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

The research team, led by Lucía Camacho-Barcia and Fernando Fernández-Aranda of Bellvitge University Hospital and the Bellvitge Biomedical Research Institute in Barcelona, together with Jordi Salas-Salvadó of Universitat Rovira i Virgili, analysed data from 448 participants enrolled in the PREDIMED-Plus Cognition sub-study. Participants had a mean age of 65.3 years and were randomly assigned to one of two groups. The intensive intervention group received an energy-reduced Mediterranean diet combined with a physical activity programme and behavioural support, while the control group was advised to follow a Mediterranean diet ad libitum, meaning without any deliberate calorie restriction or structured support. The researchers tracked food addiction symptomatology using the Yale Food Addiction Scale 2.0, a validated instrument that applies criteria analogous to those used for substance-related disorders in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, alongside anthropometric measurements, diet and physical activity adherence, and quality of life at baseline and at one and three years.

Food addiction is not a formal diagnosis in current psychiatric classification manuals, but the construct has gained traction among researchers because it captures a cluster of behaviours that many patients with obesity describe: loss of control over eating, continued consumption despite negative consequences, unsuccessful attempts to cut down, and withdrawal-like distress when palatable foods are unavailable. The Yale Food Addiction Scale 2.0 operationalises these symptoms and allows researchers to quantify both the presence of a food addiction phenotype and the severity of symptoms on a continuous scale. Critics have long argued that the label risks medicalising ordinary overeating, while proponents counter that a subset of patients genuinely exhibits an addictive-like relationship with food, particularly with ultra-processed products engineered for high palatability. The new trial is notable because it examines this phenotype not in a laboratory or a specialist eating disorders clinic, but within one of the largest and most rigorous nutrition intervention trials ever conducted.

The results on symptom change were nuanced. Food addiction severity declined in both study arms over the three-year follow-up, which the authors interpret as partly reflecting the natural fluctuation of symptoms and the effects of study participation itself. However, only the intensive intervention group sustained those reductions to the three-year mark, and at that final assessment the intensive group had significantly lower food addiction scores than the control group, a difference that reached statistical significance at p equals 0.011. In other words, simply being advised to eat a Mediterranean diet freely was not enough to produce lasting change in addictive-like eating, whereas a structured, energy-restricted, behaviourally supported programme was. This pattern mirrors what addiction science would predict: sustained change in compulsive behaviours typically requires active, repeated intervention rather than passive advice.

Where the trial becomes particularly striking is in the stratified analysis by baseline food addiction status. Among participants who did not meet criteria for food addiction at the start of the study, the intensive intervention dramatically increased the odds of achieving clinically meaningful outcomes. The likelihood of losing at least eight percent of body weight was nearly tripled, with an odds ratio of 2.87 and a 95 percent confidence interval of 1.99 to 4.14. The odds of achieving at least a five percent reduction in waist circumference, a proxy for visceral adiposity and cardiometabolic risk, were similarly elevated, with an odds ratio of 3.01 and a confidence interval of 2.20 to 4.11. Improvements in adherence to the Mediterranean diet were even more pronounced, with participants without food addiction in the intensive arm showing an odds ratio of 5.82 for meaningful adherence gains, significant at p less than 0.001.

For participants with food addiction at baseline, the picture was considerably less encouraging. The intensive intervention still produced some benefit, and food addiction symptoms did improve, but the magnitude of weight loss, waist circumference reduction, and dietary adherence gains was attenuated compared with their counterparts without the phenotype. The researchers used structural equation modelling, a statistical technique that allows researchers to test hypothesised networks of causal pathways in observational and trial data, to explore how these variables related over the three-year period. The models indicated that improvements in Mediterranean diet adherence mediated, or statistically explained, the long-term improvements in body weight, waist circumference, and quality of life, but only in individuals without food addiction. In the food addiction group, that mediating pathway was absent or substantially weakened, suggesting that the behavioural mechanism through which the diet programme usually works was disrupted.

