The Cheese, Wine and Foie Gras...

La Coupole restaurant is jammed and, what with the noise and the difficulty of troweling just the right amount of pate onto my grilled bread, I’m having a hard time making out what Dr. Jacques Richard is saying. Richard, the reigning authority on heart disease rates in France, has his own problems. He can’t seem to decide whether he wants yet another bite of lardons, the fatty bacon chunks that adorn his salad, or whether he should move on to the gooey, golden yolk of his poached egg.

Contrary to appearances, this is work. I’ve crossed the ocean to untangle a mystery, and if anyone can help, it’s Richard. The question is best put as a riddle: Of the Western world’s industrialized countries, which has the lowest rate of death from heart disease?

Oui. C’est la France. The United States isn’t even close. In France each year, 143 of every 100,000 middle-aged men die of heart disease, according to the World Health Organization. In the United States, that figure is more than twice as high: 315. French women do even better, with the world’s lowest rate of death from heart disease.

If you look at all industrialized countries, only Japan beats France. Japan’s good health is no surprise, since the Japanese diet is light on fat and heavy on rice and fish. But despite their bad habits the French seem to be thriving.

How could it be, I’d come to ask Richard, that while Americans are dutifully downing bran muffins and the French are happily polishing off every butter flake of their croissants, they have healthier hearts than we do? This is, after all, the country that conceived bearnaise sauce--three egg yolks and half a pound of butter--and then thought to pour it over filet mignon.

Richard, an epidemiologist, has spent 25 years compiling and verifying the figures. Their message is clear: The French should be having heart attacks everywhere you look. They’re not. And French women actually outlive American women by a year.

Richard, a researcher at INSERM, the French equivalent of our National Institutes of Health, is tall and thin, friendly, in a shy way, and extravagantly polite. He speaks quietly, almost apologizing as he replies to my nasty-minded question.

Maybe the French diagnose heart disease in some funny way that pretties up their statistics? No, he says, skeptics have checked and rechecked French death certificates, reworking the figures to include all the fuzzy diagnoses that just might have been heart disease deaths, and the same picture always emerges.

Maybe some regions of France have high rates of heart disease but ride the coattails of regions that are especially healthy? I’m wondering about Normandy, famous for its butter and cream, and Richard grants me an indulgent smile.

“Yes, Normandy is doing poorly relative to France, but it’s doing well”--he pauses a moment trying vainly to come up with a delicate way to frame the comparison--”but it’s doing well relative to you.”

Another prominent French epidemiologist, Serge Renaud, had cackled cheerfully when I’d asked him about heart disease in different parts of France. “Do you know who has the lowest rate of death from heart disease in all of France?” he had asked me. “The least heart disease is in southwest France. That’s the place where they have duck fat instead of butter, where they eat foie gras. “

As I sit at dinner, sipping my vintage Sauternes, Richard gestures toward the pinkish slab of pate on my plate. “That’s fat,” he warns. “Not so good for you.” Then, with a conspiratorial grin as he indicates my wine glass. “You’d better drink your wine for protection.”

Richard may be joking, but it’s not entirely a joke. One study after another has found that moderate wine drinkers--those who drink about two glasses per day--have far less heart disease than either teetotalers or heavy drinkers. Eight studies in the 1970s and 1980s, in the United States and abroad, reported that moderate drinkers had between 30% and 40% less heart disease than control subjects.

Still another study looked at 18 countries and found “a strong and specific negative association between heart disease deaths and wine consumption.” A chart spelled out the message: Finland, the United States and Scotland were in a group that drank the least wine and had the most deaths from heart disease: Belgium, West Germany and Austria drank more wine and had fewer deaths; Switzerland, Italy and France drank the most wine and had the fewest deaths.

If wine should prove to have some ingredient that protects against heart disease, the authors concluded, “we consider it almost a sacrilege that this constituent should be isolated . . . the medicine is already in a highly palatable form.”

“Ah, Roquefort,” Richard sighs. I’ve been inquiring about his customary diet, and he’s been recalling the previous evening’s after-dinner cheese at home. Richard is not a rhapsodic fellow--he spends his days pondering mortality tables and calculating correlation coefficients--but the contemplation of cheese seems to induce a brief reverie.

He’s hardly alone in that enthusiasm. Cheese shops are everywhere in France. The tiny, immaculate fromagerie nearest my hotel was always jammed with customers who brought to their marketing a seriousness that Americans might reserve for an art gallery.

The French eat about 40 pounds of cheese per person each year, compared with about half that amount in the United States. That makes it all the more perplexing that France ranks so low in heart disease. Cheese is higher in cholesterol and saturated fat than even beef or pork.

One of the best known of the anti-cheese preachers is William Connor, a doctor and a highly regarded nutritionist at Oregon Health Sciences University. Connor, engaged in a study of heart disease in 40 countries, has been analyzing the relationship between different countries’ consumption of dairy fat--milk, butter, cheese, and so on--and their rate of heart disease. As he had expected, he found the higher the intake of dairy fat, the higher the rate of heart disease. It holds for cream, butter and milk, but there’s yet to be shown any correlation between how much cheese a country eats and how much heart disease it has. That sounds like a cue to break out the party hats to me, but Connor dismisses his own finding.

“Cheese is an awfully expensive food,” he says, “and the amount of cheese consumed was probably too low for a correlation to show up.”

But Serge Renaud, an epidemiologist based in Lyon, has just visited Connor’s lab and thinks Connor has given cheese a bad rap. “Even if you look only at countries that eat a lot of cheese, you see the same discrepancy,” he says. “We’ve seen for years that if you want to get a nice correlation between dairy fat and heart disease in different countries, then you’ve got to remove the cheese.”

The theory is that calcium neutralizes fat by combining with it so that both are excreted rather than absorbed. Curiously, researchers studying the entirely different problem of colon cancer have come to similar, though tentative, conclusion: Their patients seemed to benefit by supplementing their diet with calcium, presumably because it helped neutralize the cancer-promoting fat.

But if calcium makes cheese OK, shouldn’t regular whole milk be OK too? It’s not--Renaud agrees with nutritionists’ “steer clear” warnings--and he concedes he has no real answer to the question. He suspects that whole milk promotes heart disease because the calcium binds not to fat, as in cheese, but to protein, leaving the fat free to be efficiently absorbed.

In the meantime, cheese remains on every American nutritionist’s warning list, but not on Renaud’s. “It’s better to have cheeses that are lower in fat, like goat cheese, and these we don’t forbid,” he says. “First of all, cheese has a taste that cannot be replaced by anything else. And secondly, it’s not as damaging as other things.”

Richard sees me looking longingly at our empty bread basket and orders us a refill. All around us, diners are gulping down oysters and digging into sea urchins and carving up cotes de boeuf. In this tableau of indulgence, the sole image of restraint comes from a thin young woman seated at the table next to me. A waiter has just brought her dinner: a single spear of asparagus perfectly centered on the plate and adorned with one large dab of hollandaise sauce.

The food on all sides has given me a chance to trot out the multifarious explanations I’d been given for France’s good health. The authorities I’d talked to had all proposed pet theories, many of them temptingly tidy, and I was sure Richard would know what to make of them.

Hugh Tunstall-Pedoe, the British epidemiologist, had placed a lot of weight on the quality of French fruits and vegetables.

“The thing that fascinates me about the French is that they shop for fresh produce every day,” Tunstall-Pedoe had said. “The French treat food with enormous respect, and their methods of cooking don’t seem to damage it to the extent that other culinary traditions do.”

The rate of death from heart disease in Scotland is triple the rate in France. “The Scots overcook their vegetables--they stew them,” Tunstall-Pedoe had said, “and there’s a proportion of Scots who eat no fresh fruit at all.

