Although the French paradox was never tested in a controlled clinical study, its acceptance is part of the long history of medical researchers connecting national dietary and lifestyle habits with disease and mortality rates. In 1819 Irish cardiologist Samuel Black observed that the French had a lower rate of heart-related deaths compared to the Irish. He attributed this to “the French habits and modes of living, coinciding with benignity of their climate and the peculiar character of their moral affections.” His observations later led to the twentieth-century belief that French dietary and lifestyle factors played a part in lowering their risk for heart disease.
Ancel Keys' Seven Countries Study (Yugoslavia, Italy, Greece, Finland, Netherlands, United States, and Japan), which ran from 1956 and was published in 1978, compared the relationship between diet and other risk factors to the occurrence of CHD. Keys concluded that high intakes of animal foods, with the exception of fish, were associated with higher CHD death rates. This study has often been cited as proof of the hypothesis that a high-fat diet causes CHD and was one of the foundations of the recommendation that all people should eat a low-fat diet. The French Paradox arose out of this thought pattern: that a nation's diet can be analyzed, that fat causes CHD, and that if a nation eating a diet high in fat does not have high CHD then some special element in the diet must be protecting the citizens from the effects of fat consumption.
The term “French paradox” was popularized in 1991 by Dr. Serge Renaud, a scientist from Bordeaux University in France, who found that middle-aged French men had a long life expectancy despite consuming a diet high in saturated fat. Although their diet included butter, cheese, eggs, and cream, which contributed to 15% of calories from saturated fats, the incidence of CHD was only 40% of the American incidence of CHD. Renaud concluded that two to three glasses of wine a day reduced death rates from all disease by up to 30%, but four glasses a day were found to have an adverse effect on health. He suggested that the combined effect of the alcohol and the antioxidants in wine played a role in reducing CHD. The French paradox became internationally recognized when Renaud and another French Paradox supporter named Dr. R. Curtis Ellison of Boston University School of Medicine described this research on the U.S. documentary 60 Minutes. Soon after this, red wine sales in the United States increased by 40%.
Links to alcohol and heart disease were first observed in 1976. English Physician William Heberden's classic description of angina pectoris, included the statement, “wines and liquors … afford considerable relief,” which led to the assumption that alcohol was a coronary vasodilator. In the 1970s, epidemiological studies began to show that moderate intakes of alcohol correlated with a low rate of CHD. In 1997, a large American study demonstrated that at least one drink a day reduced death risk from CHD, but more than three drinks daily was associated with an increased death rate. Another study that year concluded frequency was as important as quantity; the lowest risk occurred in those who drank moderate amounts of alcohol four to six days a week. Defining heavy and moderate drinking has always proved to be a problem, but experts generally agree that more than three units of alcohol a day for men and two a day for women is considered unhealthy.
Further studies supported the hypothesis that alcohol had a protective effect on CHD. The 1995 Copenhagen Heart Study found that those who drank wine daily lowered their risk of heart-related deaths by half when compared to nondrinkers or consumers of other alcoholic beverages. Researchers suggested the antioxidants in red wine, such as tannins and flavonoids, were key factors in its protective effects. The Dutch arm of the Seven Countries Study, the 40-year Zutphen study, looked independently at the effect of wine consumption on a diet high in meat and butter. Their conclusion, reported at the 2007 American Heart Association's 47th Annual Conference on Cardiovascular Disease Epidemiology and Prevention, was that “Drinking a little alcohol every day, especially wine, may be associated with an increase in life expectancy.”
By 2017, belief in the French paradox had declined significantly. Research had not born out any special benefit in red wine. Individual diets in France were not particularly different from diets in the rest of the wealth world; poor diets and obesity were becoming a problem, particularly in poor communities where fresh food and farmers' markets were not readily available. France has always had a diversity of cultures, including a large Muslim population, which makes it impossible to identify any single French diet.
Critics of the lipid hypothesis, who maintain that dietary fat has nothing to do with heart disease, claim that there has never been a paradox at all. They argue that the data on rates of heart disease in France should have led to the conclusion that the lipid hypothesis is incorrect, and that fat does not cause heart disease. The fact is, there are a number of countries in which high rates of saturated fat and low rates of heart disease go hand in hand. These include Switzerland, the Netherlands, Belgium, Finland, Austria, and several others. In fact, looking at graphs of the data by country, it appears that high saturated fat consumption is associated with a lower risk of heart disease.
Historically, France has been known for a diet relatively high in fat. Data from the Food and Agriculture Organization of the United Nations (FAO), showed in 2002 that although the intake of saturated fat in France was higher than in the United States, 108 grams (g) compared to 72 g per day, France had a 30%–40% lower risk of CHD. The FAO reported that in 2012 that fat made up 42% of the typical French diet. Life expectancy in France in 2015 was 81.6 years, compared to 78.8 years in the United States.
A stereotypical depiction of the French diet would have it include a good deal of butter, cheese, paté, fatty rillettes, bread, pastries, and cream. Popular descriptions of the French diet tend to mention behavioral factors such as avoiding diets, calorie counting, and snacking; choosing high-quality food; eating mindfully and savoring each bite; allowing for regular small indulgences; and sitting down at a table to eat leisurely meals with family.
The French generally buy much of their food the day that the eat it, visiting local markets for fresh produce and meat and buying bread daily. Coffee is a regular component of many people's diets, along with wine. Portion sizes at French meals are relatively moderate.
Although the French drink more alcohol a year than the British, they generally drink with meals. Unlike in the United Kingdom or United States, binge drinking is a rarity. The French have a moderate consumption of one to two glasses of wine a day.
The French paradox suggests that by following the French diet, which is typically taken to mean eating a lot of cheese and butter and drinking red wine regularly, a person can lower his or her risk of heart disease.
As of the late 2010s, despite considerable research on the topic, no evidence had shown conclusively that red wine or any of the substances in it accounted for lower rates of heart disease in France. Much research has focused on antioxidants. Red wine contains flavonoid antioxidants called resveratrol and quercetin, found in the skin of red grapes, which are thought to help prevent the buildup of fatty deposits within the wall of the arteries. A 2006 study indicated that the antioxidant procyanidin, found in red wines from the area of France that has the lowest incidence of CHD in the country, might help lower blood pressure and thus account for the lower rates of heart disease. Resveratol has been the subject of numerous studies, and researchers point to its anticancer properties and cardiovascular benefit, but as of 2016, the Mayo Clinic claimed that no link had been proven between drinking red wine and avoiding heart disease.
Alcohol itself does have beneficial effects, including raising HDL cholesterol levels. Alcohol also has the effect of decreasing thrombosis or blood clotting. By decreasing fibrinogen (a blood-clotting enzyme that reduces the stickiness of platelets) production, alcohol reduces the incidence of clots, which can be responsible for a heart attack or stroke.
Dr. Malcolm Kendrick suggests that heart disease is caused by stress and that the lower rates of heart disease among the French might be the result of a less stressful way of life than is common in areas with higher incidence of heart disease. He argues that moderate consumption of alcohol is a good stress reducer.
Individuals should not drink red wine simply because they imagine it might help them avoid heart disease. Individuals involved with activities that require attention, skill, or coordination, such as driving or operating machinery, should avoid alcoholic beverages. Alcohol has a depressant effect on the central nervous system and slows down brain function, which can affect judgment and emotions as well as behavior.
There is conflicting advice on moderate alcohol or no alcohol with breastfeeding. The American Academy of Pediatricians still recommends avoiding alcohol while breastfeeding. Alcohol can be passed on to the baby through the milk, which can affect the baby's feeding, sleeping, or digestion. Heavy alcohol intakes have also been shown to reduce lactation. The National Childbirth Trust and the Association of Breastfeeding Mothers in the United Kingdom advocate similar precautions. The recommendation is to allow sufficient time between drinking and breastfeeding for the mother to fully metabolize the alcohol.
Individuals taking prescription and over-the-counter medications also need to be aware of the potential interactions any of their medications may have with alcohol and should consult a doctor.
