Chronic Disease Surge Reshapes South Africa's Mortality Market; Diabetes Now Top Killer

Diabetes claimed approximately 79 South African lives every day in 2024, accounting for 6.1% of the 474,366 deaths recorded that year, according to Stats SA’s latest Mortality Report. The disease now ranks ahead of tuberculosis and HIV as the country’s leading cause of death, marking a decisive epidemiological shift toward non-communicable, chronic conditions as the primary mortality drivers.

The three conditions responsible for the most deaths are no longer infectious diseases. Hypertensive diseases ranked second at 5.5% of deaths, followed by cerebrovascular diseases, which include strokes, at 5.4%. Together, these three chronic illnesses accounted for more fatalities than any single infectious disease in the country. HIV accounted for 3.8% of all deaths, down from 4.3% in 2022 and 4.0% in 2023. Tuberculosis remained the leading cause of death among men at 4.8%. COVID-19, which dominated mortality statistics in 2020 and 2021, claimed just 450 lives in 2024, representing less than 0.1% of total deaths.

Diabetes disproportionately affects women, accounting for 7.9% of all female deaths. Geographic variation was pronounced: Gauteng recorded the highest share of deaths at 21.2%, followed by KwaZulu-Natal at 18.8%, while the Northern Cape recorded the lowest at 3.1%. The health department’s treatment literacy guidance notes that more than half of South African adults live with at least one chronic condition and that diabetes affects one in every eight adults.

Diagnosis remains a critical gap. More than half of South Africans living with diabetes are unaware of their condition, complicating both individual treatment and public health surveillance. Stats SA also warned that 18.2% of natural deaths in 2024 were recorded under ill-defined causes, creating a distorted picture of the population’s true health status.

Professor Tim Noakes, the Cape Town scientist who founded the Noakes Foundation, frames the three leading killers not as separate diseases but as manifestations of a single underlying metabolic dysfunction. He argues all three are caused by insulin resistance and high-carbohydrate diets, explaining that insulin resistance prevents the body from metabolizing carbohydrates effectively and forces their conversion into fat stored in the liver, pancreas, and other organs. This process worsens insulin resistance over time. “We are in the middle of the tsunami I have talked about years ago, and the problem is it’s only going to get worse,” Noakes said. “It’s never going to go away if government doesn’t change food policy.” He advocates removing ultra-processed foods entirely and shifting subsidies from grains and seed oils to animal produce. His foundation runs a campaign called Eat Better SA in poor communities, teaching people to eat well on minimal budgets, with some patients reversing their diabetes through the programme. His claim that conventional treatment makes no difference without dietary change, however, runs counter to national treatment guidelines and is disputed by doctors. The health department’s treatment literacy flip chart, published this year, recommends a varied diet including high-fibre foods such as wholewheat bread, brown rice, oats and barley, alongside vegetables, fruit, beans, lentils, lean proteins and healthier fats.

By contrast, Reverend Sean Cameron Gunn, branch manager of Diabetes SA in Durban, challenges the narrative that sugar itself causes diabetes. “There are many contributing factors, but one of them is that misconception that sugar causes diabetes and that’s not true,” Gunn told IOL. He notes that people diagnosed with type 2 diabetes generally have poor eating habits and little exercise. Type 1 diabetes, an autoimmune condition where the body fails to produce insulin, is not reversible. Type 2 can be reversed through diet and exercise, according to research by the International Diabetes Federation. Gunn reports seeing diabetes in teenagers and notes that rates among Durban’s Indian and African communities are now almost on par with each other, attributing much of this to households where both parents work and children no longer receive cooked meals at home.

Armand de Wet, a return-to-play specialist in Stellenbosch who works with professional athletes, reports seeing insulin resistance in people far from retirement age. Elite endurance athletes now consume between 120 and 150 grams of carbohydrates per hour, up from 60 to 80 grams a few years ago, with some arriving pre-diabetic as a result. Over the past year, de Wet worked with between 20 and 30 people who were pre-diabetic or diabetic, and about 10 reversed the condition through dietary intervention. On the question of eating well on a tight budget, he was candid: “Unfortunately meat is a little bit more on the expensive side. Eggs are going to cost you a lot more, and milk is expensive, so everyone is unfortunately going to go with what their budget can uphold.”

The Diabetes Alliance has written to President Cyril Ramaphosa, finance minister Enoch Godongwana and health minister Dr Aaron Motsoaledi, urging government action on the death toll. In April, 24 civil society organisations called for a national diabetes registry and for health funding to be redirected toward managing the disease. Whether those calls translate into a shift in food policy or public health spending may determine how far the death toll climbs before it turns.