Combined benefits of Mediterranean diet and drinking pattern better than individual?

In this large prospective study, the combined effects of the Mediterranean diet and Mediterranean alcohol drinking pattern was not significantly higher than their individual effects, however, a low adherence to both was associated with two-fold higher rates of all-cause mortality compared to subjects with a high adherence to both patterns. The association was similar for cancer and cardiovascular mortality.

The health benefits of the Mediterranean diet (MedDiet) have been widely studied. Controversy remains, however, for one of its main components: the intake of alcoholic beverages. Several studies have shown lower all-cause mortality rates associated with a higher adherence to the Med Diet. Moderate intake of alcoholic beverages is one of the traditional components of the MedDiet and the beneficial effects of the MedDiet may in part be attributed to moderate alcohol consumption.

This prospective Spanish study (the Seguimiento Universidad de Navarra = SUN study) with over 20,000 participants assessed the combined effect of adhering to the MedDiet and the alcohol drinking pattern on all-cause mortality. Previous studies have focused mainly on the average quantity of alcohol consumed without considering the drinking frequency, type of beverage, consumption with meals and binge episodes. The current study examined the effects of overall dietary patterns instead of looking at individual nutrients or foods and considered synergistic effects of individual foods and nutrients. This approach can also be applied to the consumption of alcoholic beverages. The traditional Mediterranean alcohol drinking pattern (MADP) (*) was defined as the customary way of drinking in Mediterranean countries.

The combined effect of the dietary and drinking patterns was not significantly higher than their individual effects. However, the results showed twofold higher rates of dying from any cause (all-cause mortality) in individuals with both a low adherence to the MedDiet and a low adherence to the MADP compared to participants with a high adherence. Similar results were observed for cancer and cardiovascular mortality. The beneficial effect of the MedDiet was not apparent among those with a drinking pattern very far from the MADP. When all aspects of the Mediterranean way of drinking (moderate consumption, red wine, mainly with meals, avoiding binge drinking) were taken into account, a strong inverse association with mortality was found. Such an approach offers a more comprehensive evaluation of alcohol consumption than merely counting the grams of alcohol consumed.

Is there an interaction between the effect of drinking pattern and the effect of dietary pattern? The potential carcinogenic effect of alcohol could be different, if consumed with meals or not. The authors describe an “alcohol washing effect”, where the consumption of foods could “wash” alcohol drinking and reduce the effect of ethanol and its carcinogenic metabolites. They further refer to the anti-oxidant effects of the MedDiet because of its high phenolic compound content (ie. wine, olive oil, vegetables). These phenolic compounds can play a preventive role in the cancer process. In the current study, the alcohol drinking pattern and the MedDiet do not interact/mutually influence each other with regards to mortality.

The authors conclude that although the combined effects of the MedDiet and MAPD does not to appear to be different from their individual effects, the joint effects of a low adherence to the MedDiet and a low adherence to the MAPD was associated with substantially higher rates of all-cause mortality. They consider such dietary approach applied to alcohol intake and including the drinking pattern as another component of the MedDiet as useful, since it may help to overcome some current controversies in epidemiological studies.

Morales, G et al, 2020, Mediterranean diet, alcohol-drinking pattern and their combined effect on all-cause mortality: the Seguimiento Universidad de Navarra (SUN) cohort, Eur J Nutr, https://doi.org/10.1007/s00394-020-02342-w

1. Moderate alcohol intake: 10-50g/day in men and 5-25g/day in women = 2 points

Lower than this range = 1 point

Higher than this range = 0 points

One point for:

2. Preferably wine (> 75% of alcohol as wine)
3. Selection of red wine (>75% of wine as red wine)
4. Low spirits consumption (<25% of total alcohol intake)
5. Consuming wine preferentially during meals (>75% of wine consumed during meal)
6. Alcohol intake spread over the week
7. Avoidance of excess drinking occasions (maximum number of drinks consumed on a single occasion did not exceed 5 drinks)

Low adherence: 0-2 points

Moderate adherence: 3-6 points

High adherence: 7-9 points