Obesity is not the ONLY cause of obstructive sleep apnea.
The VA examiner almost always opine the the veteran’s obstructive sleep apnea is caused by obesity and as obesity is not considered a disability his claim is denied.
The examiner relied on studies of the general public, where obesity was associated with an incidence of 12.1% obstructive sleep apnea, but ignored the vast medical literature coming from the veteran community, where the incidence of 70% obstructive sleep apnea among veterans suffering from PTSD was reported. To prevail, the VA examiner must show that the incidence of obstructive sleep apnea in obese veterans is higher than that in veterans suffering from PTSD.
The VA examiner noted multiple risk factors, to include the Veteran’s elevated BMI that result in obstructive sleep apnea. Obesity is one of the major causes of obstructive sleep apnea in the general population; however, it is not the only one. Obstructive sleep apnea is a common condition affecting a large number of veterans due to service-connected disabilities such as PTSD and tinnitus, which are conditions that are far more prevalent in veterans than in the general population.
As noted supra, the incidence of obstructive sleep apnea in obese men (BMI >30) is 12.1%, while the incidence of obstructive sleep apnea in all veterans is 27.3%, and reported to be as high as 70% in veterans suffering from PTSD, while veterans are usually leaner than the general population.
Thus, obesity, which plays a major role in the causation of obstructive sleep apnea in the general public, is not a major cause of obstructive sleep apnea in veterans, as compared to conditions uniquely affecting veterans namely PTSD, mood disorders and tinnitus.
- The veteran’s sleep apnea is more likely than not secondary to PTSD.
Dr. Benham states in her IMO dated June 22, 2021 [R. at 83-85 (76-109)]:
“It is well established in the scientific literature that sleep apnea in a veteran is more likely than not secondary to PTSD; 47.6% of combat veterans with PTSD were found to have OSA compared to only 12.5% of healthy controls.[1] In the study, Sleep Disorders in US Military Personnel: A High Rate of Comorbid Insomnia and Obstructive Sleep Apnea, Mysliwiec et al. observed that sleep disturbances are increasing in frequency and are commonly diagnosed during deployment and when military personnel return from deployment (redeployment).[2] They evaluated 110 active duty soldiers referred to the sleep disorders clinic within 18 months of deployment. These soldiers were young (average age 33.6 years) and not obese. Overall, 62.7% met diagnostic criteria for obstructive sleep apnea (OSA) and 63.6% for insomnia. 38.2% had comorbid insomnia and OSA. The incidence of PTSD, TBI and mood disorder reached statistical significance when compared to control group. The study reports (emphasis added)…:
“In this study, we report that medical and psychologic comorbidities are frequent in military personnel referred for sleep disturbances, with 70% having at least one of the following: depression, mild TBI, pain, or PTSD, and almost one-half (47.3%) reporting two or more diagnoses…Patients with comorbid insomnia and OSA had the highest rates of depression, mild TBI, PTSD, and two or more diagnoses.”
The incidence of sleep apnea in veterans suffering from PTSD, TBI, and mood disorder is almost 10 times higher than the incidence of sleep apnea in the general population, and 3-4 times higher than the obese population…
The mere fact that obesity causes sleep apnea does not mean that PTSD, TBI and mood disorders do not cause sleep apnea. Rather, a combination of these conditions is more likely to cause sleep apnea than any of these conditions alone. I conclude that PTSD, TBI and mood disorder cause sleep apnea directly and/or aggravate the effect of obesity on the causation of sleep apnea…”
[1] Mellman TA, Kulick-Bell R, Ashlock LE et al. Sleep events among veterans with
combat-realetd post traumatic stress disorder. Am J Psychiatry 1995
[2] Peterson AL, Goodie JL, Satterfield WA, Brim WL. Sleep disturbance during military deployment. Mil Med. 2008;173:230–5