SLEEP APNEA SYNDROMES (OBSTRUCTIVE CENTRAL MIXED)

Summary

The veteran served from October 1976 to September 1983. The veteran appealed the denial of service connection for obstructive sleep apnea, claiming it was secondary to his service-connected depressive disorder due to chronic pain associated with degenerative arthritis of the lumbar spine, with obesity as an intermediate step. The Board reviewed the case under the AMA Direct Review pathway, focusing on evidence from the agency of original jurisdiction's January 2022 decision. The Board found that the veteran had a current diagnosis of obstructive sleep apnea and was already service-connected for depressive disorder due to chronic pain from lumbar degenerative arthritis. The key evidence was a January 2022 private medical opinion from C.M.B., PA-C, MPLC. This opinion concluded it was at least as likely as not that the veteran's weight gain and obesity were due to his depressive disorder, and that his sleep apnea was secondary to this obesity. The opinion cited medical literature supporting the link between mental health conditions, weight gain, and obstructive sleep apnea, as well as the impact of chronic pain on activity levels and weight. The Board found this opinion persuasive, establishing the necessary nexus for secondary service connection, with obesity acting as a valid intermediate step. Consequently, service connection for obstructive sleep apnea secondary to the service-connected depressive disorder with obesity as an intermediate step was granted.

Rationale

Current diagnosis of obstructive sleep apnea established by AOJ.; Service-connected depressive disorder due to chronic pain associated with degenerative arthritis of the lumbar spine.; Private medical opinion established nexus via obesity as intermediate step.

Full Decision Text

Citation Nr: A25004703
Decision Date: 01/21/25	Archive Date: 01/21/25

DOCKET NO. 230125-316845
DATE: January 21, 2025

ORDER

Entitlement to service connection for obstructive sleep apnea as secondary to depressive disorder due to chronic pain associated with degenerative arthritis of the lumbar spine is granted.

FINDING OF FACT

The Veteran's service-connected depressive disorder due to chronic pain associated with degenerative arthritis of the lumbar spine caused the Veteran to become obese; the obesity was a substantial factor in causing the obstructive sleep apnea; and the obstructive sleep apnea would not have occurred but for obesity caused by service-connected depressive disorder due to chronic pain associated with degenerative arthritis of the lumbar spine.

CONCLUSION OF LAW

The criteria for service connection for obstructive sleep apnea, secondary to service-connected depressive disorder due to chronic pain associated with degenerative arthritis of the lumbar spine, with obesity as an intermediate step, are met.  38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.310.

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REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty from October 1976 to September 1983.  

The Department of Veteran Affairs (VA) rating decision on appeal was issued in January 2022 under The Veterans Appeals Improvement Modernization Act of 2017 (AMA) review system.  In the January 2023 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement) (NOD), the Veteran elected the Direct Review option.  Therefore, the Board may only consider the evidence of record at the time of the agency of original jurisdiction (AOJ) decision on appeal. 38 C.F.R. § 20.301

In the January 2022 VA rating decision, the AOJ found that new and relevant evidence was submitted to warrant readjudicating the claim.  The Board is bound by these favorable findings.  38 C.F.R. § 3.104(c).  As such the Board will address the claim on its merits. 

Service Connection

Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service.  38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a).  Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a link between the claimed in-service disease or injury and the present disability.  Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013).

Additionally, service connection may be established on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a).  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) proximately due to or the result of; or (b) aggravated by a service-connected disability.  38 C.F.R. § 3.310 (b); Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc).

Obstructive Sleep Apnea

The Board finds that the evidence of record supports a finding that the Veteran's sleep apnea is secondary to his service-connected depressive disorder due to chronic pain associated with degenerative arthritis of the lumbar spine, with obesity as an intermediate step.

As stated above, the first element of secondary service connection requires evidence of a current disorder.  In a January 2022 VA rating decision, the AOJ made a favorable finding that the Veteran has a current diagnosis of obstructive sleep apnea.  Given such, the first element of secondary service connection is met. 

The second element of secondary service connection requires evidence of a service-connected disability.  The evidence of record reflects that the Veteran is service connected for depressive disorder due to chronic pain associated with degenerative arthritis of the lumbar spine.  See December 2022 VA Rating Decision- Code sheet.  Thus, the Veteran has satisfied the second element of secondary service connection.

Lastly, the third element of secondary service connection requires medical nexus evidence establishing a connection between the service-connected disability and the current disorder.

In a January 2022 private medical opinion, C.M.B., PA-C, MPLC opined that it is at least as likely as not that the Veteran's weight gain and obesity are due to his depressive disorder due
 service connection is met. 

The second element of secondary service connection requires evidence of a service-connected disability.  The evidence of record reflects that the Veteran is service connected for depressive disorder due to chronic pain associated with degenerative arthritis of the lumbar spine.  See December 2022 VA Rating Decision- Code sheet.  Thus, the Veteran has satisfied the second element of secondary service connection.

Lastly, the third element of secondary service connection requires medical nexus evidence establishing a connection between the service-connected disability and the current disorder.

In a January 2022 private medical opinion, C.M.B., PA-C, MPLC opined that it is at least as likely as not that the Veteran's weight gain and obesity are due to his depressive disorder due to chronic pain associated with degenerative arthritis of the lumbar spine.  It is at least as likely as not that the Veteran's sleep apnea is secondary to the weight gain and obesity that was caused by his depressive disorder due to chronic pain associated with degenerative arthritis of the lumbar spine.  And that it is at least as likely as not that without the Veteran's obesity, his sleep apnea would not have occurred. 

The examiner noted that it is well documented in medical literature that mental health disorders lead to social isolation, impaired functioning, and weight gain.  A study by Bixler et al. found depression to be a major factor in development of daytime somnolence, a condition that typically precedes development of obstructive sleep apnea.  Furthermore, the examiner reported that recent studies in the medical literature support that mental health conditions, to include, major depressive disorder, depression, induce weight gain and obesity.  The examiner also stated that the Veteran's depressive disorder is productive of depressed mood and sleep impairment. 

Additionally, the examiner noted that the Veteran is service connected with degenerative arthritis of the lumbar spine, and due to his chronic pain, he has participated in less physical activities and led a more sedentary lifestyle.  This is a contributing factor to his weight gain.  The Veteran stated he weighed 180 pounds at military entrance, and 230 upon separation, and currently weighs 258 pounds.  The examiner pointed out that the Veteran's weight gain was after the stressor events of service.  The examiner explained that the Veteran has a total weight gain of approximately 78 pounds from his service to the present time, which a major factor in his obesity.  

The examiner determined that based on the medical literature a nexus existed between the Veteran's weight gain and his obstructive sleep apnea.  Essentially, the pathophysiology of obstructive sleep apnea is linked to obesity.  

Furthermore, the examiner noted that individuals who suffer from chronic pain are at a higher risk for developing weight gain and becoming obsess due to several factors, which include decreased activity due to pain.  One study concluded that weight is associated with co-morbid disability, depression, and reduced quality for life for physical function in chronic pain.  

Therefore, the examiner concluded that the Veteran's service-connected depressive disorder due to chronic pain, degenerative arthritis of the lumbar spine promoted sleep disturbance and weight gain and led to his current obesity, which led to his obstructive sleep apnea. 

In other words, the Board notes that the examiner is opined that the Veteran's obesity is an intermediate step between his depressive disorder due to chronic pain associated with degenerative arthritis of the lumbar spine and his sleep apnea.  In such a case, while obesity is not a disease or disability for which service connection may be granted, obesity may be an "intermediate step" between a service-connected disability and a current disability that may be connected on a secondary basis.  VAOPGCPREC 1-2017 (January 6, 2017).  Specifically, to meet the criteria, the Veteran must demonstrate that a service-connected disability caused the Veteran to become obese; that obesity was a substantial factor in causing secondary disability; and the secondary disability would only have occurred but for the obesity.

Based on the foregoing, the Board finds that the private medical opinion supports a finding that the Veteran's depressive disorder due to chronic pain associated with degenerative arthritis of the lumbar spine caused the Veteran to become obese; that obesity was a substantial factor in causing sleep apnea; and that sleep apnea would only have occurred but for the obesity.  Thus, establishing a nexus between the Veteran's obstructive sleep apnea and his service-connected depressive disorder with obesity as an intermediate step.  As such, the third element of secondary service connection is satisfied.  Accordingly, entitlement to service connection for obstructive sleep apnea is warranted on a secondary, causation basis, with obesity as an intermediate step.

 

 

YVETTE R. WHITE

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Dalia Abdelbary, Counsel

The Board's decision in
 arthritis of the lumbar spine caused the Veteran to become obese; that obesity was a substantial factor in causing sleep apnea; and that sleep apnea would only have occurred but for the obesity.  Thus, establishing a nexus between the Veteran's obstructive sleep apnea and his service-connected depressive disorder with obesity as an intermediate step.  As such, the third element of secondary service connection is satisfied.  Accordingly, entitlement to service connection for obstructive sleep apnea is warranted on a secondary, causation basis, with obesity as an intermediate step.

 

 

YVETTE R. WHITE

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Dalia Abdelbary, 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.