Abstract This study investigates food trade patterns in relation to water resources availability in the Southern and Eastern Mediterranean countries (SEMED). Examinations show that most of these countries have a high dependence on the import of water intensive crops – cereal, vegetable oil and sugar, in the domestic food supply. The region as a whole is marginally a net exporter of fruits and vegetables, while variations are substantial across countries. Multi-variable regression analyses show that intensification of water scarcity is an important factor in explaining the increase in food import in the SEMED countries during the past two decades. It also finds that while GDP per capita has a strong influence on the level of food import in a country, its impact on changes in the import during the same period is rather modest. No significant relationship is found between the trade of fruits and vegetables and water resources availability. The projection on food import with respect to the decline in per capita water resources availability results in an increase of 40%, 39% and 14%, respectively, for cereal, vegetable oil and sugar by 2020 in the region, holding other factors constant. The European Union (EU) is the major food trade partner of the SEMED countries, except for cereal. About 70% of the fruit export and 55% of the vegetable export of the region currently go to the EU market. Expanding the export of fruits and vegetables is conducive to improving the value of water use in the SEMED countries. However, the expansion is constrained partly by the barriers in the destination markets, notably the EU.