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Healthy Living January Issue

The French Paradox

Although the French consume more alcohol than Americans, they have less heart disease deaths. Heart disease is the number two killer in France, while it remains number one in America. Some scientists believe that France’s lower heart disease rate is due to their more liberal alcohol intake. At first glance, the studies seem to point in that direction. However, additional studies have provided a different solution to this paradox. We will look at them in detail later in the chapter.

No one today is suggesting that heavy alcohol consumption is healthful. However, some are interpreting data (like that from France) as showing that "moderate" amounts of alcohol are healthy for the heart. Unfortunately, many of these advocates have totally ignored the harmful effects of even moderate alcohol use. In this chapter we will look at the evidence regarding various levels of alcohol consumption, from light to moderate to heavy. We will also see other studies examining the French Paradox which explain the underlying reasons for France’s lower level of heart disease. All of this information should be useful to anyone who is asked, "Want a drink?"

The Widespread Use of Alcohol

Few people advocate prohibiting alcohol anymore, even though it is a drug. Actually, it is one of the most widely used drugs in our nation; it is often addictive, and is a known killer. Government research reveals that alcohol causes more than 100,000 deaths per year in the U.S.2 Thus, among drugs, alcohol is second only to tobacco as a cause of premature deaths in our nation and is the third leading actual cause of death overall. For more information on actual (underlying) causes of death, see Chapter 1, "Principles for Optimal Health."

When researchers look at the death toll from alcohol, they do not advocate "moderate amounts" for purported heart health benefits. Even if research did show clearly that alcohol could help our hearts, how could health professionals advocate any amount of a potentially addictive drug that can cause great harm to other organs? Alcohol is dangerous even at levels currently called "moderate," but like any dangerous drug, it is even more hazardous in higher amounts. And, where is that line between "moderate" and "heavy," if indeed there is one? As we saw in the true case history of Jane,3 what begins as moderate drinking can quickly escalate to frank abuse in some people. It is estimated that up to 15 percent of those that use alcohol will at some point become either problem drinkers or actual alcoholics.4, 5 It is estimated that the number of alcohol abusers in the U.S. is more than 15 million.6

The use of alcohol often is multiplied into the use of other dangerous and damaging drugs. A parents’ organization called "National Parents’ Resource Institute for Drug Education" (PRIDE) conducts an annual survey of middle and high school students regarding substance abuse. Doug Hall, PRIDE executive director, says, "Use of every illicit drug . . . is at the highest level PRIDE has ever recorded" by students mostly 11 to 18 years old. In their 1996 study of about 130,000 students, 69 percent of marijuana users also drank alcohol, compared with only about 7 percent of non-marijuana users. Regarding cocaine users, 13 percent used alcohol compared to less than one percent of non-users. Use of drugs is preceded and accompanied by the use of alcohol. Campaigns to educate our youth on the dangers of alcohol would be expected to result in a corresponding reduction of hard drug usage as well.

Students who use drugs are getting more intoxicated than before. About 36 percent of 12th grade beer drinkers said they get "very high, bombed, or stoned," compared with 27 percent nine years ago.

Most people are somewhat aware of the social problems caused by alcohol. It is involved in marital problems, divorce, problems in parenting, violence in the home, poor job performance, missed days of work, unsupervised children, illicit sex, and the list goes on and on. Even many homicides and suicides are often directly related to the use of alcoholic drinks. For these reasons, alcoholic drinks are regarded by many social analysts as America’s number one public enemy. Some of the damage done by alcohol is conveyed in Figure 1: Public Enemy No. 1.7

Dollars Spent on Alcohol

How much money do Americans spend each year to buy alcoholic beverages? I have asked this many times in my public lectures. Some say, "Perhaps two million dollars, perhaps ten million dollars." The highest estimate I have ever received is 100 million dollars. These estimates are extremely low. The actual amount is stated in Figure 2: Dollars Spent on Alcohol.8, 9These statistics translate into an average expenditure of $330 per year for every man, woman, and child in America for the purchase of alcohol, and over $450 per year for alcohol-related damages, according to official records. Off the record, there are large quantities of alcoholic drinks made and purchased "underground." This production and consumption are not reflected in the statistics-the 86 billion-dollar figure is a conservative estimate.

The next time you go to a restaurant, think of these costs as an extra amount added to your bill. You order no alcoholic drinks, but when you see the bill you notice an alcohol surcharge of $8.80. The waiter explains that the four diners sitting at an adjacent table each ordered a one ounce drink of alcohol, and you must cover your share of "alcohol damage to society" which amounts to $2.20 per ounce consumed.10 He further states that 80 cents of the amount is for drunk driving, $1.00 is for the cost of violent crime committed under the influence of alcohol, and 40 cents is for medical and health care costs. If we were all forced to pay these costs in this manner, how long would we tolerate it? In all fairness, the cost should be borne by the user. The surcharge should be paid by drinker and placed in a fund to cover the damage to society. The greatest benefit of this plan would be the reduction in sales of alcohol due to the increased price.

Truly we have made a dramatic "about face" in our relatively brief history as a nation. From a society that once prohibited alcohol use, we are approaching 100 billion dollars per year in legal alcohol sales. The very mention of prohibition reminds me that, in modern history, alcohol statistics are almost always shrouded in a cloak of deception. For example, ask any high school student about the "Prohibition Era" in America. They likely will be able to tell you what a miserable failure that experiment was. They will describe quite clearly that it did not prevent people from drinking alcohol nor did it reduce the physical harms of alcohol use. To this day, many even in the medical community will cite the desperate failure of Prohibition as grounds for legalization of everything from marijuana to cocaine. There is only one problem with "the facts" about the failure of prohibition: they are not factual. Listen to one of the most authoritative voices in Public Health and Preventive Medicine, the definitive textbook on this subject edited by Drs. Last and Wallace: "The commonly held view of Prohibition in the United States is that it was a failure, but there are major limitations to this view, since during Prohibition, health and social problems associated with alcohol use certainly were reduced dramatically."11

The Broad Nature of Alcohol’s Destructiveness

Let us look now at the widespread damage that alcohol inflicts on a number of fronts. Before we do so, we must dispel several myths. First, there is a common belief that wine and beer are not nearly as damaging as "hard liquor" and mixed drinks. The truth is that most of the adverse consequences of alcohol consumption seem to be more related to the total amount consumed rather than where it came from. As surprising as it is to most people, a standard can of beer or glass of wine has just as much alcohol as a cocktail made with 1 1/2 ounces of 80 proof liquor.12 (For those not familiar with alcoholic beverages, most mixed drinks call for 1 1/2 to 2 oz. of liquor.13 The 1 1/2-ounce measure in bar terminology is called a "jigger."14). Its equivalence to wine and beer is shown in Figure 3: Equivalent Amounts of Alcohol.

The essential equivalence of alcohol exposure from beer, wine, and mixed drinks is important for research purposes as well. When I refer to studies that measured how many drinks a person had, those drinks can be made up of any combination of standard glasses of wine, cans of beer, or mixed drinks. Keep this in mind throughout the chapter. As far as the research is concerned, a person that averages two beers each evening is drinking "two drinks" per day just as much as the individual who averages a couple of mixed drinks-or a couple of glasses of wine-every day.

A second myth that must be dispelled often arises in the form of an objection. Individuals often say at this juncture, "I am not a heavy drinker-I only drink occasionally. I do not need to worry about these alcohol-related problems." There are two points that are relevant here. First is that many alcohol-related illnesses do not occur merely in heavy drinkers. They can also occur in social drinkers who on occasion have "one too many." Even individuals who consistently consume alcohol "in moderation" and are careful never to "drink too much" are still at risk for some of alcohol’s problems. Drs. Rankin and Ashley made some insightful observations in their excellent chapter, "Alcohol-related Health Problems."15 These are summarized in Figure 4: Perspectives on the Dangers of Moderate Alcohol Usage. A second relevant point dealing with moderate alcohol use comes from the World Health Organization. They have underscored the fact that anyone who drinks socially today is potentially tomorrow’s heavy drinker. If you have "a genetic tendency toward alcoholism," that is, an inherited tendency to become a heavy drinker, that potential will be greatly increased. However, even individuals without any apparent family history of alcohol problems can become alcoholics. The message is simple: the only sure way to avoid becoming a heavy drinker is to be a non-drinker. Do not start drinking in the first place. Since my arguments have dispelled the two common myths, we have established a framework for evaluating even the moderate use of beer and wine. With this in mind, let us now turn our attention to some of alcohol’s physical effects.

Side Effects of Alcohol Consumption

Besides affecting the intestinal and immune systems, there are other far-reaching side effects from alcohol consumption. Some of these effects are shown in Figure 8: Side Effects of Alcohol Use.42, 43, 44, 45, 46

It is astonishing to me that the news media is so enthusiastic about proclaiming the virtues of drinking alcohol "in moderation" when there is such a long list of severe problems caused by both moderate and heavy alcohol consumption. Some of the problems listed in Figure 8: Side Effects of Alcohol Use can occur with as little as one drink of alcohol per week. Let us take a little time to more fully appreciate these alcohol-related conditions.

Summary Of Physical Problems Associated With Alcohol

There are many more problems with alcohol than I have focused on here. However, what we have examined thus far should be sufficient to impress us with the broad range of adverse effects brought on by alcohol. The sad thing about these problems is that if Americans had recognized alcohol for what it was and avoided it, this extensive list would not even exist. As an Internal Medicine specialist, I deal every single working day with people whose illnesses are caused by alcohol and tobacco. People are hospitalized due to these abuses of their bodies more than any other lifestyle factors. If you could see through my eyes, you would be strongly influenced to emphatically say "no" the next time you are asked the question, "Want a drink?"

Alcohol Affects More than the Drinker

So far, we have focused on how alcohol affects the drinker. We looked at a long list of physical problems. Then we went on to make observations about alcohol’s mental effects. However, alcohol affects more than just the person consuming this addictive drink. To many, the social effects are among the most sobering realities. These conditions come as no surprise. However, I would be remiss not to at least devote some space to them in this chapter. A partial listing of the way alcohol affects others is found in Figure 14: Alcohol’s Effects on Others Besides the Drinker.

Are There Healthful Benefits of Alcohol?

I have spent the bulk of this chapter looking at the broad range of harmful effects of alcohol. However, I have yet to fully address one of today’s most pressing issues: might alcohol consumption help one’s heart? Notice, I did not phrase the question as some do: namely, "Could moderate alcohol use be healthy?" Many are quick to answer that question in the affirmative. However, after seeing the extensive list of toxic effects of alcohol, it should be easy enough for the unbiased reader to see that alcohol is not a health-giving substance.

Still, what about the heart effects of alcohol? Often the question is based in part, at least, on reports about the French. With that in mind, let us return to the subject of the French Paradox that the news media has so eagerly publicized. First, we need to reframe the issues. After all, at least one news media report posed this question: "Why don’t the French have heart disease?" That, of course, is a misstatement. The French have plenty of heart disease: it is their second leading cause of death. The correct question would be, "Why do the French have less heart disease than Americans?" This is the question that we must address. Some interesting studies have apparently unlocked the mystery.

Before we look at this data, however, I think it is important to make a telling observation. Many in America have been saying in effect, "Just think, if we only drank more alcohol like the French, how much better off our hearts would be." However, the French-who have been living with the results of their high alcohol consumption-have had a completely different response. When Drs. Rankin and Ashley compared the alcohol use trends for 24 nations in Europe and North America, they made a startling discovery that illuminated the French attitude. On average, from 1950 to 1985, western nations nearly doubled their per capita alcohol consumption. The median percentage increase was between 70 and 82 percent. In fact, every country but one increased their alcohol consumption. Do you have any idea what country was the sole nation to decrease alcohol consumption? If you guess France, you are right. In that 35-year period the average French citizen decreased his or her use of alcohol by 23 percent.114

The explanation provided by these alcohol researchers is illuminating: "The decline in alcohol consumption in France was almost certainly in part due to national measures to reduce consumption because of concern about the health-related outcomes associated with the highest national per capita consumption."115 Thus, while France has been working for years to decrease their alcohol consumption because of the health-related toll it has been taking in their country, the American alcohol industry and the media are idolizing the use of alcohol by the French. It is ironic that those living first hand with alcohol’s effects see it as a curse, while those looking on from a distance idolize its benefits. What about "the French paradox"? Let us examine the French lifestyle to see why heart disease may be lower there than in America. Along with comparing American and French alcohol consumption, we must also assess other dietary factors. We have done this in Figure 20: Lifestyle Comparison of French and Americans.116

Higher butter and lard consumption coupled with higher blood pressure and cholesterol levels would lead one to expect more heart disease in France. However, as we have already observed, just the opposite is the case. The next point in the figure is generally used to explain why their heart disease is less: they have a much higher intake of red wine. Many have concluded that red wine reduces their risk of heart attacks.

However, we must look further. Cigarette smoking and obesity do not appear to be factors; French rates in these areas are comparable to those in America. The French also have another dietary distinction: they drink very little milk. The news media has failed to publicize this fact. Dairy fat is strongly related to heart disease. In fact, if you look at the consumption of dairy products in one country compared to another, including France, the heart disease rate is proportional to the amount of dairy products consumed.117, 118, 119, 120 Thus, the lower consumption of dairy fat would help to explain the lower levels of heart disease in France. Another factor that would be expected to decrease French heart disease risk is their high consumption of vegetables and fruits. The heart-protective benefits of these foods are presented in Chapter 3 and Chapter 4. This important fact has also not been widely publicized.

Another important but unpublicized fact: there are certain groups in America that have a much lower rate of deaths due to heart disease than the French. American Seventh-day Adventist vegetarians have far less risk of heart disease than does the average Frenchman.121 But they drink no wine or alcohol.

Are there any factors in addition to lower milk consumption and higher fruit and vegetable consumption that would explain the apparent French advantage? What about wine-might there be something to the wine connection after all? Having looked carefully at the issues, we will see that wine does have some heart-protective benefits. But before we jump to any conclusions, I must point out the obvious: wine contains much more than alcohol. Dr. Demrow and colleagues at the University of Wisconsin looked directly at the constituents of red wine, white wine, and juice made from red grapes.122 This study provides some amazing insights into the French paradox.

Before they embarked on the aforementioned study, the University of Wisconsin group already knew several things. First, if the blood’s clotting cells, the platelets, become sticky, the risk of heart attack and similar problems increase. Second, wine and alcohol consumption had been demonstrated to make platelets less sticky. Third, the tendency of platelets to make heart problems worse could be measured in a special dog model that had been developed in their laboratory. There was still a burning question, however: how much of the effect of wine was due to alcohol and how much was due to other properties in the grapes?

To find the answer, the researchers obtained 47 mongrel dogs. In preparation for the test, after anesthesia, each dog had a single coronary artery experimentally narrowed and damaged in a way that reproduced the blockages occurring in humans with coronary artery disease. These artery changes included damage to the inner lining of the blood vessel known as the intima. Intimal damage, in turn, stimulated platelets to clump periodically and form sticky little clots referred to as thrombi. Collectively, these processes caused periodic interruptions of flow in the affected coronary arteries, known as "cyclic flow reductions" or CFRs. This experimentally induced condition thus mimicked the exact mechanism for human heart attacks.

After these changes were induced in the dogs, they were then divided into three major groups. Group 1 received red wine, Group 2 received red grape juice, and Group 3 received white wine. What the researchers were looking for was a reduction in the tendency of the platelets to clump and a resulting decrease in the cyclic flow reductions (CFRs). They carefully measured these CFRs to see if adding the wines or grape juice would decrease platelet stickiness. Their results are summarized in Figure 21: A Study that Helps Explain the French Paradox.123

The test results indicated that there were one or more substances in both red grape juice and red wine that should significantly reduce the risk of a heart attack. That substance cannot be alcohol, because there was none in the grape juice. Moreover, white wine contains alcohol but had no significant effect. In another study, the same lab found that alcohol alone, in very large amounts, could decrease CFRs.124 Extremely high levels were needed-the equivalent of about 12 drinks for a 180 pound man125-producing blood alcohol levels well over double the legal limit for drivers. In contrast to the study with pure alcohol, the red and white wine in the Demrow study was given in amounts typically attained in social drinking-approximating one drink in a 180 pound man126-only eight percent of the amount needed to decrease CFRs. This amount produces blood alcohol levels within legal limits at about 0.02 or 0.03 gm/dl.

If it was not the alcohol, what are the substances that made the difference in the effects of the red wine and the grape juice? The most likely candidates were a group of substances called flavonoids that are known to prevent platelet clumping. They are found abundantly in grapes, red grape juice, and red wine. In fact, compared to the white wine, the red grape products-the wine and grape juice-had four to five times as much of two key flavonoids (quercetin and rutin) by actual measurement. It is likely that the presence of these substances caused the reduction of blood clot formation. In earlier research, the University of Wisconsin group had demonstrated that both quercetin and rutin could decrease platelet stickiness and eliminate the CFRs in the same dog model.127

Grape Juice - A Multifaceted Food

Flavonoids, especially quercetin, as found in grapes and grape juice, have other beneficial effects in reducing the risk of heart disease besides their platelet actions. Some of the benefits of flavonoids are listed in Figure 22: Grape Flavonoids Fight Heart Disease.128, 129 Note that grapes contain potent antioxidants. Quercetin, for example, is even more potent than Vitamin E. As described in Chapter 3 on heart disease, oxidized LDL cholesterol is a major culprit in atherosclerosis and heart disease.130 Quercetin blocks LDL oxidation, and thus the process of arterial narrowing. Additionally, antioxidant effects are helpful in cancer prevention. These heart-healthy compounds may thus decrease cancer risk as well. Both animal studies131 and studies of human cancers132, 133 have demonstrated such anticancer effects. Still other flavonoid benefits include antiviral activity.134

Grapes are not alone in possessing such health benefits. Figure 23: Foods Containing Flavonoids shows other foods that contain significant quantities of flavonoids.135, 136, 137

Some grapes also appear to contain another heart-protective substance, called resveratrol. This naturally occurring fungicide also has promise but did not seem to be one of the main heart-protective chemicals in Demrow’s wine research. Resveratrol was found in significant amounts only in the beverage that had no significant beneficial affect-the white wine. No detectable amounts were found in the red wine or the grape juice in this study. Nonetheless, resveratrol may have more benefits than we have given it credit for. White grapes and white grape juice may thus also have some cardioprotective benefits. And do not count out red wine and grape juice regarding resveratrol: other studies suggest that they also contain this potentially healthful compound. Consider resveratrol’s beneficial effects listed in Figure 24: Grape Resveratrol Fight Heart Disease.138, 139 Resveratrol has recently been found to prevent cancer in mice.140

How does this information fit with the French Paradox? The dog study evaluated the differences in the effect of platelets on clotting, and not the differences in cholesterol levels. The differences in cholesterol levels would have no effect in such a blood clotting study. There is no contradiction here.

I would be negligent to close the topic of grapes and grape juice without at least listing some of the other beneficial qualities of this unique and delicious food group. To illustrate the abundance of necessary nutrients in grapes and grape juice, assume that you were to live on grapes alone (which I do not and would not advocate), and would eat enough to maintain your body weight. The variety and quantity of the many nutrients in such a diet and the lack of some negative factors in the typical American diet are shown in Figure 25: Nutritive Qualities of Grapes.141

We see that grapes have significant quantities of 15 nutrients while containing only five percent fat, a very low amount of sodium, and no cholesterol. Notice the high quantity of vitamins B, C, and E, as well as iron and copper. They are also very high in potassium, which along with a low-sodium diet helps to lower blood pressure, and very high in selenium, a trace element that appears to have a cancer-protective role.

Back to the Paradox

All of these lines of evidence bring us back to the major topic under discussion, namely, the French Paradox. The best evidence suggests that the lower heart disease rate in France has to do with much more than alcohol. Contrary to what many lay news reports have implied, the alcohol in the wine is not the ingredient that provides the benefit. As we have seen, much of the benefits attributed to drinking wine should be attributed to the main ingredient of wine-grapes.

Alcoholic beverages do appear to have the tendency to raise heart-protective HDL cholesterol levels in people who are on a poor lifestyle. A recent Tufts University Diet and Nutrition Letter put this in perspective, however: "While alcohol boosts HDL-cholesterol levels, exercising and losing excess weight raise them even more."142 The truth is that no one has ever proven that a person on an excellent lifestyle gets any benefits whatsoever by drinking in moderation. Considering HDL in particular, as we have seen, alcoholic beverages are not the only dietary factors that hold promise for increasing HDL cholesterol. Wholesome grapes and grape juice may also raise this lipoprotein through such compounds as resveratrol. Furthermore, no one is suggesting that everything that raises HDL is desirable. For example, organic pesticides can boost HDL. Yet, no one is recommending pesticide consumption for heart health: we recognize its harms outweigh any benefits.

Why add or continue to use a toxic chemical such as alcohol, when there is no evidence that it is as beneficial as a healthful lifestyle in reducing heart disease? Even the Tufts University special report (that on the surface may have looked pro "alcohol for your heart") reminded readers of some of the bigger concerns that we have already addressed. They cited recent Harvard data that showed as little as three drinks per week raised the breast cancer risk for women significantly. And they made this telling summary: "Researchers agree almost universally that no one should take up drinking for the express purpose of staving off heart disease ¡¦there are much safer and generally more healthful ways to protect the cardiovascular system."143

The "Modified French Diet" for Good Health

If you want to get the benefits that the French are reaping, the best plan is to use an abundance of fruits and vegetables which may include grape juice itself. This plant-rich diet defuses another argument of the wine proponents. While some have touted the flavonoid content of red wine as being superior to that of grape juice, the relative amounts of flavonoids in grape juice and wine probably vary considerably depending on the type of grape, where it was grown, and the type and year of the wine. For example, in the Demrow study, measurements of the actual samples used in the experiment suggested that the grape juice had somewhat more rutin, while the red wine had more quercetin.146 Even if wine consistently had more of all the flavonoids than grape juice (which the evidence does not indicate), eating vegetables and other plant sources of flavonoids-in addition to grapes-would be expected to provide a higher quantity of these compounds than moderate wine drinking alone. Thus, the plant-rich diet also furnishes a further reason for a lower heart attack rate among the French: they consume higher quantities of flavonoids than Americans due to their higher intake of fruits and vegetables.

Let us follow the example of the French in a modified way as outlined in Figure 27: "Modified French Diet" for Good Health. With the "Modified French Diet," Americans’ risk of heart disease will become lower than that of the French. What a tragic mistake it would be for a person to drink alcohol in an attempt to reduce heart disease risk, only to suffer some of the irreversible consequences of alcohol use. If you really are interested in your health, why not do things the truly healthful way? A fitting summary of the healthfulness of grape juice contrasted with the tragic effects of alcoholic drinks appeared in print nearly one hundred years ago. I have reproduced the statement in Figure 28: Grape Juice vs. Wine.147

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