SLEEP APNEA SYNDROMES (OBSTRUCTIVE CENTRAL MIXED)

Summary

The veteran, who served from July 1978 to September 2000, appeals the denial of service connection for obstructive sleep apnea (OSA). The veteran's primary contention was that OSA was secondary to service-connected psychiatric disability and left knee disability, which allegedly caused weight gain and obesity, leading to OSA. The veteran submitted two private consultant opinions supporting this claim, finding it at least as likely as not that OSA was secondary to weight gain caused by service-connected conditions. These opinions cited medical studies linking depression and musculoskeletal pain to obesity and OSA. However, the Board found these opinions speculative, as they did not adequately consider the veteran's diet or alternative exercise options, and the medical record did not show prescribed activity restrictions. In contrast, a VA examiner concluded it was less likely than not that OSA was caused by obesity, depression, or chronic pain, citing that obesity is only one of many risk factors for OSA and that psychological conditions do not have a proven causal relationship with OSA. The Board afforded more weight to the VA examiner's opinion, finding the evidence weighed against the claim. Service connection for OSA was denied.

Rationale

Service treatment records do not reflect OSA or sleep problems in service.; Veteran did not contend symptoms began in service.; Private opinions found OSA secondary to weight gain from service-connected disabilities.; VA examiner found OSA less likely than not caused by obesity, depression, or chronic pain.; Board found private opinions speculative and VA opinion more probative.; Medical evidence does not support that inability to exercise due to service-connected disabilities caused obesity.

Full Decision Text

Citation Nr: A24034355
Decision Date: 06/26/24	Archive Date: 06/26/24

DOCKET NO. 210317-147103
DATE: June 26, 2024

ORDER

Service connection for obstructive sleep apnea (OSA) is denied.

FINDINGS OF FACT

1. The Veteran served on active duty from July 1978 to September 2000. 

2. OSA was not shown in service, is not causally or etiologically related to service, and was not caused by or permanently worsened in severity by a service-connected disability.

CONCLUSION OF LAW

OSA was not incurred in service and is not proximately due to, aggravated by, or the result of a service-connected disability. 38 U.S.C. §§ 1110, 1131, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303, 3.310 (2023).

REASONS AND BASES FOR FINDINGS AND CONCLUSION

This decision has been written under the guidelines of the Veterans Appeals Improvement and Modernization Act, also known as the Appeals Modernization Act (AMA). In October 2020, the agency of original jurisdiction (AOJ) denied the claim. In March 2021, the Veteran appealed to the Board via a Form 10182 and elected the Evidence Submission docket. Therefore, the Board will review the evidence of record at the time of the AOJ's October 2020 decision, in addition to evidence submitted with the Form 10182 or within 90 days following receipt of the Form 10182. 

Turning to the relevant laws and regulations, service connection may be granted on a direct basis as a result of disease or injury incurred in service based on nexus using a three-element test: (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 in or aggravated by service. See 38 C.F.R. §§ 3.303 (a), (d); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009).

Service connection may be granted on a secondary basis for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury under 38 C.F.R. § 3.310. Allen v. Brown, 7 Vet. App. 439 (1995). In order to establish service connection on a secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a link between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998).

Service connection may be granted on a secondary basis with an intercurrent cause of obesity if a service-connected disability caused or aggravated a veteran's obesity, and the aggravation of obesity was then a substantial factor in causing or aggravating the claimed disorder, and whether the claimed disorder would have occurred but for obesity aggravated by the service-connected disability. See Walsh v. Wilkie, 32 Vet. App, 300, 307 (2020).

Turning to the medical evidence, the Veteran was diagnosed with OSA following an October 2015 sleep study. As such, a current diagnosis is shown and the first element of service connection is met. 

As to in-service incurrence, the service treatment records (STRs) do not reflect complaints of, treatment for, or a diagnosis of OSA or any sleep problems during service. Moreover, he does not contend that symptoms of OSA began during a period of active duty. As such, the medical evidence does not support service connection for OSA on a direct basis.

Rather, the Veteran's main contention is that OSA is secondary to a service-connected psychiatric disability and left knee disability. He contends that these disabilities prevented him from exercising, which in turn caused him to gain weight. He further argues that OSA developed as a direct result of this weight gain and obesity.

In support of the claim, a July 2020 private consultant opined that the Veteran's weight gain and obesity were at least as likely as not due to or related to service-connected depressive disorder and left knee fracture. Next, she found it at least as likely as not that OSA was secondary to, related to, or aggravated by the weight gain caused by these service-connected disabilities. Finally, she concluded that it was at least as likely as not that OSA would not have occurred without this weight gain and obesity. 

The
 disability and left knee disability. He contends that these disabilities prevented him from exercising, which in turn caused him to gain weight. He further argues that OSA developed as a direct result of this weight gain and obesity.

In support of the claim, a July 2020 private consultant opined that the Veteran's weight gain and obesity were at least as likely as not due to or related to service-connected depressive disorder and left knee fracture. Next, she found it at least as likely as not that OSA was secondary to, related to, or aggravated by the weight gain caused by these service-connected disabilities. Finally, she concluded that it was at least as likely as not that OSA would not have occurred without this weight gain and obesity. 

The consultant reasoned that the Veteran weighed 205 pounds upon service enlistment, 240 pounds upon separation, and 280 pounds at the time of the examination. She found this to be evidence of progressive weight gain and obesity which developed after the mental health stressors and musculoskeletal symptoms related to service-connected disabilities. 

Moreover, the consultant cited to medical studies which showed that depression led to a higher risk of obesity due to excessive food intake related to mood disturbances and sleep disturbance. Further, the consultant found that musculoskeletal pain reduced sleep quality and limited the Veteran's ability to exercise, which further contributed to obesity. 

Next, in February 2021, a private consultant opined that it was at least as likely as not that OSA was secondary to, related to, or aggravated by service-connected disabilities, to include depressive disorder and knee fracture, with subsequent sleep disturbance and weight gain/obesity. The consultant cited to medical studies which supported the claim that mental health disorders induced weight gain. Further, he noted that chronic knee pain led to a more sedentary lifestyle, which was a contributing factor to weight gain. In addition, the consultant cited to medical literature which confirmed a nexus between body weight and the development of OSA. 

Weighing against the claim, an August 2020 VA examiner concluded that it was less likely than not that OSA was caused by obesity, depressive disorder, related medications, or chronic pain issues. After a review of the medical literature, the examiner found that the evidence failed to show that psychological conditions, such as depression, have a proven causal relationship with OSA. Rather, he explained that the collapse of the airway that caused OSA was not well understood. Further, he noted that psychological conditions could often cause insomnia, a separate sleep disorder.

Next, the VA examiner explained that obesity was just one risk factor out of many for the development of OSA. These many factors included obesity, neck circumference, narrowed airway, male gender, age, family history, smoking, alcohol use, and nasal congestion. Regardless of where obesity ranked on this list of risk factors, the examiner explained that obesity was just one risk factor out of many. In other words, he stated that medical literature showed that obesity was a risk factor for OSA and not the definitive cause. 

As such, the VA examiner concluded that it was impossible to say that had the Veteran not been obese, then he would not have developed OSA. He explained that there were obese segments of the population without OSA and thin segments of the population that did have OSA. Therefore, he concluded that OSA was less likely than not caused by obesity, depressive disorder, or chronic pain. 

After review, the Board affords more probative value to the August 2020 VA examiner's opinion because it is supported by the weight of the medical evidence. While the Veteran progressively gained weight throughout service and into the present, it is speculative to attribute that weight gain solely to the knee or psychiatric disability. 

Moreover, the medical evidence does not show that the Veteran was prescribed a restriction of activities which would prohibit exercise due to a knee disability or psychiatric disability; rather, the record shows that clinicians suggested that he exercise as well as monitor his diet. 

For example, in a November 1999 STR, a clinician indicated that the Veteran's diet readiness test indicated that he needed to focus on boosting his readiness to make lifestyle changes, develop strategies to overcome external and internal cues to eating, improve recovery from lapses, and increase motivation for exercise. The Veteran indicated that he had a family history of obesity and was counseled on healthy eating and exercise habits. The medical professional made no indication that the Veteran was unable to exercise due to any disabilities; rather, he encouraged more exercise. 

Moreover, an October 2015 VA physician encouraged the Veteran to increase daily exercise and eat healthy to decrease obesity. Further, a March 2017 VA clinician advocated for a healthy diet and exercise to improve general health. In sum, the medical record shows that multiple clinicians advised a healthy diet and exercise to combat obesity. 

Therefore, the medical evidence does not support the conclusion that the absence of an ability to
 and internal cues to eating, improve recovery from lapses, and increase motivation for exercise. The Veteran indicated that he had a family history of obesity and was counseled on healthy eating and exercise habits. The medical professional made no indication that the Veteran was unable to exercise due to any disabilities; rather, he encouraged more exercise. 

Moreover, an October 2015 VA physician encouraged the Veteran to increase daily exercise and eat healthy to decrease obesity. Further, a March 2017 VA clinician advocated for a healthy diet and exercise to improve general health. In sum, the medical record shows that multiple clinicians advised a healthy diet and exercise to combat obesity. 

Therefore, the medical evidence does not support the conclusion that the absence of an ability to exercise due to service connected disabilities caused the Veteran to become obese. Rather, it is just the opposite. He was encouraged to exercise even with the service connected disabilities.

In contrast, the private examiners attempted to reduce the cause of obesity to two service-connected disabilities and did not adequately consider the Veteran's diet or alternative options for exercise which did not involve the injured knee (rated at 10 percent disabling). Accordingly, the medical evidence does not support a finding that obesity was an intermediate step causing OSA due to service-connected disabilities.

The Board has considered the Veteran's lay statements that OSA and obesity were caused by service-connected disabilities. While he is competent to report symptoms as this requires only personal knowledge as it comes to him through his senses, he is not competent to offer an opinion as to the etiology of the current disorder due to the medical complexity of the matter involved.

Such competent evidence concerning the etiology and nature of  OSA and obesity has been provided by the medical personnel who examined him during the current appeal, and who rendered pertinent opinions in conjunction with the evaluations.

Their findings (as provided in the examination reports and other clinical evidence) directly address the criteria under which this disorder is evaluated. The VA medical professionals explained their reasoning based on an accurate characterization of the evidence. Therefore, the Board attaches greater probative weight to the clinical findings than to the lay statements regarding etiology.

In sum, after a careful review of the record, the evidence weighs persuasively against the claim for service connection and there is no doubt to be resolved. As such, the appeal is denied.

Finally, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, for the Board's consideration. See Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record).  

 

L. HOWELL

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	T. Kokolas, Associate 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.