Sex-Specific Insights into Adherence to Mediterranean Diet and Lifestyle: Analysis of 4000 Responses from the MEDIET4ALL Project

Mohamed Ali Boujelbane¹Achraf Ammar^1*Atef Salem¹Mohamed Kerkeni²Khaled Trabelsi^2,3Bassem BOUAZIZ⁴Liwa Masmoudi²Juliane Heydenreich⁵Christiana Schallhorn¹Gabriel Müller¹Ayse Merve Uyar¹Hadeel Ghazzawi⁶Adam Tawfiq AMAWI⁶Bekir Erhan Orhan⁷Guiseppe Grosso⁸Osama Abdelkarim⁹Tarak DRISS¹⁰Kais Elabed²Piotr Zmijewski¹¹Nasreddine Benbettaieb¹²Clément Poulain¹²Laura Reyes¹³Amparo Gamero¹⁴Marta Cuenca-Ortolá¹⁴Nicola Francesca¹⁵Concetta Maria Messina¹⁵Björn Lorenzen¹⁶Stefania Felice¹⁶Aadil Bajoub¹⁷El-Mehdi Ajal¹⁷El-Amine Ajal¹⁸Majdouline Obtel¹⁸LAHIANI SADJIA¹⁹Taha Khaldi¹⁹Nafaa Souissi²Omar Boukhris²⁰Haitham Jahrami²¹Waqar Husain²²Walid MAHDI⁴Hamdi Chtourou²Wolfgang Immanuel Schöllhorn¹

• ¹Johannes Gutenberg University Mainz, Mainz, Germany
• ²High Institute of Sport and Physical Education of Sfax, Sfax, Sfax, Tunisia
• ³Faculty of Sports Sciences, The University of Jordan, Amman, Amman, Jordan
• ⁴Higher Institute of Computer Science and Multimedia of Sfax, Sakiet Ezzit, Sfax, Tunisia
• ⁵Faculty of Sport Science, Leipzig University, Leipzig, Lower Saxony, Germany
• ⁶Department of Nutrition and Food Technology, School of Agriculture, The University of Jordan, Aljubeiha, Amman, Jordan
• ⁷Istanbul Aydın University, Istanbul, Türkiye
• ⁸University of Catania, Catania, Sicily, Italy
• ⁹Assiut University, Assiut, Asyut, Egypt
• ¹⁰Université Paris Nanterre, Nanterre, Île-de-France, France
• ¹¹Józef Piłsudski University of Physical Education in Warsaw, Warsaw, Masovian Voivodeship, Poland
• ¹²Université de Bourgogne, Dijon, Burgundy, France
• ¹³Vitagora innovation cluster, 21000 Dijon, France, Dijon, Burgundy, France
• ¹⁴University of Valencia, Valencia, Valencian Community, Spain
• ¹⁵University of Palermo, Palermo, Sicily, Italy
• ¹⁶Microtarians Luxembourg, Luxembourg, Luxembourg
• ¹⁷Ecole Nationale d'Agriculture de Meknès, Meknès, Fes-Meknes, Morocco
• ¹⁸Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Rabat-Sale-Kenitra, Morocco
• ¹⁹Departement of Biology, Faculty of Science, University of Boumerdes, Boumerdes, Algeria
• ²⁰La Trobe University, Melbourne, Victoria, Australia
• ²¹Arabian Gulf University, Manama, Capital Governorate, Bahrain
• ²²COMSATS University, Islamabad Campus, Islamabad, Islamabad, Pakistan

AbstractBackground: The Mediterranean Diet (MedDiet) is widely recognized for its health benefits, though adherence varies across populations and is influenced by multiple lifestyle and demographic factors. This study examined MedDiet adherence patterns and their associations with lifestyle behaviors, with particular attention to sex differences in a large, multinational cohort.Methods: Data were obtained via the MEDIET4ALL survey, an international cross-sectional study that included 4,010 participants (mean age: 36.04 ± 15.06 years; 59.5% female) across 10 countries. The evaluation of adherence to the MedDiet was conducted using the MedLife Index, a validated tool that assesses adherence to MedDiet patterns and lifestyle behaviors through three blocks: Mediterranean food consumption, MedDiet habits, and lifestyle behaviors. Additionally, validated instruments were used to measure associated factors, including perceived barriers to adherence, physical activity, sleep quality and disturbances, mental health, life satisfaction, social participation, and technology use behaviors. Results: While total Mediterranean lifestyle (MedLife) scores showed no significant sex differences, women demonstrated better adherence to food consumption components (p < 0.001), while men showed greater physical activity and social participation. Women reported poorer sleep metrics (efficiency, latency, duration) and higher insomnia severity (all p < 0.05). Psychological distress was more prevalent among women, who also expressed greater needs for psychosocial and nutritional support (p < 0.001). The MedLifeMEDLIFE Index showed significant positive correlations with physical activity (r = 0.298), social participation (r = 0.227), and sleep satisfaction (r = 0.181), and negative correlations with mental health measures (insomnia: r = -0.137; depression: r = -0.115; stress: r = -0.089; anxiety: r = -0.076; all p < 0.001).Conclusion: Our findings reveal distinct sex-specific patterns in MedDiet adherence and associated lifestyle factors. These results underscore the need for differentiated public health approaches that address the unique behavioral and psychosocial needs of men and women to promote MedLife adoption.