Annual Cycle of Care
Your checklist to keep your diabetes on track
The Annual Cycle of Care is a checklist designed to help you and your health team keep your diabetes care on track.
Diabetes changes over time and what works for you today, may not work next year. Diabetes can lead to complications that affect your kidneys, eyes, feet and heart. That’s why the Annual Cycle of Care is so important. It can help identify health concerns early and allow you to discuss the best treatment with your health care team. Importantly, you can reduce your risk of diabetes-related complications.
Annual Cycle of Care targets mean different things to different people so it is important that you develop your individual goals with your diabetes health care team. If you don’t understand why these targets are important, or how often you should be getting your checks, discuss this with your doctor.
Remember, regular visits with your diabetes healthcare team will allow you to identify any problems early and put the best management plans and treatment in place.
The annual cycle of care includes the following health checks:
| REVIEWS | GOAL | HOW OFTEN? | WHO CHECKS IT? |
| HEALTHY EATING | Review your diet and healthy eating each year | At least every 12 months | Dietitian, Diabetes educator, Practice Nurse or GP |
| EXERCISE | Review your physical activity level each year | At least every 12 months | Dietitian, Diabetes educator, Practice Nurse or GP |
| SMOKING STATUS | Do not smoke | At least every 12 months | Dietitian, Diabetes educator, Practice Nurse or GP |
| HEALTHY WEIGHT | |||
| WEIGHT | My goal weight is: _____ kg | At least every 6 months | GP, Endocrinologist, Diabetes educator or Practice Nurse |
| WAIST | MEN: aim for less than 94cm WOMEN: aim for less than 80cm | At least every 6 months | GP, Endocrinologist, Diabetes educator or Practice Nurse |
| BODY MASS INDEX (BMI) | Less than 25kg/m2 where appropriate (between 18.5 – 24.9) | At least every 6 months | GP, Endocrinologist, Diabetes educator or Practice Nurse |
| BLOOD PRESSURE | Equal to or less than 130/80mmHg | At least every 6 months | GP, Endocrinologist, Diabetes educator or Practice Nurse |
| TESTS AND CHECKS | |||
| CHOLESTEROL (Blood fats) | Total cholesterol less than 4 mmol/L LDL less than 2 mmol/L; HDL is 1 mmol/L or above | At least every 6 -12 months | GP or Endocrinologist |
| TRIGLYCERIDES (Blood fats) | Less than 2 mmol/L | At least every 6 -12 months | GP or Endocrinologist |
| MICROALBUMINURIA (Kidney health) | Urine albumin levels in target range. | At least every 6 -12 months | GP or Endocrinologist |
| eGFR (Kidney health) | Kidney function test in target range. | At least every 6 -12 months | GP or Endocrinologist |
| HBA1C (Blood glucose) | Equal to or less than 53 mmol/mol (7%) | At least every 6 -12 months | GP or Endocrinologist |
| EXAMS AND PLANS | |||
| FEET EXAMINATION | Foot health maintained | Low risk feet: At least every year
High risk feet: At least every 3-6 months | Podiatrist or Practice Nurse |
| EYES | A comprehensive eye examination at least every 2 years | At least every 2 years | Optometrist or Ophthalmologist |
| MEDICATIONS | Review medications at least every year | At least every year | Diabetes educator. Endocrinologist or GP |
| YOUR CARE PLAN | |||
| DIABETES MANAGEMENT PLAN | Review your diabetes management plan at least every year | At least every 12 months | Diabetes educator, Endocrinologist, Practice Nurse, Nurse Practitioner or GP |
Please note that the recommendations for children and adolescents with diabetes may vary from those listed above.
For more information, see the Annual Cycle of Care factsheet
