Ending Trans Fat—The First-Ever Global Elimination Program for a Noncommunicable Disease Risk Factor

Abstract

Industrially produced trans fat (iTFA) is a harmful compound created as a substitute for animal and saturated fats. Estimated to cause up to 500,000 deaths per year, it is replaceable. In 2018, Resolve to Save Lives, the World Health Organization (WHO), Global Health Advocacy Incubator, and NCD Alliance partnered to achieve global trans fat elimination. The WHO Director-General called for the elimination of trans fat by 2023 through best practice policies outlined in the WHO REPLACE package. Since the accelerated global efforts in 2018, 43 countries have adopted best practice regulations protecting an additional 3.2 billion people and building momentum toward global elimination. Current coverage will prevent 66% of deaths estimated to be caused each year by trans fat in foods. Despite producing and selling iTFA-free products in many countries, companies continue to sell iTFA-containing products in unregulated markets. Global incentives, accountability mechanisms, and regional policies will help achieve the elimination goal.

Highlights

• •Policies can reduce known risk of coronary heart disease due to trans fat consumption.
• •A strategic partnership accelerated progress toward global elimination of trans fats by 2023.
• •Policies in place today will prevent 66% of the deaths estimated to be caused by trans fats each year.
• •Global trans fat elimination offers a model to tackle other nutrition policy priorities.

Industrially produced trans fat (iTFA) is a harmful compound that is used in baked and fried foods, prepackaged snacks, and in certain cooking oils and fats that are used at home, in restaurants, and in street food. Partially hydrogenated oils (PHOs), the main source of iTFA, were developed in the early 1900s as a replacement for butter and other animal fats. PHOs became popular in the 1950s to 1970s as part of the effort to reduce consumption of saturated fat.

By the late 20th century, an extensive body of evidence had accumulated showing that trans fat (TFA) intake increases low-density lipoprotein cholesterol, lowers high-density lipoprotein cholesterol, and causes coronary heart disease.¹ In 2010, TFA intake was estimated to cause >500,000 coronary heart disease deaths globally each year.² Successful global elimination of iTFA could delay 17.5 million TFA-attributable deaths over the next 25 years.³ TFA from natural sources (as opposed to iTFA) occurs in lower quantities in meat and dairy from ruminant animals, such as cattle, sheep, and goats. Although it appears that ruminant and iTFAs may have similar impacts, real-world intake of ruminant TFA is typically too low to see a health effect.^1,4,5

Using iTFA in food products is attractive to the food industry because it is inexpensive, extends shelf life of processed foods, and does not have to be changed as often as natural oils when used for deep frying. However, removing iTFA from the food supply has proven to be technically and economically feasible, and lifesaving. In 2003, Denmark became the first country to restrict iTFA, limiting it to 2 g per 100 g of fat or oil in all foods. In 2007, New York City banned iTFA in restaurants, showing that it can be eliminated and replaced with healthier alternatives without altering taste, cost, or availability of food.⁶ Evaluations of these regulations found a 10% reduction in deaths from coronary heart disease relative to similar countries in Denmark and 6.2% greater declines in heart attack and stroke hospitalizations in New York State counties with restrictions compared with counties without.^{7, 8, 9}

Because of early action by Denmark, New York, and other jurisdictions, the food and beverage industry has been reformulating products that contained iTFA for >20 years. However, despite producing and selling iTFA-free foods is some countries, companies continue to sell iTFA-containing products in unregulated markets. As iTFA restrictions went into effect in Western Europe, the number of foods high in TFA increased in Eastern European countries that did not have regulations in place.¹⁰

By mid-2018, 15 years after Denmark’s pioneering action, 27 countries—mostly high-income countries in Europe and the Americas—had introduced mandatory iTFA restrictions. Only 14 of these countries used regulations as strict as Denmark’s, which would become one of the 2 best practices recommended by the World Health Organization (WHO). WHO identified iTFA elimination as a highly cost-effective intervention for low- and middle-income countries to prevent and control noncommunicable diseases (NCDs).¹¹ Despite this, before 2018, few low-and middle-income countries had restrictions in place, risking high levels of iTFA in their food supply and resulting in avoidable heart attacks.

Removing iTFA from the global food supply was identified as a winnable goal but new and focused effort was needed to achieve results and catalyze global action. This paper describes the global effort to scale up iTFA elimination, its components, and successes and challenges to date.

Methods

Building a global movement

The global iTFA elimination partnership (referred to moving forward as the global partnership) was established with the launch of Resolve to Save Lives (RTSL) in 2017. (RTSL’s TFA work is funded by Bloomberg Philanthropies, the Chan Zuckerberg Initiative Foundation, the Bill and Melinda Gates Foundation, Founders Pledge, and Lyda Hill Philanthropies.) At the same time, WHO was working to update its guidelines on saturated fat and TFA intake.¹² This common interest and influx of new funding enabled the creation of a global partnership among RTSL, WHO, and the Global Health Advocacy Incubator (GHAI) to tackle TFA elimination. The NCD Alliance joined the partnership in 2018.

The global partnership adapted the framework used in the groundbreaking work of the Bloomberg Global Tobacco Control Initiative, which has contributed to the protection of >4 billion people with effective tobacco control strategies, and substantially reduced tobacco use, preventing >37 million deaths.^13,14 The global iTFA elimination framework (Central Illustration) has 6 core components, beginning with prioritization and establishing normative guidance, which builds the evidence base for global coalition building, supporting country governments, empowering civil society, and targeted advocacy, including addressing industry opposition. Impact and progress are then measured through the monitoring framework.

Central Illustration.

The Global Industrially Produced Trans Fat Elimination Framework

The global industrially produced trans fat (iTFA) elimination framework, based on the Bloomberg Global Tobacco Control Initiative, was used by the global partnership as a way of structuring the approach to iTFA elimination.

Global iTFA elimination model

Prioritization

In 2018, the WHO prioritized the elimination of iTFA as a target within its 13th General Work Program (GPW13). This decision was driven by the extensive evidence that iTFA causes coronary heart disease events and death and the experience from Denmark and New York State showing that iTFA restrictions improve health outcomes.^{7, 8, 9} Member states committed to eliminate iTFA by approving the GPW13 at the 71st World Health Assembly in 2018. This commitment is also aligned with the United Nations’ Sustainable Development Goals, in particular target 3.4: to reduce premature death from NCDs by one-third by 2030.

Development of normative guidance

In May 2018, WHO published draft guidelines on saturated fat and TFA intake for public consultation, recommending that total TFA intake be limited to <1% of total energy intake.¹² That same month at the 2018 World Health Assembly, WHO Director-General Dr Tedros Adhanom Ghebreyesus and RTSL President and CEO Dr Tom Frieden set an ambitious goal: to achieve an iTFA-free world by 2023. The REPLACE framework with recommended iTFA elimination policies was released in support of this goal. Following this announcement, Argentina, Denmark, Portugal, Russia, and Thailand, made statements of commitment to eliminate iTFA.

In May 2019, WHO, with support from RTSL and GHAI, released the REPLACE technical package, providing countries with more detailed guidance to eliminate iTFA.¹⁵ The 6 modules (Figure 1) are based on country experiences, and include resources to support country action on iTFA and continue to be⁵ promoted widely among member states, civil society, and the media.¹⁵

Figure 1.

REPLACE Package Modules

This figure lists the modules and content for each of the 6 REPLACE Package modules developed to support elimination of industrially produced trans fat (iTFA).

Coalition building at global level

The global partnership was formed to achieve global iTFA elimination by leveraging each group’s respective positions and strengths. A matrix of each organization’s roles and responsibilities is included in Table 1. RTSL plays a leading role on communication, coordination, and strategy development among partners, fund raising, and grant making.

Table 1.

Matrix of Responsibilities for Global TFA Partnership

	WHO	RTSL	GHAI	NCDA
Partnership coordination		X
Normative guidance	X	X	X
Global advocacy	X	X		X
Regional operation	X		X
Country operation	X	X	X	X
Technical support	X	X	X	X
Landscape assessment	X	X	X	X
Coordination	X	X	X
Policy advocacy	X	X	X	X
Laboratory support and capacity building	X	X	X
Mass media and communication			X	X
Media Training			X	X
Capacity building–government	X	X	X
Capacity building–civil society organizations		X	X	X
Research	X	X	X	X
Grant making		X	X	X
Coalition building			X	X
Countering industry opposition			X	X

GHAI = Global Health Advocacy Incubator; NCDA = NCD Alliance ; RTSL = Resolve to Save Lives; WHO = World Health Organization.

