THYROID ENLARGEMENT TOXIC (GRAVES' DISEASE OR THYROTOXICOSIS)

M. TENNER · 2026 · Case ID: 26005121

GRANTED

Summary

The Veteran, a Navy Veteran who served from 1988 to 1993 including service in the Southwest Asia theater of operations, appeals the denial of service connection for multiple conditions. The Veteran sought service connection for chronic lymphocytic thyroiditis (CLT), hypothyroidism, hypogonadism, morbid obesity, dysmetabolic syndrome, edema, skin tags, acanthosis nigricans, striae, and fatigue. The Regional Office denied all claims in 2010. The Board of Veterans' Appeals also denied the claims in 2016, but the Veterans Court vacated that decision in 2021, remanding the claims for readjudication due to deficiencies in the Board's reasoning regarding medical opinions and the definition of "disability." The Board now grants service connection for chronic lymphocytic thyroiditis and hypogonadism, finding them related to in-service environmental toxin exposure. Consequently, it grants secondary service connection for hypothyroidism, morbid obesity, dysmetabolic syndrome, edema, skin tags, acanthosis nigricans, striae, and fatigue, all found to be caused by the primary conditions. The Board's decision reflects a thorough review of the Veteran's claims, addressing the Court's remand instructions by providing detailed findings and conclusions for each condition.

Rationale

Related to in-service environmental toxin exposure; Southwest Asia theater of operations service

Service Branch

NAVY

Special Benefit

NO SPECIAL BENEFIT

Docket No.

12-03 657

Full Decision Text

Citation Nr: 26005121
Decision Date: 04/30/26 Archive Date: 04/30/26

DOCKET NO. 12-03 657
DATE: April 30, 2026

ORDER

Service connection for chronic lymphocytic thyroiditis is granted.

Service connection for hypothyroidism as secondary to chronic lymphocytic thyroiditis is granted.

Service connection for hypogonadism is granted.

Service connection for morbid obesity as secondary to chronic lymphocytic thyroiditis, hypothyroidism, and/or hypogonadism is granted.

Service connection for dysmetabolic syndrome (also claimed as insulin resistance syndrome) as secondary to morbid obesity is granted.

Service connection for edema as secondary to morbid obesity is granted.

Service connection for skin tags as secondary to morbid obesity is granted.

Service connection for acanthosis nigricans as secondary to morbid obesity is granted.

Service connection for striae as secondary to morbid obesity is granted.

Service connection for fatigue secondary to morbid obesity is granted.

FINDINGS OF FACT

1. The Veteran's chronic lymphocytic thyroiditis is related to in-service environmental toxin exposure via service in the Southwest Asia theater of operations.

2. The Veteran's hypothyroidism is caused by his chronic lymphocytic thyroiditis.

3. The Veteran's hypogonadism is related to in-service environmental toxin exposure via service in the Southwest Asia theater of operations.

4. The Veteran's morbid obesity is caused by chronic lymphocytic thyroiditis, hypothyroidism, and/or hypogonadism.

5. The Veteran's dysmetabolic syndrome (also claimed as insulin resistance syndrome) is caused by his morbid obesity.

6. The Veteran's edema is caused by his morbid obesity.

7. The Veteran's skin tags are caused by his morbid obesity.

8. The Veteran's acanthosis nigricans is caused by his morbid obesity.

9. The Veteran's striae are caused by his morbid obesity.

10. The Veteran's fatigue is caused by his morbid obesity.

CONCLUSIONS OF LAW

1. The criteria for service connection for chronic lymphocytic thyroiditis are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

2. The criteria for service connection for hypothyroidism as secondary to service-connected chronic lymphocytic thyroiditis are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

3. The criteria for service connection for hypogonadism are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

4. The criteria for service connection for morbid obesity as secondary to service-connected chronic lymphocytic thyroiditis, hypothyroidism, and/or hypogonadism are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

5. The criteria for service connection for dysmetabolic syndrome (also claimed as insulin resistance syndrome) as secondary to service-connected morbid obesity are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

6. The criteria for service connection for edema as secondary to service-connected morbid obesity are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

7. The criteria for service connection for skin tags as secondary to service-connected morbid obesity are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

8. The criteria for service connection for acanthosis nigricans as secondary to service-connected morbid obesity are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

9. The criteria for service connection for striae as secondary to service-connected morbid obesity are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

10. The criteria for service connection
, 5107; 38 C.F.R. §§ 3.102, 3.310.

8. The criteria for service connection for acanthosis nigricans as secondary to service-connected morbid obesity are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

9. The criteria for service connection for striae as secondary to service-connected morbid obesity are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

10. The criteria for service connection for fatigue as secondary to service-connected morbid obesity are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served a period of active duty for training in the United States Naval Reserve from June to November 1988 and served honorably on active duty in the United States Navy from February 1989 to February 1993, including service in the Southwest Asia theater of operations from 1990 to 1991.

This appeal is being treated expeditiously on the Board of Veterans' Appeals' (Board) docket pursuant to 38 U.S.C. §§ 5109B, 7112 and 38 C.F.R. § 20.902(d).

This appeal is being adjudicated in the Legacy Appeal system. See, e.g., Pub. L. 115-55 § 6; 38 C.F.R. §§ 19.1, 19.2, 3.2400.

This case has a long procedural history dating back to 2009. The Board will provide a discussion of the most relevant history as background information.

On August 11, 2009, the Veteran filed an application, VA Form 21-526, to reopen a claim for service connection for hypothyroidism, hypogonadism, morbid obesity, dysmetabolic syndrome, chronic lymphocytic thyroiditis (CLT), fatigue, edema, skin tags, acanthosis nigricans, and striae. The prior decisions in this case have treated hypothyroidism and CLT as similar conditions. On review of the record, the Board now treats them as separate conditions for reasons that will be explained later.

A Regional Office of the United States Department of Veterans Affairs (VA) denied each claim for service connection in an October 22, 2010, Rating Decision. The Veteran appealed that decision to the Board.

The Veteran testified at a hearing before the undersigned Veterans Law Judge on May 29, 2013, as part of his appeal.

In a December 8, 2016, decision, the Board denied all claims for service connection. The Veteran appealed that decision to the United States Court of Appeals for Veterans Claims (Veterans Court). Relevant here, the Veterans Court issued a decision on November 15, 2021, vacating the Board's decision as to the claims for service connection identified above.

With respect to the claims for service connection for hypothyroidism, CLT, and hypogonadism, the Veterans Court held that the Board did not address the Veteran's challenge to a medical examiner's qualifications. And the Board did not provide adequate reasons and bases addressing the deficiencies in the examiner's medical opinion, including whether it lacked sufficient rationales in support of the conclusions. It remanded those claims for readjudication.

With respect to the claims for service connection for morbid obesity and dysmetabolic syndrome, the Veterans Court held that the Board needed to address whether those conditions were "disabilities" subject to service connection pursuant to Saunders v. Wilkie, 886 F.3d 1356 (2018) ("[t]o establish the presence of a disability, a [claimant] will need to show that [his or] her [condition] reaches the level of functional impairment of earning capacity."). It remanded those claims for readjudication.

With respect to the remaining claims for service connection for fatigue, edema, skin tags, acanthosis nigricans, and striae, the Veteran had claimed that those conditions were secondary to his morbid obesity and dysmetabolic syndrome. The Veterans Court found that those reaming claims were inextricably intertwined with the claims for service connection for morbid obesity and dysmetabolic syndrome. It remanded those claims as well.

The appeal now returns to the Board for readjudication.

Service Connection

All claims on appeal to the Board involve requests for service connection. The Veteran
that [his or] her [condition] reaches the level of functional impairment of earning capacity."). It remanded those claims for readjudication.

The appeal now returns to the Board for readjudication.

Service Connection

All claims on appeal to the Board involve requests for service connection. The Veteran, and the record, raise several theories of entitlement to service connection. Below, the Board sets forth the general law applicable to the theories of direct and secondary service connection. Additional theories of service connection will be discussed where appropriate.

The VA provides compensation for a disability resulting from disease or injury incurred in or aggravated by service. This is referred to as "service connection." 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d).

