Knowing Isn’t Enough: Why Diabetes Patients in Accra Struggle to Eat Right

One of the most stubborn puzzles in global health is the gap between what patients know and what they actually do. Nowhere is that puzzle more consequential than in type 2 diabetes, where diet sits at the very center of disease control. A new cross-sectional study from Accra, Ghana, published in BMC Public Health, has put hard numbers on this so-called know-do gap, and the findings carry a message that resonates far beyond the clinic walls of the Ghanaian capital: teaching people about nutrition, on its own, is simply not enough to change what ends up on their plates.

The research team, led by Kasim Abdulai of the University of Cape Coast’s Translational Nutrition Research Group, surveyed 392 adults living with type 2 diabetes at the 37 Military Hospital in Accra between May and October 2024. Participants were recruited through systematic random sampling, and the study’s methodology followed the STROBE reporting guidelines for observational research. Nutritional knowledge was measured with the 24-item Diabetes Knowledge Questionnaire, a validated instrument covering the essentials of carbohydrate management, meal timing, and food choices for people living with diabetes. Dietary behavior, in turn, was assessed with the Summary of Diabetes Self-Care Activities scale, a widely used tool that asks patients how many days per week they actually performed specific self-care behaviors, including following their recommended diet.

The headline numbers reveal a striking asymmetry between minds and mouths. Fully 74.4 percent of participants demonstrated what the researchers classified as good knowledge of diabetes nutrition, scoring at or above 70 percent on the knowledge questionnaire. Yet only 68.4 percent achieved good dietary practice, defined as adhering to the recommended diet at least four days per week, a threshold the authors deliberately calibrated to reflect the realities of resource-constrained food environments rather than idealized clinical standards. That yields a population-level knowledge-practice gap of six percentage points. More revealing still is what the team calls the individual-level Failure to Translate rate: among the 292 patients who possessed good knowledge, 64, or 21.9 percent, nonetheless ate poorly. Roughly one in five informed patients could not convert understanding into action.

To understand why, the researchers organized the barriers patients reported using the Socio-Ecological Model, a framework that maps health behavior across nested levels, from individual psychology up through household, community, and structural forces. The results paint a picture of obstruction at every layer. At the broadest level, 84.6 percent of participants said the foods their diets required were simply unavailable in local markets. At the level of taste and culture, 65.9 percent found the prescribed clinical diet unpalatable, a barrier that speaks to a deep mismatch between standard dietary advice and traditional Ghanaian cuisine. Financial constraints affected 60.1 percent of respondents, while within the health system itself, 54.8 percent cited long outpatient waiting times and 50.5 percent reported inconsistent access to dietitians.

The statistical core of the study is a multivariable logistic regression that isolates the independent predictors of good dietary practice while adjusting for confounding factors. Good nutritional knowledge emerged as a genuine asset: patients with strong knowledge had 2.80 times higher odds of adhering to their diet than those without it, with a 95 percent confidence interval of 1.61 to 4.16. But knowledge, the analysis showed, operates within a web of constraints that can neutralize it. Patients whose daily household income fell below 100 Ghanaian cedis, roughly 6.70 US dollars at the time of the study, had only 0.54 times the odds of adherence, a statistically significant reduction with a confidence interval of 0.31 to 0.94. The absence of family support cut the odds nearly in half again, at 0.48, with a confidence interval of 0.26 to 0.89 and a p-value of 0.019.

The model behind these estimates passed a battery of diagnostic tests that lend the findings credibility. The Hosmer-Lemeshow goodness-of-fit test returned a p-value of 0.554, indicating no significant departure between observed and predicted outcomes. The mean variance inflation factor of 1.24 signaled minimal multicollinearity among predictors, meaning each variable contributes distinct information. And the area under the receiver operating characteristic curve reached 0.76, a level of discriminative capacity the authors characterize as strong for a behavioral model. In plain terms, the model distinguishes adherent from non-adherent patients considerably better than chance, and its conclusions rest on solid statistical footing.

What makes this study compelling is not merely its numbers but the story they tell about the anatomy of behavior change. For decades, diabetes education programs in low- and middle-income countries have operated on an implicit assumption borrowed from older health psychology: that information is the primary driver of action. The Accra data dismantle that assumption with unusual precision. Knowledge does matter, nearly tripling the odds of adherence, but its effect is systematically attenuated by forces no individual patient can control. A woman who understands perfectly which carbohydrates spike her glucose cannot follow that advice if the appropriate foods never reach her neighborhood market. A man who can recite the dietary guidelines from memory cannot shop for them on less than seven dollars a day while feeding an entire household.

The family support finding deserves particular attention, because it locates diabetes care where it is actually lived: at the dinner table. In Ghanaian households, as in much of the world, meals are communal affairs, and the person with diabetes rarely controls what is cooked or served. When family members understand and accommodate the dietary regimen, the patient’s odds of adherence nearly double. When they do not, the patient faces a daily negotiation between medical advice and household solidarity, a contest that the statistics suggest the medical advice frequently loses. This reframes dietary adherence not as an individual virtue but as a household achievement, with direct implications for how counseling should be designed and delivered.

The unpalatability barrier is equally instructive and, in some respects, the most fixable. Clinical diets are often designed around generic nutritional targets with little regard for culinary tradition, and the finding that two-thirds of patients found their prescribed diets unappetizing points to a design failure rather than a patient failure. The authors argue for culinarily competent, culturally tailored dietary counseling, an approach that would work with Ghanaian foodways rather than against them, adapting staple dishes and cooking methods to meet glycemic goals while preserving the flavors and textures that make a diet sustainable over years rather than weeks.

The policy implications reach well beyond Accra. The study’s central conclusion, that theoretical knowledge is necessary but insufficient when structural and socioeconomic barriers remain unaddressed, challenges health systems everywhere to shift resources from generic patient education toward targeted nutritional safety nets. That could mean subsidizing diabetes-appropriate foods, strengthening supply chains so recommended items actually appear in local markets, and integrating dietitians more reliably into outpatient care to reduce the waiting times and inconsistent access patients reported. As type 2 diabetes continues its relentless expansion across Africa and other rapidly urbanizing regions, the Accra findings offer both a warning and a roadmap: the battle against diabetes will not be won in lecture halls, but in markets, kitchens, and household budgets, where knowledge finally meets the means to use it.

Subject of Research: Multi-level barriers to dietary adherence among adults with type 2 diabetes in Accra, Ghana

Article Title: Bridging the know-do gap in diabetes care: multi-level barriers to dietary adherence among adults with type 2 diabetes in Accra, Ghana—a cross-sectional study

Article References: Abdulai, K., Addae-Mensah, I., Aidoo, A. K., Kafui, E. A., Seidu, A. M., Jibril, A. T., & Adane, F. (2026). Bridging the know-do gap in diabetes care: multi-level barriers to dietary adherence among adults with type 2 diabetes in Accra, Ghana—a cross-sectional study. BMC Public Health. https://doi.org/10.1186/s12889-026-29500-9

Image Credits: AI Generated

DOI: 10.1186/s12889-026-29500-9

Keywords: type 2 diabetes, dietary adherence, knowledge-practice gap, Ghana, nutrition, Socio-Ecological Model, food insecurity, family support, public health, diabetes education, Accra, cross-sectional study