Monday, March 10, 2008

The French Paradox

According to the World Health Organization, 82 out of every 100,000 French men between ages 35 and 74 died as a result of cardiovascular disease (CVD) in the year 2000. In that same year, 216 out of 100,000 men between the same ages in the U.S. succumbed to the same disease.

According to the Food and Agriculture Organization of the UN, during roughly the same time period, the average French person ate slightly more total fat and almost three times more animal fat than the average American. Animal fats came from dairy, lard, red meats, fish and poultry, and contributed to a much higher overall saturated fat intake in the French. This has been called the "French paradox", the paradox being that saturated fat is supposed to cause CVD.

Researchers have been scrambling to identify the factor that is protecting French hearts from the toxic onslaught of saturated fat. What could possibly be preventing the buttery sludge coursing through their arteries from killing them on the spot? One hypothesis is that wine is protective. Although the modern French don't actually drink much more alcohol than Americans on average, wine contains a number of molecules that are potentially protective.

One of these that has gotten a lot of attention is resveratrol, an activator of SIRT1, a deacetylase enzyme that is involved in stress resistance and lifespan regulation. But lo and behold, it turns out that there isn't enough of it in wine to be helpful. Now researchers are turning their attention to a class of molecules called procyanidins, but I suspect that this will turn up negative as well. The protective molecule is probably ethanol, but no one wants to hear that because it doesn't resolve the paradox.

As a person with a French background who has spent quite a bit of time in France, the notion of a French paradox is insulting. It implies that the French are eating an unhealthy diet, but are somehow miraculously protected by a compound they're ingesting by accident. Any French person will tell you there is no paradox. When you make a commitment to seek out the freshest, most delicious ingredients available and cook them yourself, your diet will be healthier than if you count the grams of this and that on your TV dinner.

There's more. Americans consume almost twice the amount of sugar as the average French person. I find this surprising, given the large amount of sugar I've seen on French tables, but I think it speaks to the huge amount of sugar we consume in the US. Much of it probably comes from the high-fructose corn syrup in soda. I'll save my rant about that for another time.

Another thing that stands out about French food habits is the absence of snacking. Mealtimes in France tend to be well-defined, and grazing is looked down upon. I think this is probably essential for maintaining adequate insulin sensitivity in the face of (delicious) refined carbohydrates like baguette.

And finally, the French enjoy their food more than the average nation. I wouldn't underestimate the value of this for health and overall well-being.

So what was the paradox again? I can't remember. Maybe a more parsimonious explanation of the data is that saturated fat isn't so bad after all, and enjoying wholesome food and limiting sugar is the true prescription for health.

Thanks to Gaetan Lee for the creative commons photo.


Chris said...

Great, interesting post

I live in Scotland. Regarding your grazing comment, a friend of mine married an Italian girl and now lives in Rome. One thing he said about Italy and food culture was related to this grazing thing - according to him you never see Italians walking along the street eating. Here people often walk alond the street with a pie, chips or burger in their hand but - according to him - that would be viewed as quite bad mannered in Italy.

Debs said...

Great post. I often wish I lived in France.

I would bet the comparatively higher percentage of natural foods makes a difference too. The French eat far fewer fake and processed ingredients than the Americans. All that processed, pre-packaged, artificially preserved and flavored food with bad oils that's the norm in America violates a lot of French values about food quality, as well it should. Margarine instead of butter? I would imagine most of France would be horrified by Americans who can't tell the difference.

French people also care about making their food taste good; enjoyment makes a big difference.

Ross said...

Could there be a genetic component as well? Within the united states, obesity is less prevalent among whites than it is among african americans, native americans, or hispanics. This might tilt the scales (heh) in favor of the USA having more heart problems than France, which has less of those minority groups.

Of course, its hard to say how much of the obesity differences between races are due to genetics and how much are due to culture, as you discussed in your post.

Stephan Guyenet said...

