Dietary perceptions and challenges in the management of type 2 diabetes in rural communities of the Eastern Cape, South Africa: a qualitative study.

Diabetes mellitus (DM) is an increasing public health concern globally, particularly in low- and middle-income countries (LMICs). Socioeconomic challenges complicate disease management. Dietary management is central to diabetes care; however, adherence to recommended dietary practices remains difficult in many rural and resource-constrained settings. This study explored perceptions of healthy eating and barriers influencing dietary practices among individuals living with diabetes in rural communities of the Mnquma sub-region in the Eastern Cape (EC), South Africa (SA). A qualitative descriptive study was conducted among adults diagnosed with type 2 diabetes attending four primary healthcare clinics. Purposive sampling was used to recruit 35 participants. Data were collected through semi-structured interviews conducted in IsiXhosa or English, audio-recorded, transcribed verbatim, translated into English, and analysed using thematic analysis. Four major themes and fifteen sub-themes emerged: knowledge and perceptions of diabetes and healthy eating; emotional and psychological factors affecting eating habits; structural, economic, and environmental barriers to healthy eating; and the role of healthcare providers and support systems. Understanding of diabetes and healthy eating, with dietary practices often shaped by personal experiences rather than formal health education. Emotional responses to diagnosis, including fear and distress, influenced self-management behaviours. Financial insecurity, food insecurity, household food practices, agricultural instability, competing health conditions, and inconsistent dietary information emerged as major barriers to healthy eating. Although healthcare professionals were viewed as trusted sources of information, participants reported limited dietary counselling and fragmented health messages, while family support varied across households. These findings highlight that healthy eating among individuals living with diabetes in rural Mnquma is shaped by complex interactions between knowledge, emotional experiences, socioeconomic conditions, and health system support. While consistent with the Theory of Planned Behaviour (TPB), the results also highlight the importance of broader socioecological influences in shaping behaviour in resource-constrained settings. These findings underscore the need for context-sensitive diabetes interventions that extend beyond individual-level education to strengthen family and community support, improve dietary counselling within primary healthcare, and address broader socioecological and structural determinants, including food insecurity, poverty, and constrained food environments in rural settings.