As the specialized United Nations agency for international public health, WHO plays a crucial role in setting normative guidance on nutrient intake and policy development and is a key partner in building government capacity to develop and implement trans fat policies. WHO also monitors progress toward the global target, leads annual reporting processes, and advocates for best practice iTFA elimination policies via global platforms and programs, including the World Health Assembly, United Nations General Assembly, and the United Nations Decade of Action on Nutrition (2016-2025).

GHAI and NCD Alliance partner with and support country advocates, government stakeholders, and civil society organizations (CSOs) to pass best practice iTFA policies through comprehensive advocacy campaigns, policy-oriented research, and technical assistance. NCD Alliance also plays a global advocacy role supporting iTFA elimination as a policy solution to address NCDs.

Country investment, civil society empowerment, advocacy/media strategies

Prioritization and technical assistance

Global, regional, and country partners have invested in and supported national governments in their iTFA elimination policymaking in >30 countries since 2018. Countries were prioritized based on the presence of high cardiovascular death and disease burden, iTFA burden, political opportunity, and readiness, such as existing scope within policy and strategy documents for action on iTFA, stated interest from health leaders, and forward-thinking health leadership. Low- and middle-income countries with the highest number of iTFA-attributable deaths were identified for targeted support using the 2010 Global Burden of Disease estimates of iTFA-related deaths.²

In priority countries and regions, global partners held iTFA regulatory and laboratory capacity-building workshops, provided legal support on regulatory drafting for policymakers, and technical guidance on iTFA replacements. WHO, RTSL, and GHAI collaborated on regulatory and laboratory capacity-building workshops for countries in Africa, South and Southeast Asia, Central and Latin America and the Caribbean, and the Middle East. Participants included government stakeholders from ministries of health, regulatory agencies, government laboratories, and in some cases, legislative drafters, alongside academics and CSOs.

Advocacy and media strategies and the role of civil society

CSOs are critical partners in shaping and accelerating public health policies in many countries. GHAI and their local civil society partners led advocacy campaigns in 13 countries, and NCD Alliance through their local alliances led efforts in Mexico and Pakistan. Civil society partners conducted chemical analysis of TFA levels in foods in 7 countries (Argentina, Bangladesh, India, Turkey, Pakistan, Nigeria, and Tanzania¹⁶) and PHO market mapping in 8 countries (Bangladesh, Philippines, Argentina, Kenya, Uganda, Tanzania, Ethiopia, and Nigeria).

In the Philippines, Imagine Law, supported by GHAI, led a public awareness campaign promoting a TFA-free Philippines and provided administrative and technical support to government through the regulatory process. In Pakistan, Heartfile, supported by the NCD Alliance, conducted cost-effectiveness analysis on a TFA elimination policy, supported upgrading government laboratory facilities to facilitate TFA analysis, and coordinated a TFA working group with government and other partners.

Addressing industry opposition

In priority countries, GHAI, in partnership with local CSOs, works to understand opposition to iTFA policies from food companies, monitors their corporate behavior and actions and interference into the policymaking process, and mitigates their interference when necessary. Common industry approaches that interfere with policy advocacy include attempts to limit the scope of regulations to certain food categories and pushing for voluntary measures or weaker legal instruments. Strategies to limit industry goals include providing policymakers with guidance to limit industry involvement in policy making, and transparent mechanisms for industry participation in the context of open consultations. CSOs and academic organizations also provide evidence to address industry concerns and provide technical guidance on reformulation options specific to the needs of the country (ie, tailored to available iTFA healthier alternatives), and on safeguarding the policymaking process against conflicts of interest.

iTFA monitoring framework

In 2019, WHO launched a global policy monitoring scorecard and map that provides a real-time snapshot of the progress toward the 2023 global elimination target (Figure 2). The scorecard categorizes countries’ TFA policies,¹⁷ showing how governments are performing and inspiring action. iTFA was also included as part of the WHO Triple Billion, a flagship initiative to improve the health of billions of people. Its indicators (including one on best practice iTFA policies) are the foundation of GPW13, acting as both a measurement and a policy strategy.

Figure 2.

Map of Country TFA Policy Implementation Using the WHO TFA Policy Scorecard, December 2023

Global TFA Country Scorecard. This scorecard reports on country trans fat (TFA) policy status. Source: World Health Organization (WHO).¹⁷ The map is based on the data available in the Global database on the Implementation of Food and Nutrition Action, and regularly updated.

Since the REPLACE framework was launched in 2018, WHO has published 4 annual progress reports.^{17, 18, 19, 20, 21} The reports track progress, identify common challenges, share country case studies, and emphasize strategies and action needed from key stakeholders to meet the 2023 global iTFA elimination target. They provide an annual touch point and media moment for iTFA to publicize success, assess what has worked, guide the partnership’s strategy, incentivize and advocate for country action, and hold countries accountable for the 2023 target.

In addition, WHO launched an iTFA elimination validation program in 2023 to recognize countries' significant effort to eliminate iTFA, incentivize accelerated policy passage, and encourage policy monitoring and enforcement. Countries that have passed and implemented best practice policies can apply for validation.²² In December 2023, Denmark, Lithuania, Poland, Saudi Arabia, and Thailand became the first 5 countries to receive the validation certificate.

Results

The release of the REPLACE policy package, the call for global elimination by 2023, and the adoption of WHO’s GPW13 prioritizing iTFA elimination in 2018 catalyzed rapid progress. Since then, 43 countries, covering 3.2 billion people, 40% of the global population, have adopted best practice policies. Including the 14 countries that had best practice limits at the time of REPLACE’s launch (in May 2018), a total of 3.7 billion people or 47% of the world’s population in 58 countries currently have best practice policies (Figure 3). A total of 66% of all deaths estimated to be caused by TFA intake each year will be prevented because of the policies in these 58 countries.²³

Figure 3.

Adoption of Best Practice TFA Policies and Population Coverage

Shown is the cumulative growth in countries adopting best practice trans fat (TFA) elimination policies, and corresponding population coverage between 2001 and 2024. The figure highlights the launch of the global industrially produced TFA Partnership and REPLACE in 2018.

Before 2018, all but 2 of the countries with best practice policies were high-income countries (South Africa and Peru, upper middle-income countries, were the exception). Since 2018, 9 additional upper middle-income countries (Argentina, Brazil, Bulgaria, Croatia, Mexico, Moldova, Paraguay, Thailand, Turkey) and 8 lower middle-income countries have adopted policies (Bangladesh, Egypt, India, Nepal, Nigeria, Philippines, Ukraine, Sri Lanka).

Nine of the 15 countries where global partners have been conducting campaigns have passed best practice policies. Intensive work and advocacy campaigns are ongoing in China, Ethiopia, and Pakistan, and with one regional body: East African Community through focus countries Tanzania, Kenya, and Uganda. Pakistan passed TFA limits in key food categories; advocacy and support is now focused on strengthening the limits to align with the best practice to cover all foods. The average timeline from starting the REPLACE package in a country to successful policy passage has been approximately 2 years.

Country example: Mexico

Since 2020, and after the 2019 advocacy win that resulted in the establishment of a new front-of-package warning labeling regulation on packaged foods and beverages, Mexico Saludhable, a coalition of local CSOs, supported by NCD Alliance and led by Salud Justa MX, sought support for the promotion and implementation of an iTFA elimination policy. The alliance generated local landscape analyses, directly engaged leading local and regional public health actors and political decision-makers, and involved the local media to build demand from the public and create momentum around iTFA elimination. In collaboration with allies from the Pan American Health Organization and other local actors from civil society, academia, and the Secretariat of Health, they promoted a legislative proposal to reform the General Health Law and include the elimination of iTFA. The coalition hosted virtual events to keep momentum around the bill on the political and media agendas.

On October 14, 2021, the Mexican Senate discussed and unanimously passed the draft bill that adds article 216 bis to the General Health Law and includes REPLACE’s best practice policies of introducing a mandatory national limit of 2 g of iTFA per 100 g of total fat in all foods and a mandatory national ban on the production and use of PHO as an ingredient in all foods. On October 28, 2021, the bill was submitted to the Chamber of Deputies, where on April 24, 2022, the Health Commission ruled on the same terms that were sent from the Senate.

On February 9, 2023, the draft bill was discussed and unanimously approved in the Chamber of Deputies, with 472 votes in favor. The bill was published in the Mexican Official Gazette of the Federation on March 24, 2023.²⁴ The regulation entered into force in September 2023.

Country example: India

In 2009, Food Safety and Standards Authority of India (FSSAI) adopted a systematic process of developing regulations for limiting iTFA, beginning with a risk assessment. The risk assessment highlighted high consumption of PHO with as much as 40% TFA²⁵ and formed the basis of the decision taken at a 2010 consultation to cap TFA content in PHOs.²⁶ In 2013, India passed a regulation limiting TFA to not >10% by weight in interesterified vegetable fat and PHOs (margarine, fat spreads, and vanaspati), which it amended to 5% in 2015. However, this did not cover all fats/oils and foods.

In 2018, in response to the WHO’s efforts to eliminate TFA, FSSAI launched a movement, “India@75: Freedom from Trans-fats by 2022,” with the aim of eliminating TFA from India on 75 years of country’s independence. FSSAI launched a mass media public-service announcement “Heart Attack Rewind”²⁷ in 17 Indian languages (with technical support from Resolve to Save Lives) and developed consumer education materials.

To reinforce FSSAI’s commitment to TFA elimination and ensure a timely and unhindered passage of TFA best practice policy, India’s leading consumer rights organization, Consumer Voice, led a nationwide campaign creating awareness about the negative health impact of TFA. These CSOs reached out to public health experts, medical practitioners, nutritionists, parliamentarians, and the media to build a consensus around international best practices and provide technical comments on draft regulations. The campaign also included consumer awareness campaigns on festive days, media sensitization workshops, and high-level roundtable discussions.

Following stakeholder consultations in 2018, it was agreed to reduce the iTFA in PHOs to <2% in a phased manner. In December 2020, FSSAI gazetted the regulation,²⁸ limiting TFA in all fats and oils to not >3%, effective January 1, 2021, and not >2%, effective January 1, 2022. Finally, in response to advocacy by civil society, in February 2021, FSSAI extended the 2% iTFA limit to all food products.²⁹ This aligned with the global best practice and came into effect from January 1, 2022, protecting >1 billion people from the harms of TFA.

Additional countries

Another 19 high-priority countries (Table 2) had interest and political will to move on iTFA elimination, and global partners provided technical support as needed. Among these 19 countries, 6 (Sri Lanka, Oman, Thailand, Egypt, Ukraine, Moldova) have passed best practice policies. The remaining 13 are continuing to conduct advocacy campaigns and receive support from global partners.

Table 2.

Priority Countries Supported to Eliminate iTFA 2018-2023, With Implementing Partner Roles

	High-Priority Countries		Partners
	Intensive Support	Less Intensive Support	RTSL	WHO	GHAI	NCDA
Best practice policies adopted 2018 or after	Brazil				X
	Turkey		C	X	X
	India		X		X
	Philippines		C	X	X
	Bangladesh			X	X
	Argentina				X
	Mexico		C	X		X
	Nigeria		X		X
	Nepal		X	X
		Thailand		X
		Oman		X
		Ukraine	X
		Egypt	X	X
		Sri Lanka		X
		Moldova		X
Best practice policies expected within 6 months		Colombia		X
Policy campaigns in progress	China		X	X	X
	Ethiopia		X		X
	Eastern African community				X
	Kenya		X		X
	Tanzania		X		X
	Uganda				X
	Pakistan		C	X	X	X
		Armenia		X
		Georgia		X
		Kazakhstan		X
		Kyrgyzstan		X
		Bhutan		X
		Maldives		X
		Indonesia	X	X
		Ghana	X
		Cameroon	X

C = intensive coordination support provided across partners; iTFA = industrially produced trans fat; X = in-country implementation partner; other abbreviations as in Table 1.

WHO’s call for action was a motivating factor even in the absence of focused technical assistance. In 2018, Saudi Arabia, the United Arab Emirates and Singapore already had less-restrictive policies in place, and the European Union and Paraguay had been working on a policy for some time—shortly after the REPLACE launch all countries adopted best practice measures citing WHO’s call for action as a key rationale for finalizing their best practice policies.

Regional efforts

Regional initiatives have also been used to accelerate policy adoption. In 2015, the Eurasian Economic Union and Gulf Cooperation Council were the first regional bodies to adopt iTFA elimination policies. These policies were enacted before the formation of the global partnership and did not meet the best practice standard. Following Saudi Arabia’s adoption of a best practice policy in 2018, the Gulf Cooperation Council strengthened its policy to align with global best practices in 2021 and, although voluntary, it has been adopted in 4 more member states (Bahrain, Kuwait, Oman, and the United Arab Emirates). In April 2019, the European Union became the first trade bloc to pass a binding best practice TFA limit, requiring all member states to enact the regulation within 2 years. This single regulation protects all people living in the European Union, extends indirect benefits to neighboring countries, and resulted in Turkey and Ukraine passing best practice policies in alignment with the European Union and to facilitate trade.

In October 2019, all member states in the Americas Region approved the Pan American Health Organization Plan of Action for the Elimination of Industrially Produced Trans-Fatty Acids 2020-2025,³⁰ which promotes adoption and regional harmonization of best practice policies. Since its adoption, Argentina, Brazil, and Paraguay have passed best practice policies under the plan, joining Canada, Chile, Peru, Uruguay, and the United States.

Building on the success of these regional initiatives and the potential for accelerated action, RTSL and GHAI identified the East African Community as a regional body with both the ability and potential political will to pass a regionally binding iTFA elimination policy. Global partners are supporting advocacy, research, and media activities to achieve policy passage in Kenya, Uganda, Tanzania, and Rwanda.

Future directions

Although the target for global iTFA elimination by 2023 was not met, the global partnership has led to an enormous increase in the number of countries with iTFA best practice policies, and as a result, the number of people who die each year because of iTFA in their food has declined drastically.

Moving forward, the global partnership will continue investing in supporting civil society and policymakers to pass best practice policies in high-priority countries. Prioritizing countries with regional influence can help spur broader policy action within regions. The partners will also continue to assist in countries with political will and momentum that could benefit from light touch investment or technical assistance.

The partnership will also increase investment in policy implementation, monitoring, and enforcement in the future, to ensure that policy progress translates to lives saved and health savings.

Challenges to iTFA elimination

Although excellent progress has been made toward iTFA elimination, there are challenges that need to be resolved to ensure continued momentum for policy passage and effective implementation.

First, laboratory assessment of TFA in foods is highly complex and resource-intensive, and very few countries have up-to-date data on TFA consumption. Laboratories around the world lack capacity to follow the minimum laboratory standards. In the absence of laboratory data, countries should use other available types of evidence (eg, national PHO market mappings, cost-effectiveness analysis, and label analysis) to support policy passage. Although national governments are interested in having local evidence, this can be challenging to collect and can inhibit progress. Partners have succeeded based on the global evidence that iTFA contributes to deaths from coronary heart disease, arguments for preventing deaths through early action on iTFA, evidence on the risk of product dumping in unregulated markets, and the demonstrated cost-effectiveness of iTFA policies.^11,31

Further, national systems for compliance monitoring can also rely on alternate approaches such as analysis of TFA on food labels, inspections of domestic facilities, and inspections of products at ports of entry, which WHO considers acceptable in considering validation applications.²² WHO will address this with global guidance on practical compliance monitoring that does not require laboratory capacity and has already released a simplified methodology for TFA analysis to support for laboratory strengthening efforts.³²

An additional challenge, governments have had difficulty ensuring that there are accessible and affordable healthier iTFA replacement solutions. The technical knowledge exists, but fats and oils high in saturated fat (eg, palm oil) tend to be the least expensive, older data show that when TFA was removed there was an increase in saturated, mono- and polyunsaturated fats.³³ Effective and locally suitable strategies are needed to minimize use of high saturated fat oils like palm as a replacement for iTFA and some countries may be resistant to pass policies without a clear solution. In countries in which there are small- and medium-sized enterprises manufacturing PHO, technical assistance to industry may be needed to transform processing technology. In Thailand following the introduction of their best practice policy in 2018, the Thai Food and Drug Administration worked with domestic PHO manufacturers on needed changes to processing techniques³⁴ to address this challenge. To provide evidence for interim policy dialogues and guidance while countries await the guidelines, WHO has also released rapid reviews that summarize existing evidence on the health effects of tropical oils.^35,36

Finally, although eliminating iTFA saves lives, other higher priority issues demand countries’ attention. This was especially true during the height of the COVID-19 pandemic.

Discussion

Countries have made substantial progress toward global iTFA elimination. In addition to policy action, some companies have also publicly committed to eliminating iTFA from their portfolios by 2023, including member companies of the International Food and Beverage Alliance and Cargill, one of the largest global fats and oils companies.^37,38 Early in 2024, Cargill announced that it has eliminated TFA from its global supply chain, in alignment with WHO best practice.³⁹ Consistency and transparency in reporting and data sharing by companies are major challenges to voluntary commitments and these announcements, although admirable, have been difficult to verify.⁴⁰ Mandatory policies are needed to achieve meaningful public health improvements and cost-effectiveness, as robust evidence has demonstrated that voluntary action or self-regulation is insufficient in scope, often weakens nutrition criteria, and lacks enforcement.^{41, 42, 43} The global iTFA elimination framework focuses on a regulatory approach to eliminate iTFA and with a specific focus on addressing industry opposition.

This model for iTFA elimination, drawn from the tobacco control framework, a more complex public health issue, could be used to tackle other policy priorities to improve the food environment and promote healthy diets, such as sodium and sugar reduction. The global iTFA elimination partnership has shown that an intensive support package to countries is an effective approach to achieving policy wins. Activating local partners through civil society coalitions and WHO country offices to influence the policymaking process through evidence generation, direct policymaker dialogues, and media and communications campaigns is critical. The launch of the REPLACE package and accompanying WHO prioritization was catalytic for country policy progress, as shown by the many countries that adopted best practice policies without additional support.

Distinguishing iTFA from other pressing nutrition policy priorities is the clearcut, unified guidance and precise policy objectives provided in REPLACE. The 2 policy options provided outlined in REPLACE are both technically feasible for industry to implement, straightforward for governments to introduce, and effective at reducing iTFA in the diet—they are also endorsed by all global stakeholders and advocates. Further, the evidence on iTFA impact and coronary heart disease is robust and uncontroversial. iTFA elimination benefits from being a narrow policy option; however, it has proven to be a cost-effective and appealing option that can create space for more complex food policy issues by demonstrating that, as with tobacco control initiatives, with the right combination of resources, commitment, evidence, and coalitions public health benefits can prevail over industry interests. The growing adoption of sugar-sweetened beverage taxes suggests that focused efforts—similar to those that led to the success of the iTFA elimination movement—could drive progress in other priority food policy areas.

Conclusions

The global partnership has achieved significant progress since its formation in 2018. iTFA elimination by 2023 was identified as a priority target for the WHO’s 13th Global Program of Work (2018-2025), and WHO has been providing support through its regional and country offices. RTSL, GHAI, and NCD Alliance have also worked to support individual countries through galvanizing CSOs at the country level and providing direct technical support to governments. Local partners have effectively built coalitions, advocated for policies, and conducted media advocacy and research. WHO-recommended best practice policies are in place in 58 countries covering 3.7 billion people or 47% of the world’s population, compared with just 7% 6 years ago. Although the original countries to pass policies were predominantly high-income countries, lower middle-income countries have increasingly acted. These policies in 58 countries will prevent 66% of the total deaths each year due to iTFA intake, marking a success for public health.

Although the REPLACE package and the global iTFA elimination partnership have helped to build momentum around iTFA elimination, there is more work to do. Global incentive and accountability mechanisms, such as the new WHO TFA elimination validation program, recognition, and support for harmonized regional policies, and continued political will of national governments to implement cost-effective, best practice policies are needed to achieve the goal of an iTFA-free world.

Funding Support and Author Disclosures

Funders include Bloomberg Philanthropies, the Bill & Melinda Gates Foundation, Chan Zuckerberg Initiative, Founders Pledge, and Lyda Hill Philanthropies. The authors have reported that they have no relationships relevant to the contents of this paper to disclose.