Diabetes mellitus (DM) is a chronic metabolic disorder characterised by persistent hyperglycaemia resulting from defects in insulin secretion, insulin action, or both (1). Diabetes is broadly classified into type 1 diabetes, an autoimmune condition characterised by absolute insulin deficiency, and type 2 diabetes mellitus (T2DM), which accounts for the majority of cases globally and is strongly associated with behavioural, environmental and metabolic risk factors (2)

The global burden of diabetes has increased substantially in recent decades, making it one of the most pressing public health challenges of the 21st century. It is estimated that approximately one in eleven adults worldwide currently live with diabetes, with projections indicating that the number of affected individuals may reach nearly 693 million by 2045 (3). Diabetes prevalence in sub-Saharan Africa is increasing rapidly, with approximately 24.6 million adults currently living with diabetes, and projections indicating a rise to nearly 60 million by 2050 (4). South Africa (SA) reflects these global trends. In SA, diabetes is a major and growing public health concern, with an estimated 4.2 million adults living with the condition (4). It is also among the leading causes of death in the country, underscoring its significant health burden (5). The rising prevalence places significant pressure on the public healthcare system, particularly in rural and resource-constrained provinces such as the Eastern Cape (EC). Data from the Eastern Cape Province, which includes rural districts such as O.R. Tambo and parts of the former Transkei and Ciskei homelands, indicate a growing incidence of diabetes in recent years, closely aligned with overall national increases (6).

The surge in diabetes prevalence globally and within SA is linked to modifiable risk factors, especially those related to diet and physical activity patterns (7). Modern lifestyles increasingly expose populations to energy-dense, nutrient-poor foods, limited opportunities for physical activity, and economic environments that constrain healthy choices (8). Many individuals in rural and low-income communities have limited or incomplete knowledge about the causes and management of diabetes (9). A comparative analysis conducted in Nigeria and South Africa demonstrated a strong correlation between diabetes prevalence and high dependence on complementary and alternative medicine, the cost of diabetes treatment, limited health system capacity, and poor adherence to diabetes management guidelines (10). Limited knowledge about the role of diet often results in poor adherence to dietary recommendations, despite clinical advice (11).

DM presents a growing global health challenge, driven by dietary shifts, lifestyle changes, and socioeconomic conditions (12). In SA, and particularly in the EC’s rural communities, rising prevalence and limited diabetes knowledge are compounded by barriers to healthy eating and lifestyle adaptation (13). While the influence of social determinants such as poverty, food insecurity, and limitations in the health system on diabetes management is well established, there is limited qualitative research exploring how individuals in rural South African contexts interpret and navigate dietary recommendations within these constraint (14). Existing studies often focus on knowledge deficits or adherence outcomes, with less attention given to the lived experiences of individuals managing diabetes within complex household, cultural, and economic environments (14). In particular, there is a lack of context-specific evidence from rural areas of the EC, where structural inequalities, food insecurity, and limited access to dietetic services intersect to influence dietary behaviours. This study therefore seeks to address this gap by exploring how individuals living with diabetes in the Mnquma sub-region perceive healthy eating and experience barriers to dietary adherence within their everyday lives.

This study explored perceptions of healthy eating and barriers influencing dietary practices among individuals living with type 2 diabetes mellitus in rural communities of the Mnquma sub-region. The findings indicate that healthy eating in this context is shaped by an interplay of limited and fragmented diabetes knowledge, emotional responses to diagnosis, structural and economic constraints, and gaps in healthcare support. Together, these findings suggest that dietary self-management among people living with diabetes in rural Mnquma cannot be understood solely as an issue of individual choice or motivation, but rather as one embedded within broader social, economic, and health-system realities. Although this study was guided by the TPB, the findings extend beyond individual-level determinants of behaviour. While TPB emphasises attitudes, subjective norms, and perceived behavioural control, participants’ experiences reflected broader influences operating at interpersonal, community, and structural levels. This highlights the relevance of a socioecological perspective in understanding dietary practices within resource-constrained settings.

Participants demonstrated partial and sometimes inconsistent knowledge of diabetes and healthy eating. Many understood diabetes through lived experience, symptoms, or family history rather than through clear biomedical explanations. Healthy eating was often simplified by participants as to eating vegetables, reducing sugar, and avoiding fatty foods or starches. While these perceptions reflect some awareness of dietary recommendations, they also suggest limited understanding of broader dietary concepts such as portion control, meal balance, carbohydrate quality, and the long-term role of diet in glycaemic control. Similar patterns have been documented in South African and other low- and middle-income settings, where limited diabetes knowledge and health literacy contribute to challenges in effective self-management behaviours (20, 21). A national systematic review and meta-analysis which synthesised prevalence data from multiple epidemiological studies conducted across several South African provinces reported that participants often equate healthy eating mainly with vegetable consumption, with limited ability to translate dietary advice into practical and sustainable daily choices within household food environments (13, 22).

In addition, participants’ beliefs about the causes of diabetes included stress, heredity, and sugar intake alone. These findings highlight how cultural interpretations and personal experiences shape health beliefs. Similar findings highlighting the influence of social and contextual factors on perceptions of diabetes have been reported among women diagnosed with gestational diabetes in low-income communities in South Africa (23). Although these explanations may help individuals make sense of illness, they may also divert attention from evidence-based management practices when not addressed through appropriate patient education. Furthermore, limited and inconsistent patient education within healthcare systems in sub-Saharan Africa has been identified as a key barrier to effective diabetes self-management and patient understanding of disease management (24). In the rural Mnquma context, where socioeconomic constraints already limit food choices, inadequate understanding of dietary principles further complicates efforts to adopt and maintain healthy eating behaviours. Similar knowledge-related barriers to effective diabetes management have been identified in a scoping review examining diabetes care in West African primary healthcare settings (25).

An important finding was the strong emotional and psychological response associated with diabetes diagnosis and ongoing disease management. Fear was particularly evident among participants who had witnessed severe diabetes-related complications or death among relatives or community members. These findings are consistent with previous research indicating that diabetes diagnosis is frequently accompanied by psychological distress, including fear, anxiety, and concerns about disease complications (26). In rural and resource-limited settings, such fear may be heightened by limited access to accurate health information and the visibility of negative health outcomes within communities (27).

Participants also described frustration and helplessness when blood glucose levels fluctuated despite medication use or attempts to change their diets. Such experiences undermined self-efficacy and contributed to feelings that diabetes was controlling them rather than the other way around. Evidence suggests that psychological and motivational factors play an important role in influencing adherence to recommended self-care behaviours among individuals living with chronic illnesses (28). Family support also played a significant role in shaping emotional adjustment and dietary behaviour. Participants who reported supportive household environments described assistance with food preparation and encouragement to maintain healthy eating practices. Conversely, lack of understanding or resistance within households contributed to distress and hindered adherence to dietary recommendations. These findings align with previous research indicating that supportive family environments improve emotional wellbeing and diabetes self-management, whereas unsupportive social environments increase diabetes-related distress (29).

Structural and economic barriers were central to participants’ accounts of why healthy eating was difficult to achieve. Participants described multiple intersecting challenges that limited their ability to follow dietary recommendations. Financial insecurity emerged as the most pervasive constraint, with many participants relying on social grants, irregular income, or support from family members. Foods perceived as healthy, such as fruits, vegetables, and lean meats, were often described as unaffordable, while maize meal, rice, and bread were prioritised because they were cheaper and filling for the entire household. These findings reflect broader evidence that financial and environmental barriers often limit access to healthier food options in low-income communities (30). In SA, poverty and food insecurity have been widely documented as significant barriers to dietary adherence among people living with diabetes, particularly in rural communities (31, 32). Household food environments further constrained dietary choices. Many participants lived in shared households where meals were prepared collectively, limiting their ability to follow individualised dietary recommendations. Similar findings have been reported in other rural contexts where shared cultural norms and collective eating practices influence household food consumption and dietary behaviour (33). Although some participants had access to land for subsistence farming, agricultural production was often unstable due to limited resources, lack of agricultural inputs, and declining physical capacity. Evidence suggests that subsistence farming alone may not significantly improve dietary quality without adequate financial and structural support (34). Health system constraints further compounded these challenges. While participants generally trusted healthcare providers as sources of dietary information, limited consultation time, high patient loads, and the absence of dietetic services reduced opportunities for tailored dietary counselling (35, 36). These structural challenges should also be understood within the broader historical context of the EC, where the legacy of apartheid-era policies, including land dispossession and spatial inequalities, continues to shape food systems, livelihoods, and access to resources in rural communities.

Healthcare providers and support systems also played an important role in shaping dietary practices Participants consistently identified healthcare professionals as their primary and most trusted source of diabetes-related information. This reliance reflects the central role of healthcare providers in shaping patients’ understanding of chronic disease management in rural and low-resource settings (37, 38). However, trust in healthcare providers did not necessarily translate into effective dietary self-management. Many participants reported receiving limited, fragmented, or inconsistent dietary counselling. In some cases, advice focused primarily on foods to avoid rather than practical guidance on how to eat within financial and household constraints. Similar challenges have been documented in the South African public health system. High patient loads, limited consultation time, and shortages of dietitians restrict the provision of comprehensive dietary counselling (39, 40).

In the absence of structured professional support, family members often became important sources of informal support. Some participants reported receiving assistance with meal preparation and encouragement from family members, which facilitated healthier eating practices. However, family support was inconsistent and sometimes constrained by limited financial resources or misunderstanding of dietary recommendations. Evidence suggests that family involvement can either support or hinder diabetes self-management depending on household resources, knowledge, and social relationships (41). In addition, some participants reported obtaining information from peers, radio programmes, or other individuals living with diabetes. While such peer learning can be empowering, reliance on informal sources without structured professional guidance may also contribute to misinformation or confusion (42).

In rural Mnquma, difficulties in maintaining healthy eating practices were not primarily due to lack of motivation but rather poverty, food insecurity, limited dietary counselling, competing health conditions, and fragile support systems.

These findings highlight the need for context-sensitive diabetes interventions that move beyond generic dietary advice and instead prioritise sustained nutrition education and practical counselling tailored to local food environments. Strengthening diabetes education within primary healthcare services may improve patients’ understanding of dietary management, while family-inclusive approaches and repeated patient education could enhance long-term adherence to recommended dietary practices. Addressing structural barriers such as food insecurity, poverty, and limited access to dietetic services may also be necessary to support sustainable dietary change among individuals living with diabetes in rural communities.

A key strength of this study is that it provides in-depth qualitative insight into the lived experiences of individuals living with diabetes in a rural South African context that remains underrepresented in the literature. The use of participant narratives allowed for a deeper understanding of how emotional, social, economic, and health system factors interact to influence dietary behaviour. However, several limitations should be acknowledged. The study was conducted within one sub-region and among participants attending selected primary healthcare clinics, which may limit the transferability of the findings to other contexts. The predominance of female (32 out of 35) participants may also have influenced the perspectives represented. This gender imbalance likely reflects healthcare utilisation patterns in primary care settings, where women are more likely to access health services and participate in health-related research. However, this overrepresentation of female voices may have influenced the findings, particularly in relation to household food preparation, dietary decision-making, and engagement with health services, which are often shaped by gendered roles within households. As a result, male perspectives on diabetes management and dietary practices may be underrepresented and it is possible that important gender-specific barriers such as work-related constraints, health-seeking behaviours, or differing perceptions of illness and diet may not be fully captured in the dataset. This may limit the extent to which the findings reflect the experiences of men living with diabetes in similar settings. Future research should aim to include more balanced gender representation and where possible, explore gender-specific differences in diabetes management behaviours and dietary practices in greater depth.

Despite these limitations, the study provides valuable context-specific insights relevant to diabetes management in rural and resource-constrained settings.

Healthy eating among individuals living with diabetes in rural Mnquma is influenced by more than individual knowledge or motivation. Participants’ dietary practices were shaped by fragmented understandings of diabetes, emotional distress, poverty, household food dynamics, limited access to affordable healthy foods, and inadequate dietary counselling within the healthcare system. Addressing these challenges highlights the importance of context-sensitive diabetes education, improved dietary counselling within primary healthcare settings, and broader structural interventions that address food insecurity and socioeconomic constraints. Strengthening multidisciplinary diabetes care and integrating family and community support systems may be essential for improving dietary practices and diabetes outcomes in rural communities. While this study does not evaluate interventions, the findings provide important insights that may inform the design of contextually appropriate strategies. These findings should be interpreted within the context of a single sub-region and may not be generalisable to other settings.