DIABETES MELLITUS

Summary

The Veteran, who served from August 1973 to August 1999, appeals the denial of service connection for diabetes mellitus, type II, on a secondary basis with obesity as an intermediate step. The Veteran has service-connected conditions including radiculopathy, sciatica, right shoulder bicipital tendonitis, GERD with hernia, degenerative disc disease of the lumbar spine, and obstructive sleep apnea. The Board previously remanded the claim for a proper VA examination addressing the secondary theory of entitlement. The VA examiner in June 2025 opined that the Veteran's service-connected shoulder and lumbar spine conditions caused or aggravated his obesity by limiting his physical activity, leading to weight gain and insulin resistance, which in turn caused his type II diabetes. The examiner concluded it was at least as likely as not that the diabetes would not have occurred but for the obesity caused or aggravated by the service-connected disabilities. No conflicting medical opinion was presented. The Board found this opinion persuasive and granted service connection for diabetes mellitus, type II, on a secondary basis.

Rationale

Service-connected disabilities aggravated obesity; Obesity was substantial factor in causing diabetes; Diabetes would not have occurred but for obesity

Full Decision Text

Citation Nr: A26040527
Decision Date: 04/30/26	Archive Date: 04/30/26

DOCKET NO. 251013-584088
DATE: April 30, 2026

ORDER

Entitlement to service connection for diabetes mellitus, type II, on a secondary basis with obesity serving as an intermediate step, is granted.

FINDING OF FACT

Resolving all doubt in his favor, the Veteran's diabetes mellitus, type II, was caused by service-connected disabilities, with obesity serving as an intermediate step.

CONCLUSION OF LAW

The criteria for establishing service connection for diabetes mellitus, type II, on a secondary basis with obesity serving as an intermediate step, have been met.  38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty from August 1973 to August 1999.  This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2025 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). 

In an October 2025 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Hearing docket.  On December 23, 2025, the Veteran, through his representative, withdrew the hearing request.

Therefore, the Board may only consider the evidence of record at the time of the August 2025 agency of original jurisdiction (AOJ) decision on appeal, as well as any evidence submitted by the Veteran or his representative within 90 days following receipt of the withdrawal of the hearing request.  38 C.F.R. § 20.302(b).  If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to receipt of the withdrawal, or (2) more than 90 days following receipt of the withdrawal, the Board did not consider it in its decision.  38 C.F.R. §§ 20.300, 20.302(b), 20.801. 

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider in its decision below, 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 claims, 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 may be granted for a current disability resulting from a service-connected disability.  38 U.S.C. § 1110; 38 C.F.R. § 3.310.  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).

Notably, when analyzing a claim for secondary service connection, the legal threshold for establishing the causal nexus between the service-connected primary disability and the claimed secondary disability is simple "but-for" causation, a broad standard that allows for multiple causes.  Spicer v. McDonough, 61 F.4th 1360, 1363 (Fed. Cir. 2023).

Similarly, but-for causation may involve intermediary steps between the primary and secondary disabilities.  Intermediary steps may be medical conditions that do not qualify on their own as VA disabilities, such as obesity (e.g., if a service-connected back injury prevents the veteran from exercising, resulting in weight gain that causes or aggravates a foot disability), as well as medications and treatments for the primary disability (e.g., if painkillers prescribed for service-connected headaches cause or aggravate a liver disability).  See, e.g., Walsh v. Wilkie, 32 Vet. App. 300, 307 (2020); Garner v. Tran, 33 Vet. App. 241, 247-48 (2021); Spicer, 61 F.4th at 1365-1366.

Indirect secondary service connection can be granted with obesity acting as an "intermediate step."  See Walsh v. Wilkie, 32 Vet. App. 300 (2020); VAOPGCPREC 1 2017 (Jan. 6, 2017).  Specifically, a grant is warranted
e.g., if painkillers prescribed for service-connected headaches cause or aggravate a liver disability).  See, e.g., Walsh v. Wilkie, 32 Vet. App. 300, 307 (2020); Garner v. Tran, 33 Vet. App. 241, 247-48 (2021); Spicer, 61 F.4th at 1365-1366.

Indirect secondary service connection can be granted with obesity acting as an "intermediate step."  See Walsh v. Wilkie, 32 Vet. App. 300 (2020); VAOPGCPREC 1 2017 (Jan. 6, 2017).  Specifically, a grant is warranted (1) if the service-connected disability caused or aggravated the Veteran's obesity, (2) if the obesity was a substantial factor in causing a subsequent disability, and (3) if the subsequent disability would not have occurred but for obesity.

When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the Veteran.  38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; see Lynch v. McDonough, 999 F.3d 1391, 1395 (Fed. Cir. 2021) (holding that if the positive and negative evidence is in approximate balance, which includes but is not limited to equipoise, the claimant receives the benefit of the doubt).

Following an Intent to File received by VA in August 2023, the Veteran filed a formal claim for service connection for diabetes mellitus, type II, in December 2023.  The claim was first denied in April 2024 based on the absence of evidence in the record that his diabetes began in service.  The Board notes that his service treatment records (STRs) do not contain treatment of a diagnosis of diabetes, or symptoms or laboratory findings suggestive of diabetes, and the record reflects a diagnosis of diabetes in 2022.  In addition, as the record reflected in-service exposure to asbestos, a VA examiner opined in April 2024 that it was less likely than not that the Veteran's diabetes diagnosis was related to this in-service toxic exposure risk activity (TERA).  The examiner explained that medical literature does not support a direct and causal relationship establishing exposure to asbestos as a risk factor or cause of type II diabetes.

After filing an appeal in June 2024, the matter came before the Board in May 2025, where the claim was remanded back to the AOJ to correct an error in VA's pre-decisional duty to assist.  38 U.S.C. § 5103A (f)(2)(A); 38 C.F.R. § 20.802(a).  In pertinent part, the Board found that theory of secondary service connection was reasonably raised by the record prior to the April 2024 rating decision on appeal with obesity as an intermediary step.  

The Board notes that while obesity cannot be service-connected on a direct basis, and obesity cannot qualify as an in-service injury or disease for service connection purposes, obesity may 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, 32 Vet. App. 300 (2020); see also VAOGCPREC 1-2017.  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 by the Veteran's service-connected disability or disabilities or the obesity aggravated by the service-connected disability or disabilities.  Walsh, 32 Vet. App. at 306-7.

As the Board noted in its previous remand, the Veteran is service connected for radiculopathy with a history of sciatica, right shoulder bicipital tendonitis, gastroesophageal reflux disease (GERD) with hernia, and degenerative disc disease of the lumbar spine.  He is also now service-connected for obstructive sleep apnea (OSA).  His STRs detail that the Veteran was 190 pounds upon his retirement examination in March 1999, which was the same as a year prior in June 1998 when he was noted to be slightly overweight.  In December 2014, the Veteran's BMI was 35.  In April 2015, 2016, and 2017, VA treatment
 in its previous remand, the Veteran is service connected for radiculopathy with a history of sciatica, right shoulder bicipital tendonitis, gastroesophageal reflux disease (GERD) with hernia, and degenerative disc disease of the lumbar spine.  He is also now service-connected for obstructive sleep apnea (OSA).  His STRs detail that the Veteran was 190 pounds upon his retirement examination in March 1999, which was the same as a year prior in June 1998 when he was noted to be slightly overweight.  In December 2014, the Veteran's BMI was 35.  In April 2015, 2016, and 2017, VA treatment records note that the Veteran declined counseling regarding the health risks of being overweight and obesity, having known health risks, including diabetes.  Further, during a VA examination for his lumbar spine, the Veteran reported difficulty walking.  During a December 2014 VA examination for his GERD, the VA examiner discussed obesity as a factor in the context of GERD and that the Veteran reported an increase in weight to 200 pounds.  The VA examiner also noted his weight in 2010 was 216 pounds, in 2012 was 218, and his current weight was 230 pounds.

As the VA examination and opinion in April 2024 did not address this theory of entitlement under Walsh, the matter was remanded for an additional opinion from a VA examiner to correct this pre-decisional error in VA's duty to assist.  The Board notes that, after obtaining that opinion in June 2025, the AOJ again denied the claim in the rating decision on appeal.  That decision, however, appears to have overlooked the fact that the June 2025 examiner, in providing negative opinion as whether the Veteran's diabetes was directly related to service or caused or aggravated by a service-connected disability, did provide a positive secondary service connection opinion with consideration of Walsh. 

Specifically, the examiner opined that the Veteran's service connected conditions "to include right shoulder bicipital tendonitis with shoulder impingement syndrome, subacromial/subdeltoid bursitis and acromioclavicular joint osteoarthritis, radiculopathy with history of sciatica, left lower extremity and degenerative disc disease, lumbar spine as least as likely than not caused or aggravated the Veteran's obesity by preventing him from engaging in physical activity."  These disabilities, the examiner continued, cause pain and limit his ability to be physically active, which lead to a more sedentary lifestyle and ultimately lead to weight gain and obesity, which significantly increases the risk of developing type II diabetes.  Excess body fat, particularly around the abdomen, can lead to insulin resistance, where the body's cells become less responsive to insulin, a hormone that regulates blood sugar.  This resistance causes glucose to build up in the bloodstream, eventually leading to type II diabetes if not managed.  Prior to the limitations caused by the service connected disabilities, the examiner observed that the Veteran was physically active and able to maintain a healthy and active lifestyle, and consequently "it is at least as likely as not the Veteran's diabetes mellitus would not have occurred but for the obesity caused or aggravated by his service-connected disabilities."  There is no other medical opinion in conflict with the foregoing.  

As such, the Board finds that service connection for diabetes mellitus, type II, is warranted on a secondary basis as proximately due to the Veteran's service-connected low back disability, sciatica, and right shoulder disabilities, with obesity as an intermediate step.  To that extent, the claim is granted. 

The Board thanks the Veteran for his honorable service. 

 

 

P.M. DILORENZO

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Scarduzio, Robert

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.