Maintenance Phase

The French Paradox

September 27, 2022
Maintenance Phase
The French Paradox
Show Notes Transcript

How an early-'90s newsmagazine show convinced a generation of Americans to start drinking red wine. For the antioxidants!

Special thanks to Susanne Stolpe and Alexander H. Sandtorv for helping us fact-check this episode!

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Thanks to Doctor Dreamchip for our lovely theme song!

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Aubrey: Hi, everybody, and welcome to Maintenance Phase, the podcast that's going for its second semester abroad, and it's going to come back twice as in insufferable. How about that one?

Mike: That’s good. Dude, I did study abroad when I was 19 and I realized years later that I was that person. [crosstalk] I was like absolutely the fucking worst.

Aubrey: Where did you study abroad?

Mike: I was in Sydney.

Aubrey: Why would you eat Oreos when there are Tim Tams?


Mike: That one's accurate though.


Mike: I'm Michael Hobbes.

Aubrey: I'm Aubrey Gordon. If you would like to support the show, you can do that at Or you can buy t-shirts, mugs, tote bags, whatever you like at TeePublic. Both of those are linked for you in the show notes. And today, Michael?

Mike: Aubrey?

Aubrey: What are we discussing?

Mike: We are talking about the French paradox. This came up when I was doing the research for our “French Women Don't Get Fat" episode. And we were going to talk about it when we were recording for that. But then I realized that adding it in would be me adding a bunch of filler to an episode about a book that's full of filler. [Aubrey laughs] I was like, "Ah, maybe I'll just do a different episode." And so I spent the last couple of weeks researching this.

Aubrey: Can you summarize really quickly like what is the French paradox? Because you said this to me--

Mike: Wait. No, no, no, no. This is your job. You’re the listener. 

Aubrey: My job?

Mike: You have to tell me? 

Aubrey: Argh.

Mike: Have you done this show before? You [crosstalk] tell me what you know.


Aubrey: Okay, so what I know about when you said this to me, I was like, "Oh, I can feel something getting dusted off in the back corners of the attic of my brain." I remember hearing a lot about this maybe 20 years ago.

Mike: Yes, true. 

Aubrey: And my recollection is that the French paradox is the thing that everyone's mom and aunt bemoaned for years, which is just like, how do French people get to eat so much butter and cream and still be thin, right?

Mike: Yes, exactly.

Aubrey: Is that the sort of kernel of it?

Mike: Well, what's interesting is the French paradox appeared at a time before the obesity epidemic.

Aubrey: Oh.

Mike: And the whole kind of attendant moral panic. So it was actually about health, which is rare-

Aubrey: Wow.

Mike: -when it comes to this field.

Aubrey: Were they talking about like heart health stuff?

Mike: Yeah. The first appearance of this was in Ancel Keys, Seven Countries Study in the 40s and 50s, which we've talked about before in our Snackwell's episode.

Aubrey: Battle chestnut.

Mike: Throughout the second half of the 20th century, the conventional wisdom was that saturated fat, like red meat, butter, cheese, etc, was what caused heart attacks. And then Ancel Keys starts going around and collecting unbelievably garbage data, but data. And he finds out that in France, they eat a lot of saturated fat and they drink a lot of wine. And yet they have no heart attacks, the lowest rate of heart attacks in Europe, basically.

Aubrey: Are we going to get into the back and forth of wine is good for you, wine is bad for you?

Mike: This is a whole episode, Aubrey, this is it.

Aubrey: What? Yeah.

Mike: Yeah, dude, this is huge.

Aubrey: Oh, I'm very excited. We're going talk about antioxidants.

Mike: Yes.

Aubrey: We're going to talk about red wine. We're going to talk about two glasses a day versus no glasses ever.

Mike: Yes, I am livid that I had to learn what an antioxidant is. [Aubrey laughs] This is like when I had to learn who Pete Davidson was.

Aubrey: When I made you listen to me yell about Karl Lagerfeld for three hours.


Aubrey: You're welcome.

Mike: This is one that had been bouncing around academia for a couple decades. It got a name in the 1980s, but it was still relatively obscure. But the creation of this narrative is almost entirely due to a single episode of 60 Minutes in 1991, which was at the time the most watched news show in America.

Aubrey: Whoa, 60 Minutes was?

Mike: There's a lot of boomers. Boomers have TVs.

Aubrey: Yeah.

Mike: And we are going to watch segments of this segment.

Aubrey: Let's go, man.

[video plays]

Morley: All you have to do is look at the numbers. If you're a middle-aged American man, your chances of dying of a heart attack are three times greater than a Frenchman of the same age. It's obvious that the French are doing something right. Something Americans are not doing. The answer to the paradox might be found here in Lyon. The city prides itself as the gastronomic capital of France. Food and its preparation are almost an obsession. Chefs have the stature of quarterbacks, but their preparations would send the American Heart Association into cardiac arrest. Butter, goose fat, lard. double cream are the staples of a decent day's cooking.

Aubrey: Chefs like quarterbacks.

Mike: I know. [laughs]

Aubrey: And now I've heard everything.

Mike: I just wanted to watch this clip with you to revel in the fact that they're presenting restaurants using butter and cream as like a uniquely French thing. [Aubrey laughs] Can you believe it? 

Aubrey: Anyway, back to my Bloomin' Onion.


Mike: When will Americans start eating fat from restaurants?

Aubrey: Yeah, come on.

Mike: Come on, guys.


Aubrey: We know our way around some animal fats, come on. [Michael laughs] How dare you?

Mike: Okay, so I literally just want to watch that with you to make fun it.

Aubrey: It's a very fun.

Mike: But then--


Mike: Okay, this is the meat of the episode.

Aubrey: The Cassoulet of the episode.

Mike: Yeah.

Morley: And yet the rates are still lower there. And why are the rates in Italy lower than in Boston? 

Responder: Well, my explanation is, of course, the consumption of alcohol. 

Morley: There has been for years the belief by doctors in many countries, that alcohol in particular, red wine reduces the risk of heart disease. Now it's been all but confirmed. The wine apparently affects the platelets, the smallest of the blood cells. It is platelets that cause blood to clot. They prevent bleeding. 

But they also cling to rough fatty deposits on the artery walls, clogging and finally blocking the artery and causing a heart attack. The wine has a flushing effect, it removes platelets from the artery wall. So, the answer to the riddle, the explanation of the paradox may lie in this inviting glass. 

If the you make that study, or if a study is made, that proves more or less conclusively, that wine with meals is a magic bullet. A protection against heart disease. You think that the American medical establishment and the American government, the National Institutes of Health, for example are going to buy that? 

Responder: I'm not setting policy, I will restrict you. I'm not a policymaker. But I think we should have the information if it is part of it. Part of the explanation, I think we should know it. I will get the answers and I'll let you talk with the policymakers to see how they deal with it.

Aubrey: Boy, I still appreciate a researcher being like, "That's not my job. Don't make me do a thing. It's not my job."

Mike: Yeah, yeah, yeah.


Aubrey: I really like that.

Mike: It's also very funny to me that Morley Safer is asking him about, "Oh, the medical establishment. It won't admit this." When it's like, you're talking to someone who works at the Boston University School of Public Health.

Aubrey: You're talking to the medical establishment? [laughs] 

Mike: I wanted to talk about this because I think this is such a prevalent part of media nowadays. And especially when it comes to health stuff. There is a huge incentive on the part of journalists, not just to deliver you information, but to also make you feel better than other people for knowing it. We're a society that celebrates independent thinking, looking at the research and coming to your own conclusions, rebellion against establishment. Everything now has to be cast as like, "You're the only one who knows this and the powers that be don't want you to know it."

Aubrey: Right. Despite the fact that, again, as you've noted, this is the most popular news program in the country at this time.

Mike: Yes, exactly. This is not-- [laughs] 

Aubrey: You're talking about shit from like JAMA and the New England Journal of Medicine and putting it on 60 Minutes and being like, "Psst, what a secret."

Mike: Yeah, exactly. No one else knows.

Aubrey: No one else knows.


Aubrey: Michael, I'm really into this little show that no one else has heard of. It's called American Idol. Like, okay.  [Mike laughs] That’s just been on the air for 20 years, what do you want for me?

Mike: But what did you think overall?

Aubrey: This just feels like a really good encapsulation of all of the sort of goofiness around this stuff. This is, I will say, particularly for the boomers that I know, the greatest ongoing debate.

Mike: Yes.

Aubrey: It feels like, the conversation has basically been one big game of Pong.

Mike: Yeah, yeah.

Aubrey: Is it on this side? Or is it on this side? Is wine good for you? Or is it bad for you?

Mike: Right.

Aubrey: But that there's not necessarily a ton more depth to our understanding.

Mike: Well, lucky for you, this episode is going to provide no clarity whatsoever. [Aubrey laughs] It only gets weirder.

Aubrey: God dammit, Michael.

Mike: I have seen different numbers. But this segment was watched by somewhere between 25 million and 50 million people. Also, within weeks, wine sales increased as much as 40%.

Aubrey: What?

Mike: I've seen different numbers and I was like, "That sounds way too fucking high." And then I found this in like a bunch of different sources. And it's actually these are numbers from the wine industry. Obviously, we're not going to trace it back to a single episode of 60 Minutes but the amount of wine that Americans were drinking did increase significantly after this.

Aubrey: No bigger impact on the wine industry than this and the release of sideways.

Mike: Yeah, exactly. I know.


Mike: The two biggest things to ever happen to the wine industry in America.

Aubrey: Morley Safer and Paul Giamatti.


Mike: The Merlot industry was never the same. [Aubrey laughs] So, those things that like they tie a string around the neck of the wine bottle and there's a little tiny like brochure, like a piece of paper there, like extra advertising?

Aubrey: Oh, sure. They'll put like a little tag.

Mike: Yes. Those are called neck hangers.

Aubrey: That's unsettling.

Mike: It's not ideal. In 1982, the wine industry started doing neck hanger ads that said that red wine decreases the stickiness of your platelets. So, these health claims start showing up in the wine industry almost immediately. There's also my favorite, like cynical marketing event with this is that the French government took out a full-page ad in New York Times, that says-- Ah. Oh, wait, let me send it to you.

Aubrey: Okay. "According to a recent report on CBS's 60 Minutes and titled The French Paradox, the intake of fat in the French diet seems to be counteracted by their drinking of French red wine." Yes, French red wine. The intake of wine per capita in France is higher than anywhere else in the world. In comparison, the United States per capita intake is among the lowest."

Mike: [laughs] I love the fucking cynicism of this, that they've taken this, like science about red wine and about alcohol consumption. And they've made it French red wine. [Aubrey laughs] They're like, "Particularly French read wine." Like, there's something special about the grapes.

Aubrey: It's very scenery chewy, like, all right, all right.

Mike: But then, what is very interesting to me looking back on all of this media from the time is that like an interesting shift happened that I don't think anybody really noticed. So, for the first couple of decades of the French paradox, it was these people eat a lot of fat, and they have low heart attacks. And then after the 60 Minutes report, it's like, "Oh, these people drink a lot of red wine and they have low heart attacks." There wasn't any specific data showing that it was the red wine that was preventing the heart attacks. This was a hypothesis.

Aubrey: Yeah. I mean, basically, the only real finding here is French people seem to have fewer heart attacks than American people. Yes?

Mike: Yeah. And French people drink more red wine. Yep, but that doesn't necessarily mean that's the reason for it.

Aubrey: Those could be two separate observations.

Mike: Exactly, so basically, without anyone really noticing or doing it deliberately, the entire focus of the media and academia goes from explaining, high fat low heart attacks in France, to explaining this J-shaped mortality curve for drinking. This is something we've talked about on the show before, it's not really J-shaped, it's more of like a checkmark. But it's basically the idea that if alcohol was just like straightforwardly bad for you, you would have like people who don't drink would have the lowest mortality. And then people who drink a little would have a bit higher, people who drink a lot would have a bit higher, you'd have this straight line. But what we actually see in study after study, and this is like an extremely consistent effect, is that the people with the lowest mortality are people who drink one or two drinks a day. And it turns out that nondrinkers, people who don't drink at all are actually more likely to die of like strokes, heart attacks, it's actually like a very broad spectrum. But the French paradox focuses on heart disease.

Aubrey: Yeah.

Mike: This idea, which is the heart of the French paradox, and the heart of the interestingness of the media reports is like, "Oh, what if this thing that seems like it's bad for you, is actually good for you in smaller doses?" You remember this, right?

Aubrey: Absolutely. And it feels like this is a conversation that really raged on throughout the 90s and 2000s in particular.

Mike: Dude, my mom started drinking. [laughs]

Aubrey: Really? She was a nondrinker?

Mike: Yeah, my folks are Christians, they don't drink at all. I've seen them drink in my life maybe five or 10 times, I've never seen them drink more than half a drink or so. I've never seen them buzz, I've never seen them drunk anything. And I was talking to my mom about like, the research that I'm doing. And she's like, "Oh, yeah, after these news reports started coming out, I started drinking a glass of red wine every day." And then eventually, she went to her doctor and mentioned, "Oh, yeah, I started drinking red wine for my health." And her doctor was like, "Are you kidding me? Why would you do this? You don't like wine and wine [Aubrey laughs] is not this magical substance. You don't need to do this." And then she stopped.

Aubrey: Yeah, that seems like a pretty solid driving force is like, "I don't like it."

Mike: This ends up in the US Dietary Guidelines, but this was the conventional wisdom for a very long time. The idea that if you're pregnant, don't drink. Heavy drinking is bad for you. But if you want to prevent various forms of chronic illness, like a little bit of drinking is actually protective.

Aubrey: Gotcha.

Mike: Meanwhile, well, the media is presenting this as, like, make sure you have one or two drinks every day. Behind the scenes academia is researching what's actually going on here. There's essentially two explanations for what explains this checkmark shaped curve. The first is the one that they talked about in the 60 Minutes report, which is basically that it's alcohol, ethanol, the actual substance of alcohol that has this flushing effect on your platelets.

Aubrey: Boy, oh, boy, the number one place that I hear ethanol now is as like a gas replacement. [laughs]

Mike: I know, right.

Aubrey: I'm like, just head on down to Chevron.

Mike: Get a nice Bordeaux with a hint of [unintelligible [00:15:47]. [Aubrey laughs] The other explanation is that it's something specific about red wine. There are antioxidants in red wine. The antioxidant in question here is resveratrol.

Aubrey: Oh, my God.

Mike: I know, do you remember when-

Aubrey: Michael.

Mike: -we first encountered this in our Dr. Oz episode, which is like a bad sign?

Aubrey: Well, I'll tell you what, I first encountered it at a mall kiosk-

Mike: Oh, yeah.

Aubrey: -from extremely suspect skincare brand. Where they'll be like, "Hey, do you want to try our resveratrol skincare or whatever?" And I'd be like, "Sure, let me try it out. Oh, that's a nice moisturizer. How much is it?" And they'll be like, $500 and I'll be like, "No."

Mike: Yeah.

Aubrey: It was like astonished. It wasn't 500, it was maybe $300. And then I started to walk away. And they thought I was just playing hardball and bartering. [Michael laughs] So they were like, "150." This is so weird, I'm down to barter, but an American shopping mall is not a place where I expect to do that.

Mike: That's bizarre. But the thing is what's annoying about resveratrol is it's actually really fucking cool.

Aubrey: Oh, is it?

Mike: Yeah, so in wine grapes, resveratrol is this little tiny trace thing that basically keeps grapes from going bad and getting burnt in the sun. The reason why it's a skincare thing is because it's in grape skins and it helps block UV rays and prevent infections.

Aubrey: That's cool as shit.

Mike: Are you aware of what antioxidants are? I had to learn this, and now you have to learn it too.

Aubrey: Would you talk me through it? I feel I've had TV yelling about antioxidants of me for my entire adult life. And I don't really have a sense of what they are or how they work.

Mike: I'm not sure if I do either, to be honest. But the best I can explain this system without getting into electrons and shit is, there's these things called free radicals that your cells produced as like a waste product. When you're breathing in pollution or you're exposed to UV rays, your cells produce little free radicals that's like their little cell poops. And the free radicals bounce around in your system and they basically cause a kind of wear and tear on various organs, on your tissues, on your veins on kind of everything, and it's bad to have them bouncing around. And then antioxidants neutralize the free radicals. When you eat things that have antioxidants, or you take vitamins that have antioxidants in them, they get rid of the free radicals, and they prevent this wear and tear and fix your crow's feet or whatever.

Aubrey: Sure.

Mike: That's the basic idea that you have this balance between bad free radicals and good antioxidants in your system. Does that make sense?

Aubrey: Yeah, totally. I'm trying to think of like, would there be any kind of mechanism for measuring how big a problem this specific thing is at a population level? But it seems the things you wouldn't be able to measure are the effects of that.

Mike: Yeah.

Aubrey: That you'd be able to measure how many heart attacks are there, how many X, Y and Z. And those can be caused by a number of other things.

Mike: This is, I think the difference between the science around these issues and the marketing around these issues. There's a million different processes going on inside of your body at all times. And what marketing does, is marketing makes one or more of these processes more salient. "Oh, you need to watch your electrolytes." "You need to watch your antioxidants." But the family of antioxidants or substances that have an antioxidant effect that resveratrol belongs to, they've identified more than 8000. You can't really manipulate all these delicate balances inside of your body to like this extent.

