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I think the common misunderstanding with the spaghetti meatballs being only an American dish is the fact that in the US you found in it in the restaurants, whereas this doesn't happen in Italy. I guess that's because they're considered two separate dishes that need to be paid separately. But in Italian houses I believe it was common from moms putting the two things together to optimize time and cooking the red sauce with meatballs as sort of a ragù... At least my mom used to do it, a thing which I always hated 😄 Because, yes, personally I believe those two things don't go well together.

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That could definitely be one of the reasons, although pasta with meatballs can actually be found in restaurants / traditionally in some regions of Italy, such as Abruzzo and Puglia. The main difference is the size of the meatballs, that perhaps has to do with the fact that meat was very expensive and so consumed less.

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