Diabetes consultant and educator Jane Kadohiro has a dream.

"That it's the norm that people are outdoors and physically active. That it is safe to ride bikes and safe to walk no matter where you live. That we don't need to be working 10 to 12 hours a day to feel like we're being productive. That we have more time for doing healthy outdoor things as a family.

"If we would just find it easier and more available to have a healthy lifestyle."

It's a dream shared by many public health officials dismayed at Hawai'i's increasing rates of obesity and diabetes that stem from poor eating and exercise habits.

Getting people to do what's good for them is one of the biggest challenges facing these officials and policy makers who want to change the way we live and reduce healthcare costs.

"The answer is very simple, but to achieve that is not so simple. We're dealing with human nature," said diabetes researcher Dr. Wilfred Fujimoto.

HEALTH LAWS, INITIATIVES

With the exception of anti-smoking laws, there has been little interest in Hawai'i in legislating healthier habits. Recent bills that died in the Legislature include a proposal that would have required "franchise retail food establishments" to include nutritional information on menu items.

Another would have asked the Health Department to determine the feasibility of reducing or eliminating the use of trans fats in restaurants.

The artificial fats, widely used for frying and in baked goods, have been linked to diabetes, clogged arteries and other serious health conditions.

Other jurisdictions have been more aggressive in pursuing obesity-related laws.

California, Boston, Baltimore and New York City are among the places that have banned trans fats in food sold in restaurants. New York City also requires fast-food restaurants to post calorie counts on the main menu above the counter.

One Los Angeles district went a step further, recently outlawing new fast-food restaurants in a 32-square-mile section of the city whose residents suffer from poverty and high obesity rates.

"Snack taxes" on soda and junk food have been enacted in more than a dozen states to discourage consumption.

The Hawai'i Department of Health instead is betting on its Healthy Hawai'i Initiative, a statewide health promotion campaign funded through tobacco settlement funds.

DOH public education coordinator Alice Silbanuz said the initiative rolled out its Start Living Healthy program in 2003 to encourage people to make "small changes that can add up to big health benefits."

Start Living Healthy encourages residents to up their consumption of fruits and vegetables, switch to drinking 1 percent fat or skim milk, and walk at least 30 minutes a day, five days a week.

Silbanuz reports some early signs the campaign is working. The milk promotion was successful in getting approximately 65,000 people to switch to 1 percent or skim milk, she said, and the percentage of people eating five or more servings of fruits and vegetables a day increased from 25.1 percent in 1998 to 28.7 percent last year.

In addition to the ongoing media campaign, the multipronged Healthy Hawai'i Initiative worked with the Department of Education to develop mandatory Wellness Guidelines now being implemented at public schools over a four-year period.

The policy bans the on-campus sale of food containing trans fats; prohibits food and beverages that list sugar in any form as the first ingredient; introduces more whole-grain ingredients and other nutrient-rich foods to school cafeteria menus; and sets minimum requirements for physical education and health education classes.

IMPROVING NEIGHBORHOODS

On a community level, Silbanuz said the Health Department is working with county planning departments, developers and others to create new neighborhoods and retrofit older ones with "complete streets" that can accommodate cars, bicyclists, pedestrians and the disabled.

The Healthy Hawai'i Initiative arranged for an expert in "walkable communities" to conduct workshops with Hawai'i County's planning and public works departments to take a closer look at community design that engineers physical activity back into residents' lives.

"At one time there was more town and village life. If you think of a plantation town, it was quite compact and it had a little store and it was developed close to the mill so people walked everywhere," said county Planning Director Christopher Yuen.

"Since then we've seen a largely suburban residential pattern that is more auto-dependent, and you don't have any destination to walk to other than parks."

The concept of creating a commercial core and other features to make it easier for residents to walk around in their communities probably won't work in the county's rural, low-density subdivisions, but Yuen said it's being encouraged for new development in Kona.

To help the process, the Health Department has funded a position in the Planning Department to develop more pedestrian, bicycle and public transportation options for Big Islanders.

Not all neighborhoods are created equal, and many older residential areas inhabited by low-income residents with high rates of obesity and diabetes lack sidewalks, safe parks and other features to draw families out of their homes.

These same places often lack farmers markets and supermarkets with well-stocked produce sections. Residents instead have to rely on small convenience stores that do brisk business in soda, chips and other low-nutrition food and sometimes lack refrigeration to sell fresh produce in place of processed food.

In Baltimore, a Healthy Stores Project project run by Johns Hopkins University aims to get better food into corner stores in urban neighborhoods by providing promotional materials, shelf labels and posters to store owners who agree to stock healthier foods.

The program offers samples to customers, conducts cooking demonstrations to introduce new foods and sometimes provide stores with bananas and whole-wheat bread on a trial basis.

GARDENING AS A COMMUNITY

In Hawai'i, improving access to low-cost, nutritious food in low-income areas is the goal of community gardens that have been sprouting up across the Islands.

Kokua Kalihi Valley has programs aimed at Micronesians and other new immigrants that combine diabetes education with English-language instruction and participation in a community garden.

Working in the garden provides participants an opportunity for physical activity and fresh produce to enhance their diet.

"It's been extremely effective and well-received. When you hit the right combination it works," said Mele Look, director of community engagement in the University of Hawai'i John A. Burns School of Medicine's Department of Native Hawaiian Health.

"It takes that innovation and willingness to get down to understanding cultural values and how people learn."

Hana Health on Maui started a small garden four years ago that has grown to 10 acres behind the clinic. The agency's Hana Fresh Farm also operates a weekly farmers market.

The remote East Maui community has a large population of Native Hawaiians, who are at higher risk for diabetes.

Hana Health executive director Cheryl Vasconcellos said the selection of fresh produce in the few local stores is meager. "It's poor quality and it's not very appetizing," she said.

"For many Native Hawaiians, eating healthy is expensive and this addressed that concern and helped them grow their own and provides a connection between land, food and health. Many people have lost that connection," she said.

According to Vasconcellos, a recent study indicated that Hana residents went from eating an average of 2.9 servings of fruits and vegetables a day to 3.7 servings in a year's time.

"We believe it's a direct result of Hana Fresh Farm," she said.

The project has gotten $1.2 million in funding from the Administration for Native Americans that was used to buy a tractor, greenhouses and other equipment, and Vasconcellos hopes the garden will one day be self-supporting.

"We think it is starting to make a difference. We're really trying to hit the prevention side of it. The evidence is overwhelming that if we can eat better and walk a little bit, we can prevent being overweight and obese and ultimately prevent the onset of diabetes."

The Healthy Hawai'i Initiative also worked with health insurance carriers, hospitals, community organizations, nonprofit groups and state and county agencies to develop the Hawai'i Physical Activity and Nutrition Plan, which was unveiled a year ago.

The plan provides strategies to increase physical activity and improve nutrition in order to reduce overweight, obesity and chronic disease among Hawai'i residents.

A follow-up forum on the Hawai'i PAN Plan is scheduled for Oct. 9.

Since these organizations and programs are dealing with human nature, no one expects immediate results from the healthy-living campaigns, which are viewed as long-term endeavors.

"It's a slow-moving process. We didn't get here overnight," said Majken Mechling, head of the American Diabetes Association in Hawai'i.

But Look said officials can take encouragement from anti-smoking efforts.

According to the Department of Health, the smoking rate in Hawai'i has dropped from 19.5 percent in 1998 to 17 percent in 2007.

"That's been a 20-year campaign. When you think about how prevalent smoking was in American culture and how that acceptance has changed so dramatically, then I think there is a lot potential for change," she said.