Aubrey: Yeah, and even if you could manipulate them more dramatically, it sounds like there's not really a way to measure whether or not you're in a target range or whatever. It's just like, "Have your blueberries with your yogurt in the morning and just kind of hope for the best."

Mike: But this is also partly why I don't want to get into the science of this more, honestly, because I feel as a layperson, you don't actually need to know this stuff in any great detail.

Aubrey: Sure.

Mike: It's not even clear that free radicals are bad for you and it's not even clear that antioxidant are good for you.

Aubrey: What?

Mike: Free radicals in certain concentrations at certain levels are actually good for you, your body also produces free radicals when you exercise, and then a lot of antioxidants in certain doses can actually be really bad for you. Beta carotene is an antioxidant, they've tried giving supplements like beta carotene supplements for people. And if you take too much that's linked to lung cancer.

Aubrey: Oh shit.

Mike: This just isn't something that you need to worry about on this micro of a scale.

Aubrey: It sounds a little bit like cholesterol in that very low cholesterol is has the same risks essentially, as very, very high cholesterol.

Mike: Right.

Aubrey: The tenor of the conversation around these things make it seem the more antioxidants you can eat, the better. The lower your cholesterol can be, the better and that's not actually borne out getting the research. Is that a fair assessment of what's happening here?

Mike: Oh, totally. I mean, this is interesting for researchers, and I'm really glad that people are looking into it. And maybe they will discover something about this system that becomes useful to consumers in 20 or 30 years or whatever. But right now, all we can really say is that like, "Yeah, try to eat a wide variety of food, try to eat fruits and vegetables." If you're super worried about your free radicals, antioxidant balance, like maybe you're neglecti1ng your blood pressure balance, or maybe you're neglecting your cholesterol balance and there's probably 50 other of these balances inside of your system that we don't know about haven't become marketing yet.

Aubrey: This taps into two things that are particular bees in my bonnet. One is this idea that every new scientific or nutritional finding has to immediately translate into individual practices.

Mike: Yeah.

Aubrey: The other thing that feels challenging about this is we have gotten so dead set on a conversation that focuses on weight as the end-all be-all of health indicators. And I'm like, there's so many systems in your body, there's so much that's happening. The idea that you could focus on any one single number, whether that's your weight or your cholesterol, or your blood pressure, or your mood evaluations or whatever. The idea that that could be the sole reflector of an entire picture of your health and the functioning of your body is bananas.

Mike: It's like, "Oh, I have 75 health points today.

Aubrey: You're not a Sim.


Mike: So basically, in the 1990s, this becomes the conventional wisdom, that there is something about alcohol that is protective of the cardiovascular system, and the most likely explanation is that it's resveratrol, some other antioxidant inside of red wines specifically. So you know I love like a TriHard structure for an episode, [Aubrey laughs] you know I like having chapters.

Aubrey: Are we going to be joined by a little skeleton?

Mike: It's going to be a little skeleton, I wanted to go through the assumptions that were going into this conventional wisdom. If you were interested in actually investigating what's going on here. What are the things that you have to actually establish first before you can give anybody individual health advice.

Aubrey: One, a direct connection between red wine and heart attacks.

Mike: Well, it goes even further back, Aubrey.

Aubrey: Tell me. 

Mike: The first thing you have to establish is, does France actually have a low rate of heart attacks?

Aubrey: [laughs] Yay, let's do this.

Mike: This is the part of the research for the episode. I don't know if there's an episode here. And then I found this, I was like, "There's like four episodes here." [Aubrey laughs] I think this is such a perfect metaphor for so many things that we talk about on the show. So, obviously, there's death statistics for every country. If you want to know how many car accidents there were in Romania last year, you can look it up. And it's something that has the weight of statistics. You're like, "Well, these are just numbers and this is just science." And obviously, there's just statistics and you can't really complain about them or whatever. The main thing to know about death statistics is that they all go back to an individual death certificate. When somebody dies at a hospital, a doctor fills out a death certificate, and then that's entered into a database and then that eventually flows upward into national death statistics. I think I've mentioned on the show before that when I was doing grad school in London, my boyfriend was an ER doctor.

Aubrey: What?

Mike: In Britain, they call it arts and entertainment.

Aubrey: Yeah.

Mike: This was like me doing journalism for this episode. I opened a Facebook Messenger window. I was like, "Excuse me, tell me about your relationship with death certificates." And so, he sent me the guidance that the UK gives to doctors of how to fill out death certificates. And this is all based, there's standardized kind of format for death certificates that are based on WHO, there's codes for what people die of. So, all of this, they're trying to standardize this as much as possible, so that you can look at different causes of death between countries. The way that death certificates work is there's the direct cause of death and then there's all of the underlying causes of death. The example that they use in the UK guidance is the immediate cause of death is ruptured liver, and then the underlying cause of death is pedestrian knocked over by car. So. it's like you'll have something like cranial fracture car accident.

Aubrey: Gotcha.

Mike: There's also you think about long term diseases. You think about something like HIV. HIV doesn't kill you. It just makes your immune system so weak that oftentimes you get pneumonia or you get some sort of opportunistic infection. So, you'd say this person died of pneumonia, but the underlying cause of death was HIV. This is also one of the things they say in the guides, is this is actually how we get-- you know the term died of old age?

Aubrey: Yeah.

Mike: In the guidance, they just say if you don't know, and somebody's over 80, just put "died of old age," is the underlying cause.

Aubrey: Whoa.

Mike: So, it's just like, "old age."

Aubrey: Yeah, this feels in mental health world, there's often a classification that's such and such, not otherwise specified. For a long time, there was eating disorder, not otherwise specified. Which is like, "Hey, man, your relationship to food is really weird, but it's not one of the big ones that we already figured out, you got a special thing going on."

Mike: This is all a completely normal system. You want to have these different layers of causes, so that you can do statistics at the end of the year. You want to be able to say there were this many car accidents this year, not like how many fractured craniums were there this year. You have to have a couple of different types of information. Where the system gets tricky is when you have older people who have more than one underlying condition. This is from a study of death certificates. It says, "The WHO disseminate standard death certificates, coding rules for determining underlying cause of death and standardized tables for comparison. However, it cannot control what is written on individual death certificates, or whether the diagnosis is evidence based, or merely an expression of one person's opinion." 

What researchers have found when they look at these kind of overall death statistics, and then they go back and they look at individual cases, so they double check the national statistics against actual individuals, is that it's kind of a judgment call what gets written on the death certificate as an underlying cause of deaths, because only around 10% of people get medical autopsies. Most of the time, it's like, "Okay, this person is 85 years old, and they went to sleep, and they just never woke up." We're not going to do like a whole big investigation.

Aubrey: Sure, and also despite what we've all seen on Law & Order, it's also unusual to have cops show up when you die.

Mike: When researchers go back and check things, what they find is that a huge number of people who had heart attack or diabetes, or whatever listed on the death certificate didn't actually have that. There's no actual evidence of that.

Aubrey: Wait, wait, wait. You're telling me that people had diabetes or heart attack or whatever listed on their death certificate as a cause of death, but they don't really know if that person had diabetes or had a heart attack?

Mike: Yes. I found this really interesting study called "Death certificates are not reliable." Where they go to a single hospital and they go back and they find 223 autopsy reports. They find 25 cases where an autopsy later finds a heart attack, but the doctor didn't write it on the death certificate. And they also find nine cases where the doctor wrote heart attack on the death certificate, but the person died of something else. Around half of the errors are not finding a heart attack that's there, and 25% of the errors are finding a heart attack that wasn't there. The study says, "Death certificates were frequently inaccurate, and in 21.5% of cases were of no value because of an inadequate diagnosis."

Aubrey: Ah, I'm sure that this is not part of the data, but what do you want to fucking bet that a bunch of that 25% was fat people?

Mike: Well, this is what's so fascinating to me. There was an interesting study in Italy that looked at diabetes deaths, and found that basically, people with the same symptoms, women, and people who were found in their home, as opposed to dying in the hospital, were much more likely to have diabetes written as an underlying cause of their death. It's basically a judgment call based on the medical examiner or whatever doctor is looking at you to determine what are the factors that contributed to this person's death.

Aubrey: Gotcha.

Mike: And that judgment call is going to draw upon preexisting beliefs. And it also follows like very cultural and national lines. A lot of the studies on these actual death certificate methodological issues, where it's not clear that we can make any comparisons in deaths of these kinds of underlying conditions across countries.

Aubrey: Hmm.

Mike: You know my greatest fear with the show is that we're going to turn people into like QAnon, antivax fucking weirdos who are just like, "Nothing matters, it's all fake."

Aubrey: This is the thing you and I talk about a lot.

Mike: I don't want to say that, "All statistics are fake. And anyone who tells you anything about deaths in any country is fucking lying, and you can throw it all out." I think for things gunshot wounds and car accidents, and the sheer number of deaths and overall trends, I think you really can say something definitive. I think that it's just really hard to know which underlying cause contributed to something like a heart attack especially.

Aubrey: I don't hear you saying it's all fucking fake. What I hear you saying is there are a lot of vicissitudes, there's a lot of variables and nuance that goes into this set of decisions to be made. And some of those are driven by medical training and research and observation. And some of those are driven by bias or by a lack of information on a particular topic or about a particular person. What I hear you saying is, "Don't passively accept these numbers at face value. Remember that there are judgment calls that go into these, and they may not be hard and fast, solid, reliable, objective truths."

Mike: Exactly. And this finally brings us back to the French paradox. What you find when you start looking into this, is that as early as 1958 methodological nerds were writing papers about why French doctors are really weirdly reluctant to write heart attack on death certificates. [Aubrey laughs] So, when you have a heart attack, it leaves a signature on your EKG thing, like, bloop, bloop thing that's next to you in the hospital bed and movies. When you have a heart attack, there's like a signature, like you can look at somebody's EKG and be that's a heart attack. And when you have a heart attack, it also leaves some enzymes in your blood, you can actually test people's blood and be like, "Oh, this person had a heart attack." 

In France, for whatever reason, they're reluctant to say that somebody had a heart attack unless they can prove it. Maybe they weren't in the hospital when they had their heart attack, so we don't have the EKG reading or we don't have access to their blood. They'll just say "cardiac event." A lot of the death certificates apparently just say "sudden death."

Aubrey: Whoa.

Mike: Whereas in most other countries, you can kind of eyeball it. You're like, "Okay, he was in the hospital with some like heart fluttering stuff, we don't know, but I'm 80% sure, I'm just going to write heart attack on the death certificate."

Aubrey: Yeah.

Mike: When people go back and look at the death statistics that were informing all this French paradox stuff, they find that France has a really low rate of heart attacks, but a very high level of unclassified cardiac events.


Aubrey: Come on.

Mike: It's like fucking driving me nuts. They do the city by city, I think they're comparing like Lille to Glasgow, and Glasgow has three unclassified cardiac events. And Lille has 23. So, it's like, these are massive differences.

Aubrey: You don't have bulimia, you have an unidentified barfing event.

Mike: Yeah, exactly.

Aubrey: Great. Okay. Sure.

Mike: One of the best papers I read on this was in 2008, a French doctor does this overall analysis, where he's like, "Okay, let's just look at the French paradox. What are we actually looking at here?" And he goes over all the death data and the data they were using to formulate the French paradox, and he says, "Strictly defined coronary death rates in French national statistics, both in the past and nowadays should be considered as negatively biased estimates at the population level and cannot be used validly in ecological correlation studies." The 60 Minutes episode says over and over again that "If you're an American, you are three times more likely to have a heart attack than if you're a French person." And when they go back, and they can rerun the numbers, and they classify everything correctly. If you're an American, you're about 30% more likely to have a heart attack than if you're French. So is that nothing? No, that's actually a pretty big difference. But 30% more likely and 200% more likely are very different sociological phenomena. And imply very different public policy responses, basically.

Aubrey: Yes.

Mike: Totally.

Aubrey: If you're trying to solve a problem, step one is, you got to be able to wrap your arms around the magnitude of the problem and who it's impacting. And it sounds we're not currently able to do that just based on the baseline data that's available.

Mike: And also, it's not really the French paradox because France has roughly the same heart attack rates as Italy and Spain.

Aubrey: Oh, my God, how long until we get reporting on a Spanish paradox and everyone starts eating like sardines.

Mike: Yeah. [laughs] Eat at 10:00 PM.

Aubrey: Yeah, that's right.

Mike: Okay, so that was TriHard structure, that was like galaxy brain level one is like, "Are heart attacks low in France?" Galaxy brain level two is, "Does drinking prevent heart attacks? Is this thing moderate drinking good for you?"

Aubrey: This is a part of health and wellness science world where I have spent almost no time is the booze end of things.

Mike: Me neither.

Aubrey: And also, I'm just not a big drinker. It's not my thing totally.

Mike: Wait, so you're a moderate drinker.

Aubrey: I'm a social drinker, pretty much exclusively. I have a bottle of whiskey at home for if something big happens, but that's once every year or two that I like-

Mike: Ah, okay.

Aubrey: -to pour a drink for myself by myself at home. Everything else is when I'm out with people. And I haven't been out with people for part because of COVID, so I just don't really drink much at all.

Mike: I mean, this is like an interesting sort of self-reported data thing, because on the surveys, you would show up as a moderate drinker, even though in reality, you're a nondrinker, basically.

Aubrey: I just don't love it. The feeling of a hangover is such a fucking bummer.

Mike: Also, like once you're in your 30s.

Aubrey: It's a whole other fucking ballgame. I thought people in their 30s were overblowing stuff when I was in my 20s. And now I'm here and I'm like, "No, I understand back pain and hangovers. I got it."

Mike: Oh, my God, yes. I just realized the other day that everything that used to bother me about my parents, I am now doing. [Aubrey laughs] I am like, "Hm, why do you have to wear earplugs to sleep?" And now I'm googling most powerful earplugs for night noise.

Aubrey: Yeah, that's right.

Mike: But then, okay, here we get methodology queenyness. I am a non-drinker, many of my friends are like moderate drinkers, because I'm fairly similar to them. I always kind of assumed that when you do these studies that compared nondrinkers to moderate drinkers, you're basically comparing like roughly the same group. It turns out that nondrinkers, or at least people who say that they do not drink on surveys are like a really distinct group. The main thing that differentiates nondrinkers from moderate drinkers, is that nondrinkers include people who have been told not to drink by their doctor, because they have preexisting health stuff.

Aubrey: Oh.

Mike: A huge number of people with diabetes do not drink, a huge number of people who have high cholesterol are at risk of things like heart attacks, have been told not to drink. Those people have stopped drinking, but they still have all of the health risks. If you're someone who's been a really severe alcoholic your entire life, at age 60, you finally quit alcohol, you're now a nondrinker. Well, you still have all of the liver damage, and all of the other health effects that the drinking caused for your entire life. But you show up on the surveys as a nondrinker.

Aubrey: Because they're essentially taking a snapshot of what is your relationship to alcohol now, not what has not ever been in your life.

Mike: Exactly.

Aubrey: Yeah.

Mike: These people in the studies are called "sick quitters." 

Aubrey: Ugh.

Mike: It just seems like a kickball team or something.

Aubrey: God, that's like the biggest loser, what a weird mean thing to name that like, fuck, dude.

Mike: But then even people who drink are called "healthy users."

Aubrey: Ugh.

Mike: Which also doesn't sound that cool. I know it's all bad. But then another thing about nondrinkers that I didn't know is that nondrinkers are distinct from moderate drinkers in a million other ways, too. So black people are twice as likely to be nondrinkers as white people, people without health insurance are 1.5 times more likely to be nondrinkers. Unemployed people 25% more likely to be nondrinkers. People who earn less than $25,000 a year are three times more likely to be nondrinkers. I think because alcohol is expensive.

Aubrey: Yeah, totally. Alcohol is expensive. And also, this is a fascinating moment of what an interesting thing that so many people who are on the downside of power and privilege are doing this thing that broadly is understood to be a health promoting behavior, and we're not talking about it one fucking bit.

Mike: Yeah.

Aubrey: The things that we were talking about as health promoting behaviors are the things that are expensive, and the things that rich people do. The end, right?

Mike: Right. And it's also really hard to make comparisons between these two groups, because when you zoom out nondrinkers and moderate drinkers aren't just groups that differ in this one behavior. Nondrinkers, it turns out, includes a disproportionate number of people with fairly serious preexisting conditions. And a lot of poor people, ethnic minorities, unemployed people, and also older people. All of those groups have higher mortality rates, but they don't have anything to do with drinking.

Aubrey: Sure. I'm thinking particularly of the uninsured people, that feels like a pretty straight line.

Mike: They've tried to solve have this problem by only comparing moderate drinkers to people who have never drunk in their lives. But then that's not a remotely representative sample either. That's mostly religious people. So, you can't really get around it that way either. I mean, we talk about this all the time, so I don't want to belabor it, but there's also the fact that all of these surveys of drinking behavior are based on self-reported data. Moderate drinkers encompasses people who have one drink a year, and people who have to drinks at night.

Aubrey: What?

Mike: A lot of people who drink very rarely, still call themselves moderate drinkers, like seldom drinkers.

Aubrey: The idea of me as someone who's had, I don't know, two drinks in the last year as a moderate drinker seems bonkers to me.

Mike: One of the things, I think it's so weird that it doesn't really come up in the literature about the French paradox, too, is that there's something about the self-reporting of a red wine consumption, that also seems off to me, because red wine is typically associated with, "I'm a sophisticated person." It's like asking people how much they go to the opera. [crosstalk] Do people who go to the opera have lower rates of heart attacks? Probably. But it's not because the opera, that's seen as kind of virtuous behavior for a certain kind of person who probably has a low death rate anyway. I just don't know how much you can actually really say about this stuff, just because it's so difficult to get clear answers from people on these really culturally loaded activities.

Aubrey: Yeah. I mean, this is a thing, I have had a number of conversations with pals from the UK who will talk about like, "Oh, my God, we had our weekly drinks out with the staff-

Mike: Yeah.

Aubrey: -on Friday night. Our whole office went out for drinks, and I got totally plastered." And I'm like, "Boy, that would be a fireable offense in the US." If you went to a staff of function and you got completely shit faced.

Mike: Dude, when I worked in London, people used to call in hungover [Aubrey laughs] "I can't make it in today. I just got hammered last night." I as an American was like, "What the fuck? Do you you’re your bosses?"

Aubrey: Totally, and it's just this fascinating moment of contradictory sort of cultural expectations and judgments of social experiences.

Mike: Yeah, it's all fake. Okay, the next sort of debunkery is the antioxidants stuff. You can't really synthesize these things. There's been various attempts to like create antioxidants in a lab and turn them into vitamin supplements. There's no evidence that they do anything.

Aubrey: This is the Americans have the most expensive pee in the world stuff. Yeah.

Mike: Thinking of expensive pee.

Aubrey: Ooh.

Mike: Basically, all of the studies on resveratrol, since the 1990s have found, you don't really absorb it, you get a spike of it for roughly 30 minutes. And then it just goes out in your pee or it goes through your system and is turned into some sort of other chemical thing through organic chemistry through your body. It basically becomes this other compound. You're not able to get the amount of resveratrol that would give you any kind of benefit.

Aubrey: "Take that mall kiosk."

Mike:  Yeah, exactly. [laughs]

Aubrey: "Your skin is going look amazing for half an hour-"

Mike: I know.

Aubrey: "-and then it's going to look like garbage."

Mike: And also as with most things, the only real evidence that resveratrol could be isolated and could have these health effects is on studies of yeast, fruit flies and mice, [Aubrey laughs] not a great start. And then the one that they gave mice, the dose was so high that to get that amount of resveratrol, you'd have to drink 100 liters of wine. [Aubrey laughs] Not recommended. Also, this is the shit that I was like about throw my fucking laptop out the window. This is from a 1992 New York Times article. Pretty early in the French paradox this was being reported. "Well, the amount of resveratrol in wine varies widely depending on the type of wine, purple grape juice has an [Aubrey laughs] amazing amazingly constant amount no matter where in the country it comes from, reported Dr. Leroy Creasy, a specialist in fruit cultivation at Cornell University. He found that grape juice had more of the heart protecting chemical than 60% of the wines he analyzed."

Aubrey: What? [Michael laughs] Get out the juicy juice.

Mike: It's such a tell to me, if you believed all this resveratrol has this magical effect on the body thing, there's no reason you have to get it from wine. There is other sources of reserves-- you can also just eat fucking grapes.

Aubrey: Yeah, totally.

Mike: It really feels like this whole thing was just a permission structure to drink red wine, which is fine. I think drinking red wine is totally legitimate. But it feels nobody actually gave a shit about what they were saying for like a decade and half. [laughs] 

Aubrey: It feels a little bit like the "Don't Worry Darling" discourse, which is just like, "Oh, we're just going to get all real fixated on this one question. Did this guy spit on this other guy?"

Mike: Yeah.

Aubrey: "Let's dig in on this thing that seems fun and interesting." And I think there is something a little bit, not quite salacious, but sort of enticing about the French paradox.

Mike: Yeah.

Aubrey: It is the ultimate claim of any diet, which is you can eat whatever you want and still lose weight. And I do think it plays into a bunch of weird cultural expectations that Americans have about French people and the sort of Europe envy that happens amongst white Americans in particular. It just plays into a bunch of things that we're already sort of primed to think.

Mike: Right.

Aubrey: Can we say anything definitively about the effects of drinking or of red wine?

Mike: I read a really interesting meta-analysis of what we know about mortality, and alcohol and J-shaped and all this kind of stuff. And they basically say that there is very good evidence that not drinking is the healthiest way to live. And there is very good evidence that moderate drinking is the healthiest way to live. Basically, if you're someone who doesn't drink and not drinking, works for you, you don't have to start drinking, you're fine. And also, if you're someone who drinks moderately, and it's not a problem, you're not blacking out, binge drinking, whatever, you're also probably fine. We don't need to do a thing where we try to identify the exact optimal amount to drink. It just depends on the study. It depends on the methodology, etc. Different studies find different things. But as far as individual advice goes, do what works for you. 

Aubrey: Yes. This feels very the Sleep episode in that way. Which is like, turns out, you can kind of relax around this thing. You don't need to force yourself to drink red wine if you don't like red wine.

Mike: Yeah.

Aubrey: Yeah, it feels like a very reasonable way to go about things.

Mike: The original sin of all of this to me was taking these two extremely broad pieces of information. French people have low heart attack rates. They also happen to drink slightly more red wine than Americans. They eat more fat and cheese, whatever. And then drilled down to these tiny trace elements in fucking red wine. I don't think anyone really realize that’s what the paradigm was. French people are more likely to walk and bike to work. It could have been that.

Aubrey: French people are more likely to speak French.

Mike: Yeah.

Aubrey: They're more likely to live in older buildings [laughs] and there's a ton of different things. They eat more cheese, sure. I don't know.

