DIABETES MELLITUS

S.C. KREMBS · 2023 · Case ID: 23004349

DENIED

Summary

The Veteran, a Veteran who served from March 1980 to October 1982, appeals the denial of service connection for type II diabetes mellitus on a secondary basis. The Veteran contends that his diabetes is secondary to his service-connected substance abuse disorder, which is associated with his service-connected acquired psychiatric disorder. The Board found that while the Veteran has a current diagnosis of type II diabetes mellitus, the evidence does not establish a secondary service connection. Multiple VA examinations were conducted to assess the nexus between the Veteran's psychiatric conditions, substance abuse, and diabetes. The examiners consistently opined that it was less likely than not that the diabetes was proximately caused or aggravated by the service-connected conditions. They noted that diabetes mellitus is primarily an endocrine disorder influenced by factors like genetics, obesity, inactivity, and diet, and found no medical literature or evidence in the record to support a link between psychiatric disorders or substance abuse and the development or aggravation of diabetes. The Board found the multiple VA opinions to be highly probative and detailed. The Board also noted that while the Veteran is competent to report his symptoms, he is not competent to provide an opinion on the etiology of his diabetes. The Board concluded the evidence persuasively weighed against service connection, rendering the benefit of the doubt doctrine inapplicable. Service connection for type II diabetes mellitus was denied.

Rationale

Multiple VA examinations opined less likely than not that diabetes mellitus was caused or aggravated by service-connected psychiatric disorder and substance abuse.; Examiners noted no medical literature supports a link between psychiatric disorders/substance abuse and diabetes mellitus development or aggravation.; Risk factors for diabetes mellitus (genetics, obesity, inactivity, diet) were identified as primary contributors, not psychiatric conditions.

Special Benefit

NO SPECIAL BENEFIT

Docket No.

15-31 151A

Full Decision Text

Citation Nr: 23004349
Decision Date: 01/24/23 Archive Date: 01/24/23

DOCKET NO. 15-31 151A
DATE: January 24, 2023

ORDER

Service connection for type II diabetes mellitus is denied.

FINDING OF FACT

The Veteran's type II diabetes mellitus was not caused or aggravated by his service-connected substance abuse disorder associated with his service-connected acquired psychiatric disorder.

CONCLUSION OF LAW

The criteria for service connection for type II diabetes mellitus secondary to service-connected substance abuse disorder associated with his service-connected acquired psychiatric disorder are not met. 38 U.S.C. §§ 1101, 1110, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.309, 3.310.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty from March 1980 to October 1982.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California.

The Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ) via videoconference in May 2017 and a transcript of the hearing has been associated with the claims file.

This matter was previously before the Board at which times it was remanded for further development.

Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004).

Certain chronic diseases will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013).

Additionally, service connection may be established on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc).

Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical evidence. VA must also consider all favorable lay evidence of record. See 38 U.S.C. § 5107 (b); see also Layno v. Brown, 6 Vet. App. 465, 469-70 (1994) (a Veteran is competent to report on that of which he or she has actually observed and is within the realm of his or her personal knowledge).

Here, the Veteran contends that he has type II diabetes mellitus secondary to his service-connected substance abuse disorder associated with his service-connected acquired psychiatric disorder. He does not contend that his type II diabetes mellitus is directly related to his active service nor does the evidence support such a finding. Moreover, there is no evidence that type II diabetes mellitus manifested in the year following his discharge from service in October 1982. Accordingly, the Board will address his claim of entitlement to service connection on a secondary basis only.

In this regard, a current disability is confirmed by the evidence of record. Specifically, the Veteran's post-service VA medical records document a current diagnosis of type II diabetes mellitus. See July 2021 and January 2022 Diabetes Mellitus VA Examination Reports.
itus secondary to his service-connected substance abuse disorder associated with his service-connected acquired psychiatric disorder. He does not contend that his type II diabetes mellitus is directly related to his active service nor does the evidence support such a finding. Moreover, there is no evidence that type II diabetes mellitus manifested in the year following his discharge from service in October 1982. Accordingly, the Board will address his claim of entitlement to service connection on a secondary basis only.

In this regard, a July 2021 VA examiner opined that the claimed condition was less likely than not proximately due to or the result of the Veteran's service-connected condition. The examiner reasoned that a review of the records showed that the Veteran was diagnosed with type II diabetes mellitus since the 1990s. Literature shows that obesity and physical inactivity along with poor dietary habits are established as risk factors for diabetes with no evidence that it is directly related to posttraumatic stress disorder (PTSD). Genetic, environmental, and metabolic risk factors are interrelated and contribute to the development of diabetes. A strong family history of type II diabetes mellitus, age, obesity, and physical inactivity identify those individuals at highest risk. Minority populations are also at higher risk, not only because of family history and genetics, but also because of adaptation to American environmental influences of poor dietary and exercise habits. Women with a history of gestational diabetes as well as their children are at greater risk for progressing to type II diabetes mellitus. Insulin resistance increases a person's risk for developing impaired glucose tolerance and type II diabetes. Individuals who have insulin resistance share many of the same risk factors as those with type II diabetes mellitus. These include hyperinsulinemia, atherogenic dyslipidemia, glucose intolerance, hypertension, prothrombic state, hyperuricemia, and polycystic ovary syndrome. Current interventions for the prevention and retardation of type II diabetes mellitus are those targeted towards modifying environmental risk factors such as reducing obesity and promoting physical activity. Awareness of risk factors for developing type II diabetes mellitus will promote screening, early detection, and treatment in high-risk populations with the goal of decreasing both microvascular and macrovascular complications. Based on this evidence, the examiner determined that it was less likely than not that the Veteran's current type II diabetes mellitus condition was proximately due to PTSD, with adjustment disorder, depressed mood, major depressive disorder, and substance abuse disorder.

In September 2021, the Board remanded the Veteran's claim to obtain a more comprehensive opinion regarding causation and an opinion addressing aggravation. In response, a January 2022 VA examiner opined that the claimed condition was less likely than not proximately due to or the result of the Veteran's service-connected condition and less likely than not aggravated beyond its natural progression by the Veteran's service-connected condition. The examiner reasoned that there is no evidence in the medical literature to support that diabetes mellitus can be caused by or secondary to a psychiatric disorder and there is no evidence in the medical records to support that the Veteran's type II diabetes mellitus was aggravated beyond its natural progression by his service-connected psychiatric condition. The examiner further reasoned that risk factors for type II diabetes mellitus include family history, age, obesity, and physical inactivity and there were no nexus letters from a specialist stating that the Veteran's diabetes was due to his psychiatric illness.

In March 2022, the Board remanded the Veteran's claim to obtain an addendum opinion addressing the Veteran's specific medical history and his contention that his substance abuse destroyed his vascular system and resulted in the onset of type II diabetes mellitus. In response, a May 2022 examiner again opined that the claimed condition was less likely than not proximately due to or the result of the Veteran's service-connected condition and less likely than not aggravated beyond its natural progression by the Veteran's service-connected condition. The examiner reasoned that there is no evidence in the medical records to support that the Veteran's type II diabetes mellitus was caused by or aggravated by his service-connected psychiatric disorder, nor are there any nexus letters from specialist stating this. The risk factors for type II diabetes mellitus are family history of diabetes, age, obesity, poor diet, and physical inactivity. The Veteran's specific risk factors are genetics, family history of diabetes, physical inactivity, and poor diet.

In August 202
2022 examiner again opined that the claimed condition was less likely than not proximately due to or the result of the Veteran's service-connected condition and less likely than not aggravated beyond its natural progression by the Veteran's service-connected condition. The examiner reasoned that there is no evidence in the medical records to support that the Veteran's type II diabetes mellitus was caused by or aggravated by his service-connected psychiatric disorder, nor are there any nexus letters from specialist stating this. The risk factors for type II diabetes mellitus are family history of diabetes, age, obesity, poor diet, and physical inactivity. The Veteran's specific risk factors are genetics, family history of diabetes, physical inactivity, and poor diet.

In August 2022, the Board again remanded the Veteran's claim to obtain a more comprehensive opinion addressing his contention that his substance abuse destroyed his vascular system and resulted in the onset of type II diabetes mellitus. In response a September 2022 examiner opined that the claimed condition was less likely than not proximately due to or the result of the Veteran's service-connected condition. The examiner reasoned that the Veteran's claim that his psychiatric disorder with substance abuse caused destruction of the vascular system is not supported by peer reviewed, credible medical evidence. Neither psychiatric disease nor substance abuse are known causes or even risk factors in the development of diabetes. Review of current medical literature does not support diabetes mellitus is caused by destruction of the vascular system. While the examiner linked the Veteran's cardiovascular conditions to destruction of the vascular system, the examiner explained that this is not relevant to the diabetes mellitus diagnosis. Type II diabetes mellitus is primarily the result of two interrelated problems: (1) cells in muscle, fat, and the liver become resistant to insulin and because these cells do not interact in a normal way with insulin, they do not take in enough sugar. (2) The pancreas is unable to produce insulin to manage blood sugar levels. The examiner explained that exactly what happens is unknown, but being overweight and inactive are key contributing factors. Storing fat mainly in your abdomen rather than your hips and thighs indicates a greater risk; your risk rises if you are a man with a waist circumference above 40 inches (101.6 centimeters) or a woman with a measurement above 35 inches (88.9 centimeters); and the less active you are, the greater your risk as physical activity helps control your weight, uses up glucose as energy and makes your cells more sensitive to insulin. The risk increases if your parent or sibling has type II diabetes mellitus. Although it is unclear why, people of certain races and ethnicities, including Black, Hispanic, Native American, Asian, and Pacific Islanders are more likely to develop type II diabetes mellitus than white people. An increased risk is associated with low levels of high-density lipoprotein (HDL) cholesterol (the good cholesterol) and high levels of triglycerides. The risk increases as you get older, especially after age 45. Prediabetes is a condition in which your blood sugar level is higher than normal, but not high enough to be classified as diabetes. Left untreated, prediabetes often progresses to type II diabetes. Risk also increases if you developed gestational diabetes when you were pregnant or if you gave birth to a baby weighing more than 9 pounds (4 kilograms).

