Adherence to the Mediterranean Diet during the COVID-19 national lockdowns: a systematic review of observational studies

Adherence to the Mediterranean Diet during the COVID-19 national lockdowns: a systematic review of observational studies


  • Petra Giulia Della Valle Department of Public Health, Forensic and Experimental Medicine, University of Pavia, Pavia, Italy
  • Giansanto Mosconi Department of Public Health, Forensic and Experimental Medicine, University of Pavia, Pavia, Italy
  • Daniele Nucci Nutritional support Unit, Veneto Institute of Oncology IOV-IRCCS, Via Gattamelata 64, 35128 Padua, Italy
  • Giacomo Pietro Vigezzi School of Medicine, Vita-Salute San Raffaele University, Via Olgettina, 60, 20132, Milan, Italy
  • Leandro Gentile Department of Public Health, Forensic and Experimental Medicine, University of Pavia, Pavia, Italy.
  • Vincenza Gianfredi School of Medicine, Vita-Salute San Raffaele University, Via Olgettina, 60, 20132, Milan, Italy;
  • Marialaura Bonaccio Department of epidemiology and prevention, IRCCS Neuromed, Pozzilli, Italy
  • Francesco Gianfagna Research Center in Epidemiology and Preventive Medicine (EPIMED), Department of Medicine and Surgery, University of Insubria, Varese, Italy; Mediterranea Cardiocentro, Napoli, Italy
  • Carlo Signorelli School of Medicine, Vita-Salute San Raffaele University, Via Olgettina, 60, 20132, Milan, Italy
  • Licia Iacoviello Department of Epidemiology and Prevention, IRCCS NEUROMED, Pozzilli, Italy; Research Center in Epidemiology and Preventive Medicine (EPIMED), Department of Medicine and Surgery, University of Insubria, Varese, Italy
  • Anna Odone Department of Public Health, Forensic and Experimental Medicine, University of Pavia, Pavia, Italy


Mediterranean Diet, Covid-19, Lockdown, Stay-At-Home Order, Adherence, Pandemic, Diet, Food, Lifestyle


Background and aim of the work: During the COVID-19 pandemic, many countries adopted restrictive measures to mitigate infection spread, which might have influenced people’s lifestyle and dietary habits. We conducted a systematic review to evaluate the impact of national lockdowns on adherence to the Mediterranean Diet (MD).

Methods: Studies were identified searching Medline, Embase, Web of Science, and the Cochrane Library. Studies published until 4th May 2021 were included. We only considered studies reporting original data from quantitative analysis and assessing changes in adherence to the MD, using validated dietary scores, or in consumption of MD food items. Data extraction, pooling, and quality appraisal of included studies were conducted following the PRISMA guidelines.

Results: Forty-two studies were retrieved. After screening, 12 studies met inclusion criteria and were included in the review, of which 4 (33%) were longitudinal studies. Six (85.7%) of the seven studies that measured changes in MD adherence before-during lockdown reported an increase (rate of change of high-adherence to MD ranged between +3.3% and +21.9%). Evidence indicates that consumption of MD food items increased during lockdown but is heterogeneous in study design, quality, and findings.

Conclusions: Our results suggest adherence to the MD during lockdown might have increased in some settings, while the determinants of such a trend are to be further explored. We raise awareness of the need to research further the impacts and long-term consequences of COVID-19 containment measures on dietary and lifestyle habits.


Kafatos A, Verhagen H, Moschandreas J, Apostolaki I, Van Westerop JJM. Mediterranean diet of Crete: Foods and nutrient content. J Am Diet Assoc. 2000;100(12):1487–93.

Willett WC, Sacks F, Trichopoulou A, et al. Mediterranean diet pyramid: A cultural model for healthy eating. Vol. 61, American Journal of Clinical Nutrition. American Society for Nutrition; 1995.

Iaccarino Idelson P, Scalfi L, Valerio G. Adherence to the Mediterranean Diet in children and adolescents: A systematic review. Nutr Metab Cardiovasc Dis. 2017 Apr 1;27(4):283–99.

Davis C, Bryan J, Hodgson J, Murphy K. Definition of the mediterranean diet: A literature review. Vol. 7, Nutrients. MDPI AG; 2015. p. 9139–53.

Da Silva R, Bach-Faig A, Raidó Quintana B, Buckland G, Vaz De Almeida MD, Serra-Majem L. Worldwide variation of adherence to the Mediterranean diet, in 1961-1965 and 2000-2003. Public Health Nutr. 2009 Sep;12(9 SPEC. ISSUE 9A):1676–84.

Saulle R, La Torre G. The Mediterranean Diet, recognized by UNESCO as a cultural heritage of humanity. Ital J Public Health. 2010;7(4):414–5.

WHO undefined. 2008-2013 Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases. 2009 [cited 2021 Apr 12];1(1):8–9. Available from:

Estruch R, Ros E, Salas-Salvadó J, et al. Retraction and Republication: Primary Prevention of Cardiovascular Disease with a Mediterranean Diet. N Engl J Med 2013;368:1279-90. N Engl J Med. 2018 Jun 21;378(25):2441–2.

Sofi F, Abbate R, Gensini GF, Casini A. Accruing evidence on benefits of adherence to the Mediterranean diet on health: An updated systematic review and meta-analysis. Vol. 92, American Journal of Clinical Nutrition. 2010. p. 1189–96.

Bonaccio M, Iacoviello L, De Gaetano G. The Mediterranean diet: The reasons for a success. Vol. 129, Thrombosis Research. 2012. p. 401–4.

Babio N, Bulló M, Salas-Salvadó J. Mediterranean diet and metabolic syndrome: The evidence. Public Health Nutr. 2009 Sep;12(9 SPEC. ISSUE 9A):1607–17.

Chiva-Blanch G, Badimon L, Estruch R. Latest Evidence of the Effects of the Mediterranean Diet in Prevention of Cardiovascular Disease. Vol. 16, Current Atherosclerosis Reports. Current Medicine Group LLC 1; 2014.

Gianfredi V, Koster A, Odone A, et al. Associations of dietary patterns with incident depression: The maastricht study. Nutrients. 2021;13(3).

Di Giuseppe R, Bonanni A, Olivieri M, et al. Adherence to Mediterranean diet and anthropometric and metabolic parameters in an observational study in the “Alto Molise” region: The MOLI-SAL project. Nutr Metab Cardiovasc Dis. 2008 Jul;18(6):415–21.

León-Muñoz LM, Guallar-Castillón P, Graciani A, et al. Adherence to the mediterranean diet pattern has declined in Spanish adults. J Nutr. 2012 Oct 1;142(10):1843–50.

Sofi F, Vecchio S, Giuliani G, et al. Dietary habits, lifestyle and cardiovascular risk factors in a clinically healthy Italian population: The “Florence” diet is not Mediterranean. Eur J Clin Nutr. 2005;59(4):584–91.

Serra-Majem L, Trichopoulou A, de la Cruz JN, et al. Does the definition of the Mediterranean diet need to be updated? Public Health Nutr. 2004 Oct;7(7):927–9.

Brown T, Moore TH, Hooper L, et al. Interventions for preventing obesity in children. Vol. 2019, Cochrane Database of Systematic Reviews. John Wiley and Sons Ltd; 2019.

Vilarnau C, Stracker DM, Funtikov A, da Silva R, Estruch R, Bach-Faig A. Worldwide adherence to Mediterranean Diet between 1960 and 2011. Eur J Clin Nutr. 2019;72.

European Centre for Disease Prevention and Control. Data on country response measures to COVID-19 [Internet]. 2021 [cited 2021 Apr 11]. Available from:

Ritchie H, Ortiz-Ospina E, Beltekian D, et al. Policy Responses to the Coronavirus Pandemic [Internet]. 2021 [cited 2021 Apr 11]. Available from:

Gianfredi V, Bertarelli G, Minelli L, Nucci D. Promoting healthy eating in childhood: results from the COcONUT (Children PrOmOting Nutrition throUght Theatre) project [Internet]. Minerva Pediatrics. 2021 [cited 2021 Sep 20]. Available from:

Odone A, Lugo A, Amerio A, et al. Covid-19 lockdown impact on lifestyle habits of Italian adults. Acta Biomed [Internet]. 2020;91:87–9. Available from:

Sallie SN, Ritou V, Bowden-Jones H, Voon V. Assessing international alcohol consumption patterns during isolation from the COVID-19 pandemic using an online survey: Highlighting negative emotionality mechanisms. BMJ Open [Internet]. 2020 Nov 26 [cited 2021 Apr 11];10(11):44276. Available from:

Yach D. Tobacco Use Patterns in Five Countries During the COVID-19 Lockdown. Nicotine Tob Res [Internet]. 2020 Aug 24 [cited 2021 Apr 11];22(9):1671–2. Available from:

Carreras G, Lugo A, Stival C, et al. Impact of COVID-19 lockdown on smoking consumption in a large representative sample of Italian adults. Tob Control. 2021;

Amerio A, Lugo A, Stival C, et al. COVID-19 lockdown impact on mental health in a large representative sample of Italian adults. J Affect Disord. 2021;292.

Lugo A, Stival C, Paroni L, et al. The impact of COVID-19 lockdown on gambling habit: A cross-sectional study from Italy. J Behav Addict. 2021;

Stockwell S, Trott M, Tully M, et al. Changes in physical activity and sedentary behaviours from before to during the COVID-19 pandemic lockdown: A systematic review [Internet]. Vol. 7, BMJ Open Sport and Exercise Medicine. BMJ Publishing Group; 2021 [cited 2021 Apr 11]. p. 960. Available from:

Bennett G, Young E, Butler I, Coe S. The Impact of Lockdown During the COVID-19 Outbreak on Dietary Habits in Various Population Groups: A Scoping Review. Front Nutr. 2021 Mar 4;8.

The World Bank. COVID-19 to Plunge Global Economy into Worst Recession since World War II [Internet]. 2021 [cited 2021 Apr 11]. Available from:

Bonaccio M, Bes-Rastrollo M, de Gaetano G, Iacoviello L. Challenges to the Mediterranean diet at a time of economic crisis [Internet]. Vol. 26, Nutrition, Metabolism and Cardiovascular Diseases. Elsevier B.V.; 2016 [cited 2021 Apr 11]. p. 1057–63. Available from:

Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. J Clin Epidemiol [Internet]. 2021 Mar 29 [cited 2021 Apr 11]; Available from:

Franco E, Urosa J, Barakat R, Refoyo I. Physical activity and adherence to the mediterranean diet among spanish employees in a health-promotion program before and during the covid-19 pandemic: The sanitas-healthy cities challenge. Int J Environ Res Public Health. 2021;18(5).

Medrano M, Cadenas-Sanchez C, Oses M, Arenaza L, Amasene M, Labayen I. Changes in lifestyle behaviours during the COVID-19 confinement in Spanish children: A longitudinal analysis from the MUGI project. Pediatr Obes. 2020;

Rodríguez-Pérez C, Molina-Montes E, Verardo V, et al. Changes in dietary behaviours during the COVID-19 outbreak confinement in the Spanish COVIDiet study. Nutrients [Internet]. 2020;12(6):1–19. Available from:

Sánchez-Sánchez E, Ramírez-Vargas G, Avellaneda-López Y, Orellana-Pecino JI, García-Marín E, Díaz-Jimenez J. Eating habits and physical activity of the spanish population during the covid-19 pandemic period. Nutrients [Internet]. 2020;12(9):1–12. Available from:

Tárraga López PJ, Panisello Royo JM, Carbayo Herencia J, et al. Changes in adherence to the Mediterranean diet observed in a Spanish population during confinement for the SARS-CoV-2 pandemic. Nutr Hosp. 2020;

Dragun R, Veček NN, Marendić M, et al. Have lifestyle habits and psychological well-being changed among adolescents and medical students due to COVID-19 lockdown in Croatia? Nutrients. 2021;

Pfeifer D, Rešetar J, Gajdoš Kljusurić J, et al. Cooking at Home and Adherence to the Mediterranean Diet During the COVID-19 Confinement: The Experience From the Croatian COVIDiet Study. Front Nutr. 2021;8.

Galali Y. The impact of COVID-19 confinement on the eating habits and lifestyle changes: A cross sectional study. Food Sci Nutr. 2021;9(4).

Giacalone D, Frøst MB, Rodríguez-Pérez C. Reported Changes in Dietary Habits During the COVID-19 Lockdown in the Danish Population: The Danish COVIDiet Study. Front Nutr. 2020;7:592112.

Kolokotroni O, Mosquera MC, Quattrocchi A, Heraclides A, Demetriou C, Philippou E. Lifestyle habits of adults during the COVID-19 pandemic lockdown in Cyprus: evidence from a cross-sectional study. BMC Public Health. 2021;21(1).

Ruggiero E, Mignogna C, Costanzo S, et al. Changes in the consumption of foods characterising the Mediterranean dietary pattern and major correlates during the COVID-19 confinement in Italy: results from two cohort studies. Int J Food Sci Nutr. 2021;

Sulejmani E, Hyseni A, Xhabiri G, Rodríguez-Pérez C. Relationship in dietary habits variations during COVID-19 lockdown in Kosovo: The COVIDiet study. Appetite. 2021;164.

Martínez-González MÁ, Corella D, Salas-salvadó J, et al. Cohort profile: Design and methods of the PREDIMED study. Int J Epidemiol. 2012;41(2).

Monteagudo C, Mariscal-Arcas M, Rivas A, Lorenzo-Tovar ML, Tur JA, Olea-Serrano F. Proposal of a mediterranean diet serving score. PLoS One. 2015;10(6).

Serra-Majem L, Ribas L, Ngo J, et al. Food, youth and the Mediterranean diet in Spain. Development of KIDMED, Mediterranean Diet Quality Index in children and adolescents. Public Health Nutr. 2004;7(7).

Schröder H, Marrugat J, Vila J, Covas MI, Elosua R. Adherence to the traditional mediterranean diet is inversely associated with body mass index and obesity in a Spanish population. J Nutr. 2004;134(12).

Panagiotakos DB, Chrysohoou C, Pitsavos C, Stefanadis C. Association between the prevalence of obesity and adherence to the Mediterranean diet: the ATTICA study. Nutrition. 2006;22(5).

Estruch R, Ros E. The role of the Mediterranean diet on weight loss and obesity-related diseases. Vol. 21, Reviews in Endocrine and Metabolic Disorders. 2020.

Bendall CL, Mayr HL, Opie RS, Bes-Rastrollo M, Itsiopoulos C, Thomas CJ. Central obesity and the Mediterranean diet: A systematic review of intervention trials. Vol. 58, Critical Reviews in Food Science and Nutrition. 2018.

Kastorini C-M, Milionis HJ, Esposito K, Giugliano D, Goudevenos JA, Panagiotakos DB. The Effect of Mediterranean Diet on Metabolic Syndrome and its Components. J Am Coll Cardiol. 2011;57(11).

Kopp W. How western diet and lifestyle drive the pandemic of obesity and civilization diseases. Diabetes, Metab Syndr Obes Targets Ther. 2019;12.

Hasegawa Y, Chen SY, Sheng L, et al. Long-term effects of western diet consumption in male and female mice. Sci Rep. 2020;10(1).

Eng JY, Moy FM, Bulgiba A, Rampal S. Dose–response relationship between western diet and being overweight among teachers in Malaysia. Nutrients. 2020;12(10).

Drake I, Sonestedt E, Ericson U, Wallström P, Orho-Melander M. A Western dietary pattern is prospectively associated with cardio-metabolic traits and incidence of the metabolic syndrome. 2018 [cited 2021 Aug 22]; Available from:

Van Dam RM, Rimm EB, Willett WC, Stampfer MJ, Hu FB. Dietary patterns and risk for type 2 diabetes mellitus in U.S. men. Ann Intern Med. 2002;136(3).

Osadnik K, Osadnik T, Lonnie M, et al. Metabolically healthy obese and metabolic syndrome of the lean: The importance of diet quality. Analysis of MAGNETIC cohort. Nutr J. 2020;19(1).

Deschasaux-Tanguy M, Druesne-Pecollo N, Esseddik Y, et al. Diet and physical activity during the coronavirus disease 2019 (COVID-19) lockdown (March-May 2020): Results from the French NutriNet-Santé cohort study. Am J Clin Nutr. 2021;113(4).

Lamarche B, Brassard D, Lapointe A, et al. Changes in diet quality and food security among adults during the COVID-19-related early lockdown: Results from NutriQuébec. Am J Clin Nutr. 2021;113(4).

Murphy B, Benson T, McCloat A, et al. Changes in consumers’ food practices during the covid-19 lockdown, implications for diet quality and the food system: A cross-continental comparison. Nutrients. 2021;13(1).

Jia P, Liu L, Xie X, et al. Changes in dietary patterns among youths in China during COVID-19 epidemic: The COVID-19 impact on lifestyle change survey (COINLICS). Appetite. 2020 Oct;158:105015.

The Lancet Gastroenterology & Hepatology. Obesity: another ongoing pandemic. Vol. 6, The Lancet Gastroenterology and Hepatology. 2021.

Meldrum DR, Morris MA, Gambone JC. Obesity pandemic: causes, consequences, and solutions—but do we have the will? Vol. 107, Fertility and Sterility. 2017.

Grundy SM. Metabolic syndrome pandemic. Vol. 28, Arteriosclerosis, Thrombosis, and Vascular Biology. 2008.

Oladejo AO. Overview of the metabolic syndrome; an emerging pandemic of public health significance. Ann Ibadan Postgrad Med. 2011;9(2).

Stefan N, Birkenfeld AL, Schulze MB. Global pandemics interconnected — obesity, impaired metabolic health and COVID-19. Vol. 17, Nature Reviews Endocrinology. 2021.

Odone A, Gallus S, Lugo A, et al. Weight perception among Italian adults, 2006-2010. Eur J Cancer Prev. 2014;23(2).

Gallus S, Odone A, Lugo A, et al. Overweight and obesity prevalence and determinants in Italy: An update to 2010. Eur J Nutr. 2013;52(2).

H C, M S, L C, A van den T. Eating in the lockdown during the Covid 19 pandemic; self-reported changes in eating behaviour, and associations with BMI, eating style, coping and health anxiety. Appetite [Internet]. 2021 Jun 1 [cited 2021 Aug 26];161. Available from:

Cicero AFG, Fogacci F, Giovannini M, et al. COVID-19-Related Quarantine Effect on Dietary Habits in a Northern Italian Rural Population: Data from the Brisighella Heart Study. Nutr 2021, Vol 13, Page 309 [Internet]. 2021 Jan 22 [cited 2021 Aug 26];13(2):309. Available from:

NJ B, LF S, K N, et al. Susceptibility to increased high energy dense sweet and savoury food intake in response to the COVID-19 lockdown: The role of craving control and acceptance coping strategies. Appetite [Internet]. 2021 Mar 1 [cited 2021 Aug 26];158. Available from:

S V, K DR, S D, R C, F B, S D. Food insecurity and its association with changes in nutritional habits among adults during the COVID-19 confinement measures in Belgium. Public Health Nutr [Internet]. 2021 Apr 1 [cited 2021 Aug 26];24(5):950–6. Available from:

Id MM, Polić N, Matek H, Orš Ulić L, Polaš Ek O, Kolčić Id I. Mediterranean diet assessment challenges: Validation of the Croatian Version of the 14-item Mediterranean Diet Serving Score (MDSS) Questionnaire. 2021; Available from:

Leó n-Muñ oz LM, Guallar-Castilló P, Graciani A, et al. Adherence to the Mediterranean Diet Pattern Has Declined in Spanish Adults 1-3. J Nutr Nutr Epidemiol J Nutr [Internet]. 2012;142:1843–50. Available from:

Schmits E, Glowacz F. Changes in Alcohol Use During the COVID-19 Pandemic: Impact of the Lockdown Conditions and Mental Health Factors. Int J Ment Health Addict. 2021 Jan;1–12.

COVID-19 impact on consumer food behaviours in Europe [Internet]. [cited 2021 Sep 20]. Available from:

Ruiz-Roso MB, Padilha P de C, Mantilla-Escalante DC, et al. Covid-19 confinement and changes of adolescent’s dietary trends in Italy, Spain, Chile, Colombia and Brazil. Nutrients. 2020;12(6).

Odone A, Landriscina T, Amerio A, Costa G. The impact of the current economic crisis on mental health in Italy: Evidence from two representative national surveys. Eur J Public Health. 2018;28(3).




How to Cite

Della Valle PG, Mosconi G, Nucci D, Vigezzi GP, Gentile L, Gianfredi V, et al. Adherence to the Mediterranean Diet during the COVID-19 national lockdowns: a systematic review of observational studies. Acta Biomed [Internet]. 2021 Oct. 19 [cited 2024 Jul. 15];92(S6):e2021440. Available from: