When Assistant Commissioner Silver joined the Bureau of Chronic Disease Prevention and Control in February 2004, she set herself a goal to aggressively promote prevention efforts. One approach was to change diet and the physical environment. The question was how. And which disease? What would have the widest impact? What would be sustainable? In general, the Health Department decided which health problems to tackle based on data from school health surveys, phone surveys and hospital statistics, as well as the epidemiology of the city, in order to focus on issues affecting the greatest number of people. We were creating a bureau of chronic disease here, and trying to figure out what our strategic approach would be to reducing the burden of chronic disease in the city, says Silver. ^[14]

Weve got 8 million people, weve got millions with chronic diseases, so its not something you do one by one, outside of the healthcare system. We had to figure out approaches that could have significant impact, reach most of the population, and be sustainable to reduce the burden of chronic disease. That was the challenge, because in the past most chronic disease public health interventions had focused on individual behavioral change, or healthcare system interventions, with limited success, rather than addressing the underlying environmental causes.

Silvers predecessor, Dr. Colin McCord, had taken an interest in trans fat. I got a message from Dr. McCord and from Dr. Mary Bassett, the deputy commissioner for health promotion and disease prevention, who hired me: You should look at trans fat and figure out whether theres any danger, Silver recalls. [But] we first had to figure out if the magnitude of the influence on cardiovascular disease was sufficient to merit public action. I started reading about it and essentially realized that this was a substance that was in the food supply that was clearly associated with harm, based on the epidemiologic literature.

McCord had talked to Dr. Walter Willett, professor of epidemiology and nutrition at Harvard, about the dangers of trans fat. Willett was one of the countrys most active campaigners against trans fat. His 1997 study estimated that use of partially hydrogenated oils resulted in 30,000 heart disease deaths per year, representing the biggest food processing disaster in US history. He subsequently helped persuade the FDA to require trans fat labeling on food products. ^[15]

But Silver had other priorities in her early months on the job. ^[16] In fall 2004, six months after joining the department, Silver created the Cardiovascular Disease Prevention and Control Program and hired Gail Goldstein as deputy director. Dr. Sonia Angell, an internist trained in clinical epidemiology, started as director a month later. The bureau was charged with developing city-wide, community-level initiatives designed to prevent cardiovascular morbidity and mortality, and primarily addressed two modifiable risk factors for cardiovascular disease: high blood pressure and high cholesterol.This concentrated effort to collectively address chronic disease had never existed before, says Goldstein.

There were two of us with a very small budget and we thought, What can we do to make an impact on a population of 8 million, where heart disease is the number one cause of death? We did an assessment of the entire spectrum of interventions in cardiovascular disease, looking at what people were doing in terms of prevention and control, and we concluded that city-wide policies were activities where we could get the biggest bang for our buck. Policy would affect a lot of people, more than community-based programs which tend to require more staff for implementation and reach a smaller number of people.

In their early discussions, Silver, Angell and Goldstein considered a wide spectrum of initiatives to address the major risk factors for cardiovascular disease, such as high blood pressure and cholesterol. ^[17] The program did launch a public health campaign on hypertension that sent health educators into doctors offices to share new guidelines and best practices for treating high blood pressure. This focus on clinical treatment began to address the goal of controlling cardiovascular risk factors. But the team started to think about how people could avoid heart disease all together. The hypertension campaign had included educational materials on a heart-healthy diet (for example, low sodium). This focus on diet led the team to think about cholesterol. High cholesterol is often controlled by medications, but diet and exercise are important factors as well, says Goldstein.

We really started looking at dietary factors that contribute to heart disease. And I think thats how [trans fat] came up. We felt like the harmful effects of [trans fat] were really clear in the scientific literature, that there was a real body of literature that said this stuff is not good for us and will have a significant effect on our health.

As Silver recalls it, they considered tackling saturated fats, which raise cholesterol and can increase the risk of heart attacks and strokes. But trans fat made more sense because, unlike saturated fats, which occur naturally in foods, most trans fat was manufactured. ^[18] She observes:

It was not like red meat and milk, that everybody loves and has for dinner. Nobody goes and says, Can I have some trans fat, please? Or, Honey, would you like trans fat for dinner? Its not that kind of thing. Its more like lead in paint, something that somebody added to something for some purpose, but it ended up causing significant harm and it didnt really need to be there, it was replaceable. You can still paint your walls and have great new yellow walls without lead, and you can still make cannoli without trans fat.

Why regulate transfats? Lynn Silver explains.

At the time, the only place in the world that had banned or restricted trans fat was Denmark, which had done so in 2003. So the team began by compiling the scientific literature and data to determine whether a public health initiative around trans fat made sense. Goldstein remembers:

There was a lot of internal discussion about it. There was certainly a feeling that perhaps we should just restrict this product, since we knew it was bad for everybody. But we also felt like this was a potentially charged issue. And we needed to start with educating people, because we felt like no one really knew what trans fat was at the time.

They looked not just at scientific data about the dangers of trans fat, but also at the ways restaurants were using it, what fats manufacturers were making, and to see what its role was in the food supply and cooking. McDonalds had set a precedent when it announced in 2002 that it would stop using trans fat (although it had not yet done so).

By the beginning of 2005, they had created a packet with articles and scientific studies about trans fat and its link to heart disease. Trans fat, for example, increased LDL bad cholesterol, and lowered HDL good cholesterol. Studies showed that it caused at least 500 deaths a year from heart disease in New York City. Moreover, there were healthier, inexpensive substances available, such as vegetable oils or those made from soybeans or sunflowers. There was no discernible difference in taste. Silver and Bassett reviewed the packet and the team sent it to Commissioner Frieden.