Impact of migration on dietary patterns and adherence to the Mediterranean diet among Northern Moroccan migrant adolescents in Madrid (Spain)

1 Introduction

In Morocco in recent years, interest in diet studies has increased due to the double burden of malnutrition [1, 2]. Until recently, the main nutritional problem in Morocco has been undernutrition, affecting vulnerable groups such as pregnant women and children aged 0 to 5 years in particular [2–4]. With increased food availability and rampant urbanisation, changes in traditional eating habits have taken place associated with nutrition transition [5]. These changes have led to a diet richer in animal proteins, saturated fats and simple sugars, with reduced consumption of vegetables, fruits, whole grains and fibre [6], resulting in a very high incidence of obesity and metabolic syndromes [7], a major public health concern for young adults [8].

Traditionally, the food consumption model in Morocco is close to the Mediterranean diet [9], which is of particular interest to nutritionists [10, 11]. Featuring a high proportion of vegetables (pulses, cereals, fruits and vegetables, nuts and seeds), moderate intake of meat and dairy products, and olive oil as the main source of fat [12], the key interest of this dietary model stems from its health benefits, as populations living in the Mediterranean regions have lower incidence and prevalence rates for chronic diseases than elsewhere, with life expectancies among the highest in the world [13–19]. This model contrasts with the diet of Northern European countries, which is rich in animal proteins, saturated fats and simple sugars and is linked to a high frequency of obesity, metabolic syndromes and cardiovascular diseases [20].

Currently, the major national surveys of the Moroccan population show a trend towards nutrition transition [4, 21]. However, the available data on the regional and social characteristics of this transition remain limited. For example, little is known about the nutritional status and dietary habits of adolescents [22–24]. In this rapid phase of human development, poor diet could have undesirable and irreversible effects on developmental processes [25]. The behaviours and lifestyles of adolescents are easily influenced by advertising and the media, which are associated with the modernisation of Morocco. Furthermore, Moroccan adolescents are generally unconcerned about the negative consequences that a poor diet may have on their health in the short term [26–28].

Migration from developing to more industrialised countries is a long-standing phenomenon. In the public health context, migrant studies make an important contribution to the knowledge of how changes in environmental, dietary and lifestyle behaviours affect the health of migrant populations [6]. Indeed, migration and acculturation are associated with significant changes in eating habits [29]. Several studies have shown that migrants adopt the dietary model of their new host country, leading to health consequences [30–32]. However, the extent of these changes varies with each ethnic group [33].

The objective of this study is to analyse diet quality in a sample of adolescents living in northern Morocco (Al Hoceima), to assess their adherence to the Mediterranean Diet and compare it with that of Moroccan adolescents living in Madrid, Spain, to determine whether migration has caused undesirable changes in their eating habits.

2 Materials and methods

3 Results

3.4 Comparison of percent contribution of food groups to total energy intake

The percent contribution of each food group to mean daily intakes of energy in migrant and autochthonous adolescents is illustrated in Fig. 1. For both sexes, meat and meat products, milk and dairy products, confectionery and sugar-sweetened beverages contributed a greater proportion of total energy in the diet of migrant adolescents than in their Moroccan-based peers. On other hand, autochthonous adolescents obtained higher percentages of energy intake from cereals and cereal products, oils/fats, fresh and processed seafood, and eggs and egg products than did their migrant counterparts. Independently of migration status, the contribution of the cereals/cereal products group to total daily energy intake was high. In addition, migrant boys reported a significantly lower percent contribution of fresh vegetables than their autochthonous peers, whereas there were no significance differences for girls. Conversely, migrant adolescents reported a significantly higher percent contribution of the fruit group to total daily energy intake than their autochthonous peers. For legumes, and sauces and condiments, no significant differences were observed.

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Fig. 1

Percent contribution of food groups to daily energy intake among the Moroccan autochthonous adolescents and their migrant peers in Madrid.

