SLEEP APNEA SYNDROMES (OBSTRUCTIVE CENTRAL MIXED)

Summary

The Veteran served on active duty from April 1987 to November 1992. This case comes before the Board of Veterans' Appeals (Board) following multiple remands and appeals, with the current matter stemming from a September 2025 Board remand for a VA addendum opinion. The Veteran seeks service connection for obstructive sleep apnea (OSA), claiming it is secondary to service-connected PTSD with alcohol use disorder. The Board previously found the September 2023 and January 2024 VA medical opinions inadequate. The March 2025 VA examiner opined that the Veteran's OSA was less likely than not proximately due to service-connected PTSD and alcohol use disorder, citing lifestyle factors as more plausible causes for obesity, which contributes to OSA. However, the Board found this opinion not probative because it failed to adequately consider medical evidence linking the Veteran's binge eating and night eating, exacerbated by PTSD-related insomnia, to her obesity. The same examiner opined that OSA would not have occurred but for the Veteran's obesity, which the Board found probative. Given the conflicting opinions and the evidence in approximate balance, the Board resolved reasonable doubt in the Veteran's favor, granting service connection for OSA secondary to PTSD with alcohol use disorder.

Rationale

March 2025 VA examiner opinion found OSA less likely than not due to PTSD; Opinion not probative as it failed to consider evidence linking binge eating/night eating to obesity; March 2025 VA examiner opinion found OSA would not have occurred but for obesity; Evidence in approximate balance, resolved in Veteran's favor

Full Decision Text

Citation Nr: 26000195
Decision Date: 01/07/26	Archive Date: 01/07/26

DOCKET NO. 20-00 893
DATE: January 7, 2026

ORDER

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

FINDING OF FACT

Resolving reasonable doubt in the Veteran's favor, her OSA is due to service-connected post-traumatic stress disorder (PTSD) with obesity as an intermediate step.

CONCLUSION OF LAW

The criteria for service connection for OSA are met.  38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty from April 1987 to November 1992.

This matter comes to the Board of Veterans' Appeals (Board) on appeal from an October 2018 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO).

The Board previously remanded this claim in January 2024 and denied this claim in July 2024.  The Veteran appealed the latter Board decision to the United States Court of Appeals for Veterans Claims (CAVC).  In the March 2025 Joint Motion for Remand (JMR), CAVC vacated and remanded the decision.  Finally, in September 2025, the Board remanded the issue to obtain a VA addendum opinion, which the RO obtained in October 2025.  As such, the Board finds that there has been substantial compliance.  Stegall v. West, 11 Vet. App. 268, 271 (1998).

Service Connection

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).

Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability.  See 38 C.F.R. § 3.310; but see Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023) (holding all that is needed is a "but for" causation or aggravation to show entitlement to secondary service connection).

The Board notes that obesity is not considered a disease or disability for VA purposes and is not subject to service connection. See Marcelino v. Shulkin, 29 Vet. App. 155, 156 (2018). However, obesity may be an intermediate step between a service-connected disability and a current disability that may be service-connected on a secondary basis. 38 C.F.R. § 3.310; see also Walsh v. Wilkie, 32 Vet. App. 300 (2020); but see Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023) (invalidating 3.310(b) for the use of the phrase "proximately due to" in the context of aggravation). 

The concept of obesity as an "intermediate step" in the service connection context was recently addressed by the Court of Appeals for Veterans Claims (Court) in Garner v. Tran, 33?Vet. App.?241 (2021). 

In Garner, the Court observed that in January 2017, VA's Office of General Counsel (OGC) issued a precedential opinion, finding that although obesity cannot be service connected on a direct basis, obesity may serve as an intermediate step between a service-connected disability and a condition claimed on a secondary basis.  VAOPGCPREC 1-2017.  To decide such claims, OGC stated the analysis involves addressing the following questions: (1) whether the service-connected disability caused the Veteran to become obese (or, aggravated the veteran's obesity); (2) if so, whether obesity/aggravation of obesity as a result of the service-connected disability, was a substantial factor in causing the claimed secondary disability; and (3) whether the claimed secondary disability would not have occurred but for obesity
's Office of General Counsel (OGC) issued a precedential opinion, finding that although obesity cannot be service connected on a direct basis, obesity may serve as an intermediate step between a service-connected disability and a condition claimed on a secondary basis.  VAOPGCPREC 1-2017.  To decide such claims, OGC stated the analysis involves addressing the following questions: (1) whether the service-connected disability caused the Veteran to become obese (or, aggravated the veteran's obesity); (2) if so, whether obesity/aggravation of obesity as a result of the service-connected disability, was a substantial factor in causing the claimed secondary disability; and (3) whether the claimed secondary disability would not have occurred but for obesity caused/obesity aggravated by the service connected disability.  Id.  The Court acknowledged that the soundness of OGC's guidance was endorsed in its decision in Walsh v. Wilkie, 32?Vet. App.?300, 305-07 (2020).  However, the Court noted that neither OGC's opinion nor Walsh provided guidance regarding what factual circumstances would give rise to claims for secondary service connection with this theory of entitlement. Therefore, if all of Walsh factors are answered in the affirmative, then the current disability may be service connected on a secondary basis, based on obesity.  

The Court provided the following non-exhaustive list of considerations that could give rise to a reasonably raised theory of secondary service connection with obesity as an intermediate step: (1) mobility limitations or reduced physical activity as a result of a service connected physical disability (in particular, orthopedic conditions or chronically painful conditions); (2) reduced physical activity or inability to follow a course of exercise or diet as a result of service-connected mental disability; (3) side effects of medication (e.g., weight gain), where the medication is prescribed for a service connected disability; (4) treatise evidence suggesting a connection between all or some combination of obesity, service connected disability, and the claimed condition; (5) lay statements by a Veteran attributing weight gain or obesity to the service connected disability; and (6) statements by treating physicians or medical examiners attributing weight gain or obesity to the service-connected disability.  Id. at 248.

1. Entitlement to service connection for OSA is granted.

The Veteran seeks service connection for sleep apnea.  

The September 2023 VA examiner found that the Veteran has had a diagnosis of OSA since 2017.  The Veteran has service connection for PTSD with alcohol use disorder, effective June 9, 2016.  As such, the only remaining issue is whether a nexus can be established.  The record contains evidence both in favor of and against the claim.

The January 2024 Board decision found the September 2023 VA medical opinion inadequate.  The March 2025 JMR found the January 2024 VA medical opinion inadequate.  Therefore, the Board will not discuss them further.

The March 2025 VA examiner opined that the Veteran's OSA was less likely than not proximately due to or the result of service-connected PTSD with alcohol use disorder.  The rationale was that while stress and psychiatric disorders can contribute to appetite changes, the Veteran's history shows long-standing dietary patterns and lifestyle factors, including high caloric intake and sedentary habits, which are more plausible causes of obesity.  Emotional binge eating, while reported, is not specifically or exclusively linked to PTSD in this case, as indicated by the absence of in-service onset or temporal correlation.  Medical literature indicates that while PTSD may modestly increase risk of obesity, obesity is multifactorial, and stress-induced weight gain alone is rarely the primary cause.

The opinion is not probative because it did not take account of medical evidence that linked the Veteran's obesity to her PTSD with alcohol use disorder.  Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (an opinion based on an inaccurate factual premise has no probative value).  For instance, September 2025 VAMC treatment records noted that the Veteran engaged in binge-eating more than once per week, and due to her insomnia, which the Board notes is linked to her PTSD with alcohol use disorder, she engaged in night eating, all of which contributed to her obesity.  See also November 2017, November 2019, and April 2020 VA PTSD DBQs.

The March 2025 VA examiner also opined that it is at least as likely as not that the Veteran's OSA would not have occurred but for her obesity.  The rationale was that the Veteran has no craniofacial abnormalities or other anatomical predispositions contributing to OSA, and mild OSA correlates strongly with obesity-related upper airway narrowing.  The examiner's opinion is probative, because it is based on
 than once per week, and due to her insomnia, which the Board notes is linked to her PTSD with alcohol use disorder, she engaged in night eating, all of which contributed to her obesity.  See also November 2017, November 2019, and April 2020 VA PTSD DBQs.

The March 2025 VA examiner also opined that it is at least as likely as not that the Veteran's OSA would not have occurred but for her obesity.  The rationale was that the Veteran has no craniofacial abnormalities or other anatomical predispositions contributing to OSA, and mild OSA correlates strongly with obesity-related upper airway narrowing.  The examiner's opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data.  Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008).

Upon review of the record, the Board finds the evidence to at least be in approximate balance as to whether the Veteran's OSA is secondary to her service-connected PTSD with alcohol use disorder.  Accordingly, after resolving reasonable doubt in favor of the Veteran, the Board finds that service connection for OSA is warranted.  38 U.S.C. § 5107; 38 C.F.R. § 3.102.

 

 

Paul R. Casey

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Shealy, Thomas C.

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.