The Long Road of Chronic Disease Management

Diabetes and Obesity: The Long Road of Chronic Disease Management

by IDS Diabetologist & Weight Management Specialist, Dr Paula Diab

This Sunday, June 8th , I won’t be able to go more than about a quarter mile from my front door. Roads will be closed off, helicopters will buzz above my home and sirens will blare down the streets. This happens once a year and I love it! It’s not some weird lockdown or crazy movie set – it’s the opportunity to be a supporter of one of the greatest events in human endurance!

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Every June, the roads between Durban and Pietermaritzburg in South Africa come alive with the footsteps of thousands of runners testing their physical and mental limits in the Comrades Marathon—a world-renowned 87 to 90 km (55 miles) ultramarathon and the largest and oldest race of its kind. For nearly a century, this race has drawn athletes from around the globe, all chasing the finish line on a course filled with hills, heat, fatigue, and personal triumphs.

But what does this have to do with diabetes or obesity?

Actually, quite a lot.

Because for anyone living with diabetes, obesity, or both, the experience of managing these conditions day in and day out is less like a sprint and more like an ultramarathon—a lifetime commitment marked by sustained effort, resilience, and a deep reservoir of mental stamina.

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The Comrades Marathon: Grit in Action

The Comrades Marathon began in 1921 as a tribute to South African soldiers who had served in World War I.

War veteran Vic Clapham envisioned a race that would honor their suffering and celebrate the human spirit’s ability to endure hardship. What began with 34 runners has since grown into an annual pilgrimage for over 20,000 athletes from all corners of the globe, including about 100 athletes each year from the United States.

Last year, American runner Courtney Olsen finished third in the women’s race with a time of 6:08:09. That’s an average speed of over 9 mph. (The men’s qualifying time for the Boston marathon is only 8.5mph for half the distance!

The route alternates each year between an “up” run (from coastal Durban to inland Pietermaritzburg) and a “down” run (the reverse), with elevation changes that punish even the fittest. Runners must complete the course in under 12 hours, with strict cut-off points along the way. Many train for 6 to 12 months for the privilege of crossing that final line.

Yet, as any Comrades finisher will tell you, the final third of the race isn’t won with fitness alone.

It’s mental stamina—the ability to keep going when the body screams “stop”—that gets you home.

And this, perhaps more than anything, is the exact same muscle required in managing a chronic condition.

Diabetes and Obesity: The Daily Grind of an Endless Race

Let’s talk about what managing diabetes and obesity actually looks like.

It’s not a pill-and-done condition.

It’s more like waking up every single day to train for a race you never signed up for—but one you must run to live well.

Here’s what that “training” can look like:

• Checking blood glucose levels (sometimes multiple times a day, or wearing a CGM and interpreting it in real-time)
• Taking medication or insulin, often with precise timing and dose adjustments based on food, stress, or exercise
• Tracking weight, which is especially difficult when society heaps judgment on people living with obesity
• Logging food—not just how much you eat, but what you eat, when, how fast, and why
• Monitoring physical activity, from structured exercise to incidental movement throughout the day
• Juggling appointments with endocrinologists, dietitians, obesity medicine specialists, psychologists, and more
• Battling misinformation and stigma in public, in clinics, and sometimes within families
• Navigating emotions like guilt, shame, burnout, and fatigue, all while trying to maintain motivation
• Now picture doing that every day, not for six months or a year—but for the rest of your life.

That’s the ultramarathon we don’t talk about enough.

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Training Every Day… Without a Finish Line

Just like Comrades runners must train daily—building aerobic base, increasing mileage, cross-training, and preventing injury—so too must people living with chronic disease invest in daily management.

But unlike an ultramarathon, there’s no single finish line to cross, no day where you hang up your shoes and declare, “Done!” Chronic conditions like diabetes and obesity require ongoing, adaptive training—and that’s what makes the challenge even greater.

And just like runners need rest days, recovery weeks, and help from coaches and teammates, individuals managing these diseases need:

• Grace for imperfect days
• Flexible treatment plans
• Compassionate clinical guidance
• Realistic, sustainable goals
• Emotional and mental health support
• The idea that “discipline” or “willpower” alone should carry someone through 60 years of illness management is not only inaccurate, it’s cruel. Nobody runs
• 90 km on motivation alone. They need a structured plan, support, coaching, and most of all—permission to struggle and still keep going.

The Mental Load: What Runners and Patients Share

Ultramarathoners often describe hitting “The Wall”—that point late in the race when energy is gone, muscles fail, and the only thing carrying you forward is mental grit. As one runner aptly put it, “Comrades is 90% mental and the other half is physical.” The race demands unwavering focus, resilience in the face of fatigue, and the ability to push through psychological barriers

Chronic disease management is probably also 90% mental and the other half all the checking and testing and monitoring that needs to be done! People with diabetes and obesity also hit their own walls: the day they feel overwhelmed by logging, or emotionally drained by stigma, or burned out by the pressure to be “perfect.” They may think: Why bother? or I can’t do this anymore.

And yet, they carry on.

That mental load—the constant decision-making, self-monitoring, course-correcting, and self-advocating—can be invisible, but it is real and relentless.

Just like the lonely middle kilometers of an ultramarathon, it’s the invisible endurance that makes the difference. The grit to keep logging food even when your weight stays the same. The decision to adjust insulin at 3:00 a.m. because your glucose alarm beeped. The courage to go for a walk when your body is sore and your mind is tired.

That is endurance. That is resilience. That is athleticism of the mind.

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The Power of Support Teams

In the Comrades, water tables dot the route, and volunteers hand out drinks, massages, and motivational high-fives. Spectators line the streets, shouting words of encouragement. Teammates pace each other. Coaches offer strategy. The spirit of togetherness is woven into the race.

Chronic disease should be the same.

People managing diabetes and obesity deserve:

• A health team that works in sync—primary care, specialists, educators, nutritionists, psychologists
• Family and friends who understand, not judge
• Digital tools that make tracking easier and less mentally taxing
• Communities, whether online or in-person, where stories are shared and strength is gained
• Policy support that protects access to medications, GLP-1s, insulin, CGMs, and surgery for those who need it
• Just as no one finishes Comrades alone, no one should have to manage their health in isolation.

From Sprint Thinking to Marathon Mindset

Too often, the healthcare system treats chronic disease like a sprint. Prescribe a drug. Recommend weight loss. See you in six months. But this sprint mindset sets people up for disappointment and shame when progress isn’t fast or linear.

We need a marathon mindset.

• Understand that plateaus are normal—in training and in weight.
• Recognize that consistency matters more than perfection.
• Emphasize that resets are part of the journey, not failures.
• Celebrate small victories, like one better food choice or one more glucose reading in range.
• Acknowledge the emotional labor and resilience involved.

Finding Meaning in the Long Game

At some point in Comrades, every runner asks, “Why am I doing this?” And yet, when they reach the finish line, the emotion is overwhelming—tears, hugs, disbelief, pride.

People living with diabetes and obesity may not have a finish line ribbon to break. But they have milestones. Moments of breakthrough. Wins that no one else sees. And those moments matter.

Whether it’s:

• Lowering an A1C after months of work
• Taking a walk when depression says stay on the couch
• Advocating for your own care at a doctor’s appointment
• Eating a meal without guilt or shame

—These are your medals. Your finish lines. Your victories.

Final Thoughts: Let’s Celebrate the Endurance of Health Warriors

This weekend, as Comrades runners make their way over Polly Shorts and inch toward Pietermaritzburg, think of the 400+ million people worldwide living with diabetes, and the 650+ million living with obesity.

They, too, are endurance athletes.

Their race isn’t televised. Their water tables are fewer. But they wake up every day and keep going.

Let us honor their journey with the same admiration we give to those who cross the finish line of Comrades—because managing a lifelong condition with courage, commitment, and self-compassion?

That’s the ultimate ultramarathon.

For more information on the Comrades Marathon, visit www.comrades.com.

To learn more about integrated, supportive chronic care, visit Integrated Diabetes Services.

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