Dietary intake and barriers to dietary compliance in black type 2 diabetic patients attending primary health-care services
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Objective: To determine the dietary intake, practices, knowledge and barriers to dietary compliance of black South African type 2 diabetic patients attending primary health-care services in urban and rural areas. Design: A cross-sectional survey. Dietary intake was assessed by three 24-hour recalls, and knowledge and practices by means of a structured questionnaire ( n =133 men, 155 women). In-depth interviews were then conducted with 25 of the patients to explore their underlying beliefs and feelings with respect to their disease. Trained interviewers measured weight, height and blood pressure. A fasting venous blood sample was collected from each participant in order to evaluate glycaemic control. Setting: An urban area (Sheshego) and rural areas near Pietersburg in the Northern Province of South Africa. Subjects: The sample comprised 59 men and 75 women from urban areas and 74 men and 80 women from rural areas. All were over 40 years of age, diagnosed with type 2 diabetes for at least one year, and attended primary health-care services in the study area over a 3-month period in 1998. Results: Reported dietary results indicate that mean energy intakes were low (<70% of Recommended Dietary Allowance), 8086–8450 kJ day −1 and 6967–7382 kJ day −1 in men and women, respectively. Urban subjects had higher ( P <0.05) intakes of animal protein and lower ratios of polyunsaturated fat to saturated fat than rural subjects. The energy distribution of macronutrients was in line with the recommendations for a prudent diet, with fat intake less than 30%, saturated fat less than 10% and carbohydrate intake greater than 55% of total energy intake. In most respects, nutrient intakes resembled a traditional African diet, although fibre intake was low in terms of the recommended 3–6 g/1000 kJ. More than 90% of patients ate three meals a day, yet only 32–47% had a morning snack and 19–27% had a late evening snack. The majority of patients indicated that they followed a special diet, which had been given to them by a doctor or a nurse. Only 3.4–6.1% were treated by diet alone. Poor glycaemic control was found in both urban and rural participants, with more than half of subjects having fasting plasma glucose above 8 mmol l −1 and more than 35% having plasma glycosylated haemoglobin level above 8.6%. High triglyceride levels were found in 24 to 25% of men and in 17 to 18% of women. Obesity (body mass index ≥30 kgm −2 ) was prevalent in 15 to 16% of men compared with 35 to 47% of women; elevated blood pressure (≥160/95 mmHg) was least prevalent in rural women (25.9%) and most prevalent in urban men (42.4%). Conclusions: The majority of black, type 2 diabetic patients studied showed poor glycaemic control. Additionally, many had dyslipidaemia, were obese and/or had an elevated blood pressure. Quantitative and qualitative findings indicated that these patients frequently received incorrect and inappropriate dietary advice from health educators.
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In rural low-income communities of eastern Uganda, poverty and large household sizes constitute prominent food environment barriers for adults living with type 2 diabetes, with local subsistence farmers relying on home-grown sweet potatoes as staple food, animal products unaffordable for most big families, deep-rooted cultural perceptions shaping dietary resistance, distinct food-related
“In rural low-income communities of eastern Uganda, poverty and large household sizes constitute prominent food environment barriers for adults living with type 2 diabetes (57). Local subsistence farmers mainly rely on home-grown sweet potatoes as staple food, while animal products such as chicken, fish and eggs are financially unaffordable for most big families (43).”
Among Black South diabetic populations, inconsistent and ambiguous nutritional counselling delivered by primary care providers acts as a key complexity obstacle.
“Among Black South diabetic populations, inconsistent and ambiguous nutritional counselling delivered by primary care providers acts as a key complexity obstacle.”
Among Black South diabetic populations, patients are forced to reconcile formal dietary rules with local funeral feasts and affordable indigenous ingredients, substantially weakening their capacity to sustain long-term dietary compliance.
“Patients are thus forced to reconcile formal dietary rules with local funeral feasts and affordable indigenous ingredients, substantially weakening their capacity to sustain long-term dietary compliance (43).”
Complicated multi-faceted intervention demands and fragmented, contradictory clinical guidance create widespread complexity barriers disrupting sustained diabetic dietary self-management, with distinct burdens observed in both high-income (HIC) and low- and middle-income (LMIC) populations.
“Complicated multi-faceted intervention demands and fragmented, contradictory clinical guidance create widespread complexity barriers disrupting sustained diabetic dietary self-management, with distinct burdens observed in both high-income (HIC) and low- and middle-income (LMIC) populations (40, 43, 70, 94).”
Among Black South diabetic populations, most participants lack access to unified food exchange tools and clear portion measurement instructions, and fragmented clinical advice fails to take local cultural traditions, household finances and daily living realities into account.
“Most participants lack access to unified food exchange tools and clear portion measurement instructions, while fragmented clinical advice fails to take local cultural traditions, household finances and daily living realities into account.”
Among Black South diabetic populations, frontline clinicians without systematic nutrition training offer conflicting recommendations on staple foods such as maize porridge, leaving patients confused about permitted food categories and standard portion sizes.
“Frontline clinicians without systematic nutrition training offer conflicting recommendations on staple foods such as maize porridge, leaving patients confused about permitted food categories and standard portion sizes.”
Cites
Turner, R. C., Millns, H., Neil, H. A. W., Stratton, I. M., Manley, S. E., Matthews, D. R., & Holman, R. R. (1998) · BMJ · doi:10.1136/bmj.316.7134.823 · Cited by 2,014 · see citing works
Hypertriglyceridemia, atherogenic dyslipidemia, and the metabolic syndrome
Grundy, S. M. (1998) · The American Journal of Cardiology · doi:10.1016/s0002-9149(98)00033-2 · Cited by 525 · cited 1× · see citing works
“The finding that patients in the present study were poorly controlled and overweight cannot be ascribed to their diet alone, since type 2 diabetes is known to be associated with several adverse cardiovascular risk factors, namely hypertension, increased serum triglycerides and decreased HDL-C 38,39 .”
Jenkins, D., Ocana, A., Jenkins, A., Wolever, T., Vuksan, V, Katzman, L., Hollands, M., Greenberg, G., Corey, P., & Patten, R. (1992) · The American Journal of Clinical Nutrition · doi:10.1093/ajcn/55.2.461 · Cited by 123 · see citing works
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Shao, K., Lei, H., Zhu, J., Chen, X., Sina, Y., & Yao, R. (2026) · Frontiers in Public Health · doi:10.3389/fpubh.2026.1870603
“…44, 46, 55, 64, 69, 80, 81, 84, 89, 99, 102–104, 107, 109, 112, 118, 120, 121); qualitative studies ( n = 20): (12, 20, 21, 28, 33, 34, 36, 41, 42, 50, 54, 57, 60, 63, 70, 73, 75, 77, 82, 86); mixed-methods studies ( n = 18) (13, 16, 32, 38, 43, 49, 51, 58, 72, 88, 90, 93–95, 97, 106, 110, 111).”
Influential
- Authors
- Nthangeni, G., Steyn, N. P., Alberts, M., Steyn, K., Levitt, N. S., Laubscher, R., Bourne, L., Dick, J., & Temple, N.
- Affiliations
- University of Cape Town (ZA)
- South African Medical Research Council (ZA)
- Athabasca University (CA)
- Corresponding author
- Steyn, Nelia P
- Venue
- Public Health Nutrition
- Publisher
- Cambridge University Press (CUP)
- Published
- 2002-04
- Volume
- 5
- Issue
- 2
- Pages
- 329-338
- ISSN
- 1368-9800 (ISSN-L)
- 1475-2727
- OpenAlex
- W2127758154
- Cited by
- 77
- References
- 3
- Citations by year
- 2026: 1 · 2024: 1 · 2023: 1 · 2022: 2 · 2021: 3 · 2020: 6 · 2019: 4 · 2018: 4 · 2017: 1 · 2016: 7 · 2015: 4 · 2014: 3 · 2013: 2 · 2012: 12
- FWCI
- 1.15
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Public Health Nutrition (publishedVersion)
- PubMed (publishedVersion)
- Open University of Cape Town (University of Cape Town) (submittedVersion)
- Funders
- Novo Nordisk
- Medical Research Council
- Topics
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Education
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Nutritional Studies and Diet
- Health Sciences › Nursing › Nutrition and Dietetics › Nutrition, Health and Food Behavior
- Keywords
- type 2 diabetes, dietary intake, dietary adherence, Black South Africans, energy intake, macronutrient distribution, dietary fiber intake, glycemic control, fasting blood glucose, urban-rural differences, meal patterns, primary care patients, diabetes education, rural health care, Northern Province, South Africa
- MeSH terms
- Adult, Black or African American, Energy Intake, Cross-Sectional Studies, Diabetes Mellitus, Diabetes Mellitus, Type 2, Diet Surveys, Female, Humans, Hyperlipidemias, Hypertension, Interviews as Topic, Health Knowledge, Attitudes, Practice, Male, Obesity, Patient Compliance, Patient Education as Topic, Primary Health Care, Surveys and Questionnaires, Rural Population, South Africa, Urban Population, Nutrition Policy, Black People, Diabetes Complications
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