In this study, the disadvantaged socio-economic characteristics of our Moroccan migrant adolescents in the province of Madrid (Spain) are similar to those of Moroccan autochthonous adolescents in Al Hoceima. The distribution by father’s and mother’s occupation of the migrant adolescents is consistent with data from the 2011 census of Spain [48], which showed that most Moroccan migrants arrived without the required administrative papers. After regularisation, they were mainly employed in low-paid occupations in the construction, personal services and agricultural sectors [49, 50]. Similarly, the distribution by father’s and mother’s occupation of the autochthonous adolescents concords with data from the 2014 census of Morocco, which showed that economic activity in Taza-Al Hoceima Taounate region is restrained, in part by the scale of the informal economy predominated by low-paying jobs. 71.9% of the active working population were temporary or seasonal workers and most mothers were housewives. The data also suggest that, despite the higher educational achievements of migrant parents, they are unable to obtain jobs fitting their profiles and meeting their expectations for more gainful and productive employment. It is probable that discrimination in key sectors is partly responsible for the difficulties Moroccans confront as they try to improve their socioeconomic situation [51]. Both migrant and autochthonous parents’ illiteracy rate is very high, which is not surprising since the illiteracy rate in Morocco in 2014 was estimated at 45.1%, substantially higher in women than in men [34]. In their study, Chia Liu et al. found the living arrangements of the 1.5 Moroccan generation (child migrants) in Spain to be more similar to those of nonmigrants in Morocco than of nonmigrant Spaniards [52]. Most of our surveyed participants resided with their parents, which suggests that they could be leaving school premises at lunchtime to eat food taken from home, or items purchased outside school, rather than eating in the school canteen. Home food has been found to be more favourable in terms of nutrient profile than out-of-home food [53].

Regardless of the geographical location, our study found that most adolescents had a normal body mass index. These results are in line with recent studies conducted among Moroccan [54] and Spanish adolescents [55]. In our autochthonous sample, underweight coexists with overweight and obesity, as in other North African countries undergoing nutritional transition [56, 57]. However, in our migrant sample, overweight and obesity are much more prevalent than underweight, which is limited only to 2% of boys. Similarly, among migrant girls, underweight has not been reported, indicating that overweight and obesity are more prevalent among girls than boys. In a study aimed to explore post-migration lifestyle and weight changes in a sample of migrant women recruited in Modena (Italy), Casali et al reported that the increased risk of weight gain after migration was significantly associated with African ethnicity [58]. On other hand, obesity is apparently more acceptable in Arab than in Western culture, especially in women where obesity is equated with beauty, health and high social class [59, 60]. This pattern may have been influenced by the increased availability of fast foods that are usually cheap but have high caloric value [60].

It should be noted that adolescence is a modal age for body image dissatisfaction because of the physical changes associated with puberty [61]. Accordingly, underweight, overweight or obese adolescents tend to abstain from participating in the survey, since they know they will be weighed. This is a potential source of bias. Indeed, the recruitment of these adolescents would have contributed to a more accurate estimation of nutritional status. Nevertheless, using the high school as the place for subject recruitment and interviews results in substantial cost savings compared with household surveys, and affords better privacy to participants.

It is estimated that nearly one third of the total burden of disease has its roots in adolescence. Preventing the initiation of risky health behaviours in adolescents, such as unhealthy dietary practices or sedentary lifestyles, will be the key to curbing the growing epidemic of non-communicable diseases, and to controlling other public health problems such as sexually-transmitted infections [62]. Overweight acquired during childhood or adolescence may persist into adulthood and increase the risk -of cancer and osteoarthritis of the weight-bearing joints later in life [63].

In autochthonous adolescents, the contribution to total energy intake of fish and processed seafood is much higher than in their migrant counterparts. Our data suggest that adolescents who eat fish have better adherence to the Mediterranean diet. This finding could be influenced by the geographical location, since Al Hoceima is a coastal region while Madrid is situated in the interior of Spain. A similar geographical pattern of fish consumption was also reported by Alsufiani et al (2015) who found that omega-3 fatty acids and fish were consumed more by people residing in the Saudi Arabian coastal region than residents in the interior regions [64]. According to an analysis of the variability of fish consumption in 10 European countries, high intakes of fish were found in Spain [65], suggesting that the low consumption of fish amongst our migrant adolescents is determined by factors other than fish availability. Factors that determine fish consumption in an adolescent population include its hedonic value, cultural and social influences [66] and also the purchasing power of their families [24].

Although the energy derived from total fat for both samples is within the recommended range, a significantly higher contribution of the oils and fat group to total energy intake was observed in the native diet compared to the migrant diet. While oils and fats are commonly regarded as major culprits in the development of obesity, it is important to distinguish between good and bad fats within our data, since oils are naturally present in foods such as olives, nuts and seafood, which contribute essential fatty acids and vitamin E to the diet. We suggest that the higher contribution of the oils and fat group to total energy intake in the native diet is due to the high consumption of olive oil and the low consumption of animal products (meat and high-fat dairy foods), which is reflected in their high ratio of unsaturated to saturated fat intake compared to their migrant counterparts. Examining the question of whether olive oil was the main factor in the health benefits of the Mediterranean diet, Serra-Majem et al reported that individuals with diets higher in dietary fat and olive oil presented significantly more favourable food profiles that are in keeping with Mediterranean diet patterns, such as greater consumption of fish, eggs, vegetables and added fats/oils [67]. Similarly, the Child Health and Heart Study in England (CHASE) reported that the diet of children of black African origin had a better cardio-protective fat profile than the diets of children of black Caribbean, South Asian, and white European origin. It is generally agreed that replacing some saturated fatty acids (such as those in solid fats) with unsaturated fatty acids (such those as in oils) lowers both total and LDL blood cholesterol levels [68].

