DIABETES MELLITUS

Summary

The veteran, who served from April 1971 to April 1991, appeals the denial of service connection for diabetes mellitus. The veteran claims entitlement to service connection on a secondary basis, asserting that his diabetes is due to his service-connected atrial fibrillation, hypertension, and the medications prescribed for these conditions. The Board reviewed the evidence, including the veteran's testimony and multiple VA medical opinions. Service treatment records were negative for diabetes. However, a September 2016 VA examination opined that it was at least as likely as not that the veteran's diabetes mellitus was related to his use of beta blockers for atrial fibrillation, noting that beta blockers can increase the risk of diabetes. Another VA opinion from August 2020 concluded negatively, stating that atrial fibrillation and hypertension are separate entities from diabetes and do not have a causal relationship, though hypertension and diabetes can be medically related. A subsequent opinion in October 2020 found that while atrial fibrillation does not cause diabetes, hydrochlorothiazide (HCTZ), a medication for hypertension, is linked to an increased risk of hyperglycemia and diabetes. Given the multiple VA opinions supporting a link between the veteran's diabetes and medications for his service-connected conditions, the Board found the evidence sufficient to grant the claim. Service connection for diabetes mellitus secondary to treatment for service-connected disabilities is granted.

Rationale

Multiple VA opinions support a link between diabetes and medications for service-connected conditions.; Veteran's testimony supported by medical evidence regarding beta blocker use and diabetes risk.; One VA opinion specifically linked diabetes to hydrochlorothiazide (HCTZ) use.

Full Decision Text

Citation Nr: A26035341
Decision Date: 04/15/26	Archive Date: 04/15/26

DOCKET NO. 210914-185716
DATE: April 15, 2026

ORDER

Entitlement to service connection for diabetes mellitus is granted.

FINDING OF FACT

The Veteran's diabetes mellitus resulted from medications for treatment of his service-connected disabilities associated with atrial fibrillation or hypertension.

CONCLUSION OF LAW

The criteria for entitlement to service connection for diabetes mellitus are met. 38 U.S.C. §§ 1151, 1110, 1131; 38 U.S.C. §§ 3.102, 3.310.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran had active service from April 1971 to April 1991.

This matter comes to the Board of Veterans' Appeals (Board) on appeal of an October 2020 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO/AOJ). The Veteran appealed by filing a VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement) on September 14, 2021. The Veteran elected the Hearing docket.

The Veteran testified before the undersigned Veterans Law Judge on October 25, 2022. A transcript of the hearing is included in the claims file. As a result of the Veteran's docket election, the Board may only consider the evidence of record at the time of the rating decision on appeal as well as any evidence submitted by the Veteran or representative at the hearing or within 90 days following the hearing (i.e., 90 days following October 25, 2022). 38 C.F.R. § 20.302(a). Evidence of record specifically identified by the Veteran or representative in the October 25, 2022, hearing is likewise considered "submitted" during the evidence submission window. See Cash v. Collins, 2026 U.S. App. LEXIS 3596, 2026 LX 94368, __ F.4th __, 2026 WL 302984, (Fed. Cir., Feb. 5, 2026). If evidence was submitted either (1) during the period after the rating decision and prior to the Board Hearing, or (2) more than 90 days following the hearing, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.302(a), 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, considering the new evidence in addition to the evidence previously considered. 38 C.F.R. § 3.2501. Specific instructions for filing a Supplemental Claim are included with this decision.

Service Connection for Diabetes Mellitus Type II

Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 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).

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Service connection may be granted on a secondary basis for a disability that is due to or aggravated by a service-connected disease or injury. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that 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); see also Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023) (invalidating the requirement of "proximate cause" and instead holding a "but for" causation or aggravation is enough to show entitlement to secondary service connection).

In making all determinations, the Boad must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of current symptomatology.  See Layno v. Brown, 6 Vet. App. 465, 470 (199
b) aggravated by a service-connected disability.  Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc); see also Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023) (invalidating the requirement of "proximate cause" and instead holding a "but for" causation or aggravation is enough to show entitlement to secondary service connection).

In making all determinations, the Boad must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of current symptomatology.  See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge).

In rendering this decision, the Board has reviewed all evidence of record whether discussed in detail.  See Newhouse v. Nicholson, 497 F.3d 1298, 1302 (Fed. Cir. 2007) (holding that the Board must only discuss the evidence which is relevant to the issues on appeal).  A Veteran is entitled to the benefit of the doubt when the evidence is in approximate balance or "nearly equal," and does not require that the evidence be in exact equipoise. Evidence is in approximate balance when the evidence in favor of and opposing the Veteran's claim is found to be almost exactly or nearly equal.  Lynch v. McDonough, 21 F.4th 776, 780 (Fed. Cir. 2021).

Service treatment records are negative for complaints, treatment, or diagnosis of diabetes mellitus.  There is likewise no evidence that the Veteran was diagnosed as having diabetes mellitus within a year of service discharge, that he experienced symptoms attributed to diabetes since service, or that his diabetes is otherwise etiologically related to his active service.  Consequently, service connection on a direct or presumptive basis or the basis of continuity is not warranted.  See 38 C.F.R. §§ 3.303, 3.307, 3.309. The Veteran does not argue the contrary.  Rather, he contends that he is entitled to service connection for diabetes mellitus as secondary to a service-connected disability of the heart, atrial fibrillation, as well as hypertension and/or the medications that he uses to treat his cardiovascular and heart disabilities. 

