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.

BACKGROUND AND AIMS: The alcohol-hypertension relation has been well documented, but whether women have protective effect or race and type of beverage consumed affect the association remain unclear. To quantify the relation between total or beverage-specific alcohol consumption and incident hypertension by considering the effect of sex and race. METHODS AND RESULTS: Articles were identified in PubMed and Embase databases with no restriction on publication date. Pooled relative risks (RRs) and 95% confidence intervals (CIs) were calculated by random effects models. Restricted cubic splines were used to model the dose-response association. This study involved 22 articles (31 studies) and included 414,477 participants. The hypertension risk was different among liquor, wine, and beer at 5.1-10 g/d of ethanol consumption (P-across subgroups…
BACKGROUND/AIMS: There are inconsistencies in the effects of low to moderate dose alcohol consumption on the development of hypertension in adult men. We hypothesized that a region-specific effect might participate in this heterogeneity. METHODS: We conducted a systematic review and meta-analysis to evaluate the effect of alcohol dose on hypertension incidence using contemporary data through December 2017. Subjects were categorized according to their level of alcohol consumption as non-drinkers (reference) and low- (0.01 to 20.0 g/day), moderate- (20.1 to 40.0 g/day), moderate- to high- (40.1 to 60.0 g/day), and high-dose (> 60.0 g/day) drinkers. We defined hypertension as a blood pressure >/= 140/90 mmHg and/or the use of anti-hypertensive drugs. RESULTS: In total, 11 articles (seven Asian and four Western)…
Importance: More than 1 million older adults develop heart failure annually. The association of alcohol consumption with survival among these individuals after diagnosis is unknown. Objective: To determine whether alcohol use is associated with increased survival among older adults with incident heart failure. Design, Setting, and Participants: This prospective cohort study included 5888 community-dwelling adults aged 65 years or older who were recruited to participate in the Cardiovascular Health Study between June 12, 1989, and June 1993, from 4 US sites. Of the total participants, 393 individuals had a new diagnosis of heart failure within the first 9 years of follow-up through June 2013. The study analysis was performed between January 19, 2016, and September 22, 2016. Exposures: Alcohol consumption…
Epidemiological studies of middle-aged populations generally find the relationship between alcohol intake and the risk of coronary heart disease (CHD) and stroke to be either U- or J-shaped. This review describes the extent that these relationships are likely to be causal, and the extent that they may be due to specific methodological weaknesses in epidemiological studies. The consistency in the vascular benefit associated with moderate drinking (compared with non-drinking) observed across different studies, together with the existence of credible biological pathways, strongly suggests that at least some of this benefit is real. However, because of biases introduced by: choice of reference categories; reverse causality bias; variations in alcohol intake over time; and confounding, some of it is likely to be…
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