Citation Nr: 21066291 Decision Date: 10/29/21 Archive Date: 10/29/21 DOCKET NO. 17-26 127 DATE: October 29, 2021 ORDER Entitlement to service connection for obstructive sleep apnea (OSA), to include as secondary to posttraumatic stress disorder (PTSD), is granted. FINDING OF FACT The evidence is in relative equipoise regarding whether the Veteran's PTSD caused or aggravated his OSA through obesity as an intermediate step. CONCLUSION OF LAW The criteria for entitlement to service connection for obstructive sleep apnea (OSA), to include as secondary to posttraumatic stress disorder (PTSD), have been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the U.S. Army from September 1969 to September 1971. This appeal to the Board of Veteran's Appeals (Board) arose from a February 2017 rating decision by the Department of Veteran Affairs (VA) Regional Office (RO). In October 2019, the Board remanded the claim for further evidentiary development. Entitlement to service connection for obstructive sleep apnea (OSA), to include as secondary to posttraumatic stress disorder (PTSD). The Veteran asserts that his obstructive sleep apnea is related to his service-connected PTSD. The evidence establishes that the Veteran has a current diagnosis of obstructive sleep apnea (OSA). Service connection may be established on a secondary basis for a disability which is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § § 3.303, 3.310. In order to prevail on the theory of secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Regarding whether there is a nexus, in February 2018, the VA examiner opined that it was less likely than not that the Veteran's OSA was proximately due to or the result of his service-connected PTSD. The examiner explained that review of the current medical literature and research showed no physiologic or biomechanical causal relationship between a mental health condition (PTSD) and the physiologic condition of sleep apnea. The examiner stated that according to the generally recognized medical literature, PTSD is not accepted as a cause or a permanent aggravation (beyond its natural progression) of OSA. The examiner continued that there is ample opportunity for confusion because both disorders cause disruption of sleep and can cause traumatic awakenings, such as panic and gasping for breath. However, the two disorders are totally different and do not affect the natural history of the other. The examiner stated that obesity is the best documented risk factor for OSA. The prevalence of OSA progressively increases as the body mass index and associated markers (e.g., neck circumference, waist-to-hip ratio) increase. In the September 2019 Appellate Brief, the Veteran's representative referenced published articles from the National Sleep Foundation regarding the association between PTSD and OSA. The representative also referenced new research regarding Iraqi and Afghanistan war veterans with PTSD being at a higher risk of developing sleep apnea. In January 2020, the VA examiner provided a negative opinion regarding the association. The examiner reiterated that the medical literature did not support a causative link or potential for aggravation between a mental health condition and OSA, and that the studies showing an association did not show causality. In response to the article published by the National Sleep Foundation and referenced in the September 2019 Appellate Brief, the examiner stated that the National Sleep Foundation is a non-profit charitable organization, not a scientific organization. It is populated with opinion articles and advertisements. Again, the examiner opined that obesity was the best documented risk factor for OSA. In the August 2021 Appellate Brief, the Veteran's representative referenced and cited more medical literature discussing the association between PTSD and OSA. Of significant note, the representative included medical literature discussing the link between PTSD and obesity. One of the articles stated that the overproduction of stress hormones can lead to increase in appetite. See August 2021 Appellate Brief (citing PTSD and the Link to Obesity, https://mvets.law.gmu.edu/2017/10/02/ptsd-and-the-link-to-obesity/; Posttraumatic stress disorder predicts future weight change in the Millennium Cohort Study, https://onlinelibrary.wiley.com/doi/abs/10.1002/oby.21025; Longitudinal Associations Among Posttraumatic Stress Disorder, Disordered Eating, and Weight Gain in Military Men and Women, https://doi.org/10.1093/aje/kwv291; Posttraumatic Stress Disorder in Male Military Veterans with Comorbid Overweight and Obesity: Psychotropic, Antihypertensive, and Metabolic Medications, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1510907/). A review of the medical records note that the Veteran has gain weight and is obese. See April 2009 Primary Care Consult Note; August 2010 Physical Medicine Rehab Consult Note (February 2018 VA Medical Treatment Records [CAPRI]). The Board notes the precedential opinion of VA's General Counsel, VAOPGCPREC 1-2017, explains that obesity may not be service-connected in and of itself, but that obesity may be 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). In such cases, the question is whether the service-connected disability(ies) or claimed service-connected disability(ies) cause a veteran to become obese; (2) if so, whether the obesity was a substantial factor in causing the disability for which service connection is sought; and (3) whether the disability for which service connection is sought would not have occurred but for obesity caused by the service-connected disability(ies) or claimed service-connected disability(ies). (Continued on the next page) After a thorough consideration of the evidence of the record, the Board finds that the evidence is in relative equipoise regarding whether the Veteran's OSA is caused or aggravated by his PTSD through obesity as an intermediate step. The medical evidence shows that the Veteran is obese. It also has been determined that obesity is an important risk factor for OSA. The VA examiners have reiterated that obesity was the best documented risk for OSA, explaining that the prevalence of OSA progressively increases as body mass index increases. Although the examiners stated that PTSD did not cause obesity, the Veteran's representative referenced medical literature that opined that PTSD could lead to obesity due to the overproduction of stress hormones. Based on the medical evidence and the information proffered in medical opinions and medical records, a reasonable doubt has arisen regarding whether the Veteran's obesity was caused by PTSD and is a substantial factor in causing his OSA, and would not have occurred but for his obesity. Resolving reasonable doubt in favor of the Veteran, the Board finds that a nexus has been established between the Veteran's OSA and his PTSD, with obesity being the intermediate step. The criteria for entitlement to service connection for OSA have been met on a secondary basis, and entitlement to service connection is warranted. R. Costello Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Middleton, Associate 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.