The Role of the Mediterranean Diet and Alcohol Consumption in Chronic Liver Disease Prevention: A Narrative Review.

The traditional Mediterranean Diet (MedDiet) has consistently demonstrated robust benefits in reducing cardiovascular, metabolic, and oncologic risks. Its high content of anti-inflammatory and antioxidant compounds, particularly (poly)phenols, underscores why this dietary pattern has been extensively researched and widely adopted for managing various metabolic conditions. This article aims to conduct a narrative review of the association between the MedDiet (and its debated alcohol consumption pattern) and a reduced risk of liver disease, with a specific focus on the potential preventive role of the MedDiet on Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD), which is now the most prevalent chronic liver disease globally. To carry out this review, relevant articles were searched on PubMed and other databases. The evidence found contributed to identifying the gaps in knowledge and allowed for the main findings to be summarized. Available randomized controlled trials and prospective cohort studies consistently support the hypothesis that high adherence to the MedDiet effectively reduces hepatic fat content, improves liver enzyme levels, and mitigates fibrosis progression. Crucially, this dietary pattern simultaneously addresses the significantly high cardiovascular risk inherent in MASLD. Historically, low-to-moderate alcohol intake, particularly moderate red wine with meals, was assumed to be a beneficial component of the MedDiet. While some observational studies suggest potential cardiovascular benefits, implying a loss of some MedDiet benefits if alcohol is excluded, a growing body of evidence highlights a deleterious synergistic interaction between alcohol, visceral adiposity, hepatic steatosis, and metabolic dysfunction. Based on the available evidence, clinical guidelines recommend the MedDiet with exercise for the prevention and management of MASLD. However, the alcohol consumption in the Mediterranean is currently under strong controversy. Furthermore, recent guidelines now advise total abstinence in patients with advanced liver disease and caution even at earlier MASLD stages. Yet, these assertions are largely based on observational data, underscoring the need for large clinical trials to address this issue with first-level evidence.