Setting

Participants were selected from two tertiary institutions, namely False Bay Hospital (Fish Hoek, Cape Town) and Groote Schuur Hospital (Observatory, Cape Town), and a primary health clinic in Hout Bay (Hout Bay, Cape Town). False Bay Hospital is a public hospital that was opened in 1965 in Fish Hoek, a town approximately 30 kilometres south of Cape Town. The hospital has approximately 80 beds, and its facilities include a 24-Hour Emergency Unit. It is the only district hospital in the South Peninsula Health District of the Metro Region and serves many communities, including Simonstown, Masiphumelele, Ocean View, Clovelly, and many other surrounding areas. Groote Schuur Hospital is one of Cape Town’s largest government-funded academic hospitals and was officially opened in 1938. The hospital has almost 900 beds and it is renowned as the hospital where the world’s first human-to-human heart transplant was performed in 1967 by Christiaan Barnard and his team [43]. The Hout Bay health clinic non-profit organization works mostly in an informal settlement called Imizamo Yethu and provides nutrition and health education to the community. Hout Bay is a seaside town in the Western Cape Province situated in the Cape Peninsula, 20 kilometres south of Cape Town.

Participants

To be eligible for the study, participants had to be health professionals; work in and see patients from the communities where EBSA has conducted a nutrition education program or a community where EBSA is planning to run future programs; and be able to understand and speak English. Community health clinics were contacted by email or phone to identify potential participants. A researcher explained the study to interested participants, either via phone or at a scheduled meeting, and if they met the inclusion criteria, they were provided with a study information sheet and the informed consent form. An interview visit was then scheduled at a convenient time and place for the participants. The participants met individually with a researcher for approximately thirty minutes to an hour in a private venue within the participating health facilities, ensuring both privacy and accessibility, where they signed the informed consent form and were interviewed in English. Although participants were selected from some facilities serving communities where EBSA had run programs, this did not guarantee their direct involvement in or awareness of the program itself. Additionally, including professionals from communities where EBSA was planning future programs allowed the study to capture prospective opinions on the program, offering insight into potential facilitators and barriers before implementation.

Procedures

The IDIs were conducted between 29th of November and 21st February 2020 and lasted, on average, 30 minutes. The number of participants is consistent with recommendations in the qualitative research literature, which suggests that meaningful insights can be gained from smaller, information-rich samples [44]. According to this literature, the first five to six IDIs generally produce the majority of new data, and the majority of concepts are identified within the first 10 interviews. As such, new participants were interviewed until saturation was reached [44]. However, as outlined by Braun and Clarke, we acknowledge that the concept of data saturation is debated, with an emphasis on depth of interpretation rather than a fixed threshold for thematic exhaustion [45]. Participants were interviewed on a one-on-one basis to explore their understanding and perceptions of chronic disease, nutrition, LCHF diets, and the EBSA program. A semi structured interview guide (see SI1 – Supporting Information File 1) was used which included both open-ended and probing questions as a guide for the discussion, although questions were not necessarily asked verbatim. Probing questions were asked only if the subjects had not already been covered.

The interview guide was developed based on a review of the literature on healthcare professionals’ perceptions of dietary interventions, particularly low-carbohydrate diets. It was piloted with two health professionals (not included in the final sample) to ensure the relevance, clarity, and cultural appropriateness of the questions. The final guide followed a semi-structured format, allowing for follow-up questions and probing to explore emerging topics in depth. It covered the following key areas: healthcare providers’ perceptions of their role in community health; major health concerns identified in their communities; views on NCDs such as obesity, diabetes, and cardiovascular disease; the type of dietary advice offered at their healthcare facilities; perspectives on the role of nutrition in chronic disease prevention and treatment; their understanding of local dietary patterns; and their awareness and impressions of the EBSA programme and the LCHF diet, including views on the feasibility of implementing such interventions in their communities.

All interviews were audio-recorded, with the permission of the participants. The interviews were conducted by GPB and saved in a password-protected folder. The recordings were transcribed by a professional transcription service (Cyber Transcription, South Africa) and the accuracy and editing of the transcriptions were double-checked by an external qualitative researcher for rigour and appropriateness. Each transcribed interview was compared with the corresponding audio to ensure that the transcription had been done in context and captured the interview as accurately as possible.