Hey Ross,

I agree it's hard to draw any firm conclusions from the data I posted, since it's nothing but associations anyway. What it does suggest is that eating saturated fat is not sufficient by itself to cause CVD.

About genetics, there may be some contribution, it's hard to say. I'd be willing to bet that the longer a population has been exposed to grains, the better they tolerate them.

I still don't think 10,000 years is long enough to become fully adapted to a radically different diet-style, but there are some examples of adaptation. For example, some populations that have been eating grains for a while have duplications on the salivary amylase gene that breaks down starch. Also, lactose tolerance into adulthood has evolved at least twice independently in dairy-based cultures. But these are crude adaptations, from a genetic standpoint.

People of African descent in the US do have higher rates of CVD, but that doesn't account for the high overall incidence. Less time to genetically adapt to grains may be part of it, but I suspect a bigger problem is vitamin D deficiency.

The darker the skin, the less D you make from sunlight. I suppose you could also call that a genetic effect, although all you have to do is spend more time in the sun to fix the problem. D is a critical vitamin for cardiovascular and overall health. Then there are the income and healthcare disparities, that probably contribute as well.

Anonymous said...

The real French paradox is how they can eat so much starch and sugar and stay thin!

A couple of anecdotal observations, from my last trip to Paris.

The French do eat rather a lot of sugar and white flour, and I suspect they'd be healthier still if they ate less. However:

1. I was never served a whole pound of pasta anywhere in Paris (or anywhere in Europe, even in Italy).

2. Never, in any café, restaurant, or bistro, anywhere in Paris were my husband and I served a giant basket of bread or rolls. The basket always had two rolls, one for each of us.

3. Sodas in France are tiny - 25 cl (about 8 oz) was the usual size. I don't think you can get an 8 oz. soda in the U.S. Sodas seem to be viewed as "just a taste"; if you are really thirsty, you order un eau minérale.

4. The only restaurant where my main dish was accompanied by a giant mound of starch was a Moroccan restaurant (couscous).

5. Lots of the desserts featured either fruits or those wonderfully nutritious eggs. Dessert portions were smaller, too.

6. Junk food is almost non-existent. You can find it if you look really really hard.

7. People do not complain about food prices the way Americans do. Haggle with the produce vendor; yes. Complain, no. People spend much more of their income on food than Americans do.

Furthermore, the French smoke a lot. This is often used to further highlight the French paradox - they smoke more than we do and they still have less heart disease! But smoking has a funny little side benefit - it improves insulin sensitivity. (This is why so many people gain weight after quitting smoking.) Improved insulin sensitivity may help smokers deal with loads of starch and sugar that would fell a nonsmoker. I'm not saying smoking is healthy, just that it has a regulating effect on insulin and may help explain how the French stay thin on high starch consumption.

Unknown said...

About a possible genetic component of obesity, I've noticed in Hawaii how there seems to be a higher than average number of obese people of Polynesian ancestry. However, this could also be because of lifestyle, income level and social environment as well as diet.

Good job dissecting the so-called paradox and also making the point that high quality foods that taste better are better for one's health as well.

Stephan Guyenet said...

Thanks everyone, great discussion.

Migraineur, I agree that the grain intake is closer to the real paradox, although they don't eat much more of it than Americans do overall. The smoking thing is interesting too; it shows how interlinked different aspects of health can be.

Also, in my opinion, although the French tend to be healthier than Americans, I still think they could do better. We're comparing the sick to the very sick.

Reid, the high prevalence of "diseases of civilization" in Hawaiians of Polynesian ancestry is typical of populations that have recently been Westernized. The same is true of American Indians on the mainland. Although it's a bit puzzling in this case, because Hawaiians traditionally ate taro, right? It's a very starchy tuber so you'd think they'd be better adapted to carbohydrate. Maybe it has something to do with the fermentation into poi.

Anonymous said...

"Also, in my opinion, although the French tend to be healthier than Americans, I still think they could do better. We're comparing the sick to the very sick."

Yeah, that was one of the points I was trying to make. You said it better than I, though. I remember reading somewhere that the French were even healthier before they got rid of the traditional breakfast and replaced it with coffee and croissants. (I love a good croissant - though I don't eat them too often, and then only if I am confident they were made with real butter instead of Crisco - but I can't understand how on earth anyone can function from 8 am to 1 pm on a single croissant punctuated with caffeine. My mornings in France improved greatly when I discovered that my hotel catered to the British tourist trade and served, among other things, meat and cheese for breakfast.)

lesitedanais said...

Du saucisson, du fromage, et c'est la fete!
I was lucky you and Debs and all your friends were there to feed me when I went to Seattle, in the first few days when I was by myself I thought the food I bought tasted awful (and I live in the UK...)
Not scientific background behind me but... I do not believe in a French Paradox, however, if a food does not taste good, most French people would tend to leave it. That goes against your previous post about superstimulus but by "tasting good" I mean being "tasty" (having a fresh taste as opposed to being bland or very sweet or salty or spicy-hot) Does it make sense?
Migraineur, I think you are very kind to French eating habits, it is not that good really, but I agree portions and glasses are smaller.
I could not ignore this post, I had to leave a comment. I could be the non-scientific expert in French food for your blog couldn't I?

Debs said...

Anais, I totally agree about tasting good. I think Americans' palates have gotten desensitized to real tastiness. Most Americans can no longer taste freshness and simple, delicious flavor; they're desensitized by artificial flavors and over-stimulating flavor enhancers. Americans also don't take much time to enjoy and savor food.

(Hi, by the way.)

Stephan Guyenet said...


You can be my French food consultant!

Ross said...

"7. People do not complain about food prices the way Americans do. Haggle with the produce vendor; yes. Complain, no. People spend much more of their income on food than Americans do."

I am amazed at how much of American food shopping centers around finding the lowest prices - no matter what the tradeoffs. Corporations respond to consumer demand, and here we are now in this country at an all-time low of what proportion of our income we spend on food. If that's a good thing or a bad thing depends on if you're an economist or a taste bud! (Or maybe a heart)

Stephan Guyenet said...

Haha, well said Ross. I think things are changing though. People are fed up with crappy food, and they're flocking to farmer's markets and high-end grocery stores in droves. I never expected to see it happen in the US, but here it is.

. said...

Some bad news for France: "Le Big Mac has conquered La Belle France" -

JBG said...

I've begun reading the blog from the beginning. (It'll take me a while!)

Couldn't help chuckling at the mention of the "tiny" 8-ounce servings of soda in France.

When I was growing up in the 1940s, I think the usual soft-drink size was 6 or 8 ounces (I never liked soft drinks, so I don't know for sure.) Anyway, Pepsi bragged up its larger size with:

Pepso Cola hits the spot.
Twelve full ounces, that's a lot.
Twice as much for a nickle, too.
Pepsi Cola is the drink for you!

Anonymous said...

Having lived in France off and on for the last decade I can honestly say that thier diet is not as healthy as the world thinks!
Thier bread is full of hydrogenated oil, as is all the once delicious croissants and pain au chocolat - they haven't seen butter for a long time!
You cannot buy a yoghurt in France without E numbers and sweeteners etc.
The cereal isle is alive with sugar and salt and flavours.
And all around the shopping centres and cities are places to grab a take away sandwich, smoothie, or icecream.
Even some of the chocolatiers have included hydrogenated in their produce!

I had to shop very carefully and read the ingredients on everything! C'est tres difficile!!

No doubt these changes will soon show in France's health statistics soon.

Mark said...

Another interesting theory is that Vit K2 is responsible for shifting calcium out of the blood stream to where it should be ie the the bones and teeth. Two of the highest food sources of K2 are Cheese and duck or goose liver pate. Both of which are consumed by the french