Starting metformin for Type 2 Diagnosis

Hi all,

I am new to this! I received my Type 2 diagnosis about two months ago an an annual checkup. My A1C was 8.5. While I am overweight and have a family history, this surprised me because just a few months earlier my numbers were normal (5.5 I think, fasting of 85 most times I would use my husband’s monitor). My doctor suggested I try diet and exercise first.

Regardless, over the last two months I have dropped 15 lbs and really cut out a lot of my carbohydrates, though at 120-160 g a day, it’s not very low. After the first month when I was struggling to see blood sugar improvements, the last month I have been able to stay between 110-130 for two hours after eating - but that is also my fasting range. I only rarely can get below 100, even if it’s been many hours since I ate. Somehow my body keeps finding glucose to burn, and I will often find (with repeated testing) that my numbers are rising with no food. For a while my highest readings (140-160) were in the morning no matter what I did the night before (exercise, eat a snack, don’t eat a snack, have a super low-carb dinner with no snack, etc). They have trended down now, but they are never below 100.

After I let my doc know about my higher morning readings, she suggested taking metformin ER once a day. But she didn’t say if I should take it in the morning or evening, and I am open to experimenting. Does anyone have any thoughts?

Also, I should say that I am about to embark on a (no doubt related) voyage with my liver, because repeated liver panels returned very high ALT and high AST numbers, which indicates some liver damage. An ultrasound found some evidence of fatty liver, but my doc said they were too high to be explained by the fatty liver. I am heading to a specialist soon to be evaluated further. Personally, I suspect autoimmune hepatitis, as I have a history of autoimmune issues.

Anyway I really appreciate this community and any thoughts people have about this - particularly what I might try with metformin and what specific things I might want to talk to my specialist about regarding my liver and diabetes. Thanks!

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Hi Ann, welcome to the club no one asks to join! There is wonderful support, information, and experience here on this forum. Although I am Type 1, I was originally diagnosed Type 2 and use Metformin. A couple of things I’ve discovered might be of use to you, given the following part of your question:

So, there are three primary ways that the body finds “glucose to burn,” or release into the bloodstream. You can digest carbohydrate and convert to glucose (why we get the postprandial spike); your body can convert ingested (or stored) protein into glucose (“gluconeogenesis,” which is pretty rare at “problematic levels” if you aren’t super-skinny, Type 1, or eating no fats or carbs at all); and your liver can convert stored glycogen and release glucose into the bloodstream. Since you have high fasting BG, and especially if they are higher than your bedtime BGs, that sounds like the last bit (also known as “Dawn Phenomenon”).

The liver often tries to be helpful by dumping glucose into the bloodstream to help us get going in the mornings. For those of us that are diabetic, this isn’t nearly as useful as it might be for someone with a “normal” metabolism. The three ways to deal with Dawn Phenomenon are pretty standard: use basal insulin which can help normalize sugars not the result of digested food; take Metformin ER (which helps to stop the liver from dumping glucose); or starve your liver of glucose (and thus glycogen) by eating very low-carb. If you’re Type 2 without a very high A1c, the latter two options are likely your best bet.

As for timing of Metformin ER: ER is extended release, and it has a fairly long action (12 hours?). You might try taking it at bedtime for starters and see if that helps with the morning BGs. It takes time to build up in the system to effective levels. I take 500mg ER at night and 500mg ER in the morning, and that helps a ton with my Dawn Phenomenon (and some related issues like exercise-induced high blood sugars).

Personal experience here, so take it for what it’s worth (“Your Diabetes May Vary” is the watchword in these parts): I can “starve” my liver of glycogen if I eat less than 50g of digestible carbs a day and exercise a lot (I lift weights 3x per week and cycle and row on off days). If I do that, my fasting BG is almost always below 90mg/dL. If I eat more than 50g of carbs, or I skip a day of exercise, my fasting BG will usually be in the 100-120mg/dL range. Many people who don’t exercise a lot find that “ketogenic” diets work well for them, and that usually means less than 25g of digestible carbohydrate per day. That amount doesn’t work for me, since I experience uncontrollable (and undesirable) weight loss if I eat that way. But it does work for a lot of people! Might be worth trying.

Personally, I suspect autoimmune hepatitis, as I have a history of autoimmune issues.

Other thing is this: with a history of autoimmune disease, you should really insist that your doctor order a full panel for Type 1 autoantibodies. Sudden onset (5.5 to 8.5 A1c and 85 fasting to 140+ in a few months) is something that is characteristic of LADA (adult onset Type 1). It’s worth finding out, since if you are Type 1 Metformin is not likely to do the trick (for long, anyways). Forewarned is forearmed…

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Thanks for the encouragement and suggestions. I might try a very strict carb diet in the future, but my next step now that I feel like my diet is sustainable is to increase my exercise levels. Or, rather, I should say - start exercising again, as I have been way too sedentary. I am pretty nervous about this liver issue.

Two things to add: if you have one autoimmune disorder, you are at elevated risk for others. They often (not always, but often) come in clusters. For example, Type 1 diabetes paired with RA is a common occurrence. In addition, misdiagnosis—being mistakenly diagnosed as Type 2 when you are in fact Type 1—is depressingly common. @David49’s experience illustrates the point perfectly. One of our valued members, @Melitta, has written extensively about the problem. Bottom line is, get those antibody tests!

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Ann, I think both Davids covered the bases, but I just wanted to pipe in because you sound a bit like me. I was diagnosed this February and it was a huge surprise.

If there is any question, get tested for Type 1. It didn’t take long for the results and it would have made a difference in our plan of attack.

And everyone IS different, so don’t panic when you don’t seem to follow a pattern. I experience Dawn Phenomenon sometimes and spikes if I get too hungry (sometimes). I can have two days that are “identical” from food to activity to testing times and get BGs that are very different.

So, please check your numbers because you are learning and you need to be aware, but don’t become obsessive about it (I was for a while). It can make you crazy. And it can make you hate food and feel horrible and defeated when you are doing everything “right” and the numbers betray you. You will get there. Even after you have kind of a rhythm, there are going to be weird readings caused by things you can’t control–hormones (HUGE one for ladies depending on where you are in life), allergies, stress, pain, and illness all mess with me. Look for trends versus immediately reacting (unless you are in medical danger). Keep good notes about what you are eating, exercising and how you are feeling. I am very new to this after all, but it is helping me to see a bigger picture.

If you do start Metformin you may or may not hate your life for a little while. I had an adverse reaction to it. I take it with meals in the morning and in the evening. For the first 2-3 weeks I was in intense intestinal/digestive distress. Every day. All day. And then it just stopped doing that. It kicked back in for a few days when I started insulin (low-dose, slow-release Levimir) and then stopped. It has not recurred, but it wasn’t anything I was warned about and it freaked me out. And I have a friend that can take it on an empty stomach and it never bothers her.

Good luck and stay tough!

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Please let us know how things go! As for exercise, there are a lot of different kinds of routines out there, and they all have different benefits. Many people find that walking (for 30 minutes +) helps to bring down moderately high BG. Many of us find that intense exercise often raises BG initially (sometimes almost uncontrollably for those who are seriously insulin deficient), and then leads to a persistent low. This is because of glycogen depletion and then the body prioritizing “refilling” the muscles’ reserves from free Blood Glucose (which isn’t always “free”). So everyone (and certainly every diabetic) has to figure out what works best for them with exercise in the same way we have to figure out our highly-individualized diets. I’ve found a couple of things about exercise that are useful for me (in both general fitness and helping to maintain “normal” BGs):

  • Intense Cardio (cycling, rowing, running, backpacking at altitude) in hot weather is a guaranteed way to induce a true, persistent low for me (<60 mg/dL). I tend to avoid purposely putting myself in those kind of situations now, but if I have to (field work in the mountains, etc.), then I bring quick carbs along, test frequently, and treat low BGs (usually with dextrose/starch combo).

  • High Intensity Interval Training (HIIT, or “Crossfit-style” workouts) will cause a pretty steep BG rise in the first fifteen minutes, and that high will be sustained as long as my body has glycogen to dump (from the liver). If I eat truly low carb, my liver doesn’t have glycogen to dump and my BG stays pretty stable. Some of my highest blood sugars have been early after diagnosis when I tried the whole “feed the exercise” routine I was used to by eating carbs an hour before training: deadly combo, for me at least, resulting in spikes to totally unacceptable levels (>250 mg/dL). I’ve since learned to eat my day’s carbs after I train, which works a treat.

  • Best Glycogen-depleting exercises: Sprints (on foot, rowing, cycling, or swimming); Box-Jumps; Heavy Olympic-style Weight-Lifting (Squats, Deadlift, Press, Snatches, Cleans, Pullups, etc.); HIIT (my current favorite “Grinder” is 500m Row; 15 Pushups; 10 Pullups and repeat as many rounds as possible in 15 minutes). These kinds of training will literally drain the body of all stored glucose if you train long enough, and the body then has a couple of choices: refill muscle glycogen from ingested post-exercise food; use body fat for fuel or convert protein to glucose.

The last bit is one of the tricks to how many people lose weight quickly and safely on low-carb diets, but it also happens to be a great way to help keep BG in check (by keeping the liver depleted of glycogen): do very high intensity muscle training (sprints, HIIT, Olympic lifts), then do 30-60 minutes of cardio. What happens is the following: the liver dumps all its glycogen in order to fuel the intense training; then the muscles use their stored glycogen to fuel intense training; then the muscles scavenge free Blood Glucose (which is problematic for those on exogenous insulin); then the body looks for other sources of fuel. The last step should align well with cardio, ideally: if you time it right, that 30-60 mins of cardio after a training session your body will be looking for fuel, and body fat is the quickest, easiest source of energy if you are glycogen depleted.

The drawback is that it sucks at first and feels terrible. The experience is what people who compete call “The Bonk” (when body has depleted all glycogen stores) and is why many athletes carb-load (so they don’t bonk, ideally ever). However, the body can get used to all sorts of things, and one of those things is doing endurance (cardio) training in a glycogen-depleted state. In fact, many people start to find it truly enjoyable (I get serious runner’s highs from hitting the wall and then continuing to push past it, myself). But, it takes time and persistence. The added bonus to serious fitness and blood sugar management effects is that this kind of training tends to be very effective at actually burning body fat, thus leading to either fat loss or maintenance of lean body condition.


tl;dr: weight training, HIIT, and cardio combined is probably the most effective type of exercise, but it’s also difficult and needs to be approached carefully. Highly suggest going to a gym and seeking the help of a personal trainer to start HIIT and weightlifting for best results. Crossfit or other HIIT type programs are a great way to get in shape and gain fitness, but they’re hard.

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@Annette_13, @David_dns, and @David49 - thank you so much! I feel like a couple months in I am now able to take all of this advice and all the rest of the great discussions on this forum and start to do something with it. I was feeling so worn down and worried at first, but this really has helped me be more solutions-oriented (which is my nature, anyway). I love the specific exercise advice from David. My only real hypoglycemic moments have come with exercise, and I have never seen a number over 220 on my monitor (and only in the first two weeks).

I check my blood sugar probably a lot more than I need to, but I am a data-oriented person in my professional life, and it just makes sense to me to check a lot to understand what the impact is of certain choices. I really wish I could get my hands on that Libre FreeStyle monitor.

I have discovered that for me, I don’t miss the big sugar or bread indulgences much (which is good, because they are disasters, obviously) but I sorely miss white rice, which was a staple of my diet. In fact, for lunch today I had a delicious fresh Thai spring roll with a rice wrapper and a small amount of rice noodles and I had a 176 reading two hours after lunch! that’s the highest it’s been since the last time I had spring roll, four weeks ago. Oh well. I know, I know i can go lettuce wraps but I do miss that rice.

