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. 2000 Jan 22;320(7229):249.

Why mortality from heart disease is low in France

Rates of coronary events are similar in France and southern Europe

Pierre Ducimetière 1,2,3,4,i, Thierry Lang 1,2,3,4, Philippe Amouyel 1,2,3,4, Dominique Arveiler 1,2,3,4, Jean Ferrières 1,2,3,4
PMCID: PMC1117444  PMID: 10642245

Editor—Law and Wald focused on the so called French paradox.1 In the 1980s national statistics and data on food balance were the only available sources of information, and the eccentric position of France on a plot of mortality from coronary heart disease against consumption of animal fat was obvious.2,3 However, we later concluded that caution was necessary because data on comparative incidence were unavailable and interpretation should not rely entirely on the dietary lipids and heart disease hypothesis, although it may be central.4

Using mortality as a surrogate for incidence may be misleading. Data from the MONICA project are now available,5 and the content of Law and Wald's article might have been considerably different had they written it a few months later. During 1985-95 rates of coronary events per 100 000 men aged 35-64 averaged 274 in three French regions, 266 in two Italian regions, 261 in two Swiss regions, 210 in Barcelona, 695 in Belfast, and 777 in Glasgow. Rates were considerably lower in women, but rankings and risk ratios were nearly identical with those in men. Unambiguously, rates of coronary heart disease in France are of the same order as those in southern Europe, to which it belongs geographically. The interesting question is therefore not why mortality from heart disease is low in France but why heart disease is less prevalent in southern than northern Europe.

Law and Wald may be reproached for introducing a time lag hypothesis to explain a problem that is not specific to France, and we think that their hypothesis is not well supported by their arguments. There is now much evidence that the southern European diet and other lifestyle factors play a part and may modulate the effect of cholesterol and fat in the aetiology of coronary heart disease.

We conclude that the time has come to relieve epidemiology of the French paradox. Much more attention should be paid to collecting reliable data to produce more satisfactory explanations for the complex causes of heart disease.

References

  • 1.Law M, Wald N. Why heart disease mortality is low in France: the time lag explanation [with commentaries by M Stampfer and E Rimm, D J P Barker, and J P Mackenbach, and A E Kunst] BMJ. 1999;318:1471–1480. doi: 10.1136/bmj.318.7196.1471. . (29 May.) [DOI] [PMC free article] [PubMed] [Google Scholar]
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BMJ. 2000 Jan 22;320(7229):249.

High cholesterol may not have same effect on cardiovascular risk in southern Europe as elsewhere

Jaume Marrugat 1,2, Mariano Sentí 1,2

Editor—Law and Wald suggest several mechanisms to explain the discrepancy between the high cholesterol concentrations and low mortality from and incidence of myocardial infarction in France.1-1 Although they criticise ecological studies, most of their evidence is ecological. Moreover, some evidence against the time lag theory merits comment. A paradox similar to that found in France has been described in other areas of southern Europe.1-2 In Gerona, Spain, the prevalence of cardiovascular risk factors is high for the low prevalence and incidence of myocardial infarction.1-2 Cholesterol concentrations may have been high for as long as 25 years in Spain without producing the expected increase in the number of coronary events.1-3 In addition, results from the seven countries study suggest that the effect of high concentrations of cholesterol may not have the same implications for cardiovascular risk over 25 years in Mediterranean countries of southern Europe as in the United States and central or northern Europe.1-4

In assessing the many factors that influence rates of coronary events it is easy to conclude that mortality from coronary heart disease results from the combined effect of these factors, an effect which remains unknown, especially with an ecological approach. To simplify the answer by adhering to the prevailing cholesterol theory alone is tempting. Although a high intake of saturated fat is associated with high serum cholesterol concentrations, the modulation of cholesterol concentrations is much more complicated. Lifestyle characteristics and the interaction between genes and the environment may play a crucial part in determining the variability in the effects of lipids. Some protective factors such as physical activity and dietary antioxidants are more prevalent in Gerona than in the United States, for example, and these factors may counteract the effect of the high prevalence of cardiovascular risk factors in southern Europe.1-5 Countries with a low incidence of myocardial infarction should investigate whether these factors play a part in protecting populations from coronary heart disease or are merely the consequence of having longer, warmer, and sunnier days and easier access to fresh fruit and vegetables than are found in central and northern Europe.

References

  • 1-1.Law M, Wald N. Why heart disease mortality is low in France: the time lag explanation [with commentaries by M Stampfer and E Rimm, D J P Barker, and J P Mackenbach, and A E Kunst] BMJ. 1999;318:1471–1480. doi: 10.1136/bmj.318.7196.1471. . (29 May.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 1-2.Masiá R, Pena A, Marrugat J, Sala J, Vila JS, Pavesi M, et al. High prevalence of cardiovascular risk factors in Gerona, Spain, a province with low myocardial infarction incidence. J Epidemiol Community Health. 1998;52:707–715. doi: 10.1136/jech.52.11.707. [DOI] [PMC free article] [PubMed] [Google Scholar]
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BMJ. 2000 Jan 22;320(7229):249.

Wine consumption clearly correlates with residual differences in mortality

John H Glaser 1

Editor—Law and Wald write that when “past animal fat consumption is used instead of recent consumption, wine consumption is no longer associated with mortality from heart disease.”2-1 In their figure 2 the five countries (Britain, Finland, Ireland, Italy, and Norway) that lie above the regression line (higher mortality) have an average alcohol consumption (from their table 3) of 7.4 litres/person. The 11 countries that are clustered close to the regression line (Australia, Austria, Canada, Denmark, Germany, Iceland, Netherlands, New Zealand, Spain, Sweden, and the United States) have an average alcohol consumption of 8.7 litres/person. The three countries (Belgium, France, and Switzerland) that lie below the regression line (lower mortality) have an average alcohol consumption of 11.2 litres/person.

Wine consumption clearly correlates with the residual differences in mortality that remain after allowance is made for the effect of past dietary animal fat.

References

  • 2-1.Law M, Wald N. Why heart disease mortality is low in France: the time lag explanation [with commentaries by M Stampfer and E Rimm, D J P Barker, and J P Mackenbach, and A E Kunst] BMJ. 1999;318:1471–1480. doi: 10.1136/bmj.318.7196.1471. . (29 May.) [DOI] [PMC free article] [PubMed] [Google Scholar]

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