SLEEP APNEA SYNDROMES (OBSTRUCTIVE CENTRAL MIXED)

MARJORIE A. AUER · 2025 · Case ID: 25000410

DENIED

Summary

The Veteran, an Army Veteran who served from May 1968 to December 1969 and June 1972 to July 1972, appeals the denial of service connection for obstructive sleep apnea (OSA). The Veteran claimed OSA was related to herbicide exposure or, alternatively, that his service-connected diabetes caused obesity, which in turn led to OSA. The Board denied service connection for OSA, finding the evidence persuasively against a service connection. The Veteran's service treatment records were silent regarding any OSA complaints or treatment. A December 2019 VA examination concluded OSA was less likely than not related to service, citing a lack of in-service evidence and no known causal link between herbicide exposure and OSA. This opinion also found OSA less likely than not proximately due to service-connected diabetes, noting a bidirectional correlation between the conditions and no clear causative effect. Subsequent VA examinations in March 2023 and August 2024 reiterated these findings, with the August 2024 examiner specifically stating that diabetes did not cause OSA and that the Veteran's OSA was less likely than not due to service-connected conditions, including diabetes, ischemic heart disease, and tinnitus. The Board found these opinions persuasive, noting the lack of contrary probative medical evidence and that the Veteran's lay statements, while competent to describe symptoms, were not sufficient to establish a medical nexus. The Board denied service connection for OSA.

Rationale

Service treatment records silent for OSA complaints or treatment.; VA examinations consistently opined OSA was less likely than not related to service.; VA examinations found OSA less likely than not proximately due to or aggravated by service-connected diabetes mellitus.; No probative medical evidence supported a service connection or aggravation.; Veteran's lay statements not competent to establish medical nexus.

Service Branch

ARMY

Special Benefit

NO SPECIAL BENEFIT

Docket No.

18-44 824

Full Decision Text

Citation Nr: 25000410
Decision Date: 01/14/25 Archive Date: 01/14/25

DOCKET NO. 18-44 824
DATE: January 14, 2025

ORDER

Entitlement to service connection for obstructive sleep apnea (OSA) is denied.

FINDING OF FACT

The evidence of record is persuasively against finding that the Veteran's OSA is due to his active service, or that it was caused or aggravated by a service-connected disability.

CONCLUSION OF LAW

The criteria for entitlement to service connection for OSA have not been met. 38 U.S.C. §§ 1110, 1117, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty in the United States Army from May 1968 to December 1969 and from June 1972 to July 1972.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2017 rating decision issued by a Department of Veterans' Affairs (VA) Regional Office (RO) (hereinafter agency of original jurisdiction (AOJ)) which denied the claims on appeal.

This appeal was most recently before the Board in February 2024, at which time it was remanded for additional development.

1. Entitlement to service connection for OSA

Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004).

Certain chronic diseases will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309; Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013).

Service connection may be granted on a secondary basis for a disability which is proximately due to or the result of an established service-connected disorder. 38 C.F.R. § 3.310. Similarly, any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, may be service connected on an aggravation basis. See 38 C.F.R. § 3.310(b); Allen v. Brown, 7 Vet. App. 439 (1995).

Service connection may also be granted on a secondary basis where the claimed disability would not have occurred but for obesity caused or aggravated by a service-connected disability. Obesity can constitute an "intermediate step" between a service-connected disability and a disability that may be service connected on a secondary basis, not only applies when a service-connected disability causes obesity, but also when a service-connected disability aggravates obesity. See Walsh v. Wilkie, 32 Vet. App. 300 (2020). When raised by the record, the Board must consider whether obesity was caused or aggravated by a service-connected disability, consistent with 38 C.F.R. § 3.310. Id.

For the time period prior to August 10, 2022, by statute and regulation, VA presumes herbicide exposure for Veterans who served in the Republic of Vietnam during a certain specified time period, for Veterans who served in the Korean Demilitarized Zone (DMZ) during a certain specified time period, and for certain specified Air Force or Air Force Reserve personnel who operated, maintained or served aboard C-123 aircraft for a certain specified time period. See 38 U.S.C. §§ 1116, 1116A, 1116B; 38 C.F.R. § 3
caused or aggravated by a service-connected disability, consistent with 38 C.F.R. § 3.310. Id.

For the time period prior to August 10, 2022, by statute and regulation, VA presumes herbicide exposure for Veterans who served in the Republic of Vietnam during a certain specified time period, for Veterans who served in the Korean Demilitarized Zone (DMZ) during a certain specified time period, and for certain specified Air Force or Air Force Reserve personnel who operated, maintained or served aboard C-123 aircraft for a certain specified time period. See 38 U.S.C. §§ 1116, 1116A, 1116B; 38 C.F.R. § 3.307(a)(6)(iii)-(v). An herbicide is defined at 38 C.F.R. § 3.307(a)(6)(i) - specifically, 2,4-D; 2,4,5-T and its contaminant TCDD; cacodylic acid; and picloram.

In other words, if a Veteran established both herbicide exposure as defined by 38 C.F.R. § 3.307(a)(6)(i) and had a presumptive disease specified at 38 C.F.R. § 3.309(e), no further evidence is needed to establish entitlement to service connection.

The fact that a veteran cannot establish entitlement to service connection on a presumptive basis does not preclude him from establishing entitlement on a direct incurrence or other basis. See 38 U.S.C. § 1113(b); 38 C.F.R. § 3.304(d) (the availability of service connection on a presumptive basis does not preclude consideration of service connection on a direct basis); Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994) (Radiation Compensation Act does not preclude a veteran from establishing service connection with proof of actual direct causation).

Lay persons are competent to provide opinions on some medical issues falling within the realm of common knowledge. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007).

It is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104(a). When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; see Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990).

Obstructive Sleep Apnea (OSA)

The Veteran asserts service connection for OSA. First, he claims that his OSA is related to his conceded exposure to herbicides. Alternatively, he suggests that the Veteran's service-connected diabetes caused his obesity, which led to his sleep apnea. For the reasons that follow, the Board finds that service connection is not warranted on either basis.

The Veteran's service treatment records are silent for any complaints, treatments, or manifestations of obstructive sleep apnea.

In December 2004, the Veteran underwent a sleep study to assess his symptoms of daily fatigue and tiredness, daytime sleepiness, snoring, witnessed apneas, restless sleep, and waking with a snort. At the time, his relevant medical history included obesity. He was ultimately diagnosed with severe obstructive sleep apnea at that time, several decades after his discharge from service.

The Veteran was afforded a VA examination in December 2019. The examiner opined the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained the Veteran's history added no significant evidence that he developed obstructive sleep apnea during his time in service. There were no records to support that his OSA was due to anything that the Veteran was exposed to or experienced during his time in service.

The examiner further opined the claimed condition was less likely than not proximately due to or the result of the Veteran's service-connected condition. The examiner noted that current medical literature supports the position that diabetes mellitus II is both a risk factor and/or complication of OSA. Diabetes, poor lifestyle choices, and obesity all interact, with no specific causal pattern accepted as a general fact. Obesity and lifestyle choices can lead to diabetes, just as diabetes can lead to obesity. Current medical literature also shows that diabetics have an increased chance of developing OSA, and that said persons tend to have worse OSA. However, there is evidence to support that OSA may have been unrecognized and lead to or contributed to the development of diabetes. There is no medical evidence to support the position that the Veteran developed OSA due to his diabetes mellitus. The examiner also noted that they could not determine a baseline level of severity of the Veteran's OSA; however, regardless of an established baseline the Veteran's OSA was not at least as likely as not aggravated beyond its natural progression by service-connected disabilities. The examiner explained that although the Veteran had very severe obstructive sleep apnea, some of that appeared to be of a central and/or mixed nature. Furthermore, the studies show that OSA severity is related to worsening glucose control; this is not to say that diabetics (due to glucose intolerance) have worse OSA, but points to the association that may in fact mean that OSA causes worse glucose control in diabetics. There is no reasonable or objective technique at this time to accurately determine which condition developed first, if they developed together, and the negative influence is most likely bidirectional and unsupportive of any specific negative influence in either direction.

The Veteran was afforded another VA examination in March 2023. In April 2023, the examiner opined the claimed condition was less likely than not proximately due to or the result of the Veteran's service-connected condition. The examiner explained OSA was characterized by episodes of complete collapse of the airway or partial collapse with an associated decrease in oxygen saturation or arousal from sleep. This disturbance results in fragmented, nonrestorative sleep. Pharyngeal narrowing and closure during sleep is a complex phenomenon, and likely multiple factors play a role in the pathogenesis. According to medical research, the clinical risk factors of OSA are advancing age, male gender, obesity, and craniofacial morphology or upper airway soft tissue abnormalities. Additional factors identified in some studies include smoking, nasal congestion (sinusitis, rhinitis), menopause, and family history. Rates of OSA are also increased in association with certain medical conditions, such as pregnancy, end-stage renal disease, congestive heart failure, chronic lung disease, post-traumatic stress disorder, and stroke. Medical records show the use of a CPAP machine with titration in 2013. The Veteran reported CPAP use since 2004. The examiner could not substantiate the previous examiner's statement in the December 2019 VA opinion that current medical literature supports that type 2 diabetes, ischemic heart disease (IHD) status post coronary artery bypass graft (CABG), scar, status post loss of tip of right ring finger, scar, status post CABG, scar, right middle finger are risk factors for obstructive sleep apnea based on the examiner's review of medical research. Based on the pathophysiology of sleep apnea, it was the examiner's position that the Veterans OSA was not related to the Veteran's service-connected type 2 diabetes, IHD status post CABG, scar, status post loss of tip of right ring finger scar, status post CABG, scar, right middle finger. The OSA was due to the collapse of the airway during sleep. The Veteran's OSA was less likely than not proximately due to his service-connected conditions, to include type 2 diabetes, IHD status post CABG, scar, status post loss of tip of right ring finger scar, status post CABG, scar, right middle finger.

The examiner could not determine a baseline level of severity as the medical evidence at the time was not sufficient to support a determination as a baseline polysomnography was not available for review. Regardless, the examiner opined the Veteran's OSA was at least as likely as not aggravated beyond its natural progression by his service-connected diabetes mellitus. OSA was characterized by repeating partial or complete obstruction of the upper airway during sleep, which leads to cyclic episodes of hypoxemia and normoxemia, as well as reduction in intrathoracic pressure. These repeated episodes lead to various pathophysiological conditions, such as intermittent hypoxia, sleep restriction and sleep fragmentation, resulting in sympathetic neural activation, systemic inflammation, oxidative stress loading and changes in hormonal systems. Changes in hormonal systems include the activation of the hypothalamic-pituitary adrenal axis and changes in adipokine profiles, both of which usually lead to fat accumulation and obesity. Using animal models, researchers established that intermittent hypoxia causes insulin resistance to deteriorate. Conversely, several reports have shown that diabetes affects central respiratory control, and is thus thought to promote OSA. These mechanisms suggest that sleep?disordered breathing and type 2 diabetes are associated, independent of aging and obesity. Therefore, the examiner opined the Veterans type 2 diabetes aggravated the Veterans OSA. The December 2019 VA opinion that persons with type 2 diabetes "tend to have worse OSA" and that "the negative influence [between diabetes and sleep apnea] is most likely bidirectional." is validated by the above research. Sleep apnea can worsen diabetes and diabetes can worsen sleep apnea based on medical evidence. Therefore, the examiner opined the Veteran's obstructive sleep apnea was at least as likely as not aggravated by his service-connected conditions, to include type 2 diabetes, IHD status post CABG, scar, status post loss of tip of right ring finger, scar, status post CABG, scar, right middle finger.

In September 2023, a VA examiner opined the claimed condition was less likely than not proximately due to or the result of the Veteran's service-connected condition nor aggravated beyond its natural progression by the Veteran's service-connected condition. The examiner noted there was no evidence that the Veteran's OSA was aggravated (worsened beyond the natural course of the disease) by his service-connected conditions, to include type 2 diabetes. The examiner noted the prior opinion provided in the December 2019 evaluation stated that there may be bidirectional influence of OSA and diabetes mellitus. However, the medical research influencing this opinion required further investigation and was not widely accepted as fact within the medical community. Therefore, the examiner opined there was no nexus between OSA and diabetes mellitus type II accepted as fact by general medical knowledge at the time and thus it was less than likely that OSA aggravated Veteran's diabetes mellitus type II.

The Veteran was provided another VA examination in August 2024. The examiner diagnosed obstructive sleep apnea with an onset date listed as December 2004.

The examiner opined the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted that in late 1970 the Veteran began to experience feelings of depression, lack of energy, fatigue, and no motivation. In 1983, while working in the post office, he reported dozing off at times and that it got worse later. He had a sleep study in December 2004. He was diagnosed with severe obstructive sleep apnea with an apnea-hypopnea index (AHI) of 155 and continuous positive airway pressure (CPAP) machine was issued. The Veteran had another sleep study and CPAP titration in 2013 and another sleep study done in April 2021 which showed AHI of 5.2. He reported significant improvement in his sleep after he started using CPAP. Based on the sleep study there was significant improvement in AHI per sleep study in 2013 and in 2021 with the use of CPAP. Review of the service treatment record did not show sleep problem or treatment of a sleep problem in service. His sleep apnea was first recorded in 2004 by sleep study which was several years after separation from service. Therefore, the examiner stated that based on the paucity of documentation of a sleep problem in the service treatment record the Veteran's current OSA was less likely than not is due to symptoms during service. Further, the examiner
study done in April 2021 which showed AHI of 5.2. He reported significant improvement in his sleep after he started using CPAP. Based on the sleep study there was significant improvement in AHI per sleep study in 2013 and in 2021 with the use of CPAP. Review of the service treatment record did not show sleep problem or treatment of a sleep problem in service. His sleep apnea was first recorded in 2004 by sleep study which was several years after separation from service. Therefore, the examiner stated that based on the paucity of documentation of a sleep problem in the service treatment record the Veteran's current OSA was less likely than not is due to symptoms during service. Further, the examiner noted the May 2023 TERA memorandum noted the Veteran was exposed to herbicide agent tetrachlorodibenzodioxin during his service. The examiner noted exposure to this herbicide agent has no known risk factor for OSA. Therefore, the examiner opined the Veteran's current OSA as less likely than not due to toxin exposure activities in service. Moreover, the examiner noted the exposure on May 2023 TERA memorandum as well as the Veteran's verified service in Korea. The examiner further noted the Veteran's risk factor outside of military service was obesity. The examiner opined the Veteran's OSA was less likely than not caused by the indicated toxic exposure risk activity after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all toxic exposure risk activities of the Veteran for the same reason as above.

The examiner also opined the claimed condition was less likely than not proximately due to or the result of the Veteran's service-connected conditions. Specifically, the examiner opined the Veteran's OSA was less likely than not proximately due to or the result of Type II diabetes mellitus. The examiner noted the Veteran had a diagnosis of diabetes since approximately 2009 and was currently on insulin and metformin. His diabetes was fairly under control. He had complication of peripheral neuropathy due to diabetes. The examiner explained pathophysiology of sleep apnea was that during rapid eye movement (REM) sleep, the muscle tone of the throat and neck, as well as the vast majority of all skeletal muscles, is almost completely attenuated, allowing the tongue and soft palate/oropharynx to relax, and in the case of sleep apnea, to impede the flow of air to complete collapse which leads to low blood oxygen level and neurological arousal. Studies have shown that OSA patients are more likely than non?OSA populations to develop type 2 diabetes, while more than half of type 2 diabetes patients suffer from OSA. So there seems to be a bidirectional correlation between the two conditions of OSA and diabetes mellitus. Therefore, it was less likely that diabetes causes OSA. Another epidemiological study showed that there was increase in insulin resistance in patient with sleep apnea and not vice versa. Based on the current studies, there was no scientific evidence that showed diabetes caused sleep apnea. Therefore, the examiner opined the Veteran's current sleep apnea was less likely than not due to service-connected diabetes mellitus.

The examiner also specifically opined the Veteran's OSA was less likely than not proximately due to or the result of coronary artery disease (CAD) status post coronary artery bypass graft (CABG). The examiner noted review of the medical record indicated that the Veteran had an acute myocardial infarction and had CABG done in 2004. He takes medication and recent ECHO revealed wall motion abnormality and dilation of left ventricle with reduced ejection fraction. Studies have shown that incident of coronary artery disease was more prevalent in patients with OSA than non-OSA patients. The pathophysiological correlation of how sleep apnea causes CAD is not known; however, a common risk factor for both conditions is obesity. There are no studies that show that sleep apnea is caused by CAD. Therefore, the examiner opined the Veteran's current OSA was less likely than not due to service-connected CAD status post CABG.

The examiner also specifically opined the Veteran's OSA was less likely than not proximately due to or the result of tinnitus. The examiner noted the Veteran was diagnosed with bilateral intermittent tinnitus and hearing loss of both ears. The examiner further noted that tinnitus was worse in a quiet environment, like at night it could seem louder and cause sleep disturbance. Tinnitus could be caused by increased neural activity in the auditory brain stem where the brain processes sounds, causing some auditory nerve cells to become over-excited. Many people with tinnitus also have sleep problems. However, there is no documentation that tinnitus causes pathological changes in the larynx to cause sleep apnea. Therefore, the examiner opined the Veteran's current OSA was less likely due to service
opined the Veteran's OSA was less likely than not proximately due to or the result of tinnitus. The examiner noted the Veteran was diagnosed with bilateral intermittent tinnitus and hearing loss of both ears. The examiner further noted that tinnitus was worse in a quiet environment, like at night it could seem louder and cause sleep disturbance. Tinnitus could be caused by increased neural activity in the auditory brain stem where the brain processes sounds, causing some auditory nerve cells to become over-excited. Many people with tinnitus also have sleep problems. However, there is no documentation that tinnitus causes pathological changes in the larynx to cause sleep apnea. Therefore, the examiner opined the Veteran's current OSA was less likely due to service-connected tinnitus.

The examiner also specifically opined the Veteran's OSA was less likely than not proximately due to or the result of his scar, status post loss of tip of right ring finger, scar, status post CABG, or scar, right middle finger. The examiner explained there was documentation of scars on the middle finger, and residual scar due to sternotomy and AICD placement. Examinations showed these scars were healed and not painful. Scars on the skin did not cause pathophysiological changes in the larynx to cause sleep apnea. Therefore, the examiner opined the Veteran's current sleep apnea was less likely than not due to service-connected scars on the finger and anterior chest wall.

The examiner noted the baseline severity was severe OSA with AHI of 155 in 2004. The current severity was not greater than the baseline. Sleep study and CPAP titration in 2013 had AHI of 1.5 and another sleep study in April 2021 showed AHI of 5.2. Further, regardless of a baseline, the Veteran's OSA was not at least as likely as not aggravated beyond its natural progression by the Veteran's service-connected disabilities. The evidence did not show increased severity from the baseline. The sleep studies show that there is improvement in AHI and therefore improvement in severity in sleep apnea compared to the initial study. Therefore, the examiner opined the Veteran's OSA was not aggravated by CAD status post CABG, diabetes mellitus type II, bilateral hearing loss, tinnitus, or his service-connected scars.

Finally, the examiner noted the Veteran's body mass index (BMI) was at the level of severe obesity since 1997. Obesity is a well-known modifiable risk factor for sleep apnea. However, studies have also shown that 25 percent of OSA patients have a BMI within the normal range (< 25 kg/m2) and approximately 50 percent are not obese are consistent with studies by Mortimore and colleagues. There are many possible pathophysiological mechanisms involved in the development and maintenance of obesity. The examiner also noted there are multiple factors leading to obesity. Inactivity and unhealthy diet are the main cause of obesity. Diet control is usually recommended for heart disease and diabetes. Doing exercise is not a contraindication for diabetes or heart disease. Therefore, obesity is not caused by service-connected disabilities of diabetes mellitus, coronary artery disease, tinnitus and hearing loss, or the scars on the body. Therefore, the examiner opined the Veteran's sleep apnea was less likely due to service-connected disabilities as they are less likely cause for his obesity. The examiner acknowledged there were studies that showed that diabetes was better controlled, and the incidence of diabetes was less in patients who did not have sleep apnea. There were also studies that showed that there was an increase in the incidence of sleep apnea in the diabetic population than those who do not have diabetes. There were also studies which showed that incidence to sleep apnea were higher in patients who have diabetes. However, the examiner noted that since the incidence is bidirectional, the causative effect of diabetes on sleep apnea was not there. Therefore, his current sleep apnea was less likely than not due to diabetes mellitus.

In an October 2024 addendum opinion, the examiner agreed with the conclusion that ischemic heart disease (IHD) is not a risk factor for OSA. The examiner noted IHD was not known to cause changes in the upper airway and larynx to cause closure of the airway during sleep. There were some studies that report worsening of ischemic heart disease due to sleep apnea and some studies reporting worsening of sleep apnea due to heart condition. The examiner explained bidirectional correlation suggests the causation of sleep apnea by ischemic heart disease is less likely possible. Therefore, the examiner agreed with the conclusion that current sleep apnea was less likely due to ischemic heart disease as reported in the opinion in March 2023.

Based on the above, the Board finds that service connection for OSA is not warranted. As the August 2024 VA examiner explained that OSA symptoms
. The examiner noted IHD was not known to cause changes in the upper airway and larynx to cause closure of the airway during sleep. There were some studies that report worsening of ischemic heart disease due to sleep apnea and some studies reporting worsening of sleep apnea due to heart condition. The examiner explained bidirectional correlation suggests the causation of sleep apnea by ischemic heart disease is less likely possible. Therefore, the examiner agreed with the conclusion that current sleep apnea was less likely due to ischemic heart disease as reported in the opinion in March 2023.

Based on the above, the Board finds that service connection for OSA is not warranted. As the August 2024 VA examiner explained that OSA symptoms were so scarce the symptoms were less likely than not symptoms of his current OSA during service and OSA would not be causally related to any toxic exposure in service. Neither the Veteran nor his representative have identified any inadequacies in this reasoning, and the Board finds the opinion responsive to the prior remand directives and as persuasive evidence against the claim on a direct basis.

With respect to secondary service connection, the August 2024 medical opinion showed diabetes mellitus type II did not cause OSA. There was no medical literature that supported that argument. Neither the Veteran nor his representative have identified any inadequacies in this reasoning. Thus, the dispositive issue pertains to aggravation of sleep apnea due to diabetes mellitus causing weight gain.

The August 2024 VA examiner provided opinion that the Veteran's diabetes did not cause or contribute to his obesity. Rather, the examiner explained that diabetes patients usually were treated with diet control and that exercise was not contraindicated for diabetes. As inactivity and unhealthy diet were the main cause of obesity, the examiner opined the Veteran's service-connected conditions did not cause his obesity. The Board finds persuasive weight in this reasoning. Additionally, the examiner explained that his service-connected conditions did not contribute to aggravating his sleep apnea reasoning that the Veteran's AHI was significantly higher when diagnosed in 2004 than it was in subsequent polysomnography. The Board also finds persuasive value in this analysis.

Thus, the Board finds that these opinions are probative as they are based on an accurate medical history and provide explanations that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). There are no probative opinions to the contrary.

The only evidence in favor of the Veteran's claims consists of the Veteran's own lay statements. As a lay witness, the Veteran in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires medical training and knowledge of anatomical relationships and respiratory pathology. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the well-reasoned VA examinations and opinions.

Significantly, the Veteran has not presented or identified any medical opinion that supports the claim for service connection. VA adjudicators are not free to ignore or disregard the medical conclusions of the VA physicians and are not permitted to substitute their own judgment on a medical matter. Colvin v. Derwinski, 1 Vet. App. 171 (1991); Willis v. Derwinski, 1 Vet. App. 66 (1991). The Board finds that the objective medical evidence of record does not establish or suggest that the Veteran's OSA was caused by or otherwise etiologically related to his period of service. Accordingly, the evidence is against the claim and entitlement to service connection for OSA is not warranted. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990).

MARJORIE A. AUER

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Gastoukian, Kelly

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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