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The diabetes Annual Cycle of Care

The diabetes Annual Cycle of Care

Written by Carolien Koreneff, CDE-RN, FADEA

The diabetes Annual Cycle of Care (ACC) is a checklist for reviewing diabetes management and the general health of your clients. It helps you and the person with diabetes keep track of all necessary checks and ensure they are up to date.

The ACC is the best way to prevent diabetes-related complications from occurring and is essential for identifying any problems early. Credentialled diabetes educator Carolien Koreneff provides some further insights. The ACC includes a variety of checkpoints to be done at specific intervals.

The Annual Cycle of Care for diabetes includes:

  • HbA1c: At least annually
  • Kidney check: Annually
  • Lipids: Annually
  • Blood pressure: Six-monthly 
  • Eye check: Every two years, or more often as needed
  • Dental check: At least annually
  • Foot check: Six-monthly
  • Weight, height and BMI: Six-monthly
  • Diet: At least annually
  • Physical activity: At least annually
  • Smoking status: Every visit
  • Self-care education: Every visit
  • Medication review: Annually
  • Emotional health: As needed

To assist your clients with diabetes understand more about what the ACC includes and the importance of keeping their diabetes on track to reduce the risk of diabetes-related complications, I recommend that you refer them to this NDSS fact sheet.

Some of the health checks can be done by the person with diabetes themselves, such as monitoring blood glucose levels and checking their feet daily for changes. Other checks are best done by specific healthcare professionals, such as optometrists, ophthalmologists, or dentists. However, the majority of the health checks that form the Annual Cycle of Care can be done by the persons’ general practitioner, practice nurse, credentialled diabetes educator or other allied health professionals.

The RACGP Management of type 2 diabetes; a handbook for general practice is a great guide that lists goals, specific assessment intervals, advice and arrangements for the optimum management for all people with type 2 diabetes.

In addition to the above checklist it is also a good idea to check how much alcohol the person consumes. The current recommendation is to limit alcohol intake to two or less standard drinks per day for men and one or less standard drinks per day for women. Women who are considering a pregnancy should not drink any alcohol at all, ideally for a minimum of 3 months prior to trying for a pregnancy.

Another thing that often gets overlooked is any concerns about sexual health. While most people with diabetes, both male and female, are able to lead normal sex lives, diabetes may contribute to sexual problems for some people. It can be difficult for both the person with diabetes and the healthcare professional alike to broach this subject. The simplest way of finding out if the person with diabetes is experiencing any problems with their sexual health is to ask them about it. Mostly people will be very happy if the healthcare professional asks them, as this will, at least in part, normalise the experience and may provide solutions to the problem.

To assist you in making sure the Annual Cycle of Care is completed regularly, this ADEA checklist may be useful for some. Additional resources you could share with the people you see include:

  • The Annual Cycle of Care podcast series by the NDSS. This podcast series provides information about what the ACC is and why it is important.
  • There are a range of NDSS fact sheets that provide information about specific diabetes-related complications in the section Health Management.
  • The Foot Forward website provides information and resources about looking after feet for both people with diabetes and health professionals.
  • The KeepSight website is an eye check reminder program for people with diabetes.
  • The healthdirect website provides a comprehensive listing of diabetes education services as well as doctors, endocrinologists, dietitians and other health professionals in your area. Alternatively you can search for: