Reference Determination Content
Suggested draft · fictitious patient
Obesity/Overweight (bmi ≥30)
Evidence
The evidence that I have considered in making this decision includes:
- Formal Claim with supporting statements;
- A Statement of your Service from the Department of Defence;
- Copies of your Service Medical Records.
- A Diagnostic Assessment by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 22 April 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 22 April 2025;
- An enlistment medical examination by the medical officer, dated 3 February 2000;
- A dietetic assessment by the defence dietitian, dated 14 May 2007;
- A trauma admission record by Role 3 hospital, Afghanistan, dated 22 July 2008;
- An MRI brain report by the radiologist, dated 30 September 2008;
- A psychiatric assessment by the consultant psychiatrist, dated 14 January 2009;
- An endocrinology consultation by the endocrinologist, dated 3 March 2009;
- A psychology treatment record by the clinical psychologist, dated 22 June 2009;
- A psychiatric review by the consultant psychiatrist, dated 16 September 2010;
- A sleep medicine consultation and actigraphy by the sleep physician, dated 11 November 2011;
- A respiratory medicine consultation by the respiratory physician, dated 1 September 2012;
- An endocrinology consultation and abdominal ultrasound by the endocrinologist and radiologist, dated 15 February 2013;
- A periodic health examination by the medical officer, Garrison health centre, dated 12 June 2013;
- An endocrinology consultation (polysomnography and pathology) by the endocrinologist and sleep physician, dated 18 November 2014.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
3 February 2000 and 25 July 2021
Obesity/Overweight (bmi ≥30)
You have stated that your condition was caused by:
- having a caloric intake that is excessive for energy needs for at least the 5 years before the clinical onset of morbid obesity
- taking a drug from the specified list of drugs for at least the 6 months before the clinical onset of morbid obesity
- taking an antipsychotic drug, excluding aripiprazole and ziprasidone, for at least the 3 months before the clinical onset of morbid obesity
- 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
- having binge eating disorder or night eating syndrome for at least the 1 year before the clinical onset of morbid obesity
- having a clinically significant disorder of mental health as specified for at least the 3 years before the clinical onset of morbid obesity
- having Cushing syndrome for at least the 3 months before the clinical onset of morbid obesity
- having hypothyroidism, including Hashimoto thyroiditis that has resulted in hypothyroidism, for at least the 3 months before the clinical onset of morbid obesity
- having a hypothalamic disorder causing excessive eating for at least the 3 months before the clinical onset of morbid obesity
- 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
- 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
- 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
- experiencing severe childhood abuse before the clinical onset of morbid obesity
Diagnosis: Obesity/Overweight (bmi ≥30)
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 22 April 2025, and is supported by a periodic health examination by the medical officer, Garrison health centre, dated 12 June 2013.
I am satisfied this is the appropriate diagnosis.
In determining your claim for this condition, I have applied the SOP:
Statement of Principles concerning Morbid Obesity (Balance of Probabilities) (No. 44 of 2022)
which sets out the factors that can connect the condition with service.
I am satisfied that you have met the following factor:
- having a caloric intake that is excessive for energy needs for at least the 5 years before the clinical onset of morbid obesity
- taking a drug from the specified list of drugs for at least the 6 months before the clinical onset of morbid obesity
- taking an antipsychotic drug, excluding aripiprazole and ziprasidone, for at least the 3 months before the clinical onset of morbid obesity
- 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
- having binge eating disorder or night eating syndrome for at least the 1 year before the clinical onset of morbid obesity
- having a clinically significant disorder of mental health as specified for at least the 3 years before the clinical onset of morbid obesity
- having Cushing syndrome for at least the 3 months before the clinical onset of morbid obesity
- having hypothyroidism, including Hashimoto thyroiditis that has resulted in hypothyroidism, for at least the 3 months before the clinical onset of morbid obesity
- having a hypothalamic disorder causing excessive eating for at least the 3 months before the clinical onset of morbid obesity
- 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
- 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
- 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
- experiencing severe childhood abuse before the clinical onset of morbid obesity
I have noted your contention as to the cause of this condition. The available evidence indicates, I have noted your contention to the cause of your condition. Your service medical records indicate that you presented to the health facility with progressive central weight gain, breathlessness and fatigue on exertion, knee and back pain on patrols and stairs, constant hunger with night eating, snoring and difficulty fitting into body armour and uniforms on 12 June 2013.
The diagnosis was made by a medical officer at the periodic health examination on 12 June 2013, when the measured weight was 128 kg at a height of 1.775 m, giving a BMI of 40.6, with a waist circumference of 128 cm. This meets the Statement of Principles definition of morbid obesity as an excessive accumulation of fat in the body resulting in a BMI of at least 40. Endocrine causes were investigated: central hypothyroidism and exogenous Cushing syndrome were confirmed and an adrenal or pituitary tumour excluded.
This has then led to further investigations and the diagnosis of your condition of Obesity/Overweight (bmi ≥30). I have accepted your condition of Obesity/Overweight (bmi ≥30).
Having considered your service records and the available medical evidence, I am satisfied the SOP is met and that this condition is related to your peacetime service.
I have therefore accepted that this condition is related to your service with effect from 12 June 2013.
Obesity/Overweight (bmi ≥30) (Worsening)
Evidence
The evidence that I have considered in making this decision includes:
- Formal Claim with supporting statements;
- A Statement of your Service from the Department of Defence;
- Copies of your Service Medical Records.
- A Diagnostic Assessment by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 22 April 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 22 April 2025;
- An enlistment medical examination by the medical officer, dated 3 February 2000;
- A dietetic assessment by the defence dietitian, dated 14 May 2007;
- A trauma admission record by Role 3 hospital, Afghanistan, dated 22 July 2008;
- An MRI brain report by the radiologist, dated 30 September 2008;
- A psychiatric assessment by the consultant psychiatrist, dated 14 January 2009;
- An endocrinology consultation by the endocrinologist, dated 3 March 2009;
- A psychology treatment record by the clinical psychologist, dated 22 June 2009;
- A psychiatric review by the consultant psychiatrist, dated 16 September 2010;
- A sleep medicine consultation and actigraphy by the sleep physician, dated 11 November 2011;
- A respiratory medicine consultation by the respiratory physician, dated 1 September 2012;
- An endocrinology consultation and abdominal ultrasound by the endocrinologist and radiologist, dated 15 February 2013;
- A periodic health examination by the medical officer, Garrison health centre, dated 12 June 2013;
- An endocrinology consultation (polysomnography and pathology) by the endocrinologist and sleep physician, dated 18 November 2014.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
3 February 2000 and 25 July 2021
Obesity/Overweight (bmi ≥30) (Worsening)
You have stated that the worsening of your condition was caused by:
- having a caloric intake that is excessive for energy needs for at least the 5 years before the clinical worsening of morbid obesity
- taking a drug from the specified list of drugs for at least the 6 months before the clinical worsening of morbid obesity
- taking an antipsychotic drug, excluding aripiprazole and ziprasidone, for at least the 3 months before the clinical worsening of morbid obesity
- 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
- having binge eating disorder or night eating syndrome for at least the 1 year before the clinical worsening of morbid obesity
- having a clinically significant disorder of mental health as specified for at least the 3 years before the clinical worsening of morbid obesity
- having Cushing syndrome for at least the 3 months before the clinical worsening of morbid obesity
- having hypothyroidism, including Hashimoto thyroiditis that has resulted in hypothyroidism, for at least the 3 months before the clinical worsening of morbid obesity
- having a hypothalamic disorder causing excessive eating for at least the 3 months before the clinical worsening of morbid obesity
- 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
- 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
- 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
- inability to obtain appropriate clinical management for morbid obesity
Diagnosis: Obesity/Overweight (bmi ≥30) (Worsening)
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 22 April 2025, and is supported by a periodic health examination by the medical officer, Garrison health centre, dated 12 June 2013.
I am satisfied this is the appropriate diagnosis.
In determining your claim for this condition, I have applied the SOP:
Statement of Principles concerning Morbid Obesity (Balance of Probabilities) (No. 44 of 2022)
which sets out the factors that can connect the condition with service.
