In a large pot or Dutch oven, cook the ground beef over medium heat until browned. Add diced onions and minced garlic, cooking until the onions are soft and fragrant. Drain any excess grease.
Stir in the tomato sauce, diced tomatoes, beef broth, Worcestershire sauce, Italian seasoning, salt, and black pepper. Bring the mixture to a gentle simmer and let it cook for 5 minutes.
Add the elbow macaroni directly into the pot and stir well. Cover and let it simmer for about 15 minutes, or until the pasta is tender. Stir occasionally to prevent sticking. For another comforting dish, try Slow Cooker Salisbury Steak Meatballs!
If using cheese, sprinkle shredded cheddar over the top and stir until melted. This adds a creamy, cheesy richness to the dish.
Remove from heat and let it sit for a couple of minutes. Serve warm and enjoy this cozy, old-fashioned meal with crusty bread or a side salad.