The French Paradox – Thompson Estate
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The French Paradox

It’s no secret that our top of range “The Specialist” wines signal my combined careers as a specialist cardiologist, medical researcher and vigneron. One question I get asked almost daily is “Is wine good for my heart?” The flippant answer is “Yes of course it is, just get the dose right”.


But the question demands more than a brief cellar door chat and opens the door a complex mix of data, controversy and some entrenched positions.  Over the coming months I plan to tell the full story, putting aside preconceptions as much as possible and examining the evidence dispassionately in sufficient detail to be accurate but, I hope, still readable and interesting.
The first step is to examine one of the most widely discussed topics – the French Paradox.
 
The French Paradox
 
Firstly, what is the “French Paradox?


The term “French Paradox” was first promoted by French epidemiologist Serge Renaud in the early 1990’s. He had grown up in Bordeaux, the heart of the French wine industry.  When Renaud popularised the Paradox, it had an immediate effect: the possibility that wine could have a health benefit rather than the opposite was not only welcome, but there was a scientific logic behind the words.  The controversy it generated in 1991 still influences the wine-alcohol-heart debate today. (1)


Renaud’s French Paradox refers to the observation that coronary heart disease rates in France were low, despite a French propensity for a high intake of saturated fat in the form of meats, paté and cheeses. It was claimed that the key dietary ingredient preventing this high saturated fat diet from blocking the French arteries was red wine. Renaud was not the first to make the observation but the first to provide evidence for the idea.


The observation that France had a lower rate of coronary heart disease had been made for many years. (2) The common perception of a high intake of fatty food in the French diet had already been confirmed in a study which had compared diet and coronary heart disease in an extensive study of seven countries. (3)  The paradox of a country with high fat intake and low coronary heart disease mortality had been discussed during the 1970s and 1980s and a possible protective effect of wine on the heart was already under investigation. (4,5,6) In 1979, British epidemiologists had added their own pithy observation:

 
“If wine is ever found to contain a constituent protective against IHD then we consider it almost sacrilege that this constituent be isolated. The medicine is already in a highly palatable form.” (7)


The observation that wine intake was inversely related to coronary heart mortality had also been made in the 19th Century and was even then of interest to cardiologists. In 1819, an Irish cardiologist Samuel Black (clearly not a Francophile) observed that the French had a lower rate of heart-related deaths compared to the Irish, attributing it to French “habits” and hinting darkly that it may be due to their “moral affections”:


Lower heart related deaths in France are due to the French habits and modes of living, coinciding with benignity of their climate and the peculiar character of their moral affections.” (8)


But it was certainly Renaud with his memorable catchphrase who was the first to catapult the concept into the public consciousness. Renaud’s landmark presentations of the French Paradox were directed to the medical profession in the medical journal The Lancet (9) and more importantly for its worldwide uptake, in a US television show.


The 1992 Lancet article


The Lancet article was entitled  “Wine, alcohol, platelets and the French paradox for coronary heart disease” by Serge Renaud and his colleague Michel de Logeril.  The Lancet is one of the most reputable medical journals in the world. For the paradox to be named in the title of an article in such a widely recognised journal conferred on it a degree of gravitas and acceptance.


The authors presented data from the international MONICA study, a worldwide collaboration which carefully documented, with standardised methods of recording, the international trends in cardiovascular disease. This massive effort (38 populations in 21 countries worldwide) was organised by British epidemiologist Hugh Tunstall-Pedoe and the World Health Organisation. (10)


 [Incidentally, the author, with delayed thanks to an inspiring team of colleagues, reports that his first exposure to cardiovascular epidemiology was to help set up and coordinate the Perth MONICA centre, one of the three Australasian centres.]


Renaud and de Logeril demonstrated that the three French MONICA centres recorded rates of myocardial infarction (heart attack) lower than other centres in Western countries while the cholesterol levels and blood pressures were similar. They also presented confirmatory data that the intake of fatty foods in France is higher than in many other countries. Surprisingly for such an influential paper, they present no international comparative data on French wine consumption compared with the rest of the world, but extrapolated from other studies from Crete (moderately high wine intake) and Japan (moderately high beer intake). The data on wine consumption presented in the article compares wine intake in the three MONICA centres in France and found the higher the wine intake, the lower the heart attack rates.


They hypothesised, based on previous work by Renaud, (11)  that the benefit of alcohol was possibly due to an effect on platelet function, making the blood cells responsible for blood clotting less sticky.


 Despite the formality of the language usually required for a medical and scientific report, the article is peppered with “quotable quotes” such as:


“This suggests that in France the untoward effects of saturated fats are counteracted with wine”
and
“Thus alcohol taken in moderation may be one of the most efficient drugs for protection from coronary heart disease”. 


These quotes have outlived the data on which they are based but not their long-lasting impact.


