Lifestyle in France and the United States: An American Perspective

In 1987, Ducimetiere and his team coined the term “the French Paradox” to refer to the fact that the French have among the lowest rates of cardiovascular disease in the world despite having among the highest intakes of saturated fat (1, 2). Since then the MONICA project, aimed at standardizing and monitoring trends in cardiovascular diseases, showed that rates of coronary deaths in France were similar to rates in adjoining countries of Southern Europe (3). However, what lingers in the American consciousness is the belief that the French eat better, drink better, and live healthier lifestyles than Americans. Perhaps a more realistic assessment is that both countries can learn valuable lessons from one another about the sociocultural and economic factors that influence lifestyle.

The paper by Malon and colleagues (4) in this issue of the Journal reports on the results of an extremely rigorous national survey assessing adherence to French nutritional recommendations. Major findings were that of 1 physical activity and 12 nutritional recommendations, the average French adult adhered to about 50% of them. Those most likely to be non-adherers were the young and middle-aged and the economically disadvantaged. These data suggested to the researchers that perhaps education alone is not enough to change eating behavior but that targets of intervention should also focus on the availability and costs of healthier food alternatives.

The need to find ways to improve national health is more urgent in the United States than it is in France. Here are several selected nutritional recommendations from the French program and their respective success rates among French and American citizens.

1. Consume ≥5 servings of fruits and vegetables/day. About 44% of the French do this; approximately 24% of Americans consume at least 5 total servings of fruits and vegetables per day (5).

2. Less than 1 glass of sweetened beverage/day. About 70% of the French do this; only 37% of Americans meet this guideline (6).

3. Brisk walking 30 minutes/day. About 65% of French walk briskly 7 days/week; only about 50% of Americans walk briskly 5 days/week (7).

These differential health behaviors translate into different rates of obesity in the two countries. Among French adults 17% are obese (8) and among American adults 34% are obese (9). These rates of obesity track well with deaths from coronary heart disease. The French retain their position of being among the lowest in the world (men: 73 per 100,000; women: 17 per 100,000, the lowest in the world) and the United States remains in the middle of a 37-country comparison (men: 174 per 100,000; women: 73 per 100,000). Americans rank right behind Eastern Europe, China, Scotland, Ireland, and England. This rank has not changed over the past 15 years, despite the enormous time and effort that has been directed toward improving the health of Americans (10).

The French study observed poorer adherence to guidelines in people with fewer economic resources (4). Disparities in health among the underserved is also a serious American problem. America's record on reducing disparities in health over the past 15 years is negligible. When disparities in 15 health indicators was examined recently, there was no difference in 10 indicators and a widening on 5 indicators. The most important indicator accounting for this widening was observed for heart disease mortality (11).

It is no surprise, therefore, that Americans look to France for ways to improve their health, rather than the other way around. It is also no surprise that Americans may have gained some wisdom following repeated and often failed attempts to improve the nation's health. Given the urgency of the American problem and the difficulties we have in making sustained improvements, the American government is encouraging a new emphasis on innovation as a requirement in getting federal grant money. American researchers are, accordingly, beginning to think “out of the box” for ways to improve lifestyle, reduce disability from chronic illnesses, and stem the extraordinary health care costs that result from them.

So what can the French learn from the American experience? First, it is not just about the price. Malon and colleagues (4) have suggested that improvement in adherence to nutritional guidelines in the economically disadvantaged could result from more attention to cost. Consistent with this suggestion, it is widely-known that nutrient-dense foods, such as fruits and vegetables, provide fewer calories for the same amount of money than energy-dense foods, such as high-calorie snacks (12). For example, in the U.S. one can purchase 1,000 kcal of energy-dense snacks for around US$4.00, whereas 1,000 kcal of fresh produce may cost upwards of US$20.00 (13). Citing this association between energy density and energy cost, a number of authors have argued that the failure of low-income individuals to consume more fruits and vegetables is driven by the high cost of fresh produce relative to energy-dense alternatives (14). However, the energy cost of a food (US$/kcal) may actually have limited value in the context of developing and disseminating guidelines for healthy weight maintenance. A recent analysis by Lipsky (13) demonstrated that fresh fruits and vegetables are substantially less expensive by weight and have much larger serving sizes than snacks. In fact, US$4.00 would procure about 0.44kg (0.97 lbs) of fresh produce (nutrient-dense foods), but only 0.2kg (0.44 lbs) of energy-dense snacks. Given that satiety is driven primarily by food weight and volume, rather than by energy content (15, 16), a novel public health message may be warranted: “Purchasing fresh produce can help socioeconomically disadvantaged individuals achieve satiety at a lower price.”

