Citation Nr: 0707171 Decision Date: 03/12/07 Archive Date: 03/20/07 DOCKET NO. 04-11 701 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUE Entitlement to service connection for type II diabetes mellitus. REPRESENTATION Veteran represented by: Georgia Department of Veterans Services WITNESSES AT HEARING ON APPEAL The veteran and his spouse ATTORNEY FOR THE BOARD D. Hachey, Associate Counsel INTRODUCTION The veteran served on active duty in the United States Navy from September 1962 to August 1966. He also service on active duty in the United States Coast Guard from November 1972 to December 1988. This case comes before the Board of Veterans' Appeals (the Board) on appeal from an April 2003 rating decision of the Department of Veterans Affairs (VA) Regional Office in Atlanta, Georgia (the RO). The veteran and his spouse presented testimony before the undersigned Veterans Law Judge at the RO in December 2006. A transcript of this hearing has been associated with the veteran's VA claims folder. The veteran submitted additional medical evidence directly to the Board at the hearing. He has waived review of this evidence by the RO. See 38 C.F.R. § 20.1304 (2006). FINDING OF FACT A preponderance of the competent medical evidence of record demonstrates that the veteran's type II diabetes is causally related to his military service. CONCLUSION OF LAW Service connection for type II diabetes mellitus is warranted. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309(a) (2006). REASONS AND BASES FOR FINDING AND CONCLUSION In the interest of clarity, the Board will first discuss certain preliminary matters. The Board will then render a decision on the issue on appeal. The Veterans Claims Assistance Act of 2000 The Board has given consideration to the provisions of the Veterans Claims Assistance Act of 2000 (VCAA). The VCAA includes an enhanced duty on the part of VA to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits. The VCAA also redefines the obligations of VA with respect to its statutory duty to assist claimants in the development of their claims. A VCAA notice letter was sent to the veteran regarding his claim in September 2002. The Board need not, however, discuss the sufficiency of either the September 2002 VCAA notice or VA's development of the claim in light of the fact that the Board is granting the claim. Thus, any potential error on the part of VA in complying with the provisions of the VCAA has essentially been rendered moot by the Board's grant of the benefit sought on appeal. Accordingly, the Board will proceed to a decision on the merits as to the issue on appeal. Analysis The veteran seeks service connection for type II diabetes. He essentially contends that he had numerous high blood glucose readings during his period of Coast Guard service, and that such constituted a "pre-diabetic" condition which eventually developed into his current type II diabetes diagnosis. The veteran has not contended during the course of this appeal that he served either in the Republic of Vietnam or in the waters off shore during his period of naval service in the 1960s. The presumptive provisions of 38 C.F.R. §§ 3.307, 3.309(e) are therefore not applicable in this case. In any event, a search of the veteran's service records from the National Personnel Records Center (NPRC) yielded no evidence which reflects Vietnam service. The Board will therefore adjudicate the claim on a direct basis only. See generally Combee v. Brown, 34 F.3d 1039, 1043-1044 (Fed. Cir.1994) [holding that when a veteran is found not to be entitled to a regulatory presumption of service connection for a given disability the claim must nevertheless be reviewed to determine whether service connection can be established on a direct basis.] Given the Board's grant of service connection herein, however, the theory of entitlement (presumptive service connection versus direct service connection) is largely immaterial. In order to establish service connection for the claimed disorder, there must be (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) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). The medical record is replete with multiple diagnoses of type II diabetes. The first Hickson element has clearly been satisfied. The veteran's service medical records also note multiple elevated blood glucose readings in the waning years of his Coast Guard service, thereby satisfying the second Hickson element. The key question is the final Hickson element, which in the instant case focuses on the question of whether the veteran's current diabetes diagnosis is related to his elevated blood glucose readings in service. After reviewing the record, the Board finds that it is. The medical record includes statements from two of the veteran's private physicians, Drs. W.J. and J.L., which indicate that blood glucose levels between 100 and 126 mg/dl fall in a "pre-diabetic" range. As pointed out by these physicians (and various outpatient treatment records), the veteran had many glucose readings in this range during his final years of Coast Guard service. "Pre-diabetes" is defined by extensive medical treatise evidence submitted by the veteran. One such article, gleaned from the website of the Department of Health and Human Services, notes that pre-diabetes is "a condition in which blood glucose levels are higher than normal but not yet diabetic." The article notes also that "most people with [pre-diabetes] go on to develop type [II] diabetes within 10 years." Another article submitted by the veteran from the website of the Centers for Disease Control (CDC) notes that "[p]eople who develop regular type [II] diabetes don't go directly from normal blood glucose (sugar) numbers to type [II] diabetes. Almost all go through a phase called impaired glucose tolerance or impaired fasting glucose" - conditions which the same treatise evidence describes as "pre- diabetic." What these articles (coupled by the opinions of Drs. W.J. and J.L.) make clear is that the veteran had pre-diabetes in service (as shown by numerous glucose readings in the 100-126 mg/dl range), which eventually led to an actual confirmed diagnosis a few short years after discharge. As this evidence shows, the veteran's actual type II diabetes diagnosis in the early 1990s was a progression of his "pre- diabetic" condition in service which was primarily manifested by repeated elevated glucose levels. Both the in- service glucose levels and the later diabetes diagnosis were part and parcel of the same developing disease process. Indeed, as discussed in the CDC article, pre-diabetes is little more than a way station between normal blood glucose and the development of type II diabetes. Other treatise evidences reinforces such sentiments, and makes clear that the vast majority of patients with "pre-diabetes" go on to develop diabetes in a decade or less. Such appears to be the case with the veteran. The third Hickson element has therefore also been met and service connection for type II diabetes is warranted. In reaching this conclusion, the Board acknowledges that an actual diabetes diagnosis was not rendered until approximately three to four years after service. The regulations make clear, however, that the lack of an in- service diagnosis does not foreclose the grant of service connection. As long as the disease process which eventually led to the diagnosis began in service (as it did in his case), service connection can be granted. See 38 C.F.R. § 3.303 (d) (2006) [noting that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service]. Because the veteran's current diabetes diagnosis is part and parcel of an ongoing disease process that had its genesis in service, his claim has been substantiated and the benefit sought on appeal is granted. ORDER Service connection for type II diabetes mellitus is granted. ____________________________________________ Robert E. Sullivan Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs