Citation Nr: 1803073 Decision Date: 01/17/18 Archive Date: 01/29/18 DOCKET NO. 14-10 003 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUE Entitlement to service connection for vitamin D deficiency, including as secondary to a service-connected disability, to include posttraumatic stress disorder (PTSD). ATTORNEY FOR THE BOARD M. Young, Counsel INTRODUCTION The Veteran had active service from August 1986 to May 1993, with prior service (September 1985 to February 1986) in the National Guard. This appeal to the Board of Veterans' Appeals (Board) arose from an April 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. The case was previously remanded in October 2015. FINDING OF FACT There is competent evidence to support the finding that the Veteran's vitamin D deficiency has been aggravated by the service-connected PTSD and has resulted in symptoms sufficiently distinct from the symptoms for which the separately service-connected chronic fatigue syndrome has been evaluated. CONCLUSION OF LAW The criteria for service connection for vitamin D deficiency as secondary to PTSD have been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION As the Veteran's claim is being granted in full, there is no need to elaborate on VA's duties to notify and assist the Veteran prior to proceeding with the merits of this case. Service connection may be granted for disability resulting from disease or injury incurred or aggravated during active military service. 38 U.S.C. §§ 1110, 1131. Generally, service connection requires (1) the existence of a present disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection is warranted for disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). To establish secondary service connection for a disability there must be evidence of: (1) a current disability (for which secondary service connection is sought); (2) an already service-connected disability; and (3) that the current disability for which service connection is sought was either (a) caused or (b) aggravated by the service-connected disability. 38 C.F.R. § 3.310(a); see Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). Notably, the Veteran's primary contention is that the vitamin D deficiency is the result of his always being indoors due to his social isolation caused by his service-connected PTSD. Accordingly, the October 2015 Board remand directed an examiner to determine whether the Veteran had a current disability as a result of his Vitamin D deficiency. The claims file now includes three Disability Benefits Questionnaires (DBQs), from December 2015, addressing the various component theories of this matter. In the first DBQ, the examiner clearly indicated that the claims file had been reviewed. The examiner went on to state that the claimed condition was less likely than not proximately due to or the result of the Veteran's service-connected condition. The rationale for this opinion was that, in the review of the service treatment records, no deficiency of vitamin D was seen. A deficiency of vitamin D and PTSD were noted to be two different conditions. Two sources of vitamin D are sunlight and food intakes. An individual can increase in food intake or supplement to increase in vitamin D. In the second DBQ, the examiner addressed the question of aggravation of the vitamin D deficiency as due to PTSD. The examiner was not able to ascertain a baseline level of severity of the vitamin D deficiency but separately found that, regardless, it was at least as likely as not that the deficiency was aggravated by PTSD. The rationale for this opinion is that a source of vitamin D is through sunlight. If a Veteran does not have enough sunlight, that can affect the vitamin D level. The third DBQ was focused on the symptoms of the vitamin D deficiency. This deficiency was noted to require vitamin D of 50,000 units once a week. Symptoms attributable to pellagra or avitaminosis were confirmed and noted to include such symptoms as decreased appetite, weight loss, abdominal discomfort, weakness, an inability to concentrate, and irritability. Symptoms attributable to active beriberi were confirmed and noted to include such symptoms as weakness, fatigue, anorexia, dizziness, heaviness and stiffness of legs, headaches, and sleep disturbance. Diagnostic test findings showed vitamin D = 18.6 (N=30.0-100.0). In summary, while the Veteran's confirmed vitamin D deficiency has not been found to have been caused by PTSD, it has been found to have been aggravated by PTSD. The rationale for the finding of aggravation - absence of sunlight - is consistent with the Veteran's own contentions. There is no competent evidence suggesting the contrary. Accordingly, the Board accepts the finding of aggravation. The Board is aware that the service connection has separately been established for chronic fatigue syndrome, with a 100 percent evaluation assigned and based upon findings from an April 2014 VA examination report. In that report, the examiner indicated symptoms including low-grade fever, generalized muscle aches or weakness, fatigue lasting 24 hours or longer after exercise, headaches, migratory joint pains, neurological symptoms (memory loss, loss of concentration, irritable), and sleep disturbance (persistent fatigue even after overnight sleep). These symptoms are not entirely duplicative of or overlapping with the symptoms indicated in the third December 2015 DBQ, which also included decreased appetite, weight loss/anorexia, dizziness, abdominal discomfort, and heaviness and stiffness of legs. The RO has considered the Veteran's service-connected chronic fatigue syndrome under 38 C.F.R. § 4.88b, Diagnostic Code 6354, whereas the vitamin D deficiency has been considered under Diagnostic Code 6315 (pellagra). Notably, Diagnostic Code 6315 speaks to certain symptoms not contemplated by Diagnostic Code 6354, including decreased appetite, weight loss, and abdominal discomfort. These symptoms were in fact indicated in the third December 2015 DBQ. Consequently, the Board finds that a separate rating would not be prohibited on the basis of duplicative/overlapping symptoms. See Esteban v. Brown, 6 Vet. App. 259 (1994), 38 C.F.R. § 4.14. In summary, the Board finds that there is competent evidence to support the finding that the Veteran's vitamin D deficiency has been aggravated by the service-connected PTSD. There is also evidence of record indicating that the symptoms of the vitamin D deficiency are sufficiently distinct from the chronic fatigue syndrome symptoms contemplated by Diagnostic Code 6354 that it would not be a violation of 38 C.F.R. § 4.14 to assign a separate rating. Accordingly, the Board finds that the criteria for service connection for vitamin D have been met under 38 C.F.R. § 3.310, and the claim is granted. ORDER Service connection for vitamin D deficiency, including as secondary to a service-connected disability, to include PTSD, is granted. ____________________________________________ A. C. MACKENZIE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs