Mediterranean diet adherence and rural-urban disparity among Moroccan adolescents: a nationally representative cross-sectional study

Background Mediterranean diet adherence (MDA) is declining globally, yet comprehensive national data on Moroccan adolescent dietary patterns remain scarce. Objective The present study aimed to assess MDA and analyze urban-rural disparities among Moroccan adolescents. Material and Methods This cross-sectional national study recruited 3600 adolescents aged 10-18 years (2160 urban and 1440 rural) across Morocco’s 12 administrative regions. The Mediterranean Diet Quality Index for children and adolescents (KIDMED) was used to assess MDA; a structured questionnaire was additionally administered to collect sociodemographic and anthropometric data. The nutritional status was assessed using body mass index-for-age z-scores according to World Health Organization (WHO) standards. Multiple logistic regression identified factors associated with poor adherence. Chi-square tests were conducted to examine differences in Mediterranean diet dietary behaviour classes by location and sex. Results Mean KIDMED score was 4.55 ± 3.51. Poor adherence (≤ 3) was found in 38.66%, medium adherence (4-7) in 38.80%, and optimal adherence (≥ 8) in 22.50%. Urban adolescents showed significantly higher adherence than rural counterparts (5.36 ± 3.54 vs. 3.33 ± 3.08; p < 0.001). Rural residence was associated with a 3.12-fold higher odds of poor adherence (adjusted OR = 3.12, 95% CI: 2.69-3.62; p < 0.001). Urban-rural disparities were more pronounced among females (2.24 points) than males (1.67 points). Fish consumption demonstrated the largest geographical disparity (41.30% vs. 27.40%; p < 0.001). Conclusions The present study reveals a critical urban-rural inequality in MDA: optimal adherence was achieved by only 22.50% of adolescents nationally, and was more than three times lower in rural (9.65%) than urban (31.10%) settings. Rural residence was the strongest independent determinant of poor adherence. These findings call for geographically targeted, school-based policies integrating both nutritional education and structural improvements in food access infrastructure, particularly in rural Morocco.