Comparing the contribution of food groups to energy intake, it was seen that the contributions to energy intake from four non-typical Mediterranean food groups such as milk and dairy products, fresh and processed meat, confectionery and sugar-sweetened beverages were notably higher in migrant adolescents then in their autochthonous peers, while the contribution of three typical Mediterranean food groups such as fresh vegetables, legumes, and fish and processed seafood were notably lower in migrant adolescents. As suggested by Dekker et al. [69], our findings indicate that migration to Spain as a “Western” country may lead to adoption of the “non-Mediterranean” dietary pattern at the expense of the Mediterranean diet, which has a more favorable macro- and micronutrient composition, higher in fibre and unsaturated fatty acids. A recent review pointed out that following migration, most ethnic groups alter their eating habits, combining parts of their traditional diet with some of the less healthy elements of the Western diet [70].

Our study showed that following migration, the contribution of cereals/cereal products group to total daily energy intake remained high. Undoubtedly, cereal products continue to occupy an important place in the Moroccan consumption pattern [71]. The importance of cereals in the Moroccan diet can be explained by the dominant dietary practices, in which cereal products are used in the preparation of many dishes and form the basis of daily meals consumed by households [22]. In our study, the MAI was found to be significantly associated with geographical location and nutritional factors (degree of fatty acid unsaturation and fibre density) rather than socio-economic factors. Being a migrant adolescent and having a dietary pattern with higher saturated fatty acid consumption and lower fibre intake were associated with lower adherence to the Mediterranean diet. Despite the disadvantaged socio-economic level of our migrant adolescents, they were more likely to lose their adherence to Mediterranean diet in exchange for a more Western-type diet that is energy-dense and rich in saturated fats. This could be due to the fact that the non-Mediterranean food groups are more freely available and cheaper in Spain than in Morocco. Differences in exposure to food advertising may also be a factor [73]. Indeed, according to the 2016 study of Montero et al [24] of the frequency of consumption of certain food groups in teenagers living in Madrid compared to the situation in Morocco, most answered that they consumed less fish and more meat, dairy products and store-bought baked goods than before. These findings are partly in disagreement with those reported among Tunisian and Lebanese adolescents, where the diet of adolescents was more “Westernised” in the more affluent households and where the mother’s education level was higher [74, 75]. Similarly, Bonaccio et al. have reported an association between higher educational level and greater consumption of organic vegetables, which is strongly determined by socioeconomic status [76]. It should be recalled that despite changes in habits and food availability, traditional dishes still enjoy great esteem amongst Moroccans, especially compared to other Mediterranean countries, including Spain, where traditional cooking is declining.

5 Conclusion

Migration can be beneficial for Moroccan migrants in terms of increased daily energy intake. However the fact that their energy intake is increasingly provided by non-Mediterranean foods could have negative consequences for their health, with increased rates of overweight and obesity. It is essential to continue to promote the Mediterranean Diet, especially among young people. The Moroccan sample living in Al Hoceima has a diet slightly lower in calories but better adjusted to the Mediterranean diet, in line with the trend described in other studies [24]. The diet quality of adolescent Moroccan migrants living in Madrid, with more calories and protein of animal origin, is closer to that of Spaniards and other populations of the European Union as suggested in other studies [77, 78], but without complete loss of the eating habits of the country of origin. This maintenance of traditional customs slows down the effects of acculturation associated with the migratory process, although some studies that have examined the effects of migration on eating habits [6, and 81] suggest significant short-term impacts on the nutritional status and growth and development of migrants, especially among adolescents [78, 79]. Although these changes in eating habits may be beneficial to the migrant group in an immediate way, the move away from the Mediterranean diet may have negative consequences on their health, in terms of increased risk of overweight and obesity and related cardiovascular and metabolic problems [82]. Since eating behaviours adopted in adolescence are likely to continue into adulthood [83], there is an immediate need to modify unhealthy behaviours during this phase of development, enabling adolescents to establish healthy eating habits for their adult lives. Healthy eating initiatives are required to promote the consumption of fruits and vegetables, dairy products and legumes while reducing the consumption of energy-rich, low-nutrient foods and sugar-sweetened beverages in adolescents [84].

Author’s contributions

OE collected data from Al Hoceima. OE, KA, AH and MC participated in the data analysis, writing, and editing of the manuscript. MC and AH designed the study and led the implementation and data collection. PM designed the study and AM carried out the data collection in Madrid. MC, PM and SL provided critical comments on the manuscript. SL carried out the linguistic correction.

Funding

None.

Conflict of interest

There are no conflicts of interest.