The present study described the patterns of the MeDi in a sample of the adult Moroccan population and its association with socioeconomic and lifestyle characteristics. Our results show that correlates of MeDi adherence are different from those observed in other Mediterranean countries.
Indeed, contrarily to other studies [20–22], we found no association between age and MeDi adherence. In Mediterranean countries, especially those that are undergoing a nutritional transition, it is believed that younger people are more likely to adopt western dietary patterns. However, our study doesn’t support this hypothesis and this may be related to the beginning stage of the nutritional transition in Morocco. It may also be due to that female participants were younger and at the same time adhered more to MeDi. Therefore, younger subjects who were male (thus adhere less to MeDi) might not be well represented in the study population, leading to an overestimation of adherence in younger subjects. Nevertheless, our sample did not include children and adolescents under age 18, who are more prone to adopt this kind of dietary behavior.
We did not find significant differences in MeDi adherence according to either average family income or education. The same results were found in other Mediterranean countries [23, 24]. Conversely, other studies showed a significant association between a healthier dietary pattern and both high education and income levels [25–27]. However, associations were found with housing categories in our study. In the new and old medina which still contains traditional houses, people are still keeping their traditional lifestyle which is maintained by availability of plants food, and their cheaper price. For people living in slums or poor housing, most of which are located in rural areas (results non shown), who are more likely living far away from markets, the low availability of food variety and the many years of drought that made them unable to grow foods in their gardens, could be an explanation for this departure from traditional MeDi.
Similarly, single, widowed and divorced persons tended to choose this westernized type of food more frequently than married ones, who seem more likely to maintain the traditional dietary habits in Morocco. This may be explained in part because married subjects eat more often regularly in family due to social obligations and share meals that are still prepared according to the traditional lifestyle.
Interestingly, higher BMI was positively associated with the lower MeDi adherence, which may be viewed as a consequence rather than a cause of the nutritional transition. The ATTICA study had already found a similar association in a Greek population [28, 29]. Nevertheless, causality between obesity and the MeDi adherence cannot be drawn because of the cross-sectional design of the present study.
Many studies [16, 30] showed that the presence of one or more cardiovascular risk factors such as hypertension, hypercholesterolemia and diabetes, is linked to a lower adherence to the simplified MeDi [29, 31]. Unfortunately, information about these cardiovascular risk factors was not available in this study. But some previous Moroccan data have shown their high prevalence . This may be partly explained by departure from traditional MeDi in Moroccan population.
The main limitation of this study could be due to self-reported food consumption. We used a FFQ to describe the dietary profile of the Moroccan population. Food consumption was not assessed with high accuracy and people might have overestimated the consumption of healthy nutrients and food items like vegetables, fruit or cereals, typical components of the MeDi and underestimated the consumption of unhealthy nutrients and food items like red meat and some fats. Moreover, as quantities of foods were not available, we could not neither adjust for total energy intake nor calculate the MeDi adherence score following the same steps as presented elsewhere [16, 17] but only a simplified score. Furthermore, there was a lack of information regarding traditional CVD risk factors, such as hypertension, diabetes mellitus and hypercholesterolaemia in the study. This may explain some discordant results. Indeed, in poor housings or slums better adherence to a MeDi in terms of food choices may be counterbalanced by insufficient quantities of nutrients and low total energy intake. Another limitation is the cross-sectional design of our study which did not allow the identification of individuals who shifted from a traditional to a western diet. The cross-sectional design also does not permit to interpret as causal the direction of the observed association between lower MeDi adherence and obesity. Nevertheless, this study has several strengths. It was conducted in a large national population sample. Participants answered a detailed questionnaire and were especially motivated by trained interviewers to answer correctly the questions without causing misclassification. The results give for the first time a description of the adherence to a MeDi in the Moroccan population and its correlates taking into account the seasonality of consumption since the FFQ asked about dietary habits in the previous year. This information could prove useful, particularly when no other type of comparable data are available, in the formulation of dietary guidelines, and in public health initiatives involving nutrition policies and their implementation.