we excluded 231 additioal purchases because of missig sex data. Whe cotrollig for total calories purchased, restaurat chai, customer sex, ad restaurat locatio, poverty rate did ot have a statistically sigificat ifluece o the chage i tras fat cotet per purchase. The adjusted mea tras fat cotet decreased by 2.3 g per purchase from 2007 to 2009 (CI, 2.8 to 2.1g[P 0.001]), similar to our uadjusted fidigs (Table 1). I this model, there was a statistically sigificat but small associatio betwee calories ad tras fat cotet (a additioal g of tras fat per additioal calorie; CI, to g [P 0.001]). We saw o associatio betwee tras fat cotet of purchases ad customer sex or eighborhood poverty level. The maximum tras fat cotet of a sigle purchase decreased from 28 g i 2007 to 5 g i 2009, substatially reducig the skewig of the tras fat cotet distributio i 2009 (Figure). The maximum tras plus saturated fat cotet i a sigle purchase decreased from 96 g i 2007 to 60 g i The percetage of purchases with tras fat cotet listed as zero grams icreased from 32% i 2007 to 59% i DISCUSSION Our study of a sample of NYC chai restaurat customers before ad after implemetatio of the NYC regulatio restrictig restaurat tras fat use demostrated a associated large ad probably cliically meaigful reductio i the tras fat cotet of luchtime purchases. The absolute decrease i tras fat per purchase amouted to 2.4 g. This reductio, which is equivalet to a 21.6-kcal decrease i tras fat per purchase (1 g tras fat 9 kcal), is expected to affect the cardiovascular health of regular restaurat patros; a icrease of oly 40 kcal of eergy per day from tras fat for a perso cosumig a 2000-kcal/d diet has bee estimated to icrease the risk for coroary heart disease by 23% (1). Give that oe third of calories i the Uited States comes from foods prepared away from Table 3. Chage i Tras Plus Saturated Fat Cotet i Luchtime Purchases at New York City Fast-Food Chais Chai Type Chage (95% CI), g P Value Mea Tras Plus Saturated Fat Cotet (±SE), g Mea Tras Plus Saturated Fat Cotet (±SE), g All receipts ( 2.52 to 1.19) Hamburger ( 4.92 to 3.49) Sadwich (1.51 to 2.55) Fried chicke ( 1.95 to 0.54) 0.27 Pizza ( 4.27 to 0.34) Mexica food ( 5.17 to 2.17) July 2012 Aals of Iteral Medicie Volume 157 Number 2

5 Chage i Tras Fatty Acid Cotet of Fast-Food Purchases i New York City Origial Research Figure. Distributio of tras fat cotet per purchase. Customers, % Tras Fat Cotet per Purchase, g Tras fat cotet may be uderestimated because compaies ca report tras fat values less tha 0.5 g as zero grams of tras fat. I 2007, oly 32% of customer purchases had zero grams of tras fat vs. 59% of customer purchases i Similarly, the maximum amout of tras fat i a idividual purchase was 28 g i 2007 vs. 5 g i home, this suggests a remarkable achievemet i potetial cardiovascular risk reductio through food policy. Our fidigs have implicatios beyod NYC. I the Uited States, as the NYC regulatio was beig implemeted, some atioal chais that had locatios i NYC aouced related reformulatios atiowide (17). Our results, therefore, suggest the potetial for broader effect of local food policy o a coutry s food compaies. Some key reasos for the observed chages i tras fat cotet per purchase may iclude customers selectig a differet mix of products, reformulated meu items, ad items that have chaged i size. Ispectio of the most commoly purchased food items i chai types with the largest reductios i tras fat per purchase (hamburger, Mexica food, ad fried chicke chais) revealed multiple examples of reformulatio ad ew product itroductios. For example, i fried chicke chais, the 2 most purchased types of food, fried chicke pieces ad biscuits, had averages of 1 g ad 1.75 g less tras fat, respectively, i 2009 tha i I 2009, KFC itroduced ew grilled chicke meu items, all of which were listed as havig zero grams of tras fat. I our data set, grilled chicke items became the fourth most commoly purchased type of food at fried chicke chais. As demostrated, adjustmet for calories i our regressio aalysis did ot chage the estimated differece i tras fat purchased per customer betwee the 2 years, ad the chage i tras fat per 1000 kcal remaied substatial, suggestig that smaller portio sizes are ot drivig the reductio i tras fat cotet per purchase. The cocer that potetial health advatages from reductios i tras fat would be offset by replacig it with saturated fat was also ot substatiated by our study. Although we observed a slight overall icrease i saturated fat cotet per purchase, tras fat ad tras plus saturated fat decreased, idicatig a et health beefit. I sadwich chais, a statistically sigificat icrease i tras plus saturated fat was observed; however, the icrease i tras fat was small ad probably cliically isigificat. Furthermore, the icrease i saturated ad tras fat may well be the result of a documeted icrease i calories per purchase associated with icreased portio size rather tha reformulated meu items (16). Studies that looked at product reformulatio aloe foud lower or uchaged levels of saturated fat whe tras fat was reduced (13, 14). Health disparities drive by socioecoomic determiats are oe of the greatest challeges to advacig populatio health. Low-icome NYC eighborhoods have death rates from heart disease that are 1.2 times those of high-icome eighborhoods (18). To cosider potetial differeces i tras fat exposure i restaurat chais based o eighborhood icome, we assessed the chage i tras fat cotet per purchase, cotrollig for eighborhood poverty rate of the store locatio. We foud o statistically sigificat differeces, suggestig that the use of a regulatory strategy provided equal beefit to patros of restaurats i high- ad low-poverty eighborhoods. Although our fidigs idicate a importat policy success, they also idetify areas that warrat further cosideratio. I 2009, 59% of purchases cotaied zero grams of total tras fat, a 86% icrease from Yet, 40% of purchases still cotaied at least 0.5 g of tras fat (Figure) i 2009, although the mea cotet per purchase was lower tha i A proportio of this tras fat is expected to be from aturally occurrig sources; the NYC regulatio made accommodatio for these types of sources to avoid restrictig milk ad meat products. Uder federal requiremets, a product labeled as cotaiig zero grams of tras fat may still cotai tras fat from atural or idustrial sources, as log as it cotais less tha 0.5 g per servig (13). For feasibility ad eforcemet purposes, the tras fat regulatios i NYC ad may other localities relied o the zero-gram criterio to exclude products from use; however, this approach may ot fully elimiate idustrial sources. Our study desig has both limitatios ad stregths. Data were collected from patros of fast-food chais oly ad are therefore ot represetative of all fast-food restaurats. Nochai restaurats are geerally ot covered by existig regulatios requirig public disclosure of utritioal iformatio. As a result, it was ot feasible to iclude them i our survey sample. The fast-food chais icluded i the study are atioal chais that have publicly available utritioal iformatio, subjectig their meu items to icreased public scrutiy. Therefore, it is possible that the magitude of the reductio i tras fat cotet associated with the NYC tras fat regulatio may differ i ochai restaurats that were also covered by the regulatio. Fially, our study desig is cross-sectioal, ad we ca therefore assess oly the associatio of observed chages with the regulatio s implemetatio causatio 17 July 2012 Aals of Iteral Medicie Volume 157 Number 2 85

