**Background:** The aging European population faces increasing rates of chronic disease and malnutrition. The Mediterranean diet (MD) is recognized for its health benefits, but its association with health-related behaviors and well-being in the 50+ population across Europe, and specifically in Croatia, had not been fully characterized. This study aimed to investigate the relationship between MD adherence and health indicators (disease incidence, grip strength, CASP-12 quality of life, BMI) in middle-aged and elderly Europeans, with a special focus on Croatia.
**Methods:** Data were drawn from the SHARE project (Survey of Health, Ageing and Retirement in Europe), Wave 8 (2019), release 8.0.0, covering 27 European countries and Israel. The total sample size was 114,199; participants under 50 years (n = 236, 0.5%) were excluded, leaving 46,643 participants for analysis. MD adherence was assessed using a binary index based on frequency of consumption of three food groups: fruits and vegetables (daily), eggs/beans/legumes (3–6 times/week), and meat/fish/poultry (3–6 times/week). Dairy consumption was recorded but not included in the MD index. Health indicators included self-perceived health (poor/fair, good, very good/excellent), CASP-12 quality of life score (low: 12–24, medium: 25–36, high: >36), BMI (normal defined as 18.5–24.9 kg/m² for age <65; 21–27.5 kg/m² for age ≥65 per ESPEN guidelines), cardio-metabolic diseases (CMDs: myocardial infarction, other heart problems, hypertension, high blood cholesterol, stroke, type 2 diabetes), maximum grip strength (low: 1–25, medium: 26–50, high: >50), and vigorous physical activity. Missing data were handled via multiple imputation; remaining missing data were <1% per country. Logistic regression models were used, adjusted for age, gender, marital status, education level, employment, and economic status (Crude, Model 1, Model 2).
**Key Results:** Among the total sample, 38.5% had zero CMDs, 31.9% had one, 19.2% had two, 8.2% had three, 1.8% had four, and 0.2% had five. The mean BMI was 26.25 kg/m² (SD ±6.85). For the CASP-12, 2.34% scored low (<24), 38.77% medium (24–35), and 58.89% high (36–48). Adjusted odds ratios (OR) showed that participants with very good/excellent self-perceived health were more likely to follow MD (OR = 1.541; 95% CI: 1.499–1.586). Those with good self-perceived health had OR = 0.927 (95% CI: 0.859–1.000, p < 0.05). For CASP, high quality of life was associated with MD adherence (OR = 1.195, p < 0.01). Regular vigorous physical activity was associated with lower MD adherence (OR = 0.91, p < 0.01). Having one or more CMDs was slightly associated with MD adherence (OR = 1.019). Normal BMI was associated with MD adherence (OR = 1.054; 95% CI: 0.993–1.119). Grip strength showed a significant relationship: low grip strength OR = 0.774 (95% CI: 0.689–0.869, p < 0.01), medium OR = 1.449 (95% CI: 1.28–1.641, p < 0.01), high OR = 1.293 (95% CI: 1.151–1.452, p < 0.05). For Croatia (n = 1197, 2.5% of sample), MD followers in the Adriatic region had 0% reporting low CASP, and 55.56% had high CASP. In the Continental region, 51.38% of MD followers had high CASP. Grip strength was 0% high among Adriatic MD followers. Croatia had 30.3% normal BMI in age 50–64, 42.4% in 65–74, 44.2% in 75–84, and 55.2% in 85+. Southern European countries had the highest daily consumption of fruits and vegetables (74.5%) and dairy (70.2%). Croatia followed Central and Eastern European trends for disease prevalence, with 61.3% reporting long-term illness, 46.7% hypertension, and 23.4% high cholesterol.
**Clinical Implications:** MD adherence is associated with better self-perceived health, higher quality of life, and normal BMI in the European 50+ population. The positive association with grip strength suggests potential benefits for physical function. Croatia shows a high burden of overweight/obesity, but MD adherence correlates with better health indicators. Public health strategies should promote MD to support healthy aging, particularly in regions with high obesity prevalence. The study is limited by the partial assessment of MD (excluding olive oil, red wine, seafood, and red meat separation) and the cross-sectional design, which precludes causal inference.