A total of 38 subjects participated in five FGDs. The mean age of the participants was 59.9 years ranging between 39 to 76 years and the time since diagnosis of diabetes ranged from 0 to 25 years. The characteristics of the participants are summarised in Table 1.

Table 1 Characteristics of the study participants

Five main themes and several sub-themes were identified and are summarised in Table 2.

Table 2 Themes and sub-themes identified during codingDiet in diabetes and the composition of the meal

Everyone mentioned that diet is an important component in managing diabetes. Further, the majority believed that the diet in diabetes differs from that of a person without diabetes.

Yes, of course, the diet is very important in controlling blood sugar (Group 1, 62-year-old, female)

We should have control over what we eat. We have to eat differently compared to a person without diabetes (Group 2, 44-year-old, female)

Overall, most of the participants believed that they should eat less starch and more vegetables. The plate method was familiar to some of the participants. However, there was a disagreement about the proportions of individual food components. Some mentioned ¼ of the plate should contain rice (the main staple in Sri Lanka), while others said 1/3.

Rice should fill ¼ of the plate, ¾ should be the vegetables and fish/meat. If you want to eat boiled jackfruit or breadfruit, you can have it instead of rice. Even if you prepare a curry with those, you have to reduce your rice portion if you want to have them on your plate (Group 1, 57-year-old, female).

But, as far as I know, 1/3 of the plate should contain rice (Group 1, 39-year-old, female)

Individual components in the dietCarbohydrate-rich foods

Most participants used the term ‘sugar’ instead of ‘starch’ or ‘carbohydrate’ when referring to carbohydrate-rich foods.

I do eat red lentils daily; does it contain sugar? I have heard that it does not (Group 1, 62-year-old, female)

I always go for red rice. I don’t eat other rice varieties; red rice has less sugar (Group 2, 58-year-old, male)

Rice which is considered the staple food in Sri Lanka seems to be the most consumed carbohydrate source in the diet. Wheat flour, kurakkan flour (finger millet), yams, jack fruit, and breadfruit were the other carbohydrate-rich staples consumed.

Rice

Participants held different views on different rice varieties. Many believed that red rice, nadu rice (a variety of medium grain rice in Sri Lanka), parboiled rice, and basmati rice are better for PLWD and believed to have less ‘sugar’. In contrast, few believed that there is no difference among rice varieties as long as they consume controlled portions.

I always go for red rice. I don’t eat other rice varieties; Red rice has less sugar (Group 2, 58-year-old, male)

Nadu is the best among rice varieties. If you can afford it, basmati is also good (Group 5, 48-year-old, male)

Flour varieties

Many had a negative impression of wheat flour-based products. Some believe that rice is better than wheat flour-based products.

Bread is not good, you have to eat rice (Group 2, 44-year-old, female)

I stopped almost all the sweet and wheat flour products after being diagnosed with diabetes (Group 1, 57-year-old, female)

Further, commonly available bread in Sri Lanka is made of refined wheat flour (white bread). Whole wheat flour was not much discussed. Two of the participants (Group 3, 60-year-old, female; Group 1, 39-year-old, female) mentioned that whole wheat products are healthier than refined wheat flour.

Kurakkan (finger millet) flour was popular, and some considered finger millet flour-based food can bring down the blood sugar level. However, a 39-year-old female participant in group 1 mentioned that they should focus on portion size even for finger millet flour. Further, she mentioned that finger millet flour is healthier than refined wheat flour.

Kurakkan controls blood sugar, we can eat kurakkan pittu (flour mixed with coconut scrapings cooked by steaming), roti (unleavened flat bread made with flour and coconut scrapings cooked on the hob), and thalapa (flour mixed with water and made into balls) (Group 2, 44-year-old, female)

It is not good to eat a large amount of even whole wheat flour or millet flour, but they are better than wheat flour (Group 1, 39-year-old, female)

Yams

Yams were discussed as a staple. A 76-year-old female participant from group 4 mentioned that she was advised to avoid yams in the diet. Similarly, a female aged 60 years in group 3 mentioned that manioc and sweet potatoes are not good. In contrast, a 69-year-old female from the same group said that yams are good, and she consumes a plate of sweet potato for her breakfast. As for legumes, participants held different views on different varieties of yams.

Underground yams such as Manioc and sweet potatoes are not good (Group 3, 60-year-old, female)

The yams like manioc and kiri ala (Taro (Colocasia esculenta) root), which are grown under the ground are good, but potatoes are not good (Group 1, 57-year-old, female)

I eat manioc frequently ……I have heard that it does not contain sugar (Group 1, 62-year-old, female)

Legumes

Participants had different views on different legumes. A few of them mentioned that some legumes contain ‘sugar’ while some do not.

Cowpeas and chickpeas do not contain sugar, but mung bean has (Group 1, 63-year-old, male)

I do eat red lentils daily; does it contain sugar? I have heard that it does not (Group 1, 62-year-old, female)

Red lentils contain some sugar, it has protein as well, but less protein compared to fish and meat. It has more sugar compared to protein. (Group 1, 39-year-old, female)

Vegetables

Almost everyone mentioned that vegetables are good, and they should consume more vegetables in their diet.

We should eat more vegetables and less rice (Group 2, 44-year-old, female)

Participants had different views on different vegetables. Some had negative impressions of carrots, beets and pumpkins. They mentioned that these vegetables contain sugar and increase their blood sugar level.

I try to avoid things like beetroot (Group 1, 63-year-old, male)

Beets contain more sugar than rice. I have completely removed them from my diet (Group 1, 57-year, female)

Carrots, beets and pumpkins are not good. I don’t know why they are including carrots in the hospital diet, I only eat them very rarely (Group 2, 37-year-old, female)

Further, some believed that bitter vegetables could bring down their blood sugar. The bitter gourd was the most discussed among bitter vegetables.

I do eat bitter gourd as people say that it is good for diabetes (Group 1,67-year-old, female)

Yes, me too, though I don’t like it (Group 1, 57-year-old, female)

Some participants did not have a clear idea of vegetables and considered yams and legumes as vegetables when these were prepared as curries.

I think manioc curry can be counted as a vegetable. Similarly dhal, potato and sweet potatoes too (Group 2, 74-year-old, female)

Fruits

Fruits were consumed at the main meal or as snacks. Some believe that fruits facilitate the digestion of food when consumed just after the main meal. A 39-year-old female from group 1 mentioned that consuming fruits at snack time helps her control portion sizes at the next main meal.

I eat them as desserts to facilitate the digestion of the main meal. I do eat one or two bananas after the main meal (Group 5, 58-year-old, male)

I believe that it is better to eat fruits in between main meals. So, I can reduce the quantity of food consumed at the next main meal (Group 1, 39-year-old, female).

The most discussed fruit was the banana. Participants believed that different banana varieties affect their glycaemic control variably. Many believe that sour bananas are good, and that other varieties especially silk banana (Kolikuttu) and Sugar bananas (Seeni) banana are not good for people with diabetes.

I was told not to eat ‘Kolikuttu’ (Group 4, 76-year-old, female)

I am scared to eat ‘Seeni’ banana as it has more sugar (Group 1, 57-year-old, female; Group1, 62-year-old, female)

Sweets

Some participants think that sweets should be completely avoided while others believe they can consume a small amount.

I eat everything, but in small quantities (Group 1, 73-year-old, female)

Few of them mentioned that they should avoid white sugar and can instead have brown sugar. However, some disagreed with this. Similarly, few believed that pure jaggery was good and some were against it.

White sugar is not good, but it is okay to have brown sugar (Group 3, 66-year-old, female)

I believe that there is no difference between these two (Group 1, 73-year-old, female)

I think pure jaggery is okay for us (Group 2, 65-year-old, female)

There is no difference between jaggary and sugar (Group 4, 61-year-old, female)

Utilisation of food labels

Some of the participants mentioned that they refer to the label. The colour code seems to be the main piece of information referred to on the label. Except for a 39-year-old female participant from group 1, none mentioned that they read the nutrition information table. Small prints seem to be limiting the utilisation of the nutrition fact tables.

Yes, I do read the table, especially when I am going for a new product (Group 1, 39-year-old, female)

I always look at the colour code. But not the table, as I cannot read small prints (Group 4, 61-year-old, female)

In contrast, few mentioned they never read the food labels. One of the participants mentioned that she could feel what was there in the food, so she did not refer to the label. Few did not read the labels as they doubted the credibility of the information given.

I don’t look at the label. If I eat some food containing sugar, I can feel it. I feel a sour taste. I have lived with diabetes for years. I can feel what is there in the food. So, why should I look at the label? (Group 4, 70-year-old, male)

Actually, I don’t believe them. So, I don’t look at the label (Group 1, 73-year-old, female)

Though the colour code says green for sugar for some foods, they taste sweet. I don’t think they have reduced sugar though they mention in the label (Group 2, 37-year-old, female)

Factors affecting the practice

Some mentioned how external factors change their practices irrespective of knowledge. Influence from the family members, financial situation and availability of certain foods in home gardens were some determining factors.

Influence of family members

A sixty-three-year-old male mentioned that his wife decides what he should eat. Further, he mentioned that he sometimes gets annoyed by this behaviour.

My wife advises me on what to eat. Sometimes if I serve myself something which she thinks is bad for diabetes, she takes it back. I know that food will not cause any issue; basically, my wife decides what I should eat. (Group 3, 63-year-old, male)

Financial situation

The financial crisis in the country had influenced the majority’s diet. Many mentioned that they find it difficult to afford vegetables, legumes and fruits.

It is difficult to change the diet due to financial issues (Group 5, 58-year-old, male)

It is very difficult to afford for recommended quantity of vegetables (Group 1, 63-year-old, male)

Though the legumes are good we cannot afford them (Group 1, 63-year-old, male)

I know that we should eat more vegetables and less rice. But we are unable to eat like that. We can afford only a small quantity of vegetables, that also for the whole family (Group 2, 44-year-old, female)

I cannot eat vegetables and fruits as recommended. I haven’t eaten some fruit for 3-4 months (Group 5, 53-year-old, female)

One of the participants mentioned a good solution for the vegetables and the majority in that group agreed to her idea.

I agree with you all. But I have found a solution to that. We can have a large portion of green leaves instead of expensive vegetables. There is a variety of green leaves in Sri Lanka, and they are not expensive as well (Group 1, 39-year-old, female)

Availability in home garden

Some participants mentioned that the yams, jackfruit, breadfruit and bananas are grown in their home gardens. Large portions of jackfruit, breadfruit, and yams are consumed with a condiment or coconut scraping and without any vegetable or protein-rich food for the main meals. This seems to be helping their economy.

We have manioc and breadfruit in our home garden. We boil them and eat them with lunumiris (a condiment made with onions and red chilli) and coconut scrapings in the mornings. ……….. Yes, it is because we have it in our garden…. Of course, it helps with my economy as well (Group 1, 63-year-old, male)

Sometimes, if we have jackfruit in the home garden, we eat boiled jackfruit with coconut scrapings for lunch (Group 1, 63-year-old, male)

Fruits are also grown in the home garden and large portions are consumed. A fifty-seven-year-old female participant from group 1 mentioned she eats a lot of bananas as she does not want to throw them away.

I eat lots of bananas if available. When I have bananas at home, I eat even 20-25 per day (Group 1, 63-year-old, male)

When available, I eat a large amount of fruit. I don’t want to throw them away. I don’t consider timing. Before meals, after meals, whatever the time…. But my sugar level is also good (Group 1, 57-year-old, female)

Sources of information

Some of the participants had received advice on diet at the healthcare facilities. A seventy-three-year-old female from group 1 said that she listened to a health talk by a nurse while waiting for the clinic and found it useful. One had received dietary advice when she was admitted to the hospital. A 63-year-old male participant who had been diagnosed with diabetes for 7–8 years, mentioned that he did not receive proper guidance on diet even though he asked the doctor.

When I was admitted to the ward, a nurse taught me about diet (Group 1, 57-year-old, female)

I haven’t had an opportunity like this. The doctor just says, ‘do not eat sugar-containing food much’. That’s all. I have been on treatment for diabetes for 7-8 years (Group 3, 63-year-old, male)

Relatives, friends, neighbours, YouTube, Facebook and magazines were the other sources of dietary information used by the participants. Further, some mentioned that the information and advice appearing on social media do not apply to everyone.

I got some advice from my brothers and neighbours (Group 5, 48-year-old, male)

When I want to know something, I check YouTube (Group 1, 39-year-old, female)

I do not believe things on Facebook. Everything does not match everyone. (Group 3, 64-year-old, male)