DIABETES MELLITUS

Summary

The Veteran, who served from August 1983 to May 1987, appeals the denial of service connection for diabetes mellitus, type II, and seeks service connection for a low back disability and a right foot disability, including secondary claims for both. The Board granted service connection for diabetes mellitus, type II, on a secondary basis to service-connected PTSD. The Veteran asserted that his diabetes was caused by in-service stress and his PTSD. While service treatment records were silent for diabetes during service, the Veteran provided lay statements linking the condition to in-service stress and mental breakdown. Multiple VA examinations were conducted. The December 2019 and June 2023 examinations provided unfavorable nexus opinions, stating the condition was less likely than not related to service or aggravated by PTSD. However, the December 2023 examination provided a favorable opinion, stating it was at least as likely as not that PTSD caused the diabetes, supported by medical literature. The March 2024 addendum provided an unfavorable opinion, citing lack of strong causal evidence. The Board found the evidence in approximate balance between the favorable December 2023 opinion and the unfavorable June 2023 and March 2024 opinions. Applying the benefit of the doubt, the Board granted service connection for diabetes mellitus, type II, as secondary to PTSD. The claims for low back and right foot disabilities were remanded for further development, as the prior VA examinations were found inadequate. Specifically, the back claim remand requires addressing degenerative changes noted in a 1993 record, and the foot claim remand requires addressing aggravation by the service-connected ankle condition.

Rationale

Favorable VA opinion (December 2023) found PTSD caused diabetes; Unfavorable VA opinions (June 2023, March 2024) found no causal link; Evidence in approximate balance, benefit of doubt applied

Full Decision Text

Citation Nr: 24024781
Decision Date: 06/28/24	Archive Date: 06/28/24

DOCKET NO. 19-10 566
DATE: June 28, 2024

ORDER

Entitlement to service connection for diabetes mellitus, type II, including as secondary to service-connected posttraumatic stress disorder (PTSD), is granted.

REMANDED

Entitlement to service connection for a low back disability is remanded.

Entitlement to service connection for a right foot disability, including as secondary to service-connected residuals, fracture, right ankle, with instability and degenerative arthritis, is remanded.

FINDING OF FACT

The Veteran's claimed diabetes mellitus, type II, was caused by his service-connected PTSD.  

CONCLUSION OF LAW

The criteria for service connection for diabetes mellitus, type II, on the basis of secondary service connection (causation), have been met.  38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.310.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty from August 1983 to May 1987.

This matter is before the Board of Veterans' Appeals (Board) on appeal of a February 2018 rating decision of the Department of Veterans Affairs (VA).

The claim for service connection for diabetes mellitus, type II, including as secondary to service-connected PTSD, was remanded by the Board in August 2019, May 2023 and August 2023 for further development.  Stegall v. West, 11 Vet. App. 268, 271 (1998).

The claims for service connection for a low back disability and service connection for a right foot disability, including as secondary to service-connected residuals, fracture, right ankle, with instability and degenerative arthritis, were last before the Board in May 2023 whereupon the Board issued a decision denying entitlement to service connection for the conditions.  The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court).  In a Joint Motion for Remand (JMR) in January 2024, the Court vacated the Board's decision of the appealed issues and remanded the issues to the Board with directions to further develop the file in support of the Veteran's claim.  These claims will be further addressed in the REMAND section of this decision.

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.  "To establish a right to compensation for a present disability, a veteran must show: "(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"-the so-called "nexus" requirement."  Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)).  Secondary service connection may be granted for a disability that is proximately due to, the result of, or aggravated by an established service-connected disability.  38 C.F.R. § 3.310; see also Allen v. Brown, 7 Vet. App. 439 (1995).

The Veteran asserts that his claimed diabetes mellitus, type II, is due to in-service stress and his service-connected PTSD.  In an April 2019 statement, the Veteran reported that his diabetes condition was a result of the trauma and stress he experienced while at a Naval Base, which included false allegations against him which caused a mental break down that commenced in a deterioration to the point of his incurring diabetes.  In his April 2019 Substantive Appeal, the Veteran noted that during service, he was confined during his pre-trial, which lead to mental deterioration that caused his diabetes mellitus.  

Service treatment records do not show complaints or treatment for diabetes mellitus, type II, problems while in service.  A post-service diagnosis of diabetes mellitus, type II, is of record. 

The Veteran underwent a VA diabetes mellitus examination in December 2019.  A diagnosis of diabetes mellitus, type II, was provided.  The VA examiner noted a review of the claims file.  The VA examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness
 his April 2019 Substantive Appeal, the Veteran noted that during service, he was confined during his pre-trial, which lead to mental deterioration that caused his diabetes mellitus.  

