“One cup. Cross my heart.”
Just a casual reply my patient threw out there, with a smile on her face, when I asked her how much rice she’d been eating per meal since her last clinic visit. Mrs. F is a sweet little lady — but I wasn’t totally buying her answer. You see, she stands a mere four foot, eleven inches, but her weight tips at a staggering 80 kg — easily earning her an obese II classification. More importantly, she is one of six million Filipino people with type 2 diabetes — a number that is swelling at an alarming rate every year.
I raised a skeptical eyebrow, and sure enough, the reluctant confession escaped her lips.
“Okay … sometimes I add a little extra.”
The first time Mrs. F showed up at the clinic, her baseline fasting glucose was high, her lipid levels were high, her blood pressure was high — an impressive combination considering her formidable daily armament of three antidiabetic drugs, two antihypertensives, two drugs for dyslipidemia and one analgesic for knee pain.
“I have been taking all my meds. I really have,” she explained earnestly.
Well, it was true. She had been exceptionally compliant with her colourful assortment of tablets, neatly stacked inside the compartments of a cute little pillbox. But her daughter, who accompanied her that day, seemed to know the problem.
“It’s the rice. Extra rice!”
Ah, rice. The beloved staple of Filipino cuisine — so much so that a meal is not a meal without it. But for people with diabetes, rice is also deliciously, sinfully evil: It jacks up glucose levels more readily than, say, apples or bran cereal. And the story doesn’t end there. In the Philippines, rice-loving people enjoy their rice with bread, or noodles, or pasta, or potatoes — the permutations multiplying with every festive season and resulting in what I term a “carbohydrate catastrophe.”
![Figure](https://www.cmaj.ca/content/cmaj/189/35/E1117/F1.medium.gif)
Image courtesy of zyxeos30/iStock
When I examined Mrs. F, I found dark, velvety patches covering the folds of her neck and upper back. It’s a dreaded sign that her body is slowly becoming resistant to the effects of chronically high blood glucose levels, despite the medications, and I knew at once what my next recourse would have to be.
“I’m afraid I’ll have to start you on insulin.”
The lighthearted beam on her face gradually morphed into a weary, drawn-out groan, and her eyes grew wide with uncharacteristic fear, like a terrified tot entering a dentist’s office for the very first time.
“But that’s like some sort of … last resort, isn’t it? I know of someone who was on insulin for the longest time. He eventually had his right leg sawn off — can you imagine?”
The last statement, in all its gruesomeness, had yet to register fully before her voice fell into a deadened whisper.
“My neighbour — she was also on insulin. She didn’t last the year.”
To my patient’s ears, I might as well have just sounded the proverbial death knell.
“I don’t want to end up like them,” she said, almost desperately, squeezing my hand. “You have to help me.”
“Then we’ll have to cut the extra rice first.”
Working with patients like Mrs. F often reminds me of why I became an endocrinologist in the first place. It’s a field that harnesses the tremendous power of trust and patient partnership. Here, things run on a two-way street: Without a patient’s full commitment and cooperation, you realize that you can only do so much, and go only so far.
On her next visit, Mrs. F came to the clinic, crying. “I had a lot of rice,” she choked. “So much of it!”
I braced myself for the impending litany of excuses. It was almost noon and I had at least 10 patients to go for the half-day clinic — all impatiently waiting outside and willing to kill for a chance to dash through the door.
And that was when the floodgates opened.
Her husband was seeing another woman. It wasn’t exactly news to her, as the affair had been going on for ages. But like countless other women, she had preferred to turn a blind eye instead, as long as “he came home every night.” One night, however, her husband stopped coming home for good. It was more than she could bear, and it had devastated her so much that she’d gorged on rice like tomorrow depended on it.
I took a few bodily measurements, which merely confirmed the obvious. Her waist circumference remained 38 inches. A quick glance at the flimsy piece of paper containing the results of her at-home blood glucose monitoring told me the numbers weren’t encouraging, either. If it had been a different scenario, I would’ve launched into a lengthy talk admonishing her for not looking after herself, but the woman was going through an awful time — dealing with a philandering fellow and all — and diabetes was probably the least of her concerns just then. I decided to cut her some slack, after all.
“I’m sorry,” she muttered. “But sometimes, the rice is all I have.”
Slowly, I remembered the daughter’s words. Mrs. F had indeed been taking extra rice all this time — all these sad, sad times — and it dawned on me that for this particular patient, rice wasn’t merely an edible grain meant to accompany the main meal or fill one’s growling insides. Rice was her emotional crutch, on which she was leaning for support during this difficult personal episode. Some people have their music, while others have their art; she had her rice.
There are probably thousands like her — multitudes of patients with diabetes who are on a chocolate binge to nurse a broken heart, who turn to endless slices of pizza to cure loneliness, who guzzle down bottles of soda as a salve for grief and despair. In endocrinology, we frequently lament the fact that patients can be incredibly stubborn with regard to how they take their meds and watch their diet. But without probing further and listening to their hidden life stories, would we even get to unlock the exact circumstances behind why they act the way they do? Why they eat the way they do?
I wanted to remind Mrs. F about keeping her side of the bargain, but at that moment, what she needed more was a pivotal push to help her remember that things might be a little rough just then, but she could do much, much better. I calmly encouraged her not to lose sight of the goal at hand.
Bit by bit, she began to pick up the pieces of her life where she’d left off. She moved back with her daughter to her parents’ house, where she started a small business to augment her meagre finances. She joined a neighbourhood Zumba class and had a blast with the other ladies every afternoon. The last time we saw each other, her weight was down to a healthy level. Her waist circumference had shrunk as well, and both her blood pressure and blood glucose readings remained consistently within target. The results were breathtaking. She was in the best shape of her life.
Before she left the clinic, it was time to pop the magic question.
“And how about the rice?”
This prompted a little laugh, lush and luxuriant, her face clearly amused.
“Just one cup. Cross my heart.”
There was a newfound sparkle of vitality in her voice. Nevertheless, I still steeled myself for the possibility of another surreptitious declaration.
“No extra?”
“Oh! None at all. I don’t think I’ll ever need it again.”
And that was how she conquered not only diabetes, dyslipidemia, obesity and hypertension, but her whole life ahead of her. Looking back, I marvel at how fate extends a generous measure of kindness to those who deserve it, and work hard for it. Oftentimes, it’s worth finding out what’s behind all that extra rice.
Footnotes
This article has been peer reviewed.
This is a true story. The patient has given her consent for this story to be told.