Statement of Principles concerning morbid obesity No. 32 of 2003

Instrument No.32 of 2003

Determination

of

Statement of Principles

concerning

MORBID OBESITY

Veterans’ Entitlements Act 1986

1. This Statement of Principles is determined by the Repatriation Medical Authority under subsection 196B(3) of the Veterans’ Entitlements Act 1986 (the Act).

Kind of injury, disease or death

2. (a) This Statement of Principles is about morbid obesity and death from morbid obesity.

(b)              For the purposes of this Statement of Principles, “morbid obesity” means an excessive accumulation of fat in the body resulting in:

(i)                a BMI of at least 40; or

(ii)              a BMI of at least 35 together with a requirement for:

(a)  ongoing, medically prescribed drug therapy for weight reduction; or

(b)  surgical intervention for weight reduction other than cosmetic surgery.

(c)               Morbid obesity attracts ICD-10-AM code E66.8.

(d)              In the application of this Statement of Principles, the definition of “morbid obesity” is that given at para 2(b) above.

Basis for determining the factors

3. On the sound medical-scientific evidence available, the Repatriation Medical Authority is of the view that it is more probable than not that morbid obesity and death from morbid obesity can be related to relevant service rendered by veterans or members of the Forces.

Factors that must be related to service

4. Subject to clause 6, at least one of the factors set out in clause 5 must be related to any relevant service rendered by the person.

Factors

5. The factors that must exist before it can be said that, on the balance of probabilities, morbid obesity or death from morbid obesity is connected with the circumstances of a person’s relevant service are:

(a)               having a caloric intake that:

(i)              is excessive for energy needs; and

(ii)           cannot be compensated by physical activity;

for the year immediately before the clinical onset of morbid obesity; or

(b)              undergoing treatment:

(i)                with a drug from the specified list; or

(ii)              with a drug which has been reported to be obesogenic in the peer reviewed medical literature;

and which drug cannot be ceased or substituted, at the time of the clinical onset of morbid obesity; or

(c)               suffering from a binge-eating disorder at the time of the clinical onset of morbid obesity; or

(d)              suffering from hypercortisolism at the time of the clinical onset of morbid obesity; or

(e)               suffering from hypothyroidism at the time of the clinical onset of morbid obesity, or

(f)                suffering from a hypothalamic disorder causing hyperphagia at the time of the clinical onset of morbid obesity; or

(g)              inability to obtain appropriate clinical management for morbid obesity.

Factors that apply only to material contribution or aggravation

6. Paragraph 5(g) applies only to material contribution to, or aggravation of, morbid obesity where the person’s morbid obesity was suffered or contracted before or during (but not arising out of) the person’s relevant service; paragraph 8(1)(e), 9(1)(e) or 70(5)(d) of the Act refers.

Inclusion of Statements of Principles

7. In this Statement of Principles if a relevant factor applies and that factor includes an injury or disease in respect of which there is a Statement of Principles then the factors in that last mentioned Statement of Principles apply in accordance with the terms of that Statement of Principles.

Other definitions

8.                  For the purposes of this Statement of Principles:

“binge-eating disorder” means a psychiatric condition meeting the following description (derived from DSM-IV):

1. Recurrent episodes of binge eating.  An episode of binge eating is characterised by both of the following:

(1)  eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances;

(2)  a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).

B.    The binge eating episodes are associated with three (or more) of the following:

(1)  eating much more rapidly than normal;

(2)  eating until feeling uncomfortably full;

(3)  eating large amounts of food when not feeling physically hungry;

(4)  eating alone because of being embarrassed by how much one is eating;

(5)  feeling disgusted with oneself, depressed, or very guilty after overeating.

C.    Marked distress regarding binge eating is present.

D.    The binge eating occurs, on average, at least 2 days a week for 6 months.

E.     The binge eating is not associated with the regular use of inappropriate compensatory behaviours (e.g., purging, fasting, excessive exercise) and does not occur exclusively during the course of Anorexia Nervosa or Bulimia Nervosa;

“BMI” means body mass index and is calculated as follows:

BMI = W/H2 where:

W is the person’s weight in kilograms; and

H is the person’s height in metres;

“death from morbid obesity” in relation to a person includes death from a terminal event or condition that was contributed to by the person’s morbid obesity;

“DSM-IV” means the fourth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders;

“hyperphagia” means ingestion of an excessive quantity of food;

“hypercortisolism” means excessive production of or administration of hydrocortisone, or other glucocorticosteroids;

“hypothalamic disorder” means a condition affecting the ventromedial area of the hypothalamus.  This can result from tumour, trauma, granulomatous infections, central nervous system infections, irradiation therapy or surgery;

“hypothyroidism” means the functional state resulting from insufficiency of thyroid hormones;

“ICD-10-AM code” means a number assigned to a particular kind of injury or disease in The International Statistical Classification of Diseases and Related Health Problems, 10th revision, Australian Modification (ICD-10-AM), Third Edition, effective date of 1 July 2002, copyrighted by the National Centre for Classification in Health, Sydney, NSW, and having ISBN 1 86487 413 9;

“relevant service” means:

(a) eligible war service (other than operational service); or

(b) defence service (other than hazardous service);

“terminal event” means the proximate or ultimate cause of death and includes:

(a) pneumonia;

(b) respiratory failure;

(c) cardiac arrest;

(d) circulatory failure; or

(e)              cessation of brain function;

“undergoing treatment with a drug from the specified list” means therapeutic administration of one of the following drugs:

(i)                     Amitriptyline

(ii)                  Carbamazepine

(iii)                Chlorpromazine

(iv)                Clofibrate

(v)                   Clonidine

(vi)                Clozapine

(vii)              Cyproheptadine

(viii)           Doxepin

(ix)                Fluphenazine

(x)                   Fluphenthixol

(xi)                a Glucocorticosteroid

(xii)              Guanabenz

(xiii)           Guanethidine

(xiv)            Imipramine

(xv)              Insulin

(xvi)            Lithium

(xvii)         Maprotiline

(xviii)       Megestrol acetate

(xix)            Methyldopa

(xx)              Nisoldipine

(xxi)            Nortriptyline

(xxii)         Olanzapine

(xxiii)       Perphenazine

(xxiv)       Phenelzine

(xxv)          Pimozide

(xxvi)       Pizotifen

(xxvii)     Prazosin

(xxviii)  Propranolol

(xxix)       Risperidone

(xxx)          Sertindole

(xxxi)       a Sulphonylurea

(xxxii)     Terazosin

(xxxiii)  Thioridazine

(xxxiv)   Trifluoperazine

(xxxv)     Valproic acid.

Dated this Twelfth  day of  August  2003

The Common Seal of the    )

Repatriation Medical Authority   )

was affixed to this instrument  )

in the presence of:    )

KEN DONALD

CHAIRMAN