_

Statement of Principles

concerning

MORBID OBESITY

No. 6 of 2014

for the purposes of the

Veterans’ Entitlements Act 1986

and

Military Rehabilitation and Compensation Act 2004

Title

1. This Instrument may be cited as Statement of Principles concerning morbid obesity No. 6 of 2014.

Determination

2. The Repatriation Medical Authority under subsection 196B(3) and (8) of the Veterans’ Entitlements Act 1986 (the VEA):

(a) revokes Instrument No. 32 of 2003 concerning morbid obesity; and

(b) determines in its place this Statement of Principles.

Kind of injury, disease or death

3. (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 current BMI of at least 40; or

(ii) in those aged 18 years or younger, a current BMI of at least 120 percent of the 97th percentile in the 2007 World Health Organisation Body Mass Index charts, for age and gender.

Basis for determining the factors

4. 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 under the VEA, or members under the Military Rehabilitation and Compensation Act 2004 (the MRCA).

Factors that must be related to service

5. Subject to clause 7, at least one of the factors set out in clause 6 must be related to the relevant service rendered by the person.

Factors

6. The factor 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 is:

(a) having a caloric intake that is excessive for energy needs for at least the five years before the clinical onset of morbid obesity; or

(b) being treated with a drug or a drug from a class of drugs from the specified list, where that drug cannot be ceased or substituted, for at least the one month before the clinical onset of morbid obesity; or

(c) having the eating disorder, binge eating disorder, for at least the three months before the clinical onset of morbid obesity; or

(d) having Cushing's syndrome for at least the three months before the clinical onset of morbid obesity; or

(e) having hypothyroidism for at least the three months before the clinical onset of morbid obesity; or

(f) having a hypothalamic disorder causing excessive eating for at least the three months before the clinical onset of morbid obesity; or

(g) inability to sleep an average of more than five hours nightly for at least the five years before the clinical onset of morbid obesity; or

(h) having a clinically significant psychiatric disorder as specified for at least the five years before the clinical onset of morbid obesity; or

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

Factors that apply only to material contribution or aggravation

7. Paragraph 6(i) 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.

Inclusion of Statements of Principles

8. 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 as in force from time to time.

Other definitions

9. For the purposes of this Statement of Principles:

"a drug or a drug from a class of drugs from the specified list" means:

(a) atypical antipsychotics, including clozapine, olanzapine, quetiapine, risperidone and sertindole;

(b) carbamazepine;

(d) clonidine;

(e) cyproheptadine;

(f) gabapentin;

(g) glucocorticosteroids;

(h) guanabenz;

(i) guanethidine;

(j) insulin;

(k) lithium;

(l) maprotiline;

(m) megestrol acetate;

(n) methyldopa;

(o) mirtazapine;

(p) nisoldipine;

(q) paroxetine;

(r) phenelzine;

(s) pizotifen;

(t) prazosin;

(u) propranolol;

(v) sulphonylureas;

(w) terazosin;

(x) tricyclic antidepressants, including amitriptyline, clomipramine, doxepin, imipramine and nortriptyline;

(y) typical antipsychotics, including chlorpromazine, fluphenazine, fluphenthixol, perphenazine, pimozide, thioridazine and trifluoperazine; or

(z) valproic acid;

"a clinically significant psychiatric condition as specified" means one of the following conditions, which is of sufficient severity to warrant ongoing management, which may involve regular visits (for example, at least monthly) to a psychiatrist, counsellor or general practitioner:

(a) bipolar I or II disorder;

(b) generalised anxiety disorder;

(d) panic disorder;

(e) persistent depressive disorder;

(f) personality disorder;

(g) posttraumatic stress disorder;

(h) schizophrenia;

(i) social phobia; or

(j) specific phobia;

"binge eating disorder" means a psychiatric condition meeting the following criteria:

(a) recurrent episodes of binge eating. An episode of binge eating is characterised by both of the following:

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

(ii) 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:

(i) eating much more rapidly than normal;

(ii) eating until feeling uncomfortably full;

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

(iv) eating alone because of feeling embarrassed by how much one is eating; or

(v) feeling disgusted with oneself, depressed, or very guilty afterward;

(d) the binge eating occurs, on average, at least once a week for three months; and

(e) the binge eating is not associated with the recurrent use of inappropriate compensatory behaviour as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa;

"BMI" means body mass index and is calculated as follows:

The BMI = W/H2 and 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;

"hypothalamic disorder" means a disease that causes structural damage to the hypothalamus. This can result from tumour, trauma, granulomatous infections, central nervous system infections, therapeutic radiation or surgery;

"relevant service" means:

(a) eligible war service (other than operational service) under the VEA;

(b) defence service (other than hazardous service and British nuclear test defence service) under the VEA; or

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

(a) pneumonia;

(b) respiratory failure;

(d) circulatory failure; or

(e) cessation of brain function.

Application

10. This Instrument applies to all matters to which section 120B of the VEA or section 339 of the MRCA applies.

Date of effect

11. This Instrument takes effect from 15 January 2014.

Dated this nineteenth day of December 2013

The Common Seal of the )

Repatriation Medical Authority )

was affixed at the direction of: )

PROFESSOR NICHOLAS SAUNDERS AO

CHAIRPERSON