Data analysis

Braun and Clarke’s approach to thematic analysis [46] was followed using NVivo 12 software (QSR International, Melbourne, Australia). The 2006 version of Braun and Clarke’s thematic analysis was used. This version is characterised by its epistemological flexibility and openness to the use of codebooks, a feature that has since been abandoned by the authors in more recent iterations of this analytical method [45].

The analysis began with CCW and GPB reading the transcripts several times, summarising them, and making notes on ideas and potential codes. These two researchers then each inductively developed a codebook based on the summaries and notes generated by reading the transcripts in the previous step. Then, they discussed their individual codebooks, merged them into one codebook, and independently coded three randomly selected interviews using separate NVivo projects. CCW and GPB then met again to compare their respective coding, and discuss and resolve disagreements by consensus. The content and structure of the final codebook was finalised through discussions involving ABF, SF, and KL, to ensure consistency and clarity in the coding framework. Once agreement on the codebook was reached among the members of the research team, the remaining interviews were divided into two groups of eight, with each group assigned to GPB or CCW. GPB and CCW held regular meetings to discuss their interpretations, resolve discrepancies, and critically engage with the data. These collaborative discussions allowed for the refinement of the coding framework and the development of sub-themes and themes, ensuring consistency in analytical decisions. The themes developed were then visually organised by GPB using thematic maps, which supported further analysis and interpretation. During and after the interviews, the research team systematically recorded observations and took field notes, including contextual insights and paraverbal cues such as tone, pauses, and emphasis. Although this data was not formally coded, it was used in the process of interpreting and understanding the participants’ narratives and in the development of the themes.

The following step involved naming the themes and defining the main concepts of each theme, resulting in a total of four themes. These themes were shared with ABF, SF, KL and JS to confirm their relevance to the research questions. The fact that, as explained above, two researchers (CCW and GPB) were involved in the analysis of the data, and that the different steps of the analysis were reviewed by the other members of the research team, helped to ensure that all the themes were identified and that the data was interpreted in a consistent way, avoiding the possibility of a premature closure of the analysis, limiting the potential effect of bias in the adoption of a singular point of view, and promoting the overall quality of the analysis. We did not use member checking for practical and methodological considerations. Logistically, time and resource constraints prevented us from following up with participants. Methodologically, we adopted an approach that recognises the dynamic and contextual nature of participants’ perceptions, which may shift over time and are not necessarily fixed or unique. Participant feedback is shaped by the circumstances in which it is elicited and does not constitute a definitive test of validity [47].

Finally, the last step, carried out mainly by GPB, consisted of producing a written report of the study findings. Quotes from the qualitative data were selected to illustrate the themes identified in the data, ensuring that each captured the essence of the theme. The study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines to ensure that the methods and findings were reported in a transparent and rigorous manner [48].

Ethical considerations

The Human Research Ethics Committee (HREC REF 512/2019) of the University of Cape Town approved the study protocol and informed consent procedures. All procedures were performed in accordance with the 1964 Helsinki Declaration and its later amendments. Informed consent was obtained from all individual participants involved in the study. The health facilities of the study consented to the interviews being conducted at their practices.

Theme 1: Foundations of dietary understanding

Health professionals recognised that they are not that well-informed about nutrition and its role in disease prevention. They felt constrained by time, stating that while nutritional advice is important for disease prevention, they struggle to incorporate it into clinical consultation. However, they acknowledged that nutrition plays a crucial role in promoting healthy-diet behaviours and preventing diet-related chronic diseases. There was a general sense of confusion regarding nutrition, as participants described encountering contradictory dietary information from different sources, making it difficult to provide clear guidance to patients. As a result, they tend to use many “catchphrases” and their own statements of beliefs. This is effectively based on what has traditionally been promoted as healthy behaviour: small portions, reducing red meat, eating fruit and vegetables, drinking water, reducing dietary fats, avoiding unsaturated fats (for instance, removing fat and skin from chickens) and practising physical activity.

