DIABETES MELLITUS

Summary

The veteran, who served from February 2009 to December 2013, appeals the denial of service connection for type II diabetes. The veteran contended that his diabetes was secondary to his service-connected PTSD, insomnia, shin splints, and related medications, exacerbated by weight gain due to inactivity and stress. The Board reviewed service treatment records, VA examinations, and the veteran's statements. Service treatment records indicated pain with running during basic training and later foot injury, while VA examinations for PTSD noted insomnia and fatigue. The Board previously remanded the claim for a new medical opinion. The March 2021 VA examination concluded that the veteran's diabetes was less likely than not caused or aggravated by his service-connected conditions. The examiner cited the veteran's genetic predisposition to type II diabetes, his ability to lose weight through exercise and diet, and noted that his medications did not cause obesity or impair his ability to exercise. The Board found the March 2021 opinion adequate, noting it addressed the veteran's specific contentions and cited relevant medical principles. The Board found the veteran's genetic history and ability to manage weight persuasive, concluding that the evidence did not establish a service connection. Service connection for diabetes is denied.

Rationale

March 2021 VA examiner opinion found diabetes less likely than not caused/aggravated by service-connected conditions.; Examiner cited genetic predisposition and veteran's ability to manage weight through diet and exercise.; Board found the March 2021 opinion adequate and persuasive.

Full Decision Text

Citation Nr: 23017996
Decision Date: 03/22/23	Archive Date: 03/22/23

DOCKET NO. 18-51 175
DATE: March 22, 2023

ORDER

Service connection for diabetes is denied.

FINDING OF FACT

The Veteran's type II diabetes was less likely than not caused or aggravated by his service-connected disabilities, to include medication to treat these disabilities and consideration of obesity as an intermediary step. 

CONCLUSION OF LAW

The criteria for service connection for diabetes mellitus, type II have not been met.  38 U.S.C. § 1110, 5107; 38 C.F.R. § 3.102, 3.303, 3.310.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty from February 2009 to December 2013.

The case is on appeal from an April 2017 rating decision.

The Board previously remanded this appeal for a new medical opinion as to the etiology of the Veteran's diabetes.  As discussed below, the Board finds that the March 2021 medical opinions are adequate and that there has been substantial compliance with the Board's remand directives.  See Stegall v. West, 11 Vet. App. 268 (1998).

Service Connection

Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service.  See 38 U.S.C. § 1110; 38 C.F.R. § 3.303.  A veteran seeking compensation under these provisions must establish three elements: "(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."  Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)).

Service connection may also be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury.  See 38 C.F.R. § 3.310.  Obesity, while not itself a disease, can be an intermediate step which leads to a service-connected disability causing or aggravating a claimed disorder.  VAOPGCPREC 1-2017 (Jan. 6, 2017); Walsh v. Wilkie, 32 Vet. App. 300 (2020).

Service connection for diabetes

The Veteran was diagnosed with type II diabetes in January 2017.  The Veteran is service connected for posttraumatic stress disorder (PTSD, primary insomnia, and shin split residuals.  In his June 2017 notice of disagreement, the Veteran stated, "Diabetes mellitus type II is secondary to his service-connected shin splints and/or his lack of energy related to PTSD/Depression/Insomnia.  After deployment, the Veteran gained a considerable amount of weight as a result of inactivity and sleep issues and developed diabetes mellitus type II."

Service treatment records from February 2010 reveal that the Veteran began to experience pain with running during basic training and that running would aggravate shin pain.  A July 2014 VA treatment record reveals that the Veteran had right leg pain that comes and goes and could not run when the leg is painful.  By October 2014, the Veteran had begun running again but suffered an injury his left foot during a morning run.  VA examinations of the Veteran's PTSD in March 2013 and December 2015 reveal that the Veteran's PTSD is productive of insomnia and fatigue.  

The Veteran was first afforded a VA examination of his diabetes in July 2018.  The examiner opined that the Veteran's diabetes was less likely than not caused by his service-connected disabilities.  The causes of diabetes were identified as genetics, lifestyle, lack of exercise, and an unhealthy diet.  Further, the service-connected disorders were not medically related to the Veteran's diabetes as they were entirely separate entities.

A May 2019 VA treatment record revealed that the Veteran had gained weight and that the Veteran has started running again two months previously.  However, the Veteran had surgery to repair an umbilical hernia in November 2019 and was restricted to lifting no more than 10 pounds for six weeks.  A VA treatment record from December 2019 indicated that the Veteran would continue exercising and dieting to lose weight.

The Board previously remanded this claim for a new medical opinion in August 2020.  The Veteran was afforded a VA examination of his diabetes in
 lifestyle, lack of exercise, and an unhealthy diet.  Further, the service-connected disorders were not medically related to the Veteran's diabetes as they were entirely separate entities.

A May 2019 VA treatment record revealed that the Veteran had gained weight and that the Veteran has started running again two months previously.  However, the Veteran had surgery to repair an umbilical hernia in November 2019 and was restricted to lifting no more than 10 pounds for six weeks.  A VA treatment record from December 2019 indicated that the Veteran would continue exercising and dieting to lose weight.

The Board previously remanded this claim for a new medical opinion in August 2020.  The Veteran was afforded a VA examination of his diabetes in March 2021.  The Veteran stated that after returning from Afghanistan, he could not do cardio exercise and started gaining weight because of stress fractures and insomnia related to PTSD.  The Veteran also revealed that his maternal grandmother and maternal uncles are type II diabetics.  

The examiner opined that the Veteran's diabetes was less likely than not caused or aggravated by his service-connected PTSD with insomnia, shin splints, or medication taken to treat these service-connected disabilities.  The causes of type II diabetes were identified as a genetic/family history and obesity from a sedentary lifestyle and lack of exercise.  The Veteran had been diagnosed with diabetes in January 2017.  By September 2017, the Veteran had lost 19 pounds, evidencing that the Veteran could lose weight by exercising and controlling his diet.  There were no treatment records indicating that the Veteran's medication would cause obesity.  Further, there were many ways to do exercise and watch diet to control body weight.

The Board finds that the Veteran's diabetes was less likely than not caused or aggravated by his service-connected PTSD, insomnia, or shin splints, including any medication for such disabilities and with obesity as an intermediary step.  First, the Board finds that the March 2021 VA examiner's medical opinion is adequate to address the claim.  Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008).  Specifically, the examiner cited to the relevant medical principles and applied those principles to the Veteran's health history.  In doing so, the examiner addressed the Veteran's specific contentions that his shin splints, fatigue, and PTSD caused him to become inactive which led to obesity and to his type II diabetes.  However, the examiner noted that the Veteran had a genetic pre-disposition to developing diabetes with his maternal grandmother and maternal uncles having type II diabetes.  Further, as noted by the VA examiner and VA treatment records, the Veteran has been able to exercise and control his diet to lose weight.  Though the Veteran's shin splints may cause pain which is aggravated by running, the Veteran has shown that he can exercise and control diet to lose weight.  Finally, the Veteran's medications to treat his service-connected disabilities have been identified as not causing fatigue or impairing the ability to exercise.  Though the Veteran has stated his belief that his fatigue from PTSD and insomnia and leg pain from shin splints caused or aggravated his diabetes as a result of weight gain, he does not have the medical expertise to draw a conclusion on a complex medical question like the etiology of diabetes.  See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007).  Therefore, the Board finds that the Veteran's diabetes was less likely than not caused or aggravated by his service-connected disabilities, and service connection for diabetes is denied.

 

 

TRACIE N. WESNER

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	J. George

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.