Study area and research design

The study was conducted at a National Diabetes Management and Research Centre (NDMRC) in Accra, Ghana. The NDMRC is a well-resourced centre for diabetes management, research and education, which is managed by highly qualified medical and paramedical staff. The centre provides all the pertinent services and support key to proper diabetes care and management. It has a diabetic clinic which serves as the outpatient department and provides medical care to patients with diabetes.

An exploratory, descriptive qualitative research design was used for this study.

Sample size and sampling technique

Purposive sampling technique was used to recruit participants for the study. The target population was all patients with diabetes attending clinic at the NDMRC. The inclusion criteria comprised all patients with type 1 or type 2 diabetes mellitus who were attending clinic at the NDMRC, were eighteen years and above, and had been diagnosed of diabetes mellitus for at least six months. The sample size of a qualitative research depends on the saturation of data, that is, the giving of similar responses by successive participants, and the emergence of no new theme or subtheme [20]. This study comprised of fifteen participants. This is because saturation of data was reached by the fifteenth participant.

Data collection

Permission was sought from the tertiary hospital’s Institutional Review Board (ethics number: KBTH-IRB /000130/2018) and the head of the NDMRC. Patients with diabetes attending clinic at the NDMRC were then informed about the study and requirements for participation. Guided by the inclusion criteria, the researchers recruited participants who willingly agreed to be part of the study for face-to-face interviews.

Before an interview was conducted, each participant was given a consent form to read, and invited to ask questions and seek clarifications based on the content of the consent form and the study. Each participant then voluntarily signed or thumb printed the consent form after he or she had sought clarification for all doubts and was satisfied with the information provided. For participants who could not read the consent form, the information was translated to them in the local Twi language which they understood.

Data was collected from the participants using a semi-structured interview guide (S1 file). The lead author who has received education and training on conducting qualitative interviews conducted the interviews. The interviews were conducted with the aid of an interview guide, which was initially piloted at a University Hospital in Ghana on three patients with diabetes. The interview guide comprised of open-ended questions on the participants’ daily dietary intake, practices and habits regarding the nutritional management of diabetes mellitus. They were also questioned on their skills and current practices on food label reading and meal planning. Further probes were made based on participants’ responses.

The semi-structured interviews, which had a duration of forty to sixty minutes, were conducted in either English or the local Twi language, depending on the dialect a participant was comfortable with. With participants’ permission, each interview was audio recorded. To ensure anonymity, the participants were given pseudonyms.

Data analysis

Braun and Clarke’s [21] method of data analysis was used to analyze the data gathered. The audio recorded interviews conducted in English were first transcribed verbatim. Those that were conducted in the local Twi language were also translated and transcribed verbatim into English by the researchers with the help of a translator to avoid distorting the data. The researchers then read and re-read the data set of fifteen transcripts in English, and noted significant ideas that emerged from the data. These ideas were coded to generate initial codes and matched with relevant extracts from the data. The researchers collated the initial codes into potential themes. The potential themes with their extracts were then reviewed to generate three main themes. A final analysis of the themes was done to come up with a research report which provided accurate answers to the research questions.

Dietary practices in the morning, afternoon, and evening

The participants mentioned the number of times they generally eat in a day, the foods they usually eat, the quantity of foods they eat, and their practices on fruits consumption. They also indicated their current practices on the intake of soft drinks and alcoholic drinks. The participants revealed that they avoid starving themselves by typically eating twice or three times a day. More than two-thirds of the participants said that they often eat three times a day. One of them narrated:

I often eat three times, that’s what the dietitian told me. (Ama).

One-fourth of the participants however specified they usually eat two times a day. One of them recounted:

I eat twice in a day most of the time, because I don’t really like food. (Yaa).

All participants revealed they habitually eat breakfast. Almost all of them said they usually eat corn porridge, millet porridge, oats or wheat for their breakfast, due to the high fibre content. They often take these foods with whole wheat bread and sometimes add vegetables to the bread. Additionally, some participants indicated they sometimes add powdered milk or a cholesterol-free milk and non-nutritive sweeteners to their foods. One such participant reported:

For breakfast, I usually take corn porridge or millet porridge, because they [dietitians, nurses and doctors] told us to eat foods rich in fibre. I always take the porridge with wheat bread and usually add dandelion, cabbage and carrots to the bread. I don’t often add sugar and milk to my food, but sometimes I add the diabetes sugar and Carnation milk or powdered milk to my porridge. I don’t take white sugar. The dietitian, nurses and doctors said it is not good for us, so I only take the diabetes sugar. (Adwoa).

Participants also emphasized that they do not consume large quantities of the high fibre foods they take as breakfast. One participant remarked:

They [dietitians, nurses and doctors] have advised us concerning the amount to take. They said two slices of bread is okay. Two thin slices. We don’t eat plenty. They told us about the amount of porridge, oats and wheat to take. They told us to take only two or three ladles, that’s all. (Kofi).

More than half of the participants said they usually have tea with whole wheat bread as their breakfast. They often add powdered milk or a cholesterol-free milk to the tea, and sometimes add vegetables or egg to the bread. However, whereas some of them sometimes add a non-nutritive sweetener to their tea, a few of them usually add white sugar to their tea. One participant stated:

What I usually eat in the morning is tea with wheat bread. I don’t add sugar to it. I only add a tablespoon of powdered milk to it. I sometimes add egg to the bread. But in order not to increase my cholesterol level, I boil the egg, I don’t fry it, and I place the boiled egg in the bread. (Kwabena).

On the quantity of tea and bread they usually take, participants said they take one cup of tea and a small quantity of bread. One of them recounted:

I take just a cup of tea. The cup I use is the common tea mug. For bread, I take just three slices of bread. (Kwadwo).

One-third of the participants mentioned that they sometimes take “kenkey” (a local Ghanaian food prepared with corn) with fish and stew or vegetables during breakfast. One participant remarked:

I sometimes take kenkey with fish in the morning. I take it with tomato stew, kontomire [spinach] stew, or cabbage stew. Sometimes, I also take it with ground pepper, sliced tomatoes, and sliced onions. (Abena).

In the narratives provided by participants, they reported eating a ball of kenkey, the size of which is equal to their closed fist. Abena commented:

I just go in for kenkey. The size is like my closed fist. (Abena).

One-fourth of the participants also mentioned boiled plantain with vegetable stew and fish as one of the foods they take as breakfast. From their accounts, they usually take two to three fingers of plantain. Akua recounted:

By 9am or 10am, I will go in for boiled plantain. I grind my kontomire, add a small amount of oil to it and take it with the plantain. I take it with fish. I take just three fingers of plantain. (Akua).

Rice with stew, fish, and vegetables was mentioned by one-third of the participants as food they take as breakfast. Participants provided information on the quantities they eat. One of them remarked:

Sometimes I eat white rice with kontomire stew and fish or brown rice with vegetables, tomato stew and fish in the morning. For the quantity, I take three ladles of rice because they [dietitians, nurses and doctors] said we should take two to four ladles of rice, so that is what I do. (Akosua).

The narratives of the participants indicated that they usually take their breakfast from 6am to 10am everyday. One of them commented:

I take my breakfast anytime from 9am to 10am. (Dede).

In addition to the discussions on breakfast, the participants mentioned the foods they usually take as lunch, as well as the quantity they take. More than half of the participants said they regularly eat “fufu” (a Ghanaian food prepared with only plantain or with cassava and plantain) with soup and fish as their lunch. They usually take their fufu with groundnut soup, palm nut soup or light vegetable soup. The following participant’s account is similar to others in this group:

I often eat fufu in the afternoon. I take it with light vegetable soup, palm nut soup or groundnut soup. I usually take it with fish, but occasionally, I take it with chicken. (Kwabena).

The participants mentioned that they consume large quantities of soup, but the size of the fufu they usually eat is equal to either one or two of their closed fists. One participant remarked:

For the fufu, I have my limit, I don’t take much. The size of the fufu I take is like my fist. It’s the soup that I take a lot. (Afia).

Half of the participants reported that they usually eat boiled plantain with vegetable stew and fish for lunch. A few sometimes eat it with egg instead of fish, while some occasionally have boiled yam instead of boiled plantain. Yaw commented:

I usually take boiled plantain with kontomire stew, or sometimes cabbage stew or garden eggs stew. I usually take it with fish. But sometimes I go in for egg. Also, sometimes, I take boiled yam instead of boiled plantain. (Yaw).

On the quantity of boiled plantain and boiled yam the participants take, they reported that they often consume two to three fingers of plantain, and four to five slices of yam. One of them recounted:

I take two fingers if the size of the plantain is big, but I take three if the size is small. For yam, I sometimes take four slices, other times too I take five slices of yam. (Akosua).

Almost half of the participants indicated that they usually have rice and stew with fish as lunch. They often take the rice with tomato stew or kontomire stew, and sometimes add chicken or egg but rarely add red meat to the food. One participant said:

I take rice with tomato stew or kontomire stew. I usually take fish. Sometimes too I take it with chicken or egg. (Yaa).

Participants concurred that they usually consume two to four ladles of rice. One stated:

I don’t take much of the rice. I take about three ladles. (Abena).

One-fifth of the participants mentioned kenkey with fish and ground pepper or okra stew as one of the meals they sometimes have for lunch. One stated:

With the kenkey, I take it with fish. If I have okra stew, I use that. If I don’t have, I prepare pepper. I buy one ball of kenkey, which is like my closed fist. (Ama).

One-fifth of the participants also said that they sometimes eat “banku” (a local Ghanaian food prepared with corn and cassava dough) or “rice-ball” (a Ghanaian food prepared with rice) with soup and fish or chicken for lunch. They usually consume one or two fist-sized balls of banku or rice-ball. One of them remarked:

I usually eat banku or rice ball in the afternoon. I take it with light vegetable soup, groundnut soup, or palm nut soup. I take them with dry fish and chicken, and on some few occasions I take them with red meat. I only take a small quantity of it—it is like my fist. (Yaa).

Participants indicated that they often have their lunch from 12pm to 3pm, as one commented:

I eat by 1pm in the afternoon. So I take my lunch anytime from 12pm to 1pm. (Abena).

On their supper intake, the participants said they usually eat early in the evening, and when they do, they take in heavy foods. However, most of them concurred that when they become hungry again later in the evening, they eat light foods due to the education they have received to avoid starving themselves and eating heavy foods at night. The types of heavy foods the participants often have for supper are not different from the ones they usually have as lunch. Similarly, the types of light foods they consume when they feel hungry later in the night are not different from the light foods they usually eat in the morning.

Two-thirds of the participants said they usually eat a fist-sized ball of fufu with light vegetable soup, groundnut soup or palm nut soup and fish as their supper. Sometimes, a few of them add red meat to their fufu.

Half of the participants reported that they usually consume banku, which size is like their closed fist, with fish and vegetable stew as supper. One commented:

I take banku with okra stew and fish. Sometimes, I also take it with pepper, sliced tomatoes, sliced onion, and fish—usually tilapia. The size of the banku I take is like my closed fist. When I am very hungry, I add half the size of my closed fist to it. But I take more of the okra stew, and if I’m taking it with pepper, I take more of the sliced tomatoes and onion. (Akosua).

Almost half of the participants mentioned boiled plantain with vegetable stew and fish as food they eat in the evening. They consume only two or three fingers of plantain, as one participant remarked:

I usually take boiled plantain with dandelion stew, kontomire stew or garden eggs stew, and fish. As for plantain, I take just two fingers. (Ama).

One-fifth of the participants said that they sometimes eat boiled yam with stew and fish, and take only four or five slices of yam. One participant recounted:

I sometimes take yam. I take about five slices. I take it with kontomire stew, cabbage stew or garden eggs stew and fish. I take four to five slices of the yam because that is what they [dietitians, nurses and doctors] told me. (Yaw).

More than half of the participants indicated they usually eat either one ball of kenkey with ground pepper and fish or rice with stew, vegetables, and fish in the evening. They stated they do not eat much of the kenkey or rice. One of them said:

In the evening I take rice. For the rice, I add vegetables and fish, then stew. I eat two or three ladles of rice. I sometimes also eat kenkey and pepper with fried fish in the evening. I eat just one ball of kenkey. (Kwaku).

On the time they usually have their supper, almost all the participants said they generally eat their supper from 4pm to 7pm. One of them commented:

I eat in the evening. I usually eat around 6:30pm till 7pm. (Yaa).

However, a 63-year-old man who has been living with diabetes for 25 years said he usually has his supper between 6pm and 10pm due to the nature of his work:

In the evening I eat anytime from 6pm to 10pm. Because of the nature of the job I’m doing, I sometimes eat late. I don’t have time for my food because of the nature of my job. (Kwaku).

More than half of the participants also mentioned that they occasionally eat light foods when they become hungry later in the evening, after taking their supper. One recounted:

Once a while, I feel hungry when I’m about sleeping. If I am hungry at that time, I eat. Around that time, I don’t eat any heavy food, I just take in something light like oats, porridge, tea, banana, or biscuit. And I don’t eat much. (Kwame).

On their practices concerning the consumption of fruits, all participants indicated that they take fruits regularly. Comments included:

I take a fruit everyday. Every blessed day I take a fruit. (Kwabena).

I take fruits three to five times a week. (Yaw).

Half of the participants mentioned that they often eat fruits in the evening, while one-third of the participants shared that they usually have fruits in the afternoon. One of them recounted:

For me, it is in the afternoon that I often take my fruits. I take some before I take my lunch. Even after lunch I take some too. (Abena).

One-fifth of the participants also indicated they often consume fruits in the morning. One person remarked:

I usually try to eat my fruits before taking my breakfast, or sometimes together with my breakfast. So usually, breakfast will be set, and the fruits will be set alongside too. (Kofi).

The participants cited orange, banana, pawpaw, mango, coconut, pineapple, apple and pear as the fruits they often consume. Statements in this respect included:

I usually take a lot of pawpaw, banana and orange. I take mango too. (Yaa).

I usually take apple or coconut. Sometimes, I take pineapple. Even pear, I take that one sometimes. (Dede).

The participants also talked about their practices concerning the consumption of soft drinks and alcoholic drinks. More than two-thirds of the participants indicated that they currently take soft drinks in moderation and occasionally, dilute Coca-Cola and Fanta with water before consuming it, and only take half a glass of non-alcoholic malt drink. A few of the participants added that they often consume Coca-Cola when their sugar level is very low. Responses on this topic included:

I don’t take soft drinks that often. I only take them once in a while. If I’m taking a drink like Coca-Cola or Fanta, I pour half of it away and mix the remainder with one sachet of water before taking it. For Malt, I only take half the amount, that’s all. But I don’t mix the half that I take with water. (Kwame).

I take Coca-Cola when my sugar level goes down. The doctors and nurses have told us to take Coca-Cola when our sugar level drops, so that’s what I do. But apart from that, I take Coca-Cola, Malt, Fanta or Soda water occasionally. (Akosua).

In contrast, one-fifth of the participants echoed they do not consume soft drinks. One of them said:

I don’t even like soft drinks because they will give me health problems, so I avoid them. (Adwoa).

More than two-thirds of the participants also indicated that they do not take alcohol. Two of them stated:

As I told you, I don’t drink. I wasn’t drinking even before diagnosis, and up till now I don’t drink. (Kwaku).

Before diagnosis I was taking alcohol, but ever since I was diagnosed, I have stopped. (Akwasi).

In contrast, a few of the male participants admitted that they currently consume alcohol occasionally and in moderation. One of them remarked:

Occasionally, I take beer. Now, I don’t take a bottle of beer, I often take a glass of beer. I’ve now limited how I take it. It’s now different from how I was taking alcohol before I got diabetes. It is on rare occasions that I even take a bottle of beer now. But even with that, I don’t take more than a bottle of beer now. (Yaw).

Reading of food labels

The participants of this study shared their views on the education received on the usage of food labels, and on their current practices of reading and using food labels in the nutritional management of their condition. Half of the participants recalled that they were educated on the use of food labels by doctors, nurses and dietitians. One-third of the participants indicated that they only check the expiry date of processed foods because that is what they were told to do, and that they rarely consume processed foods. One of them remarked:

They [dietitians, nurses and doctors] educated us to check the expiry date of processed foods. For me, I don’t like canned foods, so I hardly buy them. If I buy those products, expiry date is what I check. I often check the expiry date of such products. (Afia).

Less than one-fifth of the participants said that they were educated to check both the expiry and manufacturing dates of processed foods. One of them recounted:

They [dietitians, nurses and doctors] educated us on the food labels. They said the manufacturing date and expiry date are very important, so we should always check them before we buy canned foods or processed foods. I always make sure I see the manufacturing and expiry dates on the labels of food products before I buy them. If I don’t see the dates, I won’t buy the food product. (Kwaku).

One participant indicated that he was educated to check the sugar content and expiry date of processed foods before consuming them, and that is what he does. He explained:

Personally, I don’t like processed foods. But if I’m buying them, what I check on those things is the expiry date. If it has expired, I won’t buy it. I know that all those foods contain sugar, so I check the sugar content too. I often check the expiry date and the sugar content of those foods, because that is what they [dietitians, nurses and doctors] told me to do. (Kwabena).

In contrast, a few of the participants said that they were not given education on the reading and usage of food labels by their health care providers, but received that education from watching or listening to health programmes on the television and radio. They indicated that what they check on food labels is the expiry date of the products. One of them commented:

The health personnel didn’t teach us about food labels. I heard about food labels on the television when I was watching a health program. They said that canned foods and bottled foods are not good for diabetics so we need to avoid them. But if we have to buy them, we need to check their expiry dates. So when I have to buy such products, I only check the expiry date. (Adwoa).

One-third of the participants confirmed they had not received education on the use of food labels from their health providers or from any other source. One-fourth of the participants also said they do not check anything when they buy processed foods. One of them stated:

The health workers haven’t taught us anything about food labels. They didn’t tell us that, so I don’t know anything about food labels. I don’t know the meaning of the things there, so I don’t check for anything before I buy those products. But for me, I don’t like the canned foods and bottled foods, so I hardly buy them. (Akua).

It was the habit of one participant to check the expiry date of processed foods even though she indicated that she was not educated on the use of food labels. She remarked:

I wasn’t given any education on food labels by the health personnel, but I always check the expiry date of those products. I also check if they have written ‘sugar free’ on it. Those are the two things I often check for. (Abena).

Meal planning

Study participants shared how they plan their meals and the factors they consider when planning their meals. More than two-thirds of them mentioned that in opting for a particular food, they consider whether they have been asked by their doctors, nurses and dietitians to eat that food or to avoid it, whether the food will increase their blood glucose level or not, and whether the food is healthy for them or detrimental to their health. One participant explained:

For me, I only check if the food will not raise my sugar level. So if it is something I have been told by the nurses, doctors and dietitian to avoid, I will not go near it. But if it is something that I have been asked to eat, that one I know it will not give me problems so I will eat it. (Akosua).

However, one-fifth of the participants said their desire for a particular food is the only thing they consider before opting for that food. One of them said:

What I have appetite for is what I consider. So, it is if I have the appetite for this food or that particular food. That’s all. (Yaa).