Monitoring Your Progress And Responding To Change

In this chapter I discuss how to monitor your progress after you have put your action plan for diabetes into motion. As you monitor your progress, you will need to document the changes in your health status in a personalized health diary. This diary should include information such as the dates and times of blood glucose levels associated with exercise and diet. You should also include your heart rate, blood pressure, weight or body mass index (BMI), any symptoms and laboratory values such as your hemoglobin A1C levels and lipid levels, and any other tests that you have undergone. I have found that some of my patients who keep health diaries like to bring them to their appointments to show me the patterns in their health and to record their laboratory test results.

As discussed in previous chapters, it is important for you to recognize the differences between type 1 diabetes and type 2 diabetes and to make regular exercise a part of your lifestyle. People with both types of diabetes benefit from exercise. The main concern for those with both types of diabetes is to monitor blood glucose levels. Those with type 1 diabetes need to monitor glucose closely when exercising, especially when starting an exercise program. Hypoglycemia, or low blood sugar, is the prime risk associated with exercise for those with type 1 diabetes. Hyperglycemia during exercise is also a serious concern in those with type 1 diabetes. People with type 2 diabetes have a very low risk of hypoglycemia unless they are taking sulfonylureas or other medications that are associated with causing hypoglycemia. Those with type 2 diabetes need to ensure that their glucose is not too high when starting their exercise program, and they need to monitor their glucose level to gauge the effectiveness of their diet and exercise. If you do not have a clear understanding of this, review chapter 4.

As you progress through your plan and become more active, you may choose to keep track of how your fitness level improves. Your health care team will track your cholesterol and blood pressure periodically. If you are using exercise and diet alone to optimize your cholesterol levels, it is generally recommended that these levels be tested every six months. If you use medication to control your cholesterol levels, your physician may choose to test your lipid levels more frequently. Your blood pressure can be tested at each visit, and you can check your own blood pressure at home twice a week by using a calibrated blood pressure cuff and meter. You can purchase a blood pressure cuff and meter at your local drug store or online. You will pay $15 to $100 for a simple cuff and meter; accuracy and durability typically increase with the cost of the unit. For $50 to $600, you can get other, more sophisticated automatic digital models that measure your heart rate and are more clinically accurate. (To determine the accuracy of your home blood pressure monitor, take your blood pressure cuff to your doctor's appointment and compare readings from the doctor's meter and your meter.) The key is to measure blood pressure at the same time each day after you have been sitting for at least five minutes. You should document these levels in your health diary so that you can determine your progress in your action plan. See table 7.1 for an example of a filled-in six-month health diary, and table 7.2 for a blank health diary you can use.

Table 7.1 Sample Six-Month Health Diary

Table 7.2 Your Six-Month Health Diary

If you have type 2 diabetes, a diary can help you keep track of how your lifestyle affects your glucose control. A complete diary that includes your weight or BMI, descriptions of meals, exercise intensities and durations, glucose levels, and other laboratory values can function as an efficient gauge to tell how well you are doing with your action plan. You can also use a diary as a motivation tool, especially once you see the effects of your action plan on your condition. For example, Tom, a gentleman of about 55 years old whom I help with his medical care, has found his health diary to be very motivational. In addition to type 2 diabetes, Tom has multiple sclerosis (MS), a disease that results in easy fatigability and other symptoms that can make exercising difficult. When I first met Tom, he was skeptical about creating a diet and exercise plan because of the complications of MS. He had tried exercising before but found that he overheated and fatigued easily. He's met with a dietitian in the past but had not seen significant positive results. After discussing with me the basics of diabetes and the differences between exercising to improve health and exercising to significantly increasing fitness level, he felt more at ease about creating an action plan. Once he realized that I was not going to ask him to do what he already knew he couldn't do, we started him on his plan. His plan included riding his bike for 10 to 15 minutes (this varied depending on how he felt on any particular day) and walking in the mall for 10 to 20 minutes on other days. He knew that he could not do these things for too long if he started to notice problems such as overheating. And we designed his action plan around this concern, allowing for daily flexibility. About six weeks after starting his program, he returned to my office, and we reviewed his diary. As I expected, he had some exercise sessions lasting 20 minutes, some that were split into smaller, more tolerable sessions, and no sessions on some days. But Tom met his minimum weekly goal of exercise. We made some adjustments to his plan, and then I saw him about two months later after doing some scheduled laboratory tests. He was very excited to find that he's normalized his fasting blood glucose and lowered his HbA1C from 8.5 to 7.5. From the expression on his face I could see that he was no longer skeptical about his action plan. Three months later, he had mastered his action plan and normalized his HbA1C, LDL, and HDL; significantly decreased his triglycerides; and lost 8 pounds. I met with Tom not long ago and he has had to make adjustments to his schedule because of work issues, but he's confident that he can adjust without a glitch.

Monitoring Your Glucose

Charting Weight Loss

Responding to Change