Background: Diet is a cornerstone of diabetes treatment. Identifying issues surrounding dietary and related self-care is critical to planning effective diabetes self-management education interventions. 

Aim: To explore and describe the challenges with dietary and other self-care areas of adults with type 2 diabetes (T2DM) as perceived by patients, to inform the adaptation of a nutrition education intervention (NEI) that was implemented for non-insulin dependent T2DM patients attending primary health care.
Methods: A qualitative study based on interpretive phenomenological design was conducted with a convenience, purposive (at least one-year living with diabetes) sample of T2DM adults attending the diabetes outpatient clinic of Steve Biko Academic Hospital, South Africa. Data were obtained using five focus group discussions guided by a semi-structured questionnaire, and were analysed using framework thematic approach.1 The study had ethical approval from Faculty of Health Sciences, Ethics Research Committee, University of Pretoria (no. 4/2016).
Findings: Twenty eight adults (11 females) with T2DM, aged 42-70 years (mean age 59±9.0) and diabetes duration of 1-37 years (median 13) participated. Participants comprised mainly black (57%) and white (35.7%) ethnic groups. The majority were on insulin therapy (82%), were unemployed (71% including pensioners) and had high school education or above (82%).
Five major problems/themes emerged. These include knowledge deficits as reflected by misunderstanding and confusion of certain aspects related to diabetes and its treatment. Second, poor adherence to treatment recommendations (e.g. irregular meals, portion size control, skipping or missing injections, irregular/no exercise, presence of hypo-and hyperglycaemia). Third, barriers to effective self-management (e.g. forgetting medication, tasteless and restrictive diets, hunger and food cravings, laziness and lack of motivation for exercise, eating differently from others, unaffordable foods, tiredness and lack of energy, co-morbidities). Fourth, strategies for coping with challenges (e.g. overeating for fear of hypoglycaemia, frequent eating due to hunger and lack of energy, resting more often due to tiredness). Lastly, challenges affecting quality of life (e.g. stress, nocturia and lack of sleep, frustration with daily medication, complications related pains and discomforts).

Conclusion: Challenges with dietary and other diabetes self-care areas are rife in this patient population and differ in some ways from those of patients in primary care. The problems are in the personal and socio-economic domains. In adapting the NEI, feasible strategies to address these problems need to be incorporated.
1.	Ritchie J, Spencer L. Qualitative data analysis for applied policy research. The qualitative researcher’s companion. In: Huberman AM, Mile MB, editors. Thousand Oaks: SAGE Publications, 2002; p. 305–329.

Dietary self-management problems: Perceptions of type 2 diabetes adults at a South African tertiary hospital clinic