Gender inequalities in diet quality and their socioeconomic patterning in a nutrition transition context in the Middle East and North Africa: a cross-sectional study in Tunisia.

Background: In a context of nutrition transition and major shifts in lifestyle and diet, the Middle East and North Africa features a marked gender excess adiposity gap detrimental to women. In this setting, where gender issues are especially acute, we investigated gender differences in dietary intake with a focus on diet quality, and how the differences varied with the area of residence and socio-demographic characteristics.

Methods: The study was conducted in 2009-2010 in the Greater Tunis region (Tunisia), as a case study of an advanced nutrition transition context in the region. A cross-sectional survey used a random, stratified, clustered sample of households: 1689 women and 930 men aged 20-49 years were analyzed. Dietary intake was assessed using a 3-day food record. Nutrient content was derived from a specific Tunisian food composition database. We analysed the Diet Quality Index-International (DQI-I) and sub-scores (variety, adequacy, moderation and balance). A score of DQI-I > 60 defined good diet quality. Inequality measures were women vs. men differences in means for interval variables and odds-ratios (OR) for DQI-I > 60. Their variation with socio-demographic characteristics was estimated using models featuring gender x covariate interactions.

Results: Mean energy intake/day was 2300 ± 15 kcal for women vs. 2859 ± 32 kcal for men. By 1000 g/kcal/d women consumed more fruits and sweets but less red meat and soft drinks than men. Women had a higher mean moderation sub-score than men (+ 1.8[1.4, 2.2], P < 0.0001) but lower variety (- 2.0[- 2.3, - 1.6], P < 0.0001) and adequacy (- 1.8[- 2.0, - 1.5], P < 0.0001). Thus, the overall mean DQI-I was lower among women than men (58.6 ± 0.3 vs. 60.4 ± 0.3, - 1.8[- 2.6, - 1.0], P < 0.0001) as was the proportion of DQI-I > 60 (45.2% vs. 55.7%, OR = 0.7[0.5, 0.8], P < 0.0001). Adjusted gender differences in DQI-I decreased with age but were higher in larger households and extreme categories of education (no-schooling and university) vs. the middle categories.

Conclusion: In this nutrition transition context with only average diet quality, it was somewhat lower for women. Socioeconomic patterning of gender contrasts was mild. Beyond, that women had lower adequacy and variety scores but better moderation is a possible pathway for gender specific prevention messages.