HYPERTENSION

Summary

The veteran, who served in the U.S. Navy from February 1990 to May 1998, including reserve service, appeals the denial of service connection for hypertension. The veteran sought review of a December 2024 rating decision that denied this claim. The Board found that while the veteran had a current diagnosis of hypertension, the evidence did not establish an in-service event or injury directly related to it. The initial VA examination in November 2024 opined that the hypertension was less likely than not caused by TERA or other toxic exposures, but more likely than not due to obesity. The Board noted that obesity itself is not a compensable disability but can serve as an intermediate step for secondary service connection. The Board found the evidence, including a December 2021 VA opinion and January 1991 service records, suggested the Veteran's obesity may have been caused by Military Sexual Trauma (MST) and service-connected PTSD. Although the November 2024 examiner did not explicitly link the obesity to service or MST/PTSD, the Board found the evidence, when viewed in its entirety and applying the benefit of the doubt, sufficient to establish that the hypertension would not have occurred but for the obesity caused by MST and PTSD. Therefore, service connection for hypertension, secondary to PTSD with obesity as an intermediate step, was granted.

Rationale

Current diagnosis of hypertension established.; Obesity identified as intermediate step between MST/PTSD and hypertension.; Evidence supports obesity caused by MST and PTSD.

Full Decision Text

Citation Nr: A26040429
Decision Date: 04/29/26	Archive Date: 04/29/26

DOCKET NO. 250919-590212
DATE: April 29, 2026

ORDER

Entitlement to service connection for hypertension, secondary to service-connected posttraumatic stress disorder (PTSD), with obesity as an intermediate step, is granted.

FINDING OF FACT

The Veteran's hypertension was caused by her obesity which had its onset during service and her service connected PTSD.

CONCLUSION OF LAW

The criteria are met for entitlement to service connection for hypertension, secondary to service-connected PTSD, with obesity as an intermediate step.  38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty in the United States Navy from February 1990 to December 1993.  The Veteran also had additional service in the United States Navy Reserve from December 1993 to May 1998.

In a June 2025 VA Form 20-0996, Decision Review Request: Higher-Level Review, the Veteran indicated that she was seeking review of a December 2024 rating decision, as to the issue of entitlement to service connection for hypertension.  In a September 2025 rating decision, a Department of Veterans Affairs (VA) Regional Office (RO) denied entitlement to service connection for hypertension.

The Veteran timely appealed the rating decision to the Board of Veterans' Appeals (Board) in a September 2025 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), and requested direct review of the evidence previously considered by the RO by a Veterans Law Judge.  38 C.F.R. §§ 20.202(b)(1); 20.301.

In her Notice of Disagreement, the Veteran indicated that she was seeking review of the December 2024 rating decision, as to the issue of entitlement to service connection for hypertension.

As an appeal in which the appellant requested, on the Notice of Disagreement, direct review by the Board without submission of additional evidence and without a Board hearing, the Board's decision is based on a review of the evidence of record at the time of the decision on the issue on appeal.  38 C.F.R. § 20.301.

Service Connection

Service connection is warranted where the facts, shown by evidence, establish that a current disability resulted from an injury or disease incurred in active military service.  38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a).  Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury.  Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018).  Service connection is warranted "for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service."  38 C.F.R. § 3.303(d).

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.  38 C.F.R. § 3.310(a)-(b).  Secondary causation exists when, but for the service-connected disability, the non-service-connected disability was caused by a service-connected disability either in a direct, etiological way or via multiple steps in a causal chain.  Spicer v. McDonough, 61 F.4th 1360, 1365 (Fed. Cir. 2023) (citations omitted).  Secondary aggravation exists when the non-service-connected disability not caused by a service-connected disability would be less severe were it not for a service-connected disability.  Id. at 1364.  For example, secondary aggravation may be established where the natural progression of the non-service-connected disability could have been arrested or improved but for the service-connected disability.  Id.

Although obesity is not a disability for VA compensation purposes, obesity may act as an "intermediate step" between a service-connected disability and a current disability that may be service-connected on a secondary basis under 38 C.F.R. § 3.310(a).  VAOPGCPREC 1-2017; Marcelino v. Shulkin, 29 Vet. App. 155 (2018) (affirm
 by a service-connected disability would be less severe were it not for a service-connected disability.  Id. at 1364.  For example, secondary aggravation may be established where the natural progression of the non-service-connected disability could have been arrested or improved but for the service-connected disability.  Id.

Although obesity is not a disability for VA compensation purposes, obesity may act as an "intermediate step" between a service-connected disability and a current disability that may be service-connected on a secondary basis under 38 C.F.R. § 3.310(a).  VAOPGCPREC 1-2017; Marcelino v. Shulkin, 29 Vet. App. 155 (2018) (affirming the Board's decision that service connection is not warranted for obesity as it is not in and of itself a disability for VA purposes, but not addressing VAOPGCPREC 1-2017).  In order to establish service connection on this basis, three criteria must be met: (1) the service-connected disability must have caused the veteran to become obese; (2) the obesity as a result of the service-connected disability must be a substantial factor in causing the disability for which service connection is sought; and (3) the disability for which service connection is sought would not have occurred but for obesity caused by the service-connected disability.

Lay statements may be competent to support a claim for service connection by establishing the occurrence of lay-observable events, the presence of disability or symptoms of disability, and the presence of continuous symptoms after separation from service.  See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) ("38 U.S.C. § 1154(a) requires that the VA give 'due consideration' to 'all pertinent medical and lay evidence' in evaluating a claim to disability or death benefits"); Barr v. Nicholson, 21 Vet. App. 303, 310 (2007) ("finder of fact must consider the credibility and weight of the [veteran's] statements, and any other competent lay or medical evidence submitted, to determine whether [the veteran] is entitled to service connection based on continuity of symptomatology"); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) ("Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional."); Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (2006) (lay evidence concerning the onset of symptoms and continuity of symptoms after service, if credible, is ultimately competent, regardless of the lack of contemporaneous medical evidence).

Due consideration "shall be given to the places, types, and circumstances of such veteran's service as shown by such veteran's service record, the official history of each organization in which such veteran served, such veteran's medical records, and all pertinent medical and lay evidence..."  38 U.S.C. § 1154(a).

All favorable findings towards claimants are binding upon all subsequent adjudicators, unless clear and unmistakable evidence is shown to the contrary to rebut such favorable findings.  38 U.S.C. §§ 5104(b)(4), 5104A; 38 C.F.R. § 20.801(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 give the benefit of the doubt to the claimant."  38 U.S.C. § 5107(b).  Thus, the benefit-of-the-doubt doctrine applies "if the competing evidence is in 'approximate balance,'" and when "the evidence is not in equipoise but nevertheless is in approximate balance."  Lynch v. McDonough, 21 F.4th 776, 781 (Fed. Cir. 2021) (en banc).  A "low standard of proof" must be employed to "resolve a scientific or medical question in the claimant's favor so long as the evidence for and against that question is in 'approximate balance.'"  Wise v. Shinseki, 26 Vet. App. 517, 531 (2014).  "Congress has not mandated that a medical principle have reached the level of scientific consensus to support a claim for VA benefits."  Id.  Thus, an absolutely "accurate determination of etiology is not a condition precedent to granting service connection; nor is definite etiology or obvious etiology."  See Alemany v. Brown, 9 Vet. App. 
 Cir. 2021) (en banc).  A "low standard of proof" must be employed to "resolve a scientific or medical question in the claimant's favor so long as the evidence for and against that question is in 'approximate balance.'"  Wise v. Shinseki, 26 Vet. App. 517, 531 (2014).  "Congress has not mandated that a medical principle have reached the level of scientific consensus to support a claim for VA benefits."  Id.  Thus, an absolutely "accurate determination of etiology is not a condition precedent to granting service connection; nor is definite etiology or obvious etiology."  See Alemany v. Brown, 9 Vet. App. 518, 519 (1996) (citing 38 U.S.C. § 5107(b)).  However, "the benefit-of-the-doubt rule does not apply" when "the evidence is not in 'approximate balance' or 'nearly equal,'" and "the evidence persuasively favors one side or the other."  Lynch at 781-82.

Entitlement to service connection for hypertension

Factual Considerations

January 1991 service treatment records indicate that the Veteran was identified as being overfat.

An April 1993 service treatment record reflects a diagnosis of obesity.  The Veteran weighed 197 pounds and previously gave birth to her child 4 months before.  Her blood pressure was 124/76.

A February 2014 VA treatment record reflects a diagnosis of obesity.  The Veteran weighed 215 pounds and had an estimated BMI of 39.5.

A March 2016 VA treatment record reflects a diagnosis of anxiety disorder.  The clinician noted that the Veteran's blood pressure was unusually high during the visit 143/73 and she did not have a history of hypertension.

A November 2019 VA treatment record reflects a diagnosis of blood pressure elevation with a blood pressure reading of 136/91.  The clinician noted that the Veteran was worried about her blood pressure.  She had been recently seen in an emergency room (ER) for chest pain.  She was worried that symptoms of bouts of headaches, sweating, lightheadedness, weakness, and nausea may have been indicators of blood pressure problems.  She had some borderline high elevations in the past but had never been diagnosed with hypertension.

A December 2021 VA medical opinion indicated that a January 1991 service treatment record documented that the Veteran failed to meet weight standards due to being overweight.  The examiner opined that the Veteran's in-service markers of having gastrointestinal (GI) distress and weight issues served as military sexual trauma (MST).

In a July 2022 rating decision, the RO granted entitlement to service connection for PTSD with a 30 percent rating effective June 30, 2021.

A February 2024 VA Toxic Risk Exposure Activities (TERA) memorandum indicated that the Veteran participated in a TERA during service.  Specifically, the memorandum indicates that the Veteran's military occupational specialty (MOS) during service was Navy Machinery Repairman of Nuclear Machinery in Submarines.  She qualified for a presumption of exposure to radiation during military service in June 1998.

In a July 2024 VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits, the Veteran indicated that she was seeking entitlement to service connection for high blood pressure.  She indicated that she had been exposed to firefighting chemicals during service in 1990.

The Veteran was afforded a VA examination in November 2024, which reflects a diagnosis of hypertension.  The examiner opined that the Veteran's hypertension was less likely than not caused by the indicated TERA after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all TERA of the Veteran.  The examiner noted that there was no evidence to show that her hypertension was due to any toxin or chemical exposure.  The examiner opined that her hypertension was more likely than not due to her obesity.  She had a BMI over 30 and her weight was over 200 pounds.  The examiner noted that being overweight or obese could contribute to the formation of hypertension (high blood pressure).  Hypertension is a condition where the force of blood against the walls of the arteries is consistently too high.  Adipose tissue (body fat) requires a greater blood supply to provide oxygen and nutrients.  As a result, the heart has to work harder to pump blood to the additional blood vessels in the fat tissue.  This increased workload can lead to higher blood pressure.  Adipose tissue can release various chemicals and hormones, including those that activate the renin-angiotensin system.  This system regulates blood pressure by constricting blood vessels and increasing fluid retention.  Overactivation of this system due to
  The examiner noted that being overweight or obese could contribute to the formation of hypertension (high blood pressure).  Hypertension is a condition where the force of blood against the walls of the arteries is consistently too high.  Adipose tissue (body fat) requires a greater blood supply to provide oxygen and nutrients.  As a result, the heart has to work harder to pump blood to the additional blood vessels in the fat tissue.  This increased workload can lead to higher blood pressure.  Adipose tissue can release various chemicals and hormones, including those that activate the renin-angiotensin system.  This system regulates blood pressure by constricting blood vessels and increasing fluid retention.  Overactivation of this system due to obesity can lead to hypertension.  Obesity and in particular central obesity have been consistently associated with hypertension and increased cardiovascular risk.  Based on population studies, risk estimates indicate that at least two-thirds of the prevalence of hypertension can be directly attributed to obesity.

In a December 2024 rating decision, the RO denied entitlement to service connection for hypertension.  The RO favorably found that the Veteran had been diagnosed with hypertension and participation in TERA had been conceded.  However, the RO the evidence did not show an event, disease or injury in service.  Specifically, the Veteran's service treatment records did not contain complaints, treatment, or diagnosis for this condition.  There was no link between her hypertension military service.  Further, although the evidence of record showed participation in a TERA, the VA examiner's medical opinion did not show an association between her hypertension and her in- service TERA.

In the June 2025 request for Higher-Level Review, the Veteran indicated that she had new information for her VA physicians.  She indicated that her hypertension was due to PTSD and sex abuse in the military and exposure to chemicals in the military.

In the September 2025 Higher-Level Review rating decision, the RO denied entitlement to service connection for hypertension, to include a secondary to PTSD.  Accordingly, service-connection for hypertension (claimed as high blood pressure) on a direct basis was denied, as it was not incurred in and/or caused by active duty service.  In addition, although the evidence of record showed participation in a TERA, the medical opinion provided by the VA examiner did not show an association between her hypertension and her in-service TERA.  Finally, the RO favorably found that the Veteran was service connected for PTSD.  However, there was no lay or medical evidence indicating an association between the Veteran's service-connected PTSD and her hypertension.  As such, the threshold for ordering a medical opinion regarding the theory of secondary service-connection had not been met.

In her September 2025 Notice of Disagreement, the Veteran indicated that she had new information from her VA physicians.  She asserted that her most recent treatment records from VA had not been obtained by VA.  She indicated that the treatment records indicated that her hypertension had worsened and had caused a brain injury.

Analysis

For reasons set forth below, the likelihood is approximately evenly balanced, if not higher, that the Veteran's obesity had its onset during service and was caused by her MST and service-connected PTSD.  In addition, the likelihood is approximately evenly balanced, if not higher, that the Veteran's obesity was a substantial factor in causing her hypertension.  Lynch, supra.

A current diagnosis of hypertension has been established.

Probative weight is given to the November 2024 VA examiner's opinion, that the Veteran's hypertension was more likely than not due to her obesity.  See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning).

As noted, the December 2021 VA medical opinion indicates that January 1991 service treatment record documented that the Veteran failed to meet weight standards due to being overweight.  The December 2021 VA examiner opinioned the Veteran's in-service markers of having GI distress and weight issues served as MST.  As such, the December 2021 VA opinion coupled with the other evidence of record supports a finding that the Veteran's obesity was caused by her MST and service-connected PTSD.  See Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) (medical reports must be read as a whole and in the context of the evidence of record); Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (the fact that the rationale provided by an examiner "did not explicitly lay out the examiner's journey from the facts to a conclusion," does not render the examination inadequate).

The November 2024 VA examiner's opinion, coupled with the other evidence of record, including the January 1991 service treatment record and the
 supports a finding that the Veteran's obesity was caused by her MST and service-connected PTSD.  See Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) (medical reports must be read as a whole and in the context of the evidence of record); Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (the fact that the rationale provided by an examiner "did not explicitly lay out the examiner's journey from the facts to a conclusion," does not render the examination inadequate).

The November 2024 VA examiner's opinion, coupled with the other evidence of record, including the January 1991 service treatment record and the December 2021 VA examiner's opinion can be interpreted as supporting a finding that the Veteran's hypertension would not have occurred but for the obesity caused by her MST and service-connected PTSD.

Although the November 2024 VA examiner did not consider and discuss whether the Veteran's obesity had its onset during service or was otherwise related to an in-service injury or event, remand is not necessary, because the evidence of record is sufficient to support a finding that the Veteran's hypertension would not have occurred but for the obesity caused by her MST and service-connected PTSD.  See Marciniak v. Brown, 10 Vet. App. 198, 201 (1997) (remand unnecessary "[i]n the absence of demonstrated prejudice"); see also 38 C.F.R. § 20.904(a) (requiring the Board to remand a claim only if such "action is essential for a proper appellate decision"); Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006) (interpreting 38 C.F.R. § 20.904(a) to contemplate prejudicial or harmless error analysis by the Board).

 

 

RAY BARTO SLABBEKORN, JR.

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	G. Johnson, 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.