Citation Nr: 1318694 Decision Date: 06/07/13 Archive Date: 06/11/13 DOCKET NO. 05-12 607 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to service connection for obesity, to include as secondary to service-connected diabetes mellitus, type II. 2. Entitlement to service connection for sleep apnea, to include as secondary to obesity or service-connected diabetes mellitus, type II. REPRESENTATION Appellant represented by: Oklahoma Department of Veterans Affairs WITNESSES AT HEARING ON APPEAL Appellant and his spouse ATTORNEY FOR THE BOARD Elizabeth Jalley, Counsel INTRODUCTION The Veteran served on active duty from December 1967 to December 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. In May 2008, the Veteran and his spouse testified at a personal hearing before the undersigned Acting Veterans Law Judge (AVLJ). A transcript of this hearing was prepared and associated with the claims file. In July 2008 and January 2013, the Board remanded this case for additional development, and the case has been returned for further appellate review. The prior Board remands also contained a claim of entitlement to service connection for urinary frequency secondary to service-connected diabetes mellitus, type II. This claim was fully resolved in the Veteran's favor with the issuance of an April 2013 rating decision that granted service connection for neurogenic bladder; a 0 percent rating was assigned effective November 15, 2005, and a 40 percent rating was assigned effective March 15, 2013. The grant of service connection for neurogenic bladder is considered a full grant of the Veteran's claim, and this issue is therefore no longer on appeal. See generally Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997), and Barrera v. Gober, 122 F.3d 1030 (Fed. Cir. 1997). FINDINGS OF FACT 1. All notification and development necessary for the equitable disposition of the instant case have been completed. 2. The Veteran did not exhibit obesity in service, and obesity is not etiologically related to any injury or disease during the Veteran's active service. 3. The Veteran did not exhibit sleep apnea in service, and sleep apnea is not etiologically related to any injury or disease during the Veteran's active service. CONCLUSIONS OF LAW 1. Obesity was not incurred in or aggravated by active service and is not proximately due to or the result of a service-connected disability. 38 U.S.C.A. §§ 1110, 1112, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2012). 2. Sleep apnea was not incurred in or aggravated by active service and is not proximately due to or the result of a service-connected disability. 38 U.S.C.A. §§ 1110, 1112, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act and other Preliminary Matters The Veterans Claims Assistance Act of 2000 (VCAA), Public Law No. 106-475, 114 Stat. 2096 (2000), substantially amended the provisions of chapter 51 of title 38 of the United States Code, concerning the notice and assistance to be afforded to claimants in substantiating their claims. VCAA § 3(a), 114 Stat. 2096, 2096-97 (2000) (now codified as amended at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012)). In addition, VA published regulations, which were created for the purpose of implementing many of the provisions of VCAA. See 66 Fed. Reg. 45,620 (Aug. 29, 2001) (now codified, in pertinent part, at 38 C.F.R. § 3.159 (2012)). The notice requirements of the VCAA require VA to notify the veteran of any evidence that is necessary to substantiate a claim, as well as the evidence VA will attempt to obtain and which evidence the veteran is responsible for providing. Quartuccio v. Principi, 16 Vet. App. 183 (2002). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Such notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction. Id; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). The VCAA notice requirements, however, may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. See Dingess, supra; Pelegrini, supra. The Board finds that the notification requirements of VCAA have been satisfied in this case. In this regard, the Board notes August 2006, November 2008, and December 2008 evidentiary development letters in which the RO advised the appellant of the evidence needed to substantiate his service connection claims. These letters advised the Veteran of his and VA's responsibilities under VCAA, to include what evidence should be provided by him and what evidence should be provided by VA. The August 2008 letter included notice on how to establish service connection on a secondary basis. The August 2006 and November 2008 letters further advised the Veteran as to the type of evidence needed to substantiate both the disability rating and effective date elements of his claims, pursuant to the Court's holding in Dingess, supra. The Board notes that the November 2008 and December 2008 notice letters were not issued prior to the initial adjudication of the Veteran's claims in September 2006. The Veteran's claims, however, were readjudicated following the issuance of these notices, most recently in an April 2013 supplemental statement of the case. Thus, any deficiencies in the timeliness of these notice letters would not be prejudicial. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006) (Mayfield III), citing Mayfield II, 444 F.3d at 1333-34. The Board further finds that the duty to assist requirements of VCAA have also been satisfied in this case. 38 U.S.C.A. §§ 5103 and 5103A. Specifically, the Board finds that all obtainable evidence identified by the Veteran relative to the issues on appeal has been obtained and associated with the claims folder. In particular, the Board notes that the RO obtained the Veteran's service treatment records, VA medical records, and identified private medical records. Further, the Veteran has had the opportunity to present evidence and argument in support of his claims, to include at the May 2008 Board hearing. Nothing indicates he has identified the existence of any relevant evidence that has not been obtained or requested. For example, he has not identified outstanding records which show that he has the claimed disabilities as a result of his military service or as due to a service-connected disability. With respect to the aforementioned May 2008 Board hearing, the Court recently held in Bryant v. Shinseki, 23 Vet. App. 488 (2010), that 38 C.F.R. 3.103(c)(2) requires that the RO official or VLJ who conducts a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, the AVLJ accurately noted the appellate issues and asked questions to clarify the Veteran's contentions. Although the AVLJ did not specifically note the bases of the prior determinations or the elements that were lacking to substantiate the Veteran's appellate claims, the Veteran, through his testimony and other statements of record, demonstrated that he had actual knowledge of the elements necessary to substantiate his claims. Finally, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2), nor has he identified any prejudice in the conduct of either hearing. In fact, the Veteran testified in May 2008 that he thought the hearing was fair. See Transcript p. 9. As such, the Board finds that, consistent with Bryant, the duties set forth in 38 C.F.R. 3.103(c)(2) have been satisfied. The Veteran also underwent VA examinations in connection with his claims in January 2009 and March 2013. The March 2013 examinations were scheduled for the purpose of addressing deficiencies in the January 2009 opinions. The Board finds that the March 2013 VA examination reports in this case are adequate for the purpose of determining the claims decided herein. The examination reports reflect review of the claims file. During the examinations, the examiner elicited from the Veteran his history of complaints and symptoms and provided clinical findings detailing the examination results. The examiner also provided diagnoses and etiology opinions and explained the reasons and bases for these opinions. For these reasons, the Board concludes that the March 2013 VA examination reports in this case provide adequate bases for a decision on the Veteran's claims. The evidence of record provides sufficient information to adequately evaluate the claims. Therefore, no further assistance to the Veteran with the development of evidence is required, nor is there notice delay or deficiency resulting in any prejudice to the Veteran. 38 U.S.C.A. § 5103A(a)(2); 38 C.F.R. § 3.159(d); see Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). The Board notes that it has thoroughly reviewed the record in conjunction with this case. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the appellant or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (The Board must review the entire record, but does not have to discuss each piece of evidence). Rather, the Board's analysis below will focus specifically on what the evidence shows, or fails to show, on the claims. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (Noting that the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the 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. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a). Moreover, the Court has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C.A. § 5107(b). When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). II. Service Connection The Veteran has claimed entitlement to service connection for obesity and sleep apnea. He essentially contends that these disabilities were either caused or aggravated by his service-connected diabetes mellitus, type II, and also contends that the sleep apnea was caused or aggravated by his obesity. In general, applicable laws and regulations state that service connection may be granted for disability resulting from a disease or injury incurred in or aggravated by military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. That a condition or injury occurred in service alone is not enough; there must be disability resulting from that condition or injury. See Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992); Brammer v. Derwinski, 3 Vet. App. 223 (1992). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish a right to compensation for a present disability, a veteran must show: "(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 or aggravated during service" - the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for chronic disabilities if such are shown to have been manifested to a compensable degree within one year after the Veteran was separated from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. As an alternative to the nexus requirement, service connection for these chronic disabilities may be established through a showing of continuity of symptomatology since service. 38 C.F.R. § 3.303(b)(2012). The option of establishing service connection through a demonstration of continuity of symptomatology rather than through a finding of nexus is specifically limited to the chronic disabilities listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (rejecting the argument that continuity of symptomatology in § 3.303(b) has any role other than to afford an alternative route to service connection for specific chronic diseases). In the case at hand, the none of the claims being decided is listed as a chronic disability under 38 C.F.R. § 3.309(a). Therefore, the option of establishing service connection through continuity of symptomatology since service is not available in this case. A disability which is proximately due to, or results from, another disease or injury for which service connection has been granted shall be considered a part of the original condition. 38 C.F.R. § 3.310(a) (2012). The Board also notes that secondary service connection on the basis of aggravation is permitted under 38 C.F.R. § 3.310, and compensation is payable for that degree of aggravation of a non-service-connected disability caused by a service-connected disability and not due to the natural progress of the nonservice-connected disease. Allen v. Brown, 7 Vet. App. 439 (1995). On his July 2006 claim form, the Veteran asserted that his "sleep apnea is cause[d] by significant weight gain since having diabetes. I have gained a lot of neck size and this is what is causing the sleep apnea." He noted in an August 2006 statement that he "did not have sleep apnea when I was in ... the service but developed this from diabetes due to weight gain." He reported that he weighed approximately 160 pounds on separation from service and that he currently weighs 220 pounds. He reported in his October 2006 notice of disagreement that his weight has increased by 50 pounds or more since his diabetes diagnosis. The Veteran's service treatment records reflect that he was found to be five feet, six inches, tall and to weigh 134 pounds at the time of his December 1967 induction examination. He was five feet, eight inches, tall and weighed 151 pounds at the time of his September 1969 separation examination. No indications of sleep apnea appear on either examination report. The Veteran expressly denied any recent gain or loss of weight on his December 1967 and September 1969 medical history reports, and denied any symptoms that have been associated with sleep apnea. His service treatment records do not otherwise reflect any obesity or sleep apnea concerns on the part of the Veteran or his medical care providers. The earliest post-service medical evidence of record is from 2004. A July 2004 VA medical record notes that the Veteran "does have a little bit of an increased body mass index," while a September 2004 record lists a usual weight of 225 pounds and a body mass index of 32.5 percent. The earliest post-service medical evidence of sleep apnea is from 2006, and the Veteran was found to have obstructive sleep apnea syndrome in April 2006. See Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (The normal medical findings at the time of separation from service, as well as the absence of any medical records of a diagnosis or treatment for many years after service is probative evidence against the claim.). In terms of nexus, the Board notes that while the Veteran is competent, as a lay person, to describe sleep problems and weight gain, whether such symptoms are due to a chronic disability appears to be of the type that competent medical evidence is required to resolve. Further, as noted in the preceding paragraphs, the first indication of the claimed disabilities appears to be years after his separation from service. As such, competent medical evidence is required to determine whether such disabilities are etiologically related to service. Similarly, to the extent the Veteran indicates the claimed disabilities are secondary to a service-connected disability, the issue of whether one disability caused or permanently aggravated another is the type of relationship that competent medical evidence is required. Moreover, this finding is supported by the holding of Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010) in which the Federal Circuit held in the context of a claimant contending secondary service connection that the claimant's own conclusory generalized statement that his service illness caused his present medical problems was not enough to entitle him to a medical examination. If such a contention is not sufficient to warrant a medical examination, it is clear that it is not sufficient to warrant a grant of service connection. Here, nothing on file shows that the Veteran has the requisite knowledge, skill, experience, training, or education to render a medical opinion. Consequently, his contentions cannot constitute competent medical evidence. 38 C.F.R. § 3.159(a)(1). The record contains a July 2007 letter from a private physician noting that the Veteran is a five foot, seven inch, 214 pound diabetic hypertensive white male with a body mass index of 34. He noted that the Veteran has had difficulty associated with his obstructive sleep apnea and dysuria with urinary frequency. He noted that the Veteran has a "[p]ast medical history of both hypertension and diabetes in addition to his moderate obesity. I feel these are all part of his diabetes mellitus and his moderate [truncle] obesity." The record also contains a private physician's February 2008 medical evaluation opining that the Veteran's sleep apnea is, to a high degree of medical certainty, due to his service-connected diabetes. As rationale, the physician noted the following: the Veteran entered service fit for duty; he gained about 50 pounds following his diabetes diagnosis; increased weight is a known cause of sleep apnea; and the Veteran's record does not contain a more likely etiology for his sleep apnea." His opinion was based on review of the medical record, the Veteran's lay statements, current applicable publications, pivotal imaging study reports, pertinent positive and negative medical data, and the professional medical opinions of other physicians. He also spoke to the Veteran and his family on the phone. He noted that he did not physically examine the Veteran but that physical examination was not necessary. The Veteran underwent VA examinations for the claims on appeal in January 2009 and March 2013. The January 2009 VA respiratory system examination report notes that the Veteran reported a date of onset of 2005. He reported that he used to have trouble sleeping and snored due to sleep and that he was diagnosed with sleep apnea in June 2006 following a sleep study. Following interview, physical examination, and testing of the Veteran, the examiner diagnosed sleep apnea. The examiner noted that sleep apnea improved with CPAP but may be due to increased body mass index. The January 2009 VA digestive conditions examination report notes that the Veteran reported that he has been gaining weight since 2005 and that he has gained about 35 to 40 pounds since 2000. On physical examination, the Veteran's abdomen was noted to be very obese and protuberant. It was noted that the Veteran was working as chief engineer on a tow boat on the Mississippi River. The examiner diagnosed increased body mass index with the associated problem of obesity. There were no significant effects on his usual occupation and no effects on his usual daily activities. The examiner opined that the Veteran's increased body weight is due to not following the guidelines or instructions of proper diabetic diet and irregular eating habits due to his occupation away from home. He reported that he stays away from home for one month and stays home one month and does not have a regular eating pattern. The Veteran also underwent VA examination in connection with both of these claims in March 2013. The March 2013 VA sleep apnea examination report diagnoses obstructive sleep apnea with a diagnosis date in July 2006. Following physical examination of the Veteran and review of the claims file and the pertinent medical literature, the examiner opined that the Veteran's sleep apnea is less likely than not proximately due to or the result of his service connected diabetes mellitus. She concluded that the obstructive sleep apnea is less likely as not permanently aggravated or a result of service, "is at least as likely as not permanently aggravated or a result of Diabetes mellitus, Type II and was not caused by and/or worsened by an already service connected disability, Diabetes mellitus, Type II." The examiner explained that the natural progression of the Veteran's obstructive sleep apnea was not altered or worsened by service, as the obstructive sleep apnea is more likely than not related to obstructive issues in the upper airway system. She noted that this conclusion is supported by information from the VHA on-line reference Up to Date, which reflects that the etiology of the Veteran's obstructive sleep apnea is other than diabetes mellitus, type II, mainly including mechanisms such as obstruction of upper airways, sleep position , upper airway dilator muscle activity, and anatomic abnormalities that cause narrowing of the upper airways that result in airway obstruction during sleep. The examiner also cited the clinical evidence in the treatment records reflecting a 2006 diagnosis of obstructive sleep apnea to support her conclusion. Also of record is a March 2013 VA examination report that addresses the question of the etiology of the Veteran's obesity. The examination report states that the Veteran's obesity is less than likely due to or aggravated by the Veteran's diabetes mellitus, type II. She noted that obesity results from an imbalance that exists when the energy intake is more than the energy output by the body, such that the calories expended are less than the calories taken in by the body. She noted that the calories, whether of fat, protein, or carbohydrates, are eventually stored as fat, resulting in obesity. She stated that obesity is not a secondary complication of diabetes mellitus, type II. She noted, however, that diabetes mellitus, type II, is a secondary complication of obesity, as the glucose release