An Opinion Paper on the Cultural Heritage of Wine Consumption in the Frame of the Mediterranean Diet: The Missing Piece of the Puzzle

The role of wine within the Mediterranean diet remains one of the most debated and paradoxical issues in nutritional epidemiology. Although moderate wine consumption, particularly alongside meals, has traditionally been incorporated into Mediterranean diet scores and has been associated with lower cardiovascular and all-cause mortality, alcohol is also an established carcinogen, with evidence of increased cancer risk even at relatively low levels of consumption. This apparent contradiction has renewed the debate over whether wine represents a genuine protective component of the Mediterranean diet or whether its observed associations reflect methodological and contextual factors. In this opinion paper, we critically examine emerging evidence on wine consumption, the Mediterranean dietary pattern and the Mediterranean alcohol-drinking pattern, with particular attention to the limitations of observational alcohol epidemiology, including abstainer-reference bias, reverse causation, exposure misclassification and the divergence between observational and Mendelian randomization evidence. Additionally, drawing on the concept of the traditional Mediterranean lifestyle, we further propose that moderation and synergy between lifestyle components may be more informative than the isolated attribution of health effects to individual foods or beverages. Thus, instead of searching for a “hidden virtue” in wine itself, the more relevant hypothesis may be that of a “hidden context”, whereby the health associations attributed to moderate wine consumption are inseparable from the broader Mediterranean lifestyle in which it is embedded.