French paradox

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Cheese, like this Brie de Meaux, is high in satured fats, and is a popular food in French cuisine.

The French paradox is a catchphrase frequently used to summarize the apparently paradoxical epidemiological observation that French people have a relatively low incidence of coronary heart disease (CHD), while having a diet relatively rich in saturated fats,[1] in apparent contradiction to the widely held belief that the high consumption of such fats is a risk factor for CHD. The paradox is that if the thesis linking saturated fats to CHD is valid, the French ought to have a higher rate of CHD than comparable countries where the per capita consumption of such fats is lower.

The French paradox implies two important possibilities. The first is that the hypothesis linking saturated fats to CHD is not completely valid (or, at the extreme, is entirely invalid). The second possibility is that the link between saturated fats and CHD is valid, but that some additional factor in the French diet or lifestyle mitigates this risk—presumably with the implication that if this factor can be identified, it can be incorporated into the diet and lifestyle of other countries, with the same lifesaving implications observed in France. Both possibilities have generated considerable media interest, as well as some scientific research.

It has also been suggested that the French paradox is an illusion, created in part by differences in the way that French authorities collect health statistics, as compared to other countries, and in part by the long-term effects, in the coronary health of French citizens, of changes in dietary patterns which were adopted years earlier.

Identifying and quantifying the French paradox[edit]

The term "French Paradox" was first used in The Letter, the newsletter of the International Organisation of Vine and Wine, in 1986. In 1989, theatre Professor George Riley Kernodle of the University of Arkansas used the term in for a chapter in his book Theatre In History, later republished as a separate academic paper.[2]

In 1991 Serge Renaud, a scientist from Bordeaux University, France - considered today the father of the phrase - presented the results of his scientific study into the term and actual scientific data behind the perception of the phrase.[3] This was followed by a public documentary broadcast on the American CBS News television channel, 60 Minutes.

Renaud's observations regarding the apparent disconnect between French patterns of high saturated fat consumption and their low rates of cardiovascular disease can be quantified using data from the Food and Agriculture Organization of the United Nations.[4] In 2002, the average French person consumed 108 grams per day of fat from animal sources, while the average American consumed only 72 grams. The French eat four times as much butter, 60 percent more cheese and nearly three times as much pork. Although the French consume only slightly more total fat (171 g/d vs 157 g/d), they consume much more saturated fat because Americans consume a much larger proportion of fat in the form of vegetable oil, with most of that being soybean oil.[5] However, according to data from the British Heart Foundation,[6] in 1999, rates of death from coronary heart disease among males aged 35–74 years were 115 per 100,000 people in the U.S. but only 83 per 100,000 in France.

In 1991, Renaud extended his studies in partnership with then junior researchers, cardiologist Michel de Lorgeril and dietician Patricia Salen. The three enhanced Renaud's study, with their paper concluding that: a diet based on southwestern Mediterranean cuisine; which is high in omega-3 oils, antioxidants and includes "moderate consumption" of red wine; created lower cases of cancer, myocardial infarction and cardiovascular disease; partly through increasing HDL cholesterol whilst reducing LDL cholesterol.[3]

Theory that the French paradox is a statistical illusion[edit]

In 1999, Malcolm Law and Nicholas Wald published a study in the British Medical Journal,[7] using data from a 1994 study of alcohol and diet to explain how the French paradox might actually be an illusion, caused by two statistical distortions.

First, Law and Wald attributed about 20% of the difference in the observed rates of CHD between France and the United Kingdom to the under-certification of CHD in France, relative to the UK.

Second, Law and Wald presented a time-lag hypothesis: if there were a delay in serum cholesterol concentrations increasing and a subsequent increase in ischaemic heart disease mortality, then the current rate of mortality from CHD is more likely to be linked to past levels of serum cholesterol and fat consumption than to current serum cholesterol levels and patterns of fat consumption. They wrote,

We propose that the difference is due to the time lag between increases in consumption of animal fat and serum cholesterol concentrations and the resulting increase in mortality from heart disease—similar to the recognised time lag between smoking and lung cancer. Consumption of animal fat and serum cholesterol concentrations increased only recently in France but did so decades ago in Britain

Evidence supports this explanation: mortality from heart disease across countries, including France, correlates strongly with levels of animal fat consumption and serum cholesterol in the past (30 years ago)....

Theory that the French paradox does not exist[edit]

A study published by INSERM, the National Institute for Health and Medical Research (INSERM) of France, showed that 31.9 percent of people over 18 were overweight in 2009, up from 29.8 percent in 1997. In addition, 14.5 percent were obese, up from 8.5 percent in 1997.

And despite the image created by best-selling books like “French Women Don’t Get Fat,” obesity has become more pronounced in that group. According to Inserm, 15.1 percent of French women were obese in 2009, against 13.9 percent of men. In 1997, 8.3 percent of women were obese, compared with 8.8 percent of men.

This research suggests that there is no paradox.

Impact of the French paradox[edit]

Much commentary has been based on the assumption that the French paradox is real and is not the statistical distortion posited by Law and Wald. If the French paradox is regarded as real, the most obvious implication is that under certain circumstances, it is possible for individuals to consume a diet rich in saturated fats, and nonetheless avoid cardiovascular disease. Therefore, proposed explanations for the paradox have attracted considerable interest in other countries, including the creation of considerable demand for foods or supplements said to explain the paradox. The search for an explanation for the paradox has also led to some additional research.

Cultural impact[edit]

The overall impact of the popular perception, in the English-speaking world, that the French paradox is a real phenomenon, has been to give added credibility to health claims associated with specific French dietary practices.

This was seen most dramatically when, in 1991, an early account of the then-novel concept of the French paradox was aired in the United States on 60 Minutes. The broadcast left the impression that France's high levels of red wine consumption accounted for much of the country's lower incidence of cardiac disease. Within a year, the consumption of red wine in the United States had increased 44%[citation needed] and some wine sellers began promoting their products as "health food."[8]

The cultural impact of the French paradox can be seen in the large number of book titles in the diet-and-health field which purport to give the reader access to the secrets behind the paradox:

  • The Fat Fallacy: The French Diet Secrets to Permanent Weight Loss (William Clower, 2003);
  • The French Don't Diet Plan: 10 Simple Steps to Stay Thin for Life (William Clower, 2006)
  • French Women Don't Get Fat (Mireille Guiliano, 2004, which became a #1 best-seller in 2006)
  • Cholesterol and The French Paradox (Frank Cooper, 2009);
  • The French Women Don't Get Fat Cookbook (Mireille Guiliano, 2010).

Other books sought to boost their credibility by reference to the French paradox. The American edition of The Dukan Diet, written by Pierre Dukan, a Paris-based doctor, is marketed with the subtitle, “The real reason the French stay thin.”

Scientific impact[edit]

The existence of the French paradox has caused some researchers to speculate that the link between dietary consumption of saturated fats and coronary heart disease might not be as strong as had previously been imagined. This has resulted in a review of the earlier studies which had suggested this link.

Some researchers have suggested that the French paradox is a statistical illusion, throwing into question the entire claimed connection between natural saturated fat consumption and cardiovascular disease. In 2006 this view received some indirect support from the results of the Nurses' Health Study run by the Women's Health Initiative. After accumulating approximately 8 years of data on the diet and health of 49,000 post-menopausal American women, the researchers found that the balance of saturated versus unsaturated fats did not appear to affect heart disease risk, whereas the consumption of trans fat was associated with significantly increased risk of cardiovascular disease.[9]

Similarly, the authors of a 2009 review of dietary studies concluded that there was insufficient evidence to establish a causal link between consumption of saturated fats and coronary heart disease risk.[10]

Possible explanations for the French paradox[edit]

Explanations based on the high per capita consumption of red wine in France[edit]

It has been suggested that France's high red wine consumption is a primary factor in the trend. This hypothesis was expounded in a 60 Minutes broadcast in 1991.[11] The program catalysed a large increase in North American demand for red wines from around the world. It is believed that one of the components of red wine potentially related to this effect is resveratrol;[12] however, the authors of a 2003 study concluded that the amount of resveratrol absorbed by drinkers of red wine is small enough that it is unlikely to explain the paradox.[13]

Alcohol in wine[edit]

Research suggests that moderate drinkers are less likely to suffer heart attacks than are abstainers or heavy drinkers (see alcohol and cardiovascular disease for details). Therefore, the alcohol in wine might be a factor in the French paradox.

However, the difference between U.S. annual per capita alcohol consumption (8.6 litres per year)[14] and French consumption (11.4 litres per year) is only 2.8 litres per year more.[15] Alcohol consumption in France is lower than in Luxembourg (15.6 litres), the Czech Republic (13.0 litres), Hungary (13.6 litres), Germany (12.0 litres), and Croatia (12.3 litres) where no similar paradoxes are observed.

