Determinants of Diet Quality Among Schoolchildren in Urban Lebanon: Findings Using the Novel Diet Quality Questionnaire (DQQ)

Abstract

Background The Eastern Mediterranean Region is experiencing a rapid nutrition transition characterized by a shift toward energy-dense, nutrient-poor diets, contributing to unhealthy dietary patterns among children and an increased risk of non communicable diseases (NCDs) later in life. In Lebanon, these challenges are exacerbated by ongoing socio-economic crises affecting food access and dietary patterns. Despite the importance of diet quality, evidence remains limited on its determinants among school-aged children using standardized global metrics. Food source is an important environmental factor influencing children’s dietary intake as foods obtained from different sources often vary in nutritional quality. Thus, the aim of this study was to assess diet quality among schoolchildren in urban Lebanon using the Diet Quality Questionnaire (DQQ), and to examine its association with food source, as an important environmental determinant, and with overweight and obesity.

Methods This study is a secondary analysis of cross-sectional data from the SCALE study, which recruited a representative sample of 2,125 schoolchildren aged 8–12 years in Greater Beirut between January and May 2022 using a two-stage cluster randomized sampling design. Diet quality was assessed using DQQ-derived indicators: the Global Dietary Recommendations (GDR) score and its components, NCD-Protect and NCD Risk. Food source was categorized as home-dominant, away-from-home dominant, or mixed based on the primary source across eating occasions. Survey-weighted multivariable linear and logistic regression models were used to examine associations between food source and diet quality (whole-day and school-restricted), and between diet quality and overweight/obesity, respectively, adjusting for confounders identified through directed acyclic graphs. All weighted analyses were conducted using Stata version 14.

Results The whole-day analytic sample included 2,004 children (mean age 10.78 years; 51.5% girls). Most children were classified as home-dominant (88.6%), while 4.9% were away-from-home dominant and 5.0% had mixed sources. The prevalence of overweight and obesity was 25.4% and 16.2%, respectively. The mean GDR score was 8.73 (SD = 1.77), indicating suboptimal adherence to dietary recommendations. Mean NCD-Protect and NCD-Risk scores were 1.53 (SD = 1.14) and 1.8 (SD = 1.35), respectively. In adjusted analyses, children with away-from-home dominant or mixed food sources had lower overall diet quality compared to those with home-dominant sources, reflected by lower GDR scores (β = −1.21; 95% CI: −1.60 to −0.81), lower NCD-Protect scores (β = −0.54; 95% CI: −0.80 to −0.27), and higher NCD-Risk scores (β = 0.67; 95% CI: 0.44 to 0.90) in whole-day models. These associations were not statistically significant in school-restricted analyses (n = 1,289). No significant associations were observed between whole-day diet quality indicators and children’s overweight or obesity in adjusted models.

Interpretation This study highlights suboptimal diet quality among schoolchildren in urban Lebanon and suggests that food sourced from home is associated with more favorable dietary patterns compared to away-from-home sources. The lack of association between diet quality and weight status may reflect the limitations of the cross-sectional design, which does not capture long-term dietary patterns or temporal relationships. These findings highlight the importance of promoting healthier food sourcing patterns, particularly encouraging foods obtained from home, to support better diet quality among schoolchildren.