Skip to main content Accessibility help

Mediterranean alcohol-drinking pattern and mortality in the SUN (Seguimiento Universidad de Navarra) Project: a prospective cohort study

  • Alfredo Gea (a1), Maira Bes-Rastrollo (a1) (a2), Estefania Toledo (a1) (a2), Martin Garcia-Lopez (a3), Juan J. Beunza (a1) (a4), Ramon Estruch (a2) (a5) and Miguel A. Martinez-Gonzalez (a1) (a2)...


Moderate alcohol intake has been related to lower mortality. However, alcohol use includes other dimensions beyond the amount of alcohol consumed. These aspects have not been sufficiently studied as a comprehensive entity. We aimed to test the relationship between an overall alcohol-drinking pattern and all-cause mortality. In a Mediterranean cohort study, we followed 18 394 Spanish participants up to 12 years. A validated 136-item FFQ was used to assess baseline alcohol intake. We developed a score assessing simultaneously seven aspects of alcohol consumption to capture the conformity to a traditional Mediterranean alcohol-drinking pattern (MADP). It positively scored moderate alcohol intake, alcohol intake spread out over the week, low spirit consumption, wine preference, red wine consumption, wine consumed during meals and avoidance of binge drinking. During the follow-up, 206 deaths were identified. For each 2-point increment in a 0–9 score of adherence to the MADP, we observed a 25 % relative risk reduction in mortality (95 % CI 11, 38 %). Within each category of alcohol intake, a higher adherence to the MADP was associated with lower mortality. Abstainers (excluded from the calculations of the MADP) exhibited higher mortality (hazard ratio 1·82, 95 % CI 1·14, 2·90) than participants highly adherent to the MADP. In conclusion, better adherence to an overall healthy alcohol-drinking pattern was associated with reduced mortality when compared with abstention or departure from this pattern. This reduction goes beyond the inverse association usually observed for moderate alcohol drinking. Even moderate drinkers can benefit from the advice to follow a traditional MADP.

  • View HTML
    • Send article to Kindle

      To send this article to your Kindle, first ensure is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the or variations. ‘’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Mediterranean alcohol-drinking pattern and mortality in the SUN (Seguimiento Universidad de Navarra) Project: a prospective cohort study
      Available formats

      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      Mediterranean alcohol-drinking pattern and mortality in the SUN (Seguimiento Universidad de Navarra) Project: a prospective cohort study
      Available formats

      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      Mediterranean alcohol-drinking pattern and mortality in the SUN (Seguimiento Universidad de Navarra) Project: a prospective cohort study
      Available formats


Corresponding author

* Corresponding author: Professor M. A. Martinez-Gonzalez, email


Hide All
1 Costanzo, S, di Castelnuovo, A, Donati, MB, et al. (2010) Alcohol consumption and mortality in patients with cardiovascular disease: a meta-analysis. J Am Coll Cardiol 55, 13391347.
2 Jin, M, Cai, S, Guo, J, et al. (2013) Alcohol drinking and all cancer mortality: a meta-analysis. Ann Oncol 24, 807816.
3 Di Castelnuovo, A, Costanzo, S, Bagnardi, V, et al. (2006) Alcohol dosing and total mortality in men and women: an updated meta-analysis of 34 prospective studies. Arch Intern Med 166, 24372445.
4 Urbano-Marquez, A, Estruch, R, Navarro-Lopez, F, et al. (1989) The effects of alcoholism on skeletal and cardiac muscle. N Engl J Med 16, 409415.
5 Fernandez-Sola, J, Estruch, R, Grau, JM, et al. (1994) The relation of alcoholic myopathy to cardiomyopathy. Ann Intern Med 120, 529536.
6 Corrao, G, Bagnardi, V, Zambon, A, et al. (2004) A meta-analysis of alcohol consumption and the risk of 15 diseases. Prev Med 38, 613619.
7 Rimm, EB, Williams, P, Fosher, K, et al. (1999) Moderate alcohol intake and lower risk of coronary heart disease: meta-analysis of effects on lipids and haemostatic factors. BMJ 319, 15231528.
8 Estruch, R, Sacanella, E, Badia, E, et al. (2004) Different effects of red wine and gin consumption on inflammatory biomarkers of atherosclerosis: a prospective randomized crossover trial. Effects of wine on inflammatory markers. Atherosclerosis 175, 117123.
9 Facchini, F, Chen, YD & Reaven, GM (1994) Light-to-moderate alcohol intake is associated with enhanced insulin sensitivity. Diabetes Care 17, 115119.
10 Heath, DB (1997) Cultural variations among drinking patterns. In Drinking Patterns and their Consequences, pp. 103128 [Grant, M and Litvak, J, editors]. Washington, DC: Taylor & Francis.
11 Valencia-Martin, JL, Galan, I & Rodriguez-Artalejo, F (2007) Binge drinking in Madrid, Spain. Alcohol Clin Exp Res 31, 17231730.
12 Seguí-Gómez, M, de la Fuente, C, Vázquez, Z, et al. (2006) Cohort profile: the ’Seguimiento Universidad de Navarra’ (SUN) study. Int J Epidemiol 35, 14171422.
13 Martin-Moreno, JM, Boyle, P, Gorgojo, L, et al. (1993) Development and validation of a food frequency questionnaire in Spain. Int J Epidemiol 22, 512519.
14 Trichopoulou, A, Costacou, T, Bamia, C, et al. (2003) Adherence to a Mediterranean diet and survival in a Greek population. N Engl J Med 348, 25992608.
15 Renaud, S & de Lorgeril, M (1992) Wine, alcohol, platelets, and the French paradox for coronary heart disease. Lancet 339, 15231526.
16 Willett, WC, Sacks, F, Trichopoulou, A, et al. (1995) Mediterranean diet pyramid: a cultural model for healthy eating. Am J Clin Nutr 61, 1402S1406S.
17 World Health Organization (2010) International classification of diseases, 10th revision.
18 Martínez-González, MA, López-Fontana, C, Varo, JJ, et al. (2005) Validation of the Spanish version of the physical activity questionnaire used in the Nurses' Health Study and the Health Professionals' Follow-up Study. Public Health Nutr 8, 920927.
19 Trichopoulou, A, Bamia, C & Trichopoulos, D (2009) Anatomy of health effects of Mediterranean diet: Greek EPIC prospective cohort study. BMJ 338, b2337.
20 Tolstrup, JS, Jensen, MK, Tjønneland, A, et al. (2004) Drinking pattern and mortality in middle-aged men and women. Addiction 99, 323330.
21 Baglietto, L, English, DR, Hopper, JL, et al. (2006) Average volume of alcohol consumed, type of beverage, drinking pattern and the risk of death from all causes. Alcohol Alcohol 41, 664671.
22 Rehm, J, Greenfield, TK & Rogers, JD (2001) Average volume of alcohol consumption, patterns of drinking, and all-cause mortality: results from the US National Alcohol Survey. Am J Epidemiol 153, 6471.
23 Mukamal, KJ, Conigrave, KM, Mittleman, MA, et al. (2003) Roles of drinking pattern and type of alcohol consumed in coronary heart disease in men. N Engl J Med 348, 109118.
24 McElduff, P & Dobson, AJ (1997) How much alcohol and how often? Population based case–control study of alcohol consumption and risk of a major coronary event. BMJ 314, 11591164.
25 Wetterling, T, Veltrup, C, Driessen, M, et al. (1999) Drinking pattern and alcohol-related medical disorders. Alcohol Alcohol 34, 330336.
26 Renaud, SC, Guéguen, R, Siest, G, et al. (1999) Wine, beer, and mortality in middle-aged men from eastern France. Arch Intern Med 159, 18651870.
27 Harriss, LR, English, DR, Hopper, JL, et al. (2007) Alcohol consumption and cardiovascular mortality accounting for possible misclassification of intake: 11-year follow-up of the Melbourne Collaborative Cohort Study. Addiction 102, 15741585.
28 Klatsky, AL, Friedman, GD, Armstrong, MA, et al. (2003) Wine, liquor, beer, and mortality. Am J Epidemiol 158, 585595.
29 Grønbaek, M, Becker, U, Johansen, D, et al. (2000) Type of alcohol consumed and mortality from all causes, coronary heart disease, and cancer. Ann Intern Med 133, 411419.
30 Theobald, H, Bygren, LO, Carstensen, J, et al. (2000) A moderate intake of wine is associated with reduced total mortality and reduced mortality from cardiovascular disease. J Stud Alcohol 61, 652656.
31 Streppel, MT, Ocké, MC, Boshuizen, HC, et al. (2009) Long-term wine consumption is related to cardiovascular mortality and life expectancy independently of moderate alcohol intake: the Zutphen Study. J Epidemiol Community Health 63, 534540.
32 Nielsen, NR, Schnohr, P, Jensen, G, et al. (2004) Is the relationship between type of alcohol and mortality influenced by socio-economic status? J Intern Med 255, 280288.
33 Grønbaek, M, Deis, A, Sørensen, TI, et al. (1995) Mortality associated with moderate intakes of wine, beer, or spirits. BMJ 310, 11651169.
34 Strandberg, TE, Strandberg, AY, Salomaa, VV, et al. (2007) Alcoholic beverage preference, 29-year mortality, and quality of life in men in old age. J Gerontol A Biol Sci Med Sci 62, 213218.
35 Vlachopoulos, C, Tsekoura, D, Tsiamis, E, et al. (2003) Effect of alcohol on endothelial function in healthy subjects. Vasc Med 8, 263265.
36 Shai, I, Rimm, EB, Schulze, MB, et al. (2004) Moderate alcohol intake and markers of inflammation and endothelial dysfunction among diabetic men. Diabetologia 47, 17601767.
37 Arranz, S, Chiva-Blanch, G, Valderas-Martinez, P, et al. (2012) Wine, beer, alcohol and polyphenols on cardiovascular disease and cancer. Nutrients 4, 759781.
38 Kiviniemi, TO, Saraste, A, Toikka, JO, et al. (2007) A moderate dose of red wine, but not de-alcoholized red wine increases coronary flow reserve. Atherosclerosis 195, e176e181.
39 Frankel, EN, Kanner, J, German, JB, et al. (1993) Inhibition of oxidation of human low-density lipoprotein by phenolic substances in red wine. Lancet 341, 454457.
40 Pace-Asciak, CR, Hahn, S, Diamandis, EP, et al. (1995) The red wine phenolics trans-resveratrol and quercetin block human platelet aggregation and eicosanoid synthesis: implications for protection against coronary heart disease. Clin Chim Acta 235, 207219.
41 Jang, M, Cai, L, Udeani, GO, et al. (1997) Cancer chemopreventive activity of resveratrol, a natural product derived from grapes. Science 275, 218220.
42 Prescott, E, Grønbaek, M, Becker, U, et al. (1999) Alcohol intake and the risk of lung cancer: influence of type of alcoholic beverage. Am J Epidemiol 149, 463470.
43 Mortensen, EL, Jensen, HH, Sanders, SA, et al. (2001) Better psychological functioning and higher social status may largely explain the apparent health benefits of wine: a study of wine and beer drinking in young Danish adults. Arch Intern Med 161, 18441848.
44 Grønbaek, M, Tjønneland, A, Johansen, D, et al. (2000) Type of alcohol and drinking pattern in 56,970 Danish men and women. Eur J Clin Nutr 54, 174176.
45 Jensen, MK, Andersen, AT, Sørensen, TI, et al. (2002) Alcoholic beverage preference and risk of becoming a heavy drinker. Epidemiology 13, 127132.
46 Norström, T (1998) Effects on criminal violence of different beverage types and private and public drinking. Addiction 93, 689699.
47 Kauhanen, J, Kaplan, GA, Goldberg, DE, et al. (1997) Beer binging and mortality: results from the Kuopio ischaemic heart disease risk factor study, a prospective population based study. BMJ 315, 846851.
48 Graff-Iversen, S, Jansen, MD, Hoff, DA, et al. (2013) Divergent associations of drinking frequency and binge consumption of alcohol with mortality within the same cohort. J Epidemiol Community Health 67, 350357.
49 Murray, RP, Connett, JE, Tyas, SL, et al. (2002) Alcohol volume, drinking pattern, and cardiovascular disease morbidity and mortality: is there a U-shaped function? Am J Epidemiol 155, 242248.
50 Mukamal, KJ, Maclure, M, Muller, JE, et al. (2005) Binge drinking and mortality after acute myocardial infarction. Circulation 112, 38393845.
51 Roerecke, M, Greenfield, TK, Kerr, WC, et al. (2011) Heavy drinking occasions in relation to ischaemic heart disease mortality – an 11–22 year follow-up of the 1984 and 1995 US National Alcohol Surveys. Int J Epidemiol 40, 14011410.
52 Malyutina, S, Bobak, M, Kurilovitch, S, et al. (2002) Relation between heavy and binge drinking and all-cause and cardiovascular mortality in Novosibirsk, Russia: a prospective cohort study. Lancet 360, 14481454.
53 Mørch, LS, Johansen, D, Løkkegaard, E, et al. (2008) Drinking pattern and mortality in Danish nurses. Eur J Clin Nutr 62, 817822.
54 Kauhanen, J, Kaplan, GA, Goldberg, DD, et al. (1997) Frequent hangovers and cardiovascular mortality in middle-aged men. Epidemiology 8, 310314.
55 Laatikainen, T, Manninen, L, Poikolainen, K, et al. (2003) Increased mortality related to heavy alcohol intake pattern. J Epidemiol Community Health 57, 379384.
56 Gruchow, HW, Hoffmann, RG, Anderson, AJ, et al. (1982) Effects of drinking patterns on the relationship between alcohol an coronary occlusion. Atherosclerosis 43, 393404.
57 Kiechl, S, Willeit, J, Rungger, G, et al. (1998) Alcohol consumption and atherosclerosis: what is the relation? prospective results from the Bruneck Study. Stroke 29, 900907.
58 McKee, M & Britton, A (1998) The positive relationship between alcohol and heart disease in eastern Europe: potential physiological mechanisms. J R Soc Med 91, 402407.
59 Standerwick, K, Davies, C, Tucker, L, et al. (2007) Binge drinking, sexual behaviour and sexually transmitted infection in the UK. Int J STD AIDS 18, 810813.
60 Brewer, RD & Swahn, MH (2005) Binge drinking and violence. JAMA 294, 616618.
61 Hätönen, KA, Virtamo, J, Eriksson, JG, et al. (2012) Modifying effects of alcohol on the postprandial glucose and insulin responses in healthy subjects. Am J Clin Nutr 96, 4449.
62 Foppa, M, Fuchs, FD, Preissler, L, et al. (2002) Red wine with the noon meal lowers post-meal blood pressure: a randomized trial in centrally obese, hypertensive patients. J Stud Alcohol 63, 247251.
63 Fuhrman, B, Lavy, A & Aviram, M (1995) Consumption of red wine with meals reduces the susceptibility of human plasma and low-density lipoprotein to lipid peroxidation. Am J Clin Nutr 61, 549554.
64 Trevisan, M, Schisterman, E, Mennotti, A, et al. (2001) Drinking pattern and mortality: the Italian Risk Factor and Life Expectancy pooling project. Ann Epidemiol 11, 312319.
65 Shaper, AG, Wannamethee, G & Walker, M (1988) Alcohol and mortality in British men: explaining the U-shaped curve. Lancet 2, 12671273.
66 Hu, FB (2002) Dietary pattern analysis: a new direction in nutritional epidemiology. Curr Opin Lipidol 13, 39.
67 Schulze, MB & Hoffmann, K (2006) Methodological approaches to study dietary patterns in relation to risk of coronary heart disease and stroke. Br J Nutr 95, 860869.
68 World Health Organization (2011) Global Status Report on Alcohol and Health. Geneva: WHO.


Related content

Powered by UNSILO

Mediterranean alcohol-drinking pattern and mortality in the SUN (Seguimiento Universidad de Navarra) Project: a prospective cohort study

  • Alfredo Gea (a1), Maira Bes-Rastrollo (a1) (a2), Estefania Toledo (a1) (a2), Martin Garcia-Lopez (a3), Juan J. Beunza (a1) (a4), Ramon Estruch (a2) (a5) and Miguel A. Martinez-Gonzalez (a1) (a2)...


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed.