Cardiovascular System

Is the “J-Curve” Real?


  1. J-curve - Lower risk for light to moderate drinkers compared to abstainers

For many decades, epidemiological studies have consistently shown that light-to-moderate  consumers of alcoholic beverages have a lower risk of cardiovascular disease (CVD) and a lower risk of death from all causes (including total cancer) compared with non-drinkers or those who drink heavily. It is not limited to alcohol-related causes of death, but instead captures all deaths combined (Brien et al 2011, Ronksley et al 2011, di Castelnuovo et al 2006, Roerecke et al 2012, Ferrari et al 2014, Jayasekara et al 2014, Xi et al 2017, Wood et al 2018, Colpani et al 2018).

  • Such a J-shaped relationship (J-curve) has been shown in many different populations and dozens of observational studies. In different degrees, it is also seen in men and women and with other types of alcoholic beverages (Corrao et al 2000, di Castelnuovo et al 2006, Gronbaek et al 2000).
  • Observational studies cannot prove causality but the observed association is considered  biologically plausible (see below). However, there is a scientific debate at which level of consumption the nadir of this curve lies.


  1. Comparison to Smoking

WHO and other institutions have repeatedly declared the risks of alcohol consumption equivalent to smoking. However, no benefit of “moderate smoking” has ever been found (de Gaetano et al 2017).



Fig. 2 Dose response analysis of smoking and all-cause mortality

(De Gaetano et al, 2017)


  1. J-shape also for other diseases

In addition to CVD and total mortality, a J-shaped curve exists for the risk of other diseases, for example for type-2 diabetes and dementia (Koppes et al 2006, Neafsey et al 2011, Koloverou et al 2014, Xu et al 2017, Lao et al 2020). 


  1. Correlation or cause?

Observational studies can only provide statistical associations/correlations and present absolute or relative risks of developing certain diseases. For example, moderate wine consumption can be correlated with a lower risk of heart attack. However, such a correlation does not necessarily mean that moderate wine consumption is the cause of a lower risk of heart attack. Only studies with a different design, such as randomized controlled trials, can prove cause and effect. In such a trial one group of participants would have to consume wine moderately every day with the meals and another (control) group would consume placebo wine. After several years of follow-up, the researchers determine whether in any of the two groups fewer heart attacks occur. If the wine group has fewer heart attacks, there is a proof that wine contributes to a lower risk of heart attack. For obvious reasons, such a study is not possible and observational studies are the second best option.

To get more certainty about a correlation, the researchers examine, if the observed effect is biologically plausible (Hill AB 1965). Does it make sense biologically/physiologically sense that wine drinkers have fewer heart attacks? Many controlled experiments have proven the beneficial physiological effects of light to moderate drinking of wine/alcoholic beverages.


What is biologically plausible: How does the protection of wine work?

These controlled experiments (Brien et al 2011) have shown that alcohol:

  • Improves the “good” cholesterol level (HDL increases) and decreases the „bad“ LDL cholesterol
  • Lowers the blood viscosity (blood becomes „thinner“)

 The phenolic, non-alcoholic compounds of wine:

  • Improve the endothelial function and maintain the elasticity of the blood vessels
  • Act as antioxidants and scavenger of free radicals


  1. Wine versus other alcoholic beverages

An increasing number of both animal experiments and human trials demonstrate that non-alcoholic substances (polyphenols) in wine provide additional protective effects against risk factors and diseases indicating that light to moderate wine consumption may be more beneficial than consuming other alcoholic beverages (Costanzo et al 2011, Gronbaek et al 2000). 

These observed positive health effects of light to moderate wine consumption may be - at least in part - linked to the protective effects of those specific bioactive ingredients in the wine as well as in the foods consumed with higher abundance in the Mediterra­nean diet.  Although these polyphenols are very poorly absorbed, recent scientific evidence suggests that wine polyphenols exert their effects through the gut microbiota. They seem to change the microbiota and at the same time, are metabolized by the intestinal bacteria (microbiota) into metabolites that are more bioavailable and can be absorbed more easily by the humans (Cueva et al 2017). 


  1. Influencing factors

Most epidemiological studies have only used the average amount of alcohol consumed (over a week or month) as the measure of exposure, however, other factors play an important role in the health outcome. i.e. Regular moderate consumers of alcoholic beverages had considerable health advantages compared to binge drinkers, even though they consumed on average the same amount.

  • Drinking pattern (moderate, regular vs. binge drinking) (Bagnardi et al 2008, Morland 2016, Saito et al 2018)
  • Drinking with the meals (Boban et al 2016, Giacosa et al 2016)
  • Alternate wine with water
  • The famous advice of Serge Renaud is: “You drink water, but you sip wine”.


  1. Underreporting

An important problem of observational studies is “under-reporting” of alcohol intake. This subsequently affects the J-curve. When “under-reporters” are removed from the study analysis, the curve shifts to the right, which means that the lowest risk of moderate drinkers is actually related to a higher amount of alcohol intake and the increased risk starts at a higher dosage (Klatsky et al 2014).