There is a lack of medical consensus about whether moderate consumption of beer, wine, or distilled spirits has a stronger association with longevity. Of ten major studies, three found stronger evidence for wine, three for beer, three for liquor, and one study found no difference between alcoholic beverages.[16]

Resveratrol[edit]

Main article: Resveratrol

Wines, particularly red wines, are a source of low levels of resveratrol. High doses of resveratrol have been linked to longevity and cancer prevention in other species.[17]

Procyanidins and polyphenols[edit]

Although research continues on resveratrol, the concentration in wine seems too low to account for the French paradox. Professor Roger Corder and team have identified a particular group of polyphenols, known as oligomeric procyanidins, which they believe offer the greatest degree of protection to human blood-vessel cells. Tests with 165 wines showed that these are found in greatest concentration in European red wines from certain areas, which correlates with longevity in those regions.[18] The highest procyanidins are found in wines from the Tannat grape, grown in the Gers area of southwest France.[citation needed]

Unlike resveratrol, procyanidins are present in wine in quantities that seem to be high enough to be significant: "Procyanidins are the most abundant flavonoid polyphenols in red wine – up to one gram per litre is found in some traditional style red wines."[19] "… clinical trials of grape seed extract . . . have shown that 200–300 mg per day will lower blood pressure. Two small glasses (125 ml glass) of a procyanidin-rich red wine, such as a Madiran wine from southwest France, would provide this amount." However, more than 200 mg of procyanidin can also be consumed by eating a Red Delicious apple.[20]

Other research suggests that polyphenols in wine reduce the absorption of malondialdehyde, which is implicated in arteriosclerosis, cancer, diabetes and other diseases.[21][22]

Explanations based on aspects of the French diet[edit]

The French diet is rich in vitamin K2[edit]

In her 2012 book, Vitamin K2 and the Calcium Paradox, Canadian nutritionist Kate Rhéume-Bleue proposes that the explanation for the lower rate of cardiovascular disease in France is the high level of vitamin K2 (also known as menaquinone) in some of the fattier foods that form a part of the French diet. Lack of vitamin K2 in the diet is linked to increased calcification of plaques in artery walls.

Rhéume-Bleue writes,

The French Paradox isn’t a paradox at all. The very same pâté de foie gras, egg yolks and creamy, buttery sauces that we inaccurately labeled “heart attack on a plate“ literally supply the single most important nutrient to protect heart health.[23]

As one example, Rhéume-Bleue points to the fact that a 3 ½-ounce serving of goose liver pate contains 369 micrograms of menaquinone, while a 3 ½-ounce serving of pan-fried calf liver of the kind frequently eaten in North America contains only 6 micrograms of menaquinone.[24]

The French diet is rich in short-chain saturated fatty acids and poor in trans fats[edit]

In his 2009 book Cholesterol and The French Paradox, Frank Cooper argues that the French paradox is due to the lack of hydrogenated and trans fats in the French diet.[25] The French diet is based on natural saturated fats such as butter, cheese and cream that the human body finds easy to metabolize, because they are rich in shorter saturated fatty acids ranging from the 4-carbon butyric acid to the 16-carbon palmitic acid. But the American diet includes greater amounts saturated fats made via hydrogenating vegetable oils which include longer 18- and 20-carbon fatty acids. In addition, these hydrogenated fats include small quantities of trans fats which may have associated health risks.[26][27][28]

Explanations relying on multiple factors[edit]

In his 2003 book, The Fat Fallacy: The French Diet Secrets to Permanent Weight Loss, Will Clower suggests the French paradox may be narrowed down to a few key factors, namely:

  • Good fats versus bad fats — French people get up to 80% of their fat intake from dairy and vegetable sources, including whole milk, cheeses, and whole milk yogurt.
  • Higher quantities of fish (at least three times a week).
  • Smaller portions, eaten more slowly and divided among courses that let the body begin to digest food already consumed before more food is added.
  • Lower sugar intake — American low-fat and no-fat foods often contain high concentrations of sugar. French diets avoid these products preferring full-fat versions without added sugar.
  • Low incidence of snacks between meals.
  • Avoidance of common American food items, such as soda, deep-fried foods, snack foods, and especially prepared foods which can typically make up a large percentage of the foods found in American grocery stores.

Clower tends to downplay the common beliefs that wine consumption and smoking are greatly responsible for the French paradox. The French diet tends to cause Americans to lose weight while visiting even if they are not wine drinkers. While a higher percentage of French people smoke, this is not greatly higher than the U.S. (35% in France vs. 25% in U.S.) and is unlikely to account for the weight difference between countries.

