DIABETES MELLITUS

K. CONNER · 2026 · Case ID: 26002664

DENIED

Summary

The veteran, who served in the U.S. Navy from September 1990 to September 1994, appeals the denial of service connection for diabetes mellitus. The veteran contended that diabetes developed during service in Southwest Asia or was secondary to service-connected hypertension. The Board found that the veteran's service treatment records (STRs) did not indicate the presence of diabetes during service, showing normal endocrine system and urinalysis results at enlistment and separation. The initial diagnosis of diabetes mellitus occurred in 2000, six years after service, with private records later indicating onset around that time. The Board considered a private physician's letter suggesting diabetes was a comorbid condition with hypertension, but found this insufficient to establish a nexus. VA examinations consistently found that diabetes was less likely than not related to service, citing a lack of in-service abnormalities and no medical literature supporting hypertension causing diabetes. While the veteran was presumed exposed to burn pits and other toxins (BPOT) due to Southwest Asia service, the VA examiner concluded that no medical evidence demonstrates a link between BPOT exposure and diabetes, dismissing a submitted article as correlative without direct causation. The Board found the VA opinions persuasive, particularly the July 2023 opinion which cited the veteran's obesity and family history as the cause of diabetes, and found no evidence linking it to service or hypertension. Service connection for diabetes mellitus was denied.

Rationale

No in-service complaints, findings, treatment, or diagnoses of diabetes.; STRs show normal endocrine system and urinalysis at separation.; Initial diagnosis post-service in 2000; private records suggest onset around that time.; VA opinions consistently found diabetes less likely than not related to service.; No medical literature supports hypertension causing or aggravating diabetes.; BPOT exposure not causally linked to diabetes by medical literature.; Diabetes attributed to obesity and family history.

Service Branch

NAVY

Special Benefit

NO SPECIAL BENEFIT

Docket No.

17-16 158

Full Decision Text

Citation Nr: 26002664
Decision Date: 02/25/26 Archive Date: 02/25/26

DOCKET NO. 17-16 158
DATE: February 25, 2026

ORDER

Entitlement to service connection for diabetes mellitus is denied.

FINDING OF FACT

The evidence persuasively weighs against finding that the Veteran's diabetes mellitus had its onset in active service, manifested to a compensable degree within one year of separation from active duty, is otherwise causally related to an in-service injury or disease, or is caused or aggravated by service-connected disability.

CONCLUSION OF LAW

The criteria for entitlement to service connection for diabetes mellitus have not been met. 38 U.S.C. §§ 1110, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty in the United States Navy from September 1990 to September 1994.

This matter originally came before the Board of Veterans' Appeals (Board) on appeal from an August 2013 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO), which, in pertinent part, denied service connection for diabetes mellitus.

In July 2014, the Veteran submitted a Notice of Disagreement (NOD). In January 2017, the RO issued a Statement of the Case (SOC), and in March 2017, the Veteran perfected a timely appeal via his submission of a VA Form 9, Appeal to Board on which he requested an optional Board hearing.

In March 2020, the Veteran testified at a Board hearing before a Veterans Law Judge. A transcript of the hearing is of record.

In April 2020, December 2020, and June 2023, the Board remanded the claim for additional development of the evidence. Upon completion of the additional development, the RO issued a Supplemental Statement of the Case (SSOC) in February 2024, which denied service connection for diabetes mellitus. The claim was thereafter returned to the Board for further appellate review.

The Board finds that there has been substantial compliance with the Board's remand directives, as VA has obtained an adequate medical opinion. Neither the Veteran nor his representative has argued otherwise. Stegall v. West, 1 Vet. App. 268, 271 (1998).

In a January 2026 letter, the Board advised the Veteran that the Veterans Law Judge who had conducted the March 2020 hearing was no longer available and offered him the opportunity for another Board hearing. He was advised that if he did not respond within 30 days, the Board would assume that he did not want another Board hearing. Having received no response, the Board will proceed to consideration of the appeal.

Entitlement to service connection for diabetes mellitus.

The Veteran contends that he developed diabetes mellitus as a result of his active service in Southwest Asia. See March 2020 Board hearing transcript. Alternatively, the Veteran contends that his diabetes mellitus is secondary to his service-connected hypertension. Id.

Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 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 specifically enumerated chronic diseases, including diabetes mellitus, may be presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service, even though there is no evidence of such disease during service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309(a).

To establish service connection under this provision, there must be: evidence of a chronic disease shown as such in service (or within an applicable presumptive period under 38 C.F.R. § 3.307), and subsequent manifestations of the same chronic disease; or if the fact of chronicity in service is not adequately supported, by evidence of continuity of symptomatology after service. The provisions of 38 C.F.R. § 3.303(b) relating to continuity of
one year of discharge from service, even though there is no evidence of such disease during service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309(a).