6 Origial Research Chage i Tras Fatty Acid Cotet of Fast-Food Purchases i New York City caot be decisively attributed. Study stregths iclude aalysis of reported utritioal value of purchases istead of meu offerigs, allowig us to cosider the combied iflueces of product availability ad cosumer choice. Furthermore, the umber of receipts collected was large (more tha ), ad the timig of collectio was proximate to regulatio (withi 3 moths before phase-i started ad withi 1 year after phase-i was complete). Our study suggests that reductios i the tras fat cotet of restaurat purchases ca be achieved without a offsettig icrease i saturated fat through regulatio of the restaurat food eviromet. It also provides objective fidigs that warrat further ivestigatio ad cosideratio for federal actio ad illustrates the importace of ogoig research ad evaluatio of utritioal policy. The marketplace has chaged substatially i recet years, demostratig that reformulatio to remove tras fat is feasible i both restaurat ad packaged foods. Local regulatio seems to be successful at reducig exposure to tras fat i restaurats. However, full elimiatio of exposure to the idustrially produced form of this harmful ad uecessary additio to our food supply, foud i partially hydrogeated oils, will require federal actio. From the New York City Departmet of Health ad Metal Hygiee, New York, New York. Note: All authors were employed by the New York City Departmet of Health ad Metal Hygiee at the time that this aalysis was coducted. For cotact purposes oly, Dr. Agell is curretly employed by the Ceters for Disease Cotrol ad Prevetio. Disclaimer: All authors had full access to the data ad ca take resposibility for the itegrity of the data ad the accuracy of the data aalysis. Ackowledgmet: The authors thak Christia Huag, MPH, doctoral fellow at Pardee RAND Graduate School, ad Tamara Dumaovsky, PhD, idepedet cosultat, for their cotributios to the desig ad implemetatio of the origial study; Gail Goldstei, MPH, New York City Departmet of Health, for her leadership i implemetig the New York City tras fat restrictio ad for her review of this article; Sarah Niederma, MPH, New York City Departmet of Health, for her assistace with data aalysis ad coordiatio; ad Stephe E. Schachterle, PhD, MPH, New York City Departmet of Health, for his assistace with data aalysis. Grat Support: The iitial study to evaluate calorie labelig was fuded by the City of New York ad the Robert Wood Johso Foudatio Healthy Eatig Research program (grat 65839). The secodary aalysis o tras fat reported here was fuded solely by the City of New York. Potetial Coflicts of Iterest: Disclosures ca be viewed at M Reproducible Research Statemet: Study protocol, statistical code, ad data set: Not available. Requests for Sigle Reprits: Christie J. Curtis, MBA, New York City Departmet of Health ad Metal Hygiee, Gotham Ceter, CN24, th Street, 9th Floor, Log Islad City, NY ; , [email protected]. Curret author addresses ad author cotributios are available at Refereces 1. Mozaffaria D, Kata MB, Ascherio A, Stampfer MJ, Willett WC. Tras fatty acids ad cardiovascular disease. N Egl J Med. 2006;354: [PMID: ] 2. Ascherio A, Kata MB, Zock PL, Stampfer MJ, Willett WC. Tras fatty acids ad coroary heart disease. N Egl J Med. 1999;340: [PMID: ] 3. U.S. Food ad Drug Admiistratio. Revealig tras fats. FDA Cosumer Magazie. 24 February Accessed at o 22 May Leth T, Jese HG, Mikkelse AA, Bysted A. The effect of the regulatio o tras fatty acid cotet i Daish food. Atheroscler Suppl. 2006;7:53-6. [PMID: ] 5. Tras fats: the move away from bad fats. CBC News. 23 December Accessed at o 17 March Severso K, Warer M. Fat substitute is pushed out of the kitche. The New York Times. 13 February Accessed at /busiess/13trasfat.html o 17 March Agricultural Research Service. Away From Home: Percetages of Selected Nutriets Cotributed by Foods Eate Away From Home, by Geder ad Age, i the Uited States, Washigto, DC: U.S. Departmet of Agriculture; Accessed at /0708/Table_9_AWY_GEN_07.pdf o 15 Jue Ceter for Sciece i the Public Iterest. Tras fat bas i restaurats. Washigto, DC: Ceter for Sciece i the Public Iterest; Accessed at o 5 April Swede s parliamet passes tras fat ba. The Local. 17 March Accessed at o 22 May Carlesso J. Coucil calls for ordiace baig use of tras fat i city restaurats. Hartford Courat. 15 March Accessed at / /commuity/hc-hartford-tras-fat _1_tras-fats -coucil-votes-ordiace o 20 March America Heart Associatio. Policy Positio Statemet o Regulatory ad Legislative Efforts to Improve Cardiovascular Health by Decreasig Cosumptio of Idustrially Produced Tras Fats. Dallas, TX: America Heart Assoc; Accessed at /dowloadable/ucm_ pdf o 7 April Ratayake WM, L Abbe MR, Mozaffaria D. Natiowide product reformulatios to reduce tras fatty acids i Caada: whe tras fat goes out, what goes i? Eur J Cli Nutr. 2009;63: [PMID: ] 13. Agell SY, Silver LD, Goldstei GP, Johso CM, Deitcher DR, Friede TR, et al. Cholesterol cotrol beyod the cliic: New York City s tras fat restrictio. A Iter Med. 2009;151: [PMID: ] 14. Mozaffaria D, Jacobso MF, Greestei JS. Food reformulatios to reduce tras fatty acids [Letter]. N Egl J Med. 2010;362: [PMID: ] 15. Bassett MT, Dumaovsky T, Huag C, Silver LD, Youg C, Noas C, et al. Purchasig behavior ad calorie iformatio at fast-food chais i New York City, Am J Public Health. 2008;98: [PMID: ] 16. Dumaovsky T, Huag CY, Noas CA, Matte TD, Bassett MT, Silver LD. Chages i eergy cotet of luchtime purchases from fast food restaurats after itroductio of calorie labellig: cross sectioal customer surveys. BMJ. 2011;343:d4464. [PMID: ] 17. Dorfma B, Baertlei L. McDoald s cookig oil tras fat-free i U.S., Caada. Reuters. 23 May Accessed at /idusn o 7 April Karpati A, Kerker B, Mostashari F, Sigh T, Hajat A, Thorpe L, et al. Health Disparities i New York City. New York: New York City Departmet of Health ad Metal Hygiee; July 2012 Aals of Iteral Medicie Volume 157 Number 2

7 Aals of Iteral Medicie Curret Author Addresses: Dr. Agell: Ceters for Disease Cotrol ad Prevetio, 1600 Clifto Road, MS D-69, Atlata, GA Ms. Cobb: Johs Hopkis Bloomberg School of Public Health, Welch Ceter, 2024 Moumet Street, Suite 2-600, Baltimore, MD Ms. Curtis: New York City Departmet of Health ad Metal Hygiee, Gotham Ceter, CN24, th Street, 9th Floor, Log Islad City, NY Mr. Koty: New York City Departmet of Health ad Metal Hygiee, 125 Worth Street, Room 315, Box CN15, New York, NY Dr. Silver: Sooma Couty Departmet of Health Services, 3313 Chaate Road, Sata Rosa, CA Author Cotributios: Coceptio ad desig: S.Y. Agell, L.D. Silver. Aalysis ad iterpretatio of the data: S.Y. Agell, L.K. Cobb, K.J. Koty, L.D. Silver. Draftig of the article: S.Y. Agell, L.K. Cobb, C.J. Curtis, K.J. Koty, L.D. Silver. Critical revisio of the article for importat itellectual cotet: S.Y. Agell, L.K. Cobb, C.J. Curtis, K.J. Koty, L.D. Silver. Fial approval of the article: S.Y. Agell, L.K. Cobb, C.J. Curtis, K.J. Koty, L.D. Silver. Statistical expertise: S.Y. Agell, L.K. Cobb, K.J. Koty. Obtaiig of fudig: L.D. Silver. Admiistrative, techical, or logistic support: L.K. Cobb, L.D. Silver. W July 2012 Aals of Iteral Medicie Volume 157 Number 2