Heavy drinking presents the risk of many health problems, including cirrhosis of the liver, various cancers, and an increased risk of heart disease, but the amounts of red wine associated with the French paradox are not high.
The French paradox has never been tested by the gold standard of research in the form of a controlled clinical study. Though it was popular throughout the 1990s and 2000s, particularly to justify the consumption of red wine, by 2017 a number of media outlets had begun to publish articles stating that the French paradox was an illusion. Critics observed that the paradox was based on epidemiological data, and that correlation is not causation.
Anthony Colpo, whose book has the same title, The Great Cholesterol Con, observes that saturated fats in diets increased in France, Italy, and Portugal in the second half of the twentieth century, but heart disease rates dropped in all three countries. Italians drink as much red wine as the French, but they have a higher rate of heart disease. The Masai in Kenya eat a traditional diet very high in saturated fat, and yet have virtually no cardiovascular disease. One possible explanation for France's lower rates of heart disease is that the French diet in the late 20th century was much lower in sugar than, say, the American diet. Masai and other people from traditional cultures who move to cities and adopt modern diets quickly develop obesity and arterial disease, suggesting that sugars and refined carbohydrates may in fact be the culprit.
Drs. Malcolm Law and Nicholas Wald, British specialists in preventive medicine at St. Bartholomew's and the Royal London School of Medicine and Dentistry, and Dr. Marion Nestle, chairwoman of the department of nutrition at New York University, have put forward another explanation for the French diet and health. They argue that it is related to France's history of lower animal fat intakes rather than their consumption of red wine. Until 1970, the French ate less animal fat and had significantly lower blood cholesterol levels than the British. French habits appear to be changing, however, as people are eating more meat and fast foods, and their consumption of animal fat is now similar to that of Britain. The 1999 National Survey on Individual Food in France by the Research Center for the Study and Monitoring of Living Standards shows that between 1950 and 1980 the consumption of meat fat and oils doubled, and alcohol intake halved. The rate of obesity in France increased from 8% in 1997 to nearly 16% in 2016, and about 50% of the French were considered overweight, closer to the 70% figure for Americans. Scientists believe it takes approximately 25–35 years for increased fat intake to translate into heart disease, so it may be only a matter of time before France faces the obesity epidemics and CHD rates that began in America and Britain more than 20 years ago.
The role of nutrition in CHD is also being explored in association with the Mediterranean diet. Foods associated with the Mediterranean diet include fish, poultry, vegetables, fruits, breads, potatoes, cereals, nuts, beans, and whole grains. Food is generally fresh, not processed. Olive oil is used more often than other fats such as butter; dairy products such as yogurt and cheese are usually low or reduced fat; and low to moderate amounts of red meat are consumed (usually lean red meats). Wine is consumed in low to moderate amounts, usually with meals. Individuals in the Mediterranean regions also adhere to daily physical activity, while paying attention to the daily intake of nutritional food.
No controlled clinical trial has been conducted to test the effect of alcohol, but experts agree that drinking too much of any kind of alcohol is not healthy, although moderate alcohol intakes may have some health benefits. As such, a number of medical associations recommend drinking alcohol in moderation. The number of drinks per day that equate to moderation differ from country to country. In the United States, moderation is defined as up to one drink per day for women and up to two drinks per day for men. In the United Kingdom, moderation is defined as not exceeding two to three units for women and three to four units for men.
See also Alcohol consumption ; Antioxidants ; Coronary heart disease ; Fats ; Triglycerides .
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Academy of Nutrition and Dietetics, 120 S. Riverside Plaza, Ste. 2190, Chicago, IL, 60606-6995, (312) 899-0040, (800) 877-1600, firstname.lastname@example.org, http://www.eatright.org .
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American Heart Association, 7272 Greenville Ave., Dallas, TX, 75231, (888) 242-8883, email@example.com, https://www.onlineaha.org .
British Heart Foundation, Greater London House, 180 Hampstead Rd., London, United Kingdom, NW1 7AW, +44 20 (0300) 330 3322, http://www.bhf.org.uk .
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Tracy J. Parker, RD
Revised by Amy Hackney Blackwell, PhD