The French Paradox
by Dr. Malcolm Kendrick
Source: Personal Communication
THE FRENCH PARADOX
We have been bombarded with the message that heart disease is caused by a raised cholesterol level for so many years that most people believe this to be the truth, absolutely, no doubt about it. But, hold on, French men have exactly the same level of cholesterol in their blood as British men, yet they suffer less than a quarter the rate of death from heart disease.
And if you examine the French in more detail, in comparison to the British, a few equally surprising facts emerge. For example, their consumption of saturated fat is virtually the same; 25.7% of dietary calories, versus 27% in the UK.
They also smoke more and take less exercise; their blood pressure is identical, as is their level of HDL, or ‘good’ cholesterol. In fact, when you look at the classical risk factors for heart disease in more detail it is obvious that French men should have a higher rate of heart disease than British men. Yet they don’t, it is much, much lower.
These figures represent the ‘French Paradox.’ A term first coined by Hugh Tunstall-Pedoe of Dundee University in 1978. Now, at this point, I believe that I know what you are thinking. You are thinking, ah but, the French consume more garlic, red-wine, lightly cooked vegetables and fruit. Most people have heard by now that these things protect against heart disease. I also know from many conversations that most people fully believe that they are protective.
But it might be worth studying these factors in a little more detail. Do they really have a beneficial effect. Before doing that it is interesting to point out quickly that these factors only emerged after the publication of French Paradox – none of them were mentioned prior to this. Which should give you a hint that their main purpose was to support, rather than illuminate. The same reason why a drunk uses a lamppost.
Anyway, let’s go back to 1978, when Hugh Tunstall-Pedoe first sprang his paradox upon the world of heart disease research. At that time the theory was that a diet high in saturated fat led to raised cholesterol levels, and then heart disease. The diet-heart hypothesis. Other factors were considered to increase the risk e.g. smoking, raised blood pressure and a few other bits and pieces, but it was mainly all to do with diet and cholesterol. Indeed, this is still the current thinking.
Then along come the French figures, which threaten to topple the entire hypothesis. Fifty-five million living exceptions to the rule. Indeed, when these figures emerged, the mainstream medical research community found themselves facing a rather stark choice. Find reasons to ignore the French figures, or accept that the diet-heart hypothesis was wrong. You may not think that the French figures are quite so important. But fifty five million people do not represent the exception that proves the rule. Data from fifty five million people represents a degree of contradictory evidence that utterly disproves the hypothesis.
However, even in 1978 it would have been incredibly difficult to discard the hypothesis. Hundreds of eminent researchers would be forced to admit they were wrong; their reputations built on sand. Low fat food manufacturers would be out of business, major international medical societies would have to admit that they advice they were handing about diet and cholesterol levels was rubbish. Pharmaceutical companies would lose billions of dollars worth of sales. In short, discarding the hypothesis was out of the question, and so began the process of immunisation.
Immunisation is a term used by Karl Popper who studied scientific thought, and scientific methodology, for many years. He recognised that certain hypotheses are sustained far beyond their sell by date – for many reasons. For example, the Catholic Church decreed that the world was flat, end of story. Anyone who dared question this orthodoxy was likely to be paid a friendly visit by the Spanish Inquisition, who’s core activity, silence the unbeliever, represents the first form of immunisation. Or, as Popper would put it, ignore the refutation. Refuse to look through the telescope.
The scientific community is highly adept at the old ‘silence the unbeliever’ method. Normally they pour scorn on the person who dares to question scientific orthodoxy, attacking the ‘unbeliever’s ideas, their methods, their lack of scientific rigour, their inside leg measurement etc. However, Hugh Tunstall-Pedoe is a highly meticulous researcher, and, crucially, he never made any attempt claim that the French figures destroyed the diet-heart hypothesis.
In fact, he pre-empted any possible criticism by using a simple semantic trick. He immediately deemed his results to be a ‘paradox.’ Paradox n 1 a ‘a seemingly absurd or contradictory statement even if actually well-founded.’ OED. Effectively, he damned his own findings. ‘I know that these figures don’t make sense. They don’t fit the hypothesis, therefore they are absurd, because we know that the diet-heart hypothesis is correct. Gentlemen, we have a Paradox on our hands.’
To be frank, dismissing absolutely contradictory findings as a paradox is not good science, never has been, never will be. It is, in reality, a none too subtle variation on ignoring the evidence. Call it a paradox and forget about it.
But there were those who didn’t want to ignore the French. Such a gaping hole in the diet-heart hypothesis had to be explained. It couldn’t really be ignored. It was just too damned big, and people kept falling into it. But when voices were raised in concern, the second form of immunisation was used. Deny that the refutation is a refutation.
To quote Karl Popper on the matter of denying the refutation:
A biologist offers the conjecture that all swans are white. When black swans are discovered in Australia, he says that it is not refuted. He insists that black swans are a new kind of bird since it is part of the defining property of a swan that it is white.
In the case of the French figures it was strongly suggested that, as the French used their own disease and death classification system, that they were wrongly classifying deaths, and that their rate of heart disease was actually no different to the UK. ‘Look, it’s not a black swan after all. ‘
This ‘denial’ clattered around for many years before being utterly disproved. But it took up a few years, and time is a great healer of many things, including huge holes in a hypothesis. People start to forget that there ever was such a thing as the French Paradox.
But a few brave souls battled on. Once it had been proven that the French really did have a very low rate of heart disease, despite identical risk factors to the UK, these people wanted to know why. Well why? It is very difficult to trace the genesis of a scientific thought. But by the early/mid 1980s the first papers were published suggesting that the greater French consumption of garlic, red-wine, lightly cooked vegetables and fruit were the answer.
This, in fact, represents the final form of Immunisation. Development of an ad-hoc hypothesis. The thinking is as follows. Why don’t the French suffer from heart disease, despite their high cholesterol level? It must be because they are protected in some way; the protective ‘factor(s)’ representing the ad-hoc hypothesis.
This is exactly the same thinking that is used to explain the low rate of heart disease in women. Women, in the UK, have a higher average cholesterol level than men, yet suffer about one third the rate of heart disease. Why, it must be because they are protected in some way. How are they protected? By their sex hormones. And what evidence would there be that women are protected by sex hormones. Well, none, zip, zero, nada. That probably surprises you, but it is absolutely true.
Moving back to the French, I can only assume that researchers cast about looking for differences between the French and the British diet, and alighted on the greatest nutritional differences that they could spot. When the consumption of red wine, garlic, fruit and lightly cooked vegetables stood out, they became the explanation, the ad-hoc hypotheses, the protective factor(s). You think it was more scientific than that? Well, you would be wrong.
Medical science is not an exact science, but I can assure you that there is not one scrap of ‘outcome’ based evidence to support the protective effects of any of the protective factors mentioned. None. It is true that alcohol – up to a point – protects against heart disease. But this is true of all forms of alcohol. Red wine has no specific benefits.
Researchers continue to claim otherwise. However, whenever anyone has looked at death rates from heart disease, and red wine consumption, no difference has been found between red wine and any other form of alcohol. Sure, different ‘factors’ go up and down in the blood, such as the level of ‘good’ cholesterol, or HDL, but that’s all that happens, no lives are saved. In my opinion, if you want to find out if something protects you against dying – measure the death rate. It’s a pretty good indicator.
What of garlic. Does garlic have any impact on lipid levels in the blood? A group from Bonn University studied this, thoroughly, a few years ago. And the conclusions thereof?
‘We were actually surprised how clearly negative the results were.’ Said Dr. Heiner Berthold. From a study published in the Journal of the American Medical Association JAMA 1998.
Further comment on this study came from Dr Ronald Krauss, chairman of the American Heart Association’s nutrition committee and head of molecular medicine at the University of California’s Lawrence Berkeley National Laboratory. A big cheese.
‘This study qualifies as a solid scientific study. It’s what people should be basing their thought processes on, instead of on folklore.’ (Pity he doesn’t go back and look at saturated fat intake with the same scepticism).
The quoting of negative studies could go on and on, but it wouldn’t add a great deal. However, perhaps a final quote from a study done in 1981, shortly after the French Paradox first appeared. The study was entitled ‘The long term use of garlic on ischaemic heart disease – an appraisal.’ Published in Atherosclerosis (yes there is a journal called Atherosclerosis, and a cracking good read it is too, order your copy now). The conclusions of this study were that:
‘The evidence cited above does not appear to substantiate the prevalent popular belief in the efficacy of garlic in the management of IHD either as a hypocholesterolemic (cholesterol lowering) or as a fibrinolytic (blood clot preventing) agent.’
In short, garlic don’t work.
Finally, fruit and vegetables. Over the years, according to mainstream research into heart disease, the factors present in fruit and vegetables that protect against heart disease are ‘anti-oxidants.’ These stop free-radical ‘oxidising’ the bad cholesterol in your blood, and oxidised bad cholesterol is a bad thing – allegedly.
And what are these anti-oxidants. Vitamins mainly. So, presumably, if you give people the correct vitamins, they will be protected against heart disease. Does this work? In fact, giving people high doses of anti-oxidant vitamins was done in a massive twenty thousand patient study in the UK. The UK Heart Protection Study.
The main purpose of the study was to look at the impact of cholesterol lowering drugs. But a major part of the trial involved giving high doses of anti-oxidants. Vitamin C 250mg/day, vitamin E 600mg/day and beta-carotene 20mg/day. All of these are anti-oxidants that are supposed to prevent CHD, and which are found in fruit and lightly cooked vegetables, and thus explain the French Paradox, apparently. Ten thousand patients received the anti-oxidants and ten thousand patients did not.
And how did anti-oxidants fare in the ‘hard end-point’ stakes.
‘’’There was no evidence of any benefit at all’ from antioxidant vitamins. On the other hand, there was no evidence of any harm.’’’ Dr Rory Collins BMJ Nov 2001
What this trial proved, beyond any reasonable doubt, is that anti-oxidants, much hailed as protective against CHD, and present in vegetables and lightly cooked vegetables, have absolutely no impact whatsoever on the rate of death from CHD.
So there you have it. When you look at red wine, garlic, fruit and lightly cooked vegetables it turns out that the so-called protective factors actually have no effect at all. So what does protect the French?
Best, perhaps, to change the question. We only think that the French are ‘protected’ against heart disease, despite high cholesterol levels, because we believe that a high cholesterol level causes CHD. If this is not true – and it isn’t – then the question becomes meaningless.
The reality is that the French figures prove that saturated fat in the diet, and raised cholesterol levels, have nothing whatsoever do to with heart disease. If they did, the French would have exactly the same rate of heart disease as the British, and they do not. Women would have the same rate of heart disease as men, and they do not.
We do not, actually, have a Paradox on our hands, the true explanation for the French figures on heart disease is that the diet-heart hypothesis is wrong. A raised blood cholesterol level does not cause heart disease. This is the only explanation that actually fits the facts. Or as Magritte would say ‘Ce n’est pas une Paradox.’
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