Chronic Disease Prevention & Management

The definition of chronic disease is a condition that lasts for one year or more and requires ongoing medical care or restricts activities of daily living. More than 50% of Australians live with some form of chronic disease, and this number goes up as we age.

Identification, treatment, and ongoing management of chronic disease is what makes general practice different to most other specialties because your GP will get to know you and how you live with your chronic disease better than any other doctor over time.

Our job is to keep your symptoms to a minimum, manage your condition optimally using the best available evidence using all methods and means (pharmacological and lifestyle), and keep you out of hospital.

People who have a chronic disease requiring extra work to keep the condition under control, may be eligible for a GP Management Plan, which is performed with your doctor and one of our nurses once we have got to know you. This sets specific goals we want to achieve for your management and can be reviewed every 3-6 months to ensure we’re on track. This is an extra service on top of any regular consultations you might need and is bulk billed to eligible patients. Your doctor will inform you if you’re eligible and this is necessary.


Diabetes is the name given to a group of conditions that make it difficult to use glucose the way it’s meant to be used. The official name is Diabetes Mellitus (Latin for sweet).

All the conditions result in excessive glucose levels in the blood, although get there in different ways. All of them however are due to some deficiency in insulin, either relative or absolute. Think of insulin as the key that unlocks the gate for insulin to get into most cells.

Type 1 Diabetes Mellitus (T1DM) is an autoimmune disease where the body’s immune system attacks the cells in the pancreas that create insulin. This soon causes an absolute deficiency of insulin, and the body is unable to move most of the glucose it’s absorbing.

It requires replacement of the insulin and cannot be treated with just diet or exercise alone.

Type 2 Diabetes Mellitus (T2DM) is considered a relative deficiency of insulin. As the body begins to take on more energy and store this the body makes more insulin to try and store this away. Eventually the receptors become desensitised, so more insulin is made, and later the ability to make insulin is reduced. So, while you still have some in production, your body makes less – and your receptors aren’t as receptive.

T2DM is associated with hereditary factors and lifestyle risk factors including diet, insufficient physical activity and being overweight or obesity.

Lifestyle management of diabetes is very possible. It does take some hard work, needs careful monitoring and learning lots of information about exercise and diet, but it is well worth it; however, diabetes medications or insulin replacement may also be required to control blood sugar levels if the glucose or HbA1C levels are particularly high.

Type 2 diabetes occurs mostly in people aged over 40 years old; however, the disease is also becoming increasingly prevalent in younger age groups.

Gestational Diabetes Mellitus (GDM) occurs during pregnancy. The condition usually disappears once the baby is born; however, a history of gestational diabetes increases a woman’s risk of developing type 2 diabetes later in life.

Three to eight percent of pregnant women are affected, and blood sugar levels are monitored quite carefully during pregnancy to detect, diagnose and manage GDM.

The condition may be managed through adopting healthy dietary and exercise habits, although diabetes medication, including insulin, may also be required to manage blood sugar levels.

Gestational diabetes can cause excessive growth and fat in the baby. If the mother’s blood glucose levels remain raised, the baby may be larger than normal. Following delivery, the baby may experience low blood glucose levels, particularly if the mother’s blood glucose levels were raised before the birth.

Gestational diabetes can be monitored and treated and, if well controlled, these risks are greatly reduced. The baby will not be born with diabetes.

Prediabetes isn’t really a condition, but a name given to people who are at much higher risk of T2DM and have had several high glucose readings, but not high enough to diagnose T2DM formally.

The way to think of having high blood glucose levels is that the body is already beginning to struggle keeping the glucose at the right set point, between 3.4-5.4mmol/L. It’s like standing on an escalator. If you do nothing, you’ll reach the level of T2DM. So here you can get back down to normal sugars, you just have to work against it. It’s very doable with the right guidance.

Complications of diabetes

Why does this glucose level matter? Because if it’s left to run wild, it causes significant damage to the body. These initially affect the smaller blood vessels (microvascular disease) and the organs that are supplied by these, and eventually the larger blood vessels (macrovascular disease) and the organs supplied by those.

Significant complications include

  • Kidney damage (nephropathy) leading to kidney failure
  • Eye damage (retinopathy) leading to blindness
  • Nerve damage (neuropathy) leading to numbness, pain, sores and infections
  • Sexual difficulties (erectile dysfunction
  • Cardiovascular disease (angina, heart attacks, strokes)


Early symptoms of high blood glucose levels include

  • being more thirsty than usual
  • passing more urine
  • feeling tired and lethargic
  • slow-healing wounds
  • itching and skin infections, particularly around the genitals
  • blurred vision
  • nausea and vomiting
  • weight loss
  • mood swings


Checking for diabetes is prompted if you have a rich family history, have high risk factors for diabetes (check out the Ausdiab T2DM risk assessment tool) and have a chat with your doctor.


Diabetes is becoming more common. T1DM is diagnosed early, and good control and management is necessary. T2DM is preventable and manageable, and in some cases curable. GDM is most definitely manageable and all pregnant women who undertake shared care with their GP will be tested for this.

But prevention is always key. Keeping a healthy weight, healthy waist circumference, regular physical activity and eating a well-balanced healthy diet will keep it at bay, but also make you feel great and get the most out of all your days.

For any questions book in with your doctor at GS Health to have a chat.


Both heart disease and stroke are forms of cardiovascular disease (CVD). The cardiovascular system (CVS) is responsible for pumping and moving blood around the body, which delivers nutrients and removes waste. Think of it as the plumbing system in a house, or the fuel delivery system in machinery.

The state of our CVS is determined somewhat by age and genetic factors, but it is more significantly determined by our lifestyle.

A good efficient plumbing system gets used frequently, works efficiently, and is monitored.

Your car’s fuel system is cleaned, checked for leaks, and serviced.

But the human CVS is often left to do its own thing. If it isn’t broke, don’t fix it.

Hopefully the rest of this article will change that way of thinking.

Types of cardiovascular disease

There are a number of conditions of the CVS that are related to lifestyle including.

    • Coronary heart disease
    • disease of the vessels that supply the heart leading to angina or heart attacks
    • Stroke or cerebrovascular disease
    • Either caused by a blockage (ischaemic stroke) or the rupturing or fragile blood vessels leading to a bleed (haemorrhagic stroke)
    • Peripheral vascular disease
    • Obstruction of the large vessels that supply arms or legs causing clots, pain, and sometimes gangrene

Cardiovascular diseases not related to lifestyle can include.

      • Acute rheumatic fever and rheumatic heart disease
      • Caused by untreated Group A Streptococcus infection – much more common in rural and remote Australia and indigenous communities
      • Congenital heart disease
      • Inherited conditions that affect the valves and septum of the heart

Causes of cardiovascular disease

Healthy blood vessels are soft, flexible and elastic. They also have incredibly smooth inner walls so blood can just glide through them. However, a variety of factors can cause them to become harder, inflexible and stiff. This leads to them becoming brittle and ‘leaky’.

They can also develop atherosclerosis which is the development of plaques, which make the narrow lumen or the arteries even narrower.

Going back to your plumbing, if your pipes are getting rustier, or things are clogging them up, then the water flow and drainage suffers. You might get leaks, or things just stop working.

Risk factors for cardiovascular disease

      • Smoking – the nicotine in cigarettes directly narrows blood vessels
      • An unhealthy diet – not specific foods, but essentially a diet that makes you gain weight
      • Sedentary behaviour – the less you move, the less your cardiovascular system is conditioned
      • Unhealthy weight – there is no magic number here, but being heavier for your height (or a significantly increased BMI) is a risk for higher blood pressure, diabetes, and reduces the effectiveness of your CVS
      • Stress – high stress = high blood pressure

Conditions that increase your chances of heart attack and stroke

      • hypertension/high blood pressure
      • Diabetes
      • High cholesterol

How do you prevent cardiovascular disease?

Well, the list above is a good start. However, it’s a list of things to avoid, not a list of things to do. Staying active, eating healthily, maintaining a healthy weight, avoiding smoking, and de-stressing all go a long way in the prevention game.

Sometimes the degree of extra prevention activities required depends on your risk factors, and family history can be a h2 predictor. If mum or dad had heart disease quite young, it can make it more likely that you might also.

When you next visit your doctor – ask about how we can estimate and reduce your cardiovascular risk.

Our scientific understanding of heart disease is increasing every day, and our treatment and prevention is improving with it.

The media will always make sensational headlines – eggs are good, eggs are bad, wine prevents heart attacks. But these are very isolated statements from very large studies. Your doctor can help put it all together for you, in your specific situation.


Asthma is a chronic inflammatory disease of the lungs, and one of the most common conditions in Australia.