Direct Service Connection

Generally, in order to be entitled to service connection there must be competent, credible evidence of (1) a current disability, (2) an in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). When these elements are satisfied, service connection may be granted on a direct basis.

Secondary Service Connection

Service connection may also be established on a secondary basis for a disability which is due to or the result of, or aggravated by, a service-connected disability. 38 C.F.R. § 3.310(a), (b). Establishing service connection on a secondary basis requires evidence sufficient to show: (1) a current disability exists, (2) the veteran has a service-connected disability; and (3) the current disability was either (a) caused by; or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(b); Allen v. Brown, 7 Vet. App. 439, 448 (1995). Recently, in Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023), the Federal Circuit Court of Appeals held 38 U.S.C. § 1110 employs only "but-for" causation in direct and secondary service connection claims. Therefore, a service-connected disability need only be a contributing cause (or aggravating factor), not the contributing cause (or aggravating factor), to establish secondary service connection.

The Board also notes that the law has substantially changed in many respects since the Veteran filed his application for service connection in 2009. The relevant changes will also be discussed where appropriate.

1. Service connection for chronic lymphocytic thyroiditis is granted.

When the Veteran's claim was filed, the VA Regional Office treated his claim for hypothyroidism to include synonymous disease of chronic lymphocytic thyroiditis (CLT). Of record is a January 8, 2025, VA-contracted medical examination assessing the Veteran's thyroid/parathyroid conditions. The examiner diagnosed the Veteran with CLT, more commonly known as Hashimoto's thyroiditis.

Another VA-contracted examiner explained in a May 7, 2025, opinion that CLT "is an autoimmune disease in which the immune system inappropriately targets and destroys thyroid tissue. It is the most common cause of hypothyroidism in iodine-sufficient regions and typically leads to a gradual, permanent loss of thyroid function." (emphasis added.) Hence, CLT causes hypothyroidism. They are separate diseases, albeit related.

The Board finds the medical examination and medical opinions are credible and probative. The Board finds that the Veteran has a current disability of CLT. The first element of direct service connection is met.

The Veteran is considered a Persian Gulf War Veteran due to his service in the Southwest Asia theater of operations between 1990 and 1991. 38 U.S.C. § 1117(f). Under a new VA regulation, 38 C.F.R. § 3.320(4), the Veteran is presumed to
roidism in iodine-sufficient regions and typically leads to a gradual, permanent loss of thyroid function." (emphasis added.) Hence, CLT causes hypothyroidism. They are separate diseases, albeit related.

Since the Veteran's appeal was certified to the Board, there has been a significant change in the law. On August 10, 2022, the President of the United States signed into law the Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics Act of 2022 or the Honoring our PACT Act of 2022 (PACT Act), Pub. L. No. 117-168, 136 Stat. 1759 (Aug. 10, 2022). The PACT Act implemented 38 U.S.C. § 101(37), which says that a veteran experienced "toxic exposure" in service if they were exposed to "a substance, chemical, or airborne hazard identified in the list under [38 U.S.C. §] 1119(b)(2)[.]" Section 1119(b)(2) provides that the Secretary shall "establish and maintain a list that contains an identification of one or more such substances, chemicals, and airborne hazards as the Secretary, in collaboration with the Secretary of Defense, may determine appropriate for purposes of this section." 38 U.S.C. § 1119(b)(2).

In addition, the PACT Act implemented 38 U.S.C. § 1168, requiring VA to schedule certain veterans for an examination and request a medical opinion for certain non-presumptive diseases if they engaged in a "toxic exposure risk activity" (TERA). "Toxic exposure risk activity" derives its definition from 38 U.S.C. § 1710(e)(4). 38 U.S.C. § 1168(c). Section 1710(e)(4) defines TERA to include, as relevant here, "any activity that the Secretary determines qualifies for purposes of this subsection when taking into account what is reasonably prudent to protect the health of veterans." 38 U.S.C. § 1710(e)(4)(C)(ii). The Secretary has published regulatory guidance addressing TERA. VBA Letter 20-22-10 (effective January 1, 2023). The Secretary has broadly construed what constitutes a TERA, instructing claims processors to consider "all available evidence." VBA Letter 20-22-10, page 10 of 28. The threshold for a TERA examination and medical opinion is low. Unlike general opinions for service connection, TERA opinions must consider "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." 38 U.S.C. § 1168(a)(2)(A) and (B).

The Board notes that the record contains two Memoranda issued by the VA Regional Office, dated August 29, 2024, and April 25, 2025. The VA Regional Office concluded that the Veteran engaged in TERA due to his service in Southwest Asia theater of operations, thus triggering the VA's duty to obtain a TERA examinations and medical opinions in relation to each claimed disability.

Furthermore, a June 3, 2025, VA Memorandum found the following. First, the Veteran's service in Southwest Asia exposed him to pesticides. Major categories of pesticides that were used in the Persian Gulf War included: methyl carbonate organochlorine (lindane), which was used to treat uninforms; diethyltoluamide (DEET), used on the skin as an insect repellant; organophosphorus (OP) pesticides; and pyrethroid pesticides (primary permethrin). The VA Regional Office relied on VA-authored literature that the Veteran submitted on June 3, 2025. The Veteran reported that he was personally exposed to pesticides (insecticides) through personal use, spraying, and use of fogs around the various camps. Second, the VA Regional Office accepted that the Veteran's service had a minimal probability of exposure to asbestos on his military occupational specialty (MOS) as a Medical Field Service Technician.

The Board finds that the Veteran experienced exposure to environmental hazards during active military service, to include burn
forms; diethyltoluamide (DEET), used on the skin as an insect repellant; organophosphorus (OP) pesticides; and pyrethroid pesticides (primary permethrin). The VA Regional Office relied on VA-authored literature that the Veteran submitted on June 3, 2025. The Veteran reported that he was personally exposed to pesticides (insecticides) through personal use, spraying, and use of fogs around the various camps. Second, the VA Regional Office accepted that the Veteran's service had a minimal probability of exposure to asbestos on his military occupational specialty (MOS) as a Medical Field Service Technician.

The Board finds that the Veteran experienced exposure to environmental hazards during active military service, to include burn pits, oil fires, pesticides, and fine, particulate matter. On review of the record, the Board finds no competent evidence that the Veteran was exposed to asbestos during active military service. Notably, he denied exposure to asbestos to his medical providers. August 14, 2018, VA Pulmonary Consult. And his military medical records and personnel records are silent as to such exposure. Despite his MOS having a minimal probability of such exposure, the Board finds no competent evidence of establishing such exposure.

The Board finds that the second element of service connection is met.

As to the final element of service connection, a causal link between the Veteran's military service and his CLT, the Board finds sufficient evidence of record establishing such a link.

As to the positive evidence of record, the VA Regional Office obtained a medical opinion from a VA examiner in March 2010. The examiner opined that the Veteran's CLT was at least as likely as not due to exposure to environmental hazards during military service. The examiner explained that there was no family history of thyroid disease noted in the record. In light of that evidence, the examiner provided the Veteran with the benefit of the doubt.

The Veteran submitted a private medical opinion from his personal VA medical provider on September 23, 2011. The medical professional endorsed the box "At least as likely as not related to" in response to whether the Veteran's CLT was caused by in-service exposure to environmental toxins. Although no rationale was provided, the opinion does have some probative weight because it was completed by an otherwise competent and informed VA medical professional.

As to the negative evidence of record, the VA Regional Office obtained a medical opinion from a VA examiner on April 28, 2010. The examiner opined that CLT is not known to have an association with Gulf War service and various environmental exposures there. A 2013 medical opinion and subsequent 2015 medical opinion from a VA endocrinologist affirmed this opinion.

The VA Regional Office obtained several more opinions on the matter in 2025. A January 2025 VA-contracted examiner opined that the Veteran's CLT was less likely than not caused by toxin exposure during military service. The examiner stated that the Veteran was not exposed to known risk factors for CLT. The examiner acknowledged familial genetics play a large part in the disease's development. He even stated that it common "as you get older."

A May 7, 2025, VA-contracted examiner opined that it was less likely than not that the Veteran's CLT was due to toxin exposure in service because there was no medically or scientifically recognized link between the two.

