Around 12am last night I found Nicole standing in the middle of the bedroom, covered in cold sweat, trying to lancet her palm while talking in slurred gibberish. About once a year my wife will have a serious insulin reaction like this; usually when three or four things go wrong at the same time.
I immediately had her sit down on the edge of the bed. The biggest danger I’ve seen with hypoglycemia is not from the glucose deprivation (however frightening it looks) but suffering a physical injury.
I didn’t bother trying to wrestle some blood out of her sweaty finger to test her glucose levels. There was no doubt she was very low.
Glucose, not data, was the priority.
I went to the kitchen, dropped two glucose tablets into the blender with a half-cup of warm water (straight from the humming distiller) and hit “high.” Sorry, neighbours, emergency midnight smoothie without the banana, milk or nuts. 30 seconds later I was sitting behind Nicole, supporting her back, trying to convince her to take small gulps of the sugar water.
In her current state, I doubted she could chew a glucose tablet. We’ve been through that before. And even if she did, one really needs liquid added to those chalky things to ensure they absorb ASAP.
Some people would say: Use fruit juice. But we’ve found straight glucose much more reliable and faster. Also, in many people of Northern European descent fruit sugar (fructose) may actually block absorption of glucose.
Thirty minutes later her blood sugar had reach 3.8 mmol/L (68.4 mg/dL). She could talk normally. But those thirty minutes were torture. She was wailing, gagging and contorting her body. I almost broke out the glucagon injection. (Glucagon injections have fairly severe side effects like vomiting. We had agreed, 15 years ago, it would be the last resort.)
Another tab and twenty minutes later she was stable at 5.5 mmol/L. Covered with sweat and sugar water, she changed her clothes and got in the sauna.
“That was the worst reaction I’ve ever had in my entire life,” she said basking the warm glow of infrared lights.
Why This Usually Never Happens
Nicole had taken the same dose of long-acting insulin before bed that she always does.
Her dinner has exactly the same, carefully weighed, ingredients every night. Some may say we are “cheating.” Yet a secret to normal post-meal blood sugars is to eat the exact same meal every night. We first learned this from Dr. Bernstein’s Diabetes Solution.
Nicole has exactly 120g (4oz) of brown rice, 60g (2oz) of either chickpeas or pinto beans, 90g (3oz) of cabbage cooked with 45g (1-1/2oz) each of parsnip and rutabega. That was her dish for the cold winter months. She injects the the exact same, well-tested, combo dose of Regular and Humalog insulin. Two hours later her blood sugar would normally still fall below 6.5mmol/L (117mg/dL) while staying above 4.0mmol/L (72mg/dL).
Sometimes, of course, Nicole’s blood sugar may only drop to 3.6mmol/L (64mg/dL). A half-tablespoon of beet juice crystals and she’s back to normal in 15 minutes. She hardly even notices mild lows now that she’s long used to quasi-norrmal blood glucose levels.
So why, that fateful night, did Nicole’s dinner insulin suddenly plummet her into one of the worst low blood sugar experiences of her life? Well, airplane crashes make for a good explanatory metaphor.
Why Airplanes Crash (According to Malcolm Gladwell)
When airplanes crash there are usually multiple causes that (unfortunately) all happened at the same time. Two or three minor causes and one major cause. For example, in Malcolm Gladwell’s Outliers, we read about Korean Air flight 801. The passenger plane crashed in Guam in 1997 killing 223 people. The minor causes were: stormy weather, out-dated charts, broken airport lights and a captain deprived of sleep and jacked up on caffeine.
The main reason for the tragedy, however, was that Korean language etiquette required too many time-consuming formalities before the co-pilot could politely inform the captain that they were about to hit a cliff face. Reading the transcript from the black box would almost be funny if they didn’t all die. “You are obliged to be deferential toward your elders and superiors in a way that would be unimaginable in the U.S.,” says Gladwell.
Three Minor Causes of Nicole’s Blood Sugar Crash
Likewise, with Nicole’s blood sugar crash there were two or three minor causes:
1. The weather. Yes, weather affects insulin needs. While stormy whether may cause a plane crash, a temperature change can cause a blood sugar dip. On the day of her blood sugar crash, the weather had gone above zero after a week of freezing temperatures. Anytime the thermometer goes above zero Nicole’s long acting insulin needs drop a little.
2. I tried cooking the pinto beans in the oven instead of the slow cooker. They ended up being a bit under-cooked. 6-hours in the slow cooker produces a delicious, soft and easy to digest bean. The slightly under-cooked version probably didn’t break down as well in our gut, not releasing as many carbohydrates to keep the insulin busy.
3. This is a maybe: Sometimes gluocometer give slightly inaccurate readings. Nicole’s blood sugar may have already been low before the meal and she didn’t realize. Likewise, insulin injections are not always perfect. She may have injected a little more than needed.
But none of these — or even all three of them together — were probably enough to cause such a serious blood sugar crash.
The Big Culprit
The big culprit was how I cooked the rice.
Normally, we don’t eat rice how you typically see it served in North America or Europe (boiled to al dente). Instead, we use a mill (or coffee grinder for small batches) to freshly grind it into a coarse meal. Think corn meal. Well, this is rice meal. We then cook it into a thick porridge (using the broth from the vegetables and beans) similar to corn grits or polenta.
But that fateful night, we tried cooking the rice whole. We did cook it until very soft and the rice was breaking up (similar to Asian congee).
Why would this make such a big difference? Absorption. Grinding the grain ensures that all the carbohydrates will be absorbed. Chewing grains cooked whole will never break them down as fine (unless you are willing to chew 200 times each mouthful). How well the rice absorbs will vary from person to person and their chewing capacity. Nicole is missing a number of molars so it’s doubly hard for her.
Yet even for those with a full set of chompers, chewing rice to the consistency of rice meal would be a ridiculously long chore. I think this is why many people who are overweight rapidly lose weight eating whole grains — they only absorb half the calories. Likewise, our 12-year old son only puts on weight if he is eating unrefined meals and flours. Give him whole grains and his growth spurt halts.
So I think that is what happened. Nicole probably only absorbed half of the calories from her bowl of rice. The next night we returned to coarsely ground rice meal and her blood sugar was 4.4mmol/lL (79mg/dL) at bedtime.
Does that mean you can’t eat whole rice and get stable blood sugars? I’m not sure. If you cook the rice exactly the same each night, for the same amount of time, heat and water, and then chew it just as well each night, I’d think you could achieve stable blood sugars (just with less insulin).
Of course, do you want to only absorb half your calories? If your trying to lose weight, you might. But it’s just not calories, it’s also the vitamins and minerals you’ll be losing.
Some theorize that the non-absorbed particles of whole grains go to the colon where they feed healthy bacteria. Personally, I’d rather feed myself. I’m very active and find eating whole grain akin to slow starvation.
Likewise, if you look at many traditional cultures around the world you see that they didn’t eat whole grains. Cornmeal was part of the three sisters staple of the aboriginals of America. The Middle East relied on flat breads made from stone ground wheat. The Celts would grind oats and cook them into a porridge. The Russians would cook buckwheat into a soft porridge. Considering the amount of extra labour and/or fuel involved, especially before mechanical mills, it must mean that the traditional cultures realized that the extra energy derived from eating coarsely ground grains was greater than that lost in grinding and cooking them.
Even the traditional rural people of China don’t eat whole rice (whether brown or white). Instead they eat congee, which Wikipedia describes as “a thick porridge of rice largely disintegrated after prolonged cooking in water. ” It states it’s popularity was because it was “easy to digest and very simple to cook.” In the north of China, where rice does not grow, they use corn, millet, barley or sorghum. So, like grinding, congee requires more cooking fuel, which would be more laborious. They must have realized that the extra energy expended boiling their rice down to the point it dissolves into a porridge was superseded by the amount of extra energy they would obtain. When you work all day, under a hot sun, in a rice paddy infested with leeches, you’re not going to waste time or fuel on cooking if the payback isn’t worth it.
Really, to me, eating whole grains is like tossing half the dish in the toilet. Much of the calories are going to go right through you. If you want to lose weight it would be easier to just skip a meal or fill up on vegetables instead.
Regardless, the above incident shows the attention to detail that is needed if you want to avoid low or high blood sugars after meals. The meal must be measured the same and cooked the same way every night, with the same doses of insulin, given at the same time relative to the meal each day.