You might have only been recently diagnosed, or have been dealing with it for a long time, but there is a lot to understand about asthma and great ways to manage how it affects you.

Who gets asthma?

  • 1 in 10 adults and 1 in 9 children are affected
  • Allergies and asthma are closely linked – it’s more common in families with lots of allergies, though people with asthma don’t necessarily have allergies
  • Adults of any age can develop asthma – even if they didn’t have it as a child
  • Some children have significant asthma, but it tends to improve with no symptoms as an adult
  • Many pre-school children who have a wheeze do not have asthma by the time they reach primary school
  • Indoor and outdoor pollution (mould, gases, chemicals, particles/dust and cigarette smoke) can increase the risk of developing asthma
  • Athletes can develop asthma after very intensive training over years, especially when inhaling polluted, cold or dry air

What are the symptoms of asthma?

The commonest symptoms of asthma are;

  • Wheezing – a continuous high pitched noise while breathing. Typically when breathing out, but can also be on breathing in
  • Shortness of breath – feeling like there just isn’t enough air
  • Tightness in the chest
  • Coughing

You don’t actually need all of the symptoms to be diagnosed with asthma

Noisy or rattling breathing in pre-school children can be common, and is usually because they don’t know how to swallow or cough up their saliva or phlegm. This can occur in healthy babies, is not the same as wheezing and does not mean they have asthma.

What causes asthma symptoms?

The increased symptoms of asthma are usually when the inflammation in the airways (which is present almost all the time) worsens, and they become narrower. This makes it difficult to get the air in and out, which causes the shortness of breath and tightness, the air moves faster causing a wheeze, and there is often mucous secreted from the airways that can cause the cough or even phlegm.

Triggers are varied but can include;

  • Viral infections like colds and influenza
  • Cigarette smoke
  • Dust
  • Allergies and pollen
  • Cold air
  • Exercise

So how is asthma diagnosed?

If you feel like your breathing isn’t right, or any of the above symptoms apply to you, let your doctor know.

Asthma is diagnosed using a combination of the clinical history, physical examination, and special tests known as peak flow and spirometry.

How is asthma managed?

Asthma as mentioned before is a chronic condition, so even when you don’t feel you have significant symptoms, the airways are still inflamed generally.

One important thing is to be prepared for any known triggers. If you know that when hayfever season approaches you start to get wheezy, then managing your allergies will help. If you know that you begin to get tightness when you go for a jog, then using your reliever before you run can help.

However the management relies on two groups of medications.

Preventers, and relievers.

Preventer medications reduce the inflammation and are used daily. There are inhaled medications and tablets.

If the asthma is really well controlled you can take breaks from this under the direction of your doctor.

Reliever medications are used to bring about quick resolution of symptoms. If you’re beginning to wheeze, cough, or are feeling tight in the chest – you use this medication. The blue puffer is most common.

However as everyone is unique, and everyone has different triggers and severity, it’s important to make an asthma action plan that covers all scenarios including emergencies.

Book in with your doctor at GS Health to make an asthma action plan.



Rhinitis, also known as coryza, is the inflammation of the membranes inside the nose and the nasal cavity. The commonest cause is allergic rhinitis, or hay fever, where pollen causes this irritation.

Viral illnesses like colds can also be a trigger.

People often complain of a stuffy or runny nose, sneezing, and a sensation of a drip down the back of the throat. This can cause a cough which might be more productive in the morning, dry through the day, and again worse on lying down.


Sinusitis is the inflammation of the nasal sinuses, which are beyond the main nasal cavity. The frontal sinuses just above the mid eyebrows and nose, the maxillary sinuses just on the cheeks and the sphenoid sinus which is further back can become swollen and inflamed causing grogginess, headaches and postnasal drip.

Sinusitis has the same triggers and causes as rhinitis, though sometimes when it is quite severe people can become rather unwell – particularly in bacterial sinusitis. This needs review and treatment by your doctor.

Triple Nasal Therapy

Nasal and sinus congestion are often the most unpleasant aspects of having a viral infection, and a flare up of allergic rhinitis. The management of these symptoms are often simple but need to be given time. In stepwise fashion, the three strategies below can clear, decongest, and have anti-inflammatory effects on the nasal passages and sinuses.

  1. Nasal rinse:
    Use a saline rinse to clear the nasal passages and sinuses of mucous and irritants. Neilmed sinus rinse, netipot or nasal flo are all excellent products. If there is only mild congestion, then a fess saline nasal spray will suffice. This will help clear blockages and allows other medicated sprays to work well.
  2. Decongestant spray:
    A spray that contains oxymetazoline or similar ingredients will cause the leaky vessels in the nose to constrict and provide up to 12 hours of relief at a time. Drixine, otrivin, Dimetapp nasal sprays or pharmacy brands all work well. It is important not to use this on an ongoing basis as the effect wears off and the rebound effect can be quite severe.
  3. Anti-inflammatory spray:
    For people suffering from chronic symptoms, you may need a daily preventative spray. Nasonex, Omnaris, Avamys or Dymista are examples. These need to be used on an ongoing basis to work well and take about 1-2 weeks to take effect. They are either used through a troublesome season, or indefinitely in some patients.

If you find that your symptoms recur a lot, or you get frequent episodes, then your doctor can help identify what your triggers may be and implement strategies to help in the long term.


If you suffer from a chronic disease and the management of it requires some planning and follow up, your doctor may suggest a chronic disease care plan.

This is a good way of not losing focus over the management of your condition in the long term. Sometimes life just gets in the way, or lots of little issues pop up and before you know it it’s been a year since someone has reviewed your diabetes, or your Crohn’s disease has gone unchecked.

As chronic disease is affecting more and more of us, keeping on top of it and preventing long term complications is paramount to live a healthy and fruitful life.

What is a care plan?

It’s when a doctor, nurse or both sit with you and establish what the goals are for your condition. If you suffer diabetes, one main goal would be to achieve stable and acceptable long term blood glucose levels. An overarching longer term goal would be to avoid the microvascular and macrovascular complications like kidney failure or heart disease. But the plan really lets us make sure we follow up and get down to the nitty gritty of it all.

At GS Health the plan is initiated once the doctor feels you would benefit from more regular follow up. Given that this is a priority in our health system these care plans are bulk billed – meaning that there is not out of pocket expense to you.

Team care arrangements

If the management of your condition requires input from several health professionals, then it’s best we work together as a team with your GP guiding the strategy. When you require the help of at least 3 people (often your GP, maybe a specialist and maybe an allied health practitioner) then we initiate a team care arrangement.

This is formed off the goals of the care plan, but specifically asks for external help.

One benefit of a team care arrangement is that in the 12 months from when we initiate it, Medicare provides up to 5 rebated sessions with certain allied health providers. This means your consult with them is cheaper by $52.95 if that practitioner has a provider number with Medicare. This helps with some of the financial burden of the extra care required to keep people healthy

What are the costs?

For regular patients of GS Health, the care plans are bulk-billed – meaning that we accept the Medicare rebate as the total payment. This means at your care plan appointment there will be not out of pocket cost to yourself.

We cannot provide a care plan on the first appointment we’ve met someone, as it is only to be used by your regular treating doctor or clinic.

Sounds great! Book me in!

Now let’s just wait a minute.

Care plans are very useful, but not necessary for everyone. If your chronic disease is already managed really well, then there’s no point adding extra appointments or paperwork to do what we’re already doing. Your doctor will let you know if we think you’d benefit from a care plan.

The same goes for the team care arrangements. While it sounds nice to get some money back from physio or get the see the podiatrist, these plans are only for people who need it to manage their chronic disease and should be initiated by the doctor.

It is not a reverse referral system where if you see a physio for a sore back following an injury, then they ask you to see your GP for a care plan or team care arrangement. Some people are still confused about the rules regarding this, but Medicare is very strict and fraudulent usage of this service can result in severe penalties for your health provider.

Please don’t ask us to do something that puts us in an awkward situation.

If you think you may benefit from a care plan or team care arrangement, please bring it up with your doctor if they haven’t already brought it up with you.


GSH Doctors who provides Chronic Disease Prevention & Management service
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Dr Natasha Bartos


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Dr Stephanie Andriputri


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Dr Caitlin Weston


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Dr Atari Metcalf

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Dr Rosemary Chen


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Dr Phillip Orme

MBBS; Clin. Dip. Pall Med; FRACGP

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Dr Katherine Hanks


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Dr Rupert Higgins

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Dr John-Alec Tynan


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Dr Angela Hurley


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Dr Min Yin Huang


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Dr Winnie Yao


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Dr Victoria Phan


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Dr Daniel Chanisheff


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