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.
Health checks and reviews
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.
Blood Glucose Levels (BGL)
Self-monitoring of your BGL’s enables you to check your own levels as often as needed or as recommended. Regular testing can reinforce your healthy lifestyle choices as well informing you of your responses to other influences. Your diabetes health professional will help you decide how many tests are needed and the levels to aim for. More about blood glucose levels.
HbA1c (Glycosylated haemoglobin)
The HbA1c test shows an average of your blood glucose level over the past 10-12 weeks. It does not show the highs and lows but gives an overall picture of your blood glucose management. High blood glucose levels can contribute to the development of long-term complications of diabetes. The general target level is 7% (53 mmol/mol) or lower.
Blood Pressure (BP)
This is the measurement of the pressure at which your heart pumps blood around the body. High blood pressure can increase the risk of heart disease, stroke and kidney disease. You should have your blood pressure checked regularly (at least every doctors visit) and treated if necessary. For someone with diabetes, the target BP is less than 130 over 80. (130/80).
Cholesterol (blood fats-lipids)
This is a type of fat in the blood. Cholesterol problems are common in people with diabetes and too much fat increases the risk of heart disease and stroke. Your target total cholesterol level is less than 4 mmol/L.
There are two types of cholesterol:
- Low-density lipoproteins (LDL’s) called bad cholesterol and high-density lipoproteins (HDL’s) called good cholesterol. LDL can narrow or block your blood vessels. Keeping your LDL low helps protect your heart. Your target level is below 2 mmol/L.
- HDL helps remove deposits from your blood vessels and stops them getting blocked. Your target level is 1mmol/L or above.
Triglycerides are another type of fat in your blood. Your target level is less than 2 mmol/L. Your cholesterol level should be tested every 12 months.
Eyes
Diabetes can cause eye problems and may lead to blindness. Complications can include cataracts, glaucoma and retinopathy. Many people don’t notice any problems with their sight until retinopathy is well advanced.
You can reduce the risk of eye damage by keeping your blood glucose levels, HbA1c and blood pressure at recommended levels and if you notice any changes in your vision, speak with your doctor or eye specialist immediately. Your eyes should be checked every one-two years.
Feet
People with diabetes can develop a number of foot problems such as changes to the skin, calluses, foot ulcers and nerve damage (neuropathy), which can lead to amputation. For these reasons it is important to take good care of your feet.
Your doctor or podiatrist should perform a complete foot exam at least annually. You can prepare by taking off your socks and shoes while you wait. You should check your feet every day as instructed by your podiatrist or educator.
Kidneys
Over time, people with diabetes face increased risk of damage to their kidneys (nephropathy). An early sign of kidney problems can be detected through a urine test for microalbumin. Finding out early that kidneys are beginning to have a problem is simple and painless. Your urine should be checked yearly for microalbumin.
Other management goals
Other checks include: Healthy eating, weight management, stopping smoking, moderate alcohol consumption (two or less standard drinks a day for men, one for women) and physical activity (at least 30 minutes most days a week) and a review of your medications and diabetes management plan.
Annual cycle of care podcast series
A series of 10 podcasts have been developed to assist you with your diabetes care. Focusing on the components of the annual cycle of care, topics include HbA1c, talking to your practitioner, eye health and programs and services.