from the tissues, insulin resistance, and lack of glycogen production are all influenced by the increased fat cells or obesity. This relationship was evident in the examiner's study of the Veteran's medical records. She noted that the primary care providers discussed the Veteran's weight, and his need to lose weight, in 2007 when the Veteran's weight increased to 223.4 pounds from 202.4 pounds in 2004. She listed the changes in the Veteran's weight from 2005 to August 2012 as recorded in his medical records and noted that his obesity occurred independently of diabetes mellitus, type II. As noted above, neither obesity nor sleep apnea was suggested by the Veteran's service treatment records. Furthermore, no medical evidence of either condition appears for approximately 35 years following the Veteran's separation from service. The Veteran, himself, has asserted that his obesity began following his diagnosis with diabetes mellitus, type II, which occurred in approximately 2005, and he has not suggested that his sleep apnea began much earlier than its 2006 diagnosis. None of the above medical opinions suggests a direct relationship between the Veteran's sleep apnea or his obesity and his military service. Therefore, the Board finds that entitlement to service connection on a direct basis for either sleep apnea or obesity must be denied. The Board will therefore evaluate whether service connection may be established for either of these disabilities on a secondary basis. In order to make this determination, the Board must analyze the probative value of the above medical opinions. The probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, his knowledge and skill in analyzing the data, and his medical conclusion. As is true with any piece of evidence, the credibility and weight to be attached to these opinions are within the province of the adjudicator. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Whether a physician provides a basis for his or her medical opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims folder and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). With respect to the secondary service connection aspect of these claims, the Board notes that all of the above opinions were offered by physicians who are highly qualified through education, training, or experience to provide competent medical evidence for the question at hand under 38 C.F.R. § 3.159(a)(1). However, the Board finds that the private medical opinions and the January 2009 VA examination reports are far less probative than the March 2013 VA examination reports for both of the issues on appeal. Because the January 2009 opinions are not supportive of the Veteran's claims, the Board need not further discuss why it finds that they are of diminished probative value, as neither of the Veteran's claims is being denied based on the January 2009 opinions. The Board will instead focus its discussion on the probative value of the private etiology opinions versus the probative value of the March 2013 VA opinions. With respect to the obesity question, the Board notes that the July 2007 private opinion does not assert that the Veteran's obesity is related to service or a service-connected disability, to include diabetes mellitus. The February 2008 private opinion's observation that the Veteran gained approximately 50 pounds following his diabetes diagnosis does not necessarily assert, and certainly does not demonstrate, a causal relationship between those two factors. Without any additional explanation, the Board finds very little, if any, probative value in the February 2008 opinion on the question of the etiology of the Veteran's obesity. On the other hand, the Board finds the March 2013 opinion as it pertains to the obesity question to be highly probative. As noted above, this opinion is based on the VA examiner's review of the claims file and interview and examination of the Veteran. She offers a diagnosis and etiology opinion that she supports through a detailed explanation of the nature of the relationship between obesity and diabetes mellitus that includes citation to relevant medical authority and a description of the pertinent medical principles and the facts of this case. For these reasons, the Board finds that the March 2013 VA obesity etiology opinion is highly probative to the obesity claim. The only remaining contrary opinion of record comes from the Veteran himself, who believes that his service-connected diabetes mellitus, type II, caused or aggravated his obesity. The Board recognizes that there are instances in which lay testimony can provide probative evidence in medical matters. A layperson may be competent to offer testimony on certain medical matters, such as describing symptoms observable to the naked eye, or even diagnosing simple conditions such as a dislocated shoulder. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (explaining in footnote 4 that a veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). However, as a layperson, the Veteran does not possess the appropriate medical expertise to competently opine that his obesity was caused or aggravated by his diabetes, especially in the absence of a supporting rationale or of any competent suggestion that such a relationship is even possible. Based on above, the Board finds that entitlement to service connection for obesity, to include as secondary to service-connected diabetes mellitus, type II, must be denied. With respect to the sleep apnea claim, the Board notes that, because service connection for obesity has been denied, service connection for sleep apnea as secondary to obesity is barred as a matter of law. 38 C.F.R. § 3.310(a); Sabonis v. Brown, 6 Vet. App. 426 (1994). The Board therefore need not further evaluate the evidence concerning this particular relationship. The Board will thus turn to the question of whether service connection may be granted for sleep apnea as secondary to service-connected diabetes mellitus. With respect to the etiology opinions of record, the Board finds that the probative value of the July 2007 private opinion is significantly diminished by the examiner's failure to explain his basis for finding a relationship between the Veteran's sleep apnea and his diabetes mellitus. The Board also finds that service connection cannot be granted based on the February 2008 opinion, as this opinion is dependent on an asserted link between the Veteran's diabetes mellitus and his obesity and, in turn, between his obesity and service. It does not assert a link between the Veteran's diabetes mellitus and his sleep apnea that is independent from the Veteran's obesity, but rather suggests an indirect link between the two based on the obesity theory of causation that has already been rejected by the Board. The Board thus grants little probative value to the February 2008 etiology opinion. On the other hand, the Board finds high probative value in the March 2013 VA examiner's sleep apnea etiology opinion. As with the March 2013 obesity opinion that has been discussed above, the sleep apnea opinion is based on the VA examiner's review of the claims file and interview and examination of the Veteran. The examiner offers a diagnosis and etiology opinion that she supports through a detailed explanation of the nature of the Veteran's sleep apnea, based on citation to relevant medical authority and a description of the pertinent medical principles and the facts of this case. For these reasons, the Board finds that the March 2013 VA sleep apnea etiology opinion is highly probative to the sleep apnea claim. In evaluating this opinion, the Board notes that the text of the March 2013 opinion itself actually states that the Veteran's sleep apnea "is at least as likely as not permanently aggravated or a result of Diabetes mellitus, Type II." The Board has considered whether this statement constitutes probative positive nexus evidence in this claim but finds that it does not. This particular clause is an obvious misstatement, as it directly contradicts the clause that immediately follows it: "and was not caused by and/or worsened by an already service connected disability, Diabetes mellitus, Type II." That is, the March 2013 sleep apnea examination report states that the Veteran's sleep apnea "is at least as likely as not permanently aggravated or a result of Diabetes mellitus, Type II and was not caused by and/or worsened by an already service connected disability, Diabetes mellitus, Type II." The Board observes that it is facially implausible for the Veteran's sleep apnea to be both "at least as likely as not permanently aggravated or a result of Diabetes mellitus, Type II" and "not caused by and/or worsened by an already service connected disability, Diabetes mellitus, Type II." The examiner's detailed explanation of the rationale for her opinion, as expressed above, makes it abundantly clear that the portion of the etiology opinion that endorses a link between the Veteran's diabetes mellitus and his sleep apnea is a misstatement of the examiner's conclusion. Thus, the only remaining contrary opinion comes from the Veteran, who asserts that there is a link between his diabetes mellitus and his sleep apnea. As with the obesity claim, the Board finds that the question of whether there is a link between the Veteran's diabetes mellitus and his sleep apnea is of sufficient complexity to require medical expertise in order for an individual to competently address it. See Jandreau, supra. Because the Veteran does not possess this expertise, the Board cannot accept his lay nexus assertions as competent medical evidence in this case. In short, the Board finds that entitlement to service connection for sleep apnea and obesity, to include as secondary to a service-connected disability, is not warranted. The Board has considered the doctrine of reasonable doubt. However, as the preponderance of the evidence is against these claims, the doctrine is not for application. Gilbert, supra; see also Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). Accordingly, entitlement to service connection for sleep apnea and obesity must be denied. ORDER Entitlement to service connection for obesity, to include as secondary to service-connected diabetes mellitus, type II, is denied. Entitlement to service connection for sleep apnea, to include as secondary to obesity or service-connected diabetes mellitus, type II, is denied. ____________________________________________ John Kitlas Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs