The University of Texas at Austin
  • Twenty Years of Diabetes Research in the Rio Grande Valley

    By Tim Green, Office of the Vice President for Research
    Published: June 25, 2012
    Colonias in Starr County, Texas

    Many of the participants in Sharon Brown’s diabetes programs lived in colonias, makeshift communities without basic services such as running water, sewers and electricity.

    When Sharon Brown started working with Hispanic patients on diabetes self-management in Starr County, colleagues warned that previous efforts had failed.

    After Brown, a professor in the School of Nursing at The University of Texas at Austin, started working in the rural county in the Rio Grande Valley, she realized why.

    “They didn’t speak the language,” she said with a hint of exasperation.

    Early efforts in diabetes self-management education programs with Hispanics along the Texas-Mexico border were conducted mostly in English, ignoring the fact that the 95-percent Hispanic population spoke mostly Spanish.

    On a deeper level, previous projects ignored important aspects of Hispanic culture when devising diabetes self-management programs.

    So Brown set out to do things differently in a series of experiments to find effective ways to educate Hispanics on managing diabetes. She didn’t want to change their way of life, just help them live it in a healthier way.

    Our goal knowing they had little access to health care and few resources, was to determine what we could do to improve their health with what they did have, because diabetes cuts off six to 10 years of your life. Professor Sharon Brown, School of Nursing.

    In short, make tortillas, but lay off the lard.

    Professor Brown

    Professor Sharon Brown

    During the past 20-plus years, Brown has pioneered programs that have helped participants reduce complications from diabetes. The programs have been adapted for use along the U.S.-Mexico border and in other parts of the United States.

    “Dr. Brown has been a leader in the development and evaluation of culturally relevant programs for Hispanic adults with type 2 diabetes,” said Robin Whittemore, an associate professor in the School of Nursing at Yale University who has studied diabetes treatments. “Her work has not only improved access and quality of care for the Latino community in Starr County, but has served as a model for programs around the country.”

    Converging Trends

    The Hispanic population is the fastest growing segment in the United States, and it has one of the highest rates of diabetes. Projections are that Hispanics will make up 40 percent of the U.S. population by 2030, up from 20 percent today.

    Chart comparing Starr County stats to the State of Texas

    At the same time, rates of obesity and diabetes are rising throughout the country. Diabetes is the third-fastest-growing chronic disease.

    Starr County, in the western Rio Grande Valley, is the third poorest county in the United States, with an average household income of $24,441. Many of its residents live in colonias, makeshift communities without basic services such as running water, sewers and electricity.

    The county is designated by the State of Texas as “medically underserved,” with ratios of residents to doctors and nurses double and triple the rates of Texas as a whole.

    The county also has one of the highest rates of diabetes in the state — 50 percent of residents 35 and older either have diabetes or have a close relative who does.

    “Our goal, knowing they had little access to health care and few resources, was to determine what we could do to improve their health with what they did have,” Brown said. “Because diabetes cuts off six to 10 years of your life.”

    Diabetes complications start with infections that don’t heal, fatigue and vision changes. Higher on the severity spectrum are blindness, amputation of limbs — usually feet — kidney damage and failure, and death.

    Getting Grounded

    Brown was introduced to Starr County by Craig Hanis, a geneticist who has conducted diabetes research in the county since the early 1980s. Brown and Hanis have collaborated over the years.

    Initially, Brown and her colleagues met with people from the community to hear what they wanted in such a program.

    “We spent days just interviewing people, finding out what their experiences were with diabetes, what they thought the problem was, what they thought needed to be done and what they thought we needed to emphasize.”

    Diabetes management can get complicated quickly. Learning about food exchange lists, counting calories and weighing servings takes a lot of time and effort.

    That’s something Starr County subjects wanted no part of. They’d gotten a taste of those strategies in previous studies and viewed them as too intrusive.

    “They told us they didn’t want to live their lives counting and weighing. ‘If you can’t come up with something better than that, forget it,’ ” she said.

    So Brown devised self-management education programs that were less strict.

    For example, instead of using scales to measure how much food they consumed, the participants were encouraged to think of an appropriate portion as the size of their palm.

    People were able to turn to each other for support. That really helped them stay with their diets and stick to the program. Hilda Guerra.

    A New Diet Plan

    Adjusting diet was a major part of the programs.

    Brown tells of going to a grocery store on one of her early visits to see how people shopped and what they bought.

    It was hard not to notice that right inside the store was a pyramid stack of cans of lard. Brown said shoppers took two carts, put cans of lard in one and the rest of their groceries in the other.

    “That became one of our main targets,” Brown said. “How can they reduce the lard?”

    Each education session included a demonstration of cooking healthier versions of Hispanic meals, such as substituting vegetable oil for lard and focusing on portion size.

    The participants pressured one another to taste the healthier dishes, fully expecting them to taste terrible.

    “Then they’d try stuff and find it’s pretty good,” Brown said.

    The next step was a field trip to the grocery store where the dietician identified healthier foods and showed them how to read labels.

    Eventually, Brown said, the grocery stores got involved and provided demonstrations on their own.

    Social Support

    Brown also designed the programs to tap into the social aspects of Hispanic culture. Although not exactly festive occasions, the sessions enabled the participants to talk about their diabetes and how they dealt with it and then draw support from their classmates.

    Starr County colonias

    Starr County, Texas

    The sessions were held in the evenings. At times, there were sessions every night of the workweek — except Friday, which was reserved for football in the fall. Locations were community gathering places where people would feel comfortable, primarily churches and schools.

    The participants enjoyed the social part of it, said Hilda Guerra, the manager of the Rio Grande City field office, who helped organize the sessions.

    “People were able to turn to each other for support,” she said. “That really helped them stick to their diets and stay with the program.”

    There was never a problem with recruiting participants for a program of classes or with absenteeism during the course of a program.

    Measuring Progress

    A key measure of diabetes is called glycosylated hemoglobin, known as HbA1c, which is a reflection of how high blood glucose has been over the past three months. Glucose molecules attach to the hemoglobin in the blood, and that causes eye and kidney damage. The higher the HbA1c, the worse the diabetes.

    Brown said the HbA1c levels of program participants at the start of a project were as high as 18 percent.

    “The first time we got those results, we reran them all,” Brown said. The high levels were confirmed.

    The average HbA1c level was 12. A non-diabetic level is less than 7, according to the American Diabetes Association.

    The interventions resulted in reducing the average level to 9, a 25 percent decrease.

    “For every point reduction, you reduce complications by 25 to 75 percent and extend life six to eight years,” Brown said.

    The results achieved by Brown’s programs were as effective as a common diabetes drug. But the programs’ cost was less than $400 per person for a year. The drug’s cost at the time was $1,200 a year.

    Brown said there is evidence that people can maintain improvements achieved through the classes as long as there is some ongoing contact with them such as checking in by phone.

    The initial self-management education sessions were conducted weekly or biweekly for a year. Later, shorter versions were designed to be conducted weekly for two months.

    “What we have found is that the typical few hours of instruction when people are diagnosed is not useful,” she said. “And that more is better.”

    More hours, however, are more costly. But it’s a reasonable price, Brown said.

    “Particularly if you offset it with the decrease in the complications that occur,” she said. “It’s much more cost effective.”

    Overall, Brown received more than $7 million in research grants from the National Institutes of Health, the State of Texas and other sources. She and colleagues published more than 60 papers on diabetes interventions.

    “The result has been a growing body of evidence about effective strategies to promote health and prevent worsening illness and diabetes complications for Mexican-American and other underserved groups,” said Alexandra Garcia, an associate professor in the School of Nursing at The University of Texas at Austin. As a graduate student, Garcia worked with Brown in Starr County.

    But the story of Brown’s diabetes research projects is about more than numbers. It’s about bringing a new health consciousness to a community and developing a supporting environment among those with diabetes.

    That was brought home in the last meeting of a yearlong course when a student was uncharacteristically late — none of the participants had missed a class.

    When the man arrived, he explained that he’d been to his doctor who put him on a different diabetes regimen.

    “He was scared to death because now everything’s changed and the group is over,” Brown said.

    Before Brown or an instructor could say anything, members of the class started asking him questions. What exactly did the doctor say? What is the new medication? They compared his answers with what they had learned in the class and their own experiences.

    “They problem-solved with him, gave him suggestions,” Brown said. “There wasn’t anything I had to correct. Everything they were telling him was right. It was amazing to watch.”

    They must have had a good teacher.

    • Quote 2
      Rene Cisneros, Ph.D. said on June 29, 2012 at 11:33 p.m.
      Where can I find details for the Spanish language diet plan that you devised? The large Central California farmworker population needs your help.
    • Quote 2
      Lois Sturgis, RN said on June 29, 2012 at 12:27 a.m.
      I just wanted to take this opportunity to THANK everyone who has been helping the people of the Rio Grande Valley, to manage their diabetes. I was impressed with the way that your research was conducted. Thank you again, for helping these poor people. They want very much to manage their diabetes. All they need is someone to educate them and to take their culture into consideration when doing so. I am a Spanish-speaking RN who has lived in the Rio Grande Valley most of my life. I have been working as a substitute school nurse for the South Texas Independent School District in Hidalgo County, since the fall of 2011. I can tell you that by far, the majority of the children who present to all 5 school clinics that I cover, are extremely overweight. Ninety per cent of the children are Hispanic. These children also need someone to educate them constantly about nutrition, portion control and about the importance of "some" exercise (they love to dance), and the health benefits of drinking plenty of water (instead of soft drinks). Perhaps your program could be incorporated in the school setting, along with "" which I just found out about today, on the Internet. It concerns me greatly because they are the future. When I see the type of lifestyle they are living, I can surmise that their future does not look good. Diabetes,Type 2, as we all know, is a complex disease that is totally avoidable. What is very sad is that diabetes is an enormous, unnecessary drain on the medical community and scarce medical resources available. Thank you again for committing 20 years of your life to such an incredibly worthy mission. May you continue to receive God's blessings.
    • Quote 2
      Melba Vasquez said on June 28, 2012 at 6:59 p.m.
      Providing interventions that have been culturally adapted is the only way those interventions will be effective. Congratulations to Dr. Brown and her team...may the success inspire us all!
    • Quote 2
      Barbara said on June 28, 2012 at 6:39 p.m.
      Great approach with outstanding results. I think one of the key factors that led to the program's success was the listening that Dr. Brown and her colleagues did at the outset. Educating people on small changes they can make in food preparation and portion sizes can go a long way to improving their health. Education and community involvement are a lot less expensive than the healthcare costs that obesity and diabetes incur. congratulations and please expand your work quickly!
    • Quote 2
      Enedelia Obregon said on June 28, 2012 at 3:48 p.m.
      I grew up in the Valley in a colonia surrounded by people with diabetes, including most of my family. I remember doctors and nurses trying to convince my mom to change her diet. Didn't happen. I'm so glad to see health care professionals taking culture into consideration. One cannot take off culture like a coat. You can't force people to change generations of eating habits overnight. But small changes yield better results and you can build from there.
    • Quote 2
      Ann Shopoff said on June 28, 2012 at 10:30 a.m.
      Craig, we can nit-pick the population statistics, but it still says the Hispanic population in the US will increase. Providing education and interventions that increase the quality of life for Hispanics with diabetes and decrease the total cost of the disease in the population targeted is what Dr. Brown's research was about. She clearly succeeded (where others had not)and should be applauded. Quality health care should not be about who has the most money, and she shows that.
    • Quote 2
      Susan Beckman said on June 28, 2012 at 9:02 a.m.
      Affecting change generally boils down to knowing and understanding the culture of the people you are serving. I believe Dr. Brown's research and approach to helping the Hispanic population manage their disease on their own turf are proof that she and her colleagues are definitly on the right track.
    • Quote 2
      Bobbie Sterling, RN, PhD. said on June 25, 2012 at 8:01 p.m.
      Great story and a reflection of the effectiveness and relevance of Dr. Brown's research when there is leadership that results in collaboration and community involvement.
    • Quote 2
      Craig said on June 25, 2012 at 3:51 p.m.
      For what its worth, if you are going to include statistics in your articles, which are abused enough as is, please try to be as accurate as possible. There are multiple examples in this article, but to reference one: "Projections are that Hispanics will make up 40 percent of the U.S. population by 2030, up from 20 percent today." The US Census Bureau has those numbers at 23 percent and 16 percent respectively. (
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