Introduction
The Mediterranean diet (MedDiet), rich in fruits, vegetables, whole grains, nuts, and healthy fats, is well established as beneficial for cardiovascular health. A debated component of this diet is wine consumption, which some studies suggest may confer health benefits, especially when consumed moderately, while others highlight potential risks. The aim of this study was to evaluate the association between adherence to the MedDiet—with and without wine consumption—and the risks of major cardiovascular disease (CVD) events and all-cause mortality in two large Spanish cohorts: the older, high-risk PREDIMED study and the younger, general-population SUN project.
Methods
The PREDIMED trial enrolled 7,447 participants at high cardiovascular risk, primarily older adults, who were followed for an average of 4.8 years. Adherence to the MedDiet was assessed using a validated 14-item questionnaire including a specific item on wine consumption, with a cut-off defined as seven glasses or fewer per week to indicate moderate drinking.
Major CVD events, such as heart attack and stroke, were systematically recorded. Mortality data were collected over 17 years. Additionally, the SUN project followed 23,133 relatively younger Spanish participants over 22 years, monitoring similar health outcomes.
Participants were categorized based on their adherence to the MedDiet, classified separately as either including or excluding wine consumption, allowing for comparison of effects.
Results
In PREDIMED, participants who adhered well to the MedDiet but excluded wine had a multivariate-adjusted hazard ratio (HR) for cardiovascular events of 0.84 (95% confidence interval [CI] 0.61-1.15) compared to poor adherents without wine. When wine consumption was included in good adherence, the HR improved to 0.55 (95% CI 0.36-0.83), indicating a stronger protective association.
Regarding mortality from any cause, good MedDiet adherence without wine was linked with an HR of 0.77 (95% CI 0.68-0.87), while including moderate wine consumption lowered the HR further to 0.67 (95% CI 0.57-0.78).
Dose-response analyses suggested that drinking three or more glasses of wine per day did not confer mortality risk reductions, highlighting the importance of moderation.
Notably, exploratory analyses that minimized bias from abstainers did not find significant differences, and wine-related interaction terms in the questionnaire were not statistically significant, suggesting some uncertainty in the specific role of wine.
In the SUN cohort, no significant associations were observed between MedDiet compliance or wine consumption and cardiovascular events. However, regarding all-cause mortality, the hazard ratio for good MedDiet adherents excluding wine was 0.94 (95% CI 0.71-1.26), and for those including wine, it was 0.54 (95% CI 0.28-1.04), showing a trend towards benefit but with wide confidence intervals.
Pooling data from both cohorts demonstrated that moderate wine consumption as part of the MedDiet was associated with a significantly lower risk of all-cause mortality (P = .01).
Discussion
The results indicate that within a Mediterranean dietary pattern, moderate wine consumption may have an additive beneficial effect on reducing mortality and cardiovascular risk, particularly in an older, higher-risk population such as that in PREDIMED. This aligns with previous hypotheses that polyphenols and antioxidants in wine could contribute to cardiovascular protection.
However, the lack of consistent findings in younger cohorts and the uncertainty due to some non-significant analyses suggest caution. Confounding factors, such as lifestyle, socioeconomic status, and drinking patterns, may influence results. Moreover, excessive drinking clearly negates benefits and increases risks.
These findings support guidelines recommending moderate, not excessive, alcohol intake and highlight the complex interplay of dietary components on heart health.
Clinical Implications
For clinicians and public health professionals, encouraging adherence to the Mediterranean diet remains a priority given its robust evidence base. Moderate wine consumption, defined here as approximately up to one glass per day, may be included for those who already drink alcohol, but it should not be started or increased solely for perceived health benefits.
It is essential to individualize advice considering patient risk factors, potential medication interactions, and personal preferences.
Conclusion
In summary, this investigation in two large Spanish cohorts suggests that moderate wine consumption as part of the Mediterranean diet may be associated with reduced cardiovascular risk and mortality, particularly among older, high-risk individuals. However, caution is warranted in interpreting these benefits due to inconsistencies and potential biases.
Further research is needed to clarify the precise role of wine and to identify which populations might benefit most while minimizing harm.
References
Martínez-González MA et al. Wine consumption, Mediterranean diet, and cardiovascular risk in two Spanish cohorts. European Heart Journal. 2026;47(27):3591-3606. PMID: 41667089.
