Why heart disease mortality is low in France: the time lag explanation Commentary: Alcohol and other dietary factors may be important Commentary: Intrauterine nutrition may be important Commentary: Heterogeneity of populations should be taken into account Authors' response

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# Why heart disease mortality is low in France: the time lag explanation {#article-title-2} In France mortality from ischaemic heart disease is about a quarter of that in Britain.1–7 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,2–5 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