Our love-to-hate-them rivalry with France may go back to the Middle Ages, but in modern times one of Britain’s main bugbears with our Gallic neighbours has been around health and lifestyle. Why, we’ve wondered, can they seemingly live on cheese, meat and red wine with little ill effect, while eating similar fatty foods and chugging alcohol has been blamed for poor heart health in Britain?
Now, what came to be known as the “French paradox” — a term coined by French epidemiologists in the Eighties — has fallen apart. A report by the French Public Health Agency last week revealed that only 11 per cent of French people now enjoy what they term “ideal” cardiovascular health, whereas the latest analysis of British heart health, conducted by looking at blood test results, suggests that 14 per cent of us have “excellent” cardiovascular function.
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In fact, a recent study published in the Archives of Cardiovascular Diseases estimated that 5.6 per cent of the adult population in France is living with coronary heart disease or CHD (also known as ischemic heart disease), while in the UK about 3 per cent of the population are believed to have the diagnosis. This particular type of heart disease is the most common and occurs when the arteries of the heart become narrowed by fatty plaques lining the blood vessel walls so that it is harder to supply the heart with enough oxygen and nutrient-rich blood. This can lead to heart pain such as angina and, eventually, a heart attack.
So what on earth has gone so wrong in France?
Although we are still fatter than the French — 64 per cent of the UK population is overweight or obese, compared with 45 per cent of those in France — and somewhat less active, they match us on a number of other serious risk factors for heart health, and in one particularly significant area they outstrip us significantly: smoking.
While the number of smokers in the UK has been on the decline for decades, in France the number of women who smoke has inexplicably risen, in spite of indoor smoking bans being active in both countries since 2007/08. According to the French Public Health Agency, 27.4 per cent of French men regularly light up, as do 21.7 per cent of women. By contrast just 11.9 per cent of Brits over the age of 18 are now smokers.
“I’ve been practising medicine for coming up to 25 years and we always ask patients whether they smoke,” says Dr Aaisha Opel, a consultant cardiologist and electrophysiologist at OneWelbeck Heart Health in London. “When I was just out of medical school and a junior doctor, the answer more often than not was yes. Now, people almost always say, ‘No, I don’t smoke’ — sometimes they are an ex-smoker, but in the main they’ll say they’re just not smokers, and that’s not just in the private sector.”
According to the Centers for Disease Control and Prevention, smoking is a major cause of cardiovascular disease and behind one in four deaths from it.
“Everything in cigarette smoke — the nicotine, tar, other chemicals in the tobacco — affects the cellular lining of all your blood vessels, including that of the arteries in your heart,” Opel explains. “The cell surface is disrupted and no longer smooth, which means that fat is more likely to deposit there.” In addition, smoking has been shown to lower levels of “good” cholesterol, raise certain types of fat called triglycerides circulating in the blood, make blood “stickier” and more likely to develop a clot, and stiffen the blood vessels themselves.
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What’s even worse for French outcomes is that smoking in women appears to increase the risk of heart disease by 25 per cent more than it does in men, according to the Public Agency report. “Over the past 15 years, this has led to an increase in coronary heart disease among women below the age of 65,” the report states. It’s not known quite what makes women more vulnerable to the effects of cigarettes, but before the menopause women benefit from the protective effect of oestrogen on their heart health, and nicotine in cigarettes has been seen in studies to interfere with oestrogen production and circulation.
The French also continue to drink a lot, with 30 per cent of French men out-drinking recommended limits — although British men are just as bad, with the same proportion exceeding weekly limits in 2022. But we now know that what’s being drunk makes little difference: it doesn’t matter if it’s a quality bottle of Bordeaux or a beer that’s being swilled. The “protective effects” of red wine drinking, once thought to be among the reasons the French paradox existed, turn out to have been overstated. According to Harvard scientists, you’d have to drink as many as a thousand glasses of red wine to take in the amount of heart-healthy polyphenols that have been seen to be beneficial in experiments with mice.
The “protective effects” of red wine drinking have been overstated
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The report also says that the French eat too much salt — a known risk factor for high blood pressure, which in turn raises the risk of heart disease. According to World Health Organisation statistics they consume 8.1g a day, close behind us at 8.4g — both well above the recommended 6g limit.
However, France still seems to be doing one thing right: somehow, fewer French people are dying from heart and circulatory diseases, despite their increasing prevalence. In 2022 there were 140,000 deaths attributed to this cause, compared with 170,000 in the UK — although we have very similar population levels (68.3 million versus 68.4 million, respectively).
One theory is disparities in healthcare. According to the latest data, Britain would have to increase public health spending by about £58 billion to match France’s health spend per capita, so it may be that French patients are having their heart disease caught earlier and managed sooner, meaning they live longer without it progressing to a more dangerous stage.
“If it is the case that people in the UK are presenting with heart disease at a later stage, it makes it more difficult to manage it as effectively, or to have all the treatment options open to us that might have been earlier on,” Opel says. “Seeking help sooner will allow you to live longer with the condition.”
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But she also notes that how deaths are reported makes a difference to the statistics, confusing the picture and meaning that France’s lower death rate may not be entirely what it seems. “Sometimes you might not die of a heart attack caused by heart disease, but later develop heart failure that can give a whole array of symptoms, and then your cause of death gets labelled as due to one of those secondary effects of heart disease instead.”
Indeed, a study published in the British Medical Journal in 1999 explained that French doctors had a tendency to certify some heart disease-related deaths as “poorly specified causes” rather than straightforwardly attributing them to CHD. The authors suggested this could have accounted for as much as 19 per cent of the difference in heart disease mortality between France and Britain at the time.
So, putting aside the fact that France has one of the highest rates of smoking in the western world, and many other heart health risk factors too — perhaps it’s disparities in record keeping that hold the answer to the French paradox, suggesting it was not so much a paradox as a fallacy all along.