With Hawai'i's elderly population expanding quickly, hiring a geriatric specialist seemed a good idea to officials at the Wai'anae Coast Comprehensive Health Center.

But when they examined the center's demographics, they found a smaller-than-expected number of patients over age 65.

The stark truth was that many patients from the largely Native Hawaiian community were dying off before reaching old age, succumbing after years of struggling with diabetes and its complications, which include stroke, heart disease and kidney failure.

"Patients age 45 to 65 were getting everything 20 years earlier. That's why we didn't have a lot of elderly patients," said medical director Dr. Rick Custodio.

In fact, Native Hawaiians are more than seven times as likely to die from diabetes than whites in Hawai'i, according to the state Department of Health. They also have the highest diabetes rate in the state and are diagnosed with the disease at an earlier average age than other ethnic groups.

"It's devastating for the Hawaiian community because so much of the population is affected," said Mele Look, director of community engagement in the University of Hawai'i medical school's Department of Native Hawaiian Health.

"What's most alarming is how much it's appearing in children, and that hits any society hard, particularly the Hawaiian community. It's very hard now that they're seeing a very serious, disabling disease in their children."

Asians and other Pacific Islanders also suffer disproportionately from diabetes, a condition marked by high levels of blood glucose resulting from defects in insulin production or use.

Researchers are uncovering clues as to why minority groups are more prone to type 2 diabetes, the most common form of the disease, but Look said hereditary conditions are overshadowed by controllable risk factors such as diet, physical activity levels and other behavioral choices.

Nearly 12 percent of Native Hawaiian adults in Hawai'i have been diagnosed with diabetes, compared with 9 percent of Japanese, 8 percent of Filipinos and 5 percent of whites, according to the Health Department's 2007 Behavioral Risk Factors Surveillance System survey.

Native Hawaiians also have the highest diabetes mortality rate of any ethnic group in the state: 47 deaths per 100,000 population. That compares with seven for whites, 19 for Japanese, 22 for Filipinos and 32 for "others," including Chinese.

The average age of diagnosis for Native Hawaiians is 43, five years younger than the nearest ethnic group, according to the survey.

LIFESTYLE COUNTS

Kane'ohe kumu hula Wayne Panoke was only 25 when he was diagnosed with type 2 diabetes. Instead of taking steps to improve his health through lifestyle changes, Panoke depended on medication to control his diabetes. Then, seven years ago he fell ill and was told he would have to immediately start dialysis or die.

At the time he weighed 485 pounds.

"I just lost my father and I realized I needed to live to fulfill my promise to him to take care of my mother and the three children they had adopted," said Panoke, 60, who began watching his diet and increased his activity levels.

Today he weighs 276 pounds and is no longer on diabetes medication, although he still requires dialysis three times a week because of the irreversible damage done to his kidneys by diabetes.

Through his own struggle, Panoke has become more aware of the toll the disease has taken on his fellow Native Hawaiians, and he has become active in native health issues.

"With diabetes, Hawaiians are dying by the minute," he said. "I'm saddened by it each day. When I go to dialysis each week I see more and more of my people sitting on those chairs, and what troubles me most is that they are getting younger. When you see 21- and 22-year-olds sitting in those chairs, it gets very hurtful."

He said the impact of Western lifestyles, the disconnect between many Native Hawaiians and their culture, and economic stresses are major contributors to many health problems in his community.

"The 'ohana structure is collapsing because of economic needs. There's not enough income to eat properly and people live off canned goods two or three nights a week, and that's not good from a health perspective."

CHEAP EATS

Nearly three-quarters of Native Hawaiians are overweight or obese, compared with approximately half of whites, Filipinos and Japanese, according to Health Department surveys.

More alarming is that 43 percent of Native Hawaiians are obese, compared with 22 percent of the overall adult population.

Lower levels of education and household income are two risk factors for obesity, and statistics reveal that Native Hawaiians are at the bottom in both categories. Native Hawaiians also rank low in daily vegetable and fruit consumption and in leisure-time physical activity.

"People with lower income have a tendency to eat cheap fast food that's very high in fat. In many communities, especially in the urban core of Honolulu where there are a lot of immigrants, they don't have as much access to fresh fruit and vegetables, or parks where they feel comfortable walking," Look said.

Dr. Wilfred Fujimoto, a diabetes expert and retired endocrinologist, said Hawaiians and Asians have undergone a dramatic shift away from traditional diets and activities that helped protect them from chronic conditions such as diabetes, hypertension and heart disease.

"Pictures from the old days show Hawaiians were all pretty lean and muscular, and now there is an increasing occurrence of being overweight and obese. The lifestyle of the Pacific people has changed. They don't have to fish or farm. Walking long distances is not part of their usual lifestyle anymore," Fujimoto said.

"It's the same story for Asians who came to Hawai'i as plantation laborers. We've seen a rise in diabetes as they have become more sedentary."

A study by University of Hawai'i researchers found a reduced prevalence of diabetes among Japanese men who had retained a more traditional lifestyle that included regular physical activity and a diet of rice, vegetables and small amounts of fat and animal protein.

For more recent arrivals, diabetes can be a byproduct of their reach for the American Dream, as they adopt Western habits and struggle to assimilate. Look said it's not uncommon for immigrants who come to Hawai'i in good health to develop diabetes or pre-diabetes within 10 years.

RICE CAN ALSO BE RISKY

The waiting room at the Kalihi-Palama Health Center fills every Wednesday morning with low-income patients seeking services at a diabetes clinic started nine years ago to serve mostly Filipino and Micronesian immigrants. Its staff of two nurse practitioners, a nutritionist and a diabetes educator see 20 to 30 patients during each weekly session, checking their blood glucose levels, charting their progress and advising them on as diet and exercise.

"Food is a big issue for a lot of our patients," said certified diabetes educator Jane Pelkey. "For many of them, rice is their main staple and that's dangerous for a diabetic."

A lot of patients are unemployed and often turn to food to deal with the stress in their lives, she said.

Nurse practitioner Anne Leake, who also works at the diabetes clinic, said a 10-pound weight gain during an immigrant's first year after arrival is not unusual.

"They're eating a more American diet and eating more calories, but it's not just because of increased calories. They also are less physically active," Leake said. "Most, especially those who lived in the provinces, were used to walking long distances.

"And now they have some money and they are less poor, and food is cheaper here as a percentage of their income and it's more available. When you come from a country where food is so limited and then you come here and it's unlimited, naturally you're going to take advantage."

Immigrants from the Micronesian islands offer additional challenges, Leake said, such as their unfamiliarity with refrigeration and other conveniences that would allow them to enjoy more fresh foods rather than rely on canned goods for nutrition.

Also foreign is the Western concept of "working out," or "sweating for the sake of sweating," Leake said.

Many Pacific languages don't even have a word for "exercise," said Puni Freitas of Kokua Kalihi Valley, a nonprofit health organization.

She recalls that when Kokua staff tried to encourage some Micronesian patients to incorporate walking into their daily routine, the puzzled response was: "Why would we walk when we can catch the bus?"

To provide the kind of useful physical activity that makes sense to Pacific Islanders, Kokua Kalihi Valley and other health programs have started community gardens where they can "work out" and harvest fresh produce to enhance their diets.

BODY TYPES

The diet dilemma is not unique to minorities and immigrants. America is a nation of snack-food-scarfing couch potatoes, leaving the question of why whites haven't been as impacted by type 2 diabetes as minorities.

Research by Fujimoto and others suggests there are genetic differences among ethnic and racial groups related to where fat is stored in the body that may raise the diabetes risk.

Fujimoto said there is a strong association between increased visceral adiposity — fat stored in the abdomen — and insulin resistance that can lead to diabetes.

"Where you put your fat is important," he said. "It's the old apple vs. the pear body shape. We see more 'apples' in type 2 diabetes."

But even within the "apple" barrel, the risk varies, he said.

"You can have two people with an apple shape, one with most of the fat under the skin and the other with most of the fat inside the abdomen, and the one with the fat inside the abdomen is at greater risk for diabetes," Fujimoto said.

Other research has found that Asians, Native Hawaiians, Pacific Islanders, Hispanics, African-Americans and some other minorities have a greater tendency to store fat in their bellies, boosting risk.

In a study of Japanese-American men in Seattle, Fujimoto discovered his subjects were least able to carry excess weight before developing diabetes and other health impacts. "They don't have to gain a lot of weight. Their BMI (body mass index) doesn't have to be as high as for Caucasians," he said.

The BMI is a measure of body fat based on height and weight. BMI of 25 to 29 is considered overweight, and 30 and above is obese. The World Health Organization recently suggested a lower BMI standard for Asians, 23 to 24 for overweight and 25 and above for obese.

For Native Hawaiians and Pacific Islanders, the cutoff is higher — 26 to 31 BMI for overweight and 32 and up for obese.

Another theory links the higher prevalence of diabetes in nonwhite immigrant populations to the so-called "thrifty gene," a genotype that allows the body to quickly store fat in times of abundance to survive periods of famine. Although helpful to hunter-gatherers, that would be a distinct disadvantage in a time of corner convenience stores and 24-hour drive-throughs.

Others hypothesize that over the centuries, European whites adapted to foods that promote diabetes, while Asians and other groups around the globe now experiencing the diabetes onslaught have had only recent broader exposure.

Kumu hula Panoke, for one, has shown that Native Hawaiians and others at greater risk of diabetes needn't be resigned to their genetic fate.

"You can live a long life if you just take control of your diabetes and the amount of food and what you put into your body," he said. "I'm not saying you have to be perfect. It's portion control: Satisfy your craving and move on. And most important, get out of bed."