By Inam Rahman, MD
Diabetes is usually described as a medical condition, but it is also a policy problem – one shaped by access to care, affordability of treatment, food systems, and preventive infrastructure.
Diabetes occurs when the body cannot properly regulate blood sugar due to insufficient insulin, insulin resistance, or both. Over time, uncontrolled blood sugar silently damages blood vessels, nerves, and vital organs, driving disability, health-care costs, and premature death.
The scale of the problem is alarming. In Hawaiʻi, approximately 134,100 adults – about 10.3% of the adult population – have been diagnosed with diabetes. Thousands more likely have the disease but remain undiagnosed, while an estimated 400,000 residents are prediabetic and at high risk of progression.
This trajectory is not inevitable, but it reflects systemic failures in prevention, early detection, and long-term management.
Diabetes is diagnosed with straightforward blood tests that are inexpensive and widely available. Yet many patients are diagnosed late, often after complications have already begun. The barrier is not science; it is access, continuity of care, and effective outreach to high-risk communities.
Uncontrolled diabetes is a leading cause of heart disease, stroke, kidney failure, blindness, amputations, nerve damage, and cognitive decline. These outcomes devastate patients and families while placing enormous strain on public health systems.
Dialysis, hospitalizations, disability, and long-term care cost Hawaiʻi an estimated $2.6 billion annually, including $1.8 billion in direct medical expenses and $830 million in lost productivity. Prevention and early control are far more cost-effective than treating advanced complications.
Diabetes management is not static. Many patients initially control blood sugar through lifestyle changes and oral medications. Over time aging, weight gain, stress, illness, and progressive insulin resistance can make control more difficult. In these cases, insulin therapy becomes necessary and often lifesaving.
Public discourse sometimes frames insulin use as failure, but it simply reflects the natural progression of the disease. Policy should support – not stigmatize – appropriate escalation of care through patient education, nutritional counseling, and close follow-up.
Newer diabetes medications have reshaped treatment. They lower blood sugar, reduce cardiovascular and kidney risks, and promote weight loss, addressing core drivers of Type 2 diabetes. These therapies can delay insulin use, prevent complications, and reduce long-term health-care costs.
Yet their high price places them out of reach for many uninsured and under-insured patients, creating a two-tiered system in which outcomes depend, not on medical need, but on ability to pay. Policymakers must address affordability through insurance reforms, negotiated pricing, and support for safety-net providers.
While individual responsibility matters, environment matters more. Communities saturated with sugary drinks, ultra-processed foods, and limited access to preventive care predictably produce higher diabetes rates.
One of the simplest interventions – encouraging water instead of soda or alcohol – has measurable benefits for blood sugar, weight, and kidney health. Public policy can support healthier choices through education, pricing strategies, and better defaults in schools, workplaces, and public facilities.
Diabetes is common, and while its complications are costly and disabling, they are largely preventable. Effective policy should prioritize early screening, affordable medications, patient education, and sustained access to primary care. Investing in prevention and equitable treatment is not only compassionate, it is fiscally responsible.
The most dangerous diabetes is not the severe case. It is the ignored one.
Dr. Inam U. Rahman, MD, is a Honolulu-based community advocate, physician and policy contributor in Hawaiʻi.
