Citation Nr: 21042124 Decision Date: 07/12/21 Archive Date: 07/12/21 DOCKET NO. 16-53 414A DATE: July 12, 2021 ORDER Entitlement to service connection for sleep apnea, to include as secondary to a psychiatric disability or a right great toe disability, is denied. Entitlement to service connection for hypertension, to include as secondary to a psychiatric disability or a right great toe disability, is denied. Entitlement to service connection for type II diabetes mellitus, to include as secondary to a psychiatric disability or a right great toe disability, is denied. FINDINGS OF FACT 1. Sleep apnea is not shown to be causally related to an in-service injury or disease or to have been caused or aggravated by another service-connected disability. 2. Hypertension manifested more than one year after separation and is not shown to be causally related to an in-service injury or disease or to have been caused or aggravated by another service-connected disability. 3. Type II diabetes mellitus manifested more than one year after separation and is not shown to be causally related to an in-service injury or disease or to have been caused or aggravated by another service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for sleep apnea have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310, 3.317. 2. The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310, 3.317. 3. The criteria for service connection for type II diabetes mellitus have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310, 3.317. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1980 to October 1988 and from February 1991 to October 1991. This matter is before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in July 2013 by a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded the issues on appeal for additional development in October 2020 and April 2021. The requested opinions were obtained in November 2020 and May 2021. As such, the directives have been substantially complied with and the matter is again properly before the Board. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268, 271 (1998). The Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ) in January 2020. A transcript of the hearing is of record. The Veteran and his representative were informed in June 2021 that his appeal had been returned to the Board, and that they had a period of 90-days to submit additional evidence or argument in support of the appeal. Neither the Veteran nor his attorney submitted anything further. As both the Veteran and his attorney have been afforded the opportunity to submit additional evidence or argument, the Board will proceed to address the appeal on the merits. 38 C.F.R. § 20.5. The Board notes that additional evidence has been associated with the file since the last adjudication of the appeal by the agency of original jurisdiction (AOJ). However, the VA examination reports associated with the file concern a claim for service connection for gastroesophageal reflux disease (GERD), and therefore does not relate to or bear on the issues currently on appeal. 38 C.F.R. § 20.1305(c). Therefore, a waiver of AOJ review of the evidence is not required. Id. Service Connection Generally, to establish service connection 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." Davidson v. Shinseki, 581 F.3d 1313, 131516 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be established for a current disability on the basis of a presumption that certain chronic diseases manifesting themselves to a certain degree within a certain time after service must have had their onset in service. 38 U.S.C. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309(a). Generally, the disease must have manifested to a degree of 10 percent or more within one year of service. 38 C.F.R. § 3.307(a)(3). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "Chronic." 38 C.F.R. § 3.303(b). When the disease identity is established, there is no requirement of evidentiary showing of continuity. Id. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. Id. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. Id. Continuity of symptomatology is only applicable to those diseases recognized as chronic for VA purposes. Walker v. Shinseki, 708 F.3d 1331 (2013); 38 C.F.R. §§ 3.303(b), 3.309. Service connection may be granted on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. The evidence must show: (1) that a current disability exists; and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated (worsened) by a service-connected disability. Id. Obesity per se is not a disease or injury and therefore may not be service connected on a direct basis. VA Gen. Coun. Prec. 1-2017 (Jan. 6, 2017); see 38 U.S.C. §§ 1110, 1131. Similarly, obesity is not a "disability" for the purposes of secondary service connection, nor may obesity be considered and in-service injury, disease or event for the purposes of establishing direct service connection for other disabilities. VA Gen. Coun. Prec. 1-2017. However, secondary service connection is warranted when a disability is proximately due to or the result of a service-connected disease or injury. Id. For the purposes of secondary service connection, obesity may act as an "intermediate step" between a service-connected disability and another separate disability. Id. When addressing the issue of proximate cause, three issues must be resolved: (1) whether the service-connected disability caused the obesity; (2) if so whether the obesity as a result of the service-connected disability was a substantial factor in causing the current disability; and, (3) whether the current disability would not have occurred but for the obesity caused by the service connected disability. Id. VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154(a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a 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. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Lay evidence cannot be determined to be not credible merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 133637 (Fed. Cir. 2006). 1. Entitlement to service connection for sleep apnea, hypertension, and type II diabetes mellitus. As the facts, argument, and analysis for all three service connection claims are nearly identical, the Board will address all three claims together for the purposes of brevity. The Veteran was diagnosed with sleep apnea, hypertension, and diabetes mellitus during October 2016 VA examinations. Therefore, current disabilities have been shown. The presiding examiner further explained that each of these disabilities were diseases with clear and specific etiologies and pathophysiologies. As such, the presumption in favor of diseases manifesting in Persian Gulf veterans is not applicable in this case. 38 C.F.R. § 3.317. With respect to an in-service injury or disease, the Veteran's service treatment records do not reflect that he was treated for or diagnosed with any of the three claimed disabilities. The Veteran's September 1991 separation examination noted that the Veteran's heart, vascular system and endocrine system were all normal, and the Veteran's blood pressure was noted to be 118/80. See 38 C.F.R. § 4.104, Diagnostic Code 7101. The Veteran also specifically denied current or a history of high or low blood pressure, dizziness, vision problems, or trouble sleeping. The Board notes that the Veteran has asserted that his disabilities are due to the fact that he is obese. Further, in a November 2020 opinion a VA examiner noted that the Veteran had a body mass index (BMI) score of 31 since 1988, which was consistent with obesity. Thus, the opinion establishes that the Veteran was obese during both periods of service. However, as noted in-service obesity may not be considered an in-service injury or disease for the purposes of awarding direct service connection. VA Gen. Coun. Prec. 1-2017. As such, the fact that the Veteran was obese cannot serve as an in-service injury or disease. Instead, the Veteran has asserted that he was exposed to environmental hazards, such as burn pits and burning oil rigs, while stationed in Southwest Asia during his second period of service. The Veteran is competent to report such exposures, and his DD-214 reflects that he served in Southwest Asia from March 1991 to September 1991, which corroborates his account. 38 U.S.C. § 1154(a); see Jandreau, 492 F.3d 1372. As such, an in-service injury or disease has been shown. However, the preponderance of the evidence is against a finding that the Veteran's disabilities are causally related to his period of service, including exposure to environmental hazards. While the Veteran has asserted that his disabilities are due to such exposure, these statements are not competent as to provide such an opinion requires medical knowledge and training that is beyond what may be expected of a lay person. Jandreau, 492 F.3d 1372; Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). As the statements are not competent, they are entitled to no probative weight. Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010). The Veteran has not at any point indicated that his hypertension or diabetes mellitus have been persistent or continuous since service, with the Veteran specifically denying any issues with high blood pressure or sugar or albumin in his urine at the time of his separation in September 1991. 38 C.F.R. § 3.303(b). VA treatment records further reflect that the Veteran denied any history of hypertension in October 2002. Id. The Veteran and his spouse further testified in January 2020 that his hypertension and diabetes manifested after his separation from service. 38 C.F.R. § 3.303(b); see Walker, 708 F.3d 1331. The Board notes that during his January 2020 hearing the Veteran stated that he experienced difficulty sleeping and daytime fatigue during service which have persisted since. The Veteran's spouse also stated that he had trouble sleeping upon his return from his second period of service. In determining the weight to be assigned to evidence, credibility can be affected by inconsistent statements, internal inconsistency of statements, inconsistency with other evidence of record, facial implausibility, bad character, interest, bias, self-interest, malingering, desire for monetary gain, and witness demeanor. Caluza v. Brown, 7 Vet. App. 498, 51112 (1995), aff'd per curiam, 78 F.3d. 604 (Fed. Cir. 1996). Here, the Veteran specifically denied any current or history of trouble sleeping on his September 1991 separation report of medical history. In an August 2010 private treatment record the Veteran reported that during a recent Department of Transportation physical the examining physician had raised concerns about possible sleep apnea, and referred the Veteran for further evaluation. The record further reflects that at the time the Veteran denied any apneic events during sleep, sore throat or headaches on awakening, daytime sleepiness or sleepiness while driving. The Veteran further stated that he had no specific complaints of any kind, and that he did not think he had any problems. The Board further notes that at the same time the Veteran denied being diabetic, despite the fact that he had been diagnosed with and was being treated for diabetes at his VA Medical Center at the time. As the January 2020 testimony is directly contradicted by the Veteran's own statements concerning impaired sleep and daytime fatigue made both at the time of separation and during the August 2010 private consultation, the Board finds that these statements are not credible and therefore are entitled to no probative weight. Id. VA obtained an opinion concerning direct service connection in October 2016. The examiner stated that it was less likely than not that the hypertension, diabetes or sleep apnea were causally related to the Veteran's service, including his exposure to environmental hazards. As to hypertension, the examiner first noted that the Veteran was diagnosed with the disability well after separation. The examiner then stated that the Veteran had several significant recognized risk factors for hypertension, including his age, obesity, race, a documented high sodium diet, a documented history of excessive alcohol consumption, and a documented history of physical inactivity. The examiner stated that it was much more likely that these factors were the cause of the hypertension, as opposed to exposure to environmental hazards. Concerning diabetes mellitus, the examiner again noted that the disability was not diagnosed or treated until well after the Veteran's September 1991 separation. The examiner further stated that type II diabetes mellitus is the result of a complex interaction among many genic and environmental factors, including obesity, diet and physical inactivity. The examiner further stated that the Veteran had all of the noted environmental risk factors, and that these were more likely the cause of his type II diabetes mellitus. Finally, with respect to the sleep apnea the examiner again noted sleep apnea was not diagnosed until years after separation. The examiner then stated that the important risk factors for sleep apnea are age, male gender, obesity and craniofacial or upper airway soft tissue abnormalities. The examiner further stated that smoking appears to increase the risk of sleep apnea or at least aggravate its symptoms. The examiner then noted that the Veteran had all of the noted risk factors, and that is was more likely that they were the cause of the sleep apnea. There is no evidence that the above examiner was not competent or credible. Further, the examiner supported each opinion with a well-reasoned rationale which discussed the nature of each claimed disability and identified common risk factors present in the Veteran which were the more likely the cause of the claimed disabilities. As such, the Board finds that the opinions are entitled to significant probative weight as to the presence of a nexus between the claimed disabilities and the Veteran's service. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). While the Veteran submitted a private opinion concerning the three disabilities, this opinion did not discuss whether the disabilities were causally related to the Veteran's service generally or his exposure to environmental hazards specifically. As such, it is of no probative weight with respect to the question of direct service connection. Id. VA treatment records reflect that the Veteran was diagnosed with hypertension in 2002, but denied any history of hypertension prior to that date. He was then diagnosed with diabetes mellitus in 2003 and sleep apnea in January 2011, based on a private sleep study. None of the private or VA treatment records associated with the file contain any opinions linking the Veteran's disabilities to his period of service generally or exposure to environmental hazards specifically. Based on the foregoing, the preponderance of the evidence is against a finding that the hypertension, diabetes mellitus or sleep apnea are causally related to the Veteran's service, including exposure to environmental hazards. While the Veteran has asserted that his disabilities are directly related to his period of service, these statements are not competent and therefore entitled to no weight. Furthermore, while the Veteran and his spouse have asserted that he has experienced trouble sleeping and daytime fatigue since his second period of service, these statements are directly contradicted by other evidence of record and therefore are not credible. The submitted private opinion in no way discussed direct service connection, and therefore is also entitled to no weight. Thus, the only competent and credible evidence of record concerning a nexus between the claimed disabilities and service is the October 2016 examiner's opinion, which provided clear conclusions supported by a well-reasoned rationale that cited directly to the medical evidence of record as well as general medical knowledge concerning the risk factors, nature and course of each disability. As such, the preponderance of the evidence is against a finding that the Veteran's hypertension, sleep apnea, or type II diabetes mellitus are directly related to the Veteran's periods of service. As such, service connection on a direct basis for the claimed disabilities is not warranted. 38 C.F.R. §§ 3.102, 3.303. Both hypertension and type II diabetes mellitus are considered chronic diseases for VA purposes. 38 C.F.R. § 3.309(a). However, there is no evidence that either disability was diagnosed during either of the Veteran's periods of service or manifested to a compensable degree within one year of his separation from service. The Veteran's September 1991 separation examination noted that the Veteran's heart, vascular system, and endocrine system were normal and that his blood pressure was 118/80. See 38 C.F.R. § 4.104, Diagnostic Code 7101. The Veteran also specifically denied current or a history of high or low blood pressure, dizziness, vision problems, or trouble sleeping. Post-service treatment records reflect that the Veteran was first noted to have hypertension in 2002, at which time he denied any prior history of hypertension. The Veteran was then diagnosed with diabetes mellitus in approximately 2003. Both diagnoses occurred well after the one year period following service. As such, service connection based on the presumption in favor of chronic diseases is not warranted in this case. 38 C.F.R. §§ 3.307(a)(2), 3.309(a). In the alternative, the Veteran has argued that his service-connected psychiatric disability and his right toe disability caused him to become obese, which in turn resulted in his development of hypertension, diabetes mellitus, and sleep apnea. As noted above, the Veteran was diagnosed with all three disabilities during his October 2016 VA examinations. Further, the Veteran is service connected for a psychiatric disability and a right great toe disability, and VA treatment records reflect that the Veteran is obese. Thus, the dispositive issue is whether the Veteran's service-connected disabilities either directly caused or aggravated the claimed disabilities, or whether the service-connected disabilities caused the Veteran's obesity, which in turn caused the claimed disabilities. VA Gen. Coun. Prec. 1-2017; see Walsh v. Wilkie, 32 Vet. App. 300, 30607 (2020). Beginning with the primary argument that the Veteran's service-connected disabilities caused him to become obese, which in turn caused his claimed disabilities, as noted at the outset of the decision the Board must address three questions: (1) whether the service-connected disability caused or aggravated the obesity; (2) if so whether the obesity as a result of the service-connected disability was a substantial factor in causing the current disability; and, (3) whether the current disability would not have occurred but for the obesity caused or aggravated by the service connected disability. VA Gen. Coun. Prec. 1-2017; see Walsh, 32 Vet. App. at 30607. As to the first question, the Veteran has asserted that his psychiatric disability and his right great toe disability caused him to become obese. Specifically, during his hearing the Veteran stated that his ability to exercise is limited by the pain from the ingrown right great toenail and tendency to self-isolate due to his psychiatric disability. However, this assertion conflicts with the other evidence associated with the file. Caluza v. Brown, 7 Vet. App. 498, 51112. In this case, treatment records throughout the period on appeal reflect that the Veteran has been consistently advised to diet and exercise by his treating physicians, with no mention of restrictions on his activities or activity levels due to his service-connected disabilities. Records from October 2002, January 2003, December 2003, January 2005 and June 2013 all reflect that the Veteran reported not adhering to his recommended diet, dietary indiscretion or refusing to follow dietary advice from his physicians. A June 2013 treatment record reflects that the Veteran reported he would start using his treadmill at home to exercise. VA treatment records from September 2016, October 2016 and October 2018 note that the Veteran was exercising, including engaging in activities such as walking and bike riding. An October 2016 report reflects that the Veteran reported wanting to lose weight, but stated that it was difficult to do so because of his job as a truck driver. A July 2017 record reflects the Veteran reported having a gym membership but that he was not currently attending. An August 2017 treatment record noted that the Veteran reported that he did not like exercising either at the gym or at home, and so he simply did not do so. The Veteran did not at any point mention any interference with his ability to exercise due to his service-connected disabilities. Thus, contrary to the Veteran's testimony in January 2020 the evidence of record clearly shows that he was not rendered incapable of activity or exercise due to pain from his right great toe ingrown toenail, as he on several occasions reported walking or biking for exercise. The Veteran displayed the ability to go outside to exercise, thus contradicting his testimony that he is unable to exercise due to his tendency to self-isolate. Further, even if the Veteran's tendency to self-isolate due to his psychiatric disability did preclude him from going outside to exercise, he reported that he had a treadmill in his house, and therefore could have exercised inside in private. Finally, the Veteran at no point attributed his trouble with, or inability to, exercise to his disabilities, despite his numerous conversations concerning diet and exercise with his physicians spanning nearly two decades. Instead, the Veteran stated that he simply did not like exercising in August 2017 and that it was difficult to exercise because of his job in October 2016. White v. Illinois, 502 U.S. 346, 356 (1992) (stating that statements made for the purpose of medical diagnosis or treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive a proper diagnosis or treatment). In light of the inconsistent nature of the Veteran's account concerning his ability to exercise specifically and the reasons underlying his obesity generally, the Board finds the statements are not credible and entitled to no probative weight. Id. VA obtained opinions concerning the cause of the Veteran's obesity in November 2020 and May 2021. The November 2020 examiner stated that it was less likely than not that the Veteran's obesity was caused by his service-connected disabilities. The examiner stated that obesity by its nature is a multi-factoral condition with many risk factors, including genetics, dietary patterns and activity level. The examiner noted that while the service-connected disabilities may affect his activity level, they did not have an impact on the other risk factors that contribute to the Veteran's obesity. Finally, the examiner noted that the Veteran had a BMI of 31 in 1988, and had been obese since that point. The examiner further opined that even if the Veteran's obesity was caused by a service-connected disability, the hypertension and diabetes mellitus would likely have occurred without the obesity. The examiner noted that the Veteran had other risk factors for both disabilities, including his race, smoking history and excessive alcohol consumption for hypertension and family history dietary pattern, ethnicity, and smoking history for diabetes mellitus. Therefore, the examiner stated that the Veteran was at an increased risk to develop both disabilities even without the presence of obesity. The May 2021 examiner stated that it was less likely than not that the Veteran's obesity was aggravated by his service-connected disabilities. Walsh, 32 Vet. App. at 30607. In support of this conclusion, the examiner stated that the evidence did not support a finding that the Veteran's obesity was aggravated by his service-connected disabilities. The examiner first noted that the Veteran's 1991 separation examination reflected a height of 70 inches and weight of 216 pounds, which resulted in a calculated body mass index (BMI) of 31, and that a February 2001 record reflected a height of 69 inches and weight of 262 pounds, for a BMI of 38.7. The examiner noted that this reflected a 46 pound weight gain since separation from service which was not an abnormal progression of weight gain. The examiner continued on to explain that obesity is multifactorial, including genetics, physical inactivity, sedentary lifestyle, diet, and metabolic and cardiovascular conditions. The examiner further stated that, in addition to the listed risk factors, obesity is a choice. The examiner noted that while the service-connected toe may affect high impact exercise activity and the psychiatric disability may impact motivation, there are multiple activities and strategies which could be used to prevent weight gain and obesity, including low impact and seated exercises such as biking, walking, aquatic therapy and limiting caloric intake. The examiner noted that the Veteran's treatment records did not show that all activity was prescribed due to the toe disability, with multiple records showing the Veteran is ambulatory. Finally, the examiner cited to the fact that a February 2017 treatment record noted that the Veteran had lost 12 pounds since the prior August, indicating that the Veteran was capable of losing weight despite his disabilities via exercise, dietary discretion, or other methods. Concerning hypertension and diabetes mellitus, the examiner further noted common risk factors for the disabilities include age, race, obesity, physical inactivity, family history, tobacco use, diet, and alcohol use. The examiner noted that an October 2002 treatment reflected that the Veteran reported adding salt to almost everything he eats, and that the Veteran was instructed to decrease salt intake and monitor his blood pressure. The examiner then noted a January 2003 treatment record noting obesity, smoking, and dietary indiscretion. The examiner additionally cited to July 2004 and August 2004 records showing that the Veteran smoked approximately one to two packs of cigarettes per day and was encouraged to discontinue alcohol use. Finally, the examiner noted that the Veteran's post-service occupation was as a long-haul truck driver, and that medical literature reflected that obesity is twice as prevalent among individuals engaged in that profession. There is no evidence that the above examiners were either not competent or credible. Further, the examiners came to clear conclusions which were supported by well-reasoned rationales that cited to the medical evidence of record, medical literature, and general medical knowledge concerning the nature of and risk factors for obesity. As such, the Board finds that the opinion is entitled to significant probative weight as to whether the Veteran's obesity was caused by his service-connected great right toe or psychiatric disability. Nieves-Rodriguez, 22 Vet. App. 295. In January 2020, the Veteran's attorney submitted a private opinion addressing the question of whether the Veteran's obesity was caused or aggravated by his service-connected disabilities. The examiner stated, in pertinent part, that the Veteran's service-connected disabilities caused or aggravated his obesity, which in turn caused the Veteran's claimed disabilities. In support of this opinion, the examiner first noted that mental illness leads to obesity, but that the exact pathophysiology has yet to be determined. The examiner stated that one postulate is that altered brain activity results in altered consumption and food choices, but that this was not confirmed. The examiner then stated that mental illness is highly prevalent, and that there are no targeted effective treatments for mental health-associated obesity or metabolic syndrome. The examiner concluded that it is reasonable to assume the Veteran's obesity was caused or aggravated at least in part by the psychiatric disability. The examiner then cited to the fact that obesity and chronic pain, such as that from the right great toe injury, co-occur frequently. However, the examiner then noted that although pain and obesity are significantly associated with one another, research evaluating the relationship has yielded conflicting results, suggesting the relationship between obesity and pain is not a direct one but is mediated by various factors, including structural changes associated with obesity, inflammatory mediators, mood disturbance, poor sleep and lifestyle issues. The Board notes that there is no evidence that the opining physician was either not competent or credible. However, the Board finds that there are several issues with the opinion which render it of no probative weight. First, the physician appears to have based the opinion at least in part on the Veteran's lay statements concerning the cause of his obesity. As these statements have been found to be not credible in light of the fact that they are contradicted by other evidence of record, the private opinion is based on an inaccurate premise and is entitled to no probative weight. Reonal v. Brown, 5 Vet. App. 458, 46061 (1993). Second, in support of his opinions the physician recited findings from a wide-variety of broad studies concerning the associations between chronic pain and obesity and mental illness and obesity, but there is no evidence that any of the cited studies came to clear conclusions concerning a causative relationship between pain and obesity or mental illness and obesity. Wallin v. West, 11 Vet. App. 509, 514 (1998). Indeed, the examiner specifically acknowledged that the research concerning the relationship between pain and obesity had yielded mixed results and that the postulate concerning altered brain activity due to mental illness resulting in altered food consumption was not confirmed. Id. Further, to the extent the cited treatises in fact came to general conclusions, these conclusions were not clearly applied to the facts of the specific case at issue. Libertine v. Brown, 9 Vet. App. 521, 523 (1996). Instead, the physician simply recited the conclusions of some studies, and concluded that in this case the Veteran's obesity was caused or aggravated by his right great toe and psychiatric disabilities. Id. Third, although the opinion stated that the Veterans' primary care records were reviewed, the examiner only cited to a September 2016 primary care physician record and a December 2019 psychiatric record. The examiner did not in any way address any other VA treatment records, many of which contained information which directly contradicted the examiner's conclusion that the Veteran's service-connected disabilities resulted in exercise intolerance which caused or aggravated his obesity. In particular, as noted above the Veteran reported exercising in September 2016, October 2016 and October 2018, and that he had a treadmill at home in October 2016. These reports show that the Veteran is in fact capable of low impact or seated exercise, as noted in the VA opinions, and further that the Veteran is able to exercise at home in isolation if he so chooses. Further, the examiner failed to address the August 2017 record where the Veteran simply reported that he did not like exercising either at home or the gym, or the October 2016 treatment record where the Veteran attributed his difficulty with exercising to his job and not his disabilities. The physician also did not address the numerous VA medical records noting that the Veteran throughout the period on appeal was not adhering to his recommended diet, which was hindering his ability to lose weight and therefore contributing to his obesity, or the fact that the Veteran's dietary issues significantly predated the first manifestations of his psychiatric disability. Finally, the physician did not reconcile his opinion that the obesity was caused or aggravated by the service-connected disabilities with the fact that based on BMI the Veteran had been obese since 1988, as noted by both VA examiners. As the examiner failed to reconcile the opinion with directly contradictory evidence from the record, and further based the opinion predominantly on inconclusive medical studies, the Board finds that the opinion is entitled to no probative weight. As discussed earlier, October 2002, January 2003, December 2003, January 2005 and June 2013 VA treatment records all reflect that the Veteran reported not adhering to his recommended diet, dietary indiscretion, or that he was not following dietary advice from his physicians, thus inhibiting his ability to stop gaining and start losing weight. A June 2013 treatment record reflects that the Veteran reported he would start using his treadmill at home to exercise. An October 2016 record reflects the Veteran reported his job interfered with exercising and weight-loss and an August 2017 record noted that the Veteran reported that he did not like exercising either at the gym or at home. VA treatment records from September 2016, October 2016 and October 2018 note that the Veteran was exercising, including engaging in activities such as walking and bike riding. Further, the records reflect that the Veteran's poor eating habits and dietary indiscretion preceded the onset of his psychiatric disability by several years, with VA treatment records from 2002 to 2014 generally reflecting negative depression screenings. As noted, the Veteran did not at any point mention any interference with his ability to exercise due to his service-connected disabilities. The Board finds that these records are entitled to significant probative weight as to the question of the cause of the Veteran's obesity. White, 502 U.S. at 356. Based on the foregoing, the preponderance of the evidence is against a finding that the Veteran's service-connected right great toe and psychiatric disabilities caused or aggravated his obesity. While the Veteran has stated that the service-connected disabilities rendered him unable to exercise and thus resulted in his obesity, these statements are directly contradicted by other evidence of record and therefore are not credible. While the private opinion linked the Veteran's obesity to his service-connected disabilities, the opinion was based on the Veteran's statements which have been found not credible and failed to address numerous VA treatment records identifying other causes of the Veteran's obesity and noting that the Veteran cited his employment as a limiting factor on his ability to exercise and lose weight. Thus the only competent and credible evidence of record are the November 2020 and May 2021 VA opinions, which clearly stated that the obesity was not caused or aggravated by the Veteran's service-connected disabilities, and the VA treatment records, which reflect that the Veteran reported other factors prohibiting exercise and reflect that the Veteran's refusal to alter his eating habits was a significant factor with his continued obesity. As the preponderance of the evidence is against a finding that the Veteran's obesity is caused or aggravated by his service-connected disabilities, the Board need not proceed to address the subsequent two questions concerning proximate causation. Based on the foregoing, service connection for hypertension, sleep apnea and diabetes mellitus as secondary to a psychiatric disability or right great toe disability, with obesity serving as an intermediary step, is not warranted in this case. 38 C.F.R. § 3.310; see VA Gen. Coun. Prec. 1-2017 (Jan. 6, 2017). Finally, turning to the question of whether the claimed disabilities were directly caused or aggravated by the service-connected psychiatric disability or right great toe disability, VA obtained medical opinions in October 2016 and November 2020. As discussed above, the October 2016 examiner clearly stated that the claimed disabilities were due to a variety of risk factors, including obesity, alcohol consumption, smoking history, physical inactivity, and diet. The November 2020 examiner stated that it was less likely than not that the hypertension, sleep apnea, or diabetes mellitus were caused or aggravated by the service-connected disabilities. As to hypertension, the examiner noted that the Veteran was diagnosed in the early 2000s and started on medication. The examiner then noted that throughout the period the Veterans' blood pressure remained stable, and therefore there was no evidence that the hypertension was aggravated by a service-connected disability. With respect to sleep apnea, the examiner noted that the Veteran was diagnosed with severe sleep apnea in 2011 and issued a CPAP machine. The examiner then stated that records since reflect that the Veteran is asymptomatic as long as he is using the CPAP machine, and that the records, including a repeat sleep study in 2018, do not reflect that the sleep apnea has worsened. Concerning diabetes mellitus, the examiner stated that medical records showed that the Veteran had abnormal Hgb A1C since 2009 and was started on Metformin. The examiner stated that since 2009 the Veteran's diabetes was stable, with his A1C staying in approximately the same range throughout the period. The examiner further noted that the diabetes appeared to be controlled with his current medication. Based on the foregoing, the examiner stated that there was no evidence the diabetes mellitus was aggravated by the service connected disabilities. There is no evidence that the above examiners were either not competent or credible. Further, both opinions were supported by a well-reasoned rationale that cited to the medical evidence in the file and discussed common risk factors for the disabilities. As such, the Board finds that each respective examination report is entitled to significant probative weight. Nieves-Rodriguez, 22 Vet. App. 295. VA and private treatment records do not contain any opinions linking the claimed disabilities directly to the psychiatric disability or right great toe disability. Likewise, the submitted private opinion did not link the claimed disabilities directly to the service-connected psychiatric or right great toe disabilities, instead focusing on obesity as an intermediary step. Based on the foregoing, the preponderance of the evidence is against a finding that the Veteran's hypertension, sleep apnea or diabetes mellitus were caused or aggravated by his service-connected disabilities. As such, service connection on a secondary basis is not warranted. 38 C.F.R. § 3.310. The preponderance of the evidence weighs against a finding that the Veteran's sleep apnea, hypertension or diabetes are causally related to his service or were caused or aggravated by another service-connected disability. Since the preponderance of the evidence is against the claims, the benefit of the doubt rule is not applicable. 38 U.S.C. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 5557 (1990); 38 C.F.R. § 3.102. For these reasons, the claims are denied. LESLEY A. REIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Wendell, 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.