Nurses and physicians often lacked confidence in their own nutritional knowledge and reported feeling uncertain when discussing dietary concepts. Rather than advising patients themselves, many preferred to refer them to dietitian, especially if they felt that the patient required specific nutritional advice. They cited contradictory information from science, media, and government policies as key sources of confusion. Health professionals highlighted this inconsistency as a challenge for both themselves and their patients, contributing to public uncertainty about nutrition. A few health professionals attributed their lack of confidence in providing nutrition advice to insufficient training in both their formal education and continued professional development. Few participants referenced scientific evidence when justifying dietary recommendations. Therefore, while science was often cited as a source of conflicting information, it was rarely directly referenced by participants. Their confusion appeared to be from inconsistent public health messaging, institutional guidelines, and media influence rather than direct interaction with scientific literature.

Despite not keeping up with new developments in nutrition science, participants agreed that more clinical trials are needed to reassess current dietary guidelines and challenge dietary stigmas, particularly regarding dietary fat and cholesterol levels. Dietary guidance often relied on simplified “catchphrases” (e.g., “balanced diet”, “portion control”, “sustainable diet”) rather than evidence-based specifics. While dietitians emphasized moderation, physicians and nurses were more likely to label foods as “good” or “bad”, focusing on reducing sugar, salt, and processed foods. Notably, healthcare professionals rarely referenced scientific literature directly, attributing confusion to conflicting public health messaging rather than engagement with primary research. These “catchphrases” can be defined as statements that are repeated without any justification or attempt to explain them, as if they were obvious. Another notable pattern in participant responses was the use of absolutes when discussing dietary beliefs, often presenting certain nutritional claims as self-evident truths. Phrases such as “obviously”, “we all know”, and “we have known for years” indicated that health professionals regarded certain dietary messages as unquestionable.

There was also some consistent advice that was tailored to specific conditions. For instance, low salt for hypertension and portion control and exercise for obesity. The professionals agreed indirectly that healthy food improves immunity; therefore, human immunodeficiency virus (HIV) patients should be encouraged to eat healthy foods because their immune system is compromised. In general, the cohort thought that good advice would be to promote physical activity, cut out simple sugar, stop or reduce smoking, lower salt intake, reduce alcohol, not eat spicy food, remove the skin off chicken, remove fat from red meat, and zero sugar sodas instead of regular ones. Although there were differences in how dietitians, physicians, and nurses approached nutrition advice, there was a shared tendency to frame dietary guidance in practical rather than prescriptive terms. While dietitians emphasized moderation and portion control, physicians and nurses were more likely to label specific foods as problematic. Foods considered detrimental to health included those high in sugar and fat, convenience foods, large portions, starchy foods, sugary drinks, processed snacks, fast foods, and overly salty foods. Examples of such foods were described as: instant or convenience food, inexpensive and easy to access, served in large portions, high-starch content, sugary drinks, “chippies and sweeties”, junk food, high-calorie food, salty food, “braai-ed” [cooked on a barbecue] meat and more. Healthy alternatives were described as vegetables, fruits, small portions, oats, three balanced meals a day, healthy snacks (such as apples or whole-wheat crackers), and avoiding processed foods and sauces. Some professionals also recommended low-fat options, choosing chicken over red meat and reducing carbohydrate intake. Some mentioned that they advised their patients to eat food in their natural state, not too overprocessed, in moderation and avoid sauces. In general, the advice on practicing physical activity seems to be non-specific and is used when explaining healthy living behaviours and promoting health.

Theme 2: LCHF controversies and beliefs

Almost all the health professionals had heard of the LCHF diet, though their understanding varied significantly. For those unfamiliar with it, “A low-carbohydrate high-fat diet is a way of eating that restricts the amount of carbohydrates and increases the number of healthy fats that you eat to optimize your health and nutrition”. Some professionals recognised LCHF diets as the Banting or Tim Noakes diet, as they said that these terms have been popularised over the past few years in South Africa, particularly through social media. While some participants correctly described LCHF as a diet promoting whole, unprocessed foods, others had limited knowledge about the specific foods recommended in the diet. When discussing their opinions on LCHF diets, health professionals frequently used vague, generalized statements such as “long-term health” (Female physician) or “not sustainable” (Female dietitian), indicating uncertainty or a lack of critical engagement with the diet. A significant number of participants had personal experience or first-hand knowledge of LCHF diets, with many describing positive outcomes such as needing to eat less, having increased energy levels, and having reduced cravings. However, some stopped following LCHF due to challenges such as a lack of family support or the perception that the diet was expensive. Those who had initially been sceptical of LCHF often noted that it contradicted their formal university nutrition education, particularly regarding the role of fruit, fibre, and starch in the diet.

