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Nutrition Journal volume 19Article : 24 Cite this article. Metrics details. Little is known about sex-based dietary differences in middle-income countries, particularly those undergoing the nutrition transition.

The study sample consisted of subjects: children and adolescents aged 6— At the households, trained nutritionists conducted face-to-face interviews with participants to complete a sociodemographic questionnaire and one h diet recall.

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Food items were categorized into 25 food groups. In all age groups, males had ificantly higher energy intakes, while females had ificantly higher fiber intakes. In addition, in adolescents aged 12— These differences in macronutrient intakes were not observed in younger children nor in older adults.

In all age groups, females had lower micronutrient intakes compared to males, including calcium, iron, and zinc. This study identified sex-specific priorities that ought to be tackled by context-specific interventions to promote healthier diets in Lebanon. Peer Review reports. While women and girls often have increased nutritional needs during the lifecycle, social norms in many parts of the world frequently lead to gender inequalities in nutrition, which tend to disfavor females [ 1 ].

Worldwide, women and girls continue to be twice as likely to suffer from all forms of malnutrition compared to their male counterparts, highlighting the need for a better understanding of sex disparities in food consumption and dietary intakes as a determinant of health [ 1 ]. Evidence stemming from different parts of the world depicts conflicting pictures of sex-based discrepancies in diet and nutrition [ 4567 ]. Studies conducted in developing, low income countries, showed that women and girls have lower intakes of nutrient-dense foods such as meats, eggs, milk, pulses, fruits, and vegetables and a higher risk for micronutrients and chronic energy deficiencies compared to males [ 8 ].

However, in Western developed countries, studies have shown that females tend to make healthier food choices and consume higher amounts of fruits, vegetables, and dietary fiber compared to males [ 9 ]. Little is known about sex-based dietary differences in middle-income countries, particularly those undergoing the nutrition transition, with its characteristic shifts in diet and lifestyle [ 5 ].

This may be particularly true for the Eastern Mediterranean Region EMRwhich has witnessed rapid changes in food consumption habits and dietary practices over the past decades. The region is also characterized by a double burden of malnutrition with strong female vs. Apart from sex-based physiological and biological differences, a variety of external factors may explain these gender disparities, including the non-egalitarian household and social roles in the region [ 13141516 ].

Lebanon, a small country of the EMR, has made substantial achievements with regard to gender equality and empowerment [ 1718 ] over the past 10 years. However, similar to other countries of the region, the country still harbors a set of traditions and social norms that may result in unequal gender roles both within the household and in the society [ 5 ]. Interestingly, studies in Lebanon showed that sex differentials in obesity prevalence were not static, but were rather dynamic across the lifespan.

For instance, while obesity rates did not differ between boys and girls in young children, ificant sex-based disparities were noted in the adolescent age group, with the prevalence of obesity being ificantly higher in boys compared to girls [ 21 ]. These differentials were most apparent in obesity class II and class III with women being ificantly more likely than men to show this type of excessive adiposity [ 20 ].

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The data for the present study were derived from the national cross-sectional food consumption survey conducted in Lebanon between May and August Details about the de and protocol of this survey are found elsewhere [ 2223 ]. Efforts were exerted to recruit a nationally representative sample with age, sex, and district distributions proportionate to that of the Lebanese population [ 2425 ].

The study sample consisted of randomly selected households, based on stratified cluster sampling: the strata were the Lebanese governorates, the clusters were selected further at the level of districts, urban, and rural areas, and the housing units constituted the primary sampling units. The study sample consisted of subjects children and adolescents aged 6— At the households, trained nutritionists conducted face-to-face interviews with participants to complete a sociodemographic questionnaire and one h diet recall HR.

The questionnaire covered information related to sex male, femaleage in yearsand governorate of current residence Beirut, Mount Lebanon, North, South, Bekaa, and Nabatieh. For children and adolescents aged between 6 and In this survey, crowding index was used as a proxy for socioeconomic status.

This index is calculated as the ratio of the of people living in the household over the of rooms, excluding the kitchen and bathrooms. Several epidemiological studies have associated a high household crowding index with low socioeconomic status [ 2627 ]. The five steps followed included 1 quick food list recall, 2 forgotten food list probe, 3 time and occasion at which foods were consumed, 4 detailed overall cycle, and 5 final probe review of the foods consumed.

For adolescents aged between 12 and The latter was determined using quantification tools [ 30 ] and which included standard measuring cups and spoons, household measures, as well as food photos and models of single servings of commonly consumed food items. The nutritionists who were collecting the dietary intake data were specifically trained to maintain a neutral attitude and avoid leading questions. The Nutritionist Pro software version 5.

For composite and mixed dishes, standardized recipes were added to the Nutritionist Pro Software using single food items. Food composition of specific Lebanese foods not included in the Nutritionist Pro software database was obtained from local food composition tables [ 31 ]. In addition to energy, macronutrients, and micronutrients, the dietary intake data was also used to obtain information about food groups intakes.

Food items were categorized into the following 25 food groups: bread, cereals, legumes, starchy vegetables, vegetables, chips and salty crackers, nuts and seeds, milk, milk derivatives, sweetened milk, red meat, processed meat, poultry, fish, eggs, fruits, fresh fruit juices, sweets, added sugars, sugar sweetened beverages, hot beverages coffee, teaalcoholic beverages, added fats and oils, fast food, and miscellaneous.

Food items included within each of the aforementioned food groups are outlined in Appendix A. The data for this study were presented and compared between sexes among the various age groups 6— In addition, data for adolescents aged 12— In the latter, the sociodemographic covariates included were those that showed statistical difference between males and females.

The Statistical Package for Social Sciences In addition, a total of 93 subjects were excluded as outliers, based on total energy intake and using the interquartile range method [ 32 ]. Sociodemographic characteristics of the study population by age and sex are presented in Table 1. Among children and adolescents, the proportions of participants aged 6— As for governorate, the highest proportions of participants came from Mount Lebanon Sixty percent of participants As for the education level, almost one in two participants Similarly, one in two participants The comparison between males and females among adults in the study population showed ificant differences related to all variables, except for education where the distributions of males and females across the three levels of education were not statistically different.

As for governorates, Beirut and Mount Lebanon had greater proportions of males, while Bekaa and Nabatieh had greater proportions of females. Furthermore, a higher proportion of females was divorced, separated, or widowed as compared to males As for employment status, Among children and adolescents, energy intake was Saturated fat and total sugars made up Fiber intake was estimated at 7. In this age group, comparison between males and females showed that males had a higher energy intake, while females had higher fiber intakes Table 2. When adolescents 12— More specifically, females had higher fat intakes as compared to males Among adults between 20 and In this age group, while males had ificantly higher energy intakes, females had higher fat, saturated fat, and fiber intakes.

Among older adults, the contributions of macronutrients to total energy intake were The contributions of the various food groups to energy intakes by sex among different age groups are presented in Table 3. Among children and adolescents, the percent contributions of the following food groups were higher in males as compared to females: red meat 5. On the other hand, females had higher contributions of whole fruits to their total energy intake than males 4. Among adolescents 12— Among adults 20— Similar were obtained when the data for adolescents aged 12— For adults 20— Our study adopted a life course approach to investigate sex-based differentials in dietary intakes and food consumption patterns in Lebanon, a country where inequalities in the prevalence of obesity and micronutrient deficiencies were reported between sexes.

Two consistent observations across the lifespan were the higher intake of energy in males compared to females and the higher intake of dietary fiber in females compared to males. On the other hand, males were found to have higher consumptions of red and processed meat, bread, fast food, soft drinks, and alcohol.

Another consistent observation was the lower micronutrient intakes in females compared to males, across the lifespan. The observed higher intakes of energy in males compared to females from all age groups are consistent with the well-established sex-based disparities in energy intakes, which reflect differences in physiological and metabolic factors [ 433 ]. Dietary fiber intakes ranged between 6. However, a consistent observation was the ificantly higher dietary fiber intake in females compared to males across the lifecycle. In agreement with our findings, a review by Kiefer et al.

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In fact, women and girls have been frequently described as being more health conscious and more inclined to comply with dietary recommendations than their male counterparts [ 935363738 ]. However, in contrast to our findings, a recent study conducted in Tunisia did not report any ificant differences in dietary fiber intake between males and females [ 5 ], while a study conducted in the United Kingdom UK showed that, compared to men, women were ificantly more likely to have an inadequate fiber intake [ 4 ].

In our study, total fat intake ranged between Noteworthy is the higher intake of saturated fat that was also observed among adult women compared to men. Similar to our findings, the National Diet and Nutrition Survey in the UK reported that women consume more fat and saturated fat than their male counterparts [ 40 ].

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A prospective study conducted on a large sample of adults in the UK has also shown that, compared to men, women were more likely to have intakes that exceeded recommendations for total fat and saturated fat [ 4 ]. Our findings contrast with data stemming from 22 European countries [ 9 ], as well as from Tunisia [ 5 ], which did not report any ificant sex-based differences in total fat intake.

Our findings are also in contrast with studies reporting women as often choosing lower fat foods in an effort to make heathier food choices [ 934 ]. Our underline a higher intake of fruits, vegetables, and milk in females compared to men, while showing that men had a higher consumption of soft drinks, red meat, fast food, bread, and alcohol.

These findings are in agreement with studies conducted in Lebanon showing that males were more likely to adhere to the Western dietary pattern, while females had higher adherence to the Traditional Lebanese dietary pattern, which has been described as a variant of the Mediterranean diet with fruits, vegetables, and dairy consumption being among its characteristic hallmarks [ 22234142 ]. Our findings are also in agreement with those reported from studies conducted in other parts of the world [ 6943 ]. For instance, in Tunisia, another country undergoing the nutrition transition, women were found to consume more fruit and less soft drinks and red meat compared to men.

Earlier studies have described ificant gender differences in opinions and behaviors related to dietary and food choices [ 9 ]. These studies reported that men choose fewer high-fiber foods, eat less fruits and vegetables, while consuming more soft drinks and high starch foods such as bread, while women tend to consume a higher of portions of fruits and vegetables compared to men [ 694344454647484950 ].

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Fruits and vegetables are rich sources of dietary fiber, antioxidants, and phytochemicals and hence dietary guidelines and recommendations have consistently encouraged a higher consumption of these food groups [ 5152 ]. In addition, despite the ificantly lower intake of red meat in females compared to males except among the elderly age groupthe consumption of red meat among Lebanese girls and women was not low compared to dietary recommendations, unlike what is usually reported from developing countries [ 8 ].

Sweets have in fact been suggested to be culturally associated with femininity [ 55 ], while meat consumption is far more commonly associated with masculinity [ 56 ]. In agreement with evidence stemming from developing countries [ 8 ], the present study showed that women and girls in Lebanon have lower micronutrient intakes compared to their male counterparts and that higher proportions of females may be at risk of micronutrient inadequacies, including calcium, iron, zinc, and vitamin B In contrast to our findings, data stemming from Western societies have documented strong similarities in micronutrient intakes between both sexes [ 9 ].

The micronutrient inadequacies characterized in our study are in line with the priority micronutrients identified by the WHO for children and women of childbearing age in the EMR [ 57 ] and with those documented in studies in Lebanon. For instance, a cross-sectional survey by Al Khatib et al.

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Importantly, women and girls with these nutritional inadequacies and deficits are likely to have lower educational attainment and work capability, thus contributing to further inequalities in social roles between genders [ 59 ]. Existent gender inequities and differences in social roles may also contribute to disparities in food and dietary intakes and may, at least partly, explain the observed sex-based dietary differences in our study. Despite its modernized flavor, Lebanon remains a patriarchal culture with a strong set of traditional social values, where boys tend to be given entitlement over their sisters from early childhood [ 62 ].

These culturally dominant attributes and social roles may in fact influence the eating behavior of women and girls in Lebanon. For instance, women who do not work outside the home or who are mostly in charge of preparing meals in the household may receive more food stimuli than men, including stimuli for unhealthy foods such as sweets [ 564 ]. A recent study by Jomaa et al. Other factors such as lower income, insufficient professional insertion, and limited decision-making within the household may also contribute to differences in dietary choices between women and men, and between boys and girls in Lebanon [ 67 ].

Overall, this study identified and characterized sex-based differences in dietary intakes and food consumption patterns in a nutrition transition context. Despite the favorable observation of higher intakes of dietary fiber, fruits, and vegetables in females compared to males, dietary intakes in women and girls remained inadequate in several micronutrients of public health concern while also being high in total and saturated fat.

These observed sex-based differences place Lebanon somewhere between developed and developing countries in terms of dietary disparities between sexes, sharing the micronutrients inequalities with developing countries, while also sharing the higher fruit, vegetables, and fiber intakes with Western societies.

These findings highlight the need for culture-specific interventions aimed at improving nutrition for women and adolescent girls as this would lay the foundation not only for their future education, productivity, and economic empowerment, but also for the health of future generations [ 1 ]. Adherence to a Westernized diet has been associated with increased risk for obesity and several non-communicable diseases, thus highlighting the need for context-specific interventions aimed at promoting healthier dietary patterns in Lebanese boys and men [ 22234142 ]. The present study has several strengths.

The study is based on an individual food consumption survey that was conducted on a nationally representative sample of children, adolescents, and adults. The survey has covered a wide age range, permitting to examine sex-based disparities in dietary intakes across the lifespan. To reduce judgmental communication and minimize social desirability bias, the HRs assessment was administered by trained nutritionists who received extensive training prior to data collection. The of the study ought however to be considered in light of the following limitations.

First, the investigation of food consumption and nutrient intakes was based on the collection of one HR, which may not be representative of dietary intakes at the individual level. However, despite its well-known limitations, such as reliance on memory and day-to-day variation, the HR may provide accurate estimates of energy intake and nutrient intakes at the population level [ 68 ]. In the present study, dietary information was collected by the multiple pass HR approach, which was shown to improve the accuracy of dietary intake estimates in children, adolescents, and adults [ 697071 ].

Second, it is important to mention that, in Lebanon, there exists no food composition database. Therefore, the USDA database of the Nutritionist Pro was used for dietary analysis including that of traditional dishes and mixed recipes.

Although this limitation could have affected the absolute estimates of nutrient intakes, it would have had limited effects on sex-specific differences.

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