I am definitely concerned about being checked for Type 1. I am not sure why the Type 1 screening isn’t automatic, because the consequences are pretty serious. My dad is 76 with psoriasis and rheumatoid arthritis. He’s also Type 2 that he was diagnosed with 35 years ago (at about my age). It progressed pretty quickly to insulin use - I’ve wondered if maybe he was also misdiagnosed. He’s great about maintaining tight control over blood sugar and while he has some complications with neuropathy, he’s really in pretty good health. So I know this is all manageable.

But it does help to have a community to come talk to about it.

And I am starting metformin tonight - preparing for the stomach rumbles!

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Don’t feel singled out. :sunglasses:

Rice can be pretty deadly, all right. Some people find that different forms of starch behave differently for them. For others (me included) they’re all about equally dreadful. For me, eating anything white (e.g., rice) is . . . well, I may as well just eat a bowl of sugar and be done with it. :wink:

You’ll learn from experience how different carbs affect you. It’s a very individual thing.

Anyway, welcome to the family. You’ve come to the right place. :slightly_smiling_face:

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Hi Ann: Based on your history of autoimmune disorders, and also based on your dad’s history with diabetes (which in my opinion (and I am not a doctor!) sounds like he is a misdiagnosed Type 1) and autoimmune diseases, if I were in your shoes I would ask my doctor to do the autoantibody tests as soon as possible. The sooner you get tested the better, because if you are Type 1 you really want to be treated appropriately, which means exogenous insulin. Here is a Diabetes Forecast article about autoantibody testing and here is an accompanying Diabetes Forecast article about adult-onset Type 1 diabetes and why misdiagnosis occurs. Best of luck to you!

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I would add to David’s ‘anything white is deadly’. Things like brown rice, wholemeal pasta, whole grain bread, wholemeal anything all are nearly as deadly as the white variety. But do test to see how they affect you.

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I agree. (I really should have said, “all carbs”.) Though, some people seem to get a less violent rise from some of those things. For me they’re all about the same. Testing is the only way to know your own individual response.

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Thanks all. For now anyway, my carb response to some grains seems much more moderate than others. So, I love steel cut oats and when I have them, my 2 hour reading is very similar to what a low-carb (veggie omelette) breakfast seems to give me. But I tried brown rice and it’s a no go. Barley and quinoa seem ok, but not bulger.

Today my toughest problem is that I set my lancet to 9 instead of 4 and just bled all over the place!

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in my 50’s i did alot of intense mountain biking. after a especially intense session i would be fatigued for days, just really dragging, sleepy and drowsy.

this was before my diagnosis. i just thought it was natural

just curious , do you think that might have been a result of low blood sugar?

Just an update. I’m testing a lot and have been on the metformin ER for about two weeks. I still rarely see a reading below 100, and my waking numbers are the still usually my highest. I’m averaging 118 for the last week and most of my readings are 105-130. I think the metformin is dropping the average a few points so far.

In the last three weeks, I’ve keeping my carbs to about 120-130g a day - enough that I feel a bit deprived, but not terribly so. I’m eating about 1600 calories, so this about a third of my caloric intake. I’m finding it really hard to bump up my protein, so my remaining calories are largely coming from fat. I’m not feeling hungry, I’m losing about 1.5-2 lbs a week steadily. I’m slowly adding cardio exercise to my routine.

I’ve noticed I feel hypoglycemic (even though I understand I’m not) at much below 100. I’ll test 20 mins later even without eating and I’m up to 125, which I assume is my liver being “helpful.” I know I used to be fine (like months ago before my diagnosis) at 85, I tested occasionally on my husband’s spare meter.

Question:
Will I be able to get back to having a below-100 reading without feeling bad or having my body helpfully raise my blood sugar? How can I help my body relearn that it’s ok to be below 100 without flooding me? Should I try restricting carbs more? (The thought fills me with sadness.) Is It reasonable to wait it out a little longer? I’m really less than 10 weeks diagnosis with 8.5 A1c, so I think I’ve made significant progress. But I would really like “normal” numbers for as long as I can managed.

If you’re like me, then the answer is yes! When I was first diagnosed, any time my BG was below 150 I thought I was going to die. Scared my wife to death, and frequently. I now routinely have stable BGs in the 70s and 80s and feel perfectly fine. I start to feel low around 60 mg/dL, which is pretty appropriate from a physiological standpoint. Took about six months for that to be the case.k

Also, fantastic on the changes to the diet! Sounds like it is really working for you. Again, be patient! Metformin might take some time to work, and I suspect that if you continue to cut carbs a bit more (if you want), increase Metformin, and keep exercising, your fasting BG will continue to drop.

As for cutting carbs, it can be a big adjustment! It was very hard for me initially, but I’ve gotten used to it. I initially cut way down (because I was so scared by my diagnosis), to less than 30g of carbs per day. Did wonders for my BG, but I started losing weight rapidly (and undesirably for me). I eventually found a sweet spot for me of about 80-90g of carbs per day, with 38g or more being dietary fiber. So about 40-50g of digestible carbohydrate, spread out among my meals. It allows me to have a stable (for now) BG, enough energy to function and work out, and is a way of eating I’ve gotten used to. But everyone is different!

I have definitely gotten to “normal” numbers, but it took about 9 months. I think serious exercise was part of my solution. And my numbers (last A1c was 4.8%) isn’t likely to stay normal, since I test positive for antibodies (I’m LADA, just taking my sweet time about it).

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Thanks! This is helpful. My husband has diabetes and keeps his numbers decent (low 6 on a1c) through exercise and oral medication, but he doesn’t seem to get too wrapped up in details or want to do a lot of investigating different options. I, on the other hand, feel competitive with myself: I want to do better than last week. And I really want to understand my liver and what the heck it’s doing.

Still, I know myself enough to know that I need to give myself transition time and have success with small goals before I step into bigger ones. 120-130g carbs a day is easily half what I was eating before, and that’s been an adjustment. But maybe I could go 110-120 and inch my way down in the next few weeks.

Are you following a particular diet plan to keep your digestible carbs so low? Like a ketogenic diet? I’m wondering if I might try something different for a month or two to see how it works and if it helps me. It’s a pretty big change from how my family eats now - I’d have to do some serious meal planning to make it work. I just have a hard time feeling ok about eating all the fat - I’m definitely a child of the late 80s, early 90s “low-fat, who cares about sugar” propaganda.

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I started off with a fairly typical ketogenic diet, eating less than 30g of carbs per day. I’ve sort of just figured out what works for me, and am not nearly at “ketogenic” levels of low-carb. I try my best to eat a lot of fiber, and I pick up some other carbs along the way. Otherwise, I really focus on hitting my protein goal, and then let fat sort of “fill in the gaps.”

Growing up, we were definitely in the “healthy carb, low-fat” sort of diet, with lots of garden vegetables and homemade bread. It was a huge transition for me to give up carbs. I had no idea I was eating so many! It was also shocking to find out that whole grain bread baked by organic elves in sustainable kitchens for high wages still spiked my blood sugar :frowning:

What I’ve found as far as fats go is that all the propaganda was total BS. My cholesterol levels have dropped through the floor, except my HDL which has gone up. And I am not picky about my fats. It differs from person to person, but for me at least higher fat and high protein diets have the opposite effect from what I learned in school. It might be worth trying for a few months, get quarterly bloodwork done, and then assess what works. Also, not all fats are created equal: if you’re worried about “Bad Fats,” try working what everyone considers good fats (olive oil, fatty fish, chicken eggs, flax seeds, etc.) into your diet. You can drink olive oil by the quart without budging your cholesterol numbers, and the more fish you eat the higher your HDL and lower your LDL tends to trend…

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@Ann20 It is difficult for me to explain just how encouraged I was at reading your entries. It is not that I want you to be frustrated. It is just that I needed to “hear” it right now.

I was diagnosed from an annual blood test about 9 months ago. BG over 350 and A1C of almost 12. My Dr/nurse couldn’t believe how fast I had changed and that I was asymptomatic.

I was stunned. I was scared. I was tested for Type I (negative). I went on Metformin and dropped the carbs to about 15g a meal (no grains, just vegetables, occasional fruit and sauces). I was hungry but so afraid of food that I didn’t care. My BGs dropped by 150-170, but still not low enough. My Dr/Nurse were concerned that I was already “too” low carb with nowhere to go, so they added a basal insulin. I take a pretty minimal amount based on where they want my averages. My last A1C came back in the low 6’s, and I know I should be celebrating, but when food is still my enemy, days can really suck.

My morning fasting numbers are never below 100 (thank you Dawn Syndrome) and I have to be on a serious fast/activity overload to drop below 100. The lowest number I have seen (tested) was an 85 and that was after going on a run, not having time for breakfast and then walking through an antique fair for hours. I felt completely void of energy and I was only an 85. After all the warnings from my doctor and the nurse about hypo’s and being careful if I drop below 70, I feel like laughing/crying in their faces. I couldn’t MAKE myself hit 70. Sometimes I swear I must be hypo based on how I feel, test and find myself at 137. It makes eating tricky since I can’t trust how I feel.

I can’t seem to find a pattern. I eat the same things and get very different test results. I have weeks somewhere between 100-140, and without changing anything, I just start climbing for a week or more. I understand that this is a game of patience, but am feeling very much like a blindfolded kid in front of a pinata, and the person holding the rope is a jerk.

I have been sitting on this post for a while because I know I am having a bad morning, and don’t like reacting to it. But I want you to know that I appreciate your sharing. It made the incomprehensible test results a little more bearable today.

@David49 If you don’t mind my asking…what is your protein goal? No one gave me nutritional targets on that. Once my A1C dropped, they consider me to be “controlled” and I don’t see my diabetic team again until next May (unless something goes horribly awry). My personal goal is to keep my post-meal BGs steadily under 140, but on days where I start high it can be tough. Maybe I need tighter control and to go more keto. I need to research it more. I am just curious.

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Hi Annette,

I workout a lot, walk or bike to work, walk when traveling, workout somemore, and do Crossfit (or similar) in between weightlifting sessions…so my protein goals are silly high (in order to maintain/build muscle under a lot of metabolic and physical stress).

Minimum protein requirement according to the FDA for a 2,000 calorie diet is 50g per day. That is, in my opinion, criminally low, and is mostly based on institutional fear of meat and pushing carb consumption. Many bodybuilders and weightlifters shoot for 1g per lb or bodyweight, and a generally accepted goal for very active people is 1g of protein per lean lb of body mass. Since I am trying to gain weight, I have my goal set slightly higher than my bodyweight, at 188g per day.

Honestly, I rarely hit that 188g. On days I lift, I definitely hit the goal and more (usually around 200g). On days I’m doing HIIT or just normal activity, I usually am fine with about 155g (which is my 1g per lb of lean mass target). Some people say that’s too much protein, and that’s OK. It’s been working for me for a long time of being a competitive athlete. I don’t compete anymore (except with my brother), but it’s still working for me in managing my blood sugars.

For active people, there is a very good macro calculator available at https://ketogains.com/ketogains-calculator/ . If you’re not actually interested in nutritional ketosis (I’m not, although I’m close to those levels), you can adjust the carb consumption to match your actual level and let it figure out protein and fats based on lifestyle and calorie goals (losing weight, maintenance, or gaining).

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I definitely get what you are saying considering our physicality and lifestyles are a bit different. :slight_smile: I am messing around with the calculator (thank you!) to get a feel for it. I would like to build more muscle, but probably not to your level. I separated a shoulder in a motorcycle accident last year and after getting cleared to start lifting weights (not just physical therapy), I have been taking it very slow.

I don’t expect your magic to be my magic, but since I haven’t found what works for me yet, understanding what has helped others gives me paths to try when I am feeling defeated. Thank you for sharing.

I track so much stuff, I think I need to pay more attention to my exercise and what combination of things I am doing each time. Maybe there is some magic in there and I haven’t been paying close enough attention to see it.

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