Citation Nr: 1336257 Decision Date: 11/07/13 Archive Date: 11/13/13 DOCKET NO. 10-19 986 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for sleep apnea, secondary to diabetes mellitus, type II. 2. Entitlement to service connection for stasis dermatitis, secondary to diabetes mellitus, type II. 3. Entitlement to service connection for obesity, secondary to diabetes mellitus, type II. 4. Entitlement to service connection for chronic venous insufficiency of the bilateral lower extremities, secondary to diabetes mellitus, type II. REPRESENTATION Veteran represented by: Vietnam Veterans of America WITNESSES AT HEARINGS ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD S. B. Mays, Counsel INTRODUCTION The Veteran, who is the appellant in this case, had active service from July 1967 to November 1968. This case comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued by the Regional Office (RO) of the Department of Veterans Affairs (VA) in Waco, Texas. In October 2010, the Veteran testified before a Decision Review Officer. In April 2012, the Veteran and his spouse testified before the undersigned Veterans Law Judge sitting at the RO. Copies of the hearing transcripts are of record and have been reviewed. FINDING OF FACT Resolving any doubt in his favor, the Veteran's sleep apnea, stasis dermatitis, obesity, and chronic venous insufficiency of the bilateral lower extremities are etiologically related to his service-connected diabetes mellitus, type II. CONCLUSIONS OF LAW 1. The criteria are met for entitlement to service connection for sleep apnea on a secondary basis. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.310 (2013). 2. The criteria are met for entitlement to service connection for stasis dermatitis on a secondary basis. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.310 (2013). 3. The criteria are met for entitlement to service connection for obesity on a secondary basis. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.310 (2013). 4. The criteria are met for entitlement to service connection for chronic venous insufficiency of the bilateral lower extremities on a secondary basis. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.310 (2013). REASONS AND BASES FOR FINDING AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) As provided for by the VCAA, 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); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2013). In this decision, the Board grants service connection for all disabilities claimed on appeal. This award represents a complete grant of the benefits sought in this case. Thus, any deficiency in VA's compliance is deemed to be harmless error, and any further discussion of VA's responsibilities is not necessary. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110. Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Service connection may also be granted on a secondary basis for a disability if it is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). The VA and private medical evidence of record reflects current diagnoses of obstructive sleep apnea, stasis dermatitis, obesity, and chronic venous insufficiency of the bilateral lower extremities, thereby satisfying the threshold element of a service connection claim, a current disability. The Veteran's primary assertion is that the claimed disabilities are related to his diabetes mellitus, type II, a service-connected disability. The dispositive issue, therefore, is whether his sleep apnea, stasis dermatitis, obesity, and chronic venous insufficiency are either proximately caused or aggravated by his service-connected diabetes mellitus, type II. In this regard, the record contains conflicting opinions. A May 2007 VA examiner determined that the Veteran's sleep apnea, stasis dermatitis, obesity and venous insufficiency of the bilateral lower extremities are not due to his diabetes. Rather, the examiner concluded that the Veteran's sleep apnea is due to his narrowed upper airways due to his anatomy and obesity. The examiner commented that the Veteran's obesity has certainly aggravated his venous disease and his sleep apnea and has contributed to the severity of his diabetes, but reiterated that diabetes, itself, has never been found to cause venous disease, stasis dermatitis, or obstructive sleep apnea, according to standard medical references. A VA examiner in July 2008 determined that the Veteran's chronic venous insufficiency of the bilateral lower extremities is not likely secondary to his diabetes. Instead, the examiner indicated that the Veteran's stasis dermatitis is more likely than not related to his primary venous insufficiency and obesity. The examiner also felt that morbid obesity is not likely caused by diabetes. He agreed however that treatment required for diabetes is made more difficult by obesity and complications more frequently seen in obese diabetics. The examiner also concluded that the Veteran's sleep apnea is not likely caused by or secondary to his diabetes but acknowledged that obesity definitely contributes to the development of sleep apnea. A December 2011 VA examiner was asked to review the record in an effort to reconcile the conflicting opinions with regard to the etiology of the Veteran's stasis dermatitis. The examiner determined that such condition is less likely related to his diabetes. The examiner stated that according to the medical literature, established risk factors for stasis dermatitis include age, family history of venous disease, female sex, a standing occupation, obesity, and history of deep vein thrombosis. Heart failure and hypertension are aggravating factors. Diabetes is not an established risk factor