  1. Moderate wine consumption within a healthy lifestyle

Light to moderate consumption of wine/alcoholic beverages should be considered only one component of lifestyle factors related to health (Ruidavets et al 2004, Muller et al 2016). The most important aspects are:

  • Don’t smoke
  • Maintain a normal body weight (avoid becoming obese)
  • Exercise regularly
  • Eat a healthy diet (e.g., a Mediterranean-type diet)
  • Consume alcoholic beverages moderately and regularly with food, unless contraindicated

These lifestyle factors contribute not only to a longer life expectancy but also a longer life free of chronic diseases (Li et al 2018, Li et al 2020).


  1. Sick-quitters

Earlier studies included ex-drinkers in the non-drinking reference/control group that may have artificially increased the risk of disease for “current abstainers”, thus, confounding the J-shaped curve and negating a protective relationship with moderate drinking. However, more recent studies have corrected this flaw and when including only lifetime abstainers in the non-drinking category, a similar J-shaped curve was found and disproved the so called “sick-quitters” hypothesis (Shaper et al 1988, Rehm et al 2008, Mukamal et al, NIH).



According to the scientific evidence, wine drinkers seem to have a lower risk of cardiovascular and other diseases as well as a lower risk of death from all causes compared to non-drinkers when consuming wine moderately and regularly as part of a meal and within a healthy lifestyle. 


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More information and a glossary of terms may be found on the Wine Information Council website:

Ursula Fradera, Nicolai Worm (Chair, Wine Information Council)

For more information about the references of this summary, we invite you to take a look at the bibliography.

BACKGROUND: Alcohol and caffeine intakes may play a role in the development of sudden cardiac death (SCD) because of their effects on cholesterol, blood pressure, heart rate variability, and inflammation. OBJECTIVE: Our objective was to examine the association between long-term alcohol and caffeine intakes and risk of SCD in women. DESIGN: We examined 93,676 postmenopausal women who participated in the Women's Health Initiative Observational Study. Women were enrolled between 1993 and 1998 and were followed until August 2009. Women completed a food-frequency questionnaire at baseline and again at year 3. We modeled exposure to alcohol 3 ways: by using baseline intake only, a cumulative average of baseline and year 3 intake, and the most recent reported intake (a simple time-varying…
The results of studies on the role of appropriate wine consumption in the prevention of cardiovascular disease are inconsistent, suggesting that the general approach to the issue needs to be revisited before further research is conducted. A number of points for consideration are raised: (1) the necessity to characterize wine analytically, as the content in important components of wine, such as resveratrol, is influenced considerably by regional factors, such as climate and local oenological procedures; (2) the bioavailability of the components of wine, which appears to be adequate as a broad range of biological effects have been documented at low concentrations that can be achieved by moderate chronic wine consumption; (3) the lack of importance of wine color, as also…
Cardiovascular diseases are among the worldwide leading causes of shorter life expectancy and loss of quality of life. Thus, any influence of diet or life habits on the cardiovascular system may have important implications for public health. Most world populations consume alcoholic beverages. Since alcohol may have both protective and harmful effects on cardiovascular health, the identification of biochemical mechanisms that could explain such paradoxical effects is warranted. The vascular endothelium is the target of important mediating pathways of differential ethanol concentrations, such as oxidative stress, lipoproteins, and insulin resistance. Alcohol-induced endothelial damage or protection may be related to the synthesis or action of several markers, such as nitric oxide, cortisol, endothelin-1, adhesion molecules, tumor necrosis factor alpha, interleukin-6, C-reactive…
OBJECTIVE: To evaluate the strength of the evidence provided by epidemiological literature investigating drinking pattern as effect modifier of alcohol intake on the risk of coronary heart disease (CHD). DESIGN: Meta-analysis of observational studies. DATA SOURCES: Medline, citation tracking, from 1966 to 2006. Review methods: Original studies investigating the amount of alcohol intake, combined with the frequency of alcohol consumption and/or pattern of alcohol drinking affecting the risk of CHD were extracted. Among them, cohort and case-control studies reporting sufficient data to perform statistical analyses and using people who abstained from alcohol as the reference were included. RESULTS: Six (4 cohort and 2 case-control) out of 118 studies reviewed met the inclusion criteria. Compared with those who abstained from alcohol,…
BACKGROUND: The association between alcohol consumption and Coronary Heart Disease (CHD) has been broadly studied. Most studies conclude that moderate alcohol intake reduces the risk of CHD. There are many discussions on whether the association is causal or biased. The objective is to analyse the association between alcohol intake and risk of CHD in the Spanish cohort of the European Prospective Investigation into Cancer (EPIC). METHODS: Participants from the EPIC Spanish cohort were included (15,630 men and 25,808 women). The median follow up period was 10 years. Ethanol intake was calculated using a validated dietary history questionnaire. Participants with a definite CHD event were considered cases. A Cox regression model was performed adjusted for relevant covariables and stratified by age.…
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