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