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The French paradox: lessons for other countries
  1. Jean Ferrières
  1. Correspondence to:
    Professor Jean Ferrières
    Department of Epidemiology, INSERM U558, University School of Medicine, 37, allées Jules Guesde, 31073 Toulouse cedex, France;

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“Life is the art of drawing sufficient conclusions from insufficient premises”—Samuel Butler

The French paradox is the observation of low coronary heart disease (CHD) death rates despite high intake of dietary cholesterol and saturated fat.1,2 The French paradox concept was formulated by French epidemiologists3 in the 1980s. France is actually a country with low CHD incidence and mortality (table 1). The mean energy supplied by fat was 38% in Belfast and 36% in Toulouse in 1985–86.4 More recently, in 1995–97, the percentage of energy from fat was 39% in Toulouse according to a representative population survey.

View this table:
Table 1

Age standardised coronary heart disease (CHD) mortality and event rate in selected European regions (men, aged 35–64 years)


The first source of error could come from an underestimated CHD mortality. According to this hypothesis, French physicians may not declare all the CHD deaths as CHD. If standardised data—for example those provided by the MONICA (monitoring of trends and determinants in cardiovascular disease) project—are used, the results concerning CHD attack and mortality rates show that France is at a low risk for CHD (table 1). Under certification of CHD deaths in France is a possible bias, but after correction, it remains a low bias. Thus, validated data on CHD mortality and incidence show that France is characterised by CHD risk, corroborating the first part of the French paradox definition.


In correlation studies, measures that represent characteristics of an entire population (consumption of animal fat, daily milk, and alcohol) are used to describe disease (CHD mortality). Limitations of correlational studies are the inability to link exposure with disease in particular individuals, the lack of ability to control the effects of potential confounding factors, and the use of average exposure levels rather than actual individual values. Numerous correlation studies have been carried out …

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    BMJ Publishing Group Ltd and British Cardiovascular Society