by Stephanie Johnson
I WAS diagnosed as a type one diabetic in Istanbul Turkey at Capa Hospital by one of the leading endocrinologists in Turkey in 2003. Because I was newly arrived and didn’t have my residence permit sorted out yet, I didn’t have health insurance and I wasn’t “in the system.” I’d had gestational diabetes when I was pregnant and in spite of having lost about 40 pounds after my pregnancy, my GP in the United States diagnosed me as a type two diabetic and gave me some pills and a meal plan to follow. Then I moved to Turkey and ran out of pills.
Fortunately, my husband at the time knew someone who knew someone who was a former student of this famous endocrinologist, and through the extensive system of giving and getting favors in Turkey, I ended up wandering the halls of Capa General Hospital looking for the Endocrinology department. It was basic with clean, cement walls, and varnished cement floors. The brown and white cat wandering in and out of the Oncology department threw me out of my comfort zone, but considering I was an uninsured supplicant seeking a favor at a public institution, I didn’t think that I was in any place to judge the Oncology department’s choice of mascot.
I waited a long time for my non-appointment. It was me and the drug reps, in their crumpled suits with their battered black rectangular leather briefcases. Every once and a while they would pop up and ask the secretary something I couldn’t understand. They got shot down every time.
I finally got in, ahead of the drug reps. I sat down with the doctor who, of course, was fluent in English, and he reviewed my paperwork. He gave me a local prescription for what I wanted, but asked me to get some additional lab-work done. I didn’t realize it at the time, but he noticed something in my sea of American test results that my GP hadn’t. I don’t know what it was to this day, but I am forever grateful that he noticed. Our first meeting was brief, and he sent me out with a sheaf of papers to shuffle with in and out of multiple offices before I could go, in addition to the paperwork for the lab. And this was me going outside insurance!
I got my tests done through the public system; since I wasn’t insured, I had to pay for them. I still had to wait six months for the results to come back. By this time, I had a residence permit and I was able to make a “proper” appointment with the doctor, but it wasn’t a long one either.
“Yes, as I thought, you have a different condition, you are actually a type one diabetic. This means that your body will slowly stop producing insulin, and you will need to take insulin injections for the rest of your life.” That was about the extent of the discussion. They gave me an insulin pen and a handful of needle tips to get me started along with a vague description of how to use the pen to inject myself and they directed me to get a followup appointment with a doctor closer to my home and with a dietician.
As you can imagine, it was a rough start. Not only did I have the language problems of any newly arrived immigrant, but I had to work through having a life-threatening condition and how to approach management of that condition through both language and cultural barriers. Remember also, there wasn’t as much internet out there in 2003 as there is now, and I just didn’t have the access to see what other people in the world were doing.
I got better at taking injections. I had to learn to use both a long acting (24 hour) and a short acting (meal-related) insulin. I couldn’t just have a cappuccino and cake whenever I felt like it any more, I had to do bold mathematical calculations that took into account not only what I was eating, but how much exercise I had done before the meal, how much I expected to do after, my position in my menstrual cycle, if I were feeling poorly and, of course, my blood sugar at the moment I ordered that snack. It was enough to put a person right off eating.
The nutritionist wanted me to follow a strict regimen of a certain number of carbs at every meal. She insisted that I needed to make a fuss at restaurants, apparently all restaurants were required to provide wheat bread upon request; I am not sure this was actually a law. I think now it might have been her wishful thinking. What ended up happening was that I ended up being “that foreigner” that was making a scene in venues around Istanbul about how they had to provide me with wheat bread. And all that effort? I was only allowed 2 oz of bread: 2 thin slices, in a culture where a person could be reasonably expected to consume half a loaf at a meal. I doubt I endeared myself to the restaurants around my workplace.
I was also expected to follow a “Turkish” diet. For example: my breakfast was expected to contain 2 slices of (wheat!) bread, 1 matchbox sized cube of feta cheese, one tomato and one cucumber, 5 olives, and tea unlimited within reason, with a half cup of yogurt on the side. That yogurt was repeated at every meal. I protested, coming from a part of the US where yogurt was an occasional breakfast food, and still had a bit of “west coast hippy” taint, but was told that the Turkish diet was the best in the world, and if I didn’t eat the yogurt, I would be considered a non-compliant patient.
I was often noncompliant, as yogurt doesn’t really “go with” many non-Turkish meals, and since it was an unfamiliar food for me, I just couldn’t force myself to eat it several times a day, every day. Over time I also realized that if I followed their assigned diet, my blood sugar would sometimes spike uncontrollably, and sometimes crash, even when we were all sure my insulin was dialed in correctly and I was sure about my food portions. I bought a food scale, it didn’t help. I kept a detailed food log for weeks at a time, it didn’t help. I was labelled by my care team as a “brittle diabetic,” a person whose sugars were out of control in spite of all our efforts. More and more of my time was spent on trying to control something that I was told couldn’t be controlled.
Eventually, I started noticing a pattern. On the occasional days that I couldn’t get the required number of carbohydrates into a meal (we had run out of bread, or there were bugs in the rice, you know… those kinds of problems), my blood sugar would actually be within desired targets. I started being noncompliant with a purpose, cutting out the bread, the rice, the dried apricots that the medical team was requiring me to eat, and every single meal with which I reduced my carbohydrate consumption, I saw an improvement in my blood sugar. In order to get back to my normal activity level I ended up needing to reduce my insulin. My doctor and nutritionist were dubious, but my bloodwork was coming back better, and my overall health improved. I had fewer extreme low and high blood sugars.
It was at this point I finally realized that regardless of what country you are in, and how well intentioned your medical team is, you are ultimately responsible for knowing your own health, taking responsibility for your own actions, and even challenging the authorities if you have evidence that they are wrong. In 2019 even the American Diabetes Association reversed decades of opposition to a low carb diet, saying there is no one way to eat that suits every person. For me, changing the way I eat probably saved my life.
One of my favorite dishes in Turkey was “ic pilavi,” or “rice stuffing,” a side dish which makes appearances inside vegetarian stuffed vegetables, or with roast lamb. Sometimes it would have bits of liver in it, and sometimes not. Unfortunately, this fell into the same class of carbohydrate and fat loaded foods which were most devastating to my blood sugar, along with pizza and macaroni & cheese, and most restaurant Chinese food. I didn’t mind giving up most of the dishes I’ve just mentioned but was determined to keep ic pilavi in my cooking repertoire, so with the substitution of cauliflower rice, I have found a compromise that keeps me happy. Now that I no longer live in Turkey, I make this dish at least once every two weeks, perhaps spiced a little more heavily than the original dish to cover the cauliflower taste, but every time I have it, I feel like I am back in Istanbul and I am able to stay healthy at the same time. Sometimes I even have that required portion of yogurt on top!
Cauliflower Turkish Rice:
1 head cauliflower or 1 package Cauliflower rice equivalent to 1 pound (approx. 500 g)
¼ cup olive oil
1/3 cup pine nuts
1/3 cup currants (or raisins, but only as a last resort)
2 tbsp. dried mint
1 tbsp. allspice
1 tsp. dill
1 tsp. cinnamon
1 tsp. Salt
1 tsp. Sugar or artificial sweetener (optional)
Water
Parsley
Break the head of cauliflower into florets and pulverize in your blender with water to cover until the cauliflower is reduced to rice or couscous sized particles.
Heat the oil in a large non-stick pan and sauté the pine nuts until they start to brown, stirring occasionally. Add the cauliflower rice and currents, and continue to cook, stirring, for about 5 minutes or until the cauliflower starts to look cooked.
Stephanie Johnson currently lives in San Francisco with her husband, Craig. After two decades abroad, she is enjoying the challenge of trying to re-integrate into an American society that has changed dramatically in that time. She is focusing on capturing her feelings about this in her writing and recently completed an AA in English Literature at City College of San Francisco.