The notion that the French enjoy a lifestyle that promotes better health, despite indulging in rich foods, has intrigued observers for decades. This concept, famously dubbed “the French Paradox” in 1987, arose from the observation that France exhibited remarkably low rates of cardiovascular disease even with a diet rich in saturated fats (1, 2). While subsequent research, such as the MONICA project, refined this view by showing coronary death rates in France were similar to neighboring Southern European countries (3), the enduring image of the French as masters of healthy living persists, particularly in the United States. This raises a pertinent question: what can France and the United States learn from each other regarding the sociocultural and economic factors shaping their respective lifestyles and health outcomes?
A revealing study by Malon and colleagues (4) delved into the adherence of French adults to their national nutritional recommendations. The survey, a comprehensive national assessment, revealed that on average, French adults followed approximately 50% of the recommended physical activity and twelve nutritional guidelines. Interestingly, younger and middle-aged individuals, along with those from economically disadvantaged backgrounds, showed the lowest adherence. This finding suggests that education alone might be insufficient to modify dietary behaviors, and interventions need to address the accessibility and affordability of healthier food choices.
The imperative to improve public health is arguably more pressing in the United States than in France. Examining specific nutritional recommendations from the French program alongside their adoption rates in both countries illuminates key differences. These disparities in health behaviors manifest clearly in obesity rates. In France, around 17% of adults are classified as obese (8), whereas in the United States, this figure nearly doubles to 34% (9). These obesity rates correlate strongly with deaths from coronary heart disease. France maintains one of the lowest rates globally (men: 73 per 100,000; women: 17 per 100,000, the lowest worldwide), while the United States occupies a middling position among 37 countries (men: 174 per 100,000; women: 73 per 100,000). The US ranks behind several Eastern European nations, China, Scotland, Ireland, and England, a position that has remained largely unchanged over the last 15 years, despite significant efforts to improve American health (10).
The French research highlighted that lower socioeconomic status correlated with poorer adherence to nutritional guidelines (4. Health disparities among underserved populations are also a significant challenge in the United States. Over the past 15 years, America’s progress in reducing these disparities has been minimal. A recent analysis of 15 health indicators revealed no improvement in 10 and a worsening in 5, with heart disease mortality being a primary driver of this widening gap (11).
Consequently, it is understandable why Americans often look to France for insights on improving their health, rather than vice versa. The repeated, often unsuccessful attempts to enhance national health in the US have perhaps fostered a sense of urgency and a need for innovative approaches. The American government is now encouraging innovation in federally funded research, prompting American researchers to explore unconventional strategies to promote healthier lifestyles, reduce chronic disease-related disabilities, and curb escalating healthcare costs.
However, the flow of learning is not unidirectional. What can the French learn from the American experience? Firstly, cost matters, but it’s not the only factor. While Malon and colleagues (4) suggested that affordability is a key barrier to guideline adherence for the economically disadvantaged, particularly regarding nutrient-dense foods like fruits and vegetables, the issue is more nuanced. It’s commonly assumed that energy-dense foods are cheaper sources of calories. For instance, in the US, $4.00 can buy approximately 1,000 kcal of energy-dense snacks, whereas the same caloric intake from fresh produce could cost upwards of $20.00 (13). This cost disparity has led to arguments that the high price of fresh produce relative to calorie-dense alternatives discourages low-income individuals from consuming more fruits and vegetables (14).
However, focusing solely on the energy cost (US$/kcal) might be misleading when formulating healthy weight maintenance guidelines. Lipsky’s analysis (13) demonstrated that fresh fruits and vegetables are significantly less expensive per weight and offer larger serving sizes compared to snacks. In fact, $4.00 can purchase about 0.44kg (0.97 lbs) of fresh produce (nutrient-dense foods) versus only 0.2kg (0.44 lbs) of energy-dense snacks. Given that satiety is primarily driven by food weight and volume, not just calorie content (15, 16), a more effective public health message could be: “Purchasing fresh produce can help socioeconomically disadvantaged individuals achieve satiety at a lower price.”
Furthermore, the absolute price of fresh produce in the United States is surprisingly affordable. Meeting the recommended daily intake of 3 fruits and 4 vegetables can cost as little as US$0.64 (17). To corroborate this, a small survey in Chicago comparing snack prices across various stores revealed that snacks, including chips, soda, yogurt, apples, and oranges, were similarly priced around US$0.80-0.85. While convenience stores often had higher prices for chips and soda and lower prices for fruits compared to grocery stores, these store types are more prevalent in inner-city areas. Although the relationship between store type and food prices is complex (18), this informal survey, along with systematic research (13, 17), suggests that factors beyond price play a significant role in fruit and vegetable consumption patterns in the context of lifestyle.
Availability is another critical factor. Price only influences food choices when those foods are accessible. As Malon and colleagues (4) mentioned, the local availability of healthy food profoundly impacts dietary intake and health, particularly for lower socioeconomic groups. Socioeconomically disadvantaged areas in North America often have fewer supermarkets (18–26). This is problematic because chain supermarkets offer a wider variety of healthy foods, while convenience stores and independent grocers primarily stock prepared foods with limited fresh produce (18, 27, 28). Studies have linked greater distance from supermarkets or proximity to convenience stores with lower fruit and vegetable consumption and higher body weight in urban multiethnic populations (29–31) and adolescents (32, 33), even after controlling for neighborhood characteristics and individual factors. Therefore, for socioeconomically disadvantaged individuals, the lack of large mainstream grocers in their neighborhoods presents a more immediate barrier to meeting dietary guidelines than food prices alone.
Another American insight relates to stress and “junk food.” The demanding pace of American life, characterized by overwork or unemployment, often leads to stress. Emotions associated with being Hurried, Agitated, Lonely, and Tired (HALT) can increase cravings for comfort foods like potato chips over healthier options like apples (34). The behavioral and neurobiological mechanisms behind “stress eating” are actively researched (35, 36). Malon and colleagues (4) found that socioeconomic factors and the absence of holiday trips predicted guideline adherence, highlighting that considering diet in isolation, without addressing stress and physical activity, might be overly simplistic.
Conversely, what can Americans learn from the French? Firstly, the value of neighborhood food markets is paramount. Anyone familiar with French culture understands the central role of local markets in shaping French eating habits. French households typically have smaller refrigerators, and food storage is less common. Instead, a daily ritual involves visiting the neighborhood market to purchase fresh ingredients for the evening meal from a diverse selection of fruits, vegetables, meats, fish, and cheeses. Traditional French culture cultivates an appreciation for food, from planning and shopping to preparing and enjoying meals together. This “slow food” approach, emphasizing local and seasonal ingredients, is gaining traction in the United States as a counterpoint to the “tyranny of the urgent,” encouraging Americans to prioritize less urgent but perhaps more vital activities (37).
Secondly, moderation is key (38). The French approach to eating embraces a variety of foods, consumed slowly, accompanied by conversation, and often with wine, always with food. In contrast, Americans often engage in restrictive low-calorie diets, which can lead to cycles of deprivation and overindulgence. A cross-cultural comparison of lifestyles in comparable cities in France and the US revealed that the French spend twice as much time eating (11.11% of their time) compared to Americans (5.22% of their time) (39). Similar contrasts exist in physical activity. The French integrate movement into their daily routines, utilizing stairs, bicycles, and public transportation. Americans are more inclined towards intense, high-frequency exercise programs, which are often unsustainable and can revert to sedentary lifestyles. The same study showed that the French spend 1.69% of their time walking, compared to 0.63% for Americans (39). French culture also values leisure and time off work. Historically, they are known for extended vacations, with 4 weeks in the summer and 2 weeks in the winter. American vacations, historically shorter at 2 weeks, are reportedly shrinking (38, 39). The cross-cultural comparison indicated that the French take 21 more vacation days annually than Americans (39).
In conclusion, as the “toxic” fast food market expands in France, potentially impacting the health of French citizens, strategies to preserve traditional French lifestyle approaches become crucial for public health. In the United States, where a culture of time-saving, fast food, and multitasking is deeply ingrained, multi-level interventions targeting individuals, social networks, communities, and policies are essential to improve health outcomes. Americans can and should look to the French as a model for a healthy lifestyle that encompasses not just diet, but also attitudes, behaviors, and social context surrounding food. Conversely, the French should strive to safeguard their cultural values related to enjoying food and prioritizing mealtime, particularly among younger generations who are increasingly exposed to the allure of the fast food industry. In this rapidly changing world, maintaining a balanced and healthy approach to lifestyle is paramount for both nations.
References
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Contributor Information
Lynda H. Powell, Medicine & Medicine and Chairperson Rush University Medical Center Department of Preventive Medicine 1700 W. Van Buren St., Ste 470 Chicago, IL 60612 (312) 942-2013 (312) 942-8119 [email protected].
Carolyn Shima, Rush University Medical Center 1700 W. Van Buren Department of Preventative Medicine Chicago, IL 60612 (312)-942-0747 (312)-563-2746 [email protected].
Rasa Kazlauskaite, Rush University Medical Center Department of Preventive Medicine 1700 W. Van Buren St., Ste 470 Chicago, IL 60612 (312) 942-3133 (312) 563-2746 [email protected].
Bradley M. Appelhans, Rush University Medical Center Department of Preventive Medicine 1700 W. Van Buren St., Ste 470 Chicago, IL 60612 312-942-3477 312-942-8119 [email protected].
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