Diabetes Secondary to Sleep Apnea: Is There a Connection for VA Disability Benefits?

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Sleep apnea isn’t just about snoring or disrupted sleep; it can also have serious health implications, including a connection to conditions like type 2 diabetes.

Emerging medical research suggests a strong link between sleep apnea and diabetes, making this a viable condition for secondary service connection through the VA.,

In this blog post, VA disability benefits expert Brian Reese explains the relationship between sleep apnea and diabetes, reviews the evidence required to establish secondary service connection, and explains how the VA rates diabetes secondary to sleep apnea.

Summary of Key Points

• Link Between Sleep Apnea and Diabetes: Medical research shows that obstructive sleep apnea (OSA) can aggravate or contribute to the development of type 2 diabetes by disrupting sleep, impairing glucose regulation, and triggering systemic inflammation.

• Evidence Requirements for Secondary Service Connection: Veterans need a current diagnosis of diabetes, a service connection for sleep apnea, and medical evidence (e.g., a Nexus Letter) linking diabetes to sleep apnea through causation or aggravation.

• Impact of Sleep Apnea on Diabetes Management: Untreated or poorly managed sleep apnea can worsen diabetes by increasing insulin resistance, elevating cortisol levels, and exacerbating poor blood sugar control, even when standard diabetes treatments are followed.

• VA Rating for Diabetes Secondary to Sleep Apnea: Diabetes is rated between 10% and 100%, with breaks at 20%, 40%, and 60%, depending on the severity of symptoms, treatment requirements (e.g., insulin use, activity regulation), and complications such as hospitalizations or progressive weight and strength loss.

Can Sleep Apnea Cause or Aggravate Diabetes?

Yes, medical research supports that obstructive sleep apnea (OSA) can aggravate or even contribute to the development of diabetes.

Here’s how:

#1. Disrupted Sleep and Glucose Regulation:

• Sleep apnea causes repeated interruptions in breathing (apneas) during sleep, leading to poor-quality sleep and reduced oxygen levels (intermittent hypoxia).

• Studies published in Diabetes Care indicate that this disruption can impair insulin sensitivity, a critical factor in maintaining blood sugar balance.

#2. Increased Stress Hormones (Cortisol):

• Chronic sleep disruptions from OSA lead to elevated levels of cortisol, a stress hormone.

• High cortisol levels are associated with insulin resistance, a hallmark of type 2 diabetes.

#3. Systemic Inflammation:

• Sleep apnea triggers systemic inflammation throughout the body.

• This inflammation can damage blood vessels and impair glucose metabolism, creating a feedback loop that worsens both conditions.

#4. Aggravation of Pre-Existing Diabetes:

• For veterans with service-connected sleep apnea, this condition can worsen existing diabetes by compounding issues like poor blood sugar control, increased insulin resistance, and daytime fatigue that interferes with healthy habits.

Evidence Requirements for Secondary Service Connection

Here’s a list of questions the C&P examiner will review along with evidence requirements for VA claims for diabetes secondary to sleep apnea:

Does the veteran have a diagnosis of diabetes mellitus (type 1 or type 2)?

• If yes, provide the date of diagnosis, any supporting lab results, and details of current treatment (e.g., medications, insulin, dietary modifications).

Does the veteran have service-connected sleep apnea rated at 0% or higher?

• If yes, provide the date of diagnosis and service connection, and include the type of sleep apnea (obstructive, central, or mixed).

Is the veteran’s diabetes proximately due to or aggravated by their service-connected sleep apnea?

• If yes, explain your medical opinion with supporting rationale, including evidence of how sleep apnea impacts glucose metabolism, insulin resistance, or overall diabetes management.

Does the veteran have symptoms of diabetes that are aggravated by sleep apnea?

• If yes, describe the symptoms, including frequency, severity, and duration, and provide evidence of how untreated or poorly managed sleep apnea contributes to complications or worsening of diabetes control.

Does the veteran’s sleep apnea treatment (e.g., CPAP use) impact their diabetes management?

• If yes, provide evidence of how effective sleep apnea treatment (or lack thereof) has influenced blood sugar control or diabetes symptoms.

How to Establish Secondary Service Connection for VA Disability Benefits

To establish a secondary service connection, veterans need to provide the VA with two primary pieces of evidence:

• Current Diagnosis of the Secondary Condition: The veteran must have a current diagnosis of the secondary condition, which in this case is diabetes. This diagnosis must be documented in a medical record by a qualified medical professional.

• Medical Nexus Evidence Between the Two Conditions: The veteran must provide medical evidence that links the new secondary condition to the already service-connected condition. Ideally, you submit a Nexus Letter for a secondary condition that explain how the new disability (diabetes) is proximately due to, caused, or aggravated by the primary service-connected condition (sleep apnea).

What is the VA Disability Rating for Diabetes Secondary to Sleep Apnea?

The VA rates type 2 diabetes under CFR Title 38, Part 4, Schedule for Rating Disabilities, DC 7913, Diabetes Mellitus at 10%, 20%, 40%, 60%, or 100% depending on the severity of symptoms, the effectiveness of insulin, diet, activity, and whether hospitalizations are required.

100% VA Rating for Diabetes

Requiring more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated rate at 100 percent.

60% VA Rating for Diabetes

Requiring one or more daily injection of insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated rate at 60 percent. 

40% VA Rating for Diabetes

Requiring one or more daily injections of insulin, restricted diet, and regulation of activities rate at 40 percent.

20% VA Rating for Diabetes

Requiring one or more daily injections of insulin and restricted diet, or; oral hypoglycemic agent and restricted diet rate at 20 percent.

10% VA Rating for Diabetes

If manageable by restricted diet only rate at 10 percent. 

Example Nexus Letter for Diabetes Secondary to Sleep Apnea [Download]

Click the link or button below to download an example nexus letter for diabetes that’s proximately due to or aggravated by a veteran’s service-connected sleep apnea.

Note: This letter is an example only and must be tailored to the facts and circumstances of your case.

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