Diabetes is now the leading cause of death in South Africa. Not HIV. Not tuberculosis. Not gun violence. Diabetes. And behind it, sitting in second place, is hypertension. Two conditions that are, in large part, driven by what we eat.
According to Stats SA’s most recent mortality data, non-communicable diseases now account for a growing share of deaths recorded between 2002 and 2023. This a trend line that climbs as communicable diseases have, in many respects, been brought under greater control.
The nutrition crisis has moved in to fill the gap, and we are largely treating it as someone else’s problem.
But in essence, it isn’t.
The epidemic hiding in plain sight
Nearly 30% of South Africans screened in a recent hypertension study had high blood pressure. Yet, 76% of those under 40 with the condition had no idea.
Among people already diagnosed with diabetes, only 14% achieve adequate blood sugar control, according to a recent South African Journal of Endocrinology study. These statistics point to people in your office, your family, your community. They are sick in ways that haven’t yet announced themselves.
Dr Adil Razack, who works within South Africa’s public health system, describes the reality clinicians face daily. “The biggest challenge is that as our communities grew over the last decade, our staffing complement remained the same or grew by very little. We are always time-challenged and only focusing on the major presenting problems, with little time to do additional screening. The community seems unaware of the need to screen or test unless they develop symptoms.”
By the time symptoms appear, the cost of getting it wrong has already been accumulating.
What wrong looks like, and what it costs
Chronic metabolic disease places a compounding financial burden on households that most people don’t calculate until it’s too late. “Direct expenses include physician visits, prescription medications, laboratory tests, imaging, hospitalisations, specialist care and medical equipment, all of which can continue for years or even decades,” says Maria Emmerich, wellness expert and best-selling author. “Indirect costs are often even greater and include missed work, reduced productivity, lower earning potential, disability, caregiver responsibilities and the need for home modifications.”
The hidden cost, she argues, may be the most insidious: “Perhaps the greatest financial burden is that chronic metabolic diseases are frequently managed rather than resolved, requiring ongoing treatment without addressing the underlying cause.
This is a system designed around reaction. And the food environment feeding that system is doing us no favours.
A research study published by the National Library of Medicine evaluating dietary quality among low-income South Africans found that, on average, 40% of the diet consisted of ultra-processed foods. Among 18-to-29-year-olds, that figure reached 40.2% of daily energy intake.
A separate study in the Western Cape found that 80% of foods in supermarkets were ultra-processed. This isn’t individual failure. It is a structural problem being mistaken for one.
The workplace is already paying the price
The cost of poor metabolic health shows up at work, often invisibly. Research reviewed by Karen Heath, Senior Researcher at The Noakes Foundation, shows that employees with poorer health are more likely to experience reduced work ability, lower productivity and presenteeism, and being physically present but performing below capacity.
“Poor metabolic health is a current workforce performance issue,” argues Heath. “The physiological mechanisms are well established: impaired glucose regulation contributes to fatigue; insulin resistance clouds concentration; chronic inflammation slows recovery. Long before a formal diagnosis, a person’s earning potential, focus and physical capacity may already be in decline”
A food system that wasn’t built for your health
Rita Venter, who has spent more than a decade working with a nutritional community of close to 2.5 million South Africans through her recipe book, Banting 7-Day Meal Plans, is frank about where individual responsibility ends and structural reality begins.
“People are living in environments where the cheapest, most heavily marketed foods are often the least nutritious,” she says. “Many are working long hours, travelling long distances and feeding families on very limited budgets. Instead of asking “Why aren’t people eating better?”, we should be asking “How can we make healthier choices easier, more affordable and more accessible?”
Venter also pushes back on the myth that better nutrition is necessarily expensive. “Improving metabolic health doesn’t require expensive ‘health foods’. Eggs, canned fish, chicken, seasonal vegetables, cabbage, frozen vegetables and organ meats can provide excellent nutrition without breaking the bank. One of the biggest misconceptions is that healthy eating has to be expensive.”
Emmerich echoes this: “In many cases, investing in healthier habits today is far less expensive than paying for years of medications, medical appointments and chronic disease management tomorrow.”
The guidelines problem
There is also a more uncomfortable conversation to be had. One about whether the nutrition advice flowing from official guidelines has itself been part of the problem.
The gap between scientific consensus and the actual evidence underpinning dietary recommendations is a debate that has intensified globally, and South Africa is not immune to its consequences.
When guidance gets it wrong at scale, the effects compound across entire populations. The next Tim Noakes Foundation World Nutrition Summit‘s day one theme, “The cost of getting it wrong,” takes direct aim at that gap, asking experts, clinicians and the public to sit with an uncomfortable question: what if some of what we’ve been told to eat has made us sicker?
It’s a question worth taking seriously. The mortality statistics suggest we don’t have much time to get the answer wrong again.