We will come later to the many criticisms which the French Paradox has received over the years in the medical literature, but Renaud’s article remains one of the most influential publications in the medical literature in recent decades. The impact of a medical article is judged by the number of citations it receives. Since its publication in 1992, Renaud and de Logeril’s article has been cited 4457 times. To put this in perspective, the average medical researcher is pleased for one of their papers to receive over 100 citations, and it is exceedingly rare for a papers to achieve over 1000 citations. (12) 


The CBS television show


While the impact of Renaud’s publication in the Lancet was an outstanding contribution to medical research, its global impact was magnified by the interview which he had with Morley Safer, host of “60 Minutes” CBS news in 1991.


Morley Safer had been a host of 60 Minutes from 1970 onwards. He was widely admired for his fearless reporting on the Vietnam War and as a gentlemanly but persistent host, winner of 12 Emmy Awards. In brief, he was a trusted news source. 


The segment on the French Paradox aired on November 17, 1991 and can still be viewed on Youtube https://www.youtube.com/watch?v=njm1LkXP2sg. In it, Safer highlighted the French Paradox for an American viewing audience. It was viewed by nearly 22 million households and is regarded by CBS as one of its most popular stories ever.


The story starts on location in a restaurant in Lyon. Having identified the paradox, Safer starts the programme with:


“The answer to the paradox might be found here in Lyon, the city that prides itself as the gastronomic capital of France,”


The viewer accompanies Safer as he visits French restaurants where he has meals heavy in cheese, butter and animal fat. The show included an interview with Dr Renaud who stated his answer to the paradox: "My explanation of course, is the consumption of alcohol”.  The key moment in the segment was when Safer turned to the camera, holding a glass of wine, and said,


“The answer to the riddle, the explanation of the paradox, may lie in this inviting glass”.


The CBS Segment was a turning point in the consumption of red wine in the US. Anecdotal stories abounded. The Los Angeles Times reported a rush on red wine (see box)


The many anecdotes were later borne out in the statistics: US red wine consumption, which had been steady through the 1980s at 25 million cases per year, jumped by 33% in the first year after the programme, (1992) to 34.8 million cases and by the second year (1993) had jumped by 44%.



The lasting influence of Serge Renaud


Thirty years on, the French Paradox continues to influence medical researchers, if not to agree, at least to take a closer look at the hypothesis that Renaud had championed. (13)


Renaud’s legacy includes the Renaud Society which is “a society of medical professionals with an interest in better health and a passion for wine, honours the legacy of Professor Serge Renaud, father of the French Paradox, supports wine & health research and education, and promotes the sharing of wine & health interests among medical colleagues worldwide”. (14)


  
 

In coming months we will examine the science behind the French Paradox and come to a conclusion on whether wine is really good for your heart….or not.


References The French Paradox

  1. https://theconversation.com/the-french-paradox-turned-out-to-be-an-illusion-but-it-led-to-some-interesting-research-78196  Accessed Sept 21 2019
  2. Richard JL, Ducimetière P, Bonnaud G, Claude JR, Lellouch J, Schwartz D, Di Mattéo J. [Incidence and evaluation of the risk of coronary disease. Prospective  study in Paris]. Arch Mal Coeur Vaiss. 1977 May;70(5):531-40.
  3. Seven countries study Keys A. Seven countries: a multivariate analysis of death and coronary heart disease. Cambridge Massuchusetts .Harvard University Press. 1980
  4. https://en.wikipedia.org/wiki/French_paradox  Accessed Sep 21 2019
  5. Richard JL. [Coronary risk factors. The French paradox]. Arch Mal Coeur Vaiss. 1987 Apr;80 Spec No:17-21.
  6.  Tunstall-Pedoe H. Autres pays, autres moeurs. BMJ. 1988 Dec 17;297(6663):1559-60.
  7.  St Leger AS, Cochrane AL, Moore F. Factors associated with cardiac mortality in developed countries with particular reference to the consumption of wine. Lancet. 1979;i:1017–1020.
  8.  https://reference.jrank.org/diets/French_Paradox.html
  9. Renaud S, de Lorgeril M. Wine, alcohol, platelets, and the French paradox for coronary heart disease. Lancet. 1992 Jun 20;339(8808):1523-6. 
  10. The World Health Organization MONICA Project (monitoring trends and determinants in cardiovascular disease): a major international collaboration. WHO MONICA Project Principal Investigators. J Clin Epidemiol. 1988;41(2):105-14.
  11. Elwood PC, Renaud S, Sharp DS, Beswick AD, O'Brien JR, Yarnell JW. Ischemic heart disease and platelet aggregation. The Caerphilly Collaborative Heart Disease Study. Circulation. 1991 Jan;83(1):38-44.
  12. van Noorden, R.; Maher, B.; Nuzzo, R. (2014). "The top 100 papers". Nature. 514 (7524): 550–553.
  13. Fragopoulou E, Antonopoulou S. The French paradox three decades later: Role of inflammation and thrombosis. Clin Chim Acta. 2020 Nov;510:160-169.
  14. Website of the Renaud Society https://renaudsociety.com/ Accessed Sep 20th 2019

 

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