Service treatment records do not show complaints or treatment for diabetes mellitus, type II, problems while in service.  A post-service diagnosis of diabetes mellitus, type II, is of record. 

The Veteran underwent a VA diabetes mellitus examination in December 2019.  A diagnosis of diabetes mellitus, type II, was provided.  The VA examiner noted a review of the claims file.  The VA examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness.  The VA examiner stated that while the Veteran did have a diagnosed condition, it was over 30 years since his last active duty date when the Veteran was diagnosed.  There was no available evidence to support a direct relation between the diabetes mellitus, type II, and his active duty service.  A nexus was not established.

As noted in the May 2023 Board decision and remand, a review of the Veteran's treatment records showed that the Veteran was first diagnosed with diabetes mellitus in July 1997.  The Board found at that time that the December 2019 VA examiner did not acknowledge the 1997 diagnosis and did not address whether the Veteran's condition was related to his service-connected psychiatric disability.   As such, another opinion was requested.  

The Veteran underwent a VA diabetes mellitus examination in June 2023.  A diagnosis of diabetes mellitus, type II, was provided.  The VA examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness.  The VA examiner stated that the medical records during the service period were silent for any condition of stress.  The VA examiner also opined that the claimed condition was less likely than not proximately due to or the result of the Veteran's service-connected condition.  The VA examiner stated that it was not medically well-known that a psychiatric disorder, PTSD, triggered an endocrinological disorder, diabetes mellitus, type II, directly.  The VA examiner also opined that the claimed condition was less likely than not caused by the indicated toxic exposure risk activity(ies) (TERA), after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all toxic exposure risk activities of the Veteran.  It was noted that a TERA memorandum associated with the claims file showed that the Veteran was exposed only to noise, vibration, radiation occasionally, which was not medically well known for a relationship with diabetes mellitus, type II.  

Subsequently, as noted in the August 2023 Board remand, the Board found that the June 2023 opinion was insufficient as the VA examiner exclusively relied on the lack of service treatment records showing treatment for stress during active duty, while not considering the Veteran's lay statements concerning the onset and continuity of his symptoms.  In addition, the VA examiner failed to address whether the Veteran's diabetes mellitus, type II, condition was aggravated by his service-connected PTSD.  As such, another opinion was requested.  

The Veteran underwent a VA diabetes mellitus examination in January 2024.  A diagnosis of diabetes mellitus, type II.  The VA examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness.  The VA examiner stated that there was no medical evidence found in the service treatment records to support the diagnosis of diabetes during service.  While he may have been stressed due to court-martial and subsequent incarceration, there was no evidence of elevated blood sugars during that time.  Nor was there any medical evidence of complaint and/or treatment for the stated "stress".  

The VA examiner then opined that the claimed condition was at least as likely than not proximately due to or the result of the Veteran's service-connected PTSD.  The VA examiner stated that there was known medical evidence showing that mental health disorders increased the risk of diabetes.  Therefore, a positive nexus existed.  The VA examiner included references to three published articles/literature in support of the opinion.  The VA examiner also opined that the claimed diabetes mellitus, type II, was less likely than not aggravated beyond its natural progression by the Veteran's service- connected PTSD as the evidence did not show that it had increased in severity from the baseline.  It was noted that the Veteran had uncontrolled diabetes mellitus in 1997 and continued to have uncontrolled diabetes mellitus to date.  

Subsequently in March 2024, a memorandum from the AOJ was associated with the file noting that a new diabetes opinion was needed because the December 2023 secondary opinion conflicted with the June
 diabetes.  Therefore, a positive nexus existed.  The VA examiner included references to three published articles/literature in support of the opinion.  The VA examiner also opined that the claimed diabetes mellitus, type II, was less likely than not aggravated beyond its natural progression by the Veteran's service- connected PTSD as the evidence did not show that it had increased in severity from the baseline.  It was noted that the Veteran had uncontrolled diabetes mellitus in 1997 and continued to have uncontrolled diabetes mellitus to date.  

Subsequently in March 2024, a memorandum from the AOJ was associated with the file noting that a new diabetes opinion was needed because the December 2023 secondary opinion conflicted with the June 2023 opinion.  In addition, the December 2023 rationale was without clinically based medical peer review literature relating the pathophysiology and etiology of diabetes mellitus.  

A March 2024 VA medical addendum reflects that the 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 VA examiner noted a review of the record and stated that while there were studies that suggested a possible relationship between diabetes mellitus and PTSD, there was no significant evidence that suggested a causal relationship between the development of diabetes mellitus from having the Veteran's service-connected conditions.  A reference to two published articles/literature in support of the opinion was included.   The VA examiner noted that while PTSD could lead to behaviors that promoted binge eating, substance abuse, or lack of drive for exercise, the Veteran's current obesity could not be attributed to just his service-connected condition alone, as it was the result of his lifestyle choices which he had through the years that continued to lead to an excess of calories and weight gain.   

While the competent evidence of record contains no opinion supporting direct service connection or secondary service connection based upon aggravation, the Board has reviewed the June 2023, December 2023 and March 2024 VA opinions and finds that the evidence is in approximate balance as to whether the Veteran's service-connected PTSD caused his diabetes mellitus, type II.  The June 2023 and March 2024 VA opinions are unfavorable in this regard.  At the same time, the December 2023 VA examiner's opinion is favorable regarding the same theory.  Both the positive December 2023 and negative March 2023 opinions are supported by a detailed medical literature.

The mandate to accord the benefit of the doubt is triggered when the evidence has reached a stage of equipoise.  In this matter, as there is competent medical evidence both in favor of and against the claim, the Board is of the opinion that this point has been attained.  38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001).  As such, after resolving all reasonable doubt in the Veteran's favor, the Board determines that the Veteran's service-connected PTSD caused his diabetes mellitus, type II.  This claim is thus granted in full.

REASONS FOR REMAND

Regarding the claims for service connection for a low back disability and service connection for a right foot disability, including as secondary to service-connected residuals, fracture, right ankle, with instability and degenerative arthritis, in its January 2024 JMR, the Court noted that the Board failed to ensure that VA provided the Veteran with an adequate medical examination regarding the issues on appeal.  For the claim for a low back disability, the Court indicated that a February 1986 Medical History Report and a July 1986 Medical History Report, which was not completely filled out, reflected that the Veteran noted that he did not experience any swollen or painful joints or recurrent back pain.  The Court also noted that the Veteran underwent a VA back conditions examination in December 2019.  The VA examiner noted that the record had been review; however, the VA examiner failed to address a September 1993 record which noted degenerative changes in the lower lumbar spine.  For the claim for a right foot disability, the Court indicated that the Veteran underwent a VA foot conditions examination in December 2019.  The VA examiner was requested to opine as to whether the claimed right foot condition was caused or aggravated by his service-connected right ankle disability.  It was noted that while the VA examiner provided a negative opinion as to causation, the VA examiner did not address aggravation. 

As the Court has remanded the issues and based on the evidence above, the Board finds that additional development of the record is needed.  Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); see also El-Amin v. Shinseki,
 the lower lumbar spine.  For the claim for a right foot disability, the Court indicated that the Veteran underwent a VA foot conditions examination in December 2019.  The VA examiner was requested to opine as to whether the claimed right foot condition was caused or aggravated by his service-connected right ankle disability.  It was noted that while the VA examiner provided a negative opinion as to causation, the VA examiner did not address aggravation. 

As the Court has remanded the issues and based on the evidence above, the Board finds that additional development of the record is needed.  Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); see also El-Amin v. Shinseki, 26 Vet. App. 136 (2013). 

The matters are REMANDED for the following action:

1. Return the Veteran's claim folder to the examiner who conducted the December 2019 VA back conditions examination for an addendum opinion.  

(a.) If an additional examination is deemed necessary, one should be scheduled.  If the prior examiner is not available, the file must be forwarded to another examiner to obtain the requested opinion.

(b.) Based on the review of the record, to include the Court's January 2024 JMR and this remand, the examiner should specifically address whether it is at least as likely as not (at least an approximate balance of positive and negative evidence) that the diagnosed low back disability had its onset during, or is otherwise related to, the Veteran's active duty service.  

(c.) In rendering the opinion, the examiner must consider and discuss the September 1993 medical record which showed that a supine view of the Veteran's abdomen demonstrated degenerative changes in the lower lumbar spine. 

2. Return the Veteran's claim folder to the examiner who conducted the December 2019 VA foot conditions examination for an addendum opinion.  If the prior examiner is not available, the file must be forwarded to another examiner to obtain the requested opinion.

(a.) If an additional examination is deemed necessary, one should be scheduled.  

(b.) Based on the review of the record, to include the Court's January 2024 JMR and this remand, the examiner should provide opinions as to the following:

(i.)	    Is it at least as likely as not (at least an approximate balance of positive and negative evidence) that the Veteran's right foot disability was caused by his service-connected right ankle disability?

(ii.)	Is it at least as likely as not (at least an approximate balance of positive and negative evidence) that the Veteran's right foot disability was aggravated (increased in severity beyond the natural progress of the condition) by his service-connected right ankle?  If aggravation is found, the examiner should provide the baseline manifestations of the Veteran's right foot disability found prior to aggravation and the increased manifestations which, in the examiner's opinion, resulted from the service-connected right ankle disability.

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3. All opinions must be based upon a claims file review and must be supported by a rationale.

 

	 

Timothy Cothrel

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Evans, A-L

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.