A smile spreads across Joe Otulau's face as he recites his food vices, most notably pork smothered in gravy with rice and macaroni salad on the side.

Otulau, a 55-year-old widower, lives by himself in Kalihi and eats almost every meal out during breaks from his work as an estimator for a construction company. He knows he has to do a better job of eating smaller, healthier portions to manage his diabetes, but the temptations of local food can be overwhelming.

"The diet — it's hard," he said. "Eating all those kinds of things, I need help. Hawaiians, Tongans, Samoans, we have a problem with all of the food."

You're not alone, Joe.

According to Department of Health surveys, 57 percent of Hawai'i adults are either overweight or obese, a major risk factor for diabetes.

Otulau has type 2 diabetes, the most common form of the disease whose complications include stroke, hypertension, lower-limb amputation, blindness, kidney failure, dental disease, pregnancy problems and sexual dysfunction.

Public health officials say it's no coincidence that type 2 diabetes is expanding at the same time as the nation's waistline.

Nearly 8 percent of Hawai'i's adult population has been diagnosed with diabetes, up from 6 percent five years ago, and 5 percent a decade ago, according to the U.S. Centers for Disease Control and Prevention.

"We live in a fast-food, super-size, sedentary society. Ten to 20 years ago we all walked home and ate home-cooked meals and were out in the yard playing," said Majken Mechling, head of the American Diabetes Association in Hawai'i.

"In Hawai'i, with both parents working and long commutes, we don't have the luxury of the home-cooked meals that we used to have. We don't have time to shop at produce markets, and the best foods aren't always the cheapest."

Although Hawai'i's diabetes rate is slightly lower than the national level, the disease has a disproportionate impact on Native Hawaiians, Pacific Islanders and Asians, who together account for more than half the state's population of 1.28 million. Research shows those groups have a significantly higher prevalence of diabetes than whites in Hawai'i.

In some communities with a higher proportion of Native Hawaiian and Pacific Islander residents, more than one in 10 people have diabetes.

"It's a growing problem and we're not going in the right direction," said Danette Wong Tomiyasu, chief of the state Health Department's Chronic Disease Management and Control Branch.

She called diabetes "a silent disease" that reaches across generations and communities.

"Until you notice you're having symptoms, people don't realize the lifestyle they're leading or things that they're doing are negatively impacting their health," she said. "People really, truly need to realize the severity of the problem is that it can lead to death. It affects the entire family."

STAGGERING COSTS

Medical costs related to diabetes in Hawai'i have been estimated at nearly $1 billion. Nationally, the figure is $116 billion, according to the American Diabetes Association. That doesn't include an additional $58 billion lost from reduced productivity from absenteeism, unemployment from chronic disability stemming from diabetes, and early death.

The dollar amounts don't consider the social cost of patients' suffering or the financial and emotional stress on family caregivers.

Yet, public health experts say there has been a lack of urgency in addressing the diabetes pandemic.

Mechling said diabetes hasn't gotten the attention it deserves "because people die from the complications and not the disease."

"People die of heart attack or they die of a stroke or cancer, but if you track back you'll find the initial diagnosis of diabetes," she said.

In 2006, diabetes leapfrogged influenza/pneumonia to become the sixth-leading disease in Hawai'i, according to the most current Health Department statistics. The death rate from diabetes was 18.1 per 100,000 residents, compared with 10.9 per 100,000 in 1996.

Diabetes-related deaths are believed to be vastly underreported, particularly in the cases of older patients with multiple chronic conditions such as heart disease and hypertension. Although 271 Hawai'i deaths were directly attributed to diabetes in 2006, healthcare officials estimate that more than 900 die annually from diabetes-related causes.

Dr. Rick Custodio, medical director at the Waianae Coast Comprehensive Health Center, agrees it often takes a heart attack or stroke before people with diabetes begin to take the disease seriously. The O'ahu communities served by the health center have the highest diabetes rates in the state.

'CONTINUAL STRUGGLE'

"It's not like cancer where you get it and suddenly you can be dead in a couple of months if you don't take care of it," he said. "In a way, diabetes is silent and then it explodes. It's not until you have a heart attack or a stroke that you start making life changes.

"There is a lot of denial."

Custodio knows something about denial. He was diabetic and overweight as a young medical school graduate and underwent a quadruple bypass at age 40. Ten years later he admits it's still difficult to maintain a healthy weight.

"It's a continual struggle. That's why I identify with a lot of the people. The hard part is we know what we need to do, we just don't do it."

Diabetes is a disease in which the body does not produce or properly use insulin, a hormone made by the pancreas that allows glucose, or sugar, from food to be converted to energy.

When diabetes is not controlled, glucose and fats build up in the blood and, over time, damage vital organs and lead to potentially fatal complications.

People with type 1 diabetes produce no insulin. In order to survive, they must have insulin, delivered by injection or a pump.

Type 1 usually develops in children and young adults, but onset can occur at any age. It accounts for 5 percent to 10 percent of all diagnosed cases of diabetes.

More prevalent is type 2 diabetes, which accounts for 90 percent to 95 percent of all cases. It used to be known as adult-onset diabetes until more children began developing the condition. Treatment includes medication, healthier diet and increased physical activity.

A third type of diabetes is gestational diabetes, which occurs in about 4 percent of all pregnant women and usually goes away after the baby is born. However, 40 percent to 60 percent of women who experience gestational diabetes will develop type 2 diabetes later down the road.

Nationally, the number of Americans with diabetes increased by more than 3 million in the past two years, according to the Centers for Disease Control and Prevention. Diabetes now affects nearly 24 million people in the United States.

Much of the increase is attributed to the country's growing elderly and minority populations, which experience higher rates of diabetes. But poor behavioral choices affecting body weight and physical activity are gaining more prominence as risk factors.

In Hawai'i, the Health Department estimates up to 102,000 adults have diabetes, including 26,000 who don't even know they have the disease. An untold number have pre-diabetes, with higher than normal blood glucose levels verging on type 2 diabetes.

As more studies are conducted, the societal, medical and economic impacts of diabetes are becoming more apparent, said Jane Kadohiro, a diabetes consultant and assistant professor at the University of Hawai'i's School of Nursing and Dental Hygiene.

"Ten or 20 years ago, there was nothing 'sexy' about diabetes. No one was worried about it," she said. "We didn't have the startling data that we now have nationally as well as in Hawai'i. We knew that it caused complications but we didn't know how badly if affected people.

"With adults it certainly was a ho-hum disease that people didn't want to give much attention to. We've started to recognize that more and more people are getting type 2 and that the cost to our country in terms of dialysis, hospitalizations for diabetes and complications is really bad," Kadohiro said.

OUNCE OF PREVENTION

As type 2 diabetes extends its grip on the nation, the American Diabetes Association has seen its traditional focus shift from educating people on how to manage the disease to prevention.

Mechling said the volume of calls to the local association from people seeking information on the disease has jumped 60 percent in the past four years. Despite the increasing awareness, many still consider type 2 diabetes an older person's disease, she said.

"People think you turn 50 and you get diabetes. In fact, people are getting diagnosed in their early teens, which was unheard of 20 years ago. We are seeing more and more children with type 2 diabetes than I've seen in a very, very long time," she said.

Diabetes still disproportionately affects the elderly. Almost 18 percent of Hawai'i residents age 65 and older have diabetes, according to Health Department estimates.

Because there may be no symptoms, people often suffer unknowingly from type 2 diabetes for years before they are diagnosed, according to retired endocrinologist and diabetes expert Dr. Wilfred Fujimoto.

"It sort of creeps up on you, then your doctor says your sugar levels are high and puts you on a diet and tells you to exercise," Fujimoto said.

"There's nothing dramatic about that type of treatment. It's not like cancer where you get surgery or chemotherapy. The disease doesn't seem to be as dramatic at onset, but in the long run, diabetes exacts a tremendous toll."

MISPERCEPTIONS

Social attitudes about people who are overweight are another reason diabetes is only now being recognized as a public health disaster-in-waiting, according to Kadohiro.

"We still tend to blame the person with diabetes: 'It's their fault so why should we care?' " she said.

Others discount the disease because diabetes is treatable, and new medications and monitoring tools have made it easier for patients to manage the condition.

"A lot of people think it is a controllable disease. But for people with type 2 diabetes it's not a matter of simple control. You're talking about major lifestyle changes," Kadohiro said.

Making those changes is a challenge for construction company estimator Otulau, who faces a triple diabetes whammy: He's a Pacific Islander, he's lax about diet and exercise, and type 2 diabetes runs in his family. His mother and two aunts died from complications of the disease and his sisters have it, too.

So Otulau has to remind himself to eat better and to stop eating late at night.

"The diet is my main problem but the other thing is exercise," he said. "I'm not doing too good with it."

Not everyone who is overweight and inactive will develop diabetes, and Fujimoto said many people are willing to gamble they won't get the disease.

"Although people know that a healthy lifestyle can help prevent diabetes, it's human nature to think, 'I still have a pretty good chance of not developing diabetes.' It's human nature to look at the flip side of the coin," Fujimoto said.

Anyone willing to take that gamble might want to first consider the worsening odds and potential losses for themselves and family members.