Mireille Guiliano, author of the 2006 bestseller French Women Don't Get Fat,[29] agrees that the weight differences are not due to French smoking habits. She points out that the smoking rates for women in France and the U.S. are virtually identical.[30] Guiliano explains the key factors to the French woman's ability to stay slim as:

  • Smaller portion sizes
  • Savoring food to increase the feeling of satisfaction, choosing a small amount of high quality food rather than larger amounts of low quality food
  • Eating 3 meals a day and not snacking
  • Taking in plenty of liquid such as water, herbal tea and soup
  • Sitting down and eating mindfully (no multitasking and eating while standing up, watching TV, or reading)
  • Emphasizing freshness, variety, balance, and, above all, pleasure[30]

Whole diet[edit]

In his 2008 book In Defense of Food, Michael Pollan suggests the explanation is not any single nutrient, but the combination of nutrients found in unprocessed food; not any one nutrient, nor the amount of carbohydrates or fats or proteins, but the whole length and breadth of nutrients found in "natural" foods as opposed to "processed" foods.[31]

Higher fruit and vegetable intake[edit]

It has been suggested that a higher intake of fruit and vegetables in the diet may explain the relatively lower risk of CHD.[32]

Early life nutrition[edit]

One proposed explanation of the French paradox regards possible effects (epigenetic or otherwise) of dietary improvements in the first months and years of life, exerted across multiple generations. Following defeat in the Franco-Prussian War in 1871, the French government introduced an aggressive nutritional program providing high quality foods to pregnant women and young children with the aim of fortifying future generations of soldiers (the program was implemented about three decades prior to an analogous initiative in England in response to the Boer War). It has been suggested that the particular timing of this historical intervention might help explain the relatively low rates of obesity and heart disease found in France.[33]

See also[edit]

References[edit]

Bibliography[edit]

  • Michel de Lorgeril and Patricia Salen (2011). Thierry Souccar, ed. Prévenir l'infarctus (Preventing heart attack). 
  • Michel de Lorgeril (2008). Thierry Souccar, ed. Cholestérol, mensonges et propagande (Cholestérol, lies & propoganda). ISBN 9782365490481. 
  • Michel de Lorgeril (2007). Thierry Souccar, ed. Dites à votre médecin que le cholestérol est innocent (Tell your doctor that cholesterol is innocent). 
  • Serge Renaud (2004). Odile Jacob, ed. Le régime crétois (The Mediterranean Regime). 
  • Serge Renaud (1998). Odile Jacob, ed. Le régime santé (The Health Plan). 
  • George Riley Kernodle (December 1, 1989). Theatre In History. University of Arkansas Press. ISBN 978-1557280121. 

Notes[edit]

  1. ^ Ferrieres, J. (2004). "The French Paradox; Lessons for other countries". Heart 90 (1): 107–111. doi:10.1136/heart.90.1.107. PMC 1768013. PMID 14676260. 
  2. ^ George Riley Kernodle (December 1, 1989). Theatre In History. University of Arkansas Press. ISBN 978-1557280121. 
  3. ^ a b B. Simini (2000). "Serge Renaud: from French paradox to Cretan miracle". The Lancet 355 (9197): 48. doi:10.1016/S0140-6736(05)71990-5. PMID 10615898. 
  4. ^ FAOSTAT[dead link]
  5. ^ FAOSTAT[dead link]
  6. ^ Tab 3.5 RSD web08: Age-standardised rate of finished consultant episodes for operations for CHD by sex and local authority, all ages and under 75 years, 2001/06, England (Table)[dead link]
  7. ^ Law, M. & Wald, N. (1999). "Why heart disease mortality is low in France: the time lag explanation". British Medical Journal 318 (7196): 1471–1480. doi:10.1136/bmj.318.7196.1471. 
  8. ^ [1]
  9. ^ Couzin, Jennifer (2006). "Women's Health: Study Yields Murky Signals on Low-Fat Diets and Disease". Science 311 (5762): 755. doi:10.1126/science.311.5762.755. PMID 16469884. 
  10. ^ Andrew Mente; Lawrence de Koning; Harry S. Shannon; Sonia S. Anand (2009). "A Systematic Review of the Evidence Supporting a Causal Link Between Dietary Factors and Coronary Heart Disease". Arch Intern Med 169 (7): 659–669. doi:10.1001/archinternmed.2009.38. PMID 19364995. 
  11. ^ The French Paradox, CBS News, 23 January 2009
  12. ^ Potentially Universal Mechanism Of Aging Identified, ScienceDaily, 27 November 2008
  13. ^ Goldberg, David M.; Yan, Joseph; Soleas, George J. (2003). "Absorption of three wine-related polyphenols in three different matrices by healthy subjects". Clinical Biochemistry 36 (1): 79–87. doi:10.1016/S0009-9120(02)00397-1. PMID 12554065. 
  14. ^ WHO Core Health Indicators: United States of America
  15. ^ WHO Core Health Indicators: France
  16. ^ Edell, D. (1999). Eat, Drink and be Merry: America’s Doctor Tells You Why the Health Experts are Wrong. HarperCollins. pp. 191–192. ISBN 0-06-019155-4. 
  17. ^ Liu, BL; Zhang, X; Zhang, W; Zhen, HN (December 2007). "New enlightenment of French Paradox: resveratrol's potential for cancer chemoprevention and anti-cancer therapy.". Cancer biology & therapy 6 (12): 1833–6. doi:10.4161/cbt.6.12.5161. PMID 18087218. 
  18. ^ Corder, R.; Mullen, W.; Khan, N. Q.; Marks, S. C.; Wood, E. G.; Carrier, M. J.; Crozier, A. (2006). "Oenology: Red wine procyanidins and vascular health". Nature 444 (7119): 566. doi:10.1038/444566a. PMID 17136085. 
  19. ^ Real Link Between Drinking Red Wine and Increased Longevity – Food and Health
  20. ^ Hammerstone, JF; Lazarus, SA; Schmitz, HH (2000). "Procyanidin content and variation in some commonly consumed foods". The Journal of nutrition 130 (8S Suppl): 2086S–92S. PMID 10917927. 
  21. ^ Red wine exercises its benefits before it enters the bloodstream
  22. ^ The Stomach as a “Bioreactor”: When Red Meat Meets Red Wine
  23. ^ Kate Rhéume-Bleue, Vitamin K2 and the Calcium Paradox: How a Little-Known Vitamin Could Save Your Life. Toronto: Wiley, 2012, p. 68
  24. ^ Rhéume-Bleue, Vitamin K2, pp. 66-67.
  25. ^ Cooper, Frank A. Cholesterol and The French Paradox. Lulu.com Publishing, 2009, pp 136–149.
  26. ^ Hu, FB; van Dam RM; Liu S.Hu FB; van Dam RM; Liu S (2001). "Diet and risk of Type II diabetes: the role of types of fat and carbohydrate". Diabetologia 44 (7): 805–17. doi:10.1007/s001250100547. PMID 11508264. Retrieved 2010-01-26. 
  27. ^ Clarke, Robert; Lewington, Sarah (2006). "Trans fatty acids and coronary heart disease". BMJ 333 (7561): 214. doi:10.1136/bmj.333.7561.214. PMC 1523500. PMID 16873835. 
  28. ^ "The Eye Digest – Macular degeneration info". University of Illinois Eye & Ear Infirmary, Chicago, IL. 19 May 2009. p. Reviewed = 05/19/2009. Retrieved 2010-01-26. 
  29. ^ Paperback best sellers, The New York Times, 9 April 2006
  30. ^ a b Arhive.org
  31. ^ Pollan, Michael In Defense of Food. Penguin Press, 2008.
  32. ^ http://www.nutrition.org/asn-blog/2013/01/the-french-paradox-was-it-really-the-wine/
  33. ^ Newnham, JP; Pennell, CE; Lye, SJ; Rampono, J; Challis, JR (June 2009). "Early life origins of obesity". Obstetrics and gynecology clinics of North America 36 (2): 227–44, xii. doi:10.1016/j.ogc.2009.03.004volume=36. PMID 19501311. 

Other sources[edit]

  • Abdulla, A. & Badaway, B. (2001). "Moderate alcohol consumption as a cardiovascular risk factor: the role of homocycteine and the need to re-explain the 'French Paradox'". Alcohol & Alcoholism 36 (3): 185–188. doi:10.1093/alcalc/36.3.185. 
  • Perdue, W. Lewis, et al. the French Paradox and Beyond. Sonoma, CA: Renaissance, 1993.
  • Rozin, P., Kabnick, K., Pete, E., Fischler, C., & Shields, C. (2003). "The ecology of eating: Part of the French paradox results from lower food intake in French than Americans, because of smaller portion sizes". Psychological Science 14 (5): 450–454. doi:10.1111/1467-9280.02452. PMID 12930475. 

External links[edit]