Annals of Medicine and Surgery 84 (2022) 104972

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Annals of Medicine and Surgery

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Case Series

Evaluation of rural-urban patterns in dietary intake: A descriptive

analytical study – Case series
Samira Nabdi a, b, *, Said Boujraf a, b, Mohammed Benzagmout a, b, c
a
Faculty of Medicine and Pharmacy of Fez, Sidi Mohamed Ben Abdellah University, Fez, Morocco
b
Clinical Neuroscience Laboratory, Faculty of Medicine, Sidi Mohamed Ben Abdellah University, Fez, Morocco
c
Department of Neurosurgery, Hassan II University Hospital, Fes, Morocco

A R T I C L E I N F O A B S T R A C T

Keywords: Purpose: This article aimed to evaluate the different epidemiological aspects of the population (Fez-Meknes re­
Mediterranean diet gion), expose the secular trends of the food habits related to it, present the basic concepts and mechanisms of
Socio-economic data food in urban and rural areas in the Fez-Meknes region, and finally to analyze the results in the light of a
Demographic data
literature review.
Morocco
Materials and method: A survey was conducted among a representative sample of the urban and rural population
in the Fez-Meknes region (654 people aged 15 years and over, of which 326 people reside in the urban commune
of Fez and 328 in the rural commune of Loulja in the province of Taounate).
Results: The results are, a difference between the two urban and rural groups concerning the rhythm of taking
meals outside the home (P < 0,001); the average frequency of consumption of certain foods according to social
class (p < 0,001); the frequency of food consumption per week of legumes, olive oil, fermented milk, and tea is
more increased than that recorded in the urban environment (p < 0,001). On the other hand, the quantification
of the consumption of sweet products, dairy products, and whole grains did not conclude a significant difference
between the two study environments (p > 0,05).
Discussion: Changing dietary patterns over the past few decades, including more shift work, more meals eaten
outside the home or family setting, and more irregular eating patterns, including skipping breakfast and eating
late at night.
Conclusion: A disparity in eating habits between urban and rural areas was noted. It would be necessary to act
judiciously on the environmental factors by encouraging the Moroccan populations to maintain, as much as
possible, their good traditional habits, and to reinforce the new good food habits.

1. Introduction physiology and the external environment, within a psycho-biological

The metropolitan environment has considerably changed over the
last few decades, which has also had an impact on people’s eating habits
and even on their health [1–3].
The dietary habits can be considered as a set of integrated behaviors
linking internal biological events to external environmental events [4,
5]. Furthermore, the act of eating is complex. It has at least two
fundamental dimensions.
The first part is from physiology to culture, from the nutritive
function to the symbolic function. The second is from the individual to
the collective, from the psychological to the social [6]. Its expression can
be represented as the last link of an intimate interaction between the
system [7]. In addition, scientific progress has made it possible in the
last decade to deconstruct eating behavior and to shed light on the many
molecular factors that allow the regulation of physiological events
(food) [4,5,7–9].
In high-income (H.I.) countries, monitoring of dietary habits using an
objective method has been conducted for decades [10]. Unlike in our
context, few studies have used objective methods to assess nutrition,
especially in urban and rural settings [11–15].
Our study aimed to evaluate the different epidemiological aspects of
the studied population (Fez-Meknes region), to expose the secular trends
of the related food habits, to present the basic concepts and mechanisms
of food in urban and rural areas in the Fez-Meknes region and finally to

* Corresponding author. Faculty of Medicine and Pharmacy of Fez, Sidi Mohamed Ben Abdellah University, Fez, Morocco.
E-mail address: nabdisamira2022@gmail.com (S. Nabdi).

https://doi.org/10.1016/j.amsu.2022.104972
Received 24 August 2022; Received in revised form 24 October 2022; Accepted 12 November 2022
Available online 17 November 2022
2049-0801/© 2022 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
S. Nabdi et al. Annals of Medicine and Surgery 84 (2022) 104972

analyze the results in the light of a review of the literature. Table 1

The socio-demographic characteristics by urban and rural areas, Fez-Meknes
2. Materiels & methods region.
Groups Total ρ
2.1. Sample study Urban Rural
(%)

(%) (%)
A representative sample of the urban and rural population was sur­
Age (y.o) 15–24 98 (58) 71 (42) 169 <
veyed in the Fez-Meknes region which is number of 654 people aged 15 (25.8) 0,001
years and over of which 326 people reside in the urban commune of Fez 25–34 59 110 169
and 328 in the rural commune of Loulja in the province of Taounate. (34.9) (65.1) (25.8)
To determine the number of women and men to be surveyed, we used 35–49 90 74 164
(54.9) (45.1) (25.1)
the cota method according to age class and type of habitat while 50–64 53 47 (47) 100
respecting the same distribution as the general population of the 2014 (53.0) (15.3)
census (HCP, 2014). ≥65 26 26 (50) 52 (8.0)
(50.0)
Gender Women 166 167 333 0,999
2.2. Data collection
(49.8) (50.2) (50.9)
Men 160 161 321
A food frequency questionnaire (FFQ) was administered to our study (49.8) (50.2) (49.1)
population to estimate their food intake during the last month before the Marital Single 148 79 227 <
survey, combined with the 24-h recall to quantify the participants’ daily status (65.2) (34.8) (34.7) 0,001
Married 137 230 367
food intake. (37.3) (62.7) (56.1)
We obtained information regarding age, gender, socioeconomic Divorced 17 4 (19.0) 21 (3.2)
status, meal patterns, meal composition, etc. (81.0)
A short parental questionnaire was distributed to assess factors of Widowed 16 8 (33.3) 24 (3.7)
(66.7)
individual socioeconomic status. Written informed consent was ob­
Remarried after 7 (53.8) 6 (46.2) 13 (2.0)
tained from the participant’s parents. divorce
Remarried after 1 (50) 1 (50) 2 (0.3)
2.3. Data analysis widowed
Education No education 50 169 219 <
(22.8) (77.2) (33.5) 0,001
Data management and analysis were performed using IBM SPSS Informal 0 (0) 12 12 (1.8)
Statistics for Windows, version 26.0.0 (IBM Corporation, Armonk, NY). education (100)
Categorical data were summarized as frequencies, and cross-tabulations Primary school 23 80 103
and x2 significance tests were used to make comparisons between (22.3) (77.7) (15.7)
Middle school 57 53 110
groups. Continuous variables were summarized as mean and variation,
(51.8) (48.2) (16.8)
and comparisons between groups were made using the ANOVA test. All High school 76 11 87
tests of significance used a 2-sided P value of 0.05. For the overall (87.4) (12.6) (13.3)
nutritional quality, we referred to the MDS score (based on the Medi­ university 120 3 (2.4) 123
terranean diet pattern) (Fig. 5) [16]. (97.6) (18.8)
Social Poor 117 299 416 <
In addition to the use of the Ciqual food composition table for caloric category (35,9) (91,2) (63) 0,001
intake. As for the social class, we defined it according to the income of Average 168 29 (8,8) 197
our respondents, based on the classification made by the HCP. (51,5) (30)
To ensure a rigorous analysis of the data from the questionnaires, we Rich 41 0 (0) 41 (7)
(12,6)
have put forward an exploitation sheet.
This case series has been reported in line with the PROCESS criteria
[17]. 97.6% of those with higher education are from urban areas (p < 0.001).
The poor population represents 91.2% of the rural population
3. Results against 35.9% of the urban population, the middle class also called the
modest class represents only 8.8% of the respondents in rural areas
3.1. The sociodemographic profile of population by place of residence against half (51.5%) of the urban population, and the wealthy class in
this sample appears only in the urban area with a proportion of 12.6%,
The characteristics of the people are divided into groups, and the thus a statistically significant difference for the social class between the
epidemiological considerations are presented in Table 1. The survey two environments (p < 0.001) (Table 1).
reveals that the rural population is younger than the urban population,
with a median age of 33 years compared to 35 years in urban areas. The
25 to 34-year-old age group represents 65% in rural areas compared to 3.2. The dietary habits
only 35% in urban areas.
Women represent 51% of the surveyed population, compared to 49% Concerning the average number of meals consumed per day, the
of men, with no significant difference between the two geographic areas. results show that the rural population residing in the commune of Loulja
Half of the population surveyed (56.1%) said that they were married, consumes 3.83 ± 0.48 meals per day, i.e. one meal more than that of the
with a very significant difference between the two areas: 62.7% in rural city of Fez, which opts on average for 2.90 ± 0.31 meals per day,
areas and 37.3% in urban areas (p < 0.001). Single people come in without any significant difference according to age and gender (p ˃
second place with 34.7% of respondents, 65.2% of whom are in urban 0.05) (Table 2).
areas. Widowers (3.7%) and divorcees (3.2%) remain in the minority, In addition, the survey reveals that only 5% (18 people) of those
with a significant difference between urban and rural areas (p < 0.001). surveyed in rural areas declare that they do not eat regularly during the
One-third (33.5%) of our sample did not have access to school, of day, compared to 35% (114) of those surveyed in “Fez”, which is a very
which 77.2% reside in rural areas and 22.8% in urban areas, while significant difference between the two urban and rural areas (p <

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S. Nabdi et al. Annals of Medicine and Surgery 84 (2022) 104972

Table 2 224.35g ± 83.54) than in urban areas (36.79g ± 27.3; 81.17g ± 49.42)
The average number of meals consumed by residence setting, gender, and age (p (P < 0.001).
˃ 0.05). However, the quantification of the consumption of sugary products,
Meals per day dairy products, and whole grains did not conclude any significant dif­
Urban Rural
ference between the two study settings (p > 0.05) and respectively as
follows (p = 0.08, p = 0.054, p = 0.069) (Fig. 2) (see Fig. 3).
Mean (σ) Mean (σ)

Gender Men 2,91 ± 0,29 3,91 ± 0,48 3.3.2. The average daily caloric intake by gender and residence setting
Women 2,89 ± 0,32 3,75 ± 0,47
Total 2,90 ± 0,31 3,83 ± 0,48
Age (y.o) 15 à 24 2,90 ± 0,30 3,73 ± 0,44
25 à 34 2,88 ± 0,32 3,83 ± 0,48 3.3.3. Frequency of food consumption per week by social class
35 à 49 2,93 ± 0,25 3,91 ± 0,50 The survey reveals that the average frequency of consumption of
50 à 64 2,91 ± 0,29 3,85 ± 0,51 certain foods (fruits, vegetables, milk, yogurt, cheese, meat, fish,
≥ à 65 2,77 ± 0,43 3,85 ± 0,46
poultry, pastries, sweets and chocolates, soft drinks and coffee, fast food,
Total 2,90 ± 0,31 3,83 ± 0,48
and cold cuts) remains higher in the wealthy class followed by the
middle class and the poor class comes last (p < 0.001).
0.001). For nuts and grains, the difference is significant between the three
As for the way these meals are eaten, the average number of days of groups (p = 0.003). However, the frequency of consumption of legumes,
food consumption outside the home in the rural area does not even reach olive oil, fermented milk, and tea is increased among the poor class than
one day per week, i.e. 0.65 ± 0.48, and the meals eaten in the home among the middle and wealthy class (p < 0.005). As for eggs and whole
cover an average of 6.74 ± 0.9 days per week. This is in contrast to what grains, no difference was recorded according to social class (p > 0.005)
was recorded in the urban area, where the surveyed population spends (Table 3).
an average of 2.26 ± 1.8 days per week eating meals away from home
and 4.74 ± 2.5 days for meals eaten at home, which is a very significant 3.3.4. The food consumption by week and residence
difference between the two survey settings (p < 0.001). The investigation of weekly food consumption frequencies by area of
Concerning the types of cooking often or always adopted by the residence of our target population shows that the average number of
surveyed population, the survey shows that the types of cooking used are days of consumption of certain foods in urban areas is higher than in
the same in both urban and rural areas, except the use of microwaves, rural areas. These include fruits and vegetables, which are consumed
which is directly related to the urban world in this survey, in addition to more frequently in urban areas than in rural areas, i.e., on average two
grills, which are used by only 2% of the rural population (Fig. 1). days more per week (p < 0.001). (Table 4).
Similarly, yogurt and cheese are consumed all week in urban areas,
whereas in rural areas they are consumed only 2.5 times a month (p <
3.3. The food intake
0.001). Also, fish consumption remains higher in urban areas (1.33 ±
0.86) than in rural areas (0.43 ± 0.51) (p < 0.001). (Table 4).
3.3.1. Average quantity of food consumed per person per day and per place
In addition to fast food, soft drinks, chips, breakfast cereals, and ice
of residence in the Fez-Meknes region
cream, are consumed once or twice a week (2.05 ± 1.29; 1.14 ± 0.96;
The quantification of food portions consumed by the target popula­
1.74 ± 1.27 respectively) in urban areas compared to a frequency that
tion shows that the average quantities ingested per person per day for
does not even reach once a week in rural areas, i.e. (0.05 ± 0.01) for fast
certain foods are greater in urban areas than in rural areas, namely
food, (0.45 ± 0.62) for soft drinks and (0.57 ± 0.44) for potato chips (p
vegetables, fruits, nuts and grains, meat, and fish. These quantities are
< 0.001).
respectively (112.04g ± 64.14; 82.99g ± 58.77; 33.17g ± 17.14;
On the other hand, in rural areas, the frequency of weekly con­
115.43g ± 63.38; 29.68g ± 20.29) in urban areas compared to (62.91g
sumption of legumes, olive oil, fermented milk, and tea was higher than
± 40.26; 31.62g ± 27.04; 12.22g ± 14.94; 75.68g ± 36.64; 8.3g ±
in urban areas (p < 0.001) (Table 4).
10.38) in rural areas (P < 0.001). Other foods, notably olive oil and
legumes, were consumed much more in rural areas (120.67g ± 64.5;

Fig. 1. The distribution of the types of cooking used often to always by urban and rural areas in the region Fez-Meknes.

3
S. Nabdi et al.
Fig. 2. The average amount of food consumed per person per day by residents in the Fez-Meknes region.
Fig. 3. Average daily caloric intake by gender.
3.4. The nutritional quality
The estimation of the global nutritional quality via the calculation of
the MDS score by place of residence shows that the average of this score
reaches its peak in the rural area with an average of 5.51 ± 1.54 [1–10],
while it is 4.96 ± 1.71 [0–9] in the urban area, i.e., a significant dif­
ference between the two areas of the study (F (1,652) = [18,888], p =
0.0001).
Furthermore, the food typologies identified according to the total
score calculated for the two areas of residence reveal that more than half
(53.4%) of the rural population studied opts for a Mediterranean diet,
compared to only 28.2% of the urban population.
Our survey also shows that processed food is adopted by 1/3 of the
urban population compared to only 13.1% of the rural population. For
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Annals of Medicine and Surgery 84 (2022) 104972
these two dietary typologies, the difference is very significant between
the two study environments (P < 0.001). Concerning the two remaining
diets, the mixed diet composed of both the Mediterranean and processed
foods and the poor diet represented by a low MDS score without pro­
cessed products, the results are not conclusive of a significant difference
between the two study settings. (Table 5).
4. Discussion
Globally, the proportion of people living in large cities has increased
dramatically in recent decades and is expected to increase further;
during the 20th century, the proportion of people living in urban areas
rose from 14% to 50% [18–21]. This process of urbanization, that is, the
growth of cities in terms of population and physical size [22–25], began
a few centuries ago and was triggered by the invention of electric light in
1879 by Thomas Edison, during the industrial revolution.
This transition is occurring primarily in developing countries, and
these demographic changes are having a major impact on public health,
possibly related to effects on sleep and eating habits [26]. This new field
of nutritional science research that studies the impact of the timing of
food on health is called Chrono nutrition and combines elements of
nutritional research and chronobiology [27–32].
The Mediterranean diet is a dietary pattern rich in plant foods
(grains, fruits, vegetables, legumes, nuts, seeds, and olives), with olive
oil as the main source of fat, as well as high to moderate intakes of fish
and seafood, moderate consumption of eggs, poultry and dairy products
(cheese and yogurt), low consumption of red meat (Fig. 5) [33].
The various epidemiological data reveal a similar percentage of
participants for both sexes. Some authors note a slight male predomi­
nance, others note a certain female predominance [16,33,35–41].
In our case series, we noted a 51% female predominance with no
significant difference between the two geographical areas.
We note that our average age is lower than that reported in the
Western series. The Moroccan and African series, on the other hand, has
a relatively young average age (Davis et al. [42], Petterson et al. [43]).
Currently, there are no official guidelines in either the U.S. or Africa
S. Nabdi et al. Annals of Medicine and Surgery 84 (2022) 104972

Table 3 Table 4
Average frequency of food consumption per week and per social class, Fez- Average frequency of food consumption per week and per residence, Fez-Meknes
Meknes region. region.
Foods Food consumption/Week/Social status ANOVA Foods Average number of days/week ANOVA test
test
Poor Middle Rich Urban (Fez) Rural (Loulja)

Mean (σ) Mean (σ) Mean (σ) The base of the food pyramid
Vegetables 6,38 ± 2.56 4,65 ± 2.64 0,0001
Vegetables 2.62 ± 2.22 3.64 ± 2.50 5.26 ± <0,001
Fruits 4,44 ± 2.89 1,87 ± 1.56
2.96
Pulses 0,67 ± 0.65 2,96 ± 1.05
Fruits 2.40 ± 2.05 4.17 ± 2.87 5.90 ±
Whole grain cereals 8,76 ± 9.92 11,61 ± 11.65
3.48
Olive oil 4,16 ± 5.61 14,88 ± 5.78
Milk 3.64 ± 3.13 5.08 ± 4.31 5.55 ± <0,001
Nuts and grains 3,24 ± 2.74 1,84 ± 2.59
3.57
Milk 4,93 ± 3.96 3,46 ± 3.15 0,0001
Yogurt 0.55 ± 2.10 1.40 ± 2.30 3.14 ±
Fermented milk 0,46 ± 0.88 2,31 ± 3.07
3.70
Yogurt 1,86 ± 3.14 0,08 ± 0.25
Cheese 1.61 ± 3.92 4.51 ± 5.14 6.63 ±
Cheese 5,55 ± 5.31 0,07 ± 0.27
4.35
Tea 8.97 ± 6.63 13.20 ± 5.74 0,0001
Fermented milk 1.76 ± 2.63 0.80 ± 2.06 0.49 ± a
Coffee 3.23 ± 4.01 2.05 ± 2.96
0.76
Weekly consumption
Meat 1.42 ± 1.16 2.09 ± 1.24 2.37 ± <0,001
Fish 1,33 ± 0.86 0,43 ± 0.51 0,0001
1.33
Poultry 2,58 ± 1.46 1,40 ± 0.83
Fish 0.67 ± 0.71 1.21 ± 0.84 1.39 ±
Eggs 3,59 ± 2.92 4,25 ± 3.30 0,007
0.78
The top of the food pyramid
Poultry 1.66 ± 1.19 2.48 ± 1.33 2.98 ±
Red meats 2,12 ± 1.39 1,24 ± 0.88 0,0001
1.45
Pastries 3,48 ± 3.54 2,20 ± 1.79 0,0001
Eggs 3.99 ± 3.06 3.60 ± 3.17 4.76 ± 0.073
Sweets 1,06 ± 1.65 0,03 ± 0.27
3.51
Chocolate 1,00 ± 1.79 0,07 ± 0.35
Cold cuts 0.22 ± 0.98 0.52 ± 1.18 1.07 ± <0,001
Unfavorable foods in the Mediterranean diet
1.42
Fast-foods 2.05 ± 1.29 0.05 ± 0.01 0,0001
Pulses 2.32 ± 1.39 1.02 ± 1.08 0.55 ± <0,001
Soft drinks 1.14 ± 0.96 0.45 ± 0.62
0.56
Chips-breakfast cereals-ice cream 1.74 ± 1.27 1.57 ± 0.44
Wholegrain 10.28 ± 7.57 ± 8.58 ± 0.014
cereals 11.26 10.08 9.44 a
Limited quantity.
Pastries 2.34 ± 1.99 3.50 ± 3.59 4.72 ± <0,001
4.67
Sweets 0.34 ± 1.09 0.88 ± 1.52 1.07 ±
Table 5
1.47
Chocolate 0.22 ± 0.76 0.99 ± 1.94 1.53 ±
Dietary typology according to the MDS score by area of residence, Fez-Meknes
1.76 Region.
Olive oil 12.15 ± 7.27 5.43 ± 6.76 2.73 ± <0,001 Urban Rural Total ρ
4.91 (%) (%) (%)
Nuts and grains 1.30 ± 2.61 1.74 ± 2.72 2.66 ± 0.003
2.72 Mediterranean diet (MDS score ≥5 92 175 267 <0,001
Soft drinks 0.63 ± 1.32 1.03 ± 1.52 1.43 ± <0,001 without processed products) (28.2) (53.4) (40.8)
2.50 Mixed diet (Score ≥ to 5 plus 103 72 175 0.005
Tea 12.24 ± 6.15 8.99 ± 6.62 9.51 ± <0,001 processed products) (31.6) (22.0) (26.8)
7.43 Poor diet (MDS Score ≤ to 4 without 22 (6.7) 38 60 (9.2) 0.032
Coffee 2.33 ± 3.28 2.88 ± 3.96 4.62 ± <0,001 processed products) (11.6)
3.74 Processed Food (MDS Score ≤4 109 43 152 <0,001
Fast-foods 0.20 ± 0.69 0.85 ± 1.32 1.09 ± <0,001 with processed products) (33.4) (13.1) (23.2)
1.22

components and antioxidant activity. Cooking method and time signif­

regarding the number of meals and snacks to be consumed; however, the
sample meal plans on the USDA’s MyPlate SuperTracker website call for
three meals and a mid-morning and mid-afternoon snack [44].
Regions of the world differ in the distribution of energy intake in
food episodes throughout the day. The lack of differences in the mean
number of meals consumed per day in our study (Rural: 3.83 ± 0.48;
Urban: 2.90 ± 0.31), by age and sex in both areas, confirms that of
Davis et al. [42], Kenney et al. [45] and Ennemana et al. [46], and
significantly lower than those found in the study by Kant et al.: 4.96
[47].
The difference between the two urban and rural groups regarding
non-regular meal patterns (5% in the rural group VS 15% in the urban
group) can be explained by changes in eating habits in recent decades,
including more shift work, more meals eaten outside the home or family
setting, and more irregular eating habits, including skipping breakfast
and eating late at night [26]. The differences between groups were
statistically significant (P < 0.001) (see Fig. 4).
Buratti et al. [48] examined the effects of three cooking methods
(boiling, steaming, and microwaving) on the nutritional and physical
properties of cauliflower, carrots, and sweet potatoes in a study. Nutri­
tional quality was assessed by determining concentrations of key
icantly influenced the quality of all three products. Boiling had a
negative effect on ascorbic acid, total phenolic concentration, and
antioxidant activity, but improved carotene accessibility. Steaming
resulted in losses of ascorbic acid, but increased total phenolic and
carotenoid concentration. Microwave cooking resulted in minor changes
in ascorbic acid concentrations, preserved carotenoids, and increased
total phenolics. The nutritional value of the vegetables was better pre­
served or improved by using shorter cooking times with relatively low
temperatures below 75 ◦ C. In our study, the most used cooking method
by the studied population is pressure cooking, this choice is related
among others to the increasing urbanization and busy lifestyles that
have given a huge impulse to the preference for a faster and unfortu­
nately with a high temperature exceeding 120 ◦ C (pressure cooker)
which can impact the sensory characteristics of the food (Fig. 6).
McCormack and Meendering 2016 looked at differences in diet and
physical activity among rural and urban children as a possible expla­
nation for the higher prevalence of obesity among rural children [8].
Five dietary studies between rural and urban children. Of the five di­
etary studies, two studies showed no difference in dietary intake be­
tween rural and urban children [26]. One study showed that rural
children consumed more energy, and one study showed that urban

5
S. Nabdi et al.
Fig. 4. The caloric intake according to the environment of residence (the re­
gion loulja & fès).
children consumed fruits and vegetables more frequently and/or more
fruits and vegetables [8].
In the United States, current work and school routines are not
conducive to eating a large breakfast or lunch. More comprehensive
dietary information, including questionnaires and consistently defined
food groups and outcomes, would provide a better understanding of the
dietary habits of the rural and urban populations, as well as potential
differences between them [8].
The consumption of milk and dairy products in different regions of
the world is subject to great disparity, mainly due to strong cultural
factors, but also partly due to the availability of products and their cost
Fig. 5. New pyramid for a sustainable Mediterranean diet [34].
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Annals of Medicine and Surgery 84 (2022) 104972
in developing countries, the lack of refrigeration equipment, and the
high prevalence of lactose intolerance in the Asian population [49].
The consumption of sweetened products, dairy products, and whole
grains in our study did not find any statistically significant difference
between the two urban and rural environments (p > 0.05) and respec­
tively as follows (p = 0.08, p = 0.054, p = 0.069).
In contrast, a study conducted in Algeria found that the sense and
cognitive perception of modernity in the urban population was related
to the consumption of sweetened beverages, and snacks by older people
[40].
In addition, fruit and vegetable consumption in our series was higher
in urban areas: 4.44 ± 2.89 than in rural areas: 1.87 ± 1.56, i.e., on
average 2 more days of consumption per week (p < 0.001). Our results
are close to those of the Stepwise survey (Morocco) [50], the number of
days per week is more important in urban 4.6 ± 0.1 than in rural 3.6 ±
0.2. Our results are also similar to those of Liu et al. [51].
In addition, the High Council for Public Health (HCSP) recom­
mended (during the 2017/2021 report), that the food day should be
globally close to the benchmarks as much as possible without each meal
necessarily being so. If the consumption of certain products should be
limited (in terms of frequency and quantity), there is no question of
banning them. Their consumption can be part of a healthy diet [52].
According to the study by Stefler et al. [35], many factors (female
gender, being married, high household equipment score, high total en­
ergy, and regular intake of vitamin supplements) were related to a high
MDS. In our series, half (53.4%) of the rural population studied opted for
a Mediterranean diet compared with only 28.2% of the urban popula­
tion. The mean MDS score in the rural population was 5.51 ± 1.54
[1–10], whereas it was 4.96 ± 1.71 [0–9] in the urban population, i.e., a
significant difference between the two study settings (F (1,652) = [18,
888], p = 0.000).
In the Benyach et al. study [36], the authors were able to demon­
strate that the strength of adherence to the Mediterranean diet (MR)
differed between the urban and rural populations, as well as according
to the level of physical activity and the two forms of obesity (abdominal
and peripheral). Our results are similar to those found in the literature.
S. Nabdi et al. Annals of Medicine and Surgery 84 (2022) 104972

Fig. 6. The different cooking methods (Copyright: Samira NABDI).

Greater adherence to the Mediterranean diet was associated with a in the timing of eating may be challenging.
reduced risk of total death, death from cardiovascular disease, and the The type, extent, and impact of measurement error, as well as vari­
occurrence of mental disorders in these large urban populations in ation in eating patterns within and between subjects, is an open area of
Eastern Europe. Application of the MDS with absolute cut-offs appears to research.
reduce the incidence of cardiovascular disease and reduce mental dis­
orders in our population [33,35,36] (Table 6). 6. Conclusion

5. Limites In the field of eating behavior, one of the issues is whether food
intake is primarily influenced by psychosocial/environmental parame­
Given these findings, the adoption of eating patterns (in urban and/ ters or by physiological events.
or rural settings) that advocate a decrease in meal frequency and a shift Obesity, associated metabolic disorders, and mental disorders are

Table 6
Food data: Rural and Urban.
Authors Year Country Type Age range Variable Résultats
(y.o)

Davis et al. [53] 2008 U.S T 2–18 Rural vs urban No significant differences.
Davis et al. [42] 2011 U.S T 2–18 Rural vs urban No significant differences.
Liu et al. [51] 2012 U.S T 2–19 Rural vs urban Ages 2–11: Rural people consumed more calories and consumed more than 2–3
cups of dairy products
Ages 12–19: Fewer rural people consumed <2 cups of fruit.
Ettienne-Gittens 2013 U.S T – Rural vs urban Urban children eat vegetables more frequently than rural children
et al. [54]
Kenney et al. [45] 2013 U.S T <18 Non-metropolitan vs. No significant differences.
metropolitan
Patterson et al. 2005 U.S D 18–75 Rural vs urban Socio-demographic, environmental correlates of obesity and physical inactivity in
[43] rural areas.
Ayala et al. [41] 2013 U.S T – Rural Positive trend for additional fruit and vegetable consumption in rural areas.
Chikhi et al. [40] 2014 Algeria T – Rural vs urban Modernity: the consumption of sweetened drinks and snacks for older people.
Ennemana et al. 2009 Guatemala T 6–12 Rural vs urban No geographic differences were observed in dietary variety or diversity.
[46] (mois)
Dauchet et al. [46] 2011 France T 12–17 Rural vs urban Nutritional education or intervention practices must be adapted according to the
socio-economic level and location (North/South) of individuals.
Bell et al. [37] 2016 Australia T 9–11 Rural vs urban No difference between urban and rural children in all eating behaviors.
Torres-Luque et al. 2018 Spain T 3–5 Rural vs urban The effect of age is more important than that of the environment (rural or urban).
[38]
Benyaich et al. 2014 Morocco T – Rural vs urban Adherence to the Mediterranean diet is higher in rural than in urban areas.
[36] Women consume more carbohydrates than men in both settings

T: Cross-sectional study, D: Descriptive study.

7
S. Nabdi et al.
one of the major public health threats we face today. At the end of our
study, we deduce a disparity in eating habits between urban and rural
areas. It would be wise to act on environmental factors by encouraging
Moroccan populations to maintain, as much as possible, their good
traditional habits, and to reinforce the new good eating habits.
Ethical approval
Written informed consent was obtained from the patient for publi­
cation of this case report and accompanying images. A copy of the
written consent is available for review by the Editor-in-Chief of this
journal on request.
Source of funding
The authors declared that this study has received no financial
support
Author contribution
Samira Nabdi: Corresponding author writing the paper, study
concept and analysis of data, Said Boujraf: Study design and Correction
of the paper, Mohammed Benzagmout: Study design and Correction of
the paper.
Trail registry number
Name of the registry: researchregistry
Unique Identifying number or registration ID: 8230.
Hyperlink to your specific registration (must be publicly accessible
and will be checked).
Garantor
Samira Nabdi.
Provenance and peer review
Not commissioned, externally peer reviewed.
Declaration of competing interest
Authors of this article have no conflict or competing interests. All of
the authors approved the final version of the manuscript.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.amsu.2022.104972.
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