To establish service connection under this provision, there must be: evidence of a chronic disease shown as such in service (or within an applicable presumptive period under 38 C.F.R. § 3.307), and subsequent manifestations of the same chronic disease; or if the fact of chronicity in service is not adequately supported, by evidence of continuity of symptomatology after service. The provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology, however, can be applied only in cases involving those conditions explicitly enumerated under 38 C.F.R. § 3.309 (a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).

Service connection may also be granted for a disability that is proximately due to, or aggravated by, a service-connected disability. 38 C.F.R. § 3.310. The three element test for secondary service connection requires evidence of: (1) a current disability; (2) a separate disability already service-connected; and (3) a causal relationship, i.e., a nexus, establishing that the current disability is due to, or aggravated beyond its natural progression by, the service-connected disability. See Allen v. Brown, 7 Vet. App. 439 (1995).

The Veteran's service treatment records (STRs) reflect that diabetes mellitus was not present during his period of active duty. A June 1990 enlistment Report of Medical Examination reflects that the Veteran's endocrine system was examined and determined to be normal. Urinalysis results reflect negative findings for albumin and sugar. On the accompanying report of medical history, the Veteran denied having, or ever having had, painful or frequent urination, sugar or albumin in his urine, or recent weight loss or gain. The STRs reflect that on multiple occasions during active duty, the Veteran denied having, or ever having had, diabetes. See STRs (dental) dated September 1990, September 1991, October 1992, January 1994, and August 1994. An August 1994 separation Report of Medical Examination reflects that the Veteran's endocrine system was again examined and again determined to be normal. Urinalysis results reflect negative findings for albumin and sugar. On the accompanying report of medical history, the Veteran denied having, or ever having had, painful or frequent urination, sugar or albumin in his urine, or recent weight loss or gain.

A December 2005, post-service private treatment note indicates that the Veteran was being treated for diabetes, the symptoms of which "began Year(s) ago," although no further information is provided. Subsequent clinical records, however, indicate that the Veteran's diabetes began in 2000. See e.g. July 2009, November 2012, and June 2013 private treatment records.

In March 2020, the Veteran submitted a letter from his private treating physician, Mohit Anand, M.D., who stated that the Veteran was currently under his care for hypertension and that it was at least as likely as not related to his service, noting that the Veteran's STRs indicated borderline hypertension at separation. Dr. Anand further stated that the Veteran "has diabetes that also goes along mutually with his high blood pressure as [a] comorbid condition."

The Veteran also submitted a medical article, published in March 2019, from the International Journal of Environmental Research and Public Health entitled "Rates of Chronic Medical Conditions in 1991 Gulf War Veterans Compared to the General Population." The article discusses a study that compared a cohort of Gulf War Veterans with self-reported toxicant exposure to a cohort of the general population and revealed that the Gulf War Veterans cohort were at significantly increased odds for reporting nine chronic conditions, including diabetes.

In October 2020, the Veteran was afforded a VA examination, at which time the examiner confirmed a diagnosis of diabetes mellitus type II, which he indicated was originally made in 1999. In an accompanying opinion, the examiner determined that, "[d]ue to the lack of documented abnormalities in metabolic testing prior to 1999, the current diabetes condition is less likely than not due to active duty military service." The examiner also opined that the Veteran's current diabetes is "less likely than not exacerbated by the hypertension condition from service." He reasoned that the medications used to treat the Veteran's hypertension, as well as the existence of elevated systemic vascular pressure, "are not directly associated
reporting nine chronic conditions, including diabetes.

In October 2020, the Veteran was afforded a VA examination, at which time the examiner confirmed a diagnosis of diabetes mellitus type II, which he indicated was originally made in 1999. In an accompanying opinion, the examiner determined that, "[d]ue to the lack of documented abnormalities in metabolic testing prior to 1999, the current diabetes condition is less likely than not due to active duty military service." The examiner also opined that the Veteran's current diabetes is "less likely than not exacerbated by the hypertension condition from service." He reasoned that the medications used to treat the Veteran's hypertension, as well as the existence of elevated systemic vascular pressure, "are not directly associated with the regulation of systemic glucose, insulin, incretins or significantly associated with changes in behavior or carbohydrate intake."

Following the Board's December 2020 remand, the RO obtained an addendum opinion regarding the etiology of the Veteran's diabetes mellitus in January 2021. The examiner indicated that he reviewed "the medical information provided, to include the remand letters, hearing transcripts and the efile." With respect to direct service connection, the examiner opined that it is less likely than not that the Veteran's diabetes mellitus was incurred in or caused by his active service. He reasoned that there was no lab data or subjective clinical complaints in the STRs that would support the onset of diabetes in, or related to, service. The examiner also opined that it is less likely than not that the Veteran's diabetes mellitus is proximately due to or the result of his service-connected hypertension. He reasoned that "the medical literature and clinical practice are pretty clear that the diabetes mellitus is a risk factor for developing hypertension. However, there is no know[n] correlation that HTN causes diabetes. There is a lot of overlap between their risk factors but on its own HTN is not a clinical known or acceptable etiology of diabetes." He also opined that it is less likely than not that the Veteran's diabetes mellitus is aggravated by his service-connected hypertension. He reasoned that "the medical literature and clinical practice are pretty clear that the diabetes mellitus is a risk factor for developing and worsening hypertension. However, there is no know[n] correlation that HTN aggravates diabetes. There is a lot of overlap between their risk factors and consequences of each condition but on its own HTN is not known clinically to worsen diabetes."

In January 2021, the RO obtained an addendum opinion. The examiner indicated that he reviewed the "medical information provided to include the remand letter, hearing transcript, the medical articles provided, the physician letter from 2020 and the rest of the efile." He opined that it is less likely than not that the Veteran's diabetes had onset in, or is otherwise related to, active service. He reasoned that "[t]here is no laboratory data or subjective clinical complaints in the STRs that would support the onset of diabetes in or related to service."

In February 2021, the RO obtained another addendum opinion. The examiner indicated that he reviewed the "medical information provided, to include the remand letters, hearing transcript, physician letter and gulf war articles and the efile." He opined that it is less likely than not that the Veteran's diabetes mellitus is caused by his service-connected hypertension. He offered the same rationale for secondary service connection and aggravation as he did in the first January 2021 addendum opinion.

In December 2022 and January 2023, VA issued memoranda confirming the Veteran had qualifying service meeting the definition of a "Persian Gulf Veteran" under 38 U.S.C. § 1117 with verified service in the Southwest Asia theater of operations that satisfied the criteria for presumptive toxic exposure under 38 U.S.C. § 1119.

In July 2023, VA issued a memorandum confirming the Veteran participated in a toxic exposure risk activity (TERA) by virtue of his service locations and dates.

Following the Board's June 2023 remand, the RO obtained an addendum opinion regarding the etiology of the Veteran's diabetes mellitus in July 2023. The examiner indicated that he reviewed the remand letter and 969-page efile . He opined that the Veteran's diabetes mellitus is less likely than not incurred in or caused by his active service. He reasoned that "[n]o permanent residual or chronic disability is shown by the service medical records or demonstrated by evidence immediately following discharge from the service. There is no evidence the service caused this condition in any way." The examiner also opined that it is less likely than not that the Veteran's diabetes mellitus is proximately due to or the result of his service-connected hypertension. The
remand, the RO obtained an addendum opinion regarding the etiology of the Veteran's diabetes mellitus in July 2023. The examiner indicated that he reviewed the remand letter and 969-page efile . He opined that the Veteran's diabetes mellitus is less likely than not incurred in or caused by his active service. He reasoned that "[n]o permanent residual or chronic disability is shown by the service medical records or demonstrated by evidence immediately following discharge from the service. There is no evidence the service caused this condition in any way." The examiner also opined that it is less likely than not that the Veteran's diabetes mellitus is proximately due to or the result of his service-connected hypertension. The examiner explained that diabetes mellitus type II is characterized by a combination of peripheral insulin resistance and inadequate insulin secretion by the pancreatic beta cells. He stated that "[a]t no point in the e-file were the DMII and HTN or HTN medications positively objectively correlated. The vet's DMII is due to a family history/genetic predisposition to DM and many years of being overweight which pathogenically has led to the development of DM. Assuming that either the HTN or the HTN medications caused the DM would be entirely speculative and does not consider actual scientific fact and research. HTN has never been determined to cause DM in any medical literature or in the entire efile."

In compliance with the PACT Act, the examiner also rendered a TERA opinion, in which he determined that the Veteran's diabetes mellitus is less likely than not caused by his service in Southwest Asia, 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. He reasoned that "[t]he vet's DM is due to many years of obesity and a family history of DM, which pathogenically have led to the development of DM. There is no evidence in the literature or job aid allowing for such a connection. The speculative article from March 2020 that suggests a link between Gulf War service and chronic conditions, including diabetes mellitus is not based on double blind studies and provides no conclusive link. It simply provides a correlative association without any objective direct evidence of causation and cannot be used to provide an objective, reproducible connection."

For the reasons set forth below, the Board finds that the evidence is persuasively against an award of service connection for diabetes mellitus.

With respect to the first element of service connection, a current disability, the evidence shows a current diagnosis of diabetes mellitus. See December 2005 private treatment note; October 2020 VA examination report. As such, the Board finds that the first element of a service connection claim has been met.

With respect to the second element, evidence of an in-service injury or disease, the Board finds that an in-service disease has not been established. The Veteran's STRs are silent for any complaints, findings, treatment, or diagnoses related to diabetes. Rather, the STRs affirmatively show that diabetes was not present during active service, given the normal endocrine system and laboratory testing at separation. VA examiners have explained that these findings established that diabetes was not present during active duty. Moreover, the Veteran's private treatment records reflect that the initial diagnosis of diabetes mellitus was made in 2000, six years after his separation from active service. This evidence persuasively supports a finding that diabetes mellitus did not have its inception during active duty or within one year of the Veteran's separation from active duty. The record contains no indication or contention of continuity of symptoms since service. Accordingly, service connection for diabetes on the basis that such became manifest in service and persisted, or on a presumptive basis (as a chronic disease under 38 C.F.R. § 1112 is not warranted.

With respect to an in-service injury, the Veteran is legally presumed to have been exposed to burn pits and other toxins (BPOT) by virtue of his service in Southwest Asia.

The record on appeal reflects that the Veteran is service connected for hypertension and, as such, the Board finds the second element of a secondary service connection claim has been met.

With respect to the question of nexus, the Board finds that the lay and medical evidence demonstrates that the Veteran's diabetes mellitus, which began after service, is not otherwise causally related to active service, or caused by or aggravated by a service-connected disability. The July 2023 VA examiner found that no permanent residual or chronic disability was shown in service or following separation from service. He considered that the Veteran was presumed exposed to BPOT through daily exposure, via inhalation, from 1991 to 1993. He concluded, however, that there is no medical or scientific evidence available that demonstrates a relationship between exposure to BPOT and the development of diabetes mellitus. The examiner specifically addressed the March 2019 article submitted by the Veteran and explained that it only provides a correlative association between Gulf War service and certain chronic conditions, without any objective direct evidence of causation. The Board finds the July 2023 VA opinion to be of significant probative value as the examiner reviewed the claims file, relied on facts that are consistent with the Board's findings of fact, addressed the Veteran's legally presumed exposure to BPOT, and supported the opinion by review of medical literature, which is against a causal relationship between the Veteran's diabetes mellitus and active service. There is no nexus opinion of record that supports an etiological relationship between the Veteran's diabetes mellitus and an in-service disease or injury to weigh against the VA examiner's opinion.

With respect to secondary service connection, the July 2023 VA examiner found that the Veteran's diabetes mellitus is due to many years of being overweight as well as his family history/genetic predisposition, not to his service-connected hypertension. He explained that hypertension 'has never been determined to cause DM in any medical literature or in the entire efile." The Board acknowledges that the examiner did not specifically indicate that he considered the March 2020 letter from the Veteran's private treating physician, although he did indicate that he reviewed the entire VA e-folder, which includes this letter. As such, the Board finds that there has been substantial compliance with the June 2023 remand directives. Critically, the Board finds that the March 2020 letter, stating that the Veteran's diabetes mellitus "goes along mutually with his high blood pressure as [a] comorbid condition," is not sufficient to grant the claim on a secondary service connection basis. The fact that the Veteran's diabetes mellitus is a "comorbid condition" in relation to his hypertension does not demonstrate that his hypertension caused or aggravated his diabetes mellitus. This is because morbidity "is a medical term that refers to the state of having a specific disease or condition. So, adding 'co' to the front of this word means two or more conditions occur together." Comorbidities, (https://my.clevelandclinic.org/health/articles/comorbidities) (last accessed February 20, 2026). As such, the March 2020 letter does nothing more than show that the Veteran had two separate and distinct conditions at the same time. It does not support a finding that the Veteran's service-connected hypertension caused or aggravated his diabetes and, as discussed above, the July 2023 VA examiner specifically explained that the medical literature does not support a causal relationship between hypertension and diabetes mellitus.

Finally, the Board has considered the evidence of record which indicates that the Veteran's diabetes is due to many years of obesity. In Garner v. Tran, 33 Vet. App. 241 (2021), the U.S. Court of Appeals for Veterans Claims (Court) held that in order to reasonably raise the theory of secondary service connection via obesity as an intermediate step, there must be some evidence in the record that draws an association or suggests a relationship between the Veteran's obesity, or weight gain resulting in obesity, and a service connected disability. In this case, the record on appeal does not suggest a relationship between the Veteran's obesity and any service-connected disability, nor has the Veteran ever raised such an argument. Incidental references to obesity, or weight gain resulting in obesity, are insufficient to reasonably raise this theory of entitlement.

Based on the foregoing, the evidence is persuasively against the claim. As there is not an approximate balance of positive and negative evidence, the benefit-of-the-doubt doctrine is not applicable and the claim is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc).

K. Conner

Veterans Law Judge

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