SLEEP APNEA SYNDROMES (OBSTRUCTIVE CENTRAL MIXED)

JONATHAN B. KRAMER · 2025 · Case ID: 25008302

GRANTED

Summary

The veteran, who served from May 1994 to May 1999, appeals the denial of service connection for obstructive sleep apnea (OSA) and erectile dysfunction (ED) as secondary to his service-connected PTSD, alcohol use disorder, and left ankle achilles tendon strain. The Board found that the veteran's service-connected conditions, including PTSD and left ankle pain, led to inactivity, poor diet, and excess alcohol consumption, causing him to become obese. Medical evidence and lay statements supported this causal link, with a psychotherapist noting the veteran's depressed state led to giving up on health. A medical journal article also supported the link between PTSD and obesity. The Board determined that this obesity was a substantial factor in causing the veteran's diagnosed OSA and ED, and that these conditions would not have occurred but for the obesity. Applying the benefit of the doubt doctrine, the Board found sufficient evidence to establish the causal chain and granted service connection for both OSA and ED as secondary to the service-connected disabilities, with obesity as an intermediate step.

Rationale

Service-connected PTSD/alcohol use disorder and left ankle disability caused obesity; Obesity was substantial factor in causing OSA; OSA would not have occurred but for obesity

Special Benefit

NO SPECIAL BENEFIT

Docket No.

19-14 225

Full Decision Text

Citation Nr: 25008302
Decision Date: 06/24/25 Archive Date: 06/24/25

DOCKET NO. 19-14 225
DATE: June 24, 2025

ORDER

Entitlement to service connection for obstructive sleep apnea (OSA) as secondary to service-connected posttraumatic stress disorder (PTSD) with alcohol use disorder and left ankle achilles tendon strain is granted.

Entitlement to service connection for erectile dysfunction as secondary to service-connected PTSD with alcohol use disorder and left ankle achilles tendon strain is granted.

FINDINGS OF FACT

1. Resolving doubt in favor of the Veteran, his OSA is caused by his obesity which was caused by his service-connected PTSD/alcohol use disorder and left ankle disability, and OSA would not have occurred but for obesity caused by his service-connected conditions.

2. Resolving doubt in favor of the Veteran, his erectile dysfunction is caused by his obesity which was caused by his service-connected PTSD/alcohol use disorder and left ankle disability, and OSA would not have occurred but for obesity caused by his service-connected conditions.

CONCLUSIONS OF LAW

1. The criteria for service connection for OSA, secondary to service-connected PTSD/alcohol use disorder and left ankle disability, with obesity as an "intermediate step" are met. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 3.310; VAOPGCPREC 1-2017 (Jan. 6, 2017).

2. The criteria for service connection for erectile dysfunction, secondary to service-connected PTSD/alcohol use disorder and left ankle disability, with obesity as an "intermediate step" are met. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 3.310; VAOPGCPREC 1-2017 (Jan. 6, 2017).

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from May 1994 to May 1999.

These matters come before the Board of Veterans' Appeals (Board) on appeal from January and September 2016 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO).

In June 2024, the Board denied, inter alia, the claims of entitlement to service connection for erectile dysfunction and sleep apnea. The Veteran appealed to the Court of Appeals for Veteran's Claims (Court) and, in a December 2024 Joint Motion for Partial Remand (PMPR), the Court vacated and remanded the Board's January 2020 decision to the extent that it had denied these claims. The claims are now before the Board upon remand from the Court.

Service Connection

Entitlement to service connection on a direct basis requires (1) evidence of current nonservice-connected disability; (2) evidence of in-service incurrence or aggravation of disease or injury; and (3) evidence of a nexus between the in-service disease or injury and the current nonservice-connected disability. 38 C.F.R. § 3.303(a); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).

Service connection on a secondary basis requires (1) evidence of a current nonservice-connected disability; (2) evidence of a service-connected disability; and (3) evidence establishing that the service-connected disability either (a) caused, or (b) aggravated, the nonservice-connected disability. 38 C.F.R. § 3.310. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc); see also Spicer v. McDonough, No. 2022-1239 (Fed. Cir. March 8, 2023) (invalidating the requirement of "proximate cause" and instead held a "but for" causation or aggravation is enough to show entitlement to secondary service connection).

While VA does not recognize obesity as a stand-alone disability, indirect secondary service connection can be granted with obesity acting as an intermediate step. See VAOPGCPREC 1 2017 (Jan. 6, 2017). Specifically, a grant is warranted (1) if the service-connected disability caused the Veteran to become obese, (2) if obesity was a substantial factor in causing a subsequent disability, and (3) if the subsequent disability would not have occurred but for obesity. Id. Indirect secondary service connection is also warranted where obesity aggravates the claimed disability. Walsh v. Wilkie, 32 Vet. App. 300 (2020).

After the evidence has been assembled
entitlement to secondary service connection).

After the evidence has been assembled, it is the Board's responsibility to evaluate the entire record. 38 U.S.C. § 7104(a). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall resolve all reasonable doubt in favor of the claimant. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990); 38 C.F.R. § 3.102. This standard does not require the evidence to be exactly equal; rather, it includes "scenarios where the evidence is not in equipoise but nevertheless is in approximate balance. Put differently, if the positive and negative evidence is in approximate balance (which includes but is not limited to equipoise), the claimant receives the benefit of the doubt." Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021).

1. Entitlement to service connection for erectile dysfunction

2. Entitlement to service connection for sleep apnea

The December 2024 Joint Motion for Partial Remand found that the Board erred when it failed to address whether the theory of entitlement to service connection for erectile dysfunction and sleep apnea, with obesity as an intermediate step between the service-connected mental disorder and left ankle disability, was raised by the record.

In this regard, January 2024 and March 2024 VA medical opinions noted obesity as risk factors for OSA and erectile dysfunction.

In addition, the evidence of suggests that the service-connected PTSD with alcohol use disorder and left ankle disability may be associated with his obesity. Specifically, in his claim for service connection for sleep apnea as secondary to the left ankle disability, the Veteran stated that he "can't properly condition my body, sleep interrupted because of chronic pain, excessive weight gain."

Additionally, VA treatment records indicate that the Veteran's service-connected alcohol use is related to dietary issues causing uncontrolled diabetes and hypertension. See September 2021 VA treatment record noting "reevaluate medication for uncontrolled diabetes and hypertension as noted veteran drinking alcohol 3-4 times a day and not follow diet"); see also October 2023 VA treatment record noting "because of uncontrolled diabetes advised avoid alcohol use low carbohydrate diet and weight loss"); and October 2023 VA treatment record noting "recommended weight loss with use low-salt diet avoid alcohol"). As noted in the JMPR, each of these treatment records specifically references the Veteran's alcohol use as a substantial factor in controlling his conditions and losing weight.

Upon reconsideration of the evidence in light of the JMPR, the Board finds the aforementioned evidence raises the theory of entitlement to service connection for OSA and ED as secondary to service connected PTSD with acquired psychiatric condition (diagnosed as alcohol use disorder) and left ankle disability, with obesity as an intermediate step. The Board also finds that service connection for OSA and ED can be granted on this basis, as explained below.

As noted, VA Office of the General Counsel Opinion 1-2017 (the "OGC Opinion") holds that obesity may qualify as an "intermediate step" between a service-connected disability and a current disability. VAOPGCPREC 1-2017. Thus, service connection for a current disability may be established under 38 C.F.R.§ 3.310(a) if it can be shown that (1) the service-connected disability in question "caused the veteran to become obese," (2) the obesity "was a substantial factor in causing" the claimed disability, and (3) the claimed disability would not have occurred but for the obesity. Id. Obesity can serve as an intermediate step both where it is caused or aggravated by a service-connected condition. See Walsh, supra.

Here, the Veteran has currently diagnosed obstructive sleep apnea and erectile dysfunction disabilities. Furthermore, there is the presence of service-connected disabilities upon which to base a claim of secondary service connection, namely PTSD with acquired psychiatric condition diagnosed as alcohol use disorder and left ankle achilles strain. Therefore, the issue
(a) if it can be shown that (1) the service-connected disability in question "caused the veteran to become obese," (2) the obesity "was a substantial factor in causing" the claimed disability, and (3) the claimed disability would not have occurred but for the obesity. Id. Obesity can serve as an intermediate step both where it is caused or aggravated by a service-connected condition. See Walsh, supra.

As an initial matter, the lay and medical evidence of record indicates that the service-connected psychiatric/alcohol use disorder and left ankle disability caused the Veteran to become obese.

With respect to the lay evidence, both the Veteran and his wife have submitted numerous statements asserting that his service-connected psychiatric disorder (and related symptoms) and left ankle disability caused him to become obese via inactivity due to chronic ankle pain and depression, poor diet, and excess food and alcohol consumption. See, e.g., March 2023 Claim; June 2024 Statement from Spouse V.M.; and July 2024 Statement from Veteran. Notably, the Veteran is competent to describe his left ankle disability caused him pain and decreased his activity level and that his PTSD/alcohol abuse symptoms caused him to overeat and drink in excess.

This is also supported by the medical evidence, including the numerous VA treatment records mentioned above which document the Veteran's alcohol use as a causative/aggravating factor in his weight issues.

Additionally, the Veteran's psychotherapist, R.L., submitted a letter in July 2024 indicating that the Veteran's psychiatric symptoms have made it "extremely difficult to make positive decisions that benefit his health." R.L. noted that the Veteran was a certified personal trainer who used to workout, but in his "depressed state he has given up, he's out of shape and for the most part remains in a drunken state."

Also, while not specific to the Veteran, he submitted a medical journal article entitled, "Is there a relationship between PTSD and obesity? A review of the literature." The article concluded that "research strongly supports the hypothesis that PTSD leads to obesity and related metabolic disturbances" and that "PTSD is linked to altered brain and neuroendocrine activity leading to altered food consumption and altered food decisions that can cause obesity." This, too, generally supports the aforementioned evidence showing that the Veteran's PTSD was a causative or aggravating factor in his obesity.

In short, the Board finds that the persuasive evidence of record weighs in favor of a finding that the Veteran's service-connected disabilities in question caused him to become obese.

On the issue of whether the obesity "was a substantial factor in causing" the Veteran's sleep apnea and erectile dysfunction, the January 2024 and March 2024 VA medical opinions both noted obesity as a risk factor for the Veteran's OSA and erectile dysfunction. Parenthetically, the Board notes that the March 2024 VA examiner also found that the Veteran's service-connected hypertension and alcohol abuse were additional attributable factors for the Veteran's erectile dysfunction).

In light of the foregoing, the Board finds that obesity was a substantial factor in causing his sleep apnea and erectile dysfunction.

Lastly, after resolving any doubt in the Veteran's favor, the Board concludes that his service-connected psychiatric and left ankle disabilities resulted in his weight gain and obesity, and if not for this obesity, he likely would not have developed erectile dysfunction and OSA. In this regard, the treatment records generally are consistent with and support the Veteran's assertions that had he not suffered from these service-connected disabilities, he would likely not have experienced substantial weight gain.

To be sure, the Board could remand for a VA opinion (which was not previously obtained as part of this claim) that specifically addresses this issue(s). The Board will instead give the Veteran the benefit of the doubt and find that there is currently sufficient evidence to determine that his service-connected psychiatric disorder and left ankle disability caused him to become obese; the obesity as a result of the service-connected disabilities was a substantial factor in causing the OSA and erectile dysfunction; and the OSA and erectile dysfunction would not have occurred but for obesity caused by the service-connected disabilities. Resolving reasonable doubt in favor of the Veteran, entitlement to service connection for OSA and erectile dysfunction is granted. See Lynch, supra; 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.

JONATHAN B. KRAMER

Veterans Law Judge

Board of Veterans
the Veteran the benefit of the doubt and find that there is currently sufficient evidence to determine that his service-connected psychiatric disorder and left ankle disability caused him to become obese; the obesity as a result of the service-connected disabilities was a substantial factor in causing the OSA and erectile dysfunction; and the OSA and erectile dysfunction would not have occurred but for obesity caused by the service-connected disabilities. Resolving reasonable doubt in favor of the Veteran, entitlement to service connection for OSA and erectile dysfunction is granted. See Lynch, supra; 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.

JONATHAN B. KRAMER

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board H. Hoeft, 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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