Back to BVA DecisionsGRANTEDSpecial Benefit NO SPECIAL BENEFIT Docket No. 16-25 386
DIABETES MELLITUS
JOHN Z. JONES · 2023 · Case ID: 23023833
Summary
The Veteran served on active duty from August 1968 to June 1970. This case involves appeals for service connection for diabetes mellitus, peripheral neuropathy of the bilateral upper and lower extremities, sleep apnea, coronary artery disease (CAD), and hypertension. The Veteran contended that these conditions were either caused by service or, in the alternative, secondary to his service-connected post-traumatic stress disorder (PTSD). The Board found that service connection was warranted for all five conditions, primarily on a secondary basis due to aggravation by PTSD. Key evidence included June 2022 VA examination opinions that linked diabetes mellitus, peripheral neuropathy, sleep apnea, CAD, and hypertension to PTSD, citing research on the association between PTSD, inflammation, obesity, and these conditions. While acknowledging some negative opinions from December 2022 that questioned the link through obesity, the Board found the positive and negative evidence to be in relative equipoise for each claim. Applying the benefit of the doubt doctrine, service connection was granted for all conditions. Specifically, diabetes mellitus, peripheral neuropathy, sleep apnea, CAD, and hypertension were all granted service connection, with the latter four being secondary to PTSD.
Rationale
Aggravated by service-connected PTSD; Positive VA opinion linking PTSD to diabetes risk factors (obesity, inflammation); Equipoise between positive and negative evidence, resolved in Veteran's favor
Full Decision Text
Citation Nr: 23023833 Decision Date: 04/25/23 Archive Date: 04/25/23 DOCKET NO. 16-25 386 DATE: April 25, 2023 ORDER Service connection for diabetes mellitus is granted. Service connection for peripheral neuropathy of the bilateral upper and lower extremities is granted. Service connection for sleep apnea is granted. Service connection for coronary artery disease (CAD) is granted. Service connection for hypertension is granted. FINDINGS OF FACT 1. The Veteran's diabetes mellitus is aggravated by his service-connected posttraumatic stress disorder (PTSD). 2. The Veteran's peripheral neuropathy of the bilateral upper and lower extremities is caused by his service-connected diabetes mellitus. 3. The Veteran's sleep apnea is aggravated by his service-connected PTSD. 4. The Veteran's CAD is aggravated by his service-connected PTSD. 5. The Veteran's hypertension is aggravated by his service-connected PTSD. CONCLUSIONS OF LAW 1. The criteria for service connection for diabetes mellitus have been met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.102, 3.310. 2. The criteria for service connection for peripheral neuropathy of the bilateral upper and lower extremities have been met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.102, 3.310. 3. The criteria for service connection for sleep apnea have been met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.102, 3.310. 4. The criteria for service connection for CAD have been met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.102, 3.310. 5. The criteria for service connection for hypertension have been met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1968 to June 1970. This matter comes to the Board of Veterans' Appeals (Board) from a July 2016 rating decision of a Department of Veterans Affairs (VA) Regional Office. In November 2018, the Board remanded the claims for the issuance of a statement of the case (SOC), pursuant to Manlincon v. West, 12 Vet. App. 238, 240-41 (1999); the SOC was issued in June 2020. The Board remanded the claims in June 2021 for additional development. The additional development has been completed as directed and the claim is returned to the Board for adjudication. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.304. Generally, service connection requires (1) medical evidence of a current disability, (2) medical evidence, or in certain circumstances lay testimony, of in-service incurrence or aggravation of an injury or disease, and (3) medical evidence of a nexus between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); Hickson v. West, 12 Vet. App. 247 (1999); Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may be granted where a disability is proximately due to or the result of, or aggravated by, a service-connected disability. 38 C.F.R. § 3.310. Compensation is payable when a service-connected disability has aggravated a nonservice-connected disorder. Allen v. Brown, 7 Vet. App. 439 (1995). Diabetes mellitus The Veteran asserts that his diabetes mellitus is caused by service, or in the alternative, caused or aggravated by his service-connected disabilities. As the Board finds that service connection is warranted on a secondary basis, only this theory of entitlement will be addressed. The VA treatment records indicate that the Veteran has been diagnosed with diabetes as early as August 2013; therefore, the first element of service connection is met. He is service connected for PTSD; therefore, the second element of secondary service connection is also met. Thus, the question before the Board is whether the Veteran's diabetes mellitus is caused or aggravated by service-connected PTSD. A June , 7 Vet. App. 439 (1995). Diabetes mellitus The Veteran asserts that his diabetes mellitus is caused by service, or in the alternative, caused or aggravated by his service-connected disabilities. As the Board finds that service connection is warranted on a secondary basis, only this theory of entitlement will be addressed. The VA treatment records indicate that the Veteran has been diagnosed with diabetes as early as August 2013; therefore, the first element of service connection is met. He is service connected for PTSD; therefore, the second element of secondary service connection is also met. Thus, the question before the Board is whether the Veteran's diabetes mellitus is caused or aggravated by service-connected PTSD. A June 2022 VA examiner opined that the Veteran's PTSD is at least as likely as not aggravated beyond its natural progression by the Veteran's PTSD. She cited to research and explained that "research shows there is increased risk for diabetes and the association may be explained by "high prevalence of obesity, glucose dysregulation, inflammation, the metabolic syndrome, depression, and other T2D risk factors among those with verus without PTSD." She also noted that it is likely that PTSD could contribute to widespread inflammation in the body and lower sensitivity to the blood sugar regulating hormone insulin which leads to diabetes. Additionally, the June 2022 VA examiner noted that the Veteran's body mass index (BMI) was 25.3 and that PTSD is associated with weight gain and overweight/obesity. She further explained that being overweight raises the risk for type 2 diabetes, heart disease, and stroke, and opined that the Veteran's obesity is an intermediate step between his PTSD and diabetes mellitus. The Board finds this positive opinion probative and adequate to find that service connection is warranted for diabetes mellitus, secondary to service-connected PTSD. The Board acknowledges the negative December 2022 VA opinion which determined that the Veteran's obesity was not caused by any of the service-connected conditions, and that his diabetes mellitus was not caused by the "claimed obesity caused or aggravated by the service-connected post-traumatic stress disorder, right knee strain with patellofemoral pain syndrome and degenerative arthritis or left knee strain with patellofemoral pain syndrome and degenerative arthritis." However, the Board finds that the positive and negative evidence is at least in relative equipoise. As such, all reasonable doubt is resolved in the Veteran's favor, and service connection for diabetes mellitus is granted. Peripheral neuropathy of the bilateral upper and lower extremities At a June 2022 diabetic sensory-motor peripheral neuropathy examination, the examiner indicated that the Veteran had bilateral upper and lower extremity peripheral neuropathy. The examiner opined that peripheral neuropathy of the bilateral upper and lower extremities was at least as likely as not caused by service-connected diabetes mellitus. Citing to research, she also opined that the neuropathy was at least as likely as not aggravated beyond its natural progression by PTSD because research concludes that veterans with PTSD have increase in neuropathic pain. As the Board has granted service-connection for diabetes mellitus in this decision, service connection for peripheral neuropathy of the bilateral upper and lower extremities is warranted based on the positive June 2022 VA opinion and the claim is granted. Sleep apnea The Veteran was diagnosed with severe sleep apnea in March 2017. He contends that his sleep apnea is caused or aggravated by his service-connected PTSD. A June 2022 VA examiner cited research that indicated that PTSD can worsen sleep apnea and its severity. She determined that the Veteran most likely suffers from nightmares and insomnia related to the PTSD which causes his obstructive sleep apnea and opined that the Veteran's sleep apnea is at least as likely as not aggravated beyond its natural progression by his PTSD. The Board acknowledges the December 2022 VA opinion that "the claimed obesity as a result of the service-connected posttraumatic stress disorder, right knee strain with patellofemoral pain syndrome and degenerative arthritis or left knee strain with patellofemoral pain syndrome and degenerative arthritis was less likely than not a substantial factor in causing or aggravating the sleep apnea." However, the Board finds that the positive and negative evidence is at least in relative equipoise. As such, all reasonable doubt is resolved in the Veteran's favor, and service connection for sleep apnea is granted. CAD The Veteran has been diagnosed with CAD. He asserts that CAD is caused or aggravated by service, or in the alternative, secondary to one of his service-connected disabilities, to include PTSD. A July 2022 VA examiner provided a positive nexus opinion, indicating that the Veteran's CAD is at least as likely as not caused or aggravated by PTSD. She explained that PTSD is known to lead to central obesity, brain changes, and likely changes in appetite than not a substantial factor in causing or aggravating the sleep apnea." However, the Board finds that the positive and negative evidence is at least in relative equipoise. As such, all reasonable doubt is resolved in the Veteran's favor, and service connection for sleep apnea is granted. CAD The Veteran has been diagnosed with CAD. He asserts that CAD is caused or aggravated by service, or in the alternative, secondary to one of his service-connected disabilities, to include PTSD. A July 2022 VA examiner provided a positive nexus opinion, indicating that the Veteran's CAD is at least as likely as not caused or aggravated by PTSD. She explained that PTSD is known to lead to central obesity, brain changes, and likely changes in appetite hormones. The brain and appetite hormone changes may be moderating the connection between PTSD and central obesity. In turn, central obesity leads to known changes and comorbidities. As such, CAD is caused or aggravated by PTSD. In September 2022, the examiner provided an addendum opinion and reiterated that the Veteran's CAD was at least as likely as not aggravated beyond its natural progression by PTSD. The Board acknowledges the December 2022 VA opinion that obesity was not caused by any service-connected conditions and that there is no competent medical evidence showing that the Veteran's heart disorder "would not have occurred but for the obesity caused by a service-connected disability. "However, the Board finds that the positive and negative evidence is at least in relative equipoise. As such, all reasonable doubt is resolved in the Veteran's favor, and service connection for CAD is granted. Hypertension The Veteran has been diagnosed with hypertension. He contends that his hypertension is caused by service, or in the alternative, caused or aggravated by service-connected disabilities, to include PTSD. The June 2022 VA examiner opined that the Veteran's hypertension is at least as likely as not aggravated beyond its natural progression by his PTSD. The examiner cited research and explained that previous studies have linked PTSD to increased risk for conditions like high blood pressure, heart disease and death, and indicated that the Veteran's PTSD results in higher levels of inflammatory markers which, therefore, increases blood pressure. The Board acknowledges the December 2022 VA opinion that the Veteran's obesity was not caused by any service-connected conditions and therefore, his hypertension was not caused by obesity because of a service-connected disability. (Continued on the next page) ? However, the Board finds that the positive and negative evidence is at least in relative equipoise. As such, all reasonable doubt is resolved in the Veteran's favor, and service connection for hypertension is granted. JOHN Z. JONES Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Hemphill, A 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.