DIABETES MELLITUS

RYAN T. KESSEL · 2026 · Case ID: 26003998

GRANTED

Summary

The veteran, who served from June 1986 to May 1992, appeals the denial of service connection for type II diabetes mellitus, hypertension, sleep apnea, hypothyroidism, and residuals of a right upper leg infection. The Board reviewed the evidence, including a December 2024 VA examination and prior Board decisions. For type II diabetes mellitus, the Board found competent evidence, particularly a May 2023 VA opinion, that the veteran's early onset metabolic syndrome during service manifested as type II diabetes, resolving doubt in the veteran's favor. Service connection for diabetes was granted. For hypertension, the Board noted the veteran's blood pressure was 140/90 at service entrance and that hypertension was not noted at separation, but found that a September 2022 VA opinion stated diabetes at least as likely as not aggravated hypertension. Given the grant of service connection for diabetes and the favorable opinion, service connection for hypertension on a secondary aggravation basis was granted. For sleep apnea, hypothyroidism, and residuals of a right upper leg infection, the Board relied on VA opinions stating these conditions were at least as likely as not caused by or secondary to the now service-connected diabetes and/or hypertension, resolving doubt in the veteran's favor. Consequently, service connection for all five conditions was granted on a secondary basis where applicable.

Rationale

Competent evidence of in-service metabolic syndrome manifesting as type II diabetes; Resolving doubt in veteran's favor; Equipoise standard met

Special Benefit

NO SPECIAL BENEFIT

Docket No.

17-01 526

Full Decision Text

Citation Nr: 26003998
Decision Date: 03/31/26 Archive Date: 03/31/26

DOCKET NO. 17-01 526
DATE: March 31, 2026

ORDER

Service connection for type II diabetes mellitus is granted.

Service connection for hypertension, based on secondary aggravation to type II diabetes mellitus, is granted.

Service connection for sleep apnea, as secondary to service-connected diabetes and/or hypertension, is granted.

Service connection for hypothyroidism, as secondary to service-connected type II diabetes mellitus, is granted.

Service connection for residuals of a right upper leg infection, as secondary to service-connected type II diabetes mellitus, is granted.

FINDINGS OF FACT

1. The Veteran's type II diabetes mellitus is related to service.

2. The Veteran's hypertension is aggravated by his service-connected type II diabetes mellitus.

3. The Veteran's sleep apnea is caused by service-connected type II diabetes mellitus and/or hypertension.

4. The Veteran's hypothyroidism is caused by service-connected type II diabetes mellitus.

5. The Veteran's residuals of a right upper leg infection are caused by service-connected type II diabetes mellitus.

CONCLUSIONS OF LAW

1. The criteria for service connection for type II diabetes mellitus have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303.

2. The criteria for service connection for hypertension, based on secondary aggravation, have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

3. The criteria for service connection for sleep apnea, on a secondary basis, have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

4. The criteria for service connection for hypothyroidism, on a secondary basis, have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

5. The criteria for service connection for residuals of a right upper leg infection, on a secondary basis, have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from June 1986 to May 1992.

The case is on appeal from a September 2016 rating decision.

Most recently, in an April 2024 decision, the Board remanded the matters for additional development.

Legal Criteria

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, 1131; 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.

A veteran is presumed to have been sound upon entry into active service, except as to conditions noted at the time of the acceptance, examination, or enrollment, or where clear and unmistakable evidence demonstrates that the condition existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b); Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004).

A preexisting injury or disease will be presumed to have been aggravated by active service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability was due to the natural progress of the disease. 38 U.S.C. § 1153
, except as to conditions noted at the time of the acceptance, examination, or enrollment, or where clear and unmistakable evidence demonstrates that the condition existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b); Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004).

A preexisting injury or disease will be presumed to have been aggravated by active service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability was due to the natural progress of the disease. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(a). Once a veteran establishes worsening, "the burden shifts to the Secretary to show by clear and unmistakable evidence that the worsening of the condition was due to the natural progress of the disease." Horn v. Shinseki, 25 Vet. App. 231, 235 n.6 (2012) (citing Wagner, 370 F.3d at 1096).

In determining whether service connection is warranted, the Board shall consider the benefit-of-the-doubt doctrine. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The claimant is entitled to the benefit-of-the-doubt when the competing evidence is in "approximate balance" or "nearly equal." That is, exact equipoise is not required to trigger the favorable benefit-of-the-doubt rule. Lynch v. McDonough, 21 F.4th 776, 781 (Fed. Cir. 2021).

Analysis

1. Service connection for type II diabetes mellitus.

The Veteran maintains that his diabetes is related to service.

In the interest of brevity, the Board incorporates herein the discussion of the prior April 2024 Board decision, to include the medical evidence related to the Veteran's diabetes.

Pursuant to the April 2024 Board remand, the Veteran was afforded a VA examination in December 2024. The examination reflects a current diagnosis of type II diabetes mellitus. The examination notes that the Veteran had early onset of metabolic syndrome during service and was obese at separation. Although the opinion notes no relationship between the Veteran's diabetes and his participation in toxic exposure risk activity (TERA) during service in the Southwest Asia theater of operations, a May 2023 VA opinion states that the Veteran's metabolic syndrome manifested as type II diabetes mellitus. Although metabolic syndrome is not a disease or injury for VA purposes at this time, see e.g., Adams v. Collins, U.S. Vet. 38 Vet. App. 273 (2025), in this case, as noted above, there is competent evidence reflecting that the Veteran's early onset metabolic syndrome during service was a manifestation of type II diabetes, particularly when resolving doubt in the Veteran's favor.

The Board acknowledges the unfavorable opinions with respect to nexus, to include with respect to the Veteran's in-service TERA. However, in this case, as noted above, there is competent evidence reflecting that the Veteran's symptoms during service were manifestations of type II diabetes, particularly when resolving doubt in the Veteran's favor.

Although the Veteran is not competent to diagnose himself with diabetes or to provide a medical nexus opinion, he is competent to attest to the symptoms he experiences and the duration of those symptoms. See Jandreau v. Nicholson, 492?F.3d 1372 (Fed. Cir. 2007).

As noted above, the Veteran's burden of proof is one of equipoise, not certainty. Lynch, 21 F.4th at 781.

Here, on balance, and taking into account the totality of the evidence, including the Veteran's in-service symptoms and his statements with respect to onset and continuity of symptoms, the Board is persuaded that the criteria for service connection for type II diabetes mellitus have been met. The evidence, at a minimum, gives rise to a reasonable doubt on the matter.

In sum, the Board determines the evidence is in favor of the claim of service connection for type II diabetes mellitus, particularly when reasonable doubt is resolved in the Veteran's favor. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. As such, service connection for type II diabetes mellitus is warranted.

2. Service connection for hypertension.

The Veteran maintains that his hypertension is related to service.

2. Service connection for hypertension.

The Veteran maintains that his hypertension is related to service.

An August 2023 VA opinion states that the Veteran's hypertension preexisted service. However, hypertension was not noted at service entrance. The October 1986 entrance examination reflects blood pressure was 140/90. The term hypertension means that the diastolic blood pressure is predominantly 90mm. or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm. or greater with a diastolic blood pressure of less than 90mm. 4.104, Diagnostic Code 7101, Note 1. Moreover, the December 2024 VA examiner stated that the Veteran did not have a diagnosis of hypertension at service entrance. The Board emphasizes that clear and unmistakable evidence is an "onerous" evidentiary standard, requiring that the preexistence of a condition and the no-aggravation result be "undebatable." Cotant v. Principi, 17 Vet. App. 116, 131 (2003). A finding of "insufficient evidence" of aggravation does not meet VA's burden, only affirmative evidence proving that there was no aggravation does. Horn v. Shinseki, 25 Vet. App. 231 (2012). Here, hypertension was not noted at service entrance. Thus, the Veteran is presumed sound.

