... Ritva Prättälä 1, Laura Paalanen 1, Daiga Grinberga 2, Ville Helasoja 1, Anu Kasmel 3, Janina Petkeviciene 4

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1 European Journal of Public Health, Vol. 17, No. 5, ß The Author Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. doi: /eurpub/ckl265 Advance Access published on December 27, Gender differences in the consumption of meat, fruit and vegetables are similar in Finland and the Baltic countries Ritva Prättälä 1, Laura Paalanen 1, Daiga Grinberga 2, Ville Helasoja 1, Anu Kasmel 3, Janina Petkeviciene 4 Background: Women s diets are healthier than men s. Finnish women eat more fruits and vegetables but less meat than men. Gender differences may be larger in the Baltic countries, which represent Eastern European transition societies than in Finland, a society characterized by the Scandinavian welfare ideology and a high degree of gender equality. Methods: The data are based on questionnaires to random samples of adults in Finland, Estonia, Latvia and Lithuania. The data provide a way of addressing gender differences at the turn of the century in the economically and culturally different countries. The purpose is to explore whether the consumption of foods classified as masculine or feminine meat, fruits and vegetables follow a similar gender pattern in Finland and the Baltic countries. Results: Men ate meat more often while women ate fruits and vegetables. A high educational level was associated with frequent consumption of fruits and vegetables. al differences in the consumption of meat were few and inconsistent. The consumption of fruits and vegetables was more common in urban areas except in Finland. Gender differences were similar in all countries throughout age and educational groups and in rural and urban areas. Conclusion: The consistent association of gender and food and the similarity of gender patterning in population subgroups point to the stability of masculine versus feminine food habits. The similarity suggests that food habits contribute equally to the gender gap in health in the Baltic countries as they do in Finland. Keywords: Baltic countries, Finland, food, gender... urveys from Western countries show gender differences in Sfood consumption, nutrient intake and attitudes towards food. Women are more concerned about healthy diet and more often classify foods according to the assumed nutrient content than men. 1,2 Women do not only take care of their own diet but also of the food choices and health of their families. 3,4 Men consume more meat, potatoes, bread and alcohol but less fruits, vegetables, fish, chicken, cheese and sweets than women. These consumption patterns lead to differences in the intake of energy and nutrients. Men have a higher energy intake, and a higher percentage of the energy in men s diets is derived from animal products, whereas the share of products of vegetable origin is higher in women s diets Increased consumption of fruits and vegetables has been observed to protect against CVD and other chronic diseases, and the WHO/FAO population goal for the consumption of fruits and vegetables is 400 g daily. 12,13 Thus, it can be inferred that men s diets are less healthy than women s. Comparing gender differences in the food habits within various cultural contexts may increase understanding of their role in public health. Finland and the Baltic countries, Estonia, Latvia and Lithuania, are suitable targets for a comparative study. They are geographically proximate but represent diverging social, cultural and public health development. 1 National Public Health Institute, Department of Health Promotion and Chronic Disease Prevention, Finland 2 Health Promotion State ncy, Strategy Development Department, Latvia 3 University of Southern Denmark, Institute for Health Promotion Research, Denmark 4 Institute for Biomedical Research, Kaunas University of Medicine, Lithuania Correspondence: Ritva Prättälä, National Public Health Institute, Department of Health Promotion and Chronic Disease Prevention, Mannerheimintie 166, Helsinki, Finland, tel: þ , fax: þ , ritva.prattala@ktl.fi The Baltic countries represent Eastern European transition societies, which are characterized by significant gender difference in life expectancy. In 2002, the gender difference in life expectancy was 12.0 years in Estonia (men 65.1, women 77.1), 11.2 years in Latvia (men 64.6, women 75.8), and 11.4 years in Lithuania (men 66.2 women 77.6). 14 The socio-economic and public health situation in Finland, on the other hand, is similar to that of other Nordic welfare countries. In Finland the gender difference was 6.7 years (men 74.8, women 81.5) and in the other Nordic countries, it varied between 3.4 and 5.4 years. The high male mortality rate in the transition societies has been linked with social conditions 15 and health lifestyles. 16 Indeed, gender differences in health related lifestyles are in line with gender differences in the mortality rate. Compared with Baltic women, Baltic men smoke more, 17 drink more alcohol 18 and are more often overweight. 19 Physical activity at work is higher among men, an observation suggesting the existence of traditional male occupations that require physical labour. 20 Even in dietary habits and beliefs, gender differences that are in line with the traditional male female pattern have been observed. Baltic men eat more meat than women and believe that meat is essential for health. 21,22 Gender differences in food habits and other dimensions of health behaviour are not a specific characteristic of the Baltic countries only: they have also been reported in studies conducted in Finland Gender differences in food consumption seem to be related to social norms and cultural beliefs. Buying and preparing food within a family has traditionally been taken care of by women. Furthermore, some foods are labelled masculine, some feminine. The consumption of meat symbolizes masculinity, the consumption of vegetables and fruits femininity. Masculine food habits are typical for working class men who otherwise also have a more traditional lifestyle than white-collar men. 8,26 Only one previous study has analysed the food habits of the Baltic and Nordic countries using a comparative setting. The Norbagreen 2002 study 27 focused on vegetables, fruits, fish and

2 Gender differences in food consumption 521 Table 1 Characteristics of the study data n, response rate n, response rate n, response rate n, response rate Year of the study , 68% 3198, 70% 2121, 77% 1874, 62% , 63% 3188, 70% 2169, 80% 2195, 74% , 67% 2968, 65% 1816, 68% 1879, 64% Total material Men Women Men Women Men Women Men Women n ¼ 1523 n ¼ 2163 n ¼ 4356 n ¼ 4998 n ¼ 2665 n ¼ 3441 n ¼ 2653 n ¼ % 59% 47% 53% 44% 56% 45% 55% years years years Low Intermediate High Rural Urban Married Other Daily consumption of Meat and meat products Fruit Vegetables bread, but not meat. According to the study, women consume more vegetables and fruits but the total consumption of bread was higher among men in all countries. The study did not specifically address the consistency of gender differences or their associations with other socio-demographic factors. The purpose of this article is to explore whether the use of foods traditionally classified as masculine or feminine, that is, meat, fruits and vegetables follow a similar gender pattern in Finland and the Baltic countries. Gender differences in the Baltic countries may be more consistent than in Finland, a society characterized by the Scandinavian welfare ideology and a high degree of equality between men and women. Furthermore, gender differences in all countries may be more consistent among less educated and rural subgroups because the most traditional beliefs about manhood and food seem to exist among these groups. The data originate from the Finbalt Health Monitor, 28 a collaborative project, monitoring health behaviours in Estonia, Finland, Latvia and Lithuania. The data, collected in 1998, 2000 and 2002, offer a possibility to address the gender differences in four societies representing different cultures and traditions. The specific questions of the study are: (i) Do women consume meat and meat products less often but more fruits and vegetables than men? (ii) Do food habits follow a similar gender pattern in Estonia, Finland, Latvia and Lithuania? (iii) Does age, educational level, place of residence and marital status modify the assumed gender differences? Methods A cross-sectional population survey on health behaviour was conducted according to the common protocol developed in the Finbalt Health Monitor project every second year in Estonia, Finland, Latvia and Lithuania starting in The data were gathered using similar mailed questionnaires that included questions on health status and on the use of health services, on food habits and other forms of health behaviours. Despite the common protocol of the Finbalt Health Monitor project, the number of questions with an exactly identical formulation was limited due to the differences in local situations and the need to add questions with local relevance. The questionnaires were mailed in April May 1998, 2000 and Each year one or two follow-up reminders were sent. Response rates were satisfactory in all the countries ranging from 62 (Lithuania, 1998) to 80% (Latvia, 2000). The characteristics of the study data are presented in table 1. The distribution of the respondents by gender, age, educational level, place of residence and marital status are presented in table 1. The age frame of the national samples varied slightly. In this article, only the people who fall into the age group were included. The respondents were divided into age groups 20 34, and years. In the Estonian, Finnish and Lithuanian questionnaire, education was measured as being the total number of years in education, in the Latvian questionnaire by using four educational levels: primary, secondary, vocational and university. In the analysis of this study, education was categorized into the following three groups: (i) low ¼ 9 years or less/primary, (ii) intermediate ¼ years/secondary or vocational, (iii) high ¼ 13 years or more/university. This classification suited the educational systems of the four countries reasonably well and yielded groups large enough for analysis. was classified into two categories, rural or urban. Respondents in every country were asked about marital status with a structured question including four alternatives: married or living in a common-law-marriage, single, separated or divorced, widowed. In this study, marital status categories were combined into married (or cohabiting) and others. The surveys included several food-related questions, which often followed local formulations. However, the patterns of food consumption reported in this article were asked in an identical way in every country. Consumption of fruits, vegetables, meat and meat products was investigated with the following questions: How often during the last week have you

3 522 European Journal of Public Health Table 2 Odds ratios (OR) and the 95% confidence intervals (CI) for daily consumption of meat and meat products Unadjusted Adjusted a Unadjusted Adjusted a Unadjusted Adjusted a Unadjusted Adjusted a OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) Gender Women Men 1.75 ( ) 1.75 ( ) 2.01 ( ) 1.96 ( ) 1.96 ( ) 1.96 ( ) 1.91 ( ) 1.84 ( ) ( ) ( ) ( 1.16) 1.06 ( ) ( 1.45) 1.16 (0.97 ) ( ) 1.41 ( ) ( ) 1.52 ( ) 0.91 (0.79 ) ( ) ( ) ( ) 1.58 ( ) 1.68 ( ) Low Intermediate 1.37 ( ) 1.37 ( 1.78) ( ) ( ) 1.18 ( ) 1.23 ( 1.48) 1.17 ( ) ( ) High 1.32 ( ) 1.46 ( ) 0.76 ( ) 0.86 ( ) 1.04 ( ) 1.15 ( ) ( ) ( ) Rural Urban 0.82 (0.71 ) 0.79 ( ) 0.75 ( ) 0.79 (0.70 ) 0.93 ( ) 0.95 ( ) 0.94 ( ) 0.98 ( ) Other Married 1.18 (1.00 ) ( 1.44) ( ) ( ) 1.11 ( ) 1.16 ( ) 1.49 ( ) ( ) a: Adjusted for all other variables included into the model consumed the following foods and drinks? The respondents could choose the frequency from five alternatives: never, 1 2 days, 3 5 days and 6 7 days. The food habits question included 18 common items. The questions on fruits, vegetables, meat and meat products followed each other and were placed in the middle of the food list in every country. For this study, the frequencies were dichotomized as daily (6 7 times/week) and other. The English version of the questionnaire form is available at the Finbalt website. 28 National data sets from Estonia, Finland, Latvia and Lithuania were analysed separately with the SPSS software package, version As the preliminary analyses did not show changes in gender differences in any of the countries, the data from 1998, 2000 and 2002 were combined to improve their statistical power and to allow the use of more variables in the models. Patterns of food consumption were compared by fitting logistic regression models to dichotomous variables. The models were fitted separately for each country, the main effects and first order interactions were included. The overall effect was added first, followed by gender, age, educational level, place of residence and marital status. Models comprising the overall effect and each main effect only were also evaluated. The statistical significance (P < 0.05) of the terms was assessed by the scaled deviance and the change of the degrees of freedom ( SD and DF). The results of the unadjusted and adjusted main effects models are presented in odds ratios and 95% confidence intervals in tables 2 4. Results Daily consumption of meat and meat products In all the countries men were more often daily users of meat and meat products. The effect of gender remained practically unchanged after adjusting for the other socio-demographic factors included in the model (table 2). The impact of age, educational level, place of residence and marital status varied by country. In Estonia, Latvia and Lithuania meat consumption was more common in the youngest age group; in Finland meat consumption was not associated with age. The educational pattern of meat consumption in Estonia was different to the other countries; Estonians with the highest educational level consumed meat most frequently. In Finland, Latvia and Lithuania the reverse was true, however, the differences were not statistically significant (table 2). Rural Estonians and Finns ate meat more often than urban respondents. In Latvia and Lithuania, meat consumption did not vary by place of residence. In Estonia and Lithuania married respondents more frequently consumed meat daily, whereas, in the other countries meat consumption was not associated with marital status. Interaction between gender and the other explanatory variables was observed only once. In Lithuania gender interacted with educational level (P ¼ 0.01). Meat consumption was lower among Lithuanian women the higher their level of education, the opposite was true for men. In the group with the lowest level of education, 18% of the women and 20% of the men ate meat daily. In the group with the highest level of education, 14% of the women, and 26% of the men were daily consumers of meat and meat products (data not shown). Daily consumption of fruits In all four countries women consumed fruit more often than men. As in the case of meat, the gender pattern was not modified by the other socio-demographic factors. The impact of educational level was consistent. In Estonia, Finland, Latvia and Lithuania, respondents with the highest educational level consumed fruit most often (table 3). Urban respondents more frequently consumed fruit daily in the Baltic countries, but in Finland fruit consumption did not vary by place of residence. The effects of age and marital status also depended on the country. In Estonia the youngest age group consumed fruit most often, in Finland the oldest. In Latvia and Lithuania, no age differences were observed. was only associated with fruit consumption in Finland: married Finns ate fruit more often than unmarried Finns (table 3).

4 Gender differences in food consumption 523 Table 3 Odds ratios (OR) and the 95% confidence intervals (CI) for daily consumption of fruit Unadjusted Adjusted a Unadjusted Adjusted a Unadjusted Adjusted a Unadjusted Adjusted a OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) Gender Women Men 0.41 ( ) 0.42 ( ) 0.39 ( ) 0.38 ( ) 0.52 ( ) 0.55 ( ) 0.53 ( ) 0.58 ( ) ( ) 1.15 ( ) 0.60 ( ) 0.54 ( ) 0.81 ( ) 0.78 (0.63 ) 1.11 ( ) ( ) ( ) 1.34 ( ) 0.37 ( ) 0.32 ( ) 0.87 ( ) ( ) ( ) ( ) Low Intermediate 1.88 ( ) 1.61 ( ) 0.79 ( ) (0.91 ) ( ) 1.40 ( ) 1.29 ( ) 1.25 ( 1.75) High 2.77 ( ) 2.11 ( ) 0.95 ( ) 1.35 ( ) 2.27 ( ) 2.00 ( ) 2.35 ( ) 2.06 ( ) Rural Urban 1.58 ( ) ( ) ( ) ( ) 1.43 ( ) 1.29 ( ) ( ) 1.34 ( ) Other Married 1.03 ( ) 1.15 ( ) 1.40 ( ) ( ) ( 1.23) 1.06 ( 1.25) 0.86 (0.73 ) 0.91 ( ) a: Adjusted for all other variables included into the model Table 4 Odds ratios (OR) and the 95% confidence intervals (CI) for daily consumption of vegetables Unadjusted Adjusted a Unadjusted Adjusted a Unadjusted Adjusted a Unadjusted Adjusted a OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) Gender Women Men 0.55 ( ) 0.55 ( ) 0.49 ( ) 0.50 ( ) 0.66 ( ) 0.68 ( ) 0.65 ( ) 0.68 ( ) ( ) ( ) ( ) 0.71 ( ) 1.11 ( ) 1.09 ( ) 1.44 ( 1.73) ( ) (0.78 ) 0.99 ( ) 0.48 ( ) 0.35 ( ) 1.10 ( ) 1.12 ( ) 1.29 ( ) 1.26 ( ) Low Intermediate 1.14 ( ) 1.03 ( ) 1.10 ( ) 1.41 ( ) 1.28 ( ) 1.14 ( ) 1.23 ( 1.57) ( ) High 1.29 ( ) ( ) 1.69 ( ) 2.31 ( ) 1.93 ( ) 1.58 ( ) 1.65 ( ) 1.33 ( ) Rural Urban 1.58 ( ) 1.56 ( ) 1.22 ( ) 1.17 ( ) 1.59 ( ) 1.49 ( ) (1.06 ) 1.16 ( 1.33) Other Married 1.14 ( ) (1.00 ) 1.52 ( ) 1.34 ( 1.48) ( ) 1.08 ( ) ( ) 0.99 ( ) a: Adjusted for all other variables included into the model The interaction of gender with the other socio-demographic variables was found only in one case regarding gender and marital status in Lithuania (P ¼ 0.05). Married Lithuanian men consumed fruit slightly more frequently, no differences were observed among women in this respect. Daily consumption of vegetables Gender had a consistent effect on the consumption of vegetables women consumed vegetables more often and this pattern was not modified by the other socio-demographic factors (table 4). The impact of place of residence was consistent; in all countries urban respondents more frequently consumed vegetables daily (table 4). The impact of the other socio-demographic factors varied in all four countries. In Estonia and Latvia, age was not associated with vegetable consumption. In Finland the oldest age group ate vegetables most often, while in Lithuania the opposite was observed (table 4).

5 524 European Journal of Public Health al level was not associated with vegetable consumption in Estonia while in the other countries significant educational differences were observed. In Finland, Latvia and Lithuania the highest educated group consumed vegetables most often (table 4). With regard to vegetable consumption, statistically significant interactions were found between gender and place of residence in Estonia (P ¼ 0.04) and between gender and age (P ¼ 0.05), as well as gender and marital status (P < 0.001) in Finland. In Estonia, vegetable consumption was more common in urban areas but this association was stronger among men than women. In rural areas, 20% of women and 10% of men consumed vegetables daily, in urban areas 26 and 19%, accordingly (data not shown). In Finland, married men more frequently consumed vegetables daily compared with unmarried men (34 versus 19%). Among Finnish women, the difference by marital status was smaller (46 versus 42%). Among Finnish men daily consumption of vegetables increased systematically by age group (19, 30 and 37%), among women the age pattern was not as systematic (35, 51 and 50%). Gender differences in the oldest age group were not greater than they were for the younger age group. Discussion Our study showed gender differences in the consumption of meat, fruits and vegetables in Estonia, Finland, Latvia and Lithuania. Men more frequently consumed meat and meat products daily while women consumed fruits and vegetables more frequently. These gender differences were not modified by educational level, age, marital status or place of residence and only arbitrary interactions were observed between gender and the other socio-demographic factors. Because the number of simple food-frequency questions used in our survey was limited, we could not calculate food consumption in quantities. A detailed dietary survey. 31 was not possible in this study, which was based on self-administered questionnaires including a large set of other health behaviour questions. The simple food questions used can give rough estimates of consumption frequencies in various population groups and identify extreme groups, such as high and low users of certain foods. 29 Furthermore, our results concerning meat are in line with separate studies carried out recently in the Baltic countries 22 and Finland 31,32 and on fruits and vegetables with the Norbagreen study. 27 Thus, our data can be used to compare consistency and the direction of gender differences in food habits in the Baltic countries and Finland. The Finbalt questionnaire has been shown to be feasible in all the countries as the number of questions left unanswered came to <10%. 29 The food questions that produced the most missing data, i.e. on the use of cereals, soft drinks and boiled vegetables, 33 were not used in this study. The response rates of the Finbalt surveys have been relatively high, but a decreasing trend has, however, been observed over the years. Comparisons of early and late respondents found that nonrespondents are more often men than women and that they have a lower level of education than those who responded. The characteristics of early versus late responders do not vary significantly by country. Therefore, response bias does not affect comparisons between the countries. 34 The gender differences in food habits were equally systematic in the Baltic countries as they were in Finland, a modern Nordic welfare state with a relatively high degree of gender equality. The gender patterns were strikingly independent of other socio-demographic factors and no changes in the gender differences between the years (data not shown) were observed. We assumed that gender differences in food habits would be more systematic in the Baltic countries than in Finland. Our empirical analyses did not, however, support this assumption. al level was associated with the consumption of fruit in all countries and with the consumption of vegetables everywhere apart from Estonia. In the more highly educated groups, fruits and vegetables were consumed more often. This result is in line with many other studies, 35 the low consumption of fruits and vegetables may be a contributing factor to socio-economic health differences both in Finland and in the Baltic countries. al differences were weaker and less consistent when it comes to consumption of meat, which is also in line with earlier studies. 36 Respondents living in rural areas consumed consistently less vegetables. With regard to fruit consumption the pattern was similar except for Finland where fruit consumption did not vary by place of residence. We assumed gender differences to be more consistent in population groups representing traditional gender identities, that is, among respondents living in rural areas and with a lower level of education. This assumption could not be confirmed. The consistent and independent association of gender with food consumption, and the lack of interaction between gender, age, educational level and place of residence, point to the stability of masculine and feminine food habits in different societies. The similarity of gender patterns in Finland, Estonia, Latvia and Lithuania suggests that food habits contribute equally to the gender gap in health in the Baltic countries as they do in Finland. Acknowledgements The sources of support were the National Public Health Institute, Finland, research grants from the Finnish Ministry of Social Affairs and Health, the Estonian Ministry of Social Affairs, and the Latvian Ministry of Health. Key points Gender patterns in food habits in the Baltic countries representing transition societies are similar to those in Finland, a Nordic welfare state. Similar gender patterns are observed in rural and urban areas and across socio-economic groups. In order to reduce gender differences in diet, increasing vegetable consumption among the men is the key message both in Finland and in the Baltic countries. References 1 Fagerli RA, Wandel M. Gender differences in opinions and practices with regard to a healthy diet. Appetite 1999;32: Rozin P, Fischler C, Imada S, et al. Attitudes to food and the role of food in life in the U.S.A., Japan, Flemish Belgium and France: possible implications for the diet-health debate. Appetite 1999;33(2): Devine CM, Olson CM. Women s Dietary Prevention Motives: life stage influences. J Nutr Educ 1991;23: Donkin AJM, Johnson AE, Lilley JM, et al. 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