Economic evaluations of the Mediterranean diet: a systematic review

Context: The Mediterranean diet (MD) is widely recognized for its health benefits and increasing relevance in health system planning and dietary policy. Understanding the costs and cost-effectiveness of MD adherence is critical for informing public health policy and dietary interventions. Objective: This systematic review summarizes the evidence on the economic implications of the MD, distinguishing between studies assessing health outcome-based cost-effectiveness and those examining the monetary costs of adhering to the MD for households. Methods: This review was conducted in accordance with PRISMA 2020. We searched PubMed/MEDLINE, Embase, Scopus, and the Cochrane Library to February 2024. Data extraction and quality assessment followed standardized protocols using CHEC-Extended and Newcastle-Ottawa tools. Results: Of 6,733 screened records, 24 studies met inclusion criteria and were included. Studies were grouped into: (A) economic evaluations (cost-effectiveness, cost-utility, cost-benefit, cost-of-illness-13 studies) and (B) cost analyses of MD adherence (11 studies). Group A studies, conducted primarily from health system perspectives, found MD interventions generally cost-effective, particularly in cardiovascular prevention, despite higher initial dietary costs. Several reported favorable incremental cost-effectiveness ratio. Group B studies, adopting a societal perspective, consistently showed that greater MD adherence is associated with higher food costs, with a disproportionate impact on low-income populations. Conclusions: MD is a cost-effective intervention from a health system perspective, with potential for substantial long-term savings. However, economic barriers at the household level may limit uptake. Future evaluations should integrate environmental co-benefits and equity considerations to fully capture the MD's public health value. (c) 2026 Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.