The Veteran has a current diagnosis of diabetes mellitus and his service-connected disabilities include atrial fibrillation and hypertension. 38 C.F.R. § 3.104(c). These elements of secondary service connection are met. 38 C.F.R. § 3.310. The remaining question is whether either, or medications therefore, resulted in his current diabetes mellitus.

The Veteran testified that beta blockers prescribed for his service connected atrial fibrillation slowed his heart rate, and that a medical expert had opined as much. The Veteran described a medical history of diabetes mellitus, to include concerns from treating medical providers regard his blood sugar levels after his beginning hydrochlorothiazide. The Veteran testified that previously, those levels were within normal range. The Veteran is competent to describe test results and report his recorded or conveyed medical history. The Board finds the Veteran's testimony consistent with and supported by the medical evidence of record described below. 

The medical evidence of record includes a September 2016, VA medical opinion. A VA examiner opined that it was at least as likely as not that the Veteran's diabetes mellitus related to his use of beta blockers for atrial fibrillation. The examiner reasoned that the Veteran had been diagnosed with diabetes mellitus since 2009, and placed on beta blockers, very high doses, for several years prior to that diagnosis. The examiner explained that beta blockers are know to increase the risk of developing diabetes mellitus, and, given that the Veteran had developed diabetes mellitus following use of beta blockers for that time, it was at least as likely as not that his diabetes mellitus related to his beta blocker use for atrial fibrillation. 

Additionally, a September 2016 VA examination notes that the Veteran was diagnosed with diabetes mellitus in 2009 after having been on beta blockers for his service-connected atrial fibrillation for many years. The Veteran's erectile dysfunction was noted to have a multifactorial etiology, including from side effects from beta blockers.

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An August 26, 2020, opinion addressed whether diabetes mellitus was at least as likely as not secondary to atrial fibrillation (irregular heartbeat) and hypertension. The examiner provided a negative opinion, opining that atrial fibrillation (irregular heartbeat) and hypertension are not medically related to diabetes mellitus. The examiner states that both disabilities are separate entities entirely from diabetes, and a thorough review of medical literature failed to demonstrate a causal relationship. As such,
 Veteran was diagnosed with diabetes mellitus in 2009 after having been on beta blockers for his service-connected atrial fibrillation for many years. The Veteran's erectile dysfunction was noted to have a multifactorial etiology, including from side effects from beta blockers.

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An August 26, 2020, opinion addressed whether diabetes mellitus was at least as likely as not secondary to atrial fibrillation (irregular heartbeat) and hypertension. The examiner provided a negative opinion, opining that atrial fibrillation (irregular heartbeat) and hypertension are not medically related to diabetes mellitus. The examiner states that both disabilities are separate entities entirely from diabetes, and a thorough review of medical literature failed to demonstrate a causal relationship. As such, the examiner concluded that a nexus has not been established. The rationale provided is that atrial fibrillation (irregular heartbeat) is a disruption of normal electrical signal pathways and hypertension is an idiopathic vascular disease that raises blood pressure, while diabetes mellitus is an endocrine disorder. The examiner states that neither hypertension nor atrial fibrillation (irregular heartbeat) have a causal relationship with diabetes mellitus type II, but explains that hypertension and diabetes mellitus can nonetheless be medically related.

The medical opinions received October 9, 2020 addressed whether diabetes mellitus type II was at least as likely as not secondary or aggravated by atrial fibrillation (irregular heartbeat) and by medications for service-connected atrial fibrillation (irregular heartbeat) and hypertension. The examiner opines that diabetes mellitus type II has not been aggravated by irregular heart rhythm, and also that it is less than likely due to hydrochlorothiazide (HCTZ). Regarding aggravation of diabetes mellitus type II by atrial fibrillation (irregular heartbeat), the examiner explains that atrial fibrillation is an erratic electrical irregular heart rhythm, while diabetes mellitus type II is a hyperglycemic state in the body usually due to low insulin production, and thus atrial fibrillation does not cause diabetes mellitus type II. Regarding whether diabetes mellitus type II is secondary (caused by) medications for service-connected disabilities, given an August 13, 2019 medical opinion, the examiner opines that while the preferred medication for hypertension for individuals with diabetes, it is the Veteran's medication in particular, hydrochlorothiazide (HCTZ), that is linked to an increased risk for hyperglycemia and diabetes. 

As described above, multiple VA examiners have either offered opinions supporting a finding of a relationship between the Veteran's currently diagnosed diabetes mellitus and medications for treatment of his various service connected disabilities associated with hypertension. This evidence is sufficient to grant the claim and other evidence was considered. Accordingly, the Board concludes that entitlement to service connection for diabetes mellitus secondary to treatment for service connected disabilities is warranted. The claim for entitlement to service connection for diabetes mellitus is thus granted. 38 C.F.R. § 3.310.

 

 

MICHAEL A. HERMAN

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	W. Dwyer

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.