Drink Like the French, Die Like the French

Winter 2000 Commentary

Johnny Carson [who underwent quadruple heart bypass surgery last year] has some advice for David Letterman [who is recovering from a quintuple bypass]:

"Drink more red wine."

-Associated Press

One of his countrymen, whose work helped make famous the paradox of having a high satu­rated fat diet and lower than expected death rate from heart disease nearly a decade ago on "60 Minutes," says that attributing a low rate of heart disease to daily consumption of wine or other forms of alcohol is wrong.

A growing number of French health researchers have news for the rest of the world: It is myth that the French are healthier than most everyone else because they drink. In truth, the French are drowning in the grape and paying a hefty price for it.

"There is no scientific consen­sus today over the protective effect of alcohol," says Dominique Gillot, France's secretary of state for health. "The link between the quantity of alcohol consumed and increase of risk of diseases, partic­ularly cancer, is, on the other hand, scientifically validated."

The fact is that according to data from the world's largest study of heart disease, conducted by the World Health Organization (WHO) during the past decade in 21 countries with 10 million men and women, French heart disease statis­tics appear to have been under­estimated and the "French Paradox" overestimated. France's rate of heart disease is actually similar to that of neighboring Italy, Spain, and southern Germany - lower than many countries in the world, but hardly as remarkable as reported in the '80s and early '90s.

The French drink one-and-a-half times more per capita than Americans and their death rate from liver cirrhosis is more than one-and-a-half times greater than that in the United States. According to WHO, France has the sixth highest adult per capita alcohol consumption in the world. (The U.S. ranks 32nd.) Alcohol may be involved in nearly half of the deaths from road accidents, half of all homicides, and one-quarter of suicides, according to the French equivalent of the U.S. Institutes of Health. And while coro­nary heart disease may be less pervasive in that country of 60 million people than in many others, it is still the number one cause of death.

Within the past year, several other revelations have highlighted this little-publicized, other side of French drinking:

. According to the first French eco­nomic study of its kind, France is more like the U.S. than Americans might real­ize in that alcohol also ranks first - above tobacco - in its cost to society. Tobacco takes more of a toll than alcohol in the rest of Europe, Canada and Australia.

. The high premature death rate of French men is largely due to alcohol abuse. It is nearly double the premature death rate of French women, and the magnitude of the difference is the highest in Europe, according to the French gov­ernment's most recent report on health.

. French youth, who can legally drink at age 16, prefer beer and distilled spirits to wine and have increased their con­sumption fivefold since 1996, in part because 12- to 14-year-olds are drinking and binge drinking. This has led to a new government "War Against Drugs" that includes alcohol.

"It is easy to say that life is beautiful far from your eyes," says Claude Got, one of France's medical experts on alcohol and president of the scientific council of the French counterpart to the U.S. National Institute on Drug Abuse (NIDA). "The oversimplification of the interpretation of the expression 'French Paradox' is one of the major challenges for public health. The association between moderate alcohol consumption and low heart disease rate is not as simple as described by the wine industry."

The French Paradox. Even in English the expression sounded romantic to 33.7 million Americans who first heard it in a report by Morley Safer on "60 Minutes" in November 1991. Although the French eat fatty foods and smoke more than Americans, said Safer, "if you're a middle-aged American man, your chances of dying of a heart attack are three times greater than a Frenchman of the same age. Obviously, they're doing something right - something Americans are not doing... Now it's all but confirmed:

Alcohol - in particular red wine - reduces the risk of heart disease."

Within four weeks, U.S. sales of red wine rocketed by 44 percent. American Airlines reported being unable to stock enough red wine to meet demand. By February 1992, a Gallup poll showed that 58 percent of Americans were aware of research linking moderate drinking to lower rates of heart disease. According to the poll, consumers had returned to drinking levels not seen since the mid-'80s. Although beer remained the preferred drink of Americans, wine preference increased from 22 to 27 percent.

Five months after the 1992 poll, "60 Minutes" re-broadcast the "French Paradox" segment. Sales of red wine shot up 49 per­cent over the previous year. Safer was honored in France with a special "com­munication" prize from LVMH Moët Hennessy Louis Vuitton.

During the next few years, the Wine Institute lobbied officials of the U.S. Department of Health to reflect studies confirming the "60 Minutes" side ofFrench drinking in the U.S. Dietary Guidelines, which the industry subse­quently used to market wine as a health elixir. Food and Wines from France, which promotes Gallic products overseas, placed full-page newspaper ads announc­ing that French consumption of fatty food was counteracted by drinking French red wine.

"[Health] announcements are increas­ing consumption more than anything else," said Stephanie Grubbs, marketing manager for Robert Mondavi Coastal, in Impact magazine in 1997. That same year, three out of four readers in the January Consumer Reports on Health survey believed that moderate red wine consumption is more beneficial than drinking beer or liquor.

Recently, the San Francisco-based Wine Institute helped some California wineries get permission from the Bureau of Alcohol, Tobacco and Firearms (BATF) to add a label referring con­sumers to the federal dietary guidelines to learn the "health effects" of alcohol. But anyone who actually sent for the docu­ment would discover that the govern­ment's advice on alcohol is mostly cau­tionary.

Inflamed by the belief that the wine industry was using the label to make it appear that the government was suggest­ing Americans drink for their health, Sen. Strom Thurmond (R-SC), whose daughter was killed by a drunk driver, recently won a battle for the BATF to hold hearings on whether the "health effects" label can legally be affixed to every wine bottle. They're scheduled to take place in a number of U.S. cities in late spring.

Today the Wine Institute touts its product on its web site with studies and press releases. One quotes David Pittman, Ph.D., researcher at Washington Univer­sity in St. Louis: "In societies such as France, Italy, Spain and Portugal, where wine and overall alcohol consumption is higher than in the United States, theyjust don't have as many alcohol-related prob­lems such as drunk driving and underage drinking."

That would be news to France.

The world view that the French are able to control their drinking habits is untrue, according to Pierre Kopp, profes­sor of economics at the Sorbonne. Kopp recently released the first French study estimating the cost of legal (alcohol and tobacco) and illegal drugs. Kopp estimates that alcohol costs France $18.5 billion (U.S.) each year. Drinking is responsible for nearly 53 percent of overall social costs of alcohol, tobacco and illegal drugs, he reports. (Annual cost to the state is $14.3 billion for tobacco and $2 billion for illegal drugs.)

But even these high alcohol economic cost figures are underestimated, cautions the researcher, because he left out alcohol-related crime and accidents, which com­prise some of the largest costs to society in the United States. Kopp focused on public and private money spent on medical treatment, lost productivity, absenteeism, uncollected taxes, unpaid health contri­butions, and preventive measures.

"There is a collective misunderstand­ing of the dangers of alcohol in a country where a regular intake is claimed as a pro­tection against heart problems," says Kopp. "Consumption is exceptionally high and the final bill is extremely heavy. Alcohol accounted for 42,963 deaths in France in 1997."

To Kopp, all the hoopla over the so-called French Paradox is "so stupid." These days, he is focused on watchdog­ging the advertising environment in France to prevent the next generation from perceiving alcohol as a health boost or an essential component of a successful, cultured life.

He is hardly alone. Prompted by con­cern over youngsters drinking like their elders, France has the strongest law con­trolling advertising of alcohol in the European Union and perhaps the world. Known as the Loi Evin after a former French health minister, it went into effect in 1993 and bans alcohol ads on television and in the movies, restricts them on radio until after 10 p.m., and forbids alcohol industry sponsorships of sporting events. Foreign magazines sold in France may carry alcohol ads, but in French maga­zines ads are restricted and must bear this health warning: "The abuse of alcohol is dangerous for health: consume in mod­eration."

So strict is the Loi Evin that in 1997, Anheuser-Busch sold its rights to in-stadi­um advertising at the 1998 World Cup soccer tournament when its lobbying for an exception to the sponsorship ban failed. The world's largest beer company had reportedly paid about $20 million to become one of the tournament's 12 sponsors.

French Secretary of State for Health Gillot says that enforcement of the Loi Evin remains "a priority of public health." She hopes to strengthen the law regard­ing billboard advertising to youth, and foresees "total prohibition of the sale and distribution of alcoholic drinks in stadi­ums and sports installations."

As its U.S. counterpart has done, the French alcohol industry has encouraged consumption of wine and spirits to improve health. When Kopp released his study, the industry's premier lobbying association in France - Entreprise et Prevention - challenged the reliability of the figures. Kopp's response was to question how an industry group formed in response to the Loi Evin can be both lobbyist and educator of schoolchildren on drinking. Answering his own question, he joined Dr. Got and a who's who of health in support of a recent campaign against owning stock in member compa­nies of Entreprise et Prevention. The boy­cott action was organized by Vie Libre, an organization founded half a century ago for recovering alcoholics that reports a membership of 20,000.

"To us, the fight is like the American fight against tobacco," says Audrey Benaim, spokesperson for Vie Libre. "The lobby of alcohol is beginning a very strong action to water down Loi Evin. They pretend to be responsible actors in prevention, but how objective could their message be if they tell children in school to drink moderately? They never define moderation or say not drinking is okay. We will ask the pension funds in charge of money for social security and retirement of civil servants to sell the alcohol stock. This boycott is not just idealistic. It will stop only when Entreprise et Prevention guarantees to stop its lobbying and pre­vention activity."

Many doctors like Got, who was one of the so-called "five sages" who wrote the Loi Evin and has decades of experience in alcohol research, acknowledge a num­ber of reliable studies demonstrating that one glass of alcohol or less a day can boost the level of artery-cleaning "good" choles­terol and reduce the risk of blood clots for men over 50 years of age and post-menopausal women. But they point out that taking a daily dose of baby aspirin, quitting smoking, and supplementing estrogen for women past menopause can reduce clotting; and cutting down on saturated fat, exercising regularly, and losing weight can increase the "good" cholesterol.

Immoderate drinking (more than one glass a day for a woman and more than two glasses a day for a man, accord­ing to the U.S. Dietary Guidelines) can actually harm the heart by raising blood pressure and weakening the heart muscle.

"I can accept, as other epidemiolo­gists, a favorable effect of a small amount of alcohol on ischaemic heart disease for some people," says Dr. Got. "But man is not only a heart, and to improve the cor­onary arteries of a group of low-alcohol consumers is not a goal for public health if it has to pay with a high rate of liver cir­rhosis, cardiomyopathy, road accidents, violence, hypertension, and nervous dis­eases produced by alcohol."

Alcohol is the number one health problem in France, according to Dr. Michel Craplet, a psychiatrist who repre­sents France at Eurocare, a coalition of European alcohol policy advocacy groups. "Many people who come here for holi­days think France is a paradise. But the French have paid a big price for drinking alcohol. The problem is that every French person is a lobbyist for wine. It's in the head, in the culture. We don't need the alcohol lobby here because we view wine passionately. We have a conflict between the figures about drinking that prove our mortality and morbidity and the positive symbolic value it has."

In the late '50s, when Craplet was a pre-teen in Paris, he drank table wine in water with meals. Little by little, his glass arrived less and less diluted. Everybody drank with meals. Then, France was rural and traditional. Now that the French are living a more urban, working life, it's dif­ferent. Since the late '80s, he says, young people have preferred American soda and beer, and the beer may be eight per­cent alcohol or higher. Most people prefer to drink with dinner.

"Our alcohol consumption is declin­ing one percent a year and our life expectancy is rising," says Craplet, "but men in their 50s drink so much that it's all relative. Today, we say that only 60 per­cent of men and 40 percent of women drink every day, because 10 or 20 years ago, 90 percent of the French drank daily."

When "60 Minutes" introduced the French Paradox to America, Morley Safer featured only one French scientific authority - Serge Renaud, a trendsetter in alcohol research who still maintains that "there is no doubt that a moderate intake of wine (one to three glasses per day for a man) is associated with a 30- to 40-percent reduction in mortality from all causes." In its first issue of the new mil­lennium, the prestigious British journal Lancet noted in a short profile of Renaud that his enthusiasm for alcohol and the French Paradox is hardly unanimous today among his French peers. In fact, at least two of the scientists instrumental in early French Paradox research today dis­agree with Renaud's belief in the central role of alcohol in a lower coronary heart disease rate. If alcohol is involved, they say, it is only one of many complex factors.

Take Pierre Ducimetière, research director of the cardiovascular and meta­bolic epidemiology unit of the French equivalent of the U.S. National Instiiiutes of Health. It was Ducimetière's team that coined the expression "French Paradox" to describe the apparent phenomenon of the country's low coronary heart disease rate despite a diet high in saturated fat. In that paper, published and largely ignored in 1987, J. L. Richard, who was working with Ducimetière, wrote that "the high mean level of alcohol consumption in France might be one of the factors responsible for this French peculiarity." In the first British Medical Journal issue of 2000, Ducimetière and a group of epi­demiologists signed a letter that ended with this statement: "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."

Ducimetière pointed out that 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." However, "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."

In the Lancet article, Ducimetière says, "Coronary incidence data now deny there is a French Paradox. [The lower coronary mortality in France compared with other countries] is a consequence of different ways of coding coronary mor­tality."

Agreeing with Ducimetiêre on the importance of new evidence is Dr. Michel de Lorgeril, a cardiologist-researcher who wrote the paper with Renaud that brought the French Paradox to the pub­lic's attention. "The French Paradox can­not be explained only by alcohol," says de Lorgeril, "...and there is no consensus to say that alcohol consumption in modera­tion is protective."

What's new for both men is the MON­ICA Project established by centers around the world to MONItor trends in CArdiovascular diseases and relate them to risk factor changes over a 10-year period. Established in the early 1980s by WHO, its final data were highlighted last September at the European Society of Cardiology in Barcelona. De Lorgeril reported there that the WHO data were 75 to 90 percent higher than France's sta­tistics for coronary heart disease deaths.

The cardiologist said he scrutinized alcohol-related deaths and found that French men, "who drink too much," have the highest rates of liver disease and - by far - more upper gastrointestinal cancer, and were more likely to die in accidents, by suicide, or as a consequence of crime than men of other nationalities. While men in Sweden can expect to live 76.5 years on average, a Frenchman's average lifespan, said de Lorgeril, is 74.11 years.

Dr. Ian Graham, a professor of epi­demiology at Trinity College in Dublin, said that de Lorgeril's statistics suggest that the lower rate of coronary deaths in France are due "to competing causes of death" - many more French men might die early from alcohol-related causes before they have the opportunity to die of heart disease.

Some specialists working on the WHO project think the data prove that there is no French Paradox. De Lorgeril, however, believes that the paradox exists in France and that a paradox also exists in adjoining countries. "I'm sure that alco­hol or wine do not totally explain the paradox and I don't know the answer," he says. "It is not true that the French are healthier than Americans. Their life expectancy is about the same. Only one thing is true from this new information we have - French women have the best life expectancy in the world. Maybe better than the Japanese. They live on the aver­age 82 years, even surpassing the Swedish woman's average 81.5 years. The key is to study French women and right now epi­demiological data on the food and alco­hol intake of French women are lacking."

Hugh Tunstall-Pedoe, professor of cardiovascular epidemiology of Dundee University at Ninewells Hospital, Scot­land, was lead author of the MONICA report.

"After correcting for underreporting, the French coronaiy mortality is still low, but comparable with neighboring coun­tries such as Italy, south Germany, Spain," he says. "So the 'French Paradox' becomes a Mediterranean or south European paradox... If you go down what is approximately the Greenwich meridian from Scotland to southern England and then France and Spain, you follow an extraordinary decline in coro­nary disease mortality over a distance of a few hundred miles. We don't know why."

What France lacks in consensus on the "paradox" it makes up for in its effort to educate the public about alcohol once and for all. It is an undertaking that includes the alcohol industry. But unlike the United States, where public health has failed to get the government to include alcohol in its taxpayer-funded "War on Drugs," France's "Lutte Contre La Drogue" includes alcohol.

In 1998, a pharmacist who is a direc­tor at the French counterpart of the U.S. National Institutes of Health handed then French Health Minister Bernard Kouchner a report that had the effect of "a sort of a bomb." In what has become known as the Roques Report, Bernard Roques classified drugs on the basis of their danger to the public rather than their legal status. Based on scientific data, alcohol took first place along with heroin and cocaine; tobacco took second place with amphetamiiies and LSD; and mari­juana was in the third, least dangerous group. "Our purpose was to reveal to the French people that alcohol must be con­ sidered as an addictive drug when con­sumed in too large amounts," says Roques.

Health Minister Kouchner presented the report urging a radical reclassifica­tion of legal and illegal drugs to the gov­ernment, and Prime Minister Lionel Jospin endorsed the findings, which were to be the basis of a new, three-year gov­ernment plan to fight drug addiction.

"An outcry by the beverage alcohol community" followed these government moves, according to the alcohol industry publication Alcohol in Moderation. "The result has been to stir producers and all those involved ... into action ... a collabo­ration of producers, professionals and restaurateurs, was lbrmed specifically to tackle the threat of alcohol being classed as a hard drug and put under the aus­pices of the Interministerial Mission of the War Against Drugs ... industry associa­tion efforts have paid off, as the final report has removed some of the most contentious points.. .Indeed, the industry has been invited to take part in working party groups to develop and implement policies to tackle and research abuse."

Roques admits that the 17-member committee of ministers overseeing the three-year plan said "that alcohol cannot be considered exactly as a drug," but the committee "finally accepted the fact that consumption in too large a quantity is very dangerous and therefore can he under control of" the War Against Drugs committee.

Although public health has a long way to go in France, Roques says, "It seems that we are now on the way."

Drink Like the French, Die Like the French

The truth is finally starting to come out: If Americans drink alcohol like the French, we will die like the French.

For all the hoopla about the "French Paradox" on these shores, the French themselves consider alcohol use their number one health problem. The para­dox that the French eat a high fat diet but have fewer than expected deaths from heart disease, and the suspicion that this is due to protection of the heart by alco­hol, begin to fade in comparison with alcohol's toll in France.

Nearly 43,000 French people die each year from alcohol-related causes, the pro­portional equivalent of 200,000 Ameri­cans - double the number who currently die annually of alcohol-related causes in the United States.

According to the World Health Organization's Global Status Report on Alcohol, the French drink 54 percent more alcohol than Americans, and die of liver cirrhosis 57 percent more often.

Yes, fewer French people die of heart disease than would be expected given their fatty diets. However, French men in particular die prematurely in dispropor­tionate numbers, and alcohol-related problems are often the cause.

In 1991, Morley Safer's "60 Minutes" report on the possible heart protective effects of drinking red wine led to a 44 percent increase in red wine sales among Americans. Assiduous lobbying by wine makers prompted the Department of Agriculture (USDA) for the first time to make positive mention of alcohol con­sumption in its Dietary Guidelines for Americans.

Now wineries want to label their prod­ucts as health food. In 1999 several winer­ies convinced the Federal Bureau of Alcohol, Tobacco and Firearms (BATF) to permit an ambiguous label on wine bottles suggesting that people write the USDA to learn more about the "health effects" of drinking alcohol.

Further pressure from the Wine Institute and complaints from Sen. Strom Thurmond, author of the warning label currently on alcohol bottles, prompted BATF to open the entire issue of putting health claims on alcohol bottles for pub­lic comment. The BATF is expected to hold hearings on the topic around the nation this spring.

To date, no U.S. government agency has recommended that Americans drink alcohol to protect themselves against heart disease. Exercising, avoiding fatty foods and eating more vegetables are much safer routes to prevention.

Scientific opinion is still sharply divid­ed on whether people should drink alco­hol fhr their health. Most French health experts certainly don't think so, contrary to U.S. media reports. On the other hand, as the French health minister recently pointed out, science has firmly estab­lished the link between alcohol use and a wide variety of health and safety problems.

The push to put a health benefits label on alcohol bottles is a marketing ploy, pure and simple. I'm all for dou­bling our pleasure, but let's riot double our deaths from alcohol at the same time. Take it from the French. There are far safer ways to protect ourselves from heart disease than drinking more alcohol.

Citation: Abramson, Hilary, "The Flip Side of French Drinking," The Marin Institute. (Winter 2000) c2000