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.
  • 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.

 

  • 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.
  • 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.

 

2. 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.

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, Alcohol and health – praise of the J-curve, J Am Coll Cardiology, vol 70, no 8

 

3. 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. 

 

4. Correlation or cause?

Observational studies can only provide statistical associations and present absolute or relative risks of developing certain diseases and cannot be interpreted as a proof of a causal relationship. However, the associations described are biologically plausible: controlled experiments have proven the beneficial physiological effects of light to moderate drinking of wine/alcoholic beverages.

 

Biologically plausible: How does it work?

Effect of alcohol:

  • Improvement of cholesterol levels: „good“ HDL increases, „bad“ LDL decreases
  • Lowering of blood viscosity (blood becomes „thinner“)

Effect of phenolic, non-alcoholic compounds of wine:

  • Improvement of endothelial function
  • Antioxidant effect/scavenger of free radicals

 

5. Wine versus other alcoholic beverages

Light to moderate wine consumption may be more beneficial than consuming 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.

 

6. 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)
  • Drinking with the meals
  • Alternate wine with water
  • The famous advice of Serge Renaud is: “You drink water, but you sip wine”.

 

7. 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.

 

8. 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. 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.

 

9. 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.

Although, three decades have pasted from the introduction of "French Paradox", is still an issue for debate. Epidemiology supports the J-shaped relationship between wine consumption and vascular events as well as cardiovascular mortality with a maximum protection at 21 g of alcohol consumption in the form of wine per day. Nevertheless, the aforementioned studies have used an observational design that raises concerns about potential confounding. Randomized clinical studies may provide data to end the controversy and in parallel with in vitro experiments to elucidate the mechanisms by which wine affects cardiovascular disease. In this concept, this review aims to address the presence of bioactive wine micro constituents, their potential mechanisms of action and also to summarize the cardio-protective effects of…
Existing data have described benefits and drawbacks of alcohol consumption on cardiovascular diseases (CVD), but no research has evaluated its association with the cardiovascular health (CVH) score proposed by the American Heart Association. Here, we conducted a cross-sectional analysis on the Kardiovize cohort (Brno, Czech Republic), to investigate the relationship between alcohol consumption and CVH. We included 1773 subjects (aged 25-64 years; 44.2% men) with no history of CVD. We compared CVD risk factors, CVH metrics (i.e., BMI, healthy diet, physical activity level, smoking status, blood pressure, fasting glucose, and total cholesterol) and CVH score between and within several drinking categories. We found that the relationship between drinking habits and CVH was related to the amount of alcohol consumed, drinking…
BACKGROUND & AIMS: Managing alcohol consumption may be an effective way of preventing hypertension, which is an important modifiable risk factor for cardiovascular diseases. However, there is little evidence on the temporal relationship between alcohol consumption and incidence of hypertension. We investigated the prospective association between repeated measures of alcohol consumption and hypertension incidence among Korean adults aged 40 and over. METHODS: This study included a total of 4989 participants that were not taking antihypertensive drugs and had normal blood pressure (BP) (systolic
BACKGROUND: Observational studies have documented lower risks of coronary heart disease and diabetes among moderate alcohol consumers relative to abstainers, but only a randomized clinical trial can provide conclusive evidence for or against these associations. AIM: The purpose of this study was to describe the rationale and design of the Moderate Alcohol and Cardiovascular Health Trial, aimed to assess the cardiometabolic effects of one alcoholic drink daily over an average of six years among adults 50 years or older. METHODS: This multicenter, parallel-arm randomized trial was designed to compare the effects of one standard serving ( approximately 11-15 g) daily of a preferred alcoholic beverage to abstention. The trial aimed to enroll 7800 people at high risk of cardiovascular disease.…
BACKGROUND: Reductions in World Health Organization (WHO) risk drinking levels have recently been shown to lower the risk of multiple adverse health outcomes, but prior work has not examined reductions in WHO risk drinking levels in relation to cardiovascular disease (CVD), the leading cause of death for men and women in the United States and of global mortality. This study examined associations between reductions in WHO risk drinking levels and subsequent risk for CVD. METHODS: In a US national survey, 1,058 very-high-risk and high-risk drinkers participated in Wave 1 interviews (2001 to 2002) and Wave 2 follow-ups (2004 to 2005). Self-reported CVD history that was communicated to the participant by a doctor or other healthcare professionals included arteriosclerosis, hypertension, angina,…
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