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Why heart disease mortality is low in France: the time lag explanationCommentary: Alcohol and other dietary factors may be importantCommentary: Intrauterine nutrition may be importantCommentary: Heterogeneity of populations should be taken into accountAuthors' response

BMJ 1999; 318 doi: (Published 29 May 1999) Cite this as: BMJ 1999;318:1471

Why heart disease mortality is low in France: the time lag explanation

  1. Malcolm Law, reader (,
  2. Nicholas Wald, professor
  1. Wolfson Institute of Preventive Medicine, St Bartholomew's and The Royal London School of Medicine and Dentistry, London EC1M 6BQ
  2. aChanning Laboratory, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston MA, 02115, USA
  3. bDepartments of Epidemiology and Nutrition, Harvard School of Public Health, Boston MA, 02115, USA
  4. MRC Environmental Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton SO16 6YD
  5. Department of Public Health, Erasmus University Rotterdam, PO Box 1738, 3000 DR Rotterdam, Netherlands
  1. Correspondence to: Dr Law

    In France mortality from ischaemic heart disease is about a quarter of that in Britain.17 The major risk factors are no more favourable in France, and this so called “French paradox” has not been satisfactorily explained. Table 1 shows the difference in mortality from heart disease between the countries, and table 2 shows the similar levels of animal fat consumption, serum total cholesterol and high density lipoprotein cholesterol concentrations, blood pressure, and (in men) smoking. The French paradox is usually attributed to the higher consumption of alcohol in France, notably of wine,25 and some have suggested a specific effect of red wine. In this article we assess quantitatively the extent to which this and other possible explanations can account for the low rate of heart disease in France. We then consider a novel “time lag” hypothesis, which, we believe, is the main explanation for the paradox.

    Summary points

    Mortality from ischaemic heart disease in France is about a quarter of that in Britain, but the major risk factors are similar

    Undercertification of ischaemic heart disease in France could account for about 20% of the difference

    The high consumption of alcohol in France, and of red wine inparticular, explains little of the difference

    We propose that the difference is due to the time lag between increases in consumption of animal fat and serum cholesterol concentrations and the resulting increase in mortality from heart disease—similar to the recognised time lag between smoking and lung cancer. Consumption of animal fat and serum cholesterol concentrations increased only recently in France but did so decades ago in Britain

    Evidence supports this explanation: mortality from heart disease across countries, including France, correlates strongly with levels of animal fat consumption and serum cholesterol in the past (30 years ago) but only weakly to …

    Correspondence to: Dr Stampfer

    Correspondence to: Professor Mackenbach

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