These findings have immediate implications for how clinicians and researchers think about personalised obesity medicine. If food addiction marks a subgroup of patients who respond less well to standard lifestyle interventions, then screening for it at the outset of treatment could identify who needs additional or different support, perhaps drawing on techniques from addiction treatment such as cognitive behavioural therapy, motivational interviewing, or pharmacological approaches that target craving and reward circuitry. The study’s authors frame food addiction as a clinically relevant behavioural phenotype, and the trial provides the kind of longitudinal, randomised evidence that has been largely missing from a debate often fuelled by cross-sectional studies and self-selected samples. It is one thing to show that people with addictive-like eating differ cross-sectionally from others; it is quite another to show, in a randomised framework over three years, that the phenotype predicts differential adherence and differential benefit from a specific intervention.

The trial also speaks to the ongoing scientific controversy over ultra-processed foods and their role in addictive eating. Although the published report focuses on the intervention effects rather than on specific food categories, the food addiction construct is closely entwined with research on ultra-processed products, which are typically high in refined carbohydrates and fats and are thought to hijack reward pathways in ways that whole foods do not. The Mediterranean diet, rich in olive oil, nuts, legumes, fish, vegetables, and whole grains, represents almost the nutritional opposite of the ultra-processed food environment, and the marked adherence improvements in the intensive group suggest that replacing the food environment, with support, is feasible even in older adults. That feasibility matters, because much of the food addiction literature has been criticised for documenting the problem without testing solutions.

Several limitations deserve attention when weighing the findings. The participants were older adults with metabolic syndrome enrolled in a cardiovascular prevention trial, so generalisation to younger populations or to patients with severe obesity remains untested. Food addiction was measured by self-report questionnaire rather than clinical interview, and the construct itself remains scientifically contested. The structural equation models, while sophisticated, describe statistical associations consistent with mediation rather than proving causal chains. The trial was registered with the International Standard Randomized Controlled Trial Number registry as ISRCTN 89898870 in July 2014, and the analysis was embedded within the broader PREDIMED-Plus Cognition sub-study, meaning the food addiction assessment was added to a trial designed primarily for other endpoints. None of these caveats undermines the central result, but they do bound the conclusions.

What makes the study resonate beyond the specialist literature is its reframing of a familiar clinical frustration. Weight-loss programmes fail for many people, and clinicians have long observed that some patients seem unable to sustain adherence no matter how well-designed the programme. This trial provides prospective, randomised evidence that one measurable psychological phenotype, food addiction, predicts exactly that pattern of attenuated response, while simultaneously showing that the phenotype itself is not fixed: symptoms improved under intensive intervention. The dual message, that food addiction both limits standard treatment response and can itself be treated, points toward a future in which obesity care begins with a brief behavioural assessment and routes patients toward the intensity and type of support their profile requires. For a field searching for ways to move beyond one-size-fits-all dietary advice, that is a genuinely consequential step.

Subject of Research: The effect of an intensive energy-reduced Mediterranean diet lifestyle intervention on food addiction symptoms and weight-loss outcomes in older adults with overweight or obesity and metabolic syndrome

Article Title: Targeting food addiction through an intensive energy-reduced Mediterranean diet lifestyle intervention: evidence from the 3-year PREDIMED-plus trial

Article References: Camacho-Barcia, L., Jimenez-Murcia, S., Granero, R., de la Torre, R., Babio, N., Pintó, X., Corella, D., Gazzoli, S., Frances, F., Riera-Mestre, A., Fitó, M., Cuenca-Royo, A., Gómez-Martínez, C., Gearhardt, A. N., Forcano, L., Salas-Salvadó, J., & Fernández-Aranda, F. (2026). Targeting food addiction through an intensive energy-reduced Mediterranean diet lifestyle intervention: evidence from the 3-year PREDIMED-plus trial. BMC Medicine. https://doi.org/10.1186/s12916-026-05283-z

Image Credits: AI Generated

DOI: 10.1186/s12916-026-05283-z

Keywords: food addiction, Mediterranean diet, PREDIMED-Plus, obesity, weight loss, metabolic syndrome, Yale Food Addiction Scale 2.0, lifestyle intervention, dietary adherence, quality of life, randomized controlled trial, personalised nutrition