Project Description

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Effect of a low-carbohydrate nutrition education program on dietary choices and metabolic health in women from low-income South African communities.

Written by: Candice Spence 27 May 2019 Researcher: Emeritus Professor Tim Noakes, Dr James Smith, Dr Kate Larmuth, Georgina Pujol-Busquet PhD Researcher

Institution: University of Cape Town


Overconsumption of sugar, refined carbohydrates and poor quality oils, increases the risk for developing chronic diseases such as obesity, type 2 diabetes and cardiovascular disease. Families from poor communities are often forced to eat these harmful nutrients due to a lack of nutrition education, or because they cannot afford or don’t know how to access healthy foods. While poverty is an important barrier to health and education for both men and women, in South Africa, it tends to yield a higher burden on women. Eat Better South Africa (EBSA), the community outreach branch of The Noakes Foundation aims to empower people from under-resourced communities to improve their health by making the best dietary choices available to them. EBSA runs nutrition education programs which last around 6 weeks and promotes LCHF diets to prevent or treat metabolic conditions. The recommended diet mostly focuses on the reduction of simple sugars, refined carbs and oils, and processed junk food and encourages consumptions of affordable vegetables, fish, meats, and food that contain healthy fats such as nuts and avocados. Participants also join an online instant messaging group where they can ask questions and share motivation with each other and the EBSA team.


This project aims to:

1) explore women’s perceptions of the EBSA program and explore the barriers and facilitators that they faced to change their dietary habits and adhere to the EBSA recommended diet.optimise the EBSA program for women from poor communities,

2) conduct community assessments in the under-resourced communities that EBSA plans to run a program to better address women’s needs and explore their willingness to participate in a nutrition and health education program, 

3) evaluate the effects of the EBSA program on women’s metabolic health and wellbeing through mixed methods,

4) explore EBSA’s team perceptions of the EBSA program and their experiences.

5) and explore health practitioners’ perceptions of the EBSA program and the health system. This is a multi-method collaborative project that will use qualitative research (one-on-one interviews and focus group discussions) to identify facilitators and barriers that women faced, and quantitative research (diet, food choice behaviour, and metabolic health markers) to assess changes before and after the program. 3) explore health practitioners’ perceptions of the health and nutritional advice recommended by EBSA.

Update on the study: 

The first part of the program consisted of providing information that could be used to improve acceptance, compliance, and sustainability of future EBSA programs for women from under-resourced communities. To do this we conducted focus group discussions (FGDs) with women from previous EBSA interventions. The aim of this was to identify the facilitators (factors favouring) and barriers (challenges) they experienced in attending the sessions, understanding the educational content of the intervention and implementing the dietary advice.

Community assessments were also done to assess modifiable risk behaviours (e.g. diet, smoking, physical activity), and qualitative interviews were conducted in a pilot sample of women from potential sites who had never taken part in the EBSA program to explore their willingness to participate in the EBSA program. The second part of the study consisted of a pilot mixed-method EBSA intervention with women from Ocean View.

A total of 32 participants were recruited for the study in July 2019 and took part in the EBSA program from the end of August to the beginning of October 2019. We gathered data to compare the health status of participants from before and after the Eat Better South Africa program and also follow up data from March 2020. The data was collected through blood tests, body measurements, blood pressure, diet assessment (food frequency and three 24-hours food recall), accelerometers (activity monitors), and several questionnaires such as demographics, household characteristics, medical conditions, chronic diseases’ risk factors, and food insecurity. Moreover, participants completed a feedback form which allowed us to better identify the potential challenges they encountered during the program.

FGDs with participants were conducted after the EBSA program. For the first set of questions, we wanted to explore participant’s experiences in the EBSA program and asked them about the facilitators and challenges they faced. Furthermore, we conducted one-on-one interviews with some key informants to better understand the participant’s experiences and also with the EBSA team members to explore their experiences. The second set of FGDs was to explore the sustainability of the program and women’s circumstances and health after several months and to identify the challenges that women are facing to follow the recommended diet three months after the program ended.

During the FGDs conducted with women who had taken part in the EBSA program between 2015 and 2017, women felt that one of the challenges they faced was that the dietary information they got from health care practitioners (nurses and doctors) from their communities was different to what EBSA recommended. They also felt that some doctors were not supportive of the diet recommended by EBSA, but that they became more encouraging of it after seeing their patients’ health results. Additionally, during the first set of FGDs with women who took part in the pilot intervention, health care practitioners’ opinions were also identified as an important factor that had an impact on women’s experiences. For these reasons, the last part of the study consisted of interviewing health practitioners that work in the communities where EBSA has run/ will run nutrition education programs about their perceptions of the EBSA program, and nutrition and health systems in general. We interviewed 16 participants of those 2 were dietitians, 7 medical doctors, and 7 nurses between January and March 2020. 

This project directly addresses national and international priorities by empowering disadvantaged women with the knowledge to improve diet and health and wellbeing for themselves and their families. This project has already and will keep be publishing data on the diet and health status of these women, the types of foods that are available and affordable to their communities, challenges they face to improve their diet and health, and the effectiveness of a low carbohydrate diet education program to change their diet and improve their health. 


This research has been shared through oral presentations in two international conferences already: the LowCarb conference in San Diego, USA in July 2018, and the Nutrients from the MDPI Journal conference in Barcelona, Spain in September 2019. Moreover, the results were planned to be shared through oral presentations at the World Public Health Nutrition congress in Brisbane, Australia at the end of March beginning of April 2020 and in Singapore in May 2020 but both events were postponed due to the pandemic. 


Pujol-Busquets, G.; Smith, J.; Larmuth, K.; Fàbregues, S.; Bach-Faig, A. Exploring the Perceptions of Women from Under-Resourced South African Communities about Participating in a Low-Carbohydrate High-Fat Nutrition and Health Education Program: A Qualitative Focus Group Study. 

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Updates on the project and its publications will first be shared via ResearchGate here

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