Dear Mama
Ndlunkulu, Mabhedla eseNdlovane, I write with a heavy heart to you, Mummy, Ntombikayise Rostar MaMlambo Mncube.
I do not know how you would respond, since you left us on 4 January 2021.
These four years have been marked by sorrow, pain and anguish.
I know Covid-19 claimed your life, but your underlying illness, type 2 diabetes, ultimately signed your death certificate.
Hardly a year later, my brother succumbed to the same enemy, leaving behind five children.
It did not help that both of you were admitted to Nkonjeni Hospital, a government facility in Ulundi, northern KwaZulu-Natal, long regarded by locals and health professionals as a “death trap”.
Diabetes is not a passing ailment. It is a serious, chronic disease that develops when blood sugar stays too high for too long, usually because the body does not either make enough insulin or cannot use it effectively.
Insulin moves sugar from food into the body’s cells for energy, the key that opens the “fuel tanks”.
When the key is missing or faulty, sugar builds up in the blood and, over time, damages the body.
This slow, silent build-up leads to complications. When symptoms appear, much of the harm is difficult to reverse.
When Diabetes Knocked on My Door
I was fortunate to be diagnosed early, almost by chance.
Twelve years ago, while working for the KwaZulu-Natal Department of Education, I attended a government event with mobile health screening.
A routine finger-prick worried the nurses.
They urged a glucose tolerance test.
A week later, at St Augustine’s Hospital in Durban, type 2 diabetes was confirmed.
My heart sank. I had no symptoms, which is why the disease so often goes unnoticed.
Although I had no symptoms, I informed my mother casually that I now had “sugar”, a colloquial term for type 2 diabetes.
We laughed about it.
It didn’t occur to me to ask her to test. But within two years, she too tested positive for the disease.
It was only when my middle brother received his diagnosis that I began to realise we might share a hereditary or genetic predisposition.
None of us carried excess weight, and our diets were mainly plant-based, with little to no refined meat or harmful carbohydrates.
As research increasingly shows, type 2 diabetes tends to run in families: genetic susceptibility contributes significantly.
However, modifiable risk factors are crucial and often determine whether someone with that susceptibility actually develops the disease.
Diabetes Complications
According to the World Health Organization (WHO), the most common complications include eye, kidney and nerve damage.
In South Africa, diabetes is already the leading cause of blindness, kidney failure and amputations.
Poor circulation and nerve damage mean even a small cut on the foot can become life-threatening.
The disease also raises the risk of heart attacks and strokes; people with type 2 diabetes are up to four times more likely to develop cardiovascular disease than those without it.
Other problems include slow wound healing, repeated skin and gum infections, sexual and reproductive health issues, and, later in life, hearing loss or dementia.
Four years on, I see more clearly that my late brother, Enoch Bonginhlanhla, you, and I faced the same illness together, bound by circumstance but without the knowledge or the right medicines, relying on willpower, prayer and hope.
This is not abstract. In May, my high school friend, S’busiso Khanyile, died at 50, after type 2 diabetes had already taken his sight. He had married his sweetheart only months earlier.
The broader picture is alarming.
The National Department of Health’s 2023/24 Annual Report, based on Statistics South Africa, reveals a staggering 58.7% surge in deaths from non-communicable diseases (NCDs) between 2002 and 2022.
Type 2 diabetes has now surpassed tuberculosis as the leading cause of death in the country.
This is not a distant threat, but a pressing crisis that demands immediate attention and action.
Globally, a 2023 Lancet analysis projects 1.31 billion people living with diabetes by 2050, most with type 2.
At the European Association for the Study of Diabetes’ 61st Annual Meeting in Vienna last month, experts confirmed diabetes is now among the world’s top ten causes of disability and death.
Without urgent action, the burden will rise sharply.
Personal Mission
For this reason, I have made it my personal mission to understand the disease more deeply, a commitment that led to my virtual attendance at the 61st EASD 2025, which serves as both the inspiration and motif for this article.
I was invited to attend the American Diabetes Association (ADA) 85th Scientific Sessions in June 2025, held in Chicago, Illinois.
Still, I could not go as I had not secured the much-sought-after US visa.
There are glimmers of progress.
The same week as the conference, my 90-day blood results arrived, and they told a story of quiet recovery.
My HbA1c, which reflects average blood glucose levels over the past three months, fell to 8.0% from 8.9%.
For most adults with diabetes, the target range is between 4% and 6.5%, according to the World Health Organization (WHO) and Diabetes UK.
Earlier this year, a bout of pneumonia and subsequent steroid treatment pushed my glucose levels dangerously high, forcing doctors to introduce insulin therapy.
But there’s been a turnaround.
My fasting glucose, the measure of blood sugar after an overnight fast, has improved from 11.2 mmol/L to 7.0 mmol/L.
Even small lifestyle changes are showing results.
Cutting back on alcohol has benefited my liver: my Gamma-GT, a key enzyme that signals liver stress, dropped significantly.
Sadly, for my late relatives, this level of medical care was never within reach.
They were enrolled in a government-approved chronic medication programme and collected their monthly prescriptions.
At best, they received an occasional finger-prick glucose test, a basic measure that offers little insight into long-term blood sugar control.
Without consistent monitoring tools such as HbA1c testing, dietary guidance, or comprehensive follow-up, effective diabetes management was impossible.
Early Prevention
There is hope. Jaakko Tuomilehto, Professor of Public Health at the University of Helsinki, spoke at the EASD and shared new analyses from the landmark Finnish Diabetes Prevention Study.
His findings show that early and intensive lifestyle changes during prediabetes, structured diet and exercise programmes can halve the risk of developing type 2 diabetes, cut cardiovascular complications, and extend life expectancy.
The message is clear: acting early can stop diabetes in its tracks.
Unfortunately, none of my late relatives had the opportunity to address their condition at the prediabetes stage.
By the time they were diagnosed, like me, the disease had already taken hold.
What has since improved my own condition before the Covid-19 complications and, more recently, pneumonia has been a combination of strict medication adherence, regular testing, and a plant-based diet.
I avoid sugar, fizzy drinks, refined foods, and red meat altogether.
My protein sources are mainly chicken and fish, which provide the nutritional balance I need without spiking my blood sugar levels.
Obesity and its impact on diabetes outcomes
At the 61st EASD Annual Meeting in 2025, experts highlighted obesity as the single most significant factor worsening type 2 diabetes.
The World Health Organization (WHO) now recognises obesity as a disease in its own right, linked to more than 230 other health problems, including diabetes, cardiovascular disease, and several cancers (WHO, 2024).
Recent global data from the NCD Risk Factor Collaboration, published in The Lancet (2024), reveal that adult obesity has doubled since 1990, while childhood obesity has quadrupled, a trend driven by ultra-processed diets, sedentary lifestyles, and urbanisation.
In South Africa, the WHO reports that more than half of adults and nearly two-thirds of women are overweight or obese, placing the country among the most affected globally.
Excess body fat, particularly around the abdomen, interferes with insulin sensitivity, a biological process known as insulin resistance, which accelerates complications and reduces the chances of remission.
Professor Mikael Rydén of the Karolinska Institutet in Sweden explained that “obesity is not simply an additional problem alongside diabetes; it is one of the main forces driving the illness forward.”
His message resonated with me personally: my late mother also battled hypertension and excess weight.
Professor Rydén’s point was clear: treating diabetes properly also means tackling obesity.
There are signs of medical progress. In 2024, the South African Health Products Regulatory Authority (SAHPRA) approved Wegovy (semaglutide) for chronic weight management in adults with obesity or overweight and at least one weight-related condition.
Access vs Cost
However, costs are prohibitive.
According to Medical Brief (2025), the monthly cost of Wegovy in South Africa is approximately R3,700 for the highest available dose of 2.4 mg, based on local pharmacy pricing reports.
In the United States, the list price published by Novo Nordisk is approximately US$ 1,349 (R25 000) for a 28-day supply.
However, some discount and assistance programmes can reduce this to about US$ 499 per month for eligible patients, as Healthline confirms here.
For context, my whole consignment of diabetes medication (empagliflozin, gliclazide, sitagliptin and insulin) is covered by medical aid, and some are on prescribed minimum benefits.
Yet in South Africa, while obesity is now recognised as a chronic disease, this policy recognition does not always translate into comprehensive coverage or benefit design change.
For instance, the mandatory coverage list for medical schemes — the Medical Schemes Act 131 of 1998’s Prescribed Minimum Benefits (PMBs) under the governance of the Council for Medical Schemes (CMS) — does not explicitly include obesity or overweight management as a PMB condition.
One recent commentary on the Medical Aid website noted: “Obesity is not listed as a chronic PMB condition, and it’s not included under any of the 271 medical emergencies or 26 chronic diseases.”
This omission creates a policy blind spot: if obesity care is not recognised in this essential coverage structure, access remains dependent on medical-scheme discretion and private means, reinforcing inequality.
Trends in diabetes complications and multimorbidity
Diabetes care has improved over the years, but not everyone benefits equally.
Professor Naveed Sattar from the University of Glasgow told one of the sessions that research shows people with type 2 diabetes are “at increased risk of death from several other diseases, including cancer and infection.”
Diabetes is already known to approximately double the risk of heart attacks and strokes, compounding the overall burden of illness, he insisted.
The number of people living with this mix of conditions is rising fast.
New medicines such as semaglutide, a GLP-1-based therapy, have helped reduce some complications, but overall, the illness burden is increasing, especially in poorer communities and in parts of the world with weaker health systems, such as South Africa.
In plain terms, the once-weekly injectable and oral semaglutide, GLP-1 medicines act like the body’s own gut hormone, helping people with diabetes by lowering blood sugar, curbing hunger and cravings, supporting weight loss, and even reducing the risk of heart problems.
At the EASD session “Fostering the next generation: What is the role of GLP-1 based therapies?”, Professor Silvio Inzucchi from Yale University and colleagues shared promising results for people with type 2 diabetes.
Their research, published in The New England Journal of Medicine in 2025, showed that an oral form of semaglutide, a GLP-1 medicine made by Novo Nordisk, reduced the risk of serious heart problems by about 14% in high-risk patients compared with a placebo.
This adds to growing evidence that GLP-1 drugs can help control blood sugar, support weight loss, and protect the heart.
As Professor Inzucchi and colleagues stressed, GLP-1 therapies mark a generational shift, from focusing solely on glucose control to delivering comprehensive cardiometabolic protection.
Diet and Exercise: When, How and What Matters
Dr D. Yu from Beijing Hospital shared new evidence that diet can be as powerful as medicine in the early stages of type 2 diabetes.
In a 16-week study, adults who followed a 5:2 intermittent fasting plan, eating normally for five days and using meal replacements on two days, lost weight and reduced harmful belly fat.
Understanding the role of belly fat, or visceral fat, is key to grasping why obesity so powerfully worsens type 2 diabetes.
Unlike the fat under the skin, visceral fat surrounds vital organs such as the liver, pancreas and intestines.
This type of fat behaves like an active endocrine organ, releasing a cocktail of hormones and inflammatory chemicals that disrupt the body’s metabolism.
The group also showed better blood sugar control, similar to improvements seen with common diabetes drugs such as metformin or empagliflozin.
I am allergic to the former, but take the latter.
At the same session, Professor Patrick Schrauwen from the German Diabetes Centre shared research showing that the time of day you exercise can make a difference.
A 2019 study in men with type 2 diabetes found that doing high-intensity workouts in the afternoon lowered blood sugar over 24 hours more than doing the same exercises in the morning.
In another 12-week study, adults with metabolic problems saw bigger improvements in insulin sensitivity, fasting glucose, body fat and fitness when they trained later in the day.
For my part, I have struggled to keep up regular gym routines, so I am focusing on a sensible diet, plenty of vegetables, fruits, fibre and protein, with limited whole-grain carbohydrates such as brown rice or seeded wholewheat brown bread, while I rethink a realistic activity plan.
For people with diabetes, say no to sugary drinks, refined carbs, fried foods and processed meats, which can dangerously spike blood sugar, worsen type 2 diabetes, and increase the risk of blindness, kidney failure, heart disease and amputations.
What Does the Future Hold?
Reviewing medical data, EASD presentations, and official statements makes it clear that, with political will, rapid adoption of non-pharmacological strategies such as diet and exercise, and timely use of treatments such as GLP-1-based therapy, health systems can significantly improve type 2 diabetes outcomes.
If this knowledge and these therapies had been available sooner, the clinical outcome for my brother and mother would have been different. These therapies offer more than hope; they deliver measurable, peer-reviewed gains.
Last year, I tried the so-called wonder drug Ozempic for two months. Still, after losing my cushy government job, I had to abandon it before any meaningful medical benefit could be realised because of its prohibitive cost.
I paid more than R2 000 for each pen, or about US $115.63. Ozempic is a medicine that helps people with type 2 diabetes control their blood sugar. It makes the body release more insulin after meals, slows digestion, and makes you feel full. This lowers blood sugar and supports weight loss, further protecting the heart and kidneys.
Closing the gap between science and access is now the urgent task. Advocacy groups, the media, health workers, researchers, and policymakers are vital to bridging information gaps and pushing for multidisciplinary care for underserved communities.
Sugar Rush
Researchers point to several key drivers behind the surge in type 2 diabetes, painting a complex picture of modern life colliding with biology.
The first is undiagnosed prediabetes, a silent condition in which blood glucose levels are higher than normal but not yet in the diabetic range.
Left unchecked, it often progresses unnoticed until serious complications appear.
A Diabetes Care (2023) study estimates that nearly half of all adults with prediabetes are unaware of their condition, missing the critical window where lifestyle interventions can still reverse the trajectory.
The second driver is the global rise in obesity, described by the NCD Risk Factor Collaboration in The Lancet (2024) as one of the defining public-health crises of our time.
Excess body fat, particularly around the abdomen, interferes with the body’s ability to use insulin effectively, a process known as insulin resistance, the biological hallmark of type 2 diabetes.
Urbanisation, ultra-processed diets, and increasingly sedentary lifestyles have accelerated this trend, even in low- and middle-income countries once thought immune.
Team-Based Care
Finally, persistent gaps remain in coordinated, team-based care, as highlighted in the 2022 Consensus Report on the Management of Hyperglycaemia in Type 2 Diabetes, jointly issued by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD).
The report calls for a more holistic approach, bringing together doctors, nurses, dietitians, psychologists, and social workers to manage the disease’s physical and emotional toll. Yet, in much of the developing world, this level of integrated care remains a distant aspiration.
What emerges from Vienna is a unified message: we cannot wait. Prevention through lifestyle change must begin early; obesity must be treated as a central driver, not a side condition; multimorbidity must be addressed head-on; and innovation from GLP-1 therapies to continuous monitoring must be made accessible to those who need it most.
Without political will and equitable access, the science risks becoming another privilege, rather than the lifeline it promises to be.
Dear Mummy and my brother, with better access to treatment, timely intervention, and a commitment to living wisely, I may yet reach my sixtieth birthday and continue to be the father figure your grandchildren still need.
*Bhekisisa Mncube is an author and columnist who won the national 2024 Standard Bank Sikuvile Journalism Award for columns/editorials and the same category at the regional 2020 Vodacom Journalist of the Year Awards.
The post Diabetes At A Crossroads: Science Versus Access appeared first on The Bulrushes.
