Introduction

Although current epidemiological evidence is largely consistent as to the detrimental effects of heavy drinking in terms of health, the public in particular receives inconsistent and confusing message regarding the safety of light-to-moderate alcohol consumption (Kunzmann et al., 2018). In a SUN (Seguimiento Universidad de Navarra) prospective study, the authors concluded that the effect on mortality of the overall healthy alcohol-drinking pattern is more important than the total quantity of alcohol consumed (Gea et al., 2014), while other studies either suggested that “there were no clear risk thresholds below which lower alcohol consumption stopped being associated with lower disease risk” (Wood et al., 2018) or restricted the beneficial effects to people with no genetic predisposition (Au Yeung et al., 2013). Moreover, in a recent prospective population-based study, (Schutte et al. (2020) highlighted that only wine could be associated with a protective role with regards to ischemic heart disease, whereas the consumption of beer/cider and spirits, even in low levels, was associated with an increased risk for all health outcomes (Schutte et al., 2020). Furthermore, the findings from an ecological US study in a nationally representative cohort of households showed that, compared to non-drinkers, participants who purchased high levels of wine or beer, but not liquor, were less likely to be diagnosed with diabetes mellitus, while participants who purchased moderate levels of wine were 25 % less likely to be diagnosed with heart disease (Adjemian et al., 2015).

Thus surprisingly little is known about the risks or benefits of moderate consumption of specific alcoholic beverages in terms of the health status of adults. The interpretation of the conclusions of epidemiological studies which examine the effects of alcohol consumption on human health will be unclear, limited and unsustainable, if they are not evaluated from a wider and more holistic perspective. Any discrimination related to type of alcoholic beverage has to be based on more than differences in chemical composition (Osorio-Paz et al., 2019), mainly because choice of beverage type usually reflects a particular lifestyle, which can be defined as healthy, less healthy or even unhealthy.

Indeed, the combined impact of lifestyle-related factors on all-cause or cause-specific mortality has been the subject of much research, shedding light on the link between alcohol and health. In particular the “HALE” project, a longitudinal European study, concluded that the combined influence of four lifestyle habits, namely Mediterranean diet, moderate alcohol use, physical activity and absence of smoking, is associated with a more than 50 % lower rate of all-cause and cause-specific mortality (Knoops et al., 2004). Moreover, another recently conducted meta-analysis suggested that the management of multiple lifestyle risk factors should be the cornerstone for combating the global burden of disease (Zhang et al., 2021).

Thus, in line with the holistic approach (Hu, 2002), instead of asking “to drink or not to drink”?, a better question - which needs further investigation - might be “What is my lifestyle and “What do I usually eat with my favourite drink?” Therefore, when evaluating the relationship between alcohol and health outcomes, dietary pattern and other lifestyle habits should be studied in combination and not individually. The answer to the question will thereby elucidate many factors which may have been underestimated or misinterpreted in numerous epidemiological studies. Indeed, the authors from the most recently conducted systematic review on the same topic (Sluik et al., 2016a), concluded that alcohol consumption alone may not be related to health outcomes, but rather the underlying dietary habits.

In light of this, the aim of this study was to conduct an updated review and critical evaluation of studies found in the literature on the relationship between alcoholic beverage preference/choice and dietary and lifestyle patterns in adults.

Methods

1. Literature search

The most important scientific databases of references and abstracts on life sciences (PubMed, and ISI Web of Science and Core Collection) were systematically searched (from database inception up to 11 April 2021). In this updated review, we used wider selection of search criteria than that used in a previous systematic review conducted by Sluik et al. (2016a). Used search strings were: #1 "beverage" AND ("diet*" OR "food*" OR "lifestyle" ) AND ("wine" OR "beer" OR "spirits" OR "liquor") #2 "alcoholic beverages" AND ("preference" OR "choice") AND ("diet*" OR "nutr*"OR "food*" OR "lifestyle") # 3 "alcohol" AND ("preference" OR "beverage" OR "choice") AND ("diet*" OR "nutr*" OR "food*" OR "lifestyle") #4 ("wine" OR "beer" OR "spirits" OR "liquor") AND ("preference" OR "choice") AND ("diet*" OR "nutr*" OR "food*" OR "lifestyle"). The flow-chart of the selection process of the literature search is shown in Figure 1. Restricted to humans and the English language, 1.611 hits were obtained from the PubMed search. Moreover, 2.983 hits for the ISI Web of Science were retrieved using the same strings (restricted to the English language and document types (Article)), thus corresponding to a total of 3,887 unique hits after the removal of duplicates. By removing articles on alcohol as such, and articles not relevant (i.e., articles excluded upon screening the “title”, articles where no distinction between the type of alcoholic beverages was considered, reviews, and articles not meeting the inclusion criteria), the number of studies retained for this review was 23. Furthermore three more eligible articles (Forshee and Storey, 2006; Herbeth et al., 2012; Johansen et al., 2006) - which had been included in the previous systematic review (Sluik et al., 2016a) - were identified by manual screening, resulting in a total of 26 articles. Two reviewers (R.I.K. and C.D.L.) independently selected the articles, and any discrepancies between them were solved by consensus or by consulting with a third researcher (P.R.).

Figure 1. Flowchart of the selection process of the literature search for studies on relationship between alcoholic beverage preference/choice and diet/lifestyle, published up to 11 April 2021.

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Results

Discussion

From this review, it seems that alcoholic beverage preference is correlated with specific dietary and lifestyle habits. Individuals with a wine preference generally had healthier dietary and lifestyle habits than individuals with other preferences, which was mainly observed in Northern European and US studies, as well as to a lesser extent in Mediterranean countries; the latter discrepancy could be explained by the fact that the Mediterranean diet is a cultural heritage in South Europe and is not limited to certain consumer groups, and therefore differences between alcoholic beverages can be expected to be less marked. Those who preferred beer and spirits displayed less healthy dietary habits, without any regional discrepancies arising from the country where the studies were carried out.

The observed relationships between wine preference and a healthier dietary and lifestyle profile could be attributed to cultural, personal (beliefs, concerns, perceptions and attitudes), behavioural and socio-demographic determinants, and their latent interrelations.

From historical perspective, in Mediterranean countries the use of wine without social aspects is meaningless. Wine is considered to be the cornerstone of the traditional Mediterranean dietary patterns in social context, always being consumed at mealtimes with a strong “essence of sharing and conviviality” (Fara, 2015). The worldwide popularity of the Mediterranean diet for its healthiness and sustainability (Fara, 2015) is undeniable, being similar in philosophy to diets in Blue Zones, areas of the world where people live exceptionally long lives (Buettner and Skemp, 2016).

Moreover, the health benefits of wine consumption - in particular regarding red wine and cardiovascular disease prevention - have been extensively studied in literature, mainly due to its high antioxidant content (Das et al., 2011), thus exposing consumers to a vast array of marketing claims for the role of resveratrol in health and wellness (Higgins and Llanos, 2015). Red wine contains polyphenolic compounds that are associated with the reduction of the inflammatory process, oxidative stress (OS), oxidation of LDL-cholesterol and platelet aggregation, and as a consequence it has a protective role against cardiovascular diseases. Resveratrol is among the most interesting polyphenols in red wine since it is believed to aid in a wide range of medical problems by reducing oxidative stress (Koushki et al., 2020). However, it has been suggested that beyond polyphenols newly detected molecules, such as melatonin and hydroxytyrosol (Marhuenda et al., 2016; Marhuenda et al., 2017), produce anti-oxidative effects in synergy. Consumers with few health issues or concerns about their health are more likely to follow a healthy diet, and the knowledge of the beneficial role of wine on health could influence their willingness to consume wine as part of their diet, suggesting that they value the relationship between food/beverage intake and their health status (Higgins and Llanos, 2015). This speculation is also justified by the following findings: a higher proportion of participants who followed a specific diet for hypertension, hypercholesterolemia or diabetes was found among wine drinkers (Ruidavets et al., 2004), wine drinkers were more likely to have dyslipidemia or to be overweight (Carmona-Torre et al., 2008), a higher percentage of wine drinkers considered themselves to be vegetarians (Paschall and Lipton, 2005), and had better health status (Sluik et al., 2016b) and the ratio of budget for healthy food over budget for unhealthy food was higher for wine drinkers, particularly Bordeaux wine (58.3 %) purchasers (Hansel et al., 2015).

In a study carried out by Sluik et al. (2014) in the Netherlands, about half of the wine consumed was found to be red (46 %), followed by white wine (32 %), and it was mostly consumed in the evening (56 %), but also often during dinner (27 %), which is in agreement with the recommended Mediterranean drinking pattern.

As regards the behavioural characteristics of wine drinkers, the literature suggests that healthy diets on their own are not sufficient for improving health, if they are not combined with daily physical exercise (Fara, 2015). Moreover, regular physical activity is considered to be related to stress reduction and better mood, partly explaining the mediating associations between depression, stress and health outcomes (Hamer et al., 2012). Research has shown the co-occurrence of anxiety disorders and alcohol-use disorders (Smith and Randall, 2012). A recently conducted study demonstrated the positive mood modulation of resveratrol (Zhu et al., 2019). Beyond that, epidemiological research showed that adherence to healthy or Mediterranean dietary patterns is associated with a reduced risk of depression (Lassale et al., 2019). In the present review, it was revealed that among wine drinkers the prevalence of physical activity was higher (Ferreira-Pêgo et al., 2017; González-Rubio et al., 2016; Ruidavets et al., 2004), the perception of their own health was better (González-Rubio et al., 2016), the prevalence of depressive symptoms and of alcohol-related problems were lower (Paschall and Lipton, 2005), a healthier drinking pattern was exhibited (Ferreira-Pêgo et al., 2017). Moreover, a recent review demonstrated that binge drinking and binge eating are different sides of the same coin (Escrivá-Martínez et al., 2020) and thus a healthy drinking pattern goes “hand in hand” with a healthy diet. A cross-sectional study conducted on Danish adults concluded that wine drinking was associated with optimal social, intellectual and personality capacities, compared to beer drinking (Mortensen et al., 2001). This is also illustrated by the results of the study by Valencia-Martin et al., which showed that binge drinking is associated with less adherence to dietary guidelines and less physical activity (Valencia-Martín et al., 2011). Other studies also reported that heavy drinking was related to a lower intake of dietary fibre, fruit and vegetables (Ruidavets et al., 2004; Tjønneland et al., 1999; Valencia-Martín et al., 2011). The trend for a healthier lifestyle among wine drinkers is also justified in the present review by a lower prevalence of smoking habits (Carmona-Torre et al., 2008; Rouillier et al., 2004). Another probable underlying explanation of the observed correlations between wine drinking and healthier dietary and lifestyle habits is the socio-demographic factors among wine drinkers, such as the female gender, older age bracket and generally higher-income, which are considered as strong determinants of health behaviours, although with contradictory effects. For instance, in our review wine preference was observed in higher-income (Barefoot et al., 2002; McCann et al., 2003) and higher education participants (Paschall and Lipton, 2005), whereas another study found no significant difference in education and employment status between the groups with different alcoholic beverage preferences (González-Rubio et al., 2016). Moreover, in the study by Rouillier et al. (2004), differences in terms of education and employment status of wine drinkers were observed depending on the type of wine they drank. The literature suggests that there is interplay between age, gender, chemosensory responsiveness and alcohol consumption (Cravero et al., 2020). It seems that regional differences in socio-demographic factors could influence the preference for a specific alcoholic beverage. In countries dominating global wine production and trade, where wine is more accessible in price and linked to gastronomy, a dominant preference for wine can be expected, as is the case in Mediterranean countries. On the other hand, in Northern-European countries and in the US, it seems that income could play a role in the preference for wine. In particular, higher income households purchase healthier foods (French et al., 2019) and can afford to purchase more expensive wine. Hence, it seems that through diverse mechanisms, socio-economic factors may influence dietary behaviour. Indeed, in the cross-sectional Dutch study on 12965 subjects conducted by Hulshof et al. (2003), the consumption of wine, especially with meals, was associated with a healthier dietary behaviour. On the other hand, beer was consumed mostly outside meals and formed part of a less healthy dietary pattern. It is worth noting that these findings were correlated with socio-economic factors; in particular, wine consumption was more frequent among subjects with higher educational and economic status, while beer consumption was found among classes with a lower income. Authors speculated that subjects with a higher educational level tended to be more aware of the characteristics of a healthy diet. Conversely, accessibility to healthy foods might be limited by low income. Similar conclusions were previously drawn in studies by Kesse et al. (2001) and Marques-Vidal et al. (2000), in which a light-to-moderate alcohol drinking pattern (especially for wine) and healthy dietary behaviour were positively correlated to socioeconomic factors in 72904 middle-aged French women and 1367 Irish men.

The aforementioned conclusions are confirmed by the results of the most recently conducted prospective cohort study on 309,123 participants with a median follow-up period of 9 years, and which studied beverage type, consumption with food and consumption frequency as exposures. This study found that the consumption of red wine within the context of a healthy drinking pattern and when consumed at meals was associated with lower risk of mortality and vascular events among regular alcohol drinkers, after adjusting for the effects of average amount consumed (Jani et al., 2021).

The following general conclusions can be drawn from the data collected in this review: i) socio-economic status and demographic characteristics are correlated with alcoholic beverage preferences: wine drinkers are generally middle aged, with higher incomes and level of education than beer or spirit consumers; wine is preferred by women and beer by men in the majority of the studies, ii) wine consumers, especially in Northern European countries and the US, generally adhere to a healthier dietary pattern and lifestyle and follow the national dietary guidelines, iii) beer is the second alcoholic beverage that is consumed, especially among young people, and it is generally associated with a less healthy dietary pattern, a higher energy intake and consumption of food with relatively poor nutritional quality, and iv) spirits are the least preferred alcoholic beverage in all the studies and are associated with less healthy dietary and lifestyle habits (including smoking), low adherence to dietary guidelines and the lowest physical activity status.

Limitations

Due to the cross-sectional and ecological nature of the included studies no temporal relationship and, hence, causal inferences can be made. However, this limitation does not weaken the importance of the findings, given that the aim of the present review was to evaluate whether alcoholic beverages preference is associated with certain dietary and lifestyle habits, and not to assess causality. Furthermore, recall bias could be an issue among wine drinkers with higher health literacy. According to Grønbaek (2001), reporting bias relevant to the type of alcoholic beverage does not appear to be a problem in the majority of the population studies (GrØnbaek, 2001). Moreover, the lack of a formal definition of “preference”, the absence of conducted studies in many regions around the world, the high heterogeneity between the studies, the wide spectrum of possible outcomes relevant to diet and lifestyle and the lack of quality assessment of the reviewed studies could influence the generalisability of the findings. The risk of bias assessment of cross-sectional studies is heterogeneous with less applicability (Migliavaca et al., 2020) than other observational study designs, for which standard, valid and widely used tools are available.

Conclusions

This review has demonstrated that alcoholic beverage preference is associated with diet and lifestyle habits, including drinking patterns and absolute alcohol consumption. Age, gender and socio-economic status are shown to be confounding factors in the association between alcoholic beverage consumption and health outcomes. Given that alcoholic beverage preference is linked to specific dietary and lifestyle patterns, it may be arbitrary and risky to attribute the risk of developing chronic diseases to alcoholic beverages without an in-depth investigation of the underlying inter-correlations with statistical adjustment for ‘dietary pattern’ as a confounding factor. Therefore, from a public health perspective it seems that drinking pattern, dietary pattern and lifestyle should be studied in combination and as such be evaluated in any future epidemiological studies analysing the relationship between alcohol consumption and underlying correlations in terms of health outcomes.

Acknowledgements

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Most authors are government delegates and/or experts to the International Organization of Vine and Wine’s (OIV) Commission IV Safety and Health. Although this work was initiated under the auspices of the OIV and its Consumption, Nutrition and Health expert group, the statements herein are the sole responsibility of the undersigned authors. The authors would like to acknowledge Ionas Papasotiriou for his support in the initial step of data curation.

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