Discussion

In the present paper we report changes in dietary patterns in the Middle Eastern and North African countries from 1961 to 2007. Our results show that the availability of energy and all food items has increased in both regions during the last half century, a finding in agreement with previous reports⁽ Reference Bermudez and Tucker ^{6 ,} Reference Schmidhuber and Traill ^{19 ,} Reference Balanza, García-Lorda and Pérez-Rodrigo ^{25 ,} Reference Garcia-Closas, Berenguer and González ^{28 )}. In North Africa most of the changes were related to increases in the availability of eggs (7-fold), fish and seafood (3·5-fold), oil crops (3-fold) and nuts (3-fold), while in the Middle East most of the changes were due to increases in the availability of vegetables (4·5-fold), nuts (4-fold), eggs (4-fold) and vegetable oils (3·5-fold). During the 47 years under study, the availability of energy in the Middle East and North Africa increased by 42 % and 61 %, respectively. Over the past four decades studies have shown that per capita energy availability has increased significantly in developing countries, by approximately 2500 kJ/d (600 kcal/d)⁽ Reference Caballero ^{29 )}; this has more significance when considering the fact that several studies suggest the energy requirement of people from developing countries is low⁽ Reference Scagliusi, Ferriolli and Lancha ^{30 )}. This dramatic increase indicates a transition from undernutrition towards overnutrition in these regions, resulting in rising rates of obesity and other chronic diseases⁽ Reference Hosseinpanah, Barzin and Eskandary ^{10 ,} Reference Reddy ^{13 )}.

In the present study, despite the ascending trend of cereal availability, the proportion of energy from cereals decreased between 1961 and 2007 in both regions. The slowing population growth and nutrition transition are the most probable causes of reduced intakes of cereals⁽ Reference Bermudez and Tucker ^{6 )}. However, data from food balance sheets show only the availability of total cereals and starchy roots, not the availability of whole or refined grains; and hence changes in the availability of whole and refined grains over the 47 years are unknown. Nevertheless, Atinmo et al.⁽ Reference Atinmo, Mirmiran and Oyewole ^{4 )} have reported that consumption of refined grains is increasing in the Middle East and North Africa, which could be attributed to globalization and the high availability of modern processed foods⁽ Reference Hu ^{31 )}.

Our findings indicate that the availability of fruits and vegetables increased in the Middle East and North Africa⁽ Reference Schmidhuber and Traill ^{19 )}. Da Silva et al. ⁽ Reference Da Silva, Bach-Faig and Raidó Quintana ^{23 )} have indicated that adherence to the Mediterranean dietary pattern increased between the periods of 1961–1965 and 2000–2003 in North Africa and some countries of the Middle East, mainly due to increased availability of fruits and vegetables, the most common cause of which is the increased diversity of fruits and vegetables worldwide⁽ Reference Schmidhuber and Traill ^{19 )}. In addition, owing to the inverse association between fruit and vegetable consumption and chronic diseases⁽ Reference Pomerleau, Lock and McKee ^{32 –} Reference Ledoux, Hingle and Baranowski ^{34 )}, most countries have increased their availability of fruits and vegetables to improve healthy eating and prevent chronic diseases⁽ Reference Schmidhuber and Traill ^{19 )}. In spite of increased availability of fruits and vegetables, however, current consumption of these food groups is low in both the Middle East and North Africa and does not meet the FAO's recommended intake value of 400 g/d. In recent years, due to land and water shortages and the low demand for agricultural products, the availability of plant-based foods has declined in some countries.

Between 1961 and 2007, the availability of meats and milk showed an increasing trend in the Middle East and North Africa. Increased demand for and production of meat, fish and milk in developing countries may have contributed to the elevated availability of these foods items in the two regions. According to the International Food Policy Research Institute, the greatest production and consumption of meats and milk takes place in developing countries, predicted to reach to 63 % and 50 %, respectively, by 2020 in these countries⁽ Reference Popkin and Gordon-Larsen ^{35 )}. In addition, increasing imports of these food groups also has affected their availability⁽ Reference Madanat, Troutman and Al-Madi ^{2 )}. However, the availability of meat in North Africa and of milk in both North Africa and the Middle East is below the minimum recommended values, which could explain the high prevalence of malnutrition disorders, particularly Fe-deficiency anaemia and protein–energy malnutrition, in these regions.

The availability of vegetable oils and their proportional contribution to total energy have both increased in the Middle East and North Africa during the 47 years of the study. In recent decades, consumption of vegetable oils has increased dramatically worldwide⁽ Reference Hawkes ^{7 )}, being the greatest contributor to increased total energy intake in developing countries. Globally, the low price of vegetable oils may have led to their increased consumption⁽ Reference Caballero ^{29 )}. In most developing countries, technological advances, increased production and the high demand and import are responsible for increased availability of vegetable oils. Global production of vegetable oils increased from 60 to 71 million tonnes between 1991 and 1997, while production of animal fats has remained constant, at approximately 12 million tonnes⁽ Reference Vareiro, Bach-Faig and Raidó Quintana ^{24 )}. The most commonly produced vegetable oils are soyabean, sunflower, canola and mixed groundnut⁽ Reference Hawkes ^{7 )}. Global availability of these oils, with the exception of mixed groundnut oil, increased threefold between 1961 and 1990⁽ Reference Popkin and Gordon-Larsen ^{35 )}. In addition, urbanization (particularly in Africa and Asia), shift in economic status (especially income increases and inequalities) and the globalization of media have affected the availability of vegetable oils⁽ Reference Popkin ^{36 )}. However, it seems that an increase in modern food consumption, including fast foods, could be the major cause of high vegetable oil intakes⁽ Reference Schmidhuber and Traill ^{19 )}, which increases total fat consumption and leads to obesity and chronic disease morbidity⁽ Reference Minihane and Harland ^{37 )}.

Availability of discretionary calories in the Middle East and North Africa was at the limit recommended by the US Department of Agriculture during the 47 years under study (12–20 % of total daily energy)^{( 27 )}. Despite the positive correlations between intake of sugar and sweeteners and chronic diseases, consumption of caloric sweeteners shows an ascending trend in the Middle East and North Africa as well as in other countries around the world. In 2000, the availability of sugar and sweeteners was three times higher than in 1961. Urbanization and increased GDP of a country contribute to high availability of caloric sweeteners⁽ Reference Ledoux, Hingle and Baranowski ^{34 )}. In addition, traditions of high consumption of tea and coffee with sugar in the Middle East and North Africa can also contribute to the elevated sugar consumption⁽ Reference Kittler and Sucher ^{38 )}. In the 47 years studied, availability of discretionary calories has shown no significant difference. Despite the increase in sugar and sweeteners, the decrease in availability of animal fats and alcoholic beverages in the Middle East and North Africa is responsible for the lack of change in availability of discretionary calories in both regions. Lower intakes of alcoholic beverages in these regions are due to religious beliefs and traditions⁽ Reference Vareiro, Bach-Faig and Raidó Quintana ^{24 )}.

Overall, the traditional diet of North Africa is based on the Mediterranean diet which includes high consumption of fruits, vegetables, cereals, beans, nuts, seeds and olive oil, moderate consumption of wine, low to moderate consumption of cheese, yoghurt, fish, poultry and eggs, and low consumption of red and processed meats⁽ Reference Willett, Sacks and Trichopoulou ^{39 )}. Over the 47 years studied, although North Africans have sustained the basic components of their traditional diet such as fruits, vegetables and pulses consumption, their intakes of sugar and vegetable oils have increased. Middle Eastern countries have also deviated from their traditional dietary patterns which consisted mainly of cereals, pulses, vegetables, fruits and lamb. Our findings show that after 47 years, the availability of fruits and cereals has decreased, while the availability of meat, sugar and vegetable oils has increased. There is a relationship between high consumption of sugars and fats and increased consumption of fast foods, processed and high-energy foods, which has occurred as a result of nutrition transition in developing countries⁽ Reference Dodd ^{40 )}. High consumption of sugars and vegetable oils is the major contributor to the increased total energy intake, which may in turn account for the alarming rise in NCD prevalence in the Middle East and North Africa. Previous studies have demonstrated that nutrition transition is associated with unhealthy diets, low physical activity, high prevalence of obesity and obesity-related diseases in developing countries⁽ Reference Willett, Sacks and Trichopoulou ^{39 )}. The Middle East and North Africa are undergoing nutrition transition and although some shifts in their dietary patterns have been beneficial, including increased supply and availability of foods, others have been detrimental, associated with the development of chronic diseases⁽ Reference Galal ^{5 )}. In the developing countries, nutrition transition has predisposed higher-income groups to the risk of obesity and diet-related diseases, while low-income groups are exposed to infectious and communicable diseases, although some also suffer from overweight and obesity due to nutrition transition⁽ Reference Satia ^{41 )}. Deviations from healthy dietary patterns can be an adverse effect of nutrition transition. According to WHO recommendations, the Mediterranean diet represents a healthy dietary pattern⁽ Reference Vareiro, Bach-Faig and Raidó Quintana ^{24 )} and several studies have demonstrated the protective effect of the Mediterranean diet against chronic diseases⁽ Reference Proietti, del Balzo and Dernini ^{42 –} Reference Kastorini, Milionis and Goudevenos ^{45 )}. Therefore, nutritional education on the importance of a healthy diet at the population level and developing policies to facilitate the availability of healthy foods could reduce the rapid trend of obesity and other chronic diseases.

The FAO food balance sheet does have its limitations. First, the food balance sheet represents only the energy available for consumption, and not real consumed values⁽ Reference Schmidhuber and Traill ^{19 )}. It overestimates energy availability in developing countries, while underestimating it in developed countries. Second, the food balance sheet shows energy per capita and does not allow for comparisons according to age, sex, SES, seasonal and regional differences; moreover, the sheet does not calculate home-made production and food consumption by tourists. However, despite the limitations, the food balance sheet is a cost-effective tool for longitudinal comparisons; and although it is not the only source of data for consumption at population level, it is still the best available data source for analysis during a specific period a time for any given country⁽ Reference Da Silva, Bach-Faig and Raidó Quintana ^{23 )}.