The slender, steel needle pierced Mary Shi’s pudgy belly. The sharp point pricked her skin and as her thumb pushed down on the syringe, cloudy insulin began to swim in her bloodstream.

Shi was running out of places to inject herself: her stomach, arms and legs all bore the bruising from regular shots. More importantly, she was tired of having to forgo wearing T-shirts and skirts for clothes that would strategically cover her body when she went out for afternoon tea with her girlfriends in Shanghai.

“When you can stand the psychosocial burden of diabetes and social discrimination, injections are really a piece of cake,” said Shi, a 30-year-old app developer. Shi was diagnosed as a diabetic when she was 18. She had been studying for the highly competitive gaokao college entrance exam when she fainted at school. An emergency doctor explained that Shi had diabetes and if the illness was left unregulated, she’d be blind within five years. Her bewildered parents became depressed and Shi came to resent the disease and the rules it imposed on her lifestyle, hiding her illness from her friends for several years.

Shi is one of millions of people caught in China’s diabetes epidemic. In the 1980s diabetes was a rarity affecting just one percent of China’s population. Now, due to rapid economic development, and the subsequent growth in availability of high-calorie diets, cars and sedentary lifestyles, China has the highest number of diabetics in the world, totaling 109 million people in 2015—roughly 11 percent of the population. That makes China home to a third of the world’s diabetic population. The scale of this public health problem is huge, particularly because it comes at a time when the country’s health system as a whole is under reform, moving from a rudimentary socialist system to one that is open to private investment and ownership. Currently, access to health care varies greatly by location and economic status, but long lines outside hospitals are a common sight, in part due to a growing ageing population. The Chinese government recently allowed foreign companies to wholly own hospitals in an attempt to meet the needs of the country.

But the burden is already massive and bound to get worse; the International Diabetes Federation estimates that 13 percent of medical expenditure in China is directly caused by diabetes, with yearly costs estimated to reach $47 billion by 2030. These costs include general loss of productivity, hospitalization, and treatment of diabetes-related illnesses, such as heart disease, dialysis, and strokes. “It will take huge resources to deal with the burden of those with diabetes,” said Paul Zimmet, president of the International Diabetes Federation. “It’s perhaps insurmountable.”

And that’s only diabetes treatment and management itself; China’s health care system will also be stretched by the the associated risks and complications of the disease. A 2016 study published in PLOS Medicine estimates that “diabetes now accounts for almost 0.5 million cardiovascular disease deaths each year in China; this disease burden will likely increase as diabetes is expected to become more prevalent in China over coming decades, especially among young adults.”

The China National Plan for Non-Communicable Disease Prevention and Treatment is the main government initiative tasked with managing the epidemic. Guang Ning, vice-chairman of the Chinese Endocrine Society and an expert advisor to the plan, offers a litany of ideas to alleviate the rampant emergence of diabetes: “nationwide health education to increase public awareness, promotion of food policies to reduce high-sodium and high-fat food consumption and improvement of accessibility to health equipment to support physical activity.”

But for the most part these policies have yet to be translated into concrete plans as the over-burdened Chinese health system grapples with the surge of diabetic patients. Though the government is starting to pay more attention to the burden of diabetes, says Dr. Linong Ji, director of the Peking University Diabetes Center, much more needs to be done in order to raise awareness among the general public.

In the meanwhile, online peer-support groups are picking up the slack. One such group, ‘The enemy of diabetes’ formed in 2013 on the popular social messaging service WeChat. At first, the group attracted around 2,000 members but three years on it has already grown to 16,000, who share advice and organize offline meetups. Most importantly, says Lijun Yang, who administers the group, is that members can learn how to manage and live with their chronic disease. He estimates that only 50 percent of diabetics in China actually get the treatment they need—and lays the blame on the government’s slow response to the crisis.

Fuxing Liang is a good example. He was physically fit throughout his four years in the military, but upon discharge in 2000, he took up a desk job as a civil servant in Shaanxi, and his lifestyle became less and less healthy. Liang described his appetite at the time as limitless. “I drank without reservation,” he said. “I also consumed lots of meat. I especially loved to eat watermelons during the summer, sometimes eating two in a row.” This was coupled with an unhealthy habit of sleeping immediately after heavy meals. Then one day, he went in for a gallbladder operation—and his doctors told him he had diabetes.

Liang admits that at first he did not manage the condition well, and his body continued to deteriorate. Eventually his father-in-law intervened, pointing out that neglecting his condition would be a long-term burden on their family. Liang has since tempered his rich diet, but his story—finding out about the disease long after it started to ravage his body—is still all too common in China.

Zimmet, of the International Diabetes Federation, refers to the escalating crisis as a “tsunami” and says the only thing to do is to take drastic steps such as ploughing huge resources into prevention and educational health campaigns underscoring the importance of exercise and balanced diets. Dealing with childhood obesity, he says, will also be key in stopping the rising tide of diabetes. China’s obesity rates have quietly surpassed the US and today four out of five Chinese adolescents are not getting enough exercise. The World Health Organization warns that many of these children will end up as type 2 diabetics—the group predicts that by 2040, 150 million people in China will be diabetic.

In addition, there are almost 500 million Chinese people believed to be pre-diabetic, more than the entire population size of the United States and Canada combined. They live on the cusp of the disease with high blood-glucose levels and are very likely to develop full-blown diabetes. Over the course of the next decade this group has the alarming potential to further exacerbate China’s critical diabetes epidemic.

“If we don’t act now,” says Bernhard Schwartländer, a World Health Organization representative in China, “diabetes will overwhelm the health system.”

Additional reporting by Vivien Wei Li and Vicky Huang.