in the development of stasis dermatitis. Therefore it is unlikely that the Veteran's diabetes either caused or aggravated his stasis dermatitis. The examiner felt that it is much more likely secondary to his obesity. The examiner stated that the statements from the Veteran's physicians that his diabetes causes stasis dermatitis are simply not supported by the medical literature. An addendum submitted in February 2012 provided no changes to the opinion or rationale. On the other hand, the Veteran's private physicians determined that the Veteran's claimed disabilities are etiologically related to his service- connected diabetes mellitus, type II. In an April 2007 statement, M.W., M. D., a private physician, attributed the Veteran's sleep apnea, stasis dermatitis, obesity and venous insufficiency of the bilateral lower extremities to his diabetes mellitus. In a December 2008 statement, Dr. M.W. stated further that it is a well-known fact that obesity and diabetes are closely related. He explained that it is well-known that sulfonylureas, which the Veteran is prescribed for his diabetes, causes weight gain and therefore make weight management much more problematic. Dr. M.W. indicated that it is more likely than not that the cause of his sleep apnea is also a result of the administration of sulfonylureas and his diabetic condition, which then leads to worsening obesity. Dr. M.W. emphasized that this above-noted relationship is an indisputable fact in the medical literature. The physician stated that it is also well-known that obesity impedes the flow of blood and causes venous insufficiency. Dr. M.W. also concluded that the administration of sulfonylureas for the Veteran's diabetic condition led to his worsening obesity, which is also more likely than not, the cause of his stasis dermatitis. In a July 2009 statement, M.S., M.D., a private endocrinologist, stated that the use of the medication Glyburide and the addition of NPH insulin have more likely than not contributed to the Veteran's weight gain. The physician also stated that the Veteran's morbid obesity has definitely caused problems resulting in the development of sleep apnea and chronic venous insufficiency. In a January 2011 statement, L.A.W., M.D., FACE, a private physician, noted that the Veteran's venous insufficiency and stasis dermatitis are the result of his diabetes and secondary peripheral neuropathy. Dr. L.A.W., in an April 2011 statement, further stated that the Veteran's diabetes has caused neuropathy which has caused abnormal sympathetic peripheral nerve function leading to increased edema and chronic stasis dermatitis and places him at a greater risk for ulceration. In addition to the above-noted private medical opinions, the Veteran submitted numerous internet and medical treatise articles concerning the causal relationships between diabetes, sleep apnea, and obesity. After a complete review of the record, the Board finds that the preponderance of the evidence shows that the Veteran's sleep apnea, stasis dermatitis, obesity, and chronic venous insufficiency of the bilateral lower extremities are etiologically related to his service-connected diabetes mellitus, type II. The May 2007 and July 2008 VA examiners determined that diabetes, itself, did not cause the Veteran's obesity. Nonetheless, Dr. M.W. and Dr. M.S. concluded that the prescribed medications to regulate the Veteran's diabetes have led to the development of his obesity. Further development of the claim could be undertaken so as to obtain an additional medical opinion because the VA examiners did not discuss whether the prescribed diabetic medications have led to the Veteran's obesity. However, under the benefit of the doubt rule, where there exists "an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter," the Veteran shall prevail upon the issue. Ashley v. Brown, 6 Vet. App. 52, 59 (1993); see also Massey v. Brown, 7 Vet. App. 204, 206-207 (1994). Consequently, the Board concludes that a medical nexus between the Veteran's obesity and his service-connected diabetes mellitus, type II, has been shown to be at least in equipoise, warranting resolving reasonable doubt in favor of the Veteran on that issue. Service connection for obesity is warranted on a secondary basis. The question then becomes whether the Veteran's sleep apnea, stasis dermatitis, and chronic venous insufficiency are also etiologically related to his diabetes and/or obesity, which has herein been determined to be service-connected. The general consensus among the VA examiners, Dr. M.W., Dr. M.S., and Dr. L.A.W. is that the Veteran's obesity has contributed to his sleep apnea. Those physicians also agree that the Veteran's obesity impedes the flow of blood, causing venous insufficiency, and that this venous insufficiency causes stasis dermatitis. In essence, all claimed disabilities stem from the service-connected diabetes mellitus, type II. For these reasons, and resolving reasonable doubt in favor of the Veteran, service connection is warranted for sleep apnea, obstructive sleep apnea, chronic venous insufficiency, and stasis dermatitis. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. ORDER Service connection for sleep apnea, secondary to diabetes mellitus, type II, is granted. Service connection for stasis dermatitis, secondary to diabetes mellitus, type II, is granted. Service connection for obesity, secondary to diabetes mellitus, type II, is granted. Service connection for chronic venous insufficiency of the lower extremities, secondary to diabetes mellitus, type II, is granted. ____________________________________________ JOHN Z. JONES Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs