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:

REVIEWSGOALHOW OFTEN?WHO CHECKS IT?
HEALTHY EATINGReview your diet and healthy eating each yearAt least every 12 monthsDietitian, Diabetes educator, Practice Nurse or GP
EXERCISEReview your physical activity level each yearAt least every 12 monthsDietitian, Diabetes educator, Practice Nurse or GP
SMOKING STATUSDo not smokeAt least every 12 monthsDietitian, Diabetes educator, Practice Nurse or GP

 

HEALTHY WEIGHT
WEIGHTMy goal weight is: _____ kgAt least every 6 monthsGP, Endocrinologist, Diabetes educator or Practice Nurse
WAISTMEN: aim for less than 94cm
WOMEN: aim for less than 80cm
At least every 6 monthsGP, 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 monthsGP, Endocrinologist, Diabetes educator or Practice Nurse
BLOOD PRESSUREEqual to or less than 130/80mmHgAt least every 6 monthsGP, 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 monthsGP or Endocrinologist
TRIGLYCERIDES

(Blood fats)

Less than 2 mmol/LAt least every 6 -12 monthsGP or Endocrinologist
MICROALBUMINURIA

(Kidney health)

Urine albumin levels in target range.At least every 6 -12 monthsGP or Endocrinologist
eGFR

(Kidney health)

Kidney function test in target range.At least every 6 -12 monthsGP or Endocrinologist
HBA1C

(Blood glucose)

Equal to or less than 53 mmol/mol (7%)At least every 6 -12 monthsGP or Endocrinologist
EXAMS AND PLANS   
FEET EXAMINATIONFoot health maintainedLow risk feet: At least every year

 

High risk feet: At least every 3-6 months

Podiatrist or Practice Nurse
EYESA comprehensive eye examination at least every 2 yearsAt least every 2 yearsOptometrist or Ophthalmologist
MEDICATIONSReview medications at least every yearAt least every yearDiabetes educator. Endocrinologist or GP
YOUR CARE PLAN 
DIABETES MANAGEMENT PLANReview your diabetes management plan at least every yearAt least every 12 monthsDiabetes 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 

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