DIABETES MELLITUS

Summary

The Veteran, who served on active duty for training (ACDUTRA) from January 2000 to May 2000, appeals the March 2025 rating decision. The appeal concerns entitlement to service connection for diabetes mellitus, type II, claimed as secondary to his service-connected PTSD. The Veteran argues that chronic stress from PTSD led to behavioral changes, including withdrawal and disengagement from a healthy lifestyle, and contributed to changes in blood sugar levels, weight gain, and excessive alcohol intake, ultimately causing his diabetes mellitus, type II. The Board reviewed evidence from a November 2024 VA examination and a May 2025 private examination. The VA examiner opined that the Veteran's diabetes was not medically related to PTSD, was a separate entity, and lacked a causal relationship. Conversely, the private examiner found the diabetes was likely caused by PTSD, citing correlations between PTSD, chronic stress, alcohol use, and metabolic dysfunction. The Board noted the private opinion's limitations regarding alcohol use but found its conclusion regarding PTSD's contribution to metabolic dysfunction persuasive. The Board also considered VA treatment records indicating the Veteran's alcohol use in the context of PTSD symptoms. Finding the evidence in approximate balance, the Board resolved doubt in the Veteran's favor, granting service connection for diabetes mellitus, type II, as secondary to PTSD.

Rationale

Private opinion found PTSD contributed to metabolic dysfunction.; Conflicting opinions between VA and private examiners.; Benefit of the doubt resolved in Veteran's favor.

Full Decision Text

Citation Nr: A26040471
Decision Date: 04/30/26	Archive Date: 04/30/26

DOCKET NO. 251212-613124
DATE: April 30, 2026

ORDER

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

FINDING OF FACT

Resolving reasonable doubt in the Veteran's favor, his diabetes mellitus, type II, is proximately due to his service-connected PTSD.

CONCLUSION OF LAW

The criteria for secondary service connection for diabetes mellitus, type II, are met.  38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310(a).

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty for training (ACDUTRA) from January 2000 to May 2000, with additional service in the Army National Guard.  The Veteran has already been granted service connection for tinnitus during this period of ACDUTRA, establishing that he has been disabled due to a disease incurred in the line of duty during this period of ACDUTRA.  Specifically, in June 2024, the Agency of Original Jurisdiction (AOJ) issued a deferred rating decision which noted this period of ACDUTRA was now considered active service based on the grant of service connection for tinnitus that was considered incurred in the line of duty during this period of service.  Therefore, Veteran status has been established for this period of ACDUTRA service.  See Mercado-Martinez v. West, 11 Vet. App. 415, 419 (1998).  The Board of Veterans' Appeals (Board) thanks the Veteran for his service to our country.

The rating decision on appeal was issued in March 2025 and constitutes an initial decision; therefore, the modernized review system, also known as the Appeals Modernization Act (AMA), applies.

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 March 2025 AOJ decision on appeal, as well as any evidence submitted by the Veteran or his 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. 

The Board also recognizes in December 2025, the Board dismissed this same claim, entitlement to service connection for diabetes mellitus, type II, as secondary to service-connected PTSD, because an earlier May 2025 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran listed a February 2025 rating decision which deferred adjudication of the claim, rendering it ineligible to appeal as it was not a final rating decision.  However, in December 2025, the Board also advised the Veteran that he still had time to appeal the March 2025 rating decision which adjudicated the claim if he desired to do so.  Subsequently, in December 2025, the Veteran submitted another VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), and this appeal ensues.  

Also, in argument attached his December 2025 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran requested his case be advanced on the docket because the March 2025 codesheet erroneously listed the original denial date for this claim as February 21, 2025 and his representative missed this error and relied on this codesheet.  However, while March 2025 codesheet does erroneously list the original denial date for this claim as February 21, 2025, there is no administrative error resulting in a significant delay in docketing the case as the Board dismissed this claim in December 2025 and the Board is now addressing the claim on the merits merely a few months later.  Therefore, the motion seeking to advance the Veteran's case on the docket, to the extent it is still pending, is denied.  38 C.F.R. § 20.902
 2025 codesheet erroneously listed the original denial date for this claim as February 21, 2025 and his representative missed this error and relied on this codesheet.  However, while March 2025 codesheet does erroneously list the original denial date for this claim as February 21, 2025, there is no administrative error resulting in a significant delay in docketing the case as the Board dismissed this claim in December 2025 and the Board is now addressing the claim on the merits merely a few months later.  Therefore, the motion seeking to advance the Veteran's case on the docket, to the extent it is still pending, is denied.  38 C.F.R. § 20.902(c).

1. Entitlement to service connection for diabetes mellitus, type II

The Veteran asserts service connection for diabetes mellitus, type II, is warranted.  Specifically, in his October 2024 application for benefits, the Veteran claimed service connection for diabetes mellitus, type II, as secondary to PTSD, and argued his PTSD caused behavioral changes, to include withdrawal and disengagement from a healthier lifestyle, and that chronic stress from his PTSD caused changes in his blood sugar levels, him being overweight, and excessive alcohol intake, which all led to his diabetes mellitus, type II.  

Generally, service connection may be established for disability resulting from disease or injury incurred in or aggravated by active military service.  38 U.S.C. § 1110; 38C.F.R. § 3.303.  The term "active military, naval, or air service" for service-connection purposes includes active duty, any period of ACDUTRA during which the individual concerned was disabled or died from disease or injury incurred or aggravated in line of duty.  38 U.S.C. § 101(24).

To establish service connection on a direct incurrence basis, the 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.  Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).

In addition, certain chronic disease, including diabetes mellitus, will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease.  38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. § §3.303, 3.307, 3.309.  Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013).

Service connection may also be granted for disability that is proximately due to or aggravated by service-connected disease or injury.  38 C.F.R. § 3.310.  See also Allen v. Brown, 7 Vet. App. 439, 448 (1995).  Obesity may also serve as an "intermediate step" between a service-connected disability and a current disability that may be service connected on a secondary basis under 38 C.F.R. § 3.310(a).  Walsh v. Wilkie, 30 Vet. App. 300 (2020).  In such a case, the evidence would need to reflect that (1) a service-connected disability or disabilities caused the Veteran to become obese or aggravated the Veteran's obesity, (2) the obesity or aggravation of obesity resulting from service-connected disability or disabilities was a substantial factor in causing another disability, and (3) the disability would not have occurred but for the obesity caused or aggravated by the Veteran's service-connected disability or disabilities.  Id.

In addition, under the Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics Act of 2022 (PACT Act), VA is required to provide an examination and/or medical opinion addressing toxic exposure risk activity (TERA) participation when the Veteran submits a claim for compensation, has evidence of a disability, has evidence of participation in a TERA, and such evidence is not sufficient to establish service connection for the disability.  See 38 U.S.C. § 1168(a).  Here, in June 2024 VA issued Memorandum which documented the Veteran participated in a TERA.  

The appeal period is from July 5, 2024, the date VA received an intent to file claim, (
In addition, under the Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics Act of 2022 (PACT Act), VA is required to provide an examination and/or medical opinion addressing toxic exposure risk activity (TERA) participation when the Veteran submits a claim for compensation, has evidence of a disability, has evidence of participation in a TERA, and such evidence is not sufficient to establish service connection for the disability.  See 38 U.S.C. § 1168(a).  Here, in June 2024 VA issued Memorandum which documented the Veteran participated in a TERA.  

The appeal period is from July 5, 2024, the date VA received an intent to file claim, (with a claim for diabetes mellitus, type II, received within a year thereafter on October 17, 2024), to March 24, 2025, the date the AOJ decision on appeal was issued.

