The French Paradox: Exploring Common Alcohol Consumption

The French Paradox is a concept put forth by French epidemiologists that despite high intake of dietary cholesterol and saturated fat, the French have low coronary heart disease (CHD) deaths rates.^1-3 This concept may have multiple variables that could contribute. I want to focus on just one of these: the consumption of red wine. 

In a seminal paper, Renaud, PhD, and his colleague examined annual CHD mortality in WHO MONICA populations which included French centers.¹ The mean serum total cholesterol was similar in France compared to the United States and United Kingdom, despite the French ingesting a diet high in saturated fat (39%).⁴ However, the authors concluded the lower CHD mortality was due to high consumption of red wine.  The message remains today that having 2 or 3 drinks per day of red wine has a protective effect, perhaps a decrease of 24% to 31% in all-cause mortality.³  True or false?

Authors of a recent study in JAMA Network Open assessed the association of habitual alcohol intake (not just red wine) with cardiovascular disease risk.⁵ The study included 371,463 participants from the UK Biobank, of mean age 57±7.9 years, 46% of whom were men, who consumed a mean of 9.2±10.6 standard drinks per week. The study was replicated in 30,716 people from the Mass General Brigham Biobank. 

Light (>0-8.4 drinks/week) to moderate (>8.4-15.4 drinks/week) alcohol consumption was associated with healthier lifestyles. Using linear Mendelian randomization analysis, authors found a 1-standard deviation increase in alcohol intake was associated with a “1.3-fold (95% CI: 1.2-1.4) higher risk of hypertension (P<.001) and 1.4-fold (95% CI: 1.1-1.8) higher risk of coronary artery disease (P=.006).” Light drinking was not significantly associated with either outcome.

On the other hand, heavy consumption (>24.5 drinks/week) was associated with significant increases in hypertension (OR 2.6; 95% CI: 1.6-4.2; P<.001) and coronary artery disease (OR 5.7; 95% CI: 2.4-13.5; P<.001). The study implies light alcohol consumption may not be protective. Clearly, heavy alcohol consumption carries high risk for cardiovascular disease. 

This brings us back to the French. If the French rate of CHD mortality is correct, then might light to even moderate consumption of red wine be protective? Perhaps it is! Or perhaps it is the maintenance of other factors, including regular exercise and genetics, along with red wine consumption. 

References:

1. Renaud S, de Lorgeril M. Wine, alcohol, platelets, and the French paradox for coronary heart disease. Lancet. 1992;339(8808):1523-1526. doi:10.1016/0140-6736(92)91277-f
2. Artaud-Wild SM, Connor SL, Sexton G, Connor WE. Differences in coronary mortality can be explained by differences in cholesterol and saturated fat intakes in 40 countries but not in France and Finland. A paradox. Circulation. 1993;88(6):2771-2779. doi:10.1161/01.cir.88.6.2771
3. Richard JL, Cambien F, Ducimehére P. Epidemiological characteristics of coronary disease in France. Nouv Presse Med. 198110:1111-4.
4. Evans A, Ruidavets JB, McCrum E, et al. Autres pays, outres cours? Dietary patterns, risk factors, and ischemic heart disease in Belfast and Toulouse. QJM. 1995;88(7):469-477.
5. Biddinger KJ, Emdin CA, Haas ME, et al. Association of habitual alcohol intake with risk of cardiovascular disease. JAMA Netw Open. 2022;5(3):e223849. doi:10.1001/jamanetworkopen.2022.3849