With World Diabetes Day on 14 November, we are reminded of the urgent and growing need for action to address the complex web of diabetes and obesity in South Africa.
This year, the International Diabetes Federation’s (IDF) theme “Access to Diabetes Care” sheds light on a troubling reality – effective diabetes care, including medications that could drastically change lives, remains inaccessible to many South Africans.
While innovative treatments for Type 2 diabetes have revolutionised diabetes management globally, the majority of South Africans – particularly those reliant on the public healthcare system – still have no access to these life-saving drugs. Even within the private sector, the cost of newer medications is often prohibitive, because many funders are reluctant to cover these newer options.
Public health crisis
South Africa faces alarmingly high obesity rates – nearly 68% of women and 31% of men are overweight or obese. This crisis is closely tied to the country’s Type 2 diabetes epidemic, fuelled by factors such as urbanisation, dietary changes and reduced physical activity.
Obesity is not only a risk factor for diabetes, but also contributes to heart disease, hypertension and some cancers. The impact is especially severe in low-income and rural areas where awareness campaigns are lacking and people have limited access to healthcare and nutritious foods.
The link between obesity and diabetes creates a damaging cycle: excess weight strains the body’s metabolic regulation, leading to insulin resistance, which can progress to diabetes. Diabetes, in turn, complicates weight management, as certain medications and metabolic changes make weight loss challenging.
With nearly 4.5 million South Africans affected by diabetes, mainly Type 2, this cycle represents a critical public health challenge. Early detection and intervention are essential, yet resources remain scarce in many communities.
In addition to a lack of resources, our healthcare system also faces a significant strain because primary healthcare facilities are overwhelmed by what is known as the “quadruple burden of disease”. This includes infectious diseases like HIV/Aids and tuberculosis, non-communicable diseases such as diabetes and cardiovascular diseases, maternal and child health challenges, and trauma-related injuries often linked to violence and accidents.
The overlap between diabetes and HIV/Aids is becoming an emerging crisis in South Africa. People living with HIV are increasingly experiencing diabetes, as some antiretroviral treatments are associated with weight gain and insulin resistance.
This dual burden puts them at risk for complications from both conditions, compounding the treatment demands on an already overextended healthcare system. Without timely interventions, the intersection of HIV and diabetes could soon result in a devastating public health crisis.
Shortage of endocrinologists
It also does not help that we have a shortage of practising endocrinologists - specialists who treat conditions such as diabetes, thyroid diseases, osteoporosis and adrenal gland disorders.
In many developing countries, the ratio of endocrinologists to patients is significantly higher than in South Africa, where specialised diabetes care remains severely limited. Countries like India and Brazil, for example, have invested heavily in training programmes for endocrinology, producing more specialists each year to meet the growing demands posed by the diabetes epidemic.
With limited training opportunities and funding constraints, the pipeline for new specialists is narrow, creating an expertise gap that places even more pressure on an already overwhelmed primary healthcare system.
This scarcity of endocrinologists underscores the critical need to shift from a reactive, treatment-focused approach to a more proactive, preventative one in diabetes care. Currently, diabetes management often begins only once the patient is symptomatic, typically after complications have already developed.
This reactive approach places an immense strain on resources, as patients require more intensive and costly interventions to manage advanced symptoms and complications. By prioritising early detection, public education and lifestyle interventions, South Africa could move towards a preventative strategy that minimises the long-term impacts of diabetes.
Diabetes education
Another key issue hindering diabetes management in the country is the lack of standardised diabetes education to empower people living with the condition. This leaves many individuals, particularly those in rural or underserved communities, with limited knowledge about diabetes prevention and management and the importance of lifestyle changes.
Patients often rely on overburdened primary-care staff for their education, which means critical information about managing their condition is overlooked.
Structured diabetes education programmes, including resources about self-management training and lifestyle changes, are essential for reducing diabetes-related complications and healthcare costs. However, the lack of such programmes within the public sector perpetuates a cycle of poorly managed diabetes, resulting in frequent hospital admissions and higher overall healthcare costs.
Barriers to care
Aligned with the IDF’s 2024 theme, Access to Diabetes Care, we must confront the barriers that prevent effective diabetes care, particularly for people who are most at risk due to obesity and the rising overlap with other conditions such as HIV/Aids. In South Africa, access to diabetes care is hampered by healthcare inequality, limited awareness and screening, cultural and dietary challenges and insufficient support for lifestyle changes.
Many people lack access to the specialised diabetes care often needed for effective management, especially in rural and underserved urban areas. Public healthcare facilities are frequently stretched beyond their limits, and private healthcare remains unaffordable for many.
Diabetes can progress quietly over years without symptoms, particularly in the early stages. A lack of awareness coupled with limited routine screening means that many people are diagnosed only once complications have set in.
Many South Africans face economic and cultural barriers to accessing healthy food. Traditional foods high in refined carbohydrates and fats contribute to obesity but are often the most affordable and accessible options in poor communities.
While lifestyle changes are crucial for diabetes prevention and management, support structures to sustain these changes are limited. Community-based programmes and workplace initiatives aimed at promoting healthy eating and physical activity remain scarce.
Collaborative action
It is clear that a comprehensive strategy involving collaboration between government, healthcare providers, communities and individuals is required to address obesity and diabetes. We need to:
- Expand access to healthcare and screening: initiatives that bring healthcare services into communities – such as mobile clinics and community health worker programmes – can improve early diagnosis and treatment for diabetes. Screening for both obesity and diabetes should be made routine in all healthcare settings to catch these conditions before complications arise;
- Increase awareness and education: health education should target the critical links between diet, weight and diabetes. Schools, workplaces and community centres could play a pivotal role in spreading this awareness, helping people understand how simple, everyday choices affect their health;
- Promote healthy lifestyle support: encouraging healthy eating and regular exercise through subsidised programmes and workplace health initiatives can help South Africans maintain a healthy weight. Government and private entities could invest in public gyms, walking trails and affordable food markets to make healthier choices more accessible;
- Subsidise medications and treatments: given the lifelong nature of diabetes, making medications and essential healthcare affordable is crucial. Expanded subsidies and partnerships with pharmaceutical companies could reduce the financial burden of diabetes management on individuals and families;
- Tackle food insecurity and nutrition: ensuring access to affordable, nutritious foods is essential in the fight against both obesity and diabetes. Government programmes could support local farming initiatives and incentivise supermarkets to offer fresh produce at affordable prices;
- Invest in research and technology: South Africa must prioritise diabetes research to better understand the unique factors contributing to the epidemic locally. Advances in telemedicine and digital health technologies could also bridge gaps in access to diabetes care, particularly for those in remote areas; and
- Expand access to skilled professionals: to improve diabetes care, South Africa must expand access to endocrinologists and address the ongoing exodus of skilled professionals driven by inadequate remuneration and other factors. Investment in training more endocrinologists and increasing funding for specialised education programmes is essential to meet the country’s growing healthcare needs and move toward more effective, preventative diabetes management.
On World Diabetes Day, let’s reaffirm our commitment to ensuring that every South African has the tools, resources and knowledge needed to combat diabetes and related life-threatening conditions. The country’s diabetes crisis will not be resolved overnight, but through a united commitment to equitable healthcare access and prevention we can make strides towards a healthier future.
Preventing and managing diabetes is a collective responsibility. When we work together to provide equitable access to care, promote healthy lifestyles and create awareness and supportive environments, we can make it possible for all South Africans to live healthier lives. DM
Dr Ankia Coetzee is a senior lecturer and endocrinologist in the Division of Endocrinology in the Faculty of Medicine and Health Sciences at Stellenbosch University.