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. 

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.

Listen now

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 

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