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Background and aims: Increasing literature data show that adherence to the Mediterranean diet is undergoing profound changes in recent years, albeit with marked differences across nations. In Italy, one of the cradles of the Mediterranean diet, the literature regarding the trend for Mediterranean diet adherence is conflicting. Thus, we aimed to explore the trends of adherence to the Mediterranean diet in a large cohort of participants living in South Italy, over 20 years from 1985–86 to 2005–06. Methods and results: Cross-sectional study with two evaluations, one made in 1985–86 and another in 2005–06; all participants were adults aged 30–70 years of age. The adherence to the Mediterranean diet was evaluated using the score proposed by Panagiotakos et al. This score features values ranging from 0 to 55, higher scores reflecting a greater adherence. The data are reported by age (30–49 vs. 50–69 years). Overall, 2451 subjects were included in 1985–86 and 2375 in 2005–06. A significant reduction was observed in the adherence to the Mediterranean diet (age 30–49 years: 31.82 ± 4.18 in 1985–86 vs. 29.20 ± 4.48 in 2005–06, reduction by 8.2%, p < 0.0001; age 50–69: 32.20 ± 4.09 in 1985–86 vs.30.15 ± 4.27 in 2005–06, reduction by 6.3%, p < 0.0001). Among all these items, the most dramatic change was observed for olive oil consumption, that decreased by 2.35 points in younger and 0.89 in older people. Conclusion: The adherence to the Mediterranean diet decreased from 1985–86 to 2005–06 in South Italy, particularly in younger people, above all due to a decreased olive oil consumption. © 2019 The Italian Society of Diabetology, the Italian Society for the Study of Atherosclerosis, the Italian Society of Human Nutrition, and the Department of Clinical Medicine and Surgery, Federico II University