Public controversy surrounding LCHF further reinforced scepticism among some health professionals, leading them to express concerns and share their reservations with patients considering or already following the diet. Their primary concern focused on the high fat content of LCHF diets and whether the diet was financially sustainable for patients from low-income communities. Many professionals believed that LCHF foods are expensive, making it difficult for patients to maintain a long-term diet. Some were willing to support patients who chose to follow LCHF, but their support was often conditional on closely monitoring patients for potential negative effects. While international consensus guidelines recognize carbohydrate restriction as an effective approach for managing type 2 diabetes, scepticism remains among some health professionals, particularly regarding its long-term sustainability and applicability in under-resourced settings. Some health professionals questioned whether LCHF could effectively treat metabolic disorders, largely due to ongoing controversy surrounding the diet and the lack of full scientific agreement on its long-term effects. Their main concerns included the sustainability of the diet, its affordability, the high intake of meat, the restriction of carbohydrates, and, most notably, its fat content owing to the perceived link between fat intake and cholesterol levels. Some professionals acknowledged that their views on cholesterol and dietary fat might be outdated, attributing this to limited access to updated nutrition science.

Health professionals also expressed concerns about patients’ ability to fully understand and follow LCHF correctly, fearing that misinformation and a lack of nutritional literacy could lead to poor adherence or unintended health risks. Some worried that patients would struggle to transition to a low-carb diet, particularly without professional guidance and ongoing monitoring. When asked whether they would introduce LCHF to treat or prevent metabolic conditions, most stated that they would support patients who chose it but would not actively advocate for the diet due to the concerns outlined above. This cautious stance led many professionals to adopt a “wait-and-see” approach, where they would monitor patients rather than actively encourage the diet.

Some alternative reasons for their reluctance included the belief that LCHF is too restrictive and that vegetables should not be excluded from a healthy diet. Many professionals also believed that patients lacked adequate knowledge about their own health before adopting LCHF, further reducing their willingness to endorse the diet. The two dietitians interviewed highlighted adherence as a key challenge, stating that while LCHF may be effective for some individuals, an individualized dietary approach may be more appropriate. As a result, they did not advocate for LCHF as a universal dietary solution, emphasizing instead that dietary interventions should be tailored to each patient’s needs.

Theme 3: EBSA’s role in community nutrition

Some of the interviewees were familiar with the EBSA program, but the majority were introduced to it for the first time during the interview. Those who were aware of EBSA had patients who had participated in the program. For clarity, the EBSA program was defined to all participants as: “Eat Better South Africa is a nutrition education program for people from under-resourced communities that promotes low-carbohydrate high-fat diet or Banting diet to prevent or treat metabolic conditions. It consists of groups of people that meet every week for an educational session for a period of six weeks”.

Many professionals viewed group support as essential for dietary interventions, stating that changing lifestyle behaviours is easier when done collectively rather than individually. Some participants saw EBSA as a positive initiative for reshaping their dietary mindset and recognised its potential to alleviate pressure on healthcare facilities by reducing the incidence of diet-related chronic diseases. However, concerns about the EBSA program often overlapped with broader concerns about LCHF diets, particularly in terms of sustainability, affordability, and accessibility in low-income communities. Health professionals also emphasized the need for structured nutrition education programs tailored for healthcare workers themselves. Many expressed that they lacked the necessary tools and training to provide effective dietary guidance and stated that a program similar to EBSA, designed for health professionals, would help them better address nutrition-related diseases in their practice. While the majority of participants stated that they would support patients participating in EBSA, they specified the limits of their support, indicating that they would monitor but not necessarily promote the program’s dietary approach.

Despite these reservations, group support was considered the most valuable aspect of the EBSA program. Many professionals agreed that individual behaviour change is difficult and that patients are more likely to succeed when they receive support from their peers. Some participants valued the educational aspect of EBSA, stating that if more at-risk individuals joined similar community-based nutrition programs, the burden of chronic diseases on hospitals could be reduced. Concerns about EBSA primarily mirrored existing concerns about LCHF diets, with professionals questioning whether the diet could be adapted to the financial and food accessibility challenges of under-resourced communities. Some interviewees stressed the importance of tailoring dietary recommendations to local food prices and availability, ensuring that any dietary intervention remains affordable and practical for long-term adherence. Several health professionals also provided suggestions on how EBSA could better address food affordability and sustainability, indicating a willingness to engage with the program if these issues were explicitly considered in its implementation.

Theme 4: Understanding socioeconomic determinants of health

Health professionals broadly acknowledged the challenges that people living in under-resourced communities face, demonstrating awareness of the socioeconomic barriers to healthy living. Many participants referred to specific communities such as Ocean View and Masiphumelele, which are often highlighted in the media for high crime rates, violence, and safety concerns. Some health professionals reside in the same communities as their patients do, providing them with firsthand insight into the rationale behind food choices and the structural challenges that shape dietary behaviours. This theme captures interconnected issues related to food accessibility, affordability, safety, and knowledge. Several health professionals noted that for many individuals, food is not a priority, and that they are in a survival mode. The cost of food was often cited as an issue, emphasizing that healthier foods tend to be more expensive than processed and unhealthy options. Meat was consistently described as expensive, though some also noted that vegetables and other fresh produce were increasingly costly, further complicating efforts to promote healthier dietary choices.

The interviewees cited poverty and lack of resources due to socio-economic circumstances as a challenge to healthy lifestyle choices and changes. According to the information that the participants provided, communities such as Ocean View and Masiphumelele face high levels of unemployment, crime, inadequate housing, and limited access to healthcare and nutrition education. Unemployment appeared to be a major contributing factor to the high level of poverty in these communities. Health professionals also considered limited education a barrier to adopting healthy lifestyle choices, changes, or nutritional interventions. They recognised that nutrition education could have a strong influence on changing unhealthy habits and improving long-term health outcomes. Alcohol abuse was mentioned as a contributing factor to both crime and the reinforcement of unhealthy behaviours, which further complicated adherence to medical and lifestyle recommendations. Compliance with prescribed medication, treatment, and lifestyle advice was identified as a challenge for the patients from the health professionals’ perspective.

Health professionals acknowledged that culture and tradition strongly influence dietary habits and perceptions of health, which are often shaped by family and community norms. Cultural stigmatization around body weight and physical appearance was a recurring theme, particularly regarding women. Some participants noted that being slim was sometimes associated with poverty and malnutrition, whereas larger body sizes were perceived as indicators of wealth and well-being. Gender roles within households were also highlighted, as women were often responsible for preparing meals yet had to navigate traditional expectations that limited their decision-making power regarding food choices, health, and financial autonomy. Another key theme was the diverse cultural backgrounds within these communities, which influenced dietary habits and nutritional choices. Some health professionals discussed how migration from rural to urban areas impacted dietary behaviours. In rural settings, individuals often had access to fresh, homegrown food and engaged in more physical activity. However, upon relocating to urban environments, they tended to maintain a high-carbohydrate diet while adopting more sedentary lifestyles, contributing to diet-related health concerns. The transition from rural to urban living was perceived as a challenge, as individuals often lost access to traditional food sources such as home gardening or farming, increasing their reliance on processed and nutrient-poor foods.

Health professionals noted that despite receiving nutritional advice, many patients do not adhere to dietary recommendations, often due to aversion to unfamiliar foods or deeply ingrained eating habits. They identified a preference for ultra-processed foods, explaining that these foods are not only widely available but also enjoyed for their taste, making compliance with healthier dietary guidance more challenging. Some professionals linked this preference to food addiction and eating disorders, highlighting the difficulty in breaking habitual consumption patterns of processed, high-sugar foods. An important cultural aspect raised by professionals was the link between food and social status in under-resourced communities. People with limited financial resources may prioritize purchasing branded, ultra-processed foods as a way to signal wealth or social belonging, even if those foods are nutritionally poor. Professionals observed that certain food choices were not solely based on affordability but also on perceptions of prestige and aspiration, further complicating efforts to promote healthier eating habits.