Citation Nr: 1202863 Decision Date: 01/26/12 Archive Date: 02/07/12 DOCKET NO. 09-22 530 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for myocardial infarction, to include as secondary to a service-connected disability. 2. Entitlement to service connection for osteoporosis, to include as secondary to a service-connected disability. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD J. M. Macierowski, Counsel INTRODUCTION The Veteran served on active duty from December 1988 to September 1993. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a January 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In his June 2009 VA Form 9, the Veteran requested a hearing before the Board in conjunction with his appeal. However, in February 2010, he withdrew that request and asked that his appeal be forwarded to the Board. FINDINGS OF FACT 1. The record reflects evidence of osteoporosis in the left femoral (hip) head and lumbar spine, and a history of myocardial infarction (heart attack) in January 2005. 2. The competent medical evidence of record relates the Veteran's history of myocardial infarction to his service-connected pancreatic insufficiency with gastroparesis. 3. The competent medical evidence of record relates the Veteran's osteoporosis to his service-connected pancreatic insufficiency with gastroparesis. CONCLUSIONS OF LAW 1. The criteria for service connection for myocardial infarction have been met. 38 U.S.C.A. §§ 1110, 1131, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.303, 3.310 (2011). 2. The criteria for service connection for osteoporosis have been met. 38 U.S.C.A. §§ 1110, 1131, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.303, 3.310 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2011). Service connection for myocardial infarction and osteoporosis, both to include as secondary to a service-connected disability, is being granted in the decision below, thus granting in full the benefit sought on appeal. Accordingly, without deciding that the VCAA applies or that any error was committed with respect to either the duty to notify or the duty to assist in relation to the lumbar syndrome rating restoration claim, the Board finds that any such error was harmless and will not be further discussed. Service connection may be established for a disability resulting from diseases or injuries which are clearly present in service or for a disease diagnosed after discharge from service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Service connection may also be established on a secondary basis for a disability that is shown to be 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) caused by or (b) aggravated by a service-connected disability. Id.; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc) (additional disability resulting from aggravation of a nonservice-connected disorder by a service-connected disorder is also compensable under 38 C.F.R. § 3.310). The Veteran asserts that his January 2005 myocardial infarction resulted from dehydration caused by his service-connected pancreatic insufficiency with gastroparesis. He also asserts that osteoporosis of the femoral head and lumbar spine, documented most recently in a June 2009 X-ray, resulted from dehydration caused by his service-connected pancreatic insufficiency with gastroparesis. The Veteran's pancreatic insufficiency with gastroparesis, previously diagnosed and characterized as irritable bowel syndrome, is well-documented in the record, and his symptomatology has existed at varying degrees of severity since his service separation. VA outpatient treatment records dated from 2006, and private treatment records dated from the late 1990s, reflect ongoing treatment for these conditions through the present, both in prescription of nutritional supplements, periodic physical evaluations, and laboratory tests. Myocardial Infarction In the January 2008 VA examination report, the VA examiner noted that the Veteran's supplements included calcium carbonate, vitamin D, alendronate, and Creon 10 capsules, plus monthly subcutaneous B12 vitamin injections, and reported a very limited diet of bread, chicken, sugar cookies, and water which the examiner found was self-imposed, almost starvation, and not under the advice of medical professionals. The VA examiner noted the Veteran's sole Framingham study risk factor was his strong family history of cardiac disease, but noted that there was no evidence of hypertension, increased lipids, obesity, or diabetes. The diagnosis was myocardial infarction secondary to coronary spasm or recanalization of the coronary artery in the setting of otherwise normal clean coronaries. The VA examiner concluded that if a dietary component was to have caused the myocardial infarction, it was due to the Veteran's self-prescribed limited diet, not the severity Veteran's service-connected gastrointestinal disorder. In an April 2008 letter, Dr. Raspa, the Veteran's private physician, indicated that the Veteran's gastroparesis was severe, so much so that he was frequently weak and dehydrated, and that dehydration led to a myocardial infarction despite having normal coronary arteries. Another statement from Dr. Raspa, this time in August 2008 as part of an insurance-company attending physician statement, noted that the Veteran had a myocardial infarction which was due to gastroparesis and pancreatic insufficiency, dehydration, and malnutrition, and later stated that the . He also stated that the myocardial infarction was due to diarrhea, vomiting, dehydration. The competent medical evidence relates the Veteran's January 2005 