Metformin and Fasting

One of the penalties for indulging in junk food and not exercising, besides obesity, is metabolic problems, like (pre)diabetes.  As I've confessed in previous blog entries, I haven't been taking dieting seriously, and now I've crossed into the (pre)diabetes zone.

Currently, I'm faced with the dilemma of whether or not to take the medication prescribed to me for glucose intolerance.  I tried it for a day and a half, had some strange symptoms (pain in my right side, feeling very fatigued), and decided to stop taking it.  My doctor wants me to take the medicine for a couple months and then test my blood levels again, at which point he'll decide if I've done well enough in my diet to be able to cut the dose in half, or if, according to his attitude, a miracle occurs and I don't need to take it anymore.

One option is to skip the pills and go balls to the wall on eating clean, exercising, and fasting to shed my weight and naturally get my metabolism back in the healthy zone.

The other option is to take the medication while doing the same.  I'm not sure how to manage intermittent fasting (IF) with the medicine.  A google search pops up all sorts of opinions, typically the scaredy cat admonition that diabetics must never skip meals and probably should be eating at least a few bites every 20 minutes.  A few people not terrified of IF offer different advice: take the pill, skip the pill.  But I haven't seen any solid information, either from someone who was taking the medication while doing the primal/paleo thing with IF, or from someone with more than a few half-informed notions of what's what.

If I send a message to my doctor's nurse, I'll get an answer in anywhere between 4 hours and 2 weeks.  Asking him, or the nurse, about whether to take the pills when I fast, there is a good chance he or she will say that skipping meals is baaaaad and not be helpful one bit.

OK, for the nitty-gritty:

Lab Results

Feb 13, 2014:

weight	(lbs.)	~240	(165-175 is my goal)
fasting blood glucose	(mg/dL)	122	(70-105 is normal)
cholesterol	(mg/dL)	197	(≤ 200 is "good" *)
HDL	(mg/dL)	43	(40-59 is "OK", ≥ 60 is "good" *)
LDL-calculated	(mg/dL)	139	(≤ 100 is "optimal" *, 100-129 is "OK" *, 130-159 is "borderline high" *)
triglycerides	(mg/dL)	76	(≤ 150 is "normal" *)

Jun 12, 2014:

weight	(lbs.)	~222	(165-175 is my goal)
fasting blood glucose	(mg/dL)	86	(70-105 is normal)
hemoglobin A1c	(DCCT %)	7.0	(4.0-6.0 is optimal for non-diabetic, ≥ 6.5 is a criterion for the diagnosis of diabetes)

* Some of the comments on the evaluation of given ranges are surrounded by scare quotes, due to the common wisdom of medical providers having a tendency towards being wrong, particularly on the subject of lipids.

The A1c glycated hemoglobin is a marker they use to estimate the average blood glucose level over the previous three months.  I've searched for the meaning of the number and gotten a variety of different interpretations for a 7.0%.  According to Wikipedia, that indicates a mean glucose level (mg/dL) of 154±31 (123-185).  My doctor said the cutoff for diabetes type 2 is 6.5%, but then he wrote on my chart a diagnosis of ICD-9 277.7, which is commonly called "prediabetes", but more formally called "metabolic syndrome X" or "insulin resistance syndrome".  So, I'm not sure if he thinks I am actually diabetic, or just flirting with it.

Prescription

Glucophage (Metformin) 500 mg pill, twice a day with meals.

I took it three times, starting in the evening of my doctor visit.  I admit I was shaken up by his words and his attitude, and worried that if I didn't take the medicine, all sorts of damage would be continuing to wreak permanent havoc.  But when I did take it, I developed a pain on my right side, below the ribcage.  It wasn't the liver or kidney area, so I'm thinking it was general intestinal distress.  I mentioned the dosage to someone who currently takes it and she was shocked that the doctor didn't start me off slowly, taking one pill every other day and working up to the twice a day level, to avoid the intestinal problems.  I also felt very fatigued, which I'm guessing was the medication artificially dropping my glucose.

So, if you have taken Metformin and fasted intermittently (whether it was just skipping a meal or a full 24-36 hour fast), I would appreciate any insight you might have on whether to take the pill during a fast.  Or, if you have expertise on the subject and can provide me with explanations for why I should or shouldn't take the pill, your advice will be welcome.  Otherwise, I'm not looking for guesses or notions.  Only experience or expertise are of interest to me.

Thank you.

Paleo/primal success and failure

Since February 2006, I successfully lost 45 pounds or more three times. Except for the first time, I lost the weight using paleo/primal eating habits. The second time, I used intermittent fasting (IF) twice a week, for 18-36 hours, depending upon how long I could hold out. I exercised towards the end of the fast to maximize fat burning. My workouts were about 20 minutes of interval strength training. The third time, I lost the weight mostly by diet, without a serious exercise program.
The first time, I lost 50 pounds via diet and exercise (mostly walking). Between 1994 and 1999, I had done a lot of weight lifting and swimming. I was under 200 lbs. at the time, and added quite a bit of muscle, so weight loss was not much of a concern to me at the time. The whole diet yo-yo has frustrated me, but I keep trying to reset and try to achieve lasting success.
The reasons for failure: fast food, ice cream, and lack of exercise. The mindset that I'll eventually get around to losing my weight again, just not today, is a denial of reality which can only go on for so long. As Ayn Rand said, "You can avoid reality, but you cannot avoid the consequences of avoiding reality."
Now, the consequence is that I'm facing type 2 diabetes, so the stakes have been significantly raised. I've seen quite a number of success stories of people using a paleo/primal diet and exercise approach, who were able to reverse diabetes and return to normal levels. I prefer to do that than to depend on medication in the long term.

Updated the first couple of paragraphs to more clearly describe previous successes.

Three Weeks

A little more than three weeks in and I still feel much better than before I resumed the Paleo fitness program. I hit a plateau this week as I lapsed in the fasting and exercise schedule, ate too many calories (nervous eating when I wasn't actually hungry), and perhaps ate too much fruit.

Exercise: I had planned to get more exercise doing yard work. However, we got some rain and I kept telling myself I'd do the work the next day. Things still haven't dried out, so I decided to get off my lazy butt and do a workout inside. I didn't fast until yesterday, when I skipped lunch. After that I used my son's new exercise equipment, a Gold's Gym short series resistance tube kit. (Here is the long series one, which is similar.) I got about 25 minutes into the DVD. Once I hit the squat thrust section, I called it a day. Yeah, I got wimpy not exercising for a year. The good thing is that I have almost no soreness today. I'll have to step it up next time.

I also have an Iron Gym workout bar that fits in the door frame for pull-ups, a couple kettle bells (4kg and 8kg), a lunge bar, and a big Labrador Retriever who loves to play tug-of-war, for working out at home.

Fasting: I only fasted once the past week, and only skipping one meal. Sometimes it's hard to synchronize meal planning with the family, grocery shopping, and fasting. I hate wasting good food by letting leftovers or uncooked food stay in the refrigerator too long*. I'm going to have to apply some scheduling and planning discipline to get back into the rhythm.

Food: I'm about 95% sticking to the Lacto-Paleo set of foods. However, the amount I'm eating is too much and unbalanced (too much fruit, which I eat to satisfy cravings for sweets).

Cheats: I tried hummus for the first time. Twice I ate it on crackers. I had a little bleu cheese dressing which was mostly soybean oil. Maybe a few small squares of chocolate. Not too bad.

Weight: I dipped down about 4-5 pounds since last week, but immediately went back up. After fasting and exercising yesterday, I went back down this morning. But I'm going to have to push harder (cut back on calories, fast and exercise more often) to speed up the weight loss.

Sleep: This is a problem for me that I think I've been overlooking. I often get less than six hours a night, which I've read may hinder weight loss and fitness.

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* I've learned the hard way not to take chances with leftovers. With the exception of a few things like cured bacon, I throw away anything I cooked more than three days prior—cooked eggs at most two days. I more readily toss out jars and cans past their expiration date. I once got violently ill from some sauerkraut because some of the cabbage was above the top of the liquid for days or weeks, giving it time to grow something nasty.

Two Weeks

About two weeks in and I feel much better. My energy is much greater and more consistent (the post-meal drugged feeling is going away). My "fat pants" are starting to get loose again. I can feel my muscles "coming alive" a little bit. I don't have that bloated, swollen feeling all the time.

Exercise: I've done some work and heavy lifting in my yard and house (it's amazing how things get overgrown and cluttered when I get fat and lazy). Overall, I have been moving around a little bit more, too. Due to my schedule and the list of things to do for work and around the house (yard work and cleaning, once again), I haven't scheduled time for formal workouts. I'm planning on starting that within a week or two. There are about three more days of weeding, leaf mulching, pruning, and trimming to do this week, so I'll have plenty to keep me busy. While I do plan to start doing 2 intense workouts per week, like I did before, I'm more concerned with diet these past two weeks, ending my seemingly addictive consumption of junk food.

Fasting: I've fasted a few times for slightly less than 24 hours. The last time was before and during the yard work I did for several hours Sunday. Working in a fasted state makes me feel like I did last time I did the Paleo diet. Like riding a bike, my body quickly adapted to the change, without any negative feeling this time.

Food: I'm about 85-90% sticking to the diet I plan to make permanent. I have been able to resist the junk, with increasing ease. I estimate I'm eating about 70-80% Paleo (if you exclude dairy from what you consider Paleo). I plan to keep dairy in my diet, which probably accounts for about 10-15% of my calories now. I've been eating some legumes (pinto beans, chick-peas, and a few peanuts), which have some negative nutritional content, but I plan to eat those only occasionally.

I would like to have only strictly organic foods, but I don't yet know of any stores which carry meat or dried fruit which are completely unpolluted. The sausage, bacon, and dried fruit I eat do have nitrites/preservatives. The beef & eggs are not grass fed/free range (I'm guessing).

Cheats: My "cheats" have included a few tortilla chips (with pinto beans I cooked and guacamole I mixed), movie popcorn, a few breadcrumbs my wife put in a meatloaf, some rice and beans at a Mexican Restaurant while travelling, and 85% cocoa organic chocolate (which I eat with pecans and dried apricots). I plan to make the Green & Black's chocolate my consistent, occasional cheat.

Weight: I'm down to 230 lbs.. My morning weight two weeks ago was 235. I did weigh myself once in the evening (so it's "unofficial") and saw an eye-popping 240. The older I get, the easier it is to add weight and the harder it is to reverse that. Telling myself that I can lose my weight again, that I'll get back to eating healthy "soon" but putting it off has been very costly.

The 100s

The last time my weight started with a "1" was sometime around January 2007. I broke through the "flab floor" ^* a few days ago. This morning, after fasting on Thursday, I weighed in at 197.5 lbs..

I realize that weight alone is insufficient to measure progress—body fat percentage, waist size, blood chemistry (lipids, glucose, etc.), strength, and stamina are probably more important. Still, it's a nice psychological boost.

When I last saw the 100s, I was gaining back the 45 lbs. I had lost in 2006. That diet (low-fat, limited calories, lots of walking) relied on a lot of willpower, and was nutritionally misguided. Still, it had been a big ego boost to get into the 170s, which made failure all the more ignominious.

Now, I don't get cravings for sweets and other junk.

[Note: I never did finish this article and left it as a draft on 12/19/08. Now 03/30/10 I'm just publishing it almost entirely as is.]