May 2024 Issue
Wine Intake and the Med Diet
By Mindy Hermann, MBA, RDN
Today’s Dietitian
Vol. 26 No. 5 P. 16
An Evidence-Based Review of Its Health Advantages and Drawbacks
Wine has a long history of use in the Mediterranean region, dating back to Neolithic and Biblical times. As populations shifted geographically, they brought viticulture and wine with them. So, wine drinking evolved as an essential element of the diets consumed in the Mediterranean.
The Mediterranean diet has been in the spotlight for many years. The Seven Countries Study was among the first to highlight the health benefits of the Mediterranean diet, focusing on its fat content and abundance of fruits and vegetables.1 In 1993, Oldways created the Mediterranean Diet Pyramid—in partnership with the Harvard School of Public Health and the World Health Organization—as a more healthful alternative to the USDA’s original food pyramid.2 The Pyramid includes wine in moderation.
In the early 2000s, National Geographic journalist Dan Buettner coined the term Blue Zones to identify communities in various regions of the world where residents live long and healthful lives.3 Two of the original Blue Zone areas are in the Mediterranean region, namely, the ancient region of Sardinia, Italy, and the Aegean Island of Ikaria, Greece. Residents in both communities eat a Mediterranean-style diet and drink alcohol regularly in moderation. In particular, the Sardinians drink a regional red wine called Cannonau (similar to Garnacha/Grenache), which is rich in flavonoids.
Studies Support the Health Benefits of Wine
Several studies support the health benefits of wine drinking as part of the Mediterranean diet. In 2014, the Spanish PREDIMED Study demonstrated that a Mediterranean diet that includes alcohol is more effective than a standard low-fat diet at reducing heart disease risk.4 The diet differs from other vegetable-based dietary patterns only in its customary use of olive oil and regular intake of wine with meals. Several studies have evaluated the impact of the Mediterranean alcohol-drinking pattern (MADP) on health outcomes from Spanish “Seguimiento Universidad de Navarra” (SUN) Prospective Cohort Study. The MADP is characterized by moderation, preference for red wine drinking with meals, and avoiding binge drinking. Among the more than 13,000 participants who were free of hypertension at the start of the SUN study, low adherence to the MADP was significantly associated with a higher incidence of arterial hypertension compared with the high-adherence group.5 Another evaluation of the SUN cohort compared adherence to the MADP with all-cause mortality in more than 2,000 women over age 55 and men over age 50.6 The study team classified participants as low, moderate, or high adherence to the MADP score or abstainers. The high adherence group had the greatest reduction in mortality risk, followed by the moderate adherence and abstention groups.
A group of Italian researchers considered the effects of the MADP and degree of adherence to the Mediterranean diet on all-cause mortality, CVD, cancer, digestive tract disease, and other causes.7 A sample of 3,411 alcohol consumers over age 18 from two prospective cohort studies was followed for approximately 16 years. Study participants with low adherence to the MADP had increases in risk of digestive diseases and cancer mortality. Those with low adherence to both the MADP and Mediterranean diet had higher overall mortality and mortality from digestive diseases.
A narrative review published in 2022 examined 24 in vitro studies on the relationship between the type and dose of alcohol or wine consumption and health (CVDs, type 2 diabetes, neurodegenerative diseases, cancer, and longevity).8 The authors concluded that wine differs from other alcoholic beverages; moderate wine consumption doesn’t increase the risk of chronic diseases; and wine may be associated with health benefits when consumed as part of a Mediterranean diet.
Several Scores for Diet Adherence Developed
In addition to evaluating the MADP and the relationship between alcohol and wine consumption and health, researchers developed many scores for diet adherence.
The Mediterranean Diet Scale (MDScale) was first created in 1995 and then revised in 2003 as a tool to study the relationship between diet and mortality among elderly residents of rural Greek villages.9 The MDScale awards one point for each of nine items, including alcohol—between 10 and 50 g per day for men and 5 and 25 g per day for women.
The Mediterranean Food Pattern includes 14 items and was developed for use in the Spanish PREDIMED study.10 Weekly consumption of each of the 14 items is tallied, with one point for consumption of at least seven glasses of wine per week.
The MD Score contains 14 diet components separated into those that are beneficial and those that are detrimental to health.11 Items receive a score of 0, 0.5, or 1 depending on frequency of consumption and nutritional value. Moderate wine consumption, ideally with meals, is considered beneficial while excessive or no wine consumption is considered detrimental.
The Short Mediterranean Diet Questionnaire assesses frequency of consumption of nine different food and beverage categories.12 Consumption of at least one glass of wine per day earns one point.
The Mediterranean Diet Score includes 11 items, each receiving a score from 0 to 5 depending on frequency per month: Never, 1–4, 5–8, 9–12, 13–18, and >18 times.13 Alcohol consumption was scored zero points for no consumption or consumption of more than 700 mL/day; 1–4 for consumption of 300 to 700 mL/day; and 5 for consumption of less than 300 mL/day but more than zero consumption.