Pursuant to the April 2024 Board remand, the Veteran was afforded a VA hypertension examination in December 2024. The opinion reflects that the onset of the Veteran's hypertension was in 2004. In addition, in a September 2022 VA opinion, the examiner stated that the Veteran's diabetes at least as likely as not aggravated the Veteran's hypertension. As noted above, the Board is herein granting service connection for diabetes.

Here, on balance, and taking into account the totality of the evidence, including the Veteran's statements, the Board is persuaded that the criteria for service connection for hypertension based on secondary aggravation to diabetes have been met. The evidence, to include the May 2023 VA opinion, is adequate as to a secondary aggravation nexus, at least to an equipoise standard.

Although the Veteran is not competent to provide a medical nexus opinion, he is competent to attest to the symptoms he experiences and the duration of those symptoms. See Jandreau, 492?F.3d at 1372.

As noted above, the Veteran's burden of proof is one of equipoise, not certainty. Lynch, 21 F.4th at 781.

After a careful review of the evidence, the Board determines that service connection is warranted for the Veteran's hypertension on a secondary aggravation basis. The most persuasive medical evidence supports that the Veteran's diagnosed hypertension was aggravated by his now service-connected diabetes. In this regard, the May 2023 VA examiner provided a positive medical opinion that linked the Veteran's hypertension to diabetes.

The Board notes that 38 C.F.R. § 3.310(b) contemplates a baseline to assess the severity of a nonservice-connected disability that is aggravated by a service-connected disability. However, the Board determines that this is more akin to a downstream rating aspect of the claim that should be addressed in the first instance by the RO following implementation of the instant decision.

In sum, the Board determines the evidence is in favor of the claim of service connection for hypertension on a secondary aggravation basis, particularly when reasonable doubt is resolved in the Veteran's favor. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. As such, service connection for hypertension on a secondary aggravation basis, is warranted.

3. Service connection for sleep apnea.

The Veteran maintains the condition is due to service or service-connected disability.

Pursuant to the April 2024 Board remand, the Veteran was afforded a VA examination in December 2024. Although the opinion did not relate the Veteran's diagnosed sleep apnea to TERA during service, a June 2022 VA opinion states that the Veteran's sleep apnea is at least as likely as not caused by diabetes and hypertension noting both conditions are known causes of sleep apnea. As noted above, the Board is herein granting service connection for diabetes and hypertension.
.R. § 3.102. As such, service connection for hypertension on a secondary aggravation basis, is warranted.

3. Service connection for sleep apnea.

The Veteran maintains the condition is due to service or service-connected disability.

The Board notes that although the December 2024 VA sleep apnea examiner did not opine as to whether the Veteran's sleep apnea is caused by diabetes or hypertension, at that time, service connection for diabetes and hypertension was not established.

Here, upon further consideration, and when resolving reasonable doubt in the Veteran's favor, the Board concludes that service connection for sleep apnea secondary to now service-connected diabetes and/or hypertension is warranted.

Although the Veteran is not competent to provide a medical nexus opinion, he is competent to attest to the symptoms he experiences and the duration of those symptoms. See Jandreau, 492?F.3d at 1372.

As noted above, the Veteran's burden of proof is one of equipoise and not certainty. See Lynch, 999 F.3d at 1391.

The Board finds that competent (medical) evidence now shows that the Veteran's sleep apnea is due to his service-connected diabetes and/or hypertension. Consequently, the evidence supports a grant of secondary service connection for hypothyroidism. 38 C.F.R. §§ 3.303, 3.310.

In sum, the Board determines the evidence is in favor of the claim of service connection for sleep apnea, as secondary to service-connected diabetes and/or hypertension, particularly when reasonable doubt is resolved in the Veteran's favor. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. As such, service connection for sleep apnea, on a secondary basis, is warranted.

4. Service connection for hypothyroidism.

The Veteran maintains the condition is due to service or service-connected disability.