A June 9, 2025, VA-contracted examiner opined that it was less likely than not that the Veteran's CLT was due to toxin exposure in service because the Veteran was not diagnosed until many years after service. An addendum opinion was obtained on September 9, 2025, from the same examiner, who added that obesity can be a risk factor. She generally cited medical literature without any substantive discussion of that literature in relation to the Veteran's circumstances of service.

When the Board reviews each relevant medical opinion, they are all deficient in one way or another. Some have no reasoning in support of the conclusion. Others have irrelevant reasoning. And some have "bare bones" reasoning that fails to link the facts and medical conclusion sufficiently. Nonetheless, the Board is aware that it can read the opinions together rather than independent of each other to form a conclusion about the evidence. See Gilbert v. Derwinski, 1 Vet. App. 49, 52 (1990) (it is the prerogative of the Board to reasonably interpret the evidence and draw reasonable inferences from it); Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) ("[E]ven if a medical opinion is inadequate to decide a claim, it does not necessarily follow that the opinion is entitled to absolutely no probative weight.").

Here, the Board finds that no single opinion is more probative than another. The positive nexus opinions are equally as prob
aware that it can read the opinions together rather than independent of each other to form a conclusion about the evidence. See Gilbert v. Derwinski, 1 Vet. App. 49, 52 (1990) (it is the prerogative of the Board to reasonably interpret the evidence and draw reasonable inferences from it); Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) ("[E]ven if a medical opinion is inadequate to decide a claim, it does not necessarily follow that the opinion is entitled to absolutely no probative weight.").

Here, the Board finds that no single opinion is more probative than another. The positive nexus opinions are equally as probative as the negative nexus opinions, considering all flaws within each opinion. As such, the Board resolves reasonable doubt in the Veteran's favor. In doing so, the Board finds that it is at least as likely as not that his CLT was caused by toxin exposure in service. The third element of service connection is met.

Accordingly, service connection for CLT is granted on direct basis.

2. Service connection for hypothyroidism as secondary to chronic lymphocytic thyroiditis is granted.

The Veteran has been diagnosed with hypothyroidism apart from CLT. See, e.g., July 4, 2008; July 8, 2025, VA Medical Examination Reports; see also generally VA Medical Records (documenting diagnosis of and treatment for hypothyroidism during the claim period). The first element of service connection is met.

The Veteran seeks service connection on a direct basis for his hypothyroidism. The Board finds that service connection can be granted on a secondary basis, which affords the Veteran the same benefits as an award based on direct service connection.

Two separate VA-contracted medical examiners authored independent medical opinions dated January 8, 2025, and May 7, 2025, explaining that the Veteran's hypothyroidism is caused by his now service-connected CLT. The Board finds that the examiners conducted thorough reviews of the Veteran's claims file, relied on accurate facts, considered the Veteran's medical history and lay statements, and otherwise provided sufficient rationales for their opinions. The Board finds the opinions credible and probative. The Board finds the second and third elements of secondary service connection are met.

Accordingly, service connection for hypothyroidism as secondary to chronic lymphocytic thyroiditis is granted.

3. Service connection for hypogonadism is granted.

The Veteran has been diagnosed with hypogonadism. See January 8, 2025, VA Medical Examination Report; see also generally VA Medical Records (documenting diagnosis of and treatment for hypogonadism during the claim period). The first element of service connection is met.

The second element of service connection, an in-serve injury, is also met for reasons discuss in connection with the Veteran's claim for service connection for CLT. He was exposed to environmental toxins in service while serving in the Southwest Asia theater of operations.

As to the final element of service connection, a causal link between the Veteran's military service and his hypogonadism, the Board finds sufficient evidence of record establishing such a link.

As to the positive evidence of record, the VA Regional Office obtained a medical opinion from a VA examiner in March 2010. The examiner opined that the Veteran's hypogonadism was at least as likely as not due to exposure to environmental hazards during military service. The examiner explained that hypogonadism did not have a clear etiology. In light of that evidence, the examiner provided the Veteran with the benefit of the doubt when providing a positive nexus opinion.

The Veteran submitted a private medical opinion from his personal VA medical provider on September 23, 2011. The medical professional endorsed the box "At least as likely as not related to" in response to whether the Veteran's hypogonadism was caused by in-service exposure to environmental toxins. Although no rationale was provided, the opinion does have some probative weight because it was completed by an otherwise competent and informed VA medical professional.

As to the negative evidence of record, the VA Regional Office obtained a medical opinion from a VA examiner on April 28, 2010. The examiner opined that hypogonadism is not known to have an association with Gulf War service and various environmental exposures there. A 2013 medical opinion and subsequent 2015 medical opinion from a VA endocrinologist affirmed this opinion.

The VA Regional Office obtained several more opinions on the matter in 2025. A January 2025 VA-contracted examiner opined that the Veteran's hypogonadism was less likely than not caused by toxin exposure during military service.

A May 7, 2025,
completed by an otherwise competent and informed VA medical professional.

A May 7, 2025, VA-contracted examiner opined that it was less likely than not that the Veteran's hypogonadism was due to toxin exposure in service because there was no medically or scientifically recognized link between the two.

A June 9, 2025, VA-contracted examiner opined that it was less likely than not that the Veteran's hypogonadism was due to toxin exposure in service because the Veteran was not diagnosed until many years after service. An addendum opinion was obtained on September 9, 2025, from the same examiner, who added that obesity can be a risk factor. She generally cited medical literature without any substantive discussion of that literature in relation to the Veteran's circumstances of service.

Here, the Board finds that no single opinion is more probative than another. The positive nexus opinions are equally as probative as the negative nexus opinions, considering all flaws within each opinion. As such, the Board resolves reasonable doubt in the Veteran's favor. In doing so, the Board finds that it is at least as likely as not that his hypogonadism was caused by toxin exposure in service. The third element of service connection is met.

Accordingly, service connection for hypogonadism is granted on direct basis.

4. Service connection for morbid obesity as secondary to chronic lymphocytic thyroiditis, hypothyroidism, and/or hypogonadism is granted.

Direct service connection for obesity does not exist because obesity is not a disease or injury. Adams v. Collins, 38 Vet. App. 273 (2025) (citing 38 U.S.C. § 1110). But the Veterans Court recently determined that obesity "may be a disability for purposes of section 1110 if it results in the functional impairment of earning capacity[.]" Id. at 284. "Deciding whether a claimant's obesity causes functional impairment requires an individualized assessment of the degree of impairment caused by a claimant's obesity." Id. (internal quotation marks and citations omitted). Consequently, obesity may become service connected secondary to another service-connected disability. Id. at 286 ("All that is required to establish entitlement to secondary service connection is evidence that a condition results in a 'disability,' defined as functional impairment of earning capacity, and a 'but-for' relationship between the disability and the service-connected disease or injury." (citing Spicer, 61 F.4th at 1364)).

First, the Board concludes that the evidence of record establishes that the Veteran is obese and that his obesity does cause functional impairment of earning capacity. Various medical records document his limitations due to his obesity. This is not called into question by any evidence of record.

Second, the Board observes several medical opinions of record have concluded that the Veteran's obesity is either due to or aggravated by his now service-connected CLT, hypothyroidism, and/or hypogonadism. See, e.g., VA Medical Opinions dated May 7, 2025; June 9, 2025; August 24, 2025. The Board finds that the examiners conducted a thorough review of the Veteran's claims file, relied on accurate facts, considered the Veteran's medical history and lay statements, and otherwise provided sufficient rationales for their respective opinions. The Board finds the opinions credible and probative.

Accordingly, service connection for morbid obesity as secondary to chronic lymphocytic thyroiditis, hypothyroidism, and/or hypogonadism is granted.

5. Service connection for dysmetabolic syndrome (also claimed as insulin resistance syndrome) as
ism, and/or hypogonadism. See, e.g., VA Medical Opinions dated May 7, 2025; June 9, 2025; August 24, 2025. The Board finds that the examiners conducted a thorough review of the Veteran's claims file, relied on accurate facts, considered the Veteran's medical history and lay statements, and otherwise provided sufficient rationales for their respective opinions. The Board finds the opinions credible and probative.

Accordingly, service connection for morbid obesity as secondary to chronic lymphocytic thyroiditis, hypothyroidism, and/or hypogonadism is granted.

5. Service connection for dysmetabolic syndrome (also claimed as insulin resistance syndrome) as secondary to morbid obesity is granted.

The Veteran has been diagnosed with dysmetabolic syndrome. See, e.g., March 10, 2010, VA Medical Examination Report. Dysmetabolic syndrome, also called metabolic syndrome, is "a combination including at least three of the following: abdominal obesity, hypertriglyceridemia, low level of high-density lipoproteins [(HDL)], hypertension, and high fasting plasma glucose level, associated with an increased risk for diabetes." Dorland's Illustrated Medical Dictionary (Dorland's) 1839 (32d ed. 2012). The first element of service connection is satisfied.

A VA-contracted medical examiner offered an opinion addressing the etiology of the Veteran's dysmetabolic syndrome on August 24, 2025. The examiner opined that "dysmetabolic syndrome, to include insulin resistance syndrome[,] is caused by genetic factors and lifestyle factors such as food intake, obesity, increased calories, and lack of exercise. A toxic exposure does not have any pathological pathway to develop a dysmetabolic syndrome to include insulin resistance syndrome." The Board finds that the examiner relied on accurate facts, considered the Veteran's medical history, claims file, and lay statements, and otherwise provided a sufficient rationale in support of her opinion. The Board finds the opinion is credible and probative.

The Board finds that the evidence establishes that the Veteran's dysmetabolic syndrome is secondary to his now service-connected morbid obesity. The Board finds a discussion of direct service connection is unnecessary because it does not provide any additional benefits beyond secondary service connection in this instance.

Accordingly, service connection for dysmetabolic syndrome (also claimed as insulin resistance syndrome) as secondary to morbid obesity is granted.

6. Service connection for edema as secondary to morbid obesity is granted.

7. Service connection for skin tags as secondary to morbid obesity is granted.

8. Service connection for acanthosis nigricans as secondary to morbid obesity is granted.

9. Service connection for striae as secondary to morbid obesity is granted.

The Board addresses the Veteran's claims for service connection for edema, skin tags, acanthosis nigricans, and striae together. Their factual and legal analyses substantially overlap, and their respective dispositions are the same.

Edema is "the presence of abnormally large amounts of fluid in the intercellular tissue spaces of the body, usually referring to subcutaneous tissues." Dorland's at 593. Acanthosis is "diffuse hyperplasia of the spinous layer of the skin," id. at 9; acanthosis nigricans is "diffuse velvety acanthosis with dark pigmentation, found in areas of body folds such as the axillae or groin," id. A stria is "a band, line, streak, or stripe." Id. at 1784.

The Veteran has been diagnosed with edema, skin tags, acanthosis nigricans, and striae at various points during the claim period. See, e.g., VA Medical Examination Reports dated January 8, 2025; May 7, 2025; VA Medical Records dated December 16, 2017; December 16, 2017; December 16, 2019; October 23; 2020. The Board finds the first element of service connection is met with respect to each disability. Although his skin conditions "wax and wane" according to some medical records, the requirement for a veteran to have a "current disability" is satisfied when he or she has a disability (1) at the time a claim for VA disability compensation is filed or (2) has a disability during the pendency of that claim. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Since the Veteran's disabilities occurred during the claim period, despite not existing at later times, the first element is met.

The Veteran has consistently asserted that these disabilities are secondary to his service-connected disabilities. The Board now agrees. According to multiple medical opinions, the Veteran's ed
with respect to each disability. Although his skin conditions "wax and wane" according to some medical records, the requirement for a veteran to have a "current disability" is satisfied when he or she has a disability (1) at the time a claim for VA disability compensation is filed or (2) has a disability during the pendency of that claim. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Since the Veteran's disabilities occurred during the claim period, despite not existing at later times, the first element is met.

The Veteran has consistently asserted that these disabilities are secondary to his service-connected disabilities. The Board now agrees. According to multiple medical opinions, the Veteran's edema, skin tags, acanthosis nigricans, and striae are caused by his morbid obesity, CLT, hypothyroidism, and/or hypogonadism, as well as associated medications with respect to those disabilities. See, e.g., VA Medical Opinions dated October 23, 2020; June 9, 2025; September 9, 2025. The Board finds that the examiners relied on accurate facts, considered the Veteran's medical history, claims file, and lay statements, and otherwise provided a sufficient rationale in support of their respective opinions. The Board finds that the opinions are credible and probative. Therefore, the Board finds that the second and third elements of secondary service connection are met.

Accordingly, service connection for edema, skin tags, acanthosis nigricans, and striae as secondary to morbid obesity, CLT, hypothyroidism, and/or hypogonadism, as well as associated medications is granted.

10. Service connection for fatigue as secondary to morbid obesity is granted.

The Veteran seeks service connection for fatigue, which he attributes to his service-connected morbid obesity. It is important to acknowledge that "chronic fatigue syndrome" is specifically defined by the VA in 38 C.F.R. § 4.88a. The Board finds no competent medical evidence of record establishes a diagnosis of chronic fatigue syndrome during the claim period consistent with the VA's regulation. See, e.g., VA Medical Examination Reports dated January 8, 2025; May 7, 2025. No medical professional has rendered such a diagnosis consistent with that regulation.

The Board observes that a May 7, 2025, medical examiner opined within an examination report that the Veteran's fatigue can be explained by his hypogonadism, morbid obesity, and obstructive sleep apnea. The Board notes that the Veteran is separately service connected for sleep apnea. The Veteran's treating VA medical professional opined that his fatigue is consistent with a symptom of his obesity and sleep apnea. September 12, 2022, VA Internal Medicine Note. The Board finds this evidence sufficiently establishes all elements of secondary service connection. The Veteran has a diagnosis of fatigue that is secondary to his now service-connected morbid obesity.

Accordingly, service connection for fatigue as secondary to morbid obesity is granted.

As a final matter, the Board wants to point out that an award of service connection does not guarantee a compensable disability rating. It may very be that some of the disabilities will not receive compensable disability ratings because of the rule against pyramiding.

"Except as otherwise provided in [the rating] schedule, the disabilities arising from a single disease entity, . . . , are to be rated separately as are all other disabling conditions, if any." 38 C.F.R. § 4.25(b). VA regulation 38 C.F.R. § 4.14 prohibits "[e]valuation of the same disability under various diagnoses," as well as "evaluation of the same manifestation under different diagnoses," events known as "pyramiding." See Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The "critical element" in determining whether separate ratings are warranted "is that none of the symptomatology of any . . . of these . . . conditions is duplicative of or overlapping with the symptomatology of the other . . . conditions." Id. at 262. In short, "[i]f the [veteran's] symptoms are distinct and separate, then the [veteran] is entitled to separate disability ratings for the various conditions." Murray v. Shinseki, 24 Vet. App. 420, 423 (2011) (internal quotation marks and citation omitted).

(Continued on the next page)

Hence, it may be that, for example, the Veteran's service-connected fatigue symptoms may be encompassed by his rating for his hypothyroidism, morbid obesity, or sleep apnea, as evidence of record indicates that
. conditions is duplicative of or overlapping with the symptomatology of the other . . . conditions." Id. at 262. In short, "[i]f the [veteran's] symptoms are distinct and separate, then the [veteran] is entitled to separate disability ratings for the various conditions." Murray v. Shinseki, 24 Vet. App. 420, 423 (2011) (internal quotation marks and citation omitted).

(Continued on the next page)

Hence, it may be that, for example, the Veteran's service-connected fatigue symptoms may be encompassed by his rating for his hypothyroidism, morbid obesity, or sleep apnea, as evidence of record indicates that those disabilities cause fatigue symptoms, such as lack of energy and drowsiness. Or it may be that the symptoms of his dysmetabolic syndrome and those of his morbid obesity overlap. In such instances, symptoms accounted for in one rating prevent the same symptoms from being accounted for in another rating. The Board is merely pointing these scenarios out to inform the Veteran and the VA Regional Office of potential issues that could arise.

M. Tenner

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board J.F. Sawka, 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.

Analyze in VA Law Explorer