The press has recently become obsessed with an epidemiological conundrum that has puzzled doctors for years: why are the French generally so thin and healthy, given how terrible their diet and drinking habits appear from a cursory glance?

There is, for example, a very striking difference between the French and Americans – the French are significantly leaner. In contrast to the 22.3 per cent of Americans who are rated as obese, only 7.4 per cent of French qualify.

Yet France and the United States share striking similarities – they are both affluent Western countries, both have a major fashion industry and both are concerned with appearances. A look at the diet and health of the two countries, however, leads to what has been widely termed the French paradox by epidemiologists. The mortality rate from heart disease and obesity is substantially lower among the French, yet they have, if anything, a higher blood cholesterol level. The French also eat what most people would consider a highly palatable diet, containing both more total fat and saturated fat than the American diet does. They consume less fat-reduced foods and they drink much more alcohol.

Another intriguing difference emerges from a study which found that the average French person spent 98.3 minutes a day eating and snacking, compared with 59.6 minutes for Americans. The French actually spend more time eating and yet remain they thinner.

Attitudes toward food are more positive in France and less affected by worries about the health consequences of consuming particular foods. During the eating experience, the French pay more attention to the sensory than the nutritional properties of food. So perhaps one clue to the French paradox is that they snack less inbetween meals, because meals in themselves are more of an event.

So the French paradox could be related to the cultural importance of food in daily life. Food, after all, is a critical contributor to physical well-being and a major source of pleasure, concern and stress. Eating and drinking take up much of people’s waking time around the world, and if food is seen as the “enemy”, this will be a major contributor to maladaptive eating patterns and general unhappiness.

The American attitude to food stands in stark contrast to this much more relaxed, pleasure-oriented attitude to food. This attitudinal difference is accompanied by relatively high consumption of high-fat foods by the French: for example, only four per cent of a sample of French adults consumed a diet that met US dietary recommendations for the percentage of calories that should be obtained from saturated fats (<10 per cent). Many Americans believe fats to be harmful to their health at even trace levels. From the American standpoint, “excess” fat intake in France should manifest itself adversely in France; to the contrary, cardiovascular disease is much lower in France than in the USA.

An international study that surveyed populations about beliefs concerning the diet–health link and concerns about, found that the group associating food most with health and least with pleasure was the Americans, and the group most pleasure-oriented and least health-oriented was the French.

 Ironically the Americans, who make the greatest efforts to alter their diet for the sake of health, are the least likely to classify themselves as healthy eaters. Actually, the way the French drink (essentially wine, every day, during meals and rarely alone) is very different from the way it is consumed in many Western countries (binge drinking on Saturday nights). Perhaps binge drinking could be characterised as a way of trying to forget a difficult life, whereas wine drinking is often associated with pleasure and conviviality – two aspects of a happy lifestyle. This illustrates the complexity of assessing lifestyle factors. Their impact on health is probably not captured by the simplistic measures doctors tend to use of just gauging how much alcohol you drink, rather than looking at how you drink it.

Maybe biologically-trained doctors and a biologically-oriented health service tend to profoundly neglect social and psychological factors in illness. Is it the psychological aspect of the way the French live their lives which explains their relative health compared to the Americans? This possibility is illustrated by the famous “Roseto effect”.

 Roseto, a small Italian-American community in Pennsylvania, was studied in the 1950s and 1960s by Stewart Wolf. Wolf, a cardiologist, observed that heart attack rates in the community were about 50 per cent lower than in four surrounding communities, in spite of the residents having a similar prevalence of fat intake, smoking and exercise.

The striking feature of the town was its close-knit social relations, family and religious traditions, and intra-ethnic marriages. Epidemiologists used the phrase “it does hurt to be alone” to explain the Roseto effect, yet it remains much less well-known at medical schools compared to more familiar, though less powerful, causes of disease.

Health may have more to do with sociology and psychology, and much less with basic biology, than you might imagine from what doctors are taught. 

For example, local sources of fresh and natural foods, such as those produced in the kitchen garden of many French families, are not often taken into account by researchers. Gardening is actually very popular in France and about 30 per cent of French adults claim to garden regularly. In contrast to most Western populations, for whom gardening means beautiful flowers and lawns, the primary motivation of the French gardener is to grow fruits and vegetables for familial consumption. In addition to the resulting light or moderate physical activity, shown to be associated with a lower risk of all-cause mortality in men with established coronary heart disease, kitchen gardening provides a number of fresh, non-processed foods rich in micronutrients that are partly lost during storage and transportation to the supermarket.
 
Another interesting theory relates to the packaging of foods in supermarkets and the tendency for American stores to offer significantly larger packet sizes compared to what most Europeans are used to. It has been shown, for both food and non-food products, that people take more out of larger containers than out of smaller containers. Thus, when pouring oil to fry chicken, they pour more out of larger containers.

American supermarkets are well known for the money-saving mega-sizes they promote.  An unintended (or perhaps intended) consequence of this is that people consume more of the products. Mega-sizes are less common in French supermarkets, as demonstrated by one survey which yielded a mean US/French ratio of 1.37 for the largest sizes of seven particular American foods or beverages compared to French, and a mean ratio of 1.46 for seven non-foods.

Basically, no-one knows how to explain the French paradox, but the answer is not the simplistic magic single step the press seems to advocate when they assert we should copy the French diet. Instead, it could be that our health is more intricately tied up with the way we lead our lives in a more holistic sense than modern medicine has so far been able to gauge. Maybe to benefit from the French paradox, we have to make some rather more radical changes to our lives and actually become much more “French”.