Recommendations of Health Organizations
The 2020–2025 Dietary Guidelines for Americans state that adults of legal drinking age and who consume alcohol can choose not to drink or drink in moderation by limiting intake to two drinks or less per day for men and one drink or less per day for women.14 One alcoholic drink equivalent is 5 fl oz of wine, that’s 12% alcohol. Drinking less is better for health than drinking more if an adult aged 21 or older chooses to drink, and adults who are or might be pregnant shouldn’t drink or start drinking. Others who shouldn’t drink include those under the legal age for drinking, people with certain medical conditions or who are taking medications that can interact with alcohol, and those who are recovering from an alcohol use disorder or are unable to control the amount they drink.
Guidance from the American Heart Association is aligned with the dietary guidelines.15 The American Heart Association cautions that excess alcohol intake can increase risk of high blood pressure, cardiomyopathy, and cardiac arrhythmias. It also can raise blood triglyceride levels, risk of heart attack, or stroke risk factors, especially in combination with high LDL and/or low HDL levels. Binge drinking increases the risk of atrial fibrillation, and heavy drinking increases risk of atherosclerosis.
The Distilled Spirits Council of the United States (DISCUS) also is aligned with the recommendations of the Dietary Guidelines for Americans that cap daily alcohol consumption for adults of legal age who choose to drink. Kathleen M. Zelman, MPH, RDN, LD, a nutrition communications expert and advisor to DISCUS, cautions professionals and consumers not to attach a health halo to wine. “Treating wine differently sends the dangerous message that some forms of alcohol are ‘safer’ than others. To get the health benefits from resveratrol or other components of wine, one would need to drink an amount that would far exceed the recommendations for moderate consumption. Furthermore, scientific evidence has shown that it isn’t necessarily wine or components of wine, such as resveratrol, but the alcohol component that has health benefits.”
Should Alcohol Guidance Be Revised?
Miguel Martínez-González, MD, PhD, was a member of research teams that developed Mediterranean diet scores and is the principal investigator on the PREDIMED-PLUS trial. In a recent narrative review, Martínez-González questions whether wine should be removed from Mediterranean diet scores.16 He acknowledges that support for the inclusion of wine comes from several hallmark studies showing that the MADP reduces risk of various aspects of CVD, as well as all-cause mortality. On the flip side, Martínez-González emphasizes the drawbacks of alcohol, including the medical and public health threats of alcohol addiction and the association of alcohol consumption with increased risk of cancer, neurological damage, and physical injury. To help answer questions regarding alcohol and health, Martínez-González is spearheading a four-year study that will randomize at least 10,000 men aged 50 to 70 and women aged 55 to 75 to receive advice on either abstention or alcohol in moderation. The team will analyze various health and disease outcomes related to alcohol intake.
Guidance for Clients and Patients
Due to the possible health risks associated with alcohol drinking, dietitians also should take into account that all clients are unique individuals and have different risk factors, Zelman says.
“Adults who choose to drink should discuss their alcohol consumption with their health providers. The assertion that there is ‘no safe level’ of alcohol consumption for everyone is not supported by the overall body of scientific evidence; [the evidence] fails to account for individual factors that are key to evaluating risk; and [it] provides no guidance on whether to drink, how to drink in moderation for those who choose to drink, or how to address alcohol misuse and excessive consumption.”
Zelman adds that alcohol can have a place in a healthful dietary pattern when consumed responsibly, in moderation, and when following the guidance for a standard drink. She cautions that some people shouldn’t consume alcohol based on individual risk factors such as family history, genetics, and lifestyle.
“Moderate alcohol intake in the form of wine is a characteristic component of a traditional Mediterranean diet, enjoyed in populations made famous for their longer lives and lower rates of chronic disease,” says Kelly LeBlanc, MLA, RD, LDN, vice president of nutrition programming, at Oldways. “It’s important to remember that wine consumption as part of a healthy Mediterranean Diet is moderate, consumed with a healthy Mediterranean meal, and coupled with daily movement and social connections.” LeBlanc notes that when alcohol intake is accompanied by unhealthy or unsafe habits, obvious health risks present themselves. “There’s no reason to start taking up drinking if you don’t already, particularly if you have a family history of alcohol dependency. As with all nutrition guidance, individuals with health concerns or risks should work directly with their health care team to find an eating pattern that works for their specific needs.”
The MIND diet, a popular and highly rated eating pattern, is based on the heart-healthy Mediterranean and DASH diets and is optimized for brain health. According to Maggie Moon, MS, RD, brain health nutrition expert for MIND Diet Meals (minddietmeals.com), an online resource for brain healthy recipes and nutrition news about brain health promoting foods, and best-selling author of The MIND Diet, “The MIND diet includes a glass of wine a day, no more, no less, but you can reach therapeutic levels of the MIND diet without it, which is important since drinking alcohol isn’t right for everyone,” Moon says. “The wine component of the MIND diet has always been about finding a sweet spot for how much, if at all. At the end of the day, it’s a matter of personal choice, perhaps informed by a discussion with your dietitian and care team.” Two studies suggest that wine may have a protective effect against cognitive decline.17,18
Karen Collins, MS, RDN, CDN, FAND, nutrition advisor for the American Institute for Cancer Research, suggests caution regarding alcohol drinking. “Alcohol increases cancer risk. Alcohol metabolism produces free radicals that can damage cell DNA and lead to mutations. The increased risk of breast cancer related to alcohol consumption also likely involves alcohol’s effects increasing levels of estrogen circulating in the body.” Collins emphasizes that human studies don’t show that phytochemicals in red wine protect against cancer.
Collins advises dietetics professionals to read studies on the benefits of wine through a critical lens. “Check study methodology, including adjustments for potential confounding factors such as lifestyle and socioeconomic status. Check whether the study grouped all people who don’t drink alcohol together, even though lifestyle choices and cancer risk may differ substantially between people who quit drinking alcohol due to illness and people who never drink it or drink it only occasionally as part of an overall healthy lifestyle. For people who want to do everything they can to reduce cancer risk, avoiding alcohol or drinking only very occasionally is supported by research. For people whose family or cultural traditions or personal preferences fit better with limiting but not excluding alcohol, I encourage limiting alcohol to no more than one standard drink per day for women or two for men.”
— Mindy Hermann, MBA, RDN, is a food and nutrition communications consultant in metro New York.
References
1. What is the Seven Countries Study? Seven Countries Study website. https://www.sevencountriesstudy.com. Accessed February 10, 2024.
2. Mediterranean diet. Oldways website. https://oldwayspt.org/traditional-diets/mediterranean-diet. Accessed February 10, 2024.
3. Live better, longer. Blue Zones website. http://bluezones.com. Accessed February 10. 2024.
4. Ros E, Martínez-González MA, Estruch R, et al. Mediterranean diet and cardiovascular health: teachings of the PREDIMED study. Adv Nutr. 2014;5(3):330S-336S.
5. Hernández-Hernández A, Oliver D, Martínez-González MA, et al. Mediterranean alcohol-drinking pattern and arterial hypertension in the "Seguimiento Universidad de Navarra" (SUN) prospective cohort study. Nutrients. 2023;15(2):307.
6. Barbería-Latasa M, Bes-Rastrollo M, Pérez-Araluce R, Martínez-González MÁ, Gea A. Mediterranean alcohol-drinking patterns and all-cause mortality in women more than 55 years old and men more than 50 years old in the “Seguimiento Universidad de Navarra” (SUN) cohort. Nutrients. 2022;14(24):5310.
7. Campanella A, Bonfiglio C, Cuccaro F, Donghia R, Tatoli R, Giannelli G. High adherence to a Mediterranean alcohol-drinking pattern and Mediterranean diet can mitigate the harmful effect of alcohol on mortality risk. Nutrients. 2024;16(1):59.
8. Hrelia S, Di Renzo L, Bavaresco L, Bernardi E, Malaguti M, Giacosa A. Moderate wine consumption and health: a narrative review. Nutrients. 2022;15(1):175.
9. Trichopoulou A, Costacou T, Bamia C, Trichopoulos D. Adherence to a Mediterranean diet and survival in a Greek population. N Engl J Med. 2003;348(26):2599-2608.
10. Martínez-González MA, García-Arellano A, Toledo E, et al. A 14-Item Mediterranean diet assessment tool and obesity indexes among high-risk subjects: the PREDIMED trial. PLoS ONE. 2012;7(8):e43134.
11. Leighton F, Polic G, Strobel P, et al. Health impact of Mediterranean diets in food at work. Public Health Nutr. 2009;12:1635-1643.
12. Zito FP, Polese B, Vozzella L, et al. Good adherence to Mediterranean diet can prevent gastrointestinal symptoms: a survey from Southern Italy. World J Gastrointest Pharmacol Ther. 2016;7(4):564-571.
13. Panagiotakos DB, Pitsavos C, Stefanadis C. Dietary patterns: a Mediterranean diet score and its relation to clinical and biological markers of cardiovascular disease risk. Nutr Metab Cardiovasc Dis. 2006;16(8):559-568.
14. US Department of Agriculture; Health and Human Services. Dietary Guidelines for Americans 2020-2025. 9th Edition. https://www.dietaryguidelines.gov/sites/default/files/2020-12/Dietary_Guidelines_for_Americans_2020-2025.pdf. Published December 2020.
15. Is drinking alcohol part of a healthy lifestyle? American Heart Association website. https://www.heart.org/en/healthy-living/healthy-eating/eat-smart/nutrition-basics/alcohol-and-heart-health. Updated December 30, 2019. Accessed February 10, 2024.
16. Martínez-González MA. Should we remove wine from the Mediterranean diet?: a narrative review. Am J Clin Nutr. 2024;119(2):262-270.
17. Martínez-Lapiscina EH, Clavero P, Toledo E, et al. Mediterranean diet improves cognition: the PREDIMED-NAVARRA randomised trial. J Neurol Neurosurg Psychiatry. 2013;84(12):1318-1325.
18. Lucerón-Lucas-Torres M, Cavero-Redondo I, Martínez-Vizcaíno V, Saz-Lara A, Pascual-Morena C, Álvarez-Bueno C. Association between wine consumption and cognitive decline in older people: a systematic review and meta-analysis of longitudinal studies. Front Nutr. 2022;9:863059.