The Wai'anae Coast Comprehensive Health Center sits at the epicenter of Hawai'i's diabetes crisis.

As the primary medical facility in this disadvantaged region, it treats more Native Hawaiians than any other facility — and diabetes among Hawaiians is four times the national average. At the same time, the number of all adults on the coast with diabetes is double the statewide rate.

The Wai'anae Coast also leads the state in the percentage of residents who smoke, have high blood pressure, don't exercise, and are obese — all of which compound the diabetes epidemic.

The result, says Dr. Stephen Bradley, associate medical director for the center, is a catastrophic surge in people of all ages and races with diabetes on the coast. The costs are diminished lifestyles, shorter life spans and an overburdened healthcare system, he says. But as bad as things are here, Bradley knows they could get worse.

"There is an enormous number of undiagnosed diabetics out there," said Bradley, who worries that the epidemic could expand beyond the center's current 26,000 annual patient load and overwhelm its $38 million annual budget.

Holding back the tsunami is the job of the health center, and it does so with a comprehensive array of tools that are as much down home as high tech.

To be sure, the center offers the latest in clinical and medical services. But on any given day, patients might go on a supermarket tour where they learn how to choose healthy foods, visit a farmers market sponsored by the center, watch a cooking demonstration or work out in the center's gym.

Still others might get a visit at home from a community health worker.

"Our philosophy is to treat folks in the most complete way possible regardless of their ability to pay," said Bradley.

The center has focused on a two-fold preventive approach: keeping younger patients who don't have diabetes from getting it, and stabilizing patients who do have diabetes so it doesn't progress to debilitating and costly related disorders — kidney failure, blindness, leg amputations, strokes, obesity, or nerve and heart disease.

DIABETES POLICE PATROL

Tusi Taumau, 50, playfully refers to herself as "The Wai'anae Diabetes Police Patrol." Actually, she is a diabetes education specialist and one of the center's traveling community health workers.

With the facility's number of primary diabetes patients reaching 2,000 and rising, Taumau's workload can be heavy. On any given day she visits eight to 10 patients, sometimes more. These are home visits, and sometimes home is a tent on the beach.

It doesn't matter to Taumau.

A recent session at the home of Junedale Pakele on Hokuukali Street in Wai'anae was typical.

Pakele, 62, was referred by her doctor because the patient's average daily blood sugar level was dangerously elevated. The doctor hoped that if Pakele better understood how diabetes affects her body, her self-management of the disease might improve.

Although Pakele had a vague comprehension of diabetes, she was confused about the specifics, as well as her insulin injection procedures. Taumau outlined in simple but specific terms the causes and effects of diabetes, and the details of using insulin.

"Your body can adjust to having abnormal blood sugar levels for a long time," Taumau told Pakele as the two sat at a table on the patio. "The problem is that it's eating at you. The longer your blood sugars are high, even though you feel OK, the more it's not good for you."

Taumau explained that the pain and numbness Pakele now feels in her legs and feet are the lasting effects of her high sugar levels throughout the past decade. Unchecked, the problems would only magnify.

THE BETTER WAY

Taumau's initial visits can take up to two hours, with follow-up chats lasting from 45 minutes to more than an hour. Taumau bases her responses on the patient's questions and concerns, patiently reiterating her responses as many times as necessary.

"I don't often tell them, 'OK, you need to do this,' but I suggest that this may be a better way of doing it. It's easier for them to grasp when you do it that way."

Part of Taumau's job is to explain practical and affordable ways in which patients can manage their diabetes in order to lower and maintain their average sugar levels. For example, when Pakele mentioned that Spam is one of her favorite foods, Taumau suggested boiling, not frying, a smaller portion of Spam, dicing it and mixing it with, say, cabbage and possibly other vegetables in a soup.

"It's not what you eat, it's how much of it you eat," Taumau told her. "Smaller portions are better."

Taumau has diabetes herself. She says she tries to be diligent about managing it to set a good example.

"But, I'm like everybody else who likes to eat everything," she said with a laugh. "At least I know when I should really not be doing it."

"Not doing it" however, goes to the heart of the diabetes dilemma in today's complex society, said Mary Francis Oneha, the center's Quality and Performance director.

"It's not as simple as 'Well, just do it — go and exercise this much and eat this type of food and it will be OK,'" she said.

"It's being able to get the right foods, having the money to get the food; it's what's easy to get that stretches the funds the furthest, and being motivated to exercise, and getting the right type of exercise that will work."

Add to that time demands, work schedules, family obligations, personal problems, financial difficulties, and it's not hard to understand why so many people develop diabetes and are unable to manage it, she said.

Lisa Zick-Mariteragi, nurse practitioner at the center, spends much of her time trying to help diabetes patients break down barriers to controlling disease.

It's an uphill battle. Yet she sees hope. Her task is to present options and help patients make informed decisions.

"I tell my patients, 'You can ignore diabetes, but it will never ignore you,' " she said. "I find that when you respect people they end up making good decisions. This is an incredibly resilient community."

DECISION-MAKING

Still, making good decisions can be a formidable task, say Arnold and Leilani Ujimori of Ma'ili, who both have diabetes. For more than a decade the two have worked with center health providers to manage their disease — with mixed results.

In the beginning, both say, they were in denial. Later, between raising a family and work, proper diet and rigorous exercise seemed out of the question.

Now that they've reached the consequences stage of the disease, Arnold Ujimori, is ambivalent.

"I just take it in stride," said Ujimori, 51, who began giving himself insulin injections for the first time in late July. "I'm still obese, I still smoke, and I still like a drink."

He admits he's done poorly when it comes to self-managing his disease. Being laid off from his plumbing job this summer has only made matters worse, he said.

His wife, on the other hand, gives her own self-management effort better marks.

"I've been where he is," she said. "I had to go on insulin. I was taking shots two times a day."

That was two years ago. Since then, she has shed more than 20 pounds through exercise and improved diet. As a consequence, she no longer needs insulin injections.

Managing her diabetes remains tough, she stressed, and there's room for improvement. Still, she's pleased to be heading in the right direction.

Even her husband has felt a tinge of motivation. For him, insulin injections were the wake-up call. He's talked of working out at the Comp Center gym, and paying attention to the personal trainer and nutritionist there. His goal is to eventually no longer need insulin shots.

IRONY OF EXERCISE

One irony associated with the diabetes crisis, said Richard Bettini, the center's chief executive officer, is that health plans are leery of paying for diet and exercise programs. Yet diet and exercise offer the best hope for bringing the epidemic under control, he said.

"You can give people expensive drugs to control their diabetes," said Bettini. "Or, you can get them walking and exercising and eating the right foods. That way you keep them out of emergency rooms and hospitals."

To change the health plan status quo, the facility has pioneered an Innovation and Design Center dedicated to finding ways of developing diet and exercise programs that have positive, measurable outcomes.

Once results can be guaranteed, health plan providers will be motivated to provide coverage for diet and exercise because it could save them money, said Bettini.

"That's the wave of the future."

In the meantime, success against diabetes on the coast is measured in tiny steps, said Bradley.

"Can we get our diabetics healthier in the sense that they're not doing further damage to their organ systems?" he said. "If we can stem that a little bit by whatever we're doing — medically or nutritionally — that's a success.

"And if we can get some of the community aware, educated, fed better and more fit, we feel that is also successful. Because those individuals will probably not go on to develop a diabetes at a later age."

AT A GLANCE

WHAT: WAI'ANAE COAST COMPREHENSIVE HEALTH CENTER

ADDRESS: 86-260 FARRINGTON HIGHWAY

EMPLOYEES: APPROXIMATELY 500

ANNUAL BUDGET: $38 MILLION

NUMBER OF PATIENTS ANNUALLY: 26,000

Programs: In addition to offering clinical and medical services, it sponsors a local farmers market, provides registered dieticians, nutritional classes, supermarket tours, a workout gym, a gardening program, cooking demonstrations, two nutrition and exercise programs for kids, and manicured walking trails (with shade trees and information kiosks stationed along the brick-laden pathways).

Where to call: For information on diabetes programs call 697-3558