Albanian paradox, another example of protective effect of Mediterranean lifestyle?

Abstract

We doubt if the Albanian paradox is a paradox at all. Arjan Gjonça and Martin Bobak's (Dec 20/27, p 1815)1Gjonça A Bobak M Albanian paradox, another example of protective effect of Mediterranean lifestyle?.Lancet. 1998; 350: 1815-1817Summary Full Text Full Text PDF Scopus (99) Google Scholar observation tells us that the population of Albania enjoys a low adult mortality rate and, in particular, a low mortality rate from coronary heart disease. What surprises these workers is that a population with low socioeconomic status has such a low mortality rate, but what their finding indicates is that geography is much more powerful a predictor of coronary heart disease than is social class. It is quite clear that there is a gradient of mortality throughout Europe, with a low mortality rate from coronary heart disease in Mediterranean areas and a high rate in north-western parts. Indeed Gjonça and Bobak indicate that mortality rates within Albania compare well with their more northerly former communist neighbours in Hungary and Poland. The powerful relation between latitude and coronary heart disease death rate led us to propose that the major latitude-related geographical factor of sunlight energy at ground level has a major protective effect on human metabolism in relation to coronary heart disease, possibly by vitamin-D-mediated immune competence against what is probably a microbial disease.2Grimes DS Hindle E Dyer T Sunlight, cholesterol and coronary heart disease.Quart J Med. 1996; 89: 579-589Crossref Scopus (113) Google Scholar This is lent support by observations in the USA that living at a high altitude is protective against coronary heart disease. Social class is related to coronary heart disease in the more northern populations of Europe, in particular in the UK and Sweden. We have suggested that the poor are especially susceptible because of various factors that restrict their exposure to sunlight while living in locations that have both a high latitude and a great deal of cloud cover. The real question is whether latitude has its effect via a direct action of sunlight on human metabolism or whether the mediation is by prevailing agriculture and diet. Thus, the Albanian observations confirm our report that deaths from coronary heart disease have a fairly low incidence in places where the olive grows to agricultural maturity. Whether the olive is thereby an index of climate or whether consumption of the olive is protective is not entirely clear, but we suggest the former. A very detailed study undertaken as part of the MONICA project compared the health and diets of the adult male populations of Belfast and Toulouse.3Evans AE Ruidavets J-B McCrum E et al.Autres pays, autres coeurs? Dietary patterns, risk factors and ischaemic heart disease in Belfast and Toulouse (WHO MONICA project).Quart J Med. 1995; 88: 469-477Google Scholar Whereas the Belfast population had a far higher death rate not only from coronary heart disease but also from all causes, the dietary difference between the two populations was remarkably little. Indeed diet is becoming international. Although it is tempting to think that lifestyle and human misbehaviour are causes of coronary heart disease, there are just too many paradoxes. The Albanian paradox that a poor population can have a low coronary heart disease mortality rate must be added to the French paradox, which indicates that a diet that is regarded as harmful by traditional dogma is associated with a low mortality rate in the southern parts of France, and what might be called the Italian paradox, which shows that a high prevalence of cigarette smoking is associated with a low mortality rate from coronary heart disease. It is undoubtedly true that life in Mediterranean countries is protective against coronary heart disease, but we believe that geographical location is directly responsible rather than lifestyle and behaviour. Too many paradoxes means that the time is right for a major paradigm shift.