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The NDSS is administered by Diabetes Australia
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Your diabetes annual cycle of care fact sheet

PDF coverThis fact sheet is available in two formats.

You can download and print out the PDF version.

Or you can read it as a website page below.

The diabetes annual cycle of care is a checklist for reviewing your diabetes management and general health. Your general practitioner (GP) will do this review to help you and your diabetes health care team manage your diabetes, and to reduce your risk of diabetes-related complications.

It’s important to do an annual cycle of care to identify any health concerns early and discuss the best treatment with your doctor and diabetes health professionals. Without regular checks, diabetes can lead to complications that can affect your whole body, including your kidneys, eyes, feet, nerves and heart.

The annual cycle of care includes the following health checks:


This blood test reflects your average blood glucose level over the last 10-12 weeks. This should be done at least every 6-12 months, or more often if required. The general recommendation is to aim for a reading of 53mmol/mol (7%) or less. HbA1c targets can be different for different groups so it’s important to discuss your individual HbA1c target with your doctor or credentialled diabetes educator (CDE).

Blood pressure

Your GP or practice nurse should be checking your blood pressure at every visit or at least every six months. As a general guide, the target for people with diabetes is 130/80 or less. If you have existing cardiovascular or kidney disease, your doctor will advise you on a blood pressure target to meet your individual health needs. Research has shown that keeping blood pressure on target decreases the risk of stroke, heart, kidney and eye disease, and nerve damage.

Foot assessment

Your GP, CDE, practice nurse or podiatrist should conduct a foot assessment to check the blood supply and sensation in both of your feet. If your feet have been assessed as low risk, you should have a foot assessment every year. If your feet have been assessed as intermediate or high risk, you should have a foot assessment at least every 3-6 months. Daily foot care is essential. Get to know your feet and check them every day. If you can’t reach your feet, you can use a mirror or have someone look at them for you.

For more information about how to look after your feet, talk to your GP,  podiatrist or diabetes health professional. You can also ask your GP if you are eligible for a management plan to see a podiatrist under Medicare.

Eye examination

Damage to the small vessels in the back of your eyes can occur even without your knowledge. That’s why it’s essential to have your eyes checked regularly by an optometrist or eye specialist (ophthalmologist) for diabetes-related damage. This is recommended every two years or more often, as directed by your health care team.

If you do notice any changes in your vision, it’s important to contact your GP or eye specialist as soon as possible.

Kidney health

If your blood pressure and blood glucose levels remain high over time, this can increase the risk of damage to your kidneys. Every 12 months your GP or endocrinologist will arrange a urine test to check for protein in your urine (albuminuria).

A blood test to assess your kidney function is also recommended.

Blood fats (cholesterol and triglycerides)

Healthy cholesterol and triglyceride levels will reduce your risk of diabetes-related complications.

Your doctor will check your blood fats. As a guide, aim for:

  • Total cholesterol of less than 4mmol/L
  • LDL (bad) cholesterol of less than 2mmol/L
  • HDL (good) cholesterol of 1mmol/L or higher
  • Triglycerides of less than 2mmol/L.

Weight, waist and body mass index

If you are carrying extra weight, losing even a small amount of weight (5–10%) will help reduce your blood pressure, blood glucose levels and cholesterol.

One way to assess your weight is by using the Body Mass Index (BMI). This measures whether or not you are in the healthy weight range. It’s calculated by dividing your weight in kilograms (kg) by your height in metres squared (m²). You can also use online calculators to know your BMI. A BMI between 18.5 and 24.9 is within the healthy weight range.

Your waist measurement is also an important indicator of your health risks. The recommended waist measurement is less than 94cm for men and less than 80cm for women.

These targets are for people from European backgrounds. Different target ranges may be used if you are from Asian or Pacific Islander backgrounds. Speak to your doctor or diabetes health professional about the BMI and waist targets that are right for you.

Healthy eating

Following a healthy eating plan will help you achieve the best possible blood glucose and cholesterol levels, and help you manage your weight. You can also ask your GP if you are eligible for a management plan to see a dietitian under Medicare.

Physical activity

Be physically active. For good health, aim to do at least 30 minutes of moderate physical activity (such as brisk walking, swimming or cycling) on most, if not all, days of the week. You can also incorporate light exercise into your daily routine. For example, choose to climb the stairs instead of using the lift or hang washing outside instead of using the dryer. The best activity is one that you enjoy and gets you moving. It’s also important to limit the amount of time you spend sitting and being sedentary.

Before starting any new exercise or activity program, check with your doctor to make sure it’s suitable for you. If you are on insulin or other glucose-lowering medications, you may need to take special precautions when exercising to prevent your blood glucose level from dropping too low (thereby increasing the risk of hypoglycaemia or ‘hypo’). Make sure you discuss this with your GP, endocrinologist or credentialled diabetes educator. Your level of physical activity will be reviewed as part of your annual cycle of care. An exercise physiologist can develop a program that is right for you. Ask your GP if you are eligible for a management plan to see an exercise physiologist under Medicare.

Medication review

A review of your medications helps ensure that the combination of all your current medications is safe and that the doses are right for you. You may be eligible for a free Home Medication Review. This would involve the pharmacy of your choice conducting a thorough review of all your medications in your own home. Ask your GP for more information.

Diabetes management

Your diabetes health care team will review your overall diabetes management and provide advice on how to keep your diabetes on track.


If you are a smoker, quitting can help reduce your risk of diabetes-related complications and improve your overall health. Some people find it hard to quit, so if you feel you cannot give up smoking on your own, ask for help—talk to your GP or call the Quitline on 137 848.

Emotional health

Your emotional health is also important. If living with diabetes is making you feel anxious or distressed, discuss how you’re feeling with your family, friends and diabetes health professionals. They can help you access the support you need.

GP management plan

By providing an organised, written approach to your care, a GP management plan can help you manage your diabetes well. These plans allow you to receive a Medicare rebate when seeing health professionals, such as credentialled diabetes educator, dietitians, podiatrists and exercise physiologists. For more information about GP management plans, talk to your GP, credentialled diabetes educator practice nurse.

Your annual cycle of care checklist
Check When Target
HbA1c At least every 6-12 months 53mmol/mol (7%) or less
Blood pressure At least every six months 130/80 or less
Foot assessment Low risk feet: At least every year

High risk feet: At least every 3-6 months

Foot health maintained
Eye examination At least every two years Eye health maintained
Kidney health At least every year Urine albumin levels in target range
Kidney function test in target range
Blood fats At least every year Total cholesterol less than 4mmol/L
LDL less than 2mmol/L
HDL 1mmol/L or above
Triglycerides less than 2mmol/L
Weight At least every six months BMI 18.5-24.9
Waist circumference* At least every six months Less than 94cm (men)
Less than 80cm (women)
Healthy eating review At least every year Following a healthy eating plan
Physical activity review At least every year At least 30 minutes of moderate physical activity, five or more days a week and minimise time spent sitting
Medication review At least every year Safe use of medications
Smoking At least every year No smoking
Diabetes management At least every year Self-management of diabetes maintained
Emotional health As needed Emotional health and well-being maintained

Note: The targets listed are for adults with diabetes. Different targets apply to children and adolescents.

*BMI and waist circumference targets may not apply to non-European ethnic groups.

The NDSS and you

A wide range of services and support is available through the NDSS to help you manage your diabetes. This includes information on diabetes management through the NDSS Helpline and website. The products, services and education programs available can help you stay on top of your diabetes.

This information is intended as a guide only. It should not replace individual medical advice and if you have any concerns about your health or further questions, you should contact your health professional.

Version 3 February 2020. First published June 2016.