Mike: Well, this is what drives me fucking nuts is that heart disease is the number one killer in America. It's the number one killer in France, it's the number one killer in most developed countries. And yet, it only comes up when we're talking about fat people. It only comes up when we're in the frame of obesity and dietary changes. I really went down a rabbit hole on this too. How much can we even say that diet contributes to heart attack risk? It would be very weird and climate denial, anti-vaccine to say that it doesn't contribute because obviously it contributes. But it would also be one dimensional to say that it's the only thing that contributes.

Aubrey: So much of our conversation around heart disease is like, "Manage your individual risks, eat these things, move in this way, with this frequency."

Mike: Yeah.

Aubrey: And I don't know that I have a great sense of sort of what is the nuance around. Is that also a thing where unemployed and underemployed people are more likely to have heart attacks. I bet.

Mike: Well, Aubrey, allow me to tell you.

Aubrey: Oh, Mike, I knew you'd pick it.

Mike: This is also like such a fun methodology queenie section. I'm sorry, I went down four fucking rabbit holes for the episode, I'm so sorry.

Aubrey: I love this, this the purest-

Mike: Oh, God.

Aubrey: -iteration of Michael Hobbes where you're like, "I spent 72 hours on the internet."

Mike: I feel bad. [Aubrey laughs] I hope this isn't too boring. This is Galaxy Brain, Part Three.

Aubrey: Bing, bang, boom.

Mike: What can we really say if country X has a low heart attack rate, with how much certainty can we say that it is due to their diet? I don't like the effort to put numbers to these things. But there is an EU report that compares heart disease risk across the EU, and concludes that diet contributes 40% to individual heart attack risk. There's a JAMA Report from 2017 that says it's 45%. Is that nothing? No, that's like a pretty significant contributor, but that still leaves the majority of heart attack risk somewhere else.

Aubrey: Is there any research that shows where else that heart attack risk might come from?

Mike: I found a really interesting study that looked at sleep and mental illness. As we discussed in our sleep episode, it's really important to get a good night's sleep. Even though the definition of good night's sleep differs between people. People who have sleep disorders have like a 30%, higher risk of heart disease. And people who have depression also have a 30% higher risk of heart disease. But people who have sleep disorders and depression have a three times higher risk.

Aubrey: Whoa.

Mike: I don't love the methodologies of these studies and I don't want to say, "That's what's really doing it or whatever." But I think as a paradigm, the idea that you would have these things that are contributing extra risk to your system, and the combination of them is having this kind of like exponential effect. I think that is like a paradigm is really useful. So, people who have mental illness have higher risk of heart disease, people who've been divorced have higher risk of heart disease, I found a super interesting study in Japan that showed that heart attacks went up after an earthquake, which indicates that stress might have something to do with it. Air pollution contributes to heart attacks in ways that we don't fully understand.

And then the biggest thing, the thing that drives me so fucking nuts about this entire conversation is why weren't we talking about like the French health care system?

Aubrey: Yeah.

Mike: If people are dying of heart attacks, a lot of that has to do with access to medicines and surgical procedures, and how fast does an ambulance come when you call and really direct? Obvious stuff about like, who dies and why. Not necessarily like who's eating cheese.

Aubrey: Yeah.

Mike: I found a really interesting study that compare different heart attack rates in different parts of France. The best predictor for heart attack deaths in France was how close are you to a large regional hospital? I don't want to swap one dimensional explanation for another. I'm not going to be like, "Oh, it's not the red wine. It's the large hospitals."

Aubrey: I think you're right. I don't think either of those entirely accounts for every understanding of the risk of heart disease or hypertension, or any of that. But to say, "It's the red wine." It's definitely not everyone can go to the hospital. And if you're closer to a hospital, you're more likely to survive.

Mike: Yeah.

Aubrey: That feels like a very facile and sort of self-serving, set of assumptions to make, because it tells Americans what we want to hear, which is you can drink a bunch if you want to drink a bunch. And it doesn't tell us what we don't want to hear, which is we should probably be paying into a universalized health care system.

Mike: I actually think that this is like behind the whole thing. I was reading obituaries of Morley Safer. And one of them mentioned that he's like, "A lifelong Red Wine Enthusiast," and like a big red wine drinker. And I was like, "Really?" "Turns out red wine is good for you." Yeah, you just want to think that your habit is healthy.

Aubrey: And again, the race and class factors here are nonzero. No one's making the argument that like, "Hey, you know what's super good for you? A [unintelligible [00:53:05]."

Mike: Yeah.

Aubrey: That's just not happening.

Mike: I went back and I read the original paper. The paper that inspired the 60 Minutes episode. France does not have the lowest rate of heart attacks. China and Japan both had far lower rates of heart attacks than France did. Death certificates, country comparisons, I'm not going to pretend that data is somehow perfect.

Aubrey: Yeah.

Mike: But also, according to the information with which they sold the French paradox to us, they should have been telling us to live like Japanese people, most of whom do not drink terribly much red wine. It's like, why will we all trying to emulate the fucking third best country on [Aubrey laughs] heart attacks and ignoring the first and second? [Aubrey laughs] Was that clearly explained to people? I don't think that it was.

Aubrey: It's as much a measure of what do people want to hear and what are the narratives were willing to latch on to-

Mike: Exactly.

Aubrey: -as anything else? Yeah.

Mike: The whole thing was basically Americans going a oh-oh-oh. [Aubrey laughs] but not really looking into the specifics of what was going on in France.

Aubrey: Mike, I don't think we've talked about this, but one of my very favorite karaoke songs is Les Poissons from The Little Mermaid.

Mike: Oh, really?

Aubrey: Do you not know that one?

Mike: Uh-huh. Is it by Blake Lively?

Aubrey: It's a-- [laughs] yeah, right. It's like full two minutes song that is just a version of oh-oh-oh. [Michael laughs] If you're ever in France, join me at the local karaoke bar and we'll sing that fucking song from The Little Mermaid.

Mike: Yeah, and afterwards, we'll kick back with some grape juice. 

Aubrey: [laughs]

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