Regional Variations in Mediterranean Diet Adherence: A Sociodemographic and Lifestyle Analysis Across Mediterranean and Non-Mediterranean Regions

Achraf Ammar^1*Mohamed Ali Boujelbane¹Atef Salem¹Mohamed Kerkeni^2,3Khaled Trabelsi^2,3Bassem BOUAZIZ⁴Liwa Masmoudi³Juliane Heydenreich⁵Christiana Schallhorn¹Gabriel Müller¹Ayse Merve Uyar¹Hadeel Ghazzawi⁶Adam Tawfiq AMAWI⁶Bekir Erhan Orhan⁷Giuseppe Grosso⁸Osama Abdelkarim⁹Tarak DRISS¹⁰Kais Elabed³Piotr Zmijewski¹¹Frédéric Debeaufort¹²Nasreddine Benbettaieb¹²Clément Poulain¹²Laura Reyes¹³Amparo Gamero¹⁴Marta Cuenca-Ortolá¹⁴Antonio Cilla¹⁴Nicola Francesca¹⁵Concetta Maria Messina¹⁶Enrico Viola¹⁶Björn Lorenzen¹⁷Stefania Felice¹⁷Aadil Bajoub¹⁸El-Mehdi Amine Ajal¹⁹El Amine Ajal²⁰Majdouline Obtel¹⁹LAHIANI SADJIA²¹Taha Khaldi²²Nafaa Souissi²³Omar Boukhris²⁴Haitham Jahrami²⁵Waqar Husain²⁶Evelyn Frias-Toral²⁷Walid MAHDI⁴Hamdi Chtourou³Wolfgang Immanuel Schöllhorn¹

• ¹Johannes Gutenberg University Mainz, Mainz, Germany
• ²High Institute of Sport and Physical Education of Sfax, University of Sfax, Tunisia, Sfax, Tunisia
• ³Research Laboratory Education, Motor Skills, Sport and Health, High Institute of Sport and Physical Education of Sfax, University of Sfax, Sfax, Tunisia
• 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
• ⁷Faculty of Sports Sciences, Istanbul Aydın University, Istanbul, TURKIYE, istanbul, Türkiye
• ⁸Department of Biomedical and Biotechnological Sciences, Faculty of Medicine, University of Catania, Catania, Sicily, Italy
• ⁹Faculty of Physical Education, Assiut University, Asyut, Asyut, Egypt
• ¹⁰Laboratoire Interdisciplinaire en Neurosciences, Physiologie et Psychologie, Université Paris Nanterre, Nanterre, Île-de-France, France
• ¹¹Józef Piłsudski University of Physical Education in Warsaw, Warsaw, Masovian Voivodeship, Poland
• ¹²Procédés Alimentaires et Microbiologiques, Université Bourgogne Franche-Comté, Dijon, Burgundy, France
• ¹³Vitagora innovation cluster, 21000 Dijon, France, Dijon, Burgundy, France
• ¹⁴Department of Preventive Medicine and Public Health, Food Sciencs, Toxicology and Forensic Medicine, Faculty of Pharmacy, University of Valencia, Burjassot, Valencia, Spain
• ¹⁵Department of Agricultural Food and Forest Sciences, University of Palermo, Viale delle Scienze, 90128 Palermo, Italy, Palermo, Italy
• ¹⁶Laboratory of Marine Biochemistry and Ecotoxicology, Department of Earth and Sea Sciences, University of Palermo, Palermo, Sicily, Italy
• ¹⁷Microtarians Luxembourg, Luxembourg, Luxembourg
• ¹⁸Laboratory of Food and Food By-Products Chemistry and Processing Technology, National School of Agriculture in Meknès, km 10, Haj Kaddour Road, B.P. S/40, Meknès 50001, Morocco, Meknès, Morocco
• ¹⁹Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Rabat-Sale-Kenitra, Morocco
• ²⁰UPR of Pharmacognosy, Faculty of Medicine and Pharmacy of Rabat, Mohammed V University, Rabat, Morocco, Rabat, Morocco
• ²¹Departement of Biology, Faculty of Science, University of Boumerdes, Boumerdes, Algeria
• ²²National Center of Biotechnology Research (Algeria), Constatine, Algeria
• ²³High Institute of Sport and Physical Education of Sfax, Sfax, Sfax, Tunisia
• ²⁴School of Allied Health, Human Services and Sport, La Trobe University, Bundoora, Victoria, Australia
• ²⁵College of Medicine and Medical Science, Arabian Gulf University, Manama, Capital Governorate, Bahrain
• ²⁶Department of Humanities, COMSATS University Islamabad, IslamabadCampus, Park Road, Islamabad, Pakistan, Islamabad, Islamabad, Pakistan
• ²⁷Escuela de Posgrado, Universidad de Especialidades Espíritu Santo, Guayaquil, Guayas, Ecuador

Introduction: The Mediterranean diet (MedDiet) is acknowledged for its health advantages; however, compliance with its principles differs by region and is influenced by geographical, cultural, economic, and life-style factors. This research examines regional differences in sociodemographic and lifestyle factors between Mediterranean (MC) and non-Mediterranean (NMC) countries, with a particular focus on adherence to the Mediterranean diet and lifestyle, as well as the associated barriers in each region. Methods: The MEDIET4ALL international survey was conducted across ten countries, and data were collected from 4,010 participants. Dietary adherence was assessed via the MEDLIFE Index, and additional lifestyle measures included physical activity (IPAQ-SF), sleep patterns (PSQI), mental health (DASS-21), and social participation (SSPQL). Statistical analyses included chi-square tests, Mann‒Whitney U tests, and standardized residual analyses to identify significant regional variations. Results: The study revealed distinct dietary patterns, with MC participants showing stronger adherence to traditional MedDiet components (legumes, fish) while NMC participants favored modern adaptations (whole grains). Both regions exhibited low physical activities dominance (60-62%), although MC participants engaged more (21.1% vs 18.5%) in moderate physical activity. MC maintained higher proportions of "sometimes socially active" individuals, NMC showed greater representation in the "always socially active" category. Sleep quality was poorer in MC (45% below recommended duration vs 40% in NMC), while NMC reported higher insomnia rates. Mental health symptoms were comparable (33-35% moderate depression/anxiety in both), reflecting post-pandemic global trends. Barriers differed regionally with MC faced economic/access constraints while NMC struggled with knowledge gaps and time limitations.Conclusions: Our findings highlight that while Mediterranean regions maintain traditional dietary patterns, globalization and modern lifestyle shifts are narrowing regional health behaviors. Public health strategies should address region-specific barriers, including economic constraints in MC regions and knowledge gaps in NMC regions, while promoting MedDiet adherence. Future research should explore the impact of cultural, socio-economic, and digital factors on dietary behaviors and mental health to develop tailored, effective interventions for improving overall well-being