I am satisfied that you have met the following factor:
- having a caloric intake that is excessive for energy needs for at least the 5 years before the clinical worsening of morbid obesity
- taking a drug from the specified list of drugs for at least the 6 months before the clinical worsening of morbid obesity
- taking an antipsychotic drug, excluding aripiprazole and ziprasidone, for at least the 3 months before the clinical worsening of morbid obesity
- 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
- having binge eating disorder or night eating syndrome for at least the 1 year before the clinical worsening of morbid obesity
- having a clinically significant disorder of mental health as specified for at least the 3 years before the clinical worsening of morbid obesity
- having Cushing syndrome for at least the 3 months before the clinical worsening of morbid obesity
- having hypothyroidism, including Hashimoto thyroiditis that has resulted in hypothyroidism, for at least the 3 months before the clinical worsening of morbid obesity
- having a hypothalamic disorder causing excessive eating for at least the 3 months before the clinical worsening of morbid obesity
- 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
- 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
- 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
- inability to obtain appropriate clinical management for morbid obesity
I have noted your contention as to the cause of this condition. The available evidence indicates, I have noted your contention to the cause of your condition. Your service medical records indicate that you presented to the health facility with progressive central weight gain, breathlessness and fatigue on exertion, knee and back pain on patrols and stairs, constant hunger with night eating, snoring and difficulty fitting into body armour and uniforms on 12 June 2013.
The diagnosis was made by a medical officer at the periodic health examination on 12 June 2013, when the measured weight was 128 kg at a height of 1.775 m, giving a BMI of 40.6, with a waist circumference of 128 cm. This meets the Statement of Principles definition of morbid obesity as an excessive accumulation of fat in the body resulting in a BMI of at least 40. Endocrine causes were investigated: central hypothyroidism and exogenous Cushing syndrome were confirmed and an adrenal or pituitary tumour excluded.
After the condition arose, it was worsened during your service. The dietitian's reviews of 2010 and 2014 recorded continuing intake of about 4,000 kilocalories a day against needs of about 2,600, so your intake was excessive throughout the 5 years before the worsening, from 18 November 2009 to 18 November 2014. Mirtazapine 30 mg and pregabalin 300 mg a day continued without interruption throughout the 6 months before the worsening, from 18 May 2014 to 18 November 2014. Quetiapine 200 mg at night continued throughout the 3 months before the worsening, from 18 August 2014 to 18 November 2014. Prednisolone continued at 10 to 15 mg daily throughout 2014, including the 3 months before the worsening, from 18 August 2014 to 18 November 2014, because weaning could not be supervised while you were deployed. Night eating syndrome persisted and was recorded by your psychiatrist in November 2013 and October 2014, so it was present throughout the 1 year before the worsening, from 18 November 2013 to 18 November 2014. Posttraumatic stress disorder and major depressive disorder required continuous management from January 2009, more than the 3 years before the worsening, from 18 November 2011 to 18 November 2014. Exogenous Cushing syndrome persisted on continued prednisolone and was recorded by the endocrinologist on 2 October 2014, so it was present throughout the 3 months before the worsening. Central hypothyroidism persisted, under-replaced with a free T4 below the reference range on 2 October 2014, throughout the 3 months before the worsening. Hypothalamic hyperphagia from the 2008 hypothalamic contusion was recorded again by the endocrinologist on 2 October 2014 and was present throughout the 3 months before the worsening. Your sleep remained at four to five hours a night from 2007, with untreated obstructive sleep apnoea added from 2013, throughout the 5 years before the worsening, from 18 November 2009 to 18 November 2014. The roughly 620 night shifts worked from January 2006 to December 2012, a continuous period of seven years, preceded the worsening of 18 November 2014. You permanently stopped smoking on 15 January 2013, after about 15 pack-years, 22 months before the worsening on 18 November 2014, within the 2-year window. On warlike service in the Middle East from January to July 2014 you had no access to a dietitian, psychologist, endocrinologist or weight management program, your thyroxine and prednisolone doses could not be monitored or adjusted, and your referral for bariatric assessment, made on 12 June 2013, lapsed during deployment.
This has then led to further investigations and the diagnosis of your condition of Obesity/Overweight (bmi ≥30) (Worsening). I have accepted your condition of Obesity/Overweight (bmi ≥30) (Worsening).
Having considered your service records and the available medical evidence, I am satisfied the SOP is met and that the worsening of this condition is related to your peacetime service.
I have therefore accepted that the worsening of this condition is related to your service with effect from 18 November 2014.