Under the AMA, the Board is bound by favorable findings of the AOJ in the absence of evidence of clear and unmistakable error.  38 C.F.R. § 3.104.  The March 2025 AOJ decision on appeal provided favorable findings as to this claim, specifically, the claimed primary disability, of PTSD, is service-connected, and the Veteran had been diagnosed with a disability, as a VA examination confirmed a diagnosis of diabetes mellitus, type II.  Indeed, a November 2024 VA examiner found the Veteran had an official diagnosis of diabetes mellitus, type II, with a diagnosis date of September 2023.  Also, an April 2025 private examiner found the Veteran had official diagnosis of diabetes mellitus, type II, with a diagnosis date of November 2022.

Thus, the question becomes whether the Veteran's diabetes mellitus, type II is related to service or is secondary to his service-connected PTSD.  However, the Board will limit the discussion addressing this claim as proximately due to service-connected PTSD.  On this question there are probative opinions in favor of and against the claim.

The evidence against the claim includes a November 2024 VA opinion.  The November 2024 VA opinion found the Veteran's diabetes mellitus, type II, and PTSD were are not medically related, that his diabetes mellitus, type II, was a separate entity entirely, that his diabetes mellitus, type II, was not proximately due to or the result of PTSD with personal trauma, and unrelated to it, that a thorough review of medical literature failed to demonstrate a causal relationship, and a nexus had not been established.  In providing the opinion, the November 2024 VA examiner also generally discussed statistics related to diabetes mellitus, type II, and explained that with diabetes mellitus, type II, the response to insulin was diminished, which was defined as insulin resistance, and during this state, insulin was ineffective and was initially countered by an increase in insulin production to maintain glucose homeostasis, but over time, insulin production decreased, resulting in diabetes mellitus, type II.  The November 2024 VA examiner also stated secondary diabetes was caused due to the complication of other diseases affecting the pancreas (for example, pancreatitis), hormone disturbances (for example, Cushing disease), or drugs (for example, corticosteroids).  The November 2024 VA examiner explained diabetes mellitus, type II, was an insulin-resistance condition with associated beta-cell dysfunction, that initially, there was a compensatory increase in insulin secretion, which maintained glucose levels in the normal range, but as the disease progressed, beta cells change, and insulin secretion was unable to maintain glucose homeostasis, producing hyperglycemia, and most of the patients with diabetes mellitus, type II were obese or had a higher body fat percentage, distributed predominantly in the abdominal region, and this adipose tissue itself promoted insulin resistance through various inflammatory mechanisms, including increased FFA release and adipokine dysregulation.  The November 2024 VA examiner also stated that a lack of physical activity, and prior gestational diabetes mellitus in those with hypertension or dyslipidemia also increased the risk of developing diabetes mellitus, type II, and evolving data suggested a role for adipokine dysregulation, inflammation, abnormal incretin biology with decreased incretins such as glucagon-like peptide-1 or incretin resistance, hyperglucagonemia, increased renal glucose reabsorption, and abnormalities in gut microbiota.  

The evidence in favor of the claim includes a May 2025 private opinion submitted within the evidence window following the filing of the VA Form 10182.  The May 2025 private opinion, from B. D., PA-C, noted review of the Veteran's treatment records since separation from service, and opined the Veteran's diabetes mellitus type II, was as most likely caused by or
 the risk of developing diabetes mellitus, type II, and evolving data suggested a role for adipokine dysregulation, inflammation, abnormal incretin biology with decreased incretins such as glucagon-like peptide-1 or incretin resistance, hyperglucagonemia, increased renal glucose reabsorption, and abnormalities in gut microbiota.  

The evidence in favor of the claim includes a May 2025 private opinion submitted within the evidence window following the filing of the VA Form 10182.  The May 2025 private opinion, from B. D., PA-C, noted review of the Veteran's treatment records since separation from service, and opined the Veteran's diabetes mellitus type II, was as most likely caused by or as a result of PTSD, with a probability of 51 percent or better.  As rationale, the May 2025 private opinion explained chronic stress from PTSD and prolonged alcohol use were both known contributors to metabolic dysfunction, including insulin resistance and impaired glucose regulation, which were key factors in the development of diabetes mellitus type, II.  The May 2025 private opinion also listed studies, which by their description, suggested correlations between diabetes mellitus, type II, and PTSD.  

Here, while the May 2025 private opinion's rationale also noted prolonged alcohol use, which is not part of the Veteran's service-connected psychiatric disorder, the May 2025 private opinion also clearly stated PTSD and prolonged alcohol use were both known contributors to metabolic dysfunction.  Thus, the May 2025 private opinion clearly found PTSD was a known contributor to metabolic dysfunction.  Moreover, a relationship between PTSD and metabolic dysfunction was not directly addressed November 2024 VA opinion as this opinion did not address the Veteran's contentions that his PTSD caused changes in his blood sugar levels, him being overweight, and excessive alcohol intake.  Miller v. Wilkie, 32 Vet. App. 249 (2020).

Further, consistent with the May 2025 private opinion, while outside the scope of this appeal, the Veteran's VA treatment records reflect indications of alcohol use in the context of PTSD symptomology.  For example, a December 2023 VA treatment record documented the Veteran reported "anxiety" "a lot nighttime anxiety" among PTSD related symptoms and denied any illicit drug use but also reported alcohol use "socially" specifically that his social life was going to the bar and spending time with his friends and that he had a couple of drinks daily.  The December 2023 VA treatment record documented diagnostic impressions, based on the DSM-5 diagnostic criteria, of adjustment disorder mix with depression and anxiety, unspecified anxiety, disorder, unspecified depressive disorder, unspecified insomnia, and alcohol use disorder, mild.  Here, because the December 2023 VA treatment record indicated some relationship between the Veteran's alcohol use and his social interaction, and a DSM-5 diagnosis of alcohol use disorder, common sense dictates there is some relationship to his psychiatric symptomology.  Further, the December 2023 VA treatment record did not distinguish between the Veteran's alcohol use disorder and other psychiatric symptoms.  See Mittleider v. West, 11 Vet. App. 181 (1998).

Also, a February 2024 VA treatment record documented the Veteran reported alcohol use of three to four beers or alcoholic drinks daily and provided an assessment, which included excess alcohol intake, and further noted the Veteran would cut down one drink per day.  A May 2024 VA treatment record documented at a February 2025 visit, the provider was concerned about alcoholic hepatitis/abuse, as the Veteran was drinking three to four drinks daily, and that he currently he stated he was drinking two drinks, three to four times a week.  A VA active problem list included alcohol intake above recommended sensible limits with modification date of June 2024.  A December 2024 VA treatment record documented the Veteran was again counselled to no more than two drinks a day, 14 drinks a week, and no more than four drinks in one day, and to continue to decrease alcohol intake.

Consequently, the Board finds the May 2025 private opinion explaining the Veteran's diabetes mellitus, type II was caused by his service-connected PTSD, to be sufficiently probative, resulting in the evidence being in approximate balance as to whether the Veteran's diabetes mellitus, type II is proximately due to his service-connected PTSD.  Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008).

Therefore, the Board finds the evidence is at least in relative equipoise as to whether the Veteran's diabetes mellitus, type II is proximately due to, or a result of, his service-connected PTSD.  Also, throughout the appeal period, the Veteran has been service-connected for PTSD, and thus, further discussion of other theories of entitlement is not warranted.  Accordingly, after
 type II was caused by his service-connected PTSD, to be sufficiently probative, resulting in the evidence being in approximate balance as to whether the Veteran's diabetes mellitus, type II is proximately due to his service-connected PTSD.  Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008).

Therefore, the Board finds the evidence is at least in relative equipoise as to whether the Veteran's diabetes mellitus, type II is proximately due to, or a result of, his service-connected PTSD.  Also, throughout the appeal period, the Veteran has been service-connected for PTSD, and thus, further discussion of other theories of entitlement is not warranted.  Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for diabetes mellitus, type II, is warranted.  38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 3.310(b); Lynch v. McDonough, 21 F.4th 776, 781-82 (Fed. Cir. 2021). 

 

 

M. C. GRAHAM

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	M. Espinoza, Counsel

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.