Diagnostic Assessment — Obesity
Example 1 of 2 · fictitious patient (Veteran J)
Example document — fictitious patient. This report is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious and bears no relationship to any real person, living or deceased. Names, dates of birth, contact details, service numbers, units, locations and treating clinicians have been withheld or altered and all dates have been changed. It must not be relied upon as a record of any real claim.
Diagnostic Assessment
Obesity
SOP Codes: Balance of Probabilities - SOP 44/2022 (Morbid Obesity - applied by analogy); Reasonable Hypothesis - SOP 43/2022 (Morbid Obesity - applied by analogy)
Note: No specific SOP exists for obesity below morbid obesity threshold. Analysis conducted using morbid obesity SOPs as analogous framework given similar pathophysiology and risk factors.
ADF History
The veteran, Medic/Medical Operator/Medical Technician, enlisted 06 December 2001, transferring to SERCAT 5 (Reserve Service) on 23 Mar 2022.
Occupational History
Military medics face significant occupational challenges that contribute to weight management difficulties including irregular meal schedules during deployments and field exercises, reliance on high-calorie processed ration packs, limited access to fresh foods during operational periods, disrupted sleep patterns affecting metabolism, high stress levels leading to emotional eating, physical injuries limiting exercise capacity, and sedentary periods during recovery from musculoskeletal injuries. The demanding nature of medical duties combined with shift work and deployment stressors creates an environment conducive to weight gain.
History
The veteran an Army Medic, developed obesity during her military service beginning in 2004 after initial weight gain during training, reaching a peak BMI of 37.1 in 2012. She had been overweight during childhood and adolescence but successfully lost 25kg before enlistment in 2003, however regained weight during Initial Employment Training.
Timeline
- July 2009: Documented BMI 34.4 representing Class I obesity during routine medical examination. This measurement occurred approximately 6 years after enlistment and demonstrated significant weight gain since her pre-military weight loss. The BMI placed her in the obesity category despite military fitness requirements. Associated health impacts included increased cardiovascular risk and potential contribution to musculoskeletal problems. Weight management counseling was provided but competing military demands made adherence challenging.
- June 2011: Peak weight recorded with BMI 37.1 reaching Class II obesity during medical review. This represented her highest documented weight throughout military service, occurring during a period of multiple musculoskeletal injuries including bilateral carpal tunnel syndrome requiring surgery. The progression from BMI 34.4 to 37.1 over two years indicated continued weight gain despite awareness and military fitness standards. This coincided with limited physical activity due to surgical recovery and chronic pain conditions. Intensive weight management intervention was clearly indicated at this stage.
- Mar 2012: Weight reduction achieved with BMI 31.04 following Medical Employment Classification Review. The veteran demonstrated approximately 15-20kg weight loss from her peak, likely motivated by career implications and fitness requirements. Despite the improvement, she remained in the Class I obesity category indicating ongoing metabolic challenges. The reduction occurred through structured intervention and increased motivation during her employment review process. Continued weight loss efforts were encouraged to reach healthy BMI range.
- August 2019: Significant improvement documented with BMI 27.24 falling into overweight category. This represented sustained weight loss of approximately 30-35kg from her peak weight over 7 years, demonstrating remarkable personal commitment. She had successfully transitioned from Class II obesity to overweight status, indicating effective long-term lifestyle modifications. This improvement coincided with resolution of acute musculoskeletal issues and improved physical activity tolerance. The achievement represented one of her most significant health improvements during service.
Symptoms
Initially, the veteran experienced gradual weight gain during Initial Employment Training in 2004 with associated decreased fitness performance and increased difficulty meeting military physical standards. During her peak obesity period (2012), she likely experienced reduced exercise tolerance, joint stress contributing to musculoskeletal problems, potential sleep disturbances, and metabolic changes affecting energy levels. Currently, following her significant weight loss achievement, she has demonstrated improved physical capacity, better management of comorbid conditions, and enhanced overall health status, though she remains slightly above ideal BMI range.
Imaging
No specific imaging performed for obesity assessment. Related imaging included abdominal ultrasound on 23 May 2013 showing mild hepatic steatosis consistent with obesity-related fatty liver disease.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Obesity (ICD-10: E66.9). Analysis conducted using DVA SOPs 44/2022 (Balance of Probabilities) and 43/2022 (Reasonable Hypothesis) for morbid obesity applied by analogy, as no specific SOP exists for obesity below BMI 40 threshold.
Obesity is a chronic disease characterized by excessive accumulation of body fat resulting in BMI ≥30 kg/m². It represents a complex multifactorial condition involving genetic, environmental, psychological, and behavioral factors. Class I obesity (BMI 30-34.9), Class II obesity (BMI 35-39.9), and Class III obesity (BMI ≥40) represent increasing severity levels with corresponding health risks including cardiovascular disease, type 2 diabetes, sleep apnea, osteoarthritis, and certain cancers.
The veteran progressed from Class I obesity (BMI 34.4 in 2010) to Class II obesity (BMI 37.1 in 2012) before achieving weight reduction to overweight status (BMI 27.24 in 2020). The temporal relationship demonstrates onset during military service with peak severity mid-career, followed by successful long-term weight management achieving near-normal BMI range.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? Weight gain began during Initial Employment Training in 2004, shortly after enlistment on 06 December 2001. [CHART REVIEW - MELISSA CAMPBELL - FINAL.docx, multiple pages reference obesity timeline]
When did the veteran first present to a health / medical provider for this condition? First documented obesity assessment occurred during routine medical examination in July 2009 when BMI 34.4 was recorded, presenting to military medical officers as part of routine health screening. [CHART REVIEW - MELISSA CAMPBELL - FINAL.docx, obesity timeline section]
When was the condition confirmed / formally diagnosed? Obesity was formally confirmed in July 2009 when BMI 34.4 was documented during routine medical examination by military medical staff, meeting clinical criteria for Class I obesity (BMI ≥30). [CHART REVIEW - MELISSA CAMPBELL - FINAL.docx, conditions section item 57]
When did the veteran first present to you (or your practice) for this condition? 22 November 2020.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions? Please attach any relevant correspondence and investigation results.
The diagnosis was confirmed through objective BMI measurements demonstrating BMI ≥30 consistently over multiple years. Key measurements included BMI 34.4 (July 2009), BMI 37.1 (June 2011), BMI 31.04 (Mar 2012), and BMI 27.24 (August 2019). Associated findings included hepatic steatosis on abdominal ultrasound (July 2014) and gallbladder polyps, both consistent with obesity-related metabolic changes. Clinical correlation included weight-related musculoskeletal stress contributing to joint pathology and reduced exercise tolerance during peak obesity periods. [CHART REVIEW - MELISSA CAMPBELL - FINAL.docx, obesity timeline and imaging sections]
4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.
Using morbid obesity SOP factors by analogy:
Having a caloric intake that is excessive for energy needs for at least the 5 years before the clinical onset of obesity - MET Military service from 2004-2010 involved high-calorie field rations, irregular meal timing during exercises and deployments, limited access to fresh foods, and stress-induced eating patterns contributing to sustained caloric excess leading to obesity onset in 2010.
Taking a drug from the specified list of drugs for at least the 6 months before the clinical onset of obesity - NOT MET No documented use of weight-gaining medications from the specified list (carbamazepine, gabapentin, insulin, lithium, antidepressants, etc.) during the 6 months prior to obesity onset in 2010.
Taking an antipsychotic drug for at least the 3 months before the clinical onset of obesity - NOT MET No documented antipsychotic medication use prior to obesity onset in 2010.
Taking at least 5 milligrams of prednisone per day, or equivalent glucocorticoid therapy, for at least the 3 months before the clinical onset of obesity - NOT MET No documented corticosteroid therapy prior to obesity onset, though NSAIDs were used for musculoskeletal conditions from 2018 onwards.
Having binge eating disorder or night eating syndrome for at least the 1 year before the clinical onset of obesity - NOT MET No documented eating disorders, though irregular military meal schedules may have contributed to disordered eating patterns.
Having a clinically significant disorder of mental health as specified for at least the 3 years before the clinical onset of obesity - NOT MET Adjustment disorder was diagnosed in December 2010, after obesity onset in 2010. However, workplace stress and relationship difficulties likely predated formal diagnosis.
Having Cushing syndrome for at least the 3 months before the clinical onset of obesity - NOT MET No documentation of Cushing syndrome or related endocrine disorders.
Having hypothyroidism for at least the 3 months before the clinical onset of obesity - NOT MET No documented thyroid dysfunction throughout her service period.
Having a hypothalamic disorder causing excessive eating for at least the 3 months before the clinical onset of obesity - NOT MET No evidence of hypothalamic pathology or neurological disorders affecting appetite regulation.
Inability to sleep for an average of more than 5 hours per night for at least the 5 years before the clinical onset of obesity- MET Military service demands including shift work, deployment sleep disruption, operational tempo, and stress-related insomnia from 2004-2010 created chronic sleep deprivation patterns known to disrupt metabolic hormones and promote weight gain.
Undertaking night shift work on at least 500 occasions within a continuous period of at least the 5 years before the clinical onset of obesity - MET Medical duties required extensive shift work including night duties in medical facilities, deployment rotations with altered sleep cycles, and emergency response callouts disrupting normal circadian rhythms from 2004-2010, easily exceeding 500 occasions over 6 years.
In a person with a prior history of a regular smoking habit, permanently ceasing to smoke within the 2 years before the clinical onset of obesity - NOT MET She quit smoking in 2007 via hypnosis, but obesity onset was documented in 2010, exceeding the 2-year timeframe.
Having consumed a cumulative total of at least 50 kilograms of alcohol from drinking beer within the 5 years before the clinical onset of obesity (RH factor) - NOT MET Her documented alcohol intake patterns from 2004-2010 show periods of heavy drinking but insufficient documentation to confirm 50kg cumulative beer consumption specifically.
Experiencing severe childhood abuse before the clinical onset of obesity - NOT MET No documentation of childhood abuse or trauma in her history.
Physical inactivity due to injury (not in SOP but relevant factor) - MET Right knee chondromalacia patella onset in June 2003, requiring arthroscopy in 2005, significantly limited exercise capacity during the critical period leading to obesity onset in 2010.
Inability to obtain appropriate clinical management for obesity - MET Military healthcare system lacked specialized obesity management programs, competing operational demands prevented consistent lifestyle interventions, limited access to dietitians and weight management specialists, and cultural stigma around weight issues in military environment created substantial barriers to appropriate clinical management per Brew v Repatriation Commission precedent, causing permanent worsening through progression to Class II obesity.
Sequelae
Obesity contributed to development of multiple secondary conditions including hepatic steatosis, gallbladder polyps, hyperlipidemia, and exacerbated existing musculoskeletal conditions through increased joint loading, creating a cycle of reduced mobility and further weight gain.
Unintended Consequence
No evidence that obesity resulted from unintended consequences of ADF medical treatment.
Inability to Attain Appropriate Medical Management
MET - As referenced in Brew v Repatriation Commission (20 May 1996), inability encompasses both objective and subjective barriers to treatment. Military healthcare focused on acute rather than chronic disease management, with no specialized obesity services available during her service period. Competing operational demands prevented consistent participation in weight management programs. Limited access to registered dietitians, endocrinologists, or bariatric specialists. Military culture stigma around weight issues created psychological barriers to seeking comprehensive treatment. The 6-year period from weight gain onset (2004) to formal recognition (2010) demonstrates systematic failure to provide appropriate preventive and therapeutic interventions, causing permanent worsening through progression from overweight to Class II obesity before eventual self-directed improvement.
The % contribution of the causes is 100% and significant.
5. Please provide a Health Summary and a medication / prescribing history. -see attached report
Example document — fictitious patient. This report is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious and bears no relationship to any real person, living or deceased. Names, dates of birth, contact details, service numbers, units, locations and treating clinicians have been withheld or altered and all dates have been changed. It must not be relied upon as a record of any real claim.
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Diagnostic Assessment — Obesity
Example 2 of 2 · fictitious patient
Example document — fictitious patient. This report is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious and bears no relationship to any real person, living or deceased. Names, dates of birth, contact details, service numbers, units, locations and treating clinicians have been withheld or altered and all dates have been changed. It must not be relied upon as a record of any real claim.
Diagnostic Assessment Obesity BOP Code: 44 of 2022 (Morbid Obesity) RH Code: 43 of 2022 (Morbid Obesity)
ADF History
The veteran, date of birth [withheld], Australian Army, Combat Engineer, 23 April 1979 to 6 February 1986
Occupational History
The veteran's weight at enlistment was 89kg with a "very thickset" build.
During service, his weight increased significantly, reaching 113kg (BMI approximately 32.3) by March 1983 and 114kg (BMI approximately 32.3) by June 1983.
He was placed on the Defence Weight Surveillance Programme.
The naval dietary environment with high-calorie mess meals, the sedentary periods of shipboard duty, and the stress of military service are recognised contributory factors to weight gain during service
History
The veteran has had obesity documented from at least 8 June 1982 during ADF service (115kg at 187cm, BMI approximately 32.9), and again in March 1983 (BMI 32.3 at 113kg/187cm).
His weight at enlistment was 89kg.
During service, he gained approximately 25kg by June 1983, reaching 114kg with body fat percentages of 23.9% to 26.6%.
He was placed on the Defence Weight Surveillance Programme and granted a weight waiver to 115kg (applied for on 8 June 1982, when he weighed 115kg with body fat of 21.4%).
A Medical Board of Survey at a field engineer regiment on 11 May 1983 recorded the disability as obesity, noting that after an initial period of weight loss on the Weight Surveillance Programme he had put on all the weight lost despite counselling on diet and exercise on numerous occasions.
The Board assessed him as unfit for sea service with 50% naval incapacity and recommended Category 10 for six months; on 25 May 1983 Category 10 was confirmed and it was decided that he had lost his weight waiver, which would be reconsidered when his body fat reduced below 22% and was maintained.
Elevated blood pressure readings (150/90 in September 1982 and March 1983, and 150/95 in May 1983) were documented concurrently with the weight gain, and the Board noted a persistently raised blood pressure.
At his discharge medical examination on 6 February 1986 he weighed 125kg (BMI 35.7) with body fat of 30.7%.
Post- discharge, his weight increased further to 168kg before bariatric surgery in 2014 reduced it to 76kg, with subsequent regain to 143.6kg (BMI approximately 41.5) by October 2019
Timeline
11 Mar 1979 — Pre-enlistment.
Weight 89kg.
GP the treating doctor build as "very thickset." Letter supporting enlistment noting weight near normal for height considering build. "Very thickset" 8 June 1982 — Application made for a weight waiver to 115kg.
Weight 115kg, body fat 21.4%, blood pressure 125/70 (as recorded by the Medical Board of Survey, May 1983). "weight waiver to 115Kgs" 05 Sep 1982 — Weight surveillance at a field engineer regiment.
Height 187cm, weight 102kg (BMI approximately 29.2).
Body fat 23.9%.
Blood pressure 150/90 (elevated).
The medical officer documented concern about the generosity of the weight waiver to 115kg, stating "I FEEL PRESENT WAIVER IS UNJUSTIFIED." "Weight surveillance" 28 Jun 1982 — Weight waiver granted by Director of Medical Services — Navy.
Upper weight limit 115kg, provided body fat remains below 22%.
The granting of this waiver permitted the veteran to remain in service at an excessive weight. "Weight waiver granted" 08 Mar 1983 — Weight surveillance at a field engineer regiment.
Height 187cm, weight 113kg (BMI approximately 32.3).
Body fat 26.1%.
Blood pressure 150/90 (elevated).
BMI now in the obese range. "Obese — BMI 32.3" 11 May 1983 — Medical Board of Survey at a field engineer regiment: disability obesity (origin a field engineer regiment, 14 Mar 1983).
Height 188cm, weight 111kg, neck 40cm, waist 102cm, body fat 26.1%, blood pressure 150/95 (persistently raised).
After an initial period of weight loss on the Weight Surveillance Programme he had put on all the weight lost.
Assessed as unfit for sea service with 50% naval incapacity; advised re diet and exercise and to continue the Weight Surveillance Programme; Category 10 for six months recommended.
On 25 May 1983 Category 10 was confirmed (resurvey by 21 Nov 1983) and he lost his weight waiver, to be reconsidered when his body fat reduced below 22%. "large thickset build but looks obese" 14 June 1983 — Weight surveillance at a field engineer regiment.
Height 188cm, weight 114kg (BMI approximately 32.3).
Body fat 26.6%.
Blood pressure 135/80.
Neck circumference 40cm.
Waist 101cm. "Weight surveillance" 23 Jul 1983 — Hospital admission at RANH a field engineer regiment.
Overweight (ICD 278.0) listed as a known secondary diagnosis on the admission record. "Overweight" 06 Feb 1986 — Discharge medical examination.
Height 187cm, weight 125kg, BMI 35.7.
Neck 44cm, abdomen 115cm, body fat 30.7%.
Blood pressure 140/90, pulse 78.
Comments note a waiver to 115kg. "BMI - 35.7" 2014 — Bariatric surgery performed.
Weight reduced from 168kg to 76kg. "Bariatric surgery" 14 Oct 2019 — Professor Panegyres neurology consultation.
Height 186cm, weight 143.6kg (BMI approximately 41.5).
Morbid obesity documented.
Weight regain post- bariatric surgery. "Morbid obesity — BMI 41.5"
Symptoms
Obesity is a chronic metabolic condition associated with increased risk of cardiovascular disease, diabetes, osteoarthritis, sleep apnoea, and other comorbidities.
The veteran has documented obesity-related conditions including bilateral hip osteoarthritis, obstructive sleep apnoea, type 2 diabetes mellitus (diagnosed approximately 2015), and elevated blood pressure
Imaging
No specific imaging related to obesity.
Body habitus noted to affect imaging quality on multiple reports
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Obesity (ICD-10: E66.01).
The relevant Statements of Principles are those concerning Morbid Obesity (Balance of Probabilities No.
44 of 2022; Reasonable Hypothesis No.
43 of 2022), applied by analogy as this is a DRCA claim.
Obesity is defined as a BMI of 30 or greater.
The veteran's BMI exceeded 30 from at least 8 June 1982 during service (approximately 32.9 at 115kg/187cm; 32.3 at 113kg/187cm in March 1983)
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? Weight gain commenced during service.
His weight was recorded as 115kg (body fat 21.4%) when a weight waiver to 115kg was applied for on 8 June 1982 [CHART REVIEW document], which at his recorded height of 187cm equates to a BMI of approximately 32.9, already in the obese range ( 30); his BMI was again in the obese range (32.3) on 8 March 1983.
He had been on the Weight Surveillance Programme from at least 5 September 1982 when his BMI was 29.2 (overweight range).
When did the veteran first present to a health / medical provider for this condition? 8 June 1982 (weight waiver application; weight 115kg, body fat 21.4%) [CHART REVIEW document]; first documented weight surveillance 5 September 1982 [CHART REVIEW document] When was the condition confirmed / formally diagnosed? 8 March 1983 (BMI 32.3 — confirmed obese) [CHART REVIEW document]; obesity formally recorded as a disability by a Medical Board of Survey on 11 May 1983 [CHART REVIEW document] When did the veteran first present to you (or your practice) for this condition? 2 September 2020
3. How was this diagnosis confirmed?
The diagnosis was confirmed by serial anthropometric measurements during the Defence Weight Surveillance Programme.
Height 187cm, weight 113kg (BMI 32.3), body fat 26.1% on 8 March 1983.
Obesity was also listed as a secondary diagnosis (ICD 278.0 — Overweight) on the hospital admission record of 23 July 1983 [ [CHART REVIEW document], pages 43, 112 113, 120].
A Medical Board of Survey at a field engineer regiment on 11 May 1983 recorded the disability as obesity (weight 111kg, body fat 26.1%, blood pressure 150/95), assessed him as unfit for sea service and recommended Category 10 for six months [ [CHART REVIEW document], pages 116 117].
At his discharge medical examination on 6 February 1986 he weighed 125kg with a BMI of 35.7 and body fat of 30.7% [CHART REVIEW document]
4. What do you consider to be the cause(s) of the condition in this veteran?
Legislation: The clinical onset of this condition was before 21 July 1999 (see
Date of Clinical Onset
Below), and it did not arise on warlike or non-warlike deployment (the veteran had no deployments).
This is therefore a DRCA claim.
Statements of Principles do not apply to DRCA claims, so there are no binding SOP factors for this condition.
The factors of the relevant Statements of Principles are applied below by analogy, as a guide to the causes of this condition that are recognised in the medical-scientific literature, and every factor of both the Balance of Probabilities and the Reasonable Hypothesis instruments is addressed.
Under the DRCA the question is whether the injury or disease arose out of, or in the course of, the veteran's ADF service, or (for a disease or an aggravation) whether that service contributed to it to a significant degree.
Plausible links to service outside the SOP factors are set out below.
The absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Definition: The Statements of Principles concern morbid obesity, which requires a BMI of at least 40 in an adult.
The veteran's BMI was in the obese range in service (32.9 from 8 June 1982, 35.7 at discharge) and reached about 48.6 before bariatric surgery in 2014 (self- reported 168 kg) and 41.5 on 14 October 2019; as the claimed condition is obesity, the SOP is applied by analogy, with the onset of obesity (on or before 8 June 1982) taken as the clinical onset.
Causative Factors — Balance of Probabilities (Statement of Principles concerning Morbid Obesity, No.
44 of 2022) Factor 9(1): having a caloric intake that is excessive for energy needs for at least the 5 years before the clinical onset of morbid obesity — MET - the veteran's weight history shows an energy intake in excess of his needs throughout the 5 years before 8 June 1982.
Before enlistment he was above the Navy's 90 kg limit and had to reduce his weight to be accepted (89 kg on 11 March 1979, with a 'very thickset' build); over the next 39 months he gained 26 kg, reaching 115 kg (BMI 32.9) on 8 June 1982.
His energy needs fell in that period through the inactivity of in-service injuries and surgery (104 days ineffective for work between August 1981 and April 1982, with light duties and periods unfit for sea), while his intake from naval messing and, on his account, regular drinking continued.
Factor 9(2): taking a drug from the specified list of drugs for at least the 6 months before the clinical onset of morbid obesity — NOT MET - None of the specified drugs was taken before 8 June 1982; gabapentin, pregabalin, amitriptyline and valproate first appear on his medication list of 14 October 2019.
Factor 9(3): taking an antipsychotic drug, excluding aripiprazole and ziprasidone, for at least the 3 months before the clinical onset of morbid obesity — NOT MET - No antipsychotic drug was taken before 8 June 1982; olanzapine and quetiapine were first recorded on his medication list in 2019.
Factor 9(4): taking at least 5 milligrams of prednisone per day, or equivalent glucocorticoid therapy, for at least the 3 months before the clinical onset of morbid obesity — NOT MET - No systemic glucocorticoid therapy is recorded before 8 June 1982; his only corticosteroids in that period were topical skin and ear preparations in 1980.
Factor 9(5): having binge eating disorder or night eating syndrome for at least the 1 year before the clinical onset of morbid obesity — NOT MET - There is no record of binge eating disorder or night eating syndrome, and nothing in his history suggests either.
Factor 9(6): having a clinically significant disorder of mental health as specified for at least the 3 years before the clinical onset of morbid obesity — NOT MET - No mental disorder is recorded before 8 June 1982; in December 1985 a psychiatrist recorded no past psychiatric history, and the adjustment disorder then diagnosed is not one of the specified disorders.
Factor 9(7): having Cushing syndrome for at least the 3 months before the clinical onset of morbid obesity — NOT MET - There is no record of Cushing syndrome at any time, and nothing in his history suggests it.
Factor 9(8): having hypothyroidism, including Hashimoto thyroiditis that has resulted in hypothyroidism, for at least the 3 months before the clinical onset of morbid obesity — NOT MET - Hypothyroidism has not been recorded at any time, and nothing in his history suggests it.
Factor 9(9): having a hypothalamic disorder causing excessive eating for at least the 3 months before the clinical onset of morbid obesity — NOT MET - There is no record of a disease or injury causing structural damage to the hypothalamus before 8 June 1982, and nothing suggests excessive eating from such a cause.
Factor 9(10): inability to sleep for an average of more than 5 hours per night for at least the 5 years before the clinical onset of morbid obesity — NOT MET - The 5 years before 8 June 1982 covered his last school years and his first three years of service, and nothing records or suggests that he averaged 5 hours' sleep a night or less over that period.
Factor 9(11): undertaking night shift work on at least 500 occasions within a continuous period of at least the 5 years before the clinical onset of morbid obesity — NOT MET - Before 8 June 1982 the veteran had served only 3 years 1 month, much of it in training, ashore or medically unfit for sea, and was a schoolboy before that, so he could not have undertaken night shift work on 500 occasions within a continuous 5-year period before onset.
Factor 9(12): in a person with a prior history of a regular smoking habit as specified, permanently ceasing to smoke within the 2 years before the clinical onset of morbid obesity — NOT MET - the veteran was still smoking in 1985 (about 5 a day on 15 September 1985) and on his account stopped only in 2004, so he did not cease smoking in the 2 years before 8 June 1982.
Factor 9(13): experiencing severe childhood abuse before the clinical onset of morbid obesity — NOT MET - There is no record of severe childhood abuse, and nothing in his history suggests it.
Causative Factors — Reasonable Hypothesis (Statement of Principles concerning Morbid Obesity, No.
43 of 2022) the veteran had no operational deployments.
The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.
Factor 9(1): having a caloric intake that is excessive for energy needs for at least the 5 years before the clinical onset of morbid obesity — MET - Before enlistment the veteran was above the Navy's 90 kg limit and had to reduce to 89 kg (11 March 1979) to join; in the next 39 months he gained 26 kg, to 115 kg (BMI 32.9) on 8 June 1982, while in-service injuries and surgery (104 days ineffective for work in 1981 87) reduced his energy needs.
This sustained gain shows a caloric intake excessive for his energy needs over at least the 5 years before onset.
Factor 9(2): taking a drug from the specified list of drugs for at least the 6 months before the clinical onset of morbid obesity — NOT MET - No drug from the specified list was taken before 8 June 1982; those he now takes (gabapentin, pregabalin, amitriptyline and valproate) were first recorded in 2019.
Factor 9(3): taking an antipsychotic drug for at least the 3 months before the clinical onset of morbid obesity — NOT MET - He took no antipsychotic drug before 8 June 1982; olanzapine and quetiapine were first recorded in 2019.
Factor 9(4): taking at least 5 milligrams of prednisone per day, or equivalent glucocorticoid therapy, for at least the 3 months before the clinical onset of morbid obesity — NOT MET - There is no record of systemic glucocorticoid therapy before 8 June 1982, only topical skin and ear preparations in 1980.
Factor 9(5): having binge eating disorder or night eating syndrome for at least the 1 year before the clinical onset of morbid obesity — NOT MET - There is no record of binge eating disorder or night eating syndrome, and nothing in his history suggests either.
Factor 9(6): having a clinically significant disorder of mental health as specified for at least the 2 years before the clinical onset of morbid obesity — NOT MET - No mental disorder is recorded before 8 June 1982, and his only in-service diagnosis, adjustment disorder in December 1985, is not a specified disorder.
Factor 9(7): having Cushing syndrome for at least the 3 months before the clinical onset of morbid obesity — NOT MET - There is no record of Cushing syndrome at any time, and nothing in his history suggests it.
Factor 9(8): having hypothyroidism, including Hashimoto thyroiditis that has resulted in hypothyroidism, for at least the 3 months before the clinical onset of morbid obesity — NOT MET - Hypothyroidism has not been recorded at any time, and nothing in his history suggests it.
Factor 9(9): having a hypothalamic disorder causing excessive eating for at least the 3 months before the clinical onset of morbid obesity — NOT MET - No disease or injury damaging the hypothalamus is recorded before 8 June 1982, and nothing suggests excessive eating from such a cause.
Factor 9(10): inability to sleep for an average of more than 5 hours per night for at least the 5 years before the clinical onset of morbid obesity — NOT MET - Nothing records or suggests that he averaged 5 hours' sleep a night or less over the 5 years before 8 June 1982, which covered his last school years and first three years of service.
Factor 9(11): undertaking night shift work on at least 500 occasions within a continuous period of at least the 5 years before the clinical onset of morbid obesity — NOT MET - With only 3 years 1 month of service before 8 June 1982, much of it in training, ashore or unfit for sea, and school before that, he could not have undertaken night shift work on 500 occasions within a continuous 5-year period before onset.
Factor 9(12): in a person with a prior history of a regular smoking habit as specified, permanently ceasing to smoke within the 2 years before the clinical onset of morbid obesity — NOT MET - He was still smoking in 1985 (about 5 a day on 15 September 1985) and stopped only in 2004, so he did not cease smoking in the 2 years before 8 June 1982.
Factor 9(13): having consumed a cumulative total of at least 50 kilograms of alcohol from drinking beer within the 5 years before the clinical onset of morbid obesity — NOT MET - On his account he drank beer in the Navy only at sea, two cans a day (about 29 grams of alcohol); even daily for the whole 3 years 1 month of service before 8 June 1982 this is about 33 kilograms, and nothing suggests regular beer drinking before he enlisted at 16.
Factor 9(14): experiencing severe childhood abuse before the clinical onset of morbid obesity — NOT MET - There is no record of severe childhood abuse, and nothing in his history suggests it.
Other Plausible Links to Service the veteran's obesity developed over a period dominated by in-service injuries and their surgical treatment.
Hammer-toe tendon transfers on 2 August 1981, a left thumb dislocation near Cooktown on 19 November 1981, bilateral thumb arthrodesis on 21 December 1981 and re- operation on 29 March 1982 (the thumb condition being found by the Medical Board of Survey of 24 February 1982 to have been aggravated by naval service) left him 104 days ineffective for work, on light duties and medically unfit for sea through much of 1981 87, and further surgery in November 1983 added 36 days.
The resulting inactivity lowered his energy needs while his intake continued, and his weight rose from 89 kg at enlistment to 115 kg by June 1982; to the extent that this followed surgery provided at Commonwealth expense, the weight gain is also an unintended consequence of that treatment within section 6A of the DRCA.
Service also placed the veteran in circumstances that favoured a positive energy balance and made weight control difficult: naval messing, with limited control over food at sea and, on his account, two cans of beer a day at sea; and watchkeeping, quartermaster and gangway duties with irregular hours and broken sleep.
His weight rose by a further 10 kg after onset, to 125 kg (body fat 30.7%) at discharge, while he remained under service medical record supervision.
Even if his thickset build and his need to reduce his weight to enlist are taken to show a pre- existing tendency, service aggravated it: he enlisted at 89 kg and was discharged at 125 kg, and service contributed to his obesity to a significant degree.
Conclusion the veteran's obesity arose during his service from a sustained caloric intake in excess of his energy needs: he enlisted at 89 kg, weighed 115 kg (BMI 32.9) by 8 June 1982 and 125 kg (BMI 35.7) at discharge.
Service contributed to it through the prolonged inactivity that followed in-service injuries and surgery, the circumstances of naval messing and watchkeeping, and in-service management limited to surveillance and sanctions without effective treatment.
After discharge it progressed into the morbid range (BMI about 48.6 before bariatric surgery in 2014 and 41.5 in 2019), with post-service contributions from weight-promoting medications, posttraumatic stress disorder and depression, disrupted sleep and the cessation of heavy smoking in 2004.
The % contribution of the causes is 100% and significant.
Worsening Factors In the alternative, if the veteran's obesity is found to have begun before enlistment (he was above the Navy's 90 kg limit before 1979) or otherwise not to have arisen out of his service, the following factors address whether anything after its clinical onset (on or before 8 June 1982) aggravated it or contributed to it in a material degree.
His weight rose in service to 125 kg (BMI 35.7) at discharge on 6 February 1986 and after discharge to about 168 kg (BMI about 48.6) before bariatric surgery in 2014, then regained from 76 kg to 143.6 kg (BMI 41.5) by 14 October 2019.
Worsening Factors — Balance of Probabilities (Statement of Principles concerning Morbid Obesity, No.
44 of 2022) Factor 9(14): having a caloric intake that is excessive for energy needs for at least the 5 years before the clinical worsening of morbid obesity — MET - After onset the veteran's weight kept rising despite the Weight Surveillance Programme: the Medical Board of Survey of 11 May 1983 recorded that after an initial loss he 'returned to his previous eating habits, and put on all the weight lost', and at discharge on 6 February 1986 he weighed 125 kg (BMI 35.7, body fat 30.7%), against 115 kg and 21.4% in June 1982.
This reflects an intake exceeding his energy needs throughout the 5 years before that worsening, with naval messing, heavy drinking (alcohol abuse was recorded in December 1985) and further inactivity after surgery in November 1983; the pattern continued after discharge, to about 168 kg before bariatric surgery in 2014.
Factor 9(15): taking a drug from the specified list of drugs for at least the 6 months before the clinical worsening of morbid obesity — MET - The pharmacy profile recorded by his neurologist on 14 October 2019 lists four drugs from the specified list (gabapentin, pregabalin, the tricyclic antidepressant amitriptyline, and valproate), at a time when his weight had regained from 76 kg after bariatric surgery in 2014 to 143.6 kg (BMI 41.5).
Start dates are not recorded, but they treat long-standing conditions, neuropathic pain managed by a pain specialist from at least June 2015 and episodes of loss of consciousness investigated from July 2014 and later treated as seizures, so he very probably took them for at least 6 months before that worsening.
This is a post-service factor, related to service only to the extent that the conditions treated are.
Factor 9(16): taking an antipsychotic drug, excluding aripiprazole and ziprasidone, for at least the 3 months before the clinical worsening of morbid obesity — MET - Olanzapine and quetiapine, antipsychotic drugs outside the aripiprazole and ziprasidone exclusion and both known to promote weight gain, were on his pharmacy profile on 14 October 2019, when his weight had regained to 143.6 kg (BMI 41.5) after bariatric surgery in 2014.
Their start dates are not recorded, but he had been under the care of a psychiatrist and pain management specialist since at least June 2015 and is treated for posttraumatic stress disorder and chronic pain, so it is probable that he had taken them for at least 3 months before that worsening.
This is a post-service factor.
Factor 9(17): taking at least 5 milligrams of prednisone per day, or equivalent glucocorticoid therapy, for at least the 3 months before the clinical worsening of morbid obesity — NOT MET - No systemic glucocorticoid course is recorded; his three single 1 mL betamethasone (Celestone) injections in March June 2012 fall far short of an average of 0.8 mg of betamethasone a day for 3 months.
Factor 9(18): having binge eating disorder or night eating syndrome for at least the 1 year before the clinical worsening of morbid obesity — NOT MET - There is no record of binge eating disorder or night eating syndrome at any time, and nothing in his history suggests either.
Factor 9(19): having a clinically significant disorder of mental health as specified for at least the 3 years before the clinical worsening of morbid obesity — MET - the veteran has had posttraumatic stress disorder, depression and anxiety since about 2005 (present for 14 years on his account in October 2019), severe enough to need ongoing psychiatric care, antipsychotic and antidepressant medication, ketamine and a psychiatric assistance dog.
These disorders had been present for well over 3 years before the documented post-service worsening, the regain from 76 kg after bariatric surgery in 2014 to 143.6 kg (BMI 41.5) by 14 October 2019.
This is a post-service factor; his only in-service diagnosis, adjustment disorder with depressed mood in December 1985, is not a specified disorder.
Factor 9(20): having Cushing syndrome for at least the 3 months before the clinical worsening of morbid obesity — NOT MET - There is no record of Cushing syndrome at any time, and nothing in his history suggests it.
Factor 9(21): having hypothyroidism, including Hashimoto thyroiditis that has resulted in hypothyroidism, for at least the 3 months before the clinical worsening of morbid obesity — NOT MET - Hypothyroidism has not been recorded at any time, and nothing in his history suggests it.
Factor 9(22): having a hypothalamic disorder causing excessive eating for at least the 3 months before the clinical worsening of morbid obesity — NOT MET - No structural damage to the hypothalamus has been recorded; brain MRIs from 2014 to 2019, performed after his head injuries including the facial blow with loss of consciousness in February 2012, showed only non-specific white-matter change.
Factor 9(23): inability to sleep for an average of more than 5 hours per night for at least the 5 years before the clinical worsening of morbid obesity — MET - On 14 October 2019 his neurologist recorded that pain keeps him 'up and down' through the night, so that he sleeps mainly in the early morning and the afternoon, and listed sleep disruption, possible obstructive sleep apnoea and a chronic pain complex among the causes of his memory impairment.
The duration is not recorded, but the causes of his broken sleep (chronic spinal and neuropathic pain, with incapacity for work since 2012; posttraumatic stress disorder since about 2005; obstructive sleep apnoea diagnosed over 10 years earlier and untreated for some years) make it probable that he averaged no more than 5 hours' sleep a night for at least 5 years before the weight regain documented in 2019.
This is a post-service factor.
Factor 9(24): undertaking night shift work on at least 500 occasions within a continuous period of at least the 5 years before the clinical worsening of morbid obesity — NOT MET - Night watches at sea, quartermaster and gangway duties and a second job as a night security guard in 1985 gave him some work of at least 3 hours between midnight and 5 am, but its frequency is not recorded; allowing for his time ashore, ineffective or unfit for sea, a reasonable estimate of 300 to 400 such nights in the 5 years before discharge falls short of 500, and none is recorded after discharge.
Factor 9(25): in a person with a prior history of a regular smoking habit as specified, permanently ceasing to smoke within the 2 years before the clinical worsening of morbid obesity — MET - On his account the veteran smoked about 50 cigarettes a day for many years, a regular smoking habit far above 5 pack-years in any 5-year period (only about 5 a day was recorded in service, on 15 September 1985), and stopped permanently in 2004.
Weight gain is usual in the first 2 years after stopping, especially in heavy smokers, and his weight rose from 125 kg at discharge to about 168 kg (BMI about 48.6) before bariatric surgery in 2014; although no weight is recorded between 1986 and 2014, a worsening within 2 years of stopping is probable.
This is a post-service factor.
Factor 9(26): inability to obtain appropriate clinical management for morbid obesity — MET - After onset the veteran's obesity was managed in service only through the Weight Surveillance Programme, by repeated weighing and counselling on diet and exercise, without any recorded dietetic or specialist referral or investigation.
When he regained weight the response was administrative rather than therapeutic: the Medical Board of Survey of 11 May 1983 made him unfit for sea and Category 10, and on 25 May 1983 his weight waiver was withdrawn, sanctions he understood to bar his sea service and promotion ('I think Jenny Craig will be the only answer'); by discharge he weighed 125 kg.
Assessed objectively and subjectively, as in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), this was an inability to obtain appropriate clinical management.
Worsening Factors — Reasonable Hypothesis (Statement of Principles concerning Morbid Obesity, No.
43 of 2022) the veteran had no operational deployments.
The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.
Factor 9(15): having a caloric intake that is excessive for energy needs for at least the 5 years before the clinical worsening of morbid obesity — MET - His weight rose in service after onset from 115 kg (body fat 21.4%) in June 1982 to 125 kg (BMI 35.7, body fat 30.7%) at discharge, the Medical Board of Survey of 11 May 1983 recording that he had 'returned to his previous eating habits', and after discharge to about 168 kg before bariatric surgery in 2014 and 143.6 kg in October 2019.
This shows a caloric intake excessive for his energy needs over at least the 5 years before each worsening.
Factor 9(16): taking a drug from the specified list of drugs for at least the 6 months before the clinical worsening of morbid obesity — MET - Gabapentin, pregabalin, amitriptyline (a tricyclic antidepressant) and valproate, all on the specified list, were on his pharmacy profile on 14 October 2019, when his weight had regained to 143.6 kg (BMI 41.5) after bariatric surgery in 2014.
As long-term treatments for neuropathic pain (managed by a pain specialist from at least June 2015) and seizures, they were very probably taken for at least 6 months before that post-service worsening.
Factor 9(17): taking an antipsychotic drug for at least the 3 months before the clinical worsening of morbid obesity — MET - Olanzapine and quetiapine, both antipsychotic drugs that promote weight gain, were on his pharmacy profile on 14 October 2019, when his weight had regained to 143.6 kg (BMI 41.5) after bariatric surgery in 2014; given his psychiatric and pain care from at least June 2015, it is probable that he had taken them for at least 3 months before that post-service worsening.
Factor 9(18): taking at least 5 milligrams of prednisone per day, or equivalent glucocorticoid therapy, for at least the 3 months before the clinical worsening of morbid obesity — NOT MET - No systemic glucocorticoid course is recorded; his three single betamethasone injections in 2012 fall far short of an average of 0.8 mg of betamethasone a day for 3 months.
Factor 9(19): having binge eating disorder or night eating syndrome for at least the 1 year before the clinical worsening of morbid obesity — NOT MET - There is no record of binge eating disorder or night eating syndrome at any time, and nothing in his history suggests either.
Factor 9(20): having a clinically significant disorder of mental health as specified for at least the 2 years before the clinical worsening of morbid obesity — MET - Posttraumatic stress disorder, depression and anxiety, present since about 2005 on his account and severe enough to require ongoing psychiatric treatment (antipsychotic and antidepressant medication, ketamine and a psychiatric assistance dog), had been present for well over 2 years before the documented post-service worsening, the regain to 143.6 kg (BMI 41.5) by 14 October 2019 after bariatric surgery in 2014.
His only in-service diagnosis, adjustment disorder in December 1985, is not a specified disorder.
Factor 9(21): having Cushing syndrome for at least the 3 months before the clinical worsening of morbid obesity — NOT MET - There is no record of Cushing syndrome at any time, and nothing in his history suggests it.
Factor 9(22): having hypothyroidism, including Hashimoto thyroiditis that has resulted in hypothyroidism, for at least the 3 months before the clinical worsening of morbid obesity — NOT MET - Hypothyroidism has not been recorded at any time, and nothing in his history suggests it.
Factor 9(23): having a hypothalamic disorder causing excessive eating for at least the 3 months before the clinical worsening of morbid obesity — NOT MET - No structural damage to the hypothalamus has been recorded; his brain MRIs from 2014 to 2019 showed only non-specific white-matter change.
Factor 9(24): inability to sleep for an average of more than 5 hours per night for at least the 5 years before the clinical worsening of morbid obesity — MET - His neurologist recorded on 14 October 2019 that pain keeps him 'up and down' through the night, and listed sleep disruption and possible obstructive sleep apnoea among the causes of his memory impairment.
Given chronic pain (incapacitated for work since 2012), posttraumatic stress disorder since about 2005 and obstructive sleep apnoea diagnosed more than 10 years earlier and not treated for some years, it is probable that he averaged no more than 5 hours' sleep a night for at least 5 years before the weight regain documented in 2019, a post-service factor.
Factor 9(25): undertaking night shift work on at least 500 occasions within a continuous period of at least the 5 years before the clinical worsening of morbid obesity — NOT MET - Night watches at sea, quartermaster and gangway duties and night security work in 1985 gave him some night shift work, but a reasonable estimate (about 300 to 400 nights in the 5 years before discharge, allowing for time ashore, ineffective or unfit for sea) falls short of 500, and none is recorded after discharge.
Factor 9(26): in a person with a prior history of a regular smoking habit as specified, permanently ceasing to smoke within the 2 years before the clinical worsening of morbid obesity — MET - On his account he smoked about 50 cigarettes a day for many years (far more than 5 pack- years in any 5-year period) and stopped permanently in 2004.
Weight gain usually follows within 2 years of stopping, especially in heavy smokers, and his weight rose from 125 kg at discharge to about 168 kg before bariatric surgery in 2014, so a worsening within 2 years of stopping is probable, although no weight is recorded between 1986 and 2014.
This is a post- service factor.
Factor 9(27): having consumed a cumulative total of at least 50 kilograms of alcohol from drinking beer within the 5 years before the clinical worsening of morbid obesity — NOT MET - On his account he drank beer in the Navy only at sea, two cans a day (about 29 grams of alcohol); with most of his last five years of service spent ashore or unfit for sea, this was well under 50 kilograms before discharge, and he reports no drinking for at least 10 years before 2019.
Factor 9(28): inability to obtain appropriate clinical management for morbid obesity — MET - In service his obesity was managed only by weighing and counselling under the Weight Surveillance Programme, without dietetic or specialist referral or investigation, and when he regained weight he was made unfit for sea and Category 10 (11 May 1983) and lost his weight waiver (25 May 1983), sanctions affecting his sea service and promotion; his weight rose to 125 kg by discharge.
Under Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), which assesses inability objectively and subjectively and includes the threat of sanctions, this was an inability to obtain appropriate clinical management
Sequelae
Obesity is a contributing factor to multiple other claimed conditions including bilateral hip osteoarthritis, lumbar spondylosis, thoracic spondylosis, haemorrhoids, obstructive sleep apnoea, and type 2 diabetes mellitus
Unintended Consequence
Not an unintended consequence of medical management.
However, the Defence Weight Surveillance Programme's weight waiver system (granting a waiver to 115kg) may have inadvertently sanctioned continued obesity rather than implementing effective weight reduction
Inability to Attain Appropriate Medical Management
This applies only to worsening.
MET — After onset the veteran's obesity was managed in service only through the Weight Surveillance Programme, by repeated weighing and counselling on diet and exercise, without any recorded dietetic or specialist referral or investigation.
When he regained weight the response was administrative rather than therapeutic: the Medical Board of Survey of 11 May 1983 made him unfit for sea and Category 10, and on 25 May 1983 his weight waiver was withdrawn, sanctions he understood to bar his sea service and promotion ('I think Jenny Craig will be the only answer'); by discharge he weighed 125 kg.
Assessed objectively and subjectively, as in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), this was an inability to obtain appropriate clinical management
Date of Clinical Onset
Obesity is a chronic condition.
Its date of clinical onset is the date on which the condition first manifested clinically.
It is not the date on which the condition was first imaged or formally diagnosed
Imaging
And specialist diagnosis record when an established condition was confirmed; a chronic condition is present, and usually symptomatic, for a considerable period before it is investigated, so the date of imaging must not be taken as the date of clinical onset.
First documented: 8 June 1982 — weight of 115kg at a height of 187cm (BMI approximately 32.9) recorded when a weight waiver was sought (his weight before enlistment was 89kg) [CHART REVIEW document].
The later records, including the BMI of 32.3 recorded on 8 March 1983 and the Medical Board of Survey of 11 May 1983, do not alter the date of clinical onset.
As the condition was already present when it was first documented, its clinical onset was no later than that date.
Date of clinical onset: on or before 8 June 1982.
This date falls within the veteran's ADF service (23 April 1979 6 February 1986).
In-service events and exposures before this date relate to clinical onset, and those after it to clinical worsening
