Citation Nr: 21074561 Decision Date: 12/15/21 Archive Date: 12/15/21 DOCKET NO. 15-28 094 DATE: December 15, 2021 ORDER Entitlement to service connection for acid reflux, to include as secondary to treatment for service-connected disabilities, is denied. FINDING OF FACT The Veteran's acid reflux was not manifested in, and is not shown to be etiologically related to, his service, and is not shown to have been caused or aggravated by medication for his service-connected disabilities. CONCLUSION OF LAW Service connection for acid reflux, to include as secondary to medication for service-connected disabilities, is not warranted. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The appellant is a Veteran who served on active duty from May 1974 to May 1977. The matter is before the Board of Veterans' Appeals (Board) on appeal from an August 2013 Department of Veterans Affairs (VA) rating decision. In December 2018, a videoconference hearing was held before the undersigned; a transcript is in the record. In November 2019, November 2020, and April 2021, the matter was remanded to the agency of original jurisdiction (AOJ) for development. Entitlement to service connection for acid reflux, to include as secondary to treatment for service-connected disabilities, is denied. Service connection may be granted for disability due to disease or injury incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may be granted for a disease initially diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To substantiate a claim of service connection, there must be evidence of: (1) a current claimed disability; (2) incurrence or aggravation of a disease or injury in service; and (3) a nexus between the disease or injury in service and the current disability. See Shedden v. Principi, 281 F.3d 1163, 1166-67 (Fed. Cir. 2004). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and an evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). Secondary service connection may be established for a disability that is proximately due to, or the result of, or aggravated by a service-connected disease or injury. Establishing secondary service connection requires evidence of: (1) a current disability (for which secondary service connection is sought); (2) an already service-connected disability; and (3) that the claimed disability was either caused or aggravated by the already service-connected disability. 38 C.F.R. § 3.310(a); see also Allen v. Brown, 7 Vet. App. 439 (1995). Obesity, in and of itself, is not a disability for VA compensation purposes. Marcelino v. Shulkin, 29 Vet. App. 155 (2018); Walsh v. Wilkie, 32 Vet. App. 300 (2020). VA's Office of General Counsel has issued VAOPGPREC 1-2017, which discusses service connection based on obesity. Particularly relevant to this claim is that "obesity may be an 'intermediate step' between a service-connected disability and a current disability (acid reflux) that may be service connected on a secondary basis." Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a layperson. 38 C.F.R. § 3.159 (a)(2). Lay evidence may be competent evidence to establish incurrence. See Davidson v. Shinseki, 581 F.3d 1313 (Fed, Cir. 2009). However, competent medical evidence is necessary where the determinative question is one requiring medical knowledge. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. A claim will be denied only if the preponderance of the evidence is against the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). On April 1974 service entrance examination, the Veteran's abdomen and viscera were normal on clinical evaluation. In a contemporaneous report of medical history, he denied stomach, liver, or intestinal trouble. A September 1976 STR notes a diagnosis of "transient gastrointestinal (GI) upset" (upset stomach/diarrhea) and treatment with Kaopectate. On May 1977 service separation examination, his abdomen and viscera were normal on clinical evaluation. A June 2015 VA treatment record notes a diagnosis of gastroesophageal reflux disease (GERD). At the December 2018 Board hearing, the Veteran was advised to submit a medical opinion relating acid reflux to service or to a service-connected disability (i.e., that the GRERD as caused or aggravated by medication for his service-connected disabilities, as he has alleged). In June 2019 written argument, the Veteran's representative raised a new theory of entitlement (that his acid reflux is due to obesity as an intermediate step between his service-connected disabilities and his GERD). On January 2020 esophageal conditions disability benefits questionnaire (DBQ), the examiner a diagnosis of GERD (initially in June 2015) and opined that it is less likely than not that it was caused or aggravated by his service-connected disabilities (to include medication used to treat them). While noting evidence of a September 1976 complaint in service of "upset stomach/diarrhea" and a diagnosis then of "transient GI upset" and treatment with Kaopectate, she found no evidence of complaints, treatment or specific diagnosis for GERD during service, observing GERD was [first] diagnosed in 2015 (over three decades after service). She stated that she was "unable to yield that the Veteran's current medications (for service-connected disabilities) aggravated his claim of GERD [and] an aggravation of GERD by a service-connected condition has not been established." On December 2020 esophageal conditions DBQ, the Veteran reported his acid reflux symptoms began 20 years prior [i.e., in about 2000], but learned to control the condition through diet. As he is largely asymptomatic (takes no medication and visualization of an area of the anatomy often inflamed by GERD was normal 5 years ago), the consulting provider stated the GERD appeared to have resolved at this juncture. (He explained that GERD is a medical condition in which stomach contents, specifically stomach acid refluxes backwards through the lower esophageal sphincter (LES) into the esophagus and can cause symptoms of heartburn and pain. This process of reflux is continual and normal to a degree, but when the degree of reflux increases, it causes symptoms (such as pain) and is recognized as a medical condition. Symptoms can occur acutely and resolve over time with or without antacid medication. According to a medical article addressing "Pathophysiology of reflux esophagitis," 3 dominant pathophysiological mechanisms causing GERD are: 1) transient LES relaxation most commonly caused by gastric distention, 2) a hypotensive (low pressure) LES most commonly aggravated by certain foods and alcohol and 3) anatomic disruption of the LES, often associated with a hiatal hernia. Obesity is also listed as a risk factor for GERD (according to "Obesity increases esophageal acid exposure," El-Serag HB, et al.) Risk factors are not necessarily decidedly causative of a condition, but simply mean that the presence of a risk factor may increase the incidence of the affected condition. However, GERD may occur without obesity, as is often the case clinically, and not all obese people have GERD. The provider stated that gastric distension can be caused by over-eating or eating before sleep (causing gastric contents to push against the LES with greater pressure) and that limiting food intake prior to sleep/eliminating food triggers are key steps in the treatment of acid reflux or GERD. The provider noted that the Veteran was obese in 2014 (with a body mass index (BMI) of 42.5) and had no GERD symptoms then (He stopped taking GERD medication in 2013). He also noted that sertraline (the medication prescribed for his service-connected depression) is not a risk factor for GERD and does not cause relaxation of the LES. He opined that despite the Veteran's obesity, his GERD symptoms were more likely than not due to ingestion of food triggers, causing transient relaxation of the LES (because the Veteran did not require medication for treatment of GERD symptoms for many years and reported his GERD ceased when he stopped eating certain foods). (His symptoms of heartburn are caused by the acid reflux or GERD.) Since he can control his GERD symptoms by limiting his food options, the provider stated that there is not likely a permanent disruption of the LES, such as is found in a hiatal hernia or potentially in some cases of obesity. The provider explained that if obesity was causative or aggravating GERD, the Veteran's persistent GERD symptoms would not cease when his BMI was so high. The provider opined that GERD is less likely than not related to service (and is not due to obesity as an intermediate step between the condition and medication for his service-connected depression). An April 2021 Board remand pointed out that the December 2020 VA opinion was inadequate for rating purposes because it was not substantially complaint with November 2020 remand instructions, as the December 2020 consulting provider did not discuss whether the acid reflux was caused or aggravated by his service-connected disabilities (specifically those for which service connection was granted, effective from 2011), to include as due to medication used for treatment of those service-connected disabilities (as the November 2020 remand directed). On May 2021 DBQ (based on re-review of the record), the December 2020 provider reiterated his previous opinion and addressed whether the acid reflux was caused or aggravated by his service-connected disabilities, to include as due to medications used for treatment of the service-connected disabilities. He cited to clinical data, emphasizing that GERD symptoms ceased when the Veteran stopped eating certain foods (and when he took non-steroidal anti-inflammatory drugs (NSAIDs) for a nonservice-connected condition and was not taking antacid), he did not have gastritis or GERD symptoms, indicating that certain foods are the only triggers for his acid reflux and GERD. The consulting provider noted that none of the service-connected disabilities (major depressive disorder); sleep apnea; pseudofolliculitis barbae; left shoulder arthritis; and left and right knee disabilities and knee scar) have any direct role in causing GERD or relaxation of the LES. (While there is some medical information of a con-incident association between GERD and sleep apnea, a review of the medical literature did not clearly elucidate a causative mechanism. The Veteran reported onset of GERD in 2000 (long before sleep apnea was diagnosed in 2017) and improvement/cessation of GERD symptoms prior to 2017 due to changes in diet. Since the GERD symptoms improved with diet change prior to the diagnosis of sleep apnea and has not recurred or worsened since, the service-connected sleep apnea did not cause or aggravate GERD. The provider noted that sertraline (for treatment of depression) is the only medication prescribed for the Veteran's service-connected disabilities. (According to MedlinePlus and WebMD, upset stomach or heartburn is an uncommon symptom with sertraline (affecting only 8% of users, making it an unlikely cause of GERD or an aggravating factor beyond the natural history of the condition)). The provider pointed out that the Veteran's GERD symptoms began in 2000 and improved with treatment (antacids) initially and subsequently resolved with elimination of food triggers. GERD symptoms are only active with ingestion of a food trigger inadvertently. The Veteran did not experience GI symptoms, heartburn, or GERD while taking sertraline (which he started taking daily in 2014 after the GERD symptoms improved), so the provider stated that the medication did not cause or aggravate GERD. The provider opined that GERD was not caused or aggravated by his service-connected disabilities (to include medications taken for treatment of them). He identified ingestion of food triggers as a nonservice-related etiological factor for his acid reflux. At the outset, the Board finds that the December 2020 and May 2021 advisory medical opinions (cumulatively) are substantially compliant with the Board's remand instructions and that the evidence is now adequate for rating purposes. It is not in dispute that the Veteran has acid reflux/GERD symptoms; he was assigned such diagnosis on June 2015 VA examination. What remains necessary to substantiate this claim is competent evidence that his acid reflux/GERD is etiologically related to his service or is secondary to his service-connected disabilities, to include medication for treatment of them, as alternatively alleged His STRs are silent for complaints, findings, treatment, or diagnosis of acid reflux. While a September 1976 STR notes a complaint in service of "upset stomach/diarrhea" nad a diagnosis of "transient GI upset," it was an isolated incident and symptoms were treated with Kaopectate, and resolved. Acid reflux was not noted on his May 1977 service separation examination. There is a 38-year postservice interval before GERD was diagnosed. Accordingly, service connection for acid reflux on the basis that such disability became manifest in service and has persisted since (even by the Veteran's own reports) is not warranted. It is also not otherwise shown by the record that the Veteran's acid reflux is related directly to his service, as indicated by the January 2020 VA examiner who so opined, in essence. (Although there was a September 1976 inservice complaint of "upset stomach/diarrhea" with a diagnosis of "transient GI upset," she noted that there was no evidence of complaints, treatment or specific diagnosis for GERD during service. GERD was diagnosed with in 2015 (over three decades postservice). There is no competent evidence in the record to the contrary. The Veteran raises two theories of entitlement for his claim of service connection for his acid reflux: 1) that obesity due to service-connected disabilities is an intermediate step between his acid reflux and his service-connected disabilities and 2) that the acid reflux is secondary (to service-connected disabilities, and specifically medications used for their treatment). Whether a disability (such as service-connected sleep apnea) caused or aggravated another disability (here, acid reflux) and whether acid reflux is due to obesity which is due to a service connected disability are medical questions beyond the scope of common knowledge/lay observation. They require medical expertise. See Jandreau v. Nicholson, 492 F. 3d, 1372, 1377. The only competent and fully adequate medical opinion evidence in this matter that addresses both these theories of entitlement is found from cumulative consideration of the December 2020 and May 2021 advisory medical opinions (by the same provider), finding that the acid reflux is not due to obesity and was not caused or aggravated by his service-connected disabilities (to include medication used to treat). The opinions reflect familiarity with all evidence of record, and the provider included a clear explanation of rationale and cited to supporting clinical data and medical principles (with citation to supporting medical text). The provider is a medical professional and explained that while obesity is a risk factor for GERD, obesity did not cause the Veteran's GERD symptoms; he did not experience GERD symptoms while he was obese (with a BMI of 42.5). He noted that sertraline the only medication prescribed for a service-connected disability is not a prominent risk factor for acid reflux. He acknowledged that while there is some medical information of an association between GERD and sleep apnea, sleep apnea as a causation/aggravation of his GERD symptoms was ruled out. (As the Veteran reported onset of GERD in 2000, many years before he was found to have sleep apnea, in 2017, and GERD symptoms improved prior to 2017 by changes in diet. He also pointed out that the Veteran did not experience GI symptoms, heartburn, or GERD while taking sertraline (which he started taking in 2014 after the GERD symptoms improved). He thoroughly discussed the science behind food triggers and identified it as the nonservice-related etiological factor for the Veteran's acid reflux. (The Veteran consistently reported that his acid reflux ceased when he stopped eating certain foods.) Because the Veteran has not presented adequate competent probative medical opinion evidence to the contrary (as to either alleged theory of entitlement), the Board finds the December 2020 and May 2021 advisory medical opinions (cumulatively) to be persuasive. Considering the foregoing, the Board finds that the preponderance of the evidence is against the Veteran's claim of service connection for his acid reflux. Accordingly, the appeal in this matter must be denied. GEORGE R. SENYK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Chu, 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.