There is strong evidence from randomised controlled trials that type 2 diabetes is preventable or can be delayed with lifestyle modification interventions that improve diet, increase physical activity and reduce body weight / waist circumference in people with a diagnosed risk of developing type 2 diabetes.

For people at risk of diabetes and other chronic diseases, the first, and most common point of access to the health system is through primary care. To this end, we offer and recommend a range of programs and support services to ensure your patients at risk of diabetes are receiving the best possible care.

Programs to support patients at high risk of diabetes
  • Get Healthy Service - This is a free, confidential telephone-based service which helps people to make lifestyle changes including healthy eating, being physically active and achieving and maintaining a healthy weight.
  • GP Exercise Referral Scheme - This program is designed for people with or at risk of chronic disease to improve confidence with lifestyle change and increasing physical activity levels.
  • Go4Fun - This is a free healthy living program for children aged 7 - 13 who are above a healthy weight.
  • Heart Foundation Walking Groups - This program aims to make regular physical activity enjoyable and easy, especially for people who are not used to being active.
ComDiab - for people who have, or are at risk of T2DM

ComDiab is a FREE community group education program for people who have, or are at risk of type 2 diabetes. Participants will learn about type 2 diabetes and what they can do to improve their health and live well. The program is provided to complement and support the treatment and care provided by general practitioners, nurses, diabetes educators, and allied health professionals.

ComDiab is expertly designed and delivered by trained registered nurses who are accredited with Diabetes NSW and ACT. The program involves interactive group sessions to help participants to:

  • Understand and monitor their diabetes or diabetes risk
  • Make healthy food choices
  • Be physically active
  • Take measures to prevent or control diabetes
  • Prevent diabetes complication

Programs are offered regularly across CESPHN. Below are the upcoming program schedules for Inner West Sydney:



Location target







21st October 2019


Canterbury Hurlstone Park RSL

20-26 Canterbury Rd, Hurlstone Park



24th October 2019


Canterbury Leagues Club

26 Bridge Rd Belmore



25th November 2019


Club Rivers

32-34 Littleton St, Riverwood



TBC (Feb 2020)


4Cs Lakemba Community Hub

130 Railway Pde, Lakemba



7th March 2020


Canterbury Leagues Club

26 Bridge Rd Belmore



6th April 2020

9:30am -12:30pm

 Club Burwood

97 Burwood Rd, Burwood NSW 2134


Click the links above to see the program flyers. For bookings and enquiries, call 1300 342 238 (for Inner West Sydney region).

Community Diabetes Education Programs in the South Eastern Sydney region

Programs are held at:

the Sutherland Hospital and Community Health Service (HealthOne, 126 Kareena Rd, Miranda NSW 2228).

Dates and Times:

  • 16 July 2019, 1pm - 3.30pm
  • 20 August 2019, 6pm – 8.30pm
  • 24 September 2019, 10am – 1pm
  • 29 October 2019, 6pm – 8.30pm
  • 12 November, 1pm - 3.30pm
  • 10 December 10am - 1pm



Research & Education Centre, St George Hospital (4-10 South Street Kogarah, NSW 2217).

Dates and Times:

  • 18 June 2019, 10.30am – 1.30pm (Seminar room 4)
  • 9 July 2019, 10am – 1pm (Seminar room 3)
  • 20 August 2019 – TBA
  • 17 September 2019, 10.30am – 1.30pm (Seminar room 3)
  • 29 October 2019, 10am – 1pm (Seminar room 3)
  • 19 November 2019, 10am – 1pm (Seminar room 1&2)


Programs can be provided in other languages and potentially in other locations at request. Click here for the program flyer. 

For bookings and enquiries, call 1300 427 603 (for South Eastern Sydney region).


Diabetes Healthy Feet


Diabetes Healthy Feet is managed by the Sydney Local Health District Podiatry Department.

The project’s objective is to prevent foot complications, unnecessary hospital admissions, and amputation. This will be achieved through optimising collaboration between primary and tertiary care and ensuring that no one falls through the cracks.

The project will accomplish the following:

  1. Increase patient awareness of diabetic foot complications.
  2. Increase timeliness and appropriateness of referrals to the SLHD Podiatry Department, RPAH Diabetes Centre HRFS, and CRGH HRFS.
  3. Increase the number of referring General Practitioners to the SLHD Podiatry Department.
  4. Increase primary care professional awareness of diabetic foot complications, foot screening,
    and appropriate referral pathways to use in response to risk assessment outcomes.
  5. Improve primary health practitioner confidence in the management of diabetic foot ulcers

Click here to download the Foot Care Referral Pathway.

Click here to access the SLHD Podiatry Intake Form.

For more information on the program, please click here

Click here  to download the SLHD Podiatry Intake Form templates, compatible for Best Practice and Medical Director.

Practice Support

We can assist your practice in setting up programs and resources to help prevent people from developing type 2 diabetes.

Click here to visit the practice support section.

Checking diabetes risk (AUSDRISK tool)

The AUSDRISK tool is a short list of questions to help both health professionals and consumers assess the risk of developing type 2 diabetes over the next five years. Adults with a total score of 12 or more are defined as being at high risk of developing type 2 diabetes.

For further information on the tool, and to order copies, click here.

We have translated this tool into a range of languages, including

We have also developed templates for document Best Practice (47 KB) and document Medical Director (27 KB) . Please see the practice support section above for assistance with loading templates into your clinical software.

Health assessments for diabetes risk

Patients aged 40 - 49 years, or 15 - 54 years for Aboriginal and Torres Strait Islander people, who score 12 or more on the AUSDRISK tool are eligible for a health assessment for type 2 diabetes risk evaluation. This assessment is completed using MBS Items 701, 703, 705 or 707 (or 715 for Aboriginal and Torres Strait Islander people). Click here for more information, or here for more information on 715 health assessments.

HbA1c for diabetes diagnosis
  • In 2015, Medicare accepted the use of HbA1c for a diagnosis of diabetes.
  • An HbA1c value of 48mmol/mol (6.5%) or more indicates a positive result, suggesting the diagnosis of diabetes.
  • HbA1c assessment should be considered in asymptomatic patients who are at high risk of developing type 2 diabetes (as defined by their AUSDRISK score).
  • The relevant MBS item number is 66841, which can only be reimbursed once during a 12-month period.
  • See the pdf MBS item description (98 KB) , and the Australian Diabetes Society position statement.