“If--and this is a big if--if the anti-oxidant theory is correct,” Tunstall-Pedoe had told me, “that could tie everything together.” Anti-oxidant theory? The idea, he explained, is that unstable molecules called free radicals maraud around our bodies, in this case damaging fat-carrying particles in the blood so they more easily inflict injury on artery walls. The anti-oxidants, including certain vitamins and minerals in fresh fruits and vegetables that might not survive lengthy cooking, may help neutralize those raiders.

But when I run that suggestion by Richard, he responds with a bemused shrug, a resigned sigh. “Perhaps,” he allows. “We cannot say.” We settle into a pattern. I present Richard with some researcher’s explanation of France’s good health, he listens attentively, judiciously considers the matter over a sip of wine and then dodges the question. This is a man who would not jump to a conclusion if his house were on fire and rescuers were waiting on the ground with nets.

I ask about the theory that the French diet is actually far more healthful than the stereotype would have it. “The French eat more vegetables and grains and beans than a lot of the rest of the world, and, of course, they’re famous bread eaters,” is what I’d heard from Sonja Connor, a dietitian at Oregon Health Sciences University.

I’d heard a related theory from a colleague of Connor’s. “The eating habits of the French are totally different from here,” Sabine Artaud-Wild had told me. Artaud-Wild is a French-born dietitian who has been in the United States for 35 years. “Desserts and the sauces you hear so much about are for special occasions,” she’d said. “Everyday dessert is cheese and fruit. Portions are much smaller, and it’s drilled into the French people that you eat at mealtimes and not in between.”

Richard listens patiently to my paraphrase of those remarks, then says, “Well, yes. But we are also eating some things that are not so good.” He allows himself a tiny, wry smile.

Sausages, for instance. Paris is dotted with charcuteries, heralded by wooden signs in the shape of pigs. I’d spent some time wandering through these shops, as fascinated and appalled as a small-town minister in Times Square. There were sausages of every description and some beyond description. So much for the theory that rich and fatty French food is for tourists and real French citizens subsist on carrot sticks and mineral water.

But the French diet contains still another mystery. The French consume almost as many calories as Americans do, but they look skinnier. I ask Richard whether Americans really are fatter. It’s unfair, I realize, to make such a pleasant man choose between politeness and honesty, but I can’t resist.

“When you go to the United States, you are very surprised,” he begins, gingerly. Then, as his memories grow more vivid, he extends his hands in front of him, facing each other, then moves them farther and farther apart, as if gauging the size of a pair of great, waddling hips. “What is possible to see in France,” he says, his hands now about a yard apart, “is usual in the United States.” He seems momentarily shaken.

Richard also gives the notion of stress, or lack of it, some credence. “In the United States,” he says, squeezing his eyes shut and clenching his fists like a man in a headache commercial, “there is much more pressure.” It’s certainly true that the five-week vacation is a rite of French life and that at my customary walking pace I’d kept whipping past French amblers who seemed to have no destination at all. But it’s hard to buy the stress theory.

Japan, after all, has by far the lowest rate of death from heart disease in the industrialized world, and the Japanese are hardly lounging in hammocks and gazing at sunsets. And in both Japan and France, the suicide rate, which ought to be at least a rough barometer of stress, is far higher than the U.S. rate.

Nor does exercise seem a likely explanation for France’s healthy hearts. And it seems unlikely that the French share any hereditary traits that might protect them. France has been invaded and colonized from all directions for thousands of years and its population is hardly homogeneous.

Dessert arrives and interrupts my questioning. Richard and I have both ordered oeufs a la neige --islands of egg white floating on a vast, yellow ocean of egg yolks and sugar and milk. The table looks as if the American Heart Assn. has come to shoot a horror film.

“So I shouldn’t switch to rich cheeses and cream sauces and butter and pate?”

It’s the first of my questions that gets a rise out of Richard. He replies in a rat-a-tat-tat of dismay, like rain on a tin roof.

“No, no, no, no, no! We do not yet know what is the answer, but it is not that.”

Richard reflects a moment, then smiles faintly. “Perhaps it is the sky, or the light over France,” he suggests, and we lift our wine glass in melancholy tribute to the abiding distinction in our fates. He lives here.

I have to go back.