The price of fresh produce in the United States is surprisingly modest. Consumers can meet the recommendation of 3 fruits and 4 vegetables per day at a price of only US$0.64 (17). Because these data are contrary to common belief, we conducted our own small survey of the cost of snacks in Chicago. We compared prices of a variety of comparably priced snacks at 5 grocery and convenience stores. We found all snacks could be purchased for about US$0.80-0.85, regardless of whether they were potato chips, soda, yogurt, an apple, or an orange. The prices for chips and soda were higher, and apples and oranges were lower, in convenience stores than in grocery stores—types of stores most frequently found in the inner city. Though the associations between store type and food prices are complex (18), our little survey complements systematic research (13, 17) suggesting that factors other than price may be more relevant to understanding fruit and vegetable intake in the context of lifestyle.

Price can only affect food choices when those foods are available to the individual. As briefly alluded to by Malon and colleagues (4), the local availability of healthy food can have a major impact on dietary intake and health for those of lower socioeconomic status. There are relatively few supermarkets in socioeconomically disadvantaged areas in North American countries (18-26). This is problematic because chain supermarkets offer the greatest variety of healthy foods, whereas convenience stores and independent grocers offer mostly prepared foods and very little fresh produce (18, 27, 28). Residing further from supermarkets or closer to convenience stores have been linked to lower fruit and vegetable consumption and higher body weight in urban multiethnic populations (29-31) and adolescents (32, 33), even after accounting for other features of the neighborhood and relevant individual characteristics. Thus, for socioeconomically disadvantaged individuals, the absence of large mainstream grocers in their neighborhood is a more proximal barrier to meeting dietary guidelines than food prices.

A second insight on the American side is that junk food may be an effective antidote for stress. Americans tend to be either overscheduled and overworked or underscheduled and out of work. The HALT emotions (Hurried, Agitated, Lonely, Tired) trigger greater interest in potato chips than in an apple (34), and the behavioral and neurobiological mechanisms underlying “stress eating” is an active area of investigation (35, 36). The fact that Malon and colleagues (4) identified both socioeconomic factors and the lack of a holiday trip as predictors of adherence to recommendations suggests that consideration of diet alone, without jointly considering other health behaviors such as stress and physical activity, may be even more limiting.

What can Americans learn from the French? First, we can learn the value of neighborhood food markets. Anyone who has lived in France understands the centrality of the neighborhood market in determining French consumption patterns. Refrigerators in French households are small and food storage is uncommon. Instead the daily ritual is to go to the market at the end of the day to find ingredients for the evening meal from an array of fresh fruits, vegetables, meats, fish, and cheese. Traditional French culture promotes interest in food—all the way from planning, shopping, and preparing to eating together. This approach to food is catching on in the United States where Americans who are stuck in the tyranny of the urgent are embracing such “slow food” and “eat local” approaches that encourage spending time engaged in activities that are less urgent but perhaps more important (37).

Second, we can learn the value of moderation (38). The French approach to food is to eat all types of food, slowly, conversing while eating, drinking wine with dinner and never without food. Americans engage in low calorie diets featuring restriction of various types of food, and, when the restriction becomes too difficult, going in the opposite direction and eating too much. A recent cross-cultural comparison of lifestyle in 2 comparable cites—one in France and the other in the U.S. showed that the French spent twice as much time eating (11.11% of time) than the Americans (5.22% of time) (39). The contrast in physical activity is similar. The French move around regularly, using stairs, bikes, and public transportation. Americans are more likely to begin exercise programs with high intensity and high frequency regimens, which are often unsustainable and lead to failure and revision to sedentary habits. This same cross-cultural comparison showed that the French spend 1.69% of time walking vs. 0.63% for the Americans (39). The French culture values time off from work for renewal. Historically, they have been known for vacation durations of 4 weeks in the summer and 2 weeks in the winter. American vacations have historically been 2 weeks in duration but recent data suggest that this is shrinking (38, 39). The cross-cultural comparison reported that the French take 21 more vacation days a year than the Americans (39).

In summary, as the “toxic” American fast food market continues to grow in France, and with it the girth of French citizens, a viable public health program might be to develop strategies to preserve traditional French approaches to lifestyle. In the United States, where the culture of saving time, eating fast food, and multi-tasking is firmly embedded, we are turning to multi-level interventions, which simultaneously target a variety of levels of influence including the individual, the social network, the community, and policy in hopes that strengthening our interventions will improve our success. Americans can and should look to the French as a model for a healthy lifestyle that includes not just what a person eats, but the attitudes, behaviors, and social context within which one operates. The French can and should look within themselves and find ways to preserve their French culture and not separate what one eats from the values associated with enjoying food and making time for it. This is particularly important for the French youth who are differentially targeted by the glamour of the fast food economy. They have a slim chance in this fast and fat world.