HYPERTENSION

A. ISHIZAWAR · 2023 · Case ID: 23013980

DENIED

Summary

The Veteran, who served on active duty from January 1973 to April 1974, appeals the denial of service connection for hypertension and obstructive sleep apnea (sleep apnea). The Veteran claimed these conditions were secondary to obesity, which he attributed to inactivity caused by his service-connected back condition and/or his service-connected acquired psychiatric disorder. The Board reviewed multiple VA medical opinions to assess these secondary claims. Service treatment records were silent regarding any in-service complaints, findings, treatment, or diagnoses for hypertension or sleep apnea, precluding direct service connection. The Board considered opinions from September 2018, February 2022, and November 2022. The September 2018 and February 2022 opinions found the conditions less likely than not related to the service-connected back condition or psychiatric disorder, noting the Veteran's obesity was multifactorial and not solely caused by inactivity due to the back condition. The November 2022 addendum opinion, deemed most probative by the Board, concluded that both hypertension and sleep apnea were less likely than not proximately due to or the result of the service-connected thoracic spine fracture. The examiner emphasized that obesity's etiology was primarily diet and caloric intake, and weight gain was secondary to foot pain limiting walking, not the back condition. The examiner also noted the Veteran's hypertension and sleep apnea had other risk factors and weak association with the psychiatric disorder. The Board found the Veteran lacked the competence to opine on the medical complexity of these claims, giving more weight to the competent medical evidence. Ultimately, the Board denied service connection for hypertension and sleep apnea, finding the evidence weighed against the claims.

Rationale

Service treatment records silent for hypertension.; VA opinions found less likely than not related to service-connected back condition or psychiatric disorder.; November 2022 opinion most probative, citing diet/caloric intake as primary etiology for obesity.

Special Benefit

NO SPECIAL BENEFIT

Docket No.

18-52 632

Full Decision Text

Citation Nr: 23013980
Decision Date: 03/08/23 Archive Date: 03/08/23

DOCKET NO. 18-52 632
DATE: March 8, 2023

ORDER

Service connection for hypertension, claimed as secondary to obesity caused by inactivity due to service-connected back condition and/or secondary to service-connected acquired psychiatric disorder, is denied.

Service connection for obstructive sleep apnea (sleep apnea), claimed as secondary to obesity caused by inactivity due to service-connected back condition and/or secondary to service-connected acquired psychiatric disorder, is denied.

FINDINGS OF FACT

1. The weight of the evidence is against a finding that the Veteran's hypertension is related to his active duty service or proximately due to or aggravated by his service-connected back condition, including obesity caused by inactivity and/or his service-connected psychiatric disorder.

2. The weight of the evidence is against a finding that the Veteran's sleep apnea is related to his active duty service or proximately due to or aggravated by his service-connected back condition, including obesity caused by inactivity and/or his service-connected psychiatric disorder.

CONCLUSIONS OF LAW

1. The criteria for service connection for hypertension, claimed as secondary to obesity caused by inactivity due to service-connected back condition and/or secondary to service-connected acquired psychiatric disorder, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.310.

2. The criteria for service connection for sleep apnea, claimed as secondary to obesity caused by inactivity due to service-connected back condition and/or secondary to service-connected acquired psychiatric disorder have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from January 1973 to April 1974.

In July 2020, the Veteran testified at a virtual hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record.

In February 2022 and September 2022, the Board of Veterans' Appeals (Board) remanded the current claims for additional development.

Service Connection

Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). To establish service connection, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d).

Secondary service connection is also warranted where a disability is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Briefly, the threshold legal requirements for a successful secondary service connection claim are: (1) evidence of a current disability for which secondary service connection is sought; (2) a disability for which service connection has been established; and (3) competent evidence of a nexus between the two.

Pertinent to this claim, although obesity itself is not considered a disability for VA purposes, when obesity has been caused by a service-connected condition, and subsequently causes another disability, obesity may be considered an "intermediate step" for establishing service connection on a secondary basis. See VAOPGCPREC 1-2017 (Jan. 6, 2017). This inquiry extends both to causation and to aggravation. See Walsh v. Wilkie, 32 Vet. App. 300, 306 (2020). The Veteran's level of physical activity is a factor that should be considered when addressing whether obesity served as an "intermediate step" in the causation or aggravation of disabilities on a secondary basis. Id. at 303.

If the positive and negative evidence is in approximate balance, the claimant receives the benefit of the doubt. 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776 (Fed
GCPREC 1-2017 (Jan. 6, 2017). This inquiry extends both to causation and to aggravation. See Walsh v. Wilkie, 32 Vet. App. 300, 306 (2020). The Veteran's level of physical activity is a factor that should be considered when addressing whether obesity served as an "intermediate step" in the causation or aggravation of disabilities on a secondary basis. Id. at 303.

If the positive and negative evidence is in approximate balance, the claimant receives the benefit of the doubt. 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021).

Entitlement to service connection for hypertension and sleep apnea, claimed as secondary to obesity caused by inactivity due to service-connected back condition and/or secondary to service-connected acquired psychiatric disorder

The Veteran seeks service connection for hypertension and sleep apnea, which he contends are due to obesity because of an inability to exercise as a result of his service-connected back condition and/or as caused or aggravated by his service-connected psychiatric disorder.

At the September 2018 and February 2022 VA examinations, the Veteran was given a diagnosis of hypertension as well as sleep apnea. However, his service treatment records (STRs) are silent for any complaints, findings, treatment, or diagnoses relating to high blood pressure/hypertension or sleep apnea. As such, there is no evidence that the Veteran's current hypertension or sleep apnea had its onset in service or is otherwise directly related to his military service, and service connection for hypertension and sleep apnea on a direct basis is not warranted.

As noted, however, it is not the Veteran's contention that his claimed disabilities are directly related to service. Rather, he contends service connection is warranted because he believes them to be caused by inactivity due to his service-connected back condition and/or as secondary to his service-connected acquired psychiatric disorder.

To address this claim, multiple VA medical opinions have been obtained.

On September 2018 VA examination, the examiner opined that both claimed conditions were less likely than not proximately due to or the result of his service-connected back condition. For the hypertension, the examiner explained that the medical record documentation provided for review indicated that the Veteran had an established history of essential hypertension, which indicated his hypertension did not have a single cause (such as obesity). The examiner also stated for sleep apnea that the disability had multiple contributing factors with obesity being one of them. The examiner then stated for both conditions that no documentation had been found in the medical records provided that indicated the Veteran's obesity was caused by his service-connected back condition. The examiner pointed out further that inactivity did not cause obesity if caloric intake was adjusted accordingly.

Thereafter, in February 2022, VA examinations were conducted to determine whether the Veteran's hypertension or sleep apnea were related to his service-connected acquired psychiatric disorder. The same VA examiner evaluated the Veteran for both conditions and opined that they were less likely than not proximately due to or the result of his service-connected acquired psychiatric disorder. The examiner also opined that the conditions were less likely than not aggravated beyond their natural progression by the service-connected acquired psychiatric disorder. For rationale, the examiner indicated the Veteran's acquired psychiatric disorder had been well-controlled on medication. The examiner also indicated that there was a lack of an association/correlation between the Veteran's hypertension and his psychiatric disorder and that the Veteran exhibited other risk factors for hypertension such as obesity/physical activity. The examiner similarly opined that there was weak evidence to support a cause/effect relationship between the Veteran's psychiatric disorder and sleep apnea, noting that other risk factors had a strong association such as male gender, obesity, and craniofacial/upper airway abnormalities. The examiner then noted that the Veteran was male and medically classified as obese and stated that the Veteran suffered a compression fracture of his back in service which limited him from extensive physical activities due to his chronic back issues, resulting in weight gain.

As discussed in the September 2022 Board remand, these medical opinions contradicted each other to the extent there was a question as to whether the Veteran's service-connected back condition had contributed to his obesity. Therefore, an addendum medical opinion was requested to reconcile the September 2018 and February 2022 medical opinions.

Pursuant to the Board's remand, a November 2022 medical addendum opinion was obtained. The examiner concluded that both the Veteran's hypertension and sleep apnea were less likely than not proximately due to or the result of his compression fracture of the thoracic spine at T12 with degenerative arthritis of the spine, residuals, fracture T12. In support of that opinion, regarding his sleep apnea, the examiner explained that obstructive sleep apnea was caused by a collapse of the soft tissues of the throat while sleep leading to apnea episodes. The examiner also noted that one risk factor for the development of this condition was obesity and stated that both diet and exercise played a role in the development of obesity. The examiner further observed that the Veteran's medical records showed he had been encouraged to change his diet multiple times with documentation in March 2019 and September 2020, showing that the Veteran had been encouraged diet changes. Additionally, the examiner highlighted a December 2007 medical record note which showed evidence of weight gain secondary to not walking due to the Veteran's feet; in particular, the Veteran reported that used to walk but stopped due to throbbing pains, especially on the heels, when walking and thus gaining weight. Lastly, the examiner provided citations to three studies which he explained showed that diet and calorie intake were the sole causative etiology in weight gain and obesity. Accordingly, the examiner provided an unfavorable nexus opinion between the Veteran's sleep apnea and his service-connected back condition.

With regard to the Veteran's hypertension, the examiner explained that most cases of hypertension were idiopathic which was also known as essential hypertension. The examiner also noted that it has long been suggested that an increase in salt intake increases the risk of developing hypertension. The examiner also acknowledged that obesity did play a role in the development of hypertension, but noted that it was not currently established that the Veteran's back condition had caused his development of obesity. The examiner reiterated the comments he had made in his medical opinion regarding sleep apnea, that both diet and exercise played a role in the development of obesity, that the Veteran had been encouraged by his treatment providers on multiple occasions to change his diet, and that there was evidence in his medical records to show that the Veteran's weight gain was secondary to not walking due to his feet. The examiner also again referenced the same three studies which he stated showed that diet and calorie intake were the sole causative etiology in weight gain and obesity. Therefore, the examiner concluded it was less likely than not that the Veteran's service-connected back condition caused his development of hypertension.

Based on the foregoing medical evidence and opinions, it is not shown that the Veteran's hypertension and sleep apnea are caused or aggravated by his service-connected back condition and/or secondary to service-connected acquired psychiatric disorder. The Board finds the November 2022 VA examiner's medical opinion to be most probative with respect to whether the Veteran's service-connected back condition has caused him to become obese or aggravated his obesity, resulting in either the causation or aggravation of his hypertension and sleep apnea. Although the November 2022 VA examiner agreed that obesity was a risk factor for both hypertension and sleep apnea, it was not the examiner's opinion that the Veteran's obesity was related (either causally or on an aggravation basis) to his service-connected back disorder. Instead, the examiner explained the Veteran's obesity had more to do with his diet and caloric intake, and noted the several occasions in his treatment records where he had been counseled to change his diet. To the extent the Veteran's inability to exercise contributed to his obesity, the examiner also highlighted how treatment records showed this to be related to his feet and not to his service-connected back. The November 2022 VA examiner's medical opinion is well-reasoned and based on a thorough review of the Veteran's claims file and his treatment records, and an accurate understanding of the Veteran's medical history. It is also supported by the September 2018 VA examiner's opinion, which also found that there was no documentation in the medical records to suggest that the Veteran's obesity had been caused by his service-connected back condition and noted that inactivity did not cause obesity if caloric intake was adjusted accordingly.

The Board acknowledges that in the February 2022 VA medical opinion, it was stated that the Veteran had gained weight as a result of his service-connected back condition. However, the February 2022 VA examiner provided no support for that finding. By contrast
medical opinion is well-reasoned and based on a thorough review of the Veteran's claims file and his treatment records, and an accurate understanding of the Veteran's medical history. It is also supported by the September 2018 VA examiner's opinion, which also found that there was no documentation in the medical records to suggest that the Veteran's obesity had been caused by his service-connected back condition and noted that inactivity did not cause obesity if caloric intake was adjusted accordingly.

The Board acknowledges that in the February 2022 VA medical opinion, it was stated that the Veteran had gained weight as a result of his service-connected back condition. However, the February 2022 VA examiner provided no support for that finding. By contrast, the November 2022 VA examiner reviewed the Veteran's treatment records and found that the only mention of inactivity resulting in weight gain was, by the Veteran's own admission, as a result of the pain in his feet as he stopped walking thereafter. For that reason, the Board finds the November 2022 VA examiner's opinion to be more probative than the February 2022 VA examiner's opinion in that regard.

The February 2022 VA examiner does, however, provide an adequate medical opinion for the question of whether the Veteran's service-connected acquired psychiatric disorder caused or aggravated his hypertension and sleep apnea. Not only did the examiner provide a well-reasoned explanation for that opinion, but the examiner also highlighted how the Veteran's acquired psychiatric disorder was well-controlled with medication and there was weak evidence to support a cause/effect relationship between the Veteran's psychiatric disorder and hypertension and sleep apnea. Instead, the examiner noted that other risk factors had strong associations with the claimed conditions, such as male gender, obesity, and craniofacial/upper airway abnormalities for sleep apnea and obesity/physical activity for hypertension.

The Board recognizes the Veteran believes his hypertension and sleep apnea are a result of his service-connected disabilities, or in the alternative, his obesity, which he believes is caused by his service-connected back condition, however, he is not competent as a lay person to opine as to whether his current hypertension and sleep apnea are caused or aggravated by his service-connected disabilities. The questions involved in this case are medically complex and require specialized knowledge and the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence, as discussed above. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303 (2008). Notably, the Veteran has not submitted any medical opinions in support of his claim.

Accordingly, the persuasive evidence of record is against the claims for service connection for hypertension and sleep apnea, claimed as secondary to obesity caused by inactivity due to service-connected back condition and/or secondary to service-connected acquired psychiatric disorder, and the claims are denied. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102.

A. ISHIZAWAR

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board K. Churchwell, Counsel

The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.

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