Pursuant to the April 2024 Board remand, the Veteran was afforded a VA examination in December 2024. The examination states that the Veteran's diagnosed hypothyroidism is not related to in-service TERA.

Nonetheless, the December 2023 VA thyroid examination states that studies show people with diabetes are likely to develop hypothyroidism, as the two conditions are closely linked.

The Board notes that although the April 2024 VA examiner did not provide an opinion as to whether Veteran's hypothyroidism is secondary to service-connected disability, as noted above, at that time, service connection for diabetes was not established. As noted above, the Board is herein granting service connection for diabetes.

Here, upon further consideration, and when resolving reasonable doubt in the Veteran's favor, the Board concludes that service connection for hypothyroidism secondary to now service-connected diabetes is warranted.

As noted above, although the Veteran is not competent to provide a medical nexus opinion, he is competent to attest to the symptoms he experiences and the duration of those symptoms. See Jandreau, 492?F.3d at 1372.

In addition, as noted above, the Veteran's burden of proof is one of equipoise and not certainty. See Lynch, 999 F.3d at 1391.

The Board finds that competent evidence now shows that the Veteran has hypothyroidism is due to his service-connected diabetes. Consequently, the evidence supports a grant of secondary service connection for hypothyroidism. 38 C.F.R. §§ 3.303, 3.310.

In sum, the Board determines the evidence is in favor of the claim of service connection for hypothyroidism, as secondary to service-connected diabetes, particularly when reasonable doubt is resolved in the Veteran's favor. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. As such, service connection for hypothyroidism on a secondary basis, is warranted.

5. Service connection for residuals of a right upper leg infection.

The Veteran maintains the condition is due to diabetes.

As noted in the prior April 2024 Board remand, the issue of service connection for a right upper leg infection was inextricably intertwined with the remanded claim of service connection for diabetes.

In that respect, VA treatment records
favor of the claim of service connection for hypothyroidism, as secondary to service-connected diabetes, particularly when reasonable doubt is resolved in the Veteran's favor. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. As such, service connection for hypothyroidism on a secondary basis, is warranted.

5. Service connection for residuals of a right upper leg infection.

The Veteran maintains the condition is due to diabetes.

As noted in the prior April 2024 Board remand, the issue of service connection for a right upper leg infection was inextricably intertwined with the remanded claim of service connection for diabetes.

In that respect, VA treatment records in April 2014 note that the Veteran had a diagnosis of uncontrolled type II diabetes mellitus with a history of necrotizing fasciitis in 2008 who had been admitted to the hospital at least twice since then for recurrences of cellulitis in the thigh area where he had multiple debridements.

Moreover, a June 2022 examiner opined that the appellant's status post right upper leg infection, with a residual scar, was at least as likely as not caused by diabetes. The examination states that diabetes affects circulation causing blood to move more slowly, making it more difficult for the body to deliver nutrients to the wounds. The opinion states that as a result, the injury may heal slowly or not at all. As noted above, the Board is herein granting service connection for diabetes.

Here, upon further consideration, and when resolving reasonable doubt in the Veteran's favor, the Board concludes that service connection for residuals of a right upper leg infection secondary to now service-connected diabetes is warranted.

In addition, as noted above, the Veteran's burden of proof is one of equipoise and not certainty. See Lynch, 999 F.3d at 1391.

The Board finds that competent evidence shows that the Veteran has residuals of a right upper leg infection due to his now service-connected diabetes. Consequently, the evidence supports a grant of secondary service connection for residuals of a right upper leg infection. 38 C.F.R. §§ 3.303, 3.310.

In sum, the Board determines the evidence is in favor of the claim of service connection for residuals of a right upper leg infection, as secondary to service-connected diabetes, particularly when reasonable doubt is resolved in the Veteran's favor. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. As such, service connection for residuals of a right upper leg infection on a secondary basis, is warranted.

RYAN T. KESSEL

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board M. Taylor

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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