The examiner also opined that the claimed condition was less likely than not aggravated beyond its natural progression by the service-connected condition. The examiner noted the Veteran's February 24, 2015 and April 2, 2015 readings and reasoned that there was no objective evidence of aggravation of diabetes mellitus beyond normal progression by his substance abuse disorder as his diabetes mellitus was in remission. The examiner further reasoned that while the Veteran's HBA1C fluctuated from 7 to 11 over the past five years, this is not evidence that substance abuse aggravated diabetes mellitus, as the Veteran's diabetes mellitus was considered uncontrolled even while he was in remission from illicit substances. In 2018 his HBA1C was 6.9 and at the time he was not abusing alcohol or drugs.

In November 2022 and December 2022 addendums the examiner considered the Veteran's service-connected coronary artery disease, cardiomyopathy, congestive heart failure, and hypertension, and the July 2021 VA examiner opinion noting excessive alcohol consumption associated with the development of hypertension and coronary artery disease, and cardiomyopathy and congestive heart failure associated with cocaine use. However, the examiner still reached the same conclusions. The examiner reasoned that there was no medical basis for substance abuse negatively affecting the Veteran's vascular system causing type II diabetes mellitus; they are entirely unrelated. Diabetes mellitus is an endocrine disorder primarily caused by cells in muscle,
6.9 and at the time he was not abusing alcohol or drugs.

In November 2022 and December 2022 addendums the examiner considered the Veteran's service-connected coronary artery disease, cardiomyopathy, congestive heart failure, and hypertension, and the July 2021 VA examiner opinion noting excessive alcohol consumption associated with the development of hypertension and coronary artery disease, and cardiomyopathy and congestive heart failure associated with cocaine use. However, the examiner still reached the same conclusions. The examiner reasoned that there was no medical basis for substance abuse negatively affecting the Veteran's vascular system causing type II diabetes mellitus; they are entirely unrelated. Diabetes mellitus is an endocrine disorder primarily caused by cells in muscle, fat, and the liver becoming resistant to insulin, and the pancreas inability to produce enough insulin to manage blood sugar levels.

Finally, the examiner determined that there is no relationship between the Veteran's diabetes and his cardiovascular conditions. The Veteran's diabetes mellitus preceded the hypertension and coronary artery disease, congestive heart failure, and cardiomyopathy by greater than 15 years.

The Board finds the July 2021, January 2022, May 2022, September 2022, November 2022, and December 2022 opinions (in the aggregate) to be highly probative. The opinions were based on review of the claims file and relevant facts, and the examiners provided detailed rationales.

To the extent that the Veteran has stated that he has type II diabetes mellitus attributable to his service-connected substance abuse disorder associated with his service-connected acquired psychiatric disorder, the Board finds that he is competent to report on his symptoms and that of which he has personal knowledge, but he is not competent to provide an opinion as to the etiology of the disability because such a question is not answerable by the application of knowledge within the realm of a lay person. See Layno, 6 Vet. App. at 469-70; Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Therefore, the Board finds that the Veteran is not competent to relate his current type II diabetes mellitus to his service-connected substance abuse disorder associated with his service-connected acquired psychiatric disorder.

In light of the foregoing, the Board concludes that the evidence in this case is neither evenly nor approximately balanced. Rather, it persuasively weighs against service connection. The benefit of the doubt doctrine (38 C.F.R. § U.S.C. § 5107(b)) is therefore not for application. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc) (only when the evidence persuasively favors one side, or another is the benefit of the doubt doctrine not for application). Service connection for type II diabetes mellitus is denied.

S.C. Krembs

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board J. Smith-Jennings, 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.

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