myocardial infarction to his service-connected pancreatic insufficiency with gastroparesis. Both medical nexus opinions are based in interview and examination of the Veteran as well as a review of his medical history, which as noted above shows continued gastrointestinal symptomatology for at least the last 12 years. However, the VA examiner made several statements that the Veteran was essentially starving himself by limiting his diet so strictly. The Veteran repeatedly discussed how foods other than those he reported to the VA examiner, specifically those foods he discussed with Dr. Beadlin, would result in an increase of symptoms. From a lay perspective, it appears understandable that someone with such a long history of gastrointestinal problems would avoid foods known to cause exacerbations, especially the Veteran, who is in a position to know his own tolerances better than anyone. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Indeed, this diet of water, bread, cookies, chicken, pears, and bananas, plus multiple oral and injected vitamin supplements, was repeatedly reported to VA medical professionals, and noted to exist, without alarm, as a result of the Veteran's gastrointestinal condition. Further, the VA examiner appears to find that the Veteran's family history was the primary causative factor as the Veteran's father died of a heart attack. But, as Dr. Raspa pointed out, that the Veteran had no history of cardiac disease, and no evidence of cardiac damage after the myocardial infarction, leading to his belief in a non-cardiac cause. Indeed, the current treatment records show that the Veteran had no heart problems, hypertension, excessive lipids or diabetes, either before or after the myocardial infarction. Ultimately, the Board finds the opinion of Dr. Raspa to be more persuasive and competent medical evidence than that of the VA examiner. On that basis, service connection for myocardial infarction is warranted. Osteoporosis In the January 2008 VA examination report, the VA examiner noted that the Veteran had a Dexa scan conducted in April 2006 which showed osteoporosis in the femoral head and the central spine area. The Veteran's supplements included calcium carbonate, vitamin D, alendronate, and Creon 10 capsules, plus monthly subcutaneous B12 vitamin injections, and reported a limited diet of bread, chicken, sugar cookies, and water which the examiner found was self-imposed, severe, and not based on instructions from a medical professional. The VA examiner concluded that the Veteran's service-connected gastrointestinal condition was not severe enough to cause the level of malnutrition and loss of calcium and other minerals which resulted in the osteoporosis, but rather that the Veteran's self-restriction in dietary intake. In an April 2008 letter, Dr. Raspa, the Veteran's private physician, indicated that the Veteran's gastroparesis was severe, so much so that he was frequently weak and dehydrated, and that his inability to absorb adequate calcium resulted in osteoporosis. Dr. Raspa further noted that the multiple medications the Veteran had been prescribed for gastroparesis had all been unsuccessful. Further, in an August 2008 insurance-company attending physician statement, Dr. Raspa noted that osteoporosis was noted on Dexa scan in April 2006. He also noted the Veteran was being treated with vitamin B12 shots and calcitonin. The competent medical evidence relates the Veteran's osteoporosis to his service-connected pancreatic insufficiency with gastroparesis. Both medical nexus opinions are based in interview and examination of the Veteran as well as a review of his medical history, which as noted above shows continued gastrointestinal symptomatology for at least the last decade. While the VA examiner concluded that the Veteran's self-limitation of food types and quantities had resulted in the osteoporosis, the Veteran clearly was given calcium supplements to make up for that missing from his diet. However, as Dr. Raspa noted, it is not a lack of intake, but a lack of absorption, that resulted in the osteoporosis. Especially in light of the Veteran's recognized lactose intolerance and his desire to avoid dairy products due to the consequent increase in symptomatology, and because the evidence does not reflect that he avoided or was otherwise noncompliant with the calcium supplements, it appears that his low calcium levels resulted not from an intentional lack of calcium intake, but the Veteran's inability to absorb it internally. Ultimately, the Board finds the opinion of Dr. Raspa to be more persuasive and competent medical evidence than that of the VA examiner. This is especially the case as the VA examiner's opinion is predicated primarily on his belief that the Veteran self-sabotaged by limiting his diet so strictly. As noted above, the Veteran's own lay experiences likely guided his food choices to include only those foods his gastrointestinal system would tolerate, and attempted to supplement whatever nutrients were lacking with oral and injectable vitamins; it appears that such efforts were unsuccessful. On that basis, service connection for osteoporosis is warranted. ORDER Entitlement to service connection for residuals of myocardial infarction is granted, subject to the applicable regulations concerning the payment of monetary benefits. Entitlement to service connection for osteoporosis is granted, subject to the applicable regulations concerning the payment of monetary benefits. ______________________________________________ ROBERT C. SCHARNBERGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs