Wai'anae has more diabetes cases than rest of state, by farTuesday, September 9, 2008By Will HooverAdvertiser Staff WriterThe 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 PatrolTusi Taumua, 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, Taumua'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 Taumua.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. Taumua 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," Taumua 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."Taumua 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 wayTaumua's initial visits can take up to two hours, with follow-up chats lasting from 45 minutes to more than an hour. Taumua 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 Taumua'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, Taumua 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," Taumua told her. "Smaller portions are better."Taumua 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-makingStill, 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 exerciseOne 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 glanceWhat: Wai'anae Coast Comprehensive Health CenterAddress: 86-260 Farrington HighwayEmployees: Approximately 500Annual budget: $38 millionNumber of patients annually: 26,000Programs: 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 697-3558The state's highest percentage of adults with diabetes — 15.2 percent (more than twice the statewide rate)Lowest percentage of residents with a "healthy weight" at 26.6 percentHighest percentage of obese residents statewide at 42.6 percentHighest percentage of residents who reported no leisure time physical activity at 27.7 percentHighest percentage of smokers in state at 26.2 percentHighest percentage of residents with high blood pressure at 32.1 percentO'ahu's lowest percentage of residents with health insurance at 87.1 percent.Source: State Department of Health's Behavior Risk Factors Surveillance System surveys for 2005-2007Reach Will Hoover at whoover@honoluluadvertiser.com.
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Nanakuli family's struggle now spans four generationsSunday, September 7, 2008By Will HooverAdvertiser Staff WriterMonica Bell is able to remain calm and cheerful even as her legs swell and ache, and she's feeling nauseous — frequent reminders of the diabetes that has laid waste to three generations of her family and taken hold of a fourth.Like many who feel fine early on despite having diabetes, Bell paid little heed to her illness after she was diagnosed 20 years ago.No more.Today, she's going blind and diabetes rules her very life."I get sick on a daily basis," said Bell. "It's a nasty disease. It's with me at all times. It never goes away. Every day it is a challenge."Her Hawaiian family has suffered profoundly because of diabetes, and to see what it has done to them is to witness the epidemic proportions the disease has reached on the Wai'anae Coast, where Bell and her family live on Mano Avenue in Nanakuli.The disease killed Monica's father, and several of his siblings. Her mother, whose kidney failure is a result of diabetes, spends four hours three times a week attached to a dialysis machine. All three of Monica's sisters have diabetes and take daily insulin injections, as do Monica and her mother.Monica's daughter, Taryn-Courtney Bell — TC to those who know her — was diagnosed with diabetes when she was only 6. At 13, she has been on insulin injections more than half her life. And last year Monica's son, Alika, 16, was also diagnosed with diabetes.As for Bell herself, diabetes has robbed her of the ability to drive, hold a job, walk easily, or ever again enjoy a sense of well-being. The vision in her right eye is gone, and although she still has limited sight in her left eye, she's unable to focus. Even the sight she has left could eventually fade."I do think about the future," she said. "And it is scary. I think you just have to get tight control on your diabetes. You probably can't get better. But you maybe can prevent it from getting worse."Household caretakerOf those who live in the Bell household, only Monica's husband, Gino, a truck driver, does not have diabetes. But the disease has affected his life all the same and rendered him the household caretaker."Gino does everything for me and our kids," said Monica, 38, who married Gino Bell in 1992. "He's just wonderful. He has things he likes to do — he fishes and surfs. But before he does anything, he makes sure that the family is doing well."He has altered his diet to meet the improving eating habits of his family. He dashes to the store on short notice at all hours. Since Monica can no longer see to drive, Gino juggles his work schedule and takes vacation days to accommodate various doctor and dialysis appointments, eye examinations, American Diabetes Association functions, or the diabetes classes his two children attend at the Kaiser Nanaikeola Clinic every month."I'm like the backbone," said Gino, 47, who has worked 17 years for a firm that subcontracts to the military. "I've saved up a lot of hours, so I can help out, taking them here and there."He says he is grateful to be able to do it.His pleasant disposition can be a calming influence on a family often straining simply to function, according to his wife.'Lot of starches'Monica's mother, Archidalia Kawa'a, 64, frets about her fellow Hawaiians who suffer in great numbers from the disease, yet tend to be the last and least to seek treatment, because of cultural pride, shame or a lack of health insurance. By the time many do reach out for medical assistance it's often too late, she says."Diabetes is terrible," said Kawa'a. "My husband, John, had both his legs amputated because of it. He died at 59. His mother died at 49. His father died at about 54. I have diabetes. All four of my daughters have diabetes, and my grandchildren have diabetes."Furthermore, those in the community who are diagnosed in time to make a difference frequently fail to heed doctors' warnings that they should exercise, eat healthy, and manage their sugar levels, she says. Since they don't feel ill or exhibit symptoms in the beginning, they are less inclined to work out or give up fast foods and snacks."It's a way of life in Hawai'i," she said. "That's how we eat since we were young — lot of starches."Monica Bell, for instance, wasn't especially bothered when she was diagnosed in 1988 as a senior at Nanakuli High and Intermediate School. She didn't know much about the disease, and although she was overweight, she considered herself generally fit.Her concern rose after her mother was diagnosed a short time later, she says. When her father became seriously ill in the late 1990s, "it opened my eyes to what diabetes is."Still, she didn't alter her habits. By the time her father died on Christmas Day in 2002, she could no longer see well enough to drive. The following year, because of her failing eyesight and debilitating nerve damage in her legs, Bell left her job and began collecting Social Security benefits.She is stoic about the outcome."It was my own fault. I never listened. But now I'm trying to do my best because I've got to help my kids out."For her the alarm bells rang loudest when her daughter was diagnosed with type 2 diabetes, the kind that has stricken the rest of the family and a form of the disease once associated with older adults."She was so young," she said. "Even the doctors were surprised."pushing healthy lifestyleA genetic susceptibility associated with type 2 diabetes can be triggered by behavioral factors such as obesity and a sedentary lifestyle. There is also evidence that diabetes may run in families, according to experts.Today, Monica worries that TC and Alika won't take diabetes seriously until they're suffering from the permanent or life-threatening effects.TC tends to eat too much and not the right foods, Monica says. Alika, who is lean and trim at 5 feet 10 and 155 pounds, doesn't eat enough of anything. And for the diabetic, eating too little can be as worrisome as pigging out on fries and double cheeseburgers.So their mother pushes them both to watch their diets and take their meds."I tell them, 'You don't want to end up like me.' "To that end, she and Gino encourage TC and Alika to attend two-hour interactive diabetes classes at Kaiser Permanente's Nanaikeola Clinic in Nanakuli, where a doctor, nurse practitioner, dietitian and behavior medicine specialist guide the Bell children and two other young diabetics through the various aspects of managing their disease.While the purpose is serious, the classes are low-pressure, light-hearted affairs in which the participants prepare healthy meals, compete on computer games aimed at diabetes education, and discuss useful ways of coping with their disease.The sessions include playful physical exercises, such as a vigorous match of balloon volleyball, or no-net ping pong waged across conference room tables shoved together. Invariably, these exercises culminate in raucous balloon popping or wild ping pong ball batting, but not before everyone — clinical staff included — has had a good workout.going for the veggiesThere are even encouraging signs that some of it may be achieving the desired effect. In a recent class, dietitian Justin Miyashiro watched as the kids whipped up a batch of healthy dill dip and served it with a platter of delicately prepared celery sticks, cut carrots, and sliced mushrooms and cucumbers.Not only did Alika polish off a plate of vegetables and dip, he quietly returned for seconds, which he also finished. Likewise, TC said she enjoyed the food — "Especially the mushrooms! I like them. We've got to get some of this stuff."As the class was winding down, Miyashiro threw the discussion open to suggestions for next month's healthy meal."Portuguese sausage with eggs," piped up Alika."Is that healthy?" wondered Miyashiro."OK," replied Alika, to the laughter of all present, "Portuguese sausage and eggs — with tofu."Reach Will Hoover at whoover@honoluluadvertiser.com.
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