Diabetes: Why ‘lifestyle disease’ is an unfair label

• Diabetes is a condition which affects how your body turns food into energy, leaving you with a high level of blood sugar that can lead to blindness, heart problems and nerve damage if it’s not managed well.
• Type 2 diabetes is called a “lifestyle disease” because it can be caused by poor eating habits. But this label doesn’t account for the fact that genetics play a role too, nor that nutritious food is unaffordable for many people in SA, says Bridget McNulty of the diabetes patient advocacy group Sweet Life.
• SA has a new action plan on diabetes and other noncommunicable diseases that aims to have 60% of adults with high blood sugar on treatment by 2027.

Tekkies*, a sheep shearer in his mid-60s, is patiently waiting in front of U-Save, a low-cost supermarket owned by Shoprite. The shop has become something of a social hub in the Eastern Cape town of Jansenville. 

It’s a typical Karoo town. Dusty with lots of churches. But Jansenville’s main export is decadence, whether it’s the white cast-iron frills that decorate Victorian porches, or mohair woven from the silvery locks of the Angora goats that roam the surrounding veld.

Tekkies didn’t move to Jansenville by choice.

His family were forced to relocate in the early days of SA’s democracy because the farm they had lived and worked on deep in the rural Eastern Cape was turned into a game lodge.

With the move came a profound change in his diet.

Farm life meant a package of food was delivered weekly as part of his pay. That benefit was gone. He couldn’t grow anything either because he didn’t have any land.

Plus, work was often scarce, so even when the fresh food aisle at the U-Save was fully stocked, his wages didn’t always go far enough to buy them.

Processed food was cheaper, so Tekkies relied on that.

A few years after moving to Jansenville, Tekkies was diagnosed with type 2 diabetes, a condition many experts call a “lifestyle disease” — but Tekkies didn’t choose his lifestyle; it was forced on him.

The silent killer

Diabetes affects how well your body can control the amount of glucose (a type of sugar) there is in the blood.

Your body is supposed to take the blood sugars from broken-down food into cells as energy. But the bodies of people with type 2 diabetes have stopped responding well enough to the hormone insulin, which makes this trip into cells possible, so the energy never gets to their cells and their blood sugar stays high. The condition, which is most common among older adults, can lead to blindness, heart problems and nerve damage that can result in amputation.

Tekkies is waiting in front of the supermarket for a researcher who wants to ask him about his diabetes and lifestyle. 

Alongside genes in some cases, the type and amount of food people eat can also increase a person’s chances of developing the condition.

Red meat, fried and processed food and sugar are bad news. Eating fruits and vegetables, on the other hand, can help to stop people from developing diabetes, research shows.

In SA, the number of people with type 2 diabetes is rising quickly. Official diagnoses of the condition shot up from 4.5% in 2010 to 12.7% in 2019 — tripling in just nine years. 

Even that’s probably an undercount. New research suggests that about 8% of people in the country who have diabetes don’t know about it.

This brings me back to Tekkies.

His diabetes diagnosis may not have been directly caused by the move to Jansenville — a move he had no control over. Tekkies was getting older, and he may have been at risk of developing diabetes for a while. Possibly, he was only diagnosed in town because he had better access to a clinic. Perhaps he has the genetic wiring to make him more likely to develop diabetes in the first place.

Still, I believe Tekkies’ story holds important lessons that should inform how we think about so-called lifestyle diseases such as diabetes.

I can see how that label came to be.

“If we can get this message across, we empower people to change.” I’m sure that’s what well-intentioned people thought at the time.

All the person with diabetes would have to do is change the way their family eats, start exercising more, perhaps lose some weight, and voilà, your “lifestyle condition” is fixed.

But it’s just not that easy to eat the right food and to exercise the required 30 minutes a day five times a week.

If it were, we’d all be walking around in the peak of health.

Just like Tekkies, most people in SA aren’t choosing cheap food because they don’t care about their health.

Exercise isn’t that simple either — particularly for women who live in unsafe areas.

As for losing weight, that’s frowned upon in some cultures.

Though diabetes is a noncommunicable disease (NCD), some of the factors that make people more likely to develop diabetes are, in fact, communicable, meaning it can spread from one person to another. 

Analysts at the actuarial consultancy Percept agree: “Diabetes is often framed as the consequence of poor lifestyle or health choices, but many of the risk factors are more a function of environment than personal choice.”

Tekkies’s story was included in two of Percept’s reports on NCDs in SA.

While diabetes doesn’t spread from one person to the next in the same way a virus does, the circumstances that contribute to diabetes certainly have a “communicable” social aspect to them.

People in the same household are likely to eat similar foods based on how much money there is, and family traditions and preferences also influence what you eat. This could put people in the same household  at a similar risk to develop diabetes.

So, Tekkiess did not get diabetes as a consequence of poor choices, nor did he “eat his way” into the condition on purpose, as people like him are unfairly accused of doing.

What could he really have done to eat a healthier diet?

Defeating diabetes: What’s the plan?

SA has a new action plan to fight NCDs including diabetes, heart disease, mental illness, lung diseases and cancer.

The document is drawn up in the same way as the country’s HIV plan. The HIV plan aims to make sure 90% of people with HIV know their status, 90% of people who know their HIV status  are on treatment, and that 90% of people on treatment are virally suppressed by the end of 2022. That means there’s so little of the virus in their blood they can no longer infect other people. The Joint UN Programme on HIV/Aids has increased these three goals to 95% by 2030.

But the NCD plan’s goals are not quite as bold.

By 2027, 90% of adults should know whether they have high blood pressure or high blood sugar.

Sixty percent of people who know that they have high blood pressure or blood sugar will be treated.

And half of people who are treated for hypertension or raised blood sugar will have their condition under control.

These are worthy targets — particularly given that they are the first diabetes targets SA has ever set. But I worry that we’ll struggle to reach them without changing the way we treat the people this plan is designed to help.

We need to stop playing the blame and shame game when it comes to type 2 diabetes.

I have been running SA’s largest online diabetes community, Sweet Life, for 11 years. I have seen first-hand that people who feel supported, heard and understood are far more likely to make positive changes in their lives — that’s what true empowerment looks like.

People aren’t inspired to change if they feel judged and sidelined.

How about as a first step, we stop calling diabetes a lifestyle disease? Then, we change the messaging to say that everyone should be eating healthier food and exercising a little each day.

I’m sure we’ll get through to more people that way.

* Not his real name 

Bridget McNulty is the co-founder of Sweet Life, SA’s largest online diabetes community, and has been living with Type 1 diabetes for 14 years. She is also a published author and co-founded the Diabetes Alliance and SA Diabetes Advocacy.

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.