DIABETES MELLITUS

JOHN J. CROWLEY · 2026 · Case ID: A26029029

DENIED

Summary

The veteran, who served from March 1995 to March 1999 and October 2003 to September 2004, appeals the denial of service connection for type 2 diabetes mellitus (DM2) as secondary to his service-connected posttraumatic stress disorder (PTSD) with major depressive disorder, with obesity as an intermediate step. The veteran contended that his PTSD led to binge eating, which in turn caused obesity and then DM2. The Board acknowledged the veteran's service connection for PTSD and the AOJ's favorable finding of a current DM2 diagnosis. However, the Board noted that obesity itself is not a ratable condition for VA purposes. While obesity can serve as an intermediate step, the veteran must demonstrate that the service-connected PTSD caused obesity, that obesity substantially caused the DM2, and that the DM2 would not have occurred but for the obesity. The Board gave significant weight to a January 2025 VA clarification opinion which concluded that the veteran's obesity was not an intermediate step causing his DM2, but rather one of several multifactorial causes, including binge eating, insulin resistance, and lack of physical activity. The veteran's treatment history showed prediabetes in 2014, poor follow-up, noncompliance with medication, and unhealthy dietary habits. A private provider opined binge eating was due to PTSD but did not link DM2 to obesity or PTSD. The Board found the evidence did not support the claim, denying service connection for DM2 secondary to PTSD with obesity as an intermediate step.

Rationale

Service-connected PTSD acknowledged; Obesity not a ratable condition; Obesity not proven as intermediate step causing DM2

Special Benefit

NO SPECIAL BENEFIT

Docket No.

251201-609364

Full Decision Text

Citation Nr: A26029029
Decision Date: 03/31/26 Archive Date: 03/31/26

DOCKET NO. 251201-609364
DATE: March 31, 2026

ORDER

Entitlement to service connection for diabetes mellitus, type 2, as secondary to posttraumatic stress disorder with major depressive disorder, with obesity as an intermediate step, is denied.

FINDING OF FACT

The Veteran's diabetes mellitus, type 2 ("DM2), was not caused by any incident of service and was not caused by his service-connected posttraumatic stress disorder with major depressive disorder ("PTSD"), with obesity as an intermediate step.

CONCLUSION OF LAW

The criteria to establish service connection for DM2 secondary to service-connected PTSD with obesity as an intermediate step, have not been met. 38 U.S.C. §§ 1101, 1131, 5107(b); 38 C.F.R. §§ 3.303, 3.304, 3.310; Walsh v. Wilkie, 32 Vet. App. 300 (2020).

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran had active service from March 1995 to March 1999 and October 2003 to September 2004.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2024 rating decision issued by the Department of Veterans Affairs (VA), Regional Office (RO), Agency of Original Jurisdiction (AOJ).

In the December 2025 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Evidence Submission docket.

Therefore, the Board may only consider the evidence of record at the time of the December 2024 rating decision on appeal, as well as any evidence submitted by the Veteran [or representative] with, or within 90 days from receipt of, the VA Form 10182. 38 C.F.R. § 20.303. If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the date the Board received the VA Form 10182, or (2) more than 90 days following the date the Board received the VA Form 10182, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.303, 20.801.

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim[s], considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

Service Connection

Service connection will be granted if the evidence demonstrates a current disability resulted from an injury or disease incurred in or aggravated by active military service, even if the disability was initially diagnosed after service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for any disease initially diagnosed after service when all the evidence, including pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d).

Service connection may also be granted on a secondary basis for a disability if it is due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) a current disability exists and (2) the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). An increase in severity of a nonservice-connected disease or injury shall not be service-connected if it is due to the natural progression of the nonservice-connected condition. Id. at 447-48. Service connection on a secondary basis may
it is due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) a current disability exists and (2) the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). An increase in severity of a nonservice-connected disease or injury shall not be service-connected if it is due to the natural progression of the nonservice-connected condition. Id. at 447-48. Service connection on a secondary basis may not be granted without medical evidence of a current disability and evidence of a nexus between the current disability and a service-connected disability. See Wallin v. West, 11 Vet. App. 509, 512-14 (1998).

Overall, the Veteran is contended that, simply stated, his PTSD caused him to become obese, which led to diabetes.

The general requirements for direct and secondary service connection notwithstanding, obesity is not considered a disease or disability for VA purposes and is not subject to service connection. See Marcelino v. Shulkin, 29 Vet. App. 155 (2018). VA's Office of General Counsel (OGC) issued a precedential opinion addressing questions regarding whether obesity may be considered a disease for the purposes of service connection under 38 U.S.C. §§ 1110 and 1131, and whether obesity may be considered a disability for purposes of secondary service connection. In general, VAOPGCPREC 1-2017 concludes that obesity per se is not a disease or injury for purposes of 38 U.S.C. §§ 1110 and 1131 and, therefore, service connection may not be awarded on a direct or secondary basis. The opinion notes that particularities of body type, such as being overweight or underweight, do not, of themselves, constitute disease or disability subject to service connection. Id. The opinion further held that, because it occurs over an extended period of time, the onset of obesity cannot qualify as an in-service event for the purposes of establishing service connection.

Furthermore, the opinion noted that obesity may be an intermediate step between a service-connected disability and a current disability that may be connected on a secondary basis. In order to meet this criterion, the Veteran must demonstrate that a previously service-connected disability caused the Veteran to become obese; that obesity was a substantial factor in causing secondary disability; and the secondary disability would not have occurred but for the obesity. VAOPGCPREC 1-2017 (January 6, 2017).

When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Lynch v. McDonough, 999 F. 3rd 1391 (2021).

Entitlement to service connection for diabetes mellitus, type 2 ("DM2"), as secondary to posttraumatic stress disorder ("PTSD") with obesity as an intermediate step.

The Veteran asserts that his service-connected PTSD caused him to binge eat which then caused his obesity leading to DM2. See June 2024 VA Form 21-526EZ.

Under the AMA, the Board is bound by favorable findings by the AOJ in the absence of evidence of clear and unmistakable error. 38 C.F.R. § 3.104 (c). The AOJ found the Veteran has a current disability of DM2 and conceded exposure to a toxic exposure related activity ("TERA") when deployed during the Persian Gulf War.

In this case, for any type of service connection, the Veteran must meet the first element by showing he has a current disability. Because the AOJ made a favorable finding that the Veteran has a current disability of DM2, the first element has been met.

Also, the AOJ found that the Veteran was exposed to a TERA. However, there is no presumption of service connection for DM2 even though his disability manifested to a compensable degree after discharge. As of August 10, 2022, the PACT Act of 2022 eliminated the manifestation period and the degree to which a qualifying chronic disability must manifest to be presumed as due to service in the Persian Gulf. See 38 U.S.C. § 1117 (2022). Therefore, there is no longer a requirement for a chronic disability to manifest to a degree of 10 percent or more prior to an end date (currently December 31
disability of DM2, the first element has been met.

In claims based on qualifying chronic disability, unlike those for "direct service connection," there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004).

However, this presumption is not available to the Veteran. A "qualifying chronic disability" for purposes of 38 U.S.C. § 1117 is a chronic disability resulting from (1) an undiagnosed illness, (2) a medically unexplained chronic multi-symptom illness (such as chronic fatigue syndrome (CFS), fibromyalgia, or irritable bowel syndrome) that is defined by a cluster of signs or symptoms, or (3) any diagnosed illness that the Secretary determines in regulation prescribed under 38 U.S.C. § 1117(d) that warrants a presumption of service connection. 38 U.S.C. § 1117(a)(2); 38 C.F.R. § 3.317(a), (c). DM2 is not a diagnosed illness that the Secretary has determined warrants a presumption of service connection.

For the second element, for secondary service connection, the Veteran must show his current disability of DM2 was caused by or aggravated by his service-connected PTSD.

In this case, the Veteran is making a secondary claim that his PTSD caused his obesity which in turn caused his DM2. He also asserts that his binge eating from PTSD caused him to become obese. The AOJ confirmed that he is service connected for his PTSD as a favorable finding.

Generally speaking, it is important for the Veteran to understand that "binge eating" is not normally associated with PTSD. The fact the Veteran has PTSD and binge eats does not, in and of itself, suggest a connection between the two problems.

While obesity is not capable of being service-connected, it may be an "intermediate step" between a service-connected disability and a current disability for which service connection may be granted on a secondary basis under 38 C.F.R. § 3.310 (a). See Walsh v. Wilkie, 32 Vet. App. 300 (2020) (holding that obesity as an "intermediate step" in a causal chain for service connection can be established on either a causal or aggravation basis).

In order for service connection to be granted based on obesity as an intermediate step, the record must show: (1) the service-connected disability caused the veteran to become obese or aggravated his obesity; (2) the obesity or the aggravation of obesity as a result of the service-connected disability was a substantial factor in causing the claimed disorder; and (3) the claimed disorder would not have occurred but for obesity caused or aggravated by the service-connected disability. See Walsh, above.

Post-service VA treatment records show that in August 2014, 10 years after discharge from service, the Veteran was prediabetic. He was given education on simple steps to lower the risk of moving from prediabetic to diabetes. In December 2019, provider notes show he had untreated and uncontrolled diabetes, reported feeling exhausted and extremely thirsty and remembered he had been told he was prediabetic back in 2014 but that he does not go to doctors nor visits to a primary care provider (the Veteran is warned that this behaviour can have serious consequences to his health). He explained his diet is not good, he eats lots of fast food and candy for years (again, this is a problem that the Veteran should address). In January 2020, notes show his mother had diabetes and has been on insulin for years and was not overweight. In June 2021 he was started on Metformin. Notes show he only took the medication a few times and is not ready for insulin. He was counseled extensively on the need for consistent medication and diet including advise to switch from regular soda (3 to 4/day) to diet soda.

He deferred a nutrition consultation.

The Veteran underwent a June 2024 VA DM2 examination
can have serious consequences to his health). He explained his diet is not good, he eats lots of fast food and candy for years (again, this is a problem that the Veteran should address). In January 2020, notes show his mother had diabetes and has been on insulin for years and was not overweight. In June 2021 he was started on Metformin. Notes show he only took the medication a few times and is not ready for insulin. He was counseled extensively on the need for consistent medication and diet including advise to switch from regular soda (3 to 4/day) to diet soda.

He deferred a nutrition consultation.

The Veteran underwent a June 2024 VA DM2 examination. The examiner clarified the opinion in a January 2025 VA Medical Opinion. The Board notes that the requested opinion in June 2024 was whether the Veteran's DM2 is proximately due to binge eating from PTSD. The examiner concluded that the Veteran's binge eating was caused by his PTSD. The examiner noted that the Veteran was initially diagnosed with hyperglycemia with concerns for diabetes in 2014 and the Veteran never followed up with any providers, nor took any treatment until 2019. He was noncompliant from 2000 to 2022 and became more compliant in 2022 with his treatment regimen and his DM2 is better controlled.

In the January 2025 VA medical opinion, the examiner clarified the earlier opinion finding that obesity is not an intermediate step between the Veteran's DM2 and his service-connected PTSD and thus, his DM2 is less likely than not secondary to PTSD with obesity as an intermediate step. The examiner opined that the Veteran's DM2 was multifactorial caused by binge eating, obesity, insulin resistance, and lack of physical activity.

Also, in a January 2025 VA Gulf War examination to provide an opinion as to whether the Veteran's DM2 was due to a TERA, the examiner found the Veteran did not meet the DSM-5 (Diagnostic and Statistical Mental of Mental Disorders) criteria for binge eating disorder. The examiner concluded the Veteran's DM2 from binge eating caused by PTSD was less likely than not caused by toxic exposure.

The Veteran submitted a June 2024 private report. The provider diagnosed the Veteran with PTSD and also with binge eating disorder. Both were noted as diagnosed under the DSM-5. The provider discussed the Veteran's history of binge eating and PTSD. While he concluded that the binge eating is due to the PTSD, he did not relate DM5 to the obesity or PTSD. Rather, the opinion was for an increase in rating of his PTSD.

The Board finds that service connection is not warranted for DM2 as secondary to PTSD with obesity as an intermediate step. The Veteran's treatment records show that the Veteran was prediabetic in 2014, ten years after service. He was alerted and counseled as to the risks of moving from prediabetic to diabetic. While the private provider opines that the Veteran's binge eating disorder is due to his PTSD, the provider did not come to any conclusion that his DM2 is due to the PTSD with obesity as an intermediate step. The VA examiner in June 2024 concluded that binge eating was due to PTSD. The Board gives little weight to these two opinions. However, the January 2025 VA clarification opinion concludes that the Veteran's obesity is not an intermediate step causing his DM2 but one of several factors, including binge eating, insulin resistance, and lack of physical activity, that led the Veteran to develop DM2. The record shows that the Veteran did not follow up with doctors after being told he was prediabetic in 2014. The Veteran's diabetes was uncontrolled and untreated in 2019, and he had been noncompliant with medication from 2000 to 2022. Treatment records also show that he refused nutritional counseling after reporting he drank several sodas (non diet) throughout the day and ate fast foods. In 2021 he had only taken a few doses of his medication and stated he did not go to doctors. The January 2025 examiner concluded that the Veteran's obesity is not an intermediate step between his DM2 and service connected PTSD.

Importantly, even if the Board concedes the first element and agrees that the Veteran's PTSD caused his obesity, the Veteran's obesity must be the substantial cause of his DM2 to meet the second element. However, the examiner in January 2025 determined that it was only one of several causes. In fact, in a treatment report, the Veteran stated his mother had diabetes, took insulin, but was thin and not obese. In other words, factors other than obesity caused the DM2. For the third element, obesity
of his medication and stated he did not go to doctors. The January 2025 examiner concluded that the Veteran's obesity is not an intermediate step between his DM2 and service connected PTSD.

Importantly, even if the Board concedes the first element and agrees that the Veteran's PTSD caused his obesity, the Veteran's obesity must be the substantial cause of his DM2 to meet the second element. However, the examiner in January 2025 determined that it was only one of several causes. In fact, in a treatment report, the Veteran stated his mother had diabetes, took insulin, but was thin and not obese. In other words, factors other than obesity caused the DM2. For the third element, obesity as an intermediate step is met when the Veteran can prove that, but for obesity, he would not have DM2. And this is not the case because as the January 2025 VA examiner stated, it is multifactorial and the Veteran could very well have DM2 without being obese. Therefore, the Board gives the greatest weight to the VA examiner's opinion and finds service connection for DM2 is not warranted.

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Accordingly, entitlement to service connection for diabetes mellitus, type 2, as secondary to PTSD with major depressive disorder, with obesity as an intermediate step, is denied.

The evidence in this case is not in approximate balance to warrant application of the benefit-of-the-doubt rule. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.

John J. Crowley

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Raborn, S.

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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