Exploring health, environmental, and psychological drivers of Mediterranean diet adherence: evidence from Italy

Purpose This study examines adherence to the Mediterranean diet (MD) among Italian adults, identifying meaningful determinants, including socioeconomic factors, health and sustainability-related practices, environmental concerns, and psychological well-being. Design/methodology/approach Data consist of 103,447 adult individual-level observations from the Multipurpose Household Survey (MHS) collected by the Italian National Institute of Statistics (ISTAT) from a representative sample of Italian households during years 2019–2021. Adherence is measured through three indexes: the Mediterranean Diet Score (MDS), the Mediterranean Diet Serving Score (MDSS), and the Mediterranean Diet Composite Score (MDCS). Ordered logit models have been used to assess the impact of individual, household, and health behaviors. Findings The cross-sectional analysis reveals that higher MD adherence is positively associated with older age, female gender, higher education, and elevated socioeconomic status. Individuals engaged in health-promoting behaviors, such as regular physical activity and non-smoking, and those with greater environmental awareness and pro-environmental behaviors are more likely to follow the MD. Psychological well-being plays a relevant role, as lower levels of psychological distress correspond with higher MD adherence. Household characteristics, including marital status and the presence of preschool children, also play a role in adherence patterns. Research limitations/implications These findings underline the importance of integrating health behaviors, environmental sustainability, and psychological well-being into public health strategies to promote the MD. Practical implications Results emerging from this research can assist policymakers to encourage a diet that supports both human and environmental health, in line with the Farm to Fork strategy's objectives and the promotion of sustainable, healthy food systems. Originality/value This study offers a novel, integrative analysis of MD adherence by jointly examining psychological well-being, pro-environmental behaviors, and socio-economic characteristics within a single empirical model. Using a nationally representative sample of over 100,000 Italian adults (2019–2021), it captures subclinical psychological distress in a non-clinical population, extending beyond traditional socio-demographic analyses. The study is also the first to simultaneously explore psychological and environmental factors during the COVID-19 period and to compare three widely used MD adherence indices (MDS, MDSS, MDCS), demonstrating how index choice affects prevalence estimates and associations, thus providing key methodological insights for research and policy.