The diabetes annual cycle of care explained


PDC Health Hub

Living with diabetes can be hard work. Most people with diabetes benefit from a multidisciplinary approach to care to supplement all of the work they do day-to-day to manage their blood sugar levels and stay healthy. As we know, diabetes has a varied impact on our overall health, and it’s important to check in with members of our health care team at regular intervals to stay on top of things.

The Diabetes Annual Cycle of Care (ACC) provides a comprehensive approach todiabetes care. The key elements involved in the ACC are:

  • Regular HbA1c testing
  • Regular check ins with your diabetes support team including diabetes educators and your Endocrinologist or GP
  • Foot checks
  • Eye checks
  • Kidney health assessments
  • Other biometric measures e.g. weight and waist circumference, cholesterol checks and blood pressure monitoring
  • Emotional health check ins

Regular HbA1c testing is a cornerstone of diabetes care, providing valuable insights into long-term blood glucose management. The HbA1c test measures the amount of glucose stuck to your red blood cells, which gives an indication of how your blood sugar levels have been over the last 3 months. The measurement allows healthcare professionals to assess the effectiveness of treatment plans and adjust them accordingly. HbA1c testing is typically recommended every 6-12 months, allowing individuals to track their progress and make necessary adjustments to maintain optimal control.

Assessing time in range, in addition to HbA1c, can also give valuable insights into day-to-day blood glucose control. While HbA1c provides an average measure of blood glucose control over several months, time in range shows the amount of time your blood glucose levels are in your target range over several days or weeks (or longer). This offers insights into fluctuations in sugar levels, glycaemic variability, and the effectiveness of treatment strategies in maintaining stable glucose levels. By focusing on time in range, healthcare professionals and individuals with diabetes can better understand the impact of their management efforts and make targeted adjustments to optimise overall blood sugar levels rather than just looking at the general picture we get from HbA1c.

Continuity of care from a diabetes educator, endocrinologist and GP plays a key role in the effective management of diabetes. Regular reviews, typically recommended every three months, ensure ongoing support and guidance tailored to the individual's specific needs. Diabetes educators, with the support of a GP or Endocrinologist, can create personalised treatment plans, encourage consistent monitoring of blood glucose levels (and recommend equipment to help you do this), and suggest adjustments to optimise diabetes management. This continuity of care ensures that individuals receive the necessary support and resources to navigate the challenges of living with diabetes and achieve their health goals, ultimately promoting long-term well-being.

Foot checks are important for all people living with diabetes to help make sure our feet stay healthy. These checks should be conducted annually by a podiatrist, GP, diabetes nurse, or certified diabetes educator (CDE) who is skilled in this area. The examination assesses circulation, nerve function, and the condition of the feet. Early detection of any issues allows for timely interventions and appropriate foot care strategies to prevent complications such as ulcers and infections.

Regular eye checks are also important for individuals living with diabetes, as diabetes can increase the risk of eye-related complications. These checks are typically conducted every two years and help detect any signs of diabetic retinopathy orother eye conditions.

Assessing kidney health through a urine test once a year is effective for early detection of any kidney-related complications. The test checks for the presence of albumin (a protein) in the urine, which can indicate kidney damage. By monitoring kidney function regularly, healthcare professionals can intervene early, implementing measures to preserve kidney health and prevent the progression of diabetic nephropathy (kidney damage).

Monitoring blood pressure is another important aspect of diabetes management. Diabetes increases the risk of cardiovascular complications (e.g. heart disease and stroke) so it is essential to keep blood pressure within a healthy range. Regular blood pressure checks during GP and other healthcare professional clinic visits enables healthcare professionals to detect any changes promptly and act accordingly. By managing blood pressure effectively, the risk of heart disease, stroke, and other related complications can be minimised or prevented.

As with regular blood pressure checks, regular cholesterol checks are important in the prevention of cardiovascular risk factors associated with diabetes. A blood test conducted at least once a year provides valuable information about lipid profiles, allowing healthcare professionals to address any risk factors. Maintaining healthy cholesterol levels contributes to reducing the risk of heart disease and stroke.

Weight, waist circumference, and body mass index (BMI) are measurements that can be collected and monitored over time. Regular assessments, at least every six months, can help individuals and their health care team to suggest and monitor the effectiveness of lifestyle strategies like choosing healthy foods and exercising regularly. Although these measures, especially BMI, don’t give us all the information, they can help to form part of a bigger health picture.

Dietitians play a significant role in the ACC by assisting individuals with diabetes in planning healthy meals, assisting with carb counting and other food related questions and issues – all of which are tailored to the specific needs of the individual. By providing guidance on food options, balanced nutrition, portion control, and meal timing, dietitians empower individuals to make informed choices that support their diabetes management goals.

Exercise physiologists are a valuable resource for individuals with diabetes, as they can develop exercise programs suited to individual needs, taking into consideration any medical conditions and medications being taken. They help individuals build confidence around exercising with diabetes and tailor programs that promote cardiovascular health, weight management, and overall well-being. Regular physical activity can improve insulin sensitivity, aid in blood glucose control, and reduce the risk of cardiovascular complications.

Emotional well-being should also be an integral part of your annual cycle of care for diabetes. The impact of managing a chronic condition can be significant, leading to increased stress, anxiety, burnout and depression. You can prioritise your mental health through regular check-ins with your GP, a psychologist, counsellor, or other mental health support professionals. You are encouraged to check in for mental health support as often as you need. Mental health professionals can provide a safe space for to express your concerns, address the emotional impact of living with diabetes, and develop effective coping strategies.

The Diabetes Annual Cycle of Care encompasses a comprehensive approach to managing diabetes and promoting overall well-being. Ultimately, the goal of the annual ycle of care is to help you and your healthcare team monitor your ongoing health and get treatment early, if it is required – almost always, the earlier the treatment, the better the outcome. By taking advantage of this multidisciplinaryteam approach, individuals with diabetes can effectively manage their condition, reduce the risk of complications, and enhance their overall quality of life.

PDC Health Hub is proud to be the home to a team of Credentialled Diabetes Educators, Accredited Practising Dietitians, Podiatry, Physio, Accredited Exercise Physiologists, Pharmacists and a Psychologist. If you would like to book in with any of our multidisciplinary team, please don't hesitate to call our wonderful client support team on 08 6110 0570 or email bookings@pdchealthhub.com.au

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