María Barbería-Latasa

Background and Aims: The benefits of the Mediterranean diet (MedDiet) are well established. However, one component, wine, remains controversial. This study assessed the association between MedDiet (with or without wine consumption) and major cardiovascular disease (CVD) or all-cause mortality. Methods: The PREDIMED trial included 7447 high-risk participants. Adherence to MedDiet was measured using a validated 14-item questionnaire, including one item on wine (cut-off: seven glasses/week). The CVD events were recorded over a 4.8-year follow-up, while all-cause mortality was tracked for 17 years. A younger Spanish cohort (the SUN project), including 23,133 participants followed up for 22 years, was also evaluated. Results: In PREDIMED, compared with poor compliers with MedDiet (excluding wine), good compliers (excluding wine), had a multivariable-adjusted hazard ratio (HR) of 0.84 [95% confidence interval (CI) 0.61–1.15] for CVD. For good compliers with MedDiet (including wine), the HR for CVD was 0.55 (95% CI 0.36–0.83). For all-cause mortality, MedDiet compliers (excluding wine) had HR of 0.77 (95% CI 0.68–0.87), which was 0.67 (95% CI 0.57–0.78) for MedDiet compliers (including wine). In exploratory dose–response analyses, reduced risk for death was not present in PREDIMED participants who drank three or more glasses of wine/day. Additionally, analyses least vulnerable to threats of abstainer bias were not significant and neither were multiplicative interaction terms for the wine item in the questionnaire. In the SUN cohort, no significant associations were observed between MedDiet compliance, wine, and CVD. However, for all-cause mortality, the HR was 0.94 (95% CI 0.71–1.26) for MedDiet compliers (excluding wine) and 0.54 (95% CI 0.28–1.04) for MedDiet compliers (including wine). When pooling both cohorts, wine consumption within the MedDiet was associated with lower all-cause mortality (P = .01). Conclusions: In PREDIMED, moderate wine consumption, as part of the MedDiet, appeared to be associated with lower mortality and CVD risk. Some non-significant associations and interactions advise caution in interpretation of these findings.

The overall health impact of alcohol remains controversial. The Global Burden of Disease (GBD) study made headlines in 2018 by stating that zero alcohol was the safest option. However, its 2022 update introduced age-specific adaptations, asserting that moderate drinking may offer net benefits in some populations. The 2025 U.S. Surgeon General report also discouraged any alcohol intake because of associated cancer risks, but a simultaneous report by the National Academies emphasized tailoring recommendations to individual risks. Mendelian randomization (MR) studies found no health benefits and highlighted increased risks—even at low alcohol doses—challenging dozens of conventional epidemiologic findings in large observational cohorts, some of them of high methodological quality. Given these contradictions, there is a pressing need for large randomized controlled trials in drinkers promoting cessation versus moderation. While small trials have shown some metabolic and cardiovascular benefits of moderate red wine consumption, no large-scale randomized trial has yet assessed hard clinical outcomes comprehensively. Without such evidence, debates will persist. Current guidelines appropriately discourage alcohol in certain populations, but generalizations such as “no safe level of alcohol” might lack sufficient empirical support and perhaps they need a tailored and practical strategy in the context of precision medicine. A balanced, evidence-based approach—free from bias, independent of the industry and grounded in rigorous research—is essential for informed public health policy decisions.

Background/Objectives: Since 1988, the IARC has classified alcohol as a type 1 carcinogen, causally linked to seven types of cancer (oral cavity, pharynx, larynx, esophagus, colorectum, liver and breast carcinomas). Several agencies, such as the WHO and the IARC, hold that there is a direct monotonic association between any gram of alcohol consumed and the risk of cancer, regardless of the drinking pattern. On the other hand, an expanding body of evidence indicates that drinking pattern may substantially modify the effect of alcohol consumption. The Mediterranean alcohol-drinking pattern (MADP) includes different aspects of alcohol consumption, such as preference for red wine, moderate alcohol consumption with meals, spreading consumption over the week and avoiding binge drinking. Conformity to this pattern has shown inverse associations with all-cause mortality, cardiovascular disease and diabetes. However, its relationship with cancer incidence has not been studied yet. Our objective was to assess how alcohol consumption patterns, with particular emphasis on the MADP, relate to the incidence of the seven alcohol-related cancers. This information is needed to support cancer prevention recommendations that may go beyond the amount of alcohol consumed to also include the drinking pattern. Methods: We prospectively followed 19,541 participants in the SUN (“Seguimiento Universidad de Navarra”) cohort for a median of 13.8 years. We classified participants into four groups, namely, abstainers and three further groups according to their adherence to the MADP score (low, moderate and high). Results: A substantial reduction in the risk of alcohol-related cancer incidence was observed only in men for high versus low adherence to the MADP, with an adjusted hazard ratio (HR) of 0.44 (95% confidence intervals (CIs) (0.21–0.92)). The category of moderate adherence to the MADP showed a lower risk of cancer incidence with a tendency towards statistical significance (HR = 0.56, 95% CI, 0.30–1.06). For women, no result reached statistical significance. Conclusions: Based on the available evidence, separate messages by sex should be delivered. In men, the association between alcohol and cancer goes beyond the amount of alcohol consumed, and a Mediterranean drinking pattern may be beneficial even for alcohol-related cancers. Men should, therefore, receive an additional message: among alcohol consumers, greater adherence to the MADP may help lower their risk of developing alcohol-related cancers. No benefit is supported for the MADP against alcohol-related cancers in women.

Since the 1950s, when Ancel Keys popularized the traditional Mediterranean diet, an immense accrual of large and valid studies, including prospective cohort studies, randomized controlled trials (RCT), and systematic reviews, have been conducted to investigate the potential health benefits related to this dietary pattern. The available evidence shows that the traditional Mediterranean diet represents a sustainable, healthy, and highly palatable pattern with a wide array of associated health benefits. In particular, its protective effects on cardiovascular disease have been supported by several consistent large RCTs, namely, the Lyon Diet-Heart Study, PREDIMED, PREDIMED-Plus and CORDIOPREV. The traditional Mediterranean diet is not a vegetarian diet, but it emphasizes the preferential consumption of minimally processed plant-based foods: fruits, vegetables, whole-grain cereals, legumes, and tree nuts. Its unique components—different from other healthy, plant-based, food patterns—are extra-virgin olive oil as the main source of fat (keeping a high monounsaturated-to-saturated fat ratio), a high consumption of tree nuts, and low-to-moderate consumption of red wine with meals. However, the inclusion of an alcoholic beverage in a healthy diet is becoming increasingly controversial. An ongoing RCT, the University of Navarra Alumni Trialist Initiative (UNATI), aims to answer this question in 10 000 drinkers. In addition to conventional epidemiologic studies, metabolomics techniques have been applied to assess the role of adherence to the Mediterranean diet and to better understand the mechanisms involved in the protection afforded by this interesting dietary pattern. In this review, we update the available scientific evidence.

The traditional Mediterranean Diet (MedDiet) has consistently demonstrated robust benefits in reducing cardiovascular, metabolic, and oncologic risks. Its high content of anti-inflammatory and antioxidant compounds, particularly (poly)phenols, underscores why this dietary pattern has been extensively researched and widely adopted for managing various metabolic conditions. This article aims to conduct a narrative review of the association between the MedDiet (and its debated alcohol consumption pattern) and a reduced risk of liver disease, with a specific focus on the potential preventive role of the MedDiet on Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD), which is now the most prevalent chronic liver disease globally. To carry out this review, relevant articles were searched on PubMed and other databases. The evidence found contributed to identifying the gaps in knowledge and allowed for the main findings to be summarized. Available randomized controlled trials and prospective cohort studies consistently support the hypothesis that high adherence to the MedDiet effectively reduces hepatic fat content, improves liver enzyme levels, and mitigates fibrosis progression. Crucially, this dietary pattern simultaneously addresses the significantly high cardiovascular risk inherent in MASLD. Historically, low-to-moderate alcohol intake, particularly moderate red wine with meals, was assumed to be a beneficial component of the MedDiet. While some observational studies suggest potential cardiovascular benefits, implying a loss of some MedDiet benefits if alcohol is excluded, a growing body of evidence highlights a deleterious synergistic interaction between alcohol, visceral adiposity, hepatic steatosis, and metabolic dysfunction. Based on the available evidence, clinical guidelines recommend the MedDiet with exercise for the prevention and management of MASLD. However, the alcohol consumption in the Mediterranean is currently under strong controversy. Furthermore, recent guidelines now advise total abstinence in patients with advanced liver disease and caution even at earlier MASLD stages. Yet, these assertions are largely based on observational data, underscoring the need for large clinical trials to address this issue with first-level evidence.

Background: Binge-drinking is one of the alcohol drinking patterns with the worst health consequences. Nonetheless, binge-drinking is highly prevalent. The perceived benefits that motivate it are ultimately related to subjective well-being. In this context, we analyzed the relationship between binge-drinking and quality of life. Methods: We evaluated 8992 participants of the SUN cohort. We classified as binge-drinkers those who reported consuming six or more drinks on at least one occasion the year before recruitment (n = 3075). We fitted multivariable logistic regression models to calculate the odds ratios (ORs) of a worse physical and mental quality of life, measured with the validated SF-36 questionnaire at 8 years of follow-up (cut-off point = P₇₅ or highest score). Results: Binge-drinking was associated with greater odds of having a worse mental quality of life, even adjusting for quality of life at 4 years of follow-up, used as an approximation to a baseline measure (OR = 1.22 (1.07–1.38)). This value was mainly due to the effects on vitality (OR = 1.17 (1.01–1.34)) and mental health (OR = 1.22 (1.07–1.39)). Conclusions: Binge-drinking may lead to poorer mental quality of life; therefore, binge-drinking for enhancement purposes does not seem to be justified by this effect.

Background: Most of the available epidemiological evidence on alcohol and chronic disease agrees on recommending alcohol abstention to young people, but some controversy exists about the most appropriate recommendation for alcohol abstention for people of older ages. A growing body of evidence suggests that the pattern of alcohol consumption is likely to be a strong effect modifier. The Mediterranean Alcohol Drinking Pattern (MADP) represents a score integrating several dimensions of drinking patterns (moderation, preference for red wine, drinking with meals, and avoiding binge drinking). Our aim was to clarify this issue and provide more precise recommendations on alcohol consumption. Methods: We prospectively followed-up 2226 participants (men older than 50 years and women older than 55 years at baseline) in the Seguimiento Universidad de Navarra (SUN) cohort. We classified participants into three categories of adherence to the MADP score (low, moderate, and high), and we added a fourth category for abstainers. Cox regression models estimated multivariable-adjusted hazard ratios (HR) of all-cause death and 95% confidence intervals (CI) using low MADP adherence as the reference category. Results: The strongest reduction in risk of mortality was observed for those with high adherence to the MADP, with an HR of 0.54 (95% CI: 0.37–0.80). The moderate adherence group (HR = 0.65, 95% CI: 0.44–0.96) and the abstention group (HR = 0.60, 95% CI: 0.36–0.98) also exhibited lower risks of mortality than the low MADP adherence group. Conclusions: based on the available evidence, a public health message can be provided to people older than 50 years as follows: among those who drink alcohol, high adherence to the MADP score could substantially reduce their risk of all-cause mortality.

This review discusses the inconsistent recommendations on alcohol consumption and its association with chronic disease, highlighting the need for an evidence-based consensus. Alcohol is an addictive substance consumed worldwide, especially in European countries. Recommendations on alcohol consumption are controversial. On one hand, many nonrandomized studies defend that moderate consumption has a beneficial cardiovascular effect or a lower risk of all-cause mortality. On the other hand, alcohol is associated with an increased risk of cancer, neurological diseases, or injuries, among others. For years, efforts have been made to answer the question regarding the safe amount of alcohol intake, but controversies remain. Observational studies advocate moderate alcohol consumption following a Mediterranean pattern (red wine with meals avoiding binge drinking) as the best option for current drinkers. However, agencies such as the IARC recommend abstention from alcohol as it is a potent carcinogen. In this context, more randomized trial with larger sample size and hard clinical endpoints should be conducted to clarify the available evidence and provide clinicians with support for their clinical practice.

The aim of this study was to assess the association between alcohol intake and premature mortality (younger than 65 years) and to explore the effect of potential alcohol underreporting by heavy drinkers. We followed-up 20 272 university graduates. Four categories of alcohol intake were considered (abstainer, light, moderate and heavy consumption). Repeated measurements of alcohol intake and updated information on confounders were used in time-dependent Cox models. Potential underreporting of alcohol intake by some heavy drinkers (likely misclassified as light or moderate drinkers) was explicitly addressed in an attempt to correct potential underreporting by using indirect information. During 12·3 years of median follow-up (interquartile range: 6·8–15·0), 226 participants died before their 65th birthday. A higher risk of early mortality was found for the highest category of alcohol intake (≥50 g/d) in comparison with abstention (multivariable-adjusted hazard ratio (HR) = 2·82, 95 % CI 1·38, 5·79). In analyses of alcohol as a continuous variable, the multivariable-adjusted HR was 1·17 (95 % CI 1·08, 1·26), for each 10 g/d of alcohol. This harmful linear association was present both in uncorrected models and in models corrected for potential underreporting. No significant inverse association between light or moderate alcohol intake and premature mortality was observed, even after correcting for potential misclassification. Alcohol intake exhibited a harmful linear dose–response association with premature mortality (<65 years) in this young and highly educated Mediterranean cohort. Our attempts to correct for potential misclassification did not substantially change these results.