Citation Nr: 1335112 Decision Date: 11/01/13 Archive Date: 11/13/13 DOCKET NO. 07-39 083 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Milwaukee, Wisconsin THE ISSUE Entitlement to service connection for type II diabetes mellitus (DM). REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD S. Becker, Counsel INTRODUCTION The Veteran served on active duty in the Marine Corps from October 1978 to October 1981. Prior thereto, he served in the Marine Corps Reserve. This included active duty for training service, one period of which was from April to August 1977, and presumably also included inactive duty for training service. This matter comes before the Board of Veterans' Appeals (Board) from an April 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Milwaukee, Wisconsin. Service connection for type II DM was denied therein. The Veteran appealed this determination and requested a hearing. However, he later canceled this request. 38 C.F.R. § 20.704(e). In October 2011, the Board remanded this matter for additional development. Such development has been completed. Adjudication thus may proceed if otherwise in order. No potential problems with adjudication are found at this time. Accordingly, the following determination is made based on review of the Veteran's paper claims file in addition to his Virtual VA electronic claims file. FINDING OF FACT The Veteran's current type II DM did not manifest during service or within the first year following his separation from service, and it is not related to his service including at Camp Lejeune which involved exposure to benzene but not to dioxin (whether via an herbicide agent or otherwise). CONCLUSION OF LAW The criteria for establishing service connection for type II DM have not been met. 38 U.S.C.A. §§ 101, 1101, 1111, 1112, 1113, 1131, 1153, 5107 (West 2002); 38 C.F.R. §§ 3.2, 3.102, 3.303, 3.304, 3.307, 3.309, 4.120, Diagnostic Code 7913 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duties to Notify and Assist VA has a duty of notification regarding a claim for VA benefits. 38 U.S.C.A. § 5103; 38 C.F.R. § 3.159. VA must provide notice prior to initial adjudication by the agency of original jurisdiction (AOJ) of any information and any evidence not of record that is necessary to substantiate the claim, that VA will seek to obtain, and that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Notification that a rating and an effective date will be assigned if service connection is granted also must be provided. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Neither the Veteran nor his representative has alleged prejudice concerning notice, as is required. Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (overturning Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007)). Via a December 2006 letter, the Veteran and his representative were informed of the criteria necessary to establish service connection, the evidence required in this regard, his and VA's respective duties for obtaining evidence, and how VA assigns a rating and effective date if service connection is granted. This was prior to the initial adjudication by the AOJ, which in this case is the RO, in the April 2007 rating decision. Additionally, VA has a duty to assist with respect to a claim for VA benefits. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). This includes a requirement to aid the claimant in the procurement of relevant records. 38 U.S.C.A. § 5103A(b-c); 38 C.F.R. § 3.159(c)(1-3). VA also is required to provide a medical examination and/or obtain a medical opinion when necessary. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). Service treatment records, service personnel records, and VA treatment records regarding the Veteran are available. In addition to VA efforts to obtain them, he submitted some of these records on his own behalf. No private treatment records are available. This is because the Veteran has indicated there are none that are pertinent. VA medical examinations were performed in August 2007 and, pursuant to the Board's remand, in November 2011. Each included a VA medical opinion. Of import is that neither the Veteran nor his representative has identified any other action or development necessary for fair adjudication. The record also does not indicate any other action or development. Thus, the Board finds that no further notice or assistance is required and that VA's duties to notify and to assist have been satisfied. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio, 16 Vet. App. at 183. Adjudication may proceed without prejudice to the Veteran. Bernard v. Brown, 4 Vet. App. 384 (1993). II. Service Connection Service connection means that the facts, shown by evidence, establish that an injury or disease resulting in disability was incurred in service, or if preexisting service, was aggravated therein. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). To establish service connection, there generally must be a current disability, the in-service incurrence or aggravation of an injury or disease, and a nexus between the current disability and the in-service disease or injury. Hickson v. West, 12 Vet. App. 247 (1999); Barr v. Nicholson, 21 Vet. App. 303 (2007). Service connection also may be established for any disease diagnosed after separation from service if it was incurred in service. 38 C.F.R. § 3.303(d). DM is a chronic disease. 38 U.S.C.A. § 1101(3); 38 C.F.R. § 3.309(a). For chronic diseases, service connection may be established through chronicity or continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). A chronic disease during service is shown when there is a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). Merely isolated findings are insufficient, as is a diagnosis including the word chronic. Id. Subsequent manifestations of the same chronic disease at any later date, however remote, may be service connected unless clearly attributable to intercurrent causes. Id.; Barr, 21 Vet. App. at 303. Continuity of symptomatology after service is required if the disease is noted during service but is not chronic, or where a determination that it is chronic may legitimately be questioned. 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488 (1997). Continuity of symptomatology does not mean continuity of treatment. Savage, 10 Vet. App. at 488. If certain requirements are met, service connection is presumed for chronic diseases and diseases associated with exposure to an herbicide agent. 38 U.S.C.A. § 1112; 38 C.F.R. §§ 3.307, 3.309. Service must have been active duty for 90 days or more during a war period or after December 31, 1946. 38 U.S.C.A. § 1112(a); 38 C.F.R. § 3.307(a)(1). With respect to diseases associated with exposure to an herbicide agent, exposure during service obviously is required. Herbicide agents contain one of a few specific chemicals such as TCDD. 38 C.F.R. § 3.307(a)(6). TCDD is a form of dioxin. Dorland's Illustrated Medical Dictionary 1897 (31st ed. 2007). In-service exposure is presumed if there was service in the Republic of Vietnam (RVN) between January 9, 1962, and May 7, 1975. 38 U.S.C.A. § 1116(f); 38 C.F.R. § 3.307(a)(6)(iii); McCartt v. West, 12 Vet. App. 164 (1999). Lastly, the disease must be manifested within a particular time period. Type II DM, which has been associated with exposure to an herbicide agent, must be manifested to a compensable degree at any time after service. 38 U.S.C.A. § 1116(a)(2); 38 C.F.R. §§ 3.307(a)(6), 3.309(e). Manifestation of a chronic disease like DM, though not necessarily diagnosis, must be to a compensable degree within one year from the date of separation from service. 38 U.S.C.A. § 1112(a)(1); 38 C.F.R. §§ 3.307(a)(2-3), (c). Evidence rebutting the presumed in-service incurrence or aggravation of the disease must be considered. 38 C.F.R. §§ 1113, 1153; 38 C.F.R. §§ 3.307(d), 3.309(a). The Board must identify the evidence it finds to be persuasive and unpersuasive and explain why any favorable evidence is unpersuasive. Gabrielson v. Brown, 7 Vet. App. 36 (1994), Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Both medical and lay evidence (also known as non-medical evidence) may be discounted in light of inherent characteristics and its relationship to other evidence. Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997). When there is an approximate balance of positive and negative evidence regarding any point, the claimant is afforded the benefit of the doubt. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 49. The claimant thus prevails on that point when the evidence supports the claim or is in relative equipoise but does not prevail when the preponderance of the evidence is against the claim. Only the most salient and relevant evidence must be discussed, although all the evidence must be reviewed. Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000). Based on the evidence, DM is among the Veteran's current disabilities. A current disability exists when there is a disability at the time a claim is filed or at any time during its pendency. McClain v. Nicholson, 21 Vet. App. 319 (2007). The Veteran filed his claim in late 2006. He was first diagnosed with DM in a November 2003 VA treatment record. As such, he had DM prior to filing his claim. He also has had it during the entire pendency of his claim since, as a chronic disease, it remains present once manifest. Type I DM is otherwise known as juvenile DM. Dorland's at 513. It has a peak age of onset of 12 years. Id. Type II DM is otherwise known as adult-onset DM. 38 C.F.R. § 3.309(e). The peak age of onset is between 50 and 60 years. Dorland's at 513. However, it usually occurs in obese individuals over age 35. Stedman's Medical Dictionary 491 (27th ed. 2000). The type of DM manifested by the Veteran is type II. Born in August 1958, the Veteran was well into his adulthood when he first was diagnosed with DM. He indeed was 45, or over 35 but not quite 50. Service treatment records contain his November 1976 entrance examination for the Marine Corps Reserve as well as another examination dated in September 1977 for retention therein. It appears that an entrance examination for the Marine Corps was conducted in August 1978, but it is unavailable. Both of the aforementioned examinations are silent with respect to DM. The Veteran's endocrine system was found to be normal at each. It is presumed that a Veteran was in sound condition when examined for entrance into service except as to defects recorded upon examination at that time. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b); Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). Accordingly, the Veteran did not have DM at least through September 1977 when he was 19. VA treatment records, to include one dated in November 2007, finally confirm his diagnosis as type II DM as opposed to type I DM. Glycosuria, the presence of the sugar glucose in urine, is characteristic of type II DM. Dorland's at 513, 805. A May 2008 Internet article submitted by the Veteran includes frequent urination, excess thirst, increased appetite, weight fluctuation, blurred vision, feeling tired and weak, and nerve damage (neuropathy) as symptoms of type II DM. Service treatment records, in addition to the aforementioned, reveal that the Veteran weighed 168 pounds and 170 pounds respectively at his November 1976 and September 1977 examinations. He was diagnosed with diarrhea in February 1979. He complained of eye pain or headaches, burning, watering, and blurred distance vision in March 1979. He was referred to optometry later that month, where he reiterated his complaints that his eyes burn and water. Hyperopic astigmia was diagnosed, and bifocal glasses were prescribed. In May 1979, the Veteran reported right lower quadrant abdominal pain along with increased appetite, increased urination that was dark yellow, and a productive cough. He denied a history of diabetes. It was noted that he recently had been diagnosed with diarrhea. The assessment was muscle strain versus stone being passed and duodenal ulcer. Referral for further evaluation was made because a final definite assessment could not be made. The diagnosis resulting from this referral was abdominal pain of questionable etiology but possible functional. In August 1979, the Veteran denied frequent or severe headache, eye trouble, frequent or painful urination, sugar or albumin in his urine, recent gain or loss of weight, and neuritis. He reported stomach pains, headaches, dizziness, not falling asleep at night, and a recent fever for the past four days in August 1980. Mild food poisoning was diagnosed. The Veteran reported general malaise, sore throat, nasal and chest congestion, and feeling feverish in October 1980. He was diagnosed with influenza. A diagnosis of general malaise, unknown etiology, was made in June 1981 after his report of such and denial of a family history of DM. Upon the Veteran's September 1981 separation examination, DM was not referenced. His endocrine system was found to be normal. He weighed 170 pounds. In a December 2006 statement, the Veteran indicated that he did not contend his DM had existed since service. He contended in a statement attached to his December 2007 VA Form 9 that his DM symptoms during service were not properly assessed. It thus seems that he changed his mind and now believes that he had DM during service. He is a lay person because there is no indication that he has a medical background. A lay person is competent to diagnose a condition only when the lay person is competent to identify it, the lay person is reporting a contemporaneous medical diagnosis, or the lay person's reports support a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Conditions such as flat feet, a dislocated shoulder, certain skin ailments, tinnitus, and varicose veins are examples of conditions a lay person is competent to identify. Jandreau, 492 F.3d at 1372; Woehlaert v. Nicholson, 21 Vet. App. 456 (2007); Charles v. Principi, 16 Vet. App. 370 (2002); Falzone v. Brown, 8 Vet. App. 398 (1995). Tinnitus is readily observable both to the person manifesting it and to others and is confirmed only by ringing or noise in the ears being personally experienced. Type II DM, in contrast, cannot be observed. There are several symptoms that may be personally experienced as opposed to just one symptom. Diagnosis is confirmed not by these symptoms but by diagnostics such as a glucose tolerance test. 38 C.F.R. § 4.120, Diagnostic Code 7913, Note (2); Dorland's at 513. As such, the Veteran is not competent to identify DM during his service. He cannot be reporting that a medical diagnosis was made then because no such diagnosis was made. It is conceded that he did have some symptoms of type II DM during service. However, these symptoms also can be indicative of other conditions. The Veteran's blurred distance vision, for example, was attributed to his hyperopic astigmia. His increased appetite and urination, which were accompanied by symptoms that are not suggestive of type II DM, ultimately were diagnosed simply as abdominal pain. A DM diagnosis was considered and rejected. Three months later, the Veteran's self-report is that his symptoms had resolved. This would be unlikely if he had DM, a chronic disease. He pointed out in an April 2008 statement that his subsequent in-service food poisoning diagnosis was made by an individual without a degree. Yet, the Internet article attached to this statement shows that such an individual likely would have undergone at least some medical training. In any event, his symptoms were not suggestive of type II DM. The Veteran's subsequent general malaise, which once was accompanied by symptoms that are not suggestive of type II DM, was attributed to a diagnosis of influenza at that time. His weight finally remained very stable throughout service. There is no medical opinion supporting his lay opinion, which is not competent, that DM diagnostics should have been undertaken during service. In sum, it cannot be found that he was not properly assessed then with respect to DM. A later diagnosis was made by a medical professional, but not until over 22 years following his separation from service. This lengthy period is significant. Maxson v. West, 12 Vet. App. 453 (1999). Indeed, the Veteran's reported symptoms during service did not support this diagnosis. The November 2003 VA treatment record is silent for any mention of service-as is a December 2003 VA treatment record that provides more detail regarding his diagnosis. Absent some notation of type II DM during service, service connection based on chronicity and continuity of symptoms is foreclosed. Presumptive service connection also is foreclosed on the basis of a chronic disease. The Veteran served more than 90 days after December 31, 1946. His active duty service spanned approximately three years during the late 1970's and early 1980s, which was after the Vietnam era ended on May 7, 1975, and before the Persian Gulf War began on August 2, 1990. 38 U.S.C.A. §§ 101(29), (33); 38 C.F.R. §§ 3.2(f), (i). Yet, there is no indication that he manifested type II DM by October 1982 when he had been separated from service for one year. It is inferred that he believes that he had type II DM during this timeframe since he believes he had it during service. As no treatment records dated between October 1981 and October 1982 exist, there is no medical diagnosis during this timeframe. Once again, the Veteran is not competent to diagnose type II DM then. A Certificate of Marriage shows that he married his wife D.F. in February 1980. She, like him, is a lay person because there is no indication of a medical background. A lay person is competent to relate observations or that which is within his/her personal knowledge. Layno v. Brown, 6 Vet. App. 465 (1994). The Veteran is competent to recount symptoms suggestive of type II DM he personally experienced during the aforementioned timeframe, while D.F. is competent to recount his observable symptoms suggestive of type II DM during it. Yet he has not done so. The only symptom mentioned by D.F. in a May 2008 statement is weight gain which started "soon after" the Veteran's separation and caused him to go from 170 pounds to 250 or 260 pounds. Even assuming she is credible, it is common knowledge that weight gain can occur for a variety of reasons. A March 2003 VA treatment record, for example, reveals that the Veteran reported gaining 40 pounds after he quit smoking a few years prior. He then weighed 247 pounds. Thus, a finding that he manifested type II DM during the aforementioned timeframe even though it was not diagnosed is not warranted. That weight gain is the only symptom suggestive of DM identified by the Veteran and D.F. between October 1981 and October 1982 reinforces the above conclusion that service connection cannot be awarded on the basis of continuity of symptomatology-as does the fact that weight gain is the only symptom suggestive of DM identified by them between October 1982 and late 2003 when the first diagnosis was made. Indeed, D.F.'s May 2008 statement applies to this period. The Veteran has not recounted any other DM symptoms within it. A May 2008 Internet article submitted by him conveys that type II DM develops slowly and may be present for several years before it is diagnosed. It indeed has a gradual onset. Dorland's at 513; Stedman's at 491. However, the above discussion applies in this regard. There is also no medical opinion to the effect that the Veteran's weight gain proves he had DM ever since he separated from service. In addition to serving more than 90 days during peacetime after December 31, 1946, it is undisputed that the Veteran had type II DM to a compensable degree of 10 percent or more once it manifest after service in late 2003. The December 2003 VA treatment record indeed references nutrition education. Other VA treatment records, to include a November 2007 VA treatment record, additionally document that his type II DM is controlled with medication. A 10 percent rating is assigned when DM is manageable y restricted diet only, whereas a higher rating is assigned when DM control requires at least insulin or an oral hypoglycemic agent along with a restricted diet. 38 C.F.R. § 4.120, Diagnostic Code 7913. Despite the aforementioned, service connection is foreclosed on the basis of a disease associated with exposure to an herbicide agent. There is no indication that the Veteran served in the RVN between January 9, 1962, and May 7, 1975. His Marine Corps Reserve service indeed began almost two years after May 7, 1975, while his service in the Marines began over three years after this date. Service treatment and personnel records also do not show that any of this service was in the RVN. Neither the Veteran nor his representative has contended such. He thus cannot be presumed to have had in-service exposure to an herbicide agent. Where service connection cannot be presumed, it still may be established. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994); Brock v. Brown, 10 Vet. App. 155 (1997); McCartt, 12 Vet. App. at 164. Proof of actual exposure thus must be considered. The contention in the Veteran's September 2006 his informal claim, which was filed by a Veterans Service Office on his behalf, was that he was exposed to dioxin during service. This contention was changed to exposure to benzene by the time he filed his formal claim in October 2006, however. Indeed, he has never mentioned dioxin. Neither has his representative. Each rather repeatedly has mentioned benzene. Benzene is found in motor fuel such as gasoline. This is confirmed by a journal article entitled "Benzene - A Review of the Literature from a Health Effects Perspective" submitted by the Veteran in July 2007 and Internet articles submitted by him in December 2007 and April 2008. S.K., a doctor and the Veteran's representative at the time in Congress, nevertheless indicated in a July 2008 letter that the Veteran's duties during service exposed him to dioxin because they placed him in the vicinity of exhaust vapors. An Internet article from the National Library of Medicine was attached. It states that "breathing automobile exhaust may ...expose [one] to dioxins." Due consideration shall be given to the circumstances of a Veteran's service. 38 U.S.C.A. § 1154; 38 C.F.R. § 3.304(d). The Veteran recounted breathing in fuel fumes daily during service in a December 2007 statement. In a July 2007 statement, D.F. remembered that his clothes smelled of fuel during service. His DD-214 denotes that he was a bulk fuelman during service. Service personnel records show that, at least from October 1980 to October 1981, the Veteran was the records non-commissioned officer for his bulk fuel company. Evaluations spanning three periods during this timeframe reflect that he kept records for all motor transport, engineer, and bulk fuel equipment, insured that scheduled maintenance was carried out on motor transport and heavy equipment, communicated the company's readiness and readiness objective to headquarters, and assisted and taught subordinates. He indicated that his in-service duties involved records and maintenance in a Reserve Qualification Summary dated in December 1981. For the same reasons as above, the Veteran and D.F. are competent regarding his being around fuel and fuel fumes during service. Competent lay statements may be discounted due to factors such as interest, self-interest, bias, internal inconsistency, inconsistency with the other evidence, facial implausibility, bad character, malingering, desire for monetary gain, and witness demeanor. Pond v. West, 12 Vet. App. 341 (1999); Macarubbo v. Gober, 10 Vet. App. 388 (1997); Caluza v. Brown, 7 Vet. App. 498 (1995); Cartright v. Derwinski, 2 Vet. App. 24 (1991). Here, it is not necessary to consider most of these factors since there is facial plausibility and consistency with the other evidence. The Veteran's DD-214 and service personnel records indeed confirm his work with fuel and thus with fuel fumes. In-service exposure to benzene therefore is conceded. It additionally is conceded because the Veteran was stationed at Camp Lejeune during service. That the ground water there was contaminated with various chemicals, primarily trichloroethylene and perchloroethylene but also benzene, from 1957 to 1987 has been acknowledged. VA Revised Training Letter 11-03 (Nov. 29, 2011). With the concession of in-service benzene exposure conceded, it is unnecessary to consider the Veteran's argument that his service treatment records reveal his complaints of symptoms indicative of such exposure. In-service exposure to dioxin, in contrast, cannot be conceded. The Veteran does not recount dioxin exposure during service. D.F. did not mention him discussing such. His DD-214 and other service personnel records do not confirm that he spent time around running vehicles emitting exhaust vapors. They reflect records keeping and maintenance. While maintenance may imply being around running vehicles emitting exhaust vapors, it appears that the Veteran primarily ensured maintenance was completed by directing others to undertake it. There is no indication that he performed maintenance himself, in other words. Even if it is assumed that he did perform some maintenance himself to include while assisting and teaching subordinates, this only means he was exposed to exhaust vapors emitted from running vehicles. Dioxin exposure from these vapors is not certain. Indeed, the article relied on by Dr. S.K. in this regard states that the vapors "may" expose one to dioxin not that they do expose one to dioxin. Use of general, equivocal, or speculative language such as "may," "it is possible," "could have been," and the like is insufficient when it comes to establishing service connection. Bostain v. West, 11 Vet. App. 124 (1998); Goss v. Brown, 9 Vet. App. 109 (1996); Warren v. Brown, 6 Vet. App. 4 (1993); Obert v. Brown, 5 Vet. App. 30 (1993); Tirpak v. Derwinski, 2 Vet. App. 609 (1992). Dr. S.K. also draws support for the conclusion that the Veteran was exposed to dioxin during service from his service treatment records. Specifically, Dr. S.K. indicated that the National Library of Medicine article attributed the Veteran's in-service complaints of abdominal pain, diarrhea, frequent urination, burning and watery eyes, headaches, and blurred vision to low levels of dioxin exposure. It indeed states that exposure to low levels of dioxin "can cause" a burning sensation in the eyes, nose, and throat as well as headache, dizziness, fatigue, blurred vision, urinary tract disorders, muscle and joint pain, impaired muscle coordination, nausea, and vomiting. As such, the Veteran manifested some symptoms but not other symptoms that "can" be due to low level dioxin exposure during service. Yet implicit from use of this general, equivocal, and speculative language is that these manifested symptoms also "can" be due to another cause. The Veteran's blurred distance vision, for example, once again was deemed a consequence of hyperopic astigmia. Some of his stomach pains and his headaches and dizziness were linked to mild food poisoning. The Veteran disputes this diagnosis. He submitted an Internet article in December 2007 which does not list headaches and dizziness as a symptom of food poisoning. However, another source indicates that neurologic symptoms can be due to food poisoning. Dorland's at 1504. The Veteran's service treatment records, in sum, are similar to the other evidence in that they do not establish his exposure to dioxin during service. Clearly, the Veteran and D.F. both believe his current type II DM is related to his exposure to benzene during service. Lay beliefs can sometimes be sufficient to prove nexus. Colantonio v. Shinseki, 606 F.3d 1378 (Fed. Cir. 2010); Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010); Davidson, 581 F.3d at 1313); Jandreau, 492 F.3d at 1372. However, the question of nexus in this case falls outside the province of a lay person. It rather is a medical question given the complexities involved. The May 2008 Internet article submitted by the Veteran discusses the numerous body parts, to include the bloodstream, pancreas, and liver, involved with type II DM. Several factors are known to contribute to it. Those discussed in the Veteran's VA treatment records and VA medical examinations include not only benzene exposure but also family history and excess weight. Type II DM is a complicated disease with many potential causes which may be present alone or in combination, in other words. Only those with medical expertise are competent where the determinative issue is one of medical nexus. Jones v. West, 12 Vet. App. 460 (1999). Therefore, the Veteran and D.F. not competent to establish nexus. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau, 492 F.3d at 1372. Their credibility in this regard accordingly need not be considered. Three medical opinions have been rendered. Dr. S.K. opined in the July 2008 letter that the Veteran's current type II DM "is at least as likely as if not to have been caused by" his in-service exposure to "high concentrations" or "high levels" of dioxin. The physician who conducted the August 2007 VA medical examination opined that the Veteran's current type II DM is unrelated to his benzene exposure during service. The primary care staff physician who conducted the November 2011 VA medical examination finally opined that the Veteran's current type II DM is less likely than not related to his service which includes benzene exposure but does not include dioxin exposure. A medical opinion may be discounted due to factors such as the qualifications of the opinion's author, the scope of the examination, review of pertinent evidence, the accuracy of the factual premises underlying the opinion, the rationale provided for it, and degree of certainty in it. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120 (2007); Prejean v. West, 13 Vet. App. 444 (2000); Ardison v. Brown, 6 Vet. App. 405 (1994); Reonal v. Brown, 5 Vet. App. 458 (1993); Guerrieri v. Brown, 4 Vet. App. 467 (1993). Two of these factors are constant across the opinions. The qualifications of Dr. S.K., the August 2007 VA physician, and the November 2011 VA primary care staff physicians are not disputed. Unlike above, language that is general, equivocal, or speculative was not utilized by any of these individuals. The rest of the factors vary across the opinions. With respect to Dr. S.K., it is unclear what pertinent evidence was reviewed. The only reference made was to "service records." This suggests that Dr. S.K. reviewed the Veteran's service treatment records and service personnel records but did not review the then available VA treatment records, the August 2007 VA medical examination, or the Internet and journal articles submitted by him. Review of the paper and Virtual VA electronic claims files containing this pertinent evidence is not strictly required, as long as there otherwise is familiarity with the Veteran's medical history. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); D'Aries v. Peake, 22 Vet. App. 97 (2008). However, there is no indication that Dr. S.K. interviewed the Veteran. He was noted to have contacted Dr. S.K.'s office, but it cannot be concluded without more that this contact involved the conveyance of his entire medical history. There additionally is no indication that the Veteran was examined by Dr. S.K. The rationale provided is somewhat inaccurate. That the Veteran has no family history of type II DM is accepted as true. Also true, as set forth above, is that presumptive service connection is granted for Veterans exposed to dioxin in herbicides who develop type II DM. However, it is not true that only 6.49 percent of the population will develop type II DM if they have no family history of it. Dr. S.K. attached an article from the journal Diabetes Care entitled "Type 2 Diabetes and Maternal Family History" in this regard. It indicates that of the 1,947 men studied, 6.49 percent developed type II DM after reporting no maternal or paternal family history. Dr. S.K. extrapolated from one study of men to the entire population which includes men and women, in other words. Of greatest import, however, is that Dr. S.K.'s opinion is based on an inaccurate factual premise. It interchangeably mentioned high and low levels of dioxin exposure during service, but the above finding was that there was no such exposure. The August 2007 VA physician and the November 2011 VA primary care staff physician each reviewed the paper claims file. There is no indication that the Virtual VA electronic claims file was reviewed by either, but this is of no consequence. The information contained therein as of the time of both examinations was of a procedural nature. Substantive information, particularly VA treatment records, has since been added. However, most duplicate those in the paper claims file. The records that are not duplicative also are not pertinent. Both the August 2007 VA physician and the November 2011 VA primary care staff physician further interviewed as well as examined the Veteran. No deficiencies with the scope of either examination are detected. Unlike with Dr. S.K.'s opinion, there is no indication that an inaccurate factual premise forms the basis of the opinion of either of the aforementioned. Both indeed conceded the Veteran's exposure to benzene during service. All that remains is the rationale provided for the August 2007 VA physician and November 2011 VA primary care staff physician opinions. As the Board indicated in its October 2011 remand, the August 2007 VA physician discussed the journal article entitled "Benzene - A Review of the Literature from a Health Effects Perspective." It was noted that the group exposed to benzene reported more adverse health outcomes to include DM when compared to a control group. However, it further was noted that the increase in DM in those with benzene exposure was limited to males under age 18. It was type I DM instead of type II DM, in other words. Several limitations identified in the article with the studies assessed were highlighted. Finally, the conclusion of the article that cause and effect relationships cannot yet be determined was highlighted. Nothing more was provided. As such, the Board determined that there essentially was no rationale. In contrast, the November 2011 VA primary care staff physician provided a rationale. The Board's remand directed that it include addressing Dr. S.K.'s opinion, the August 2007 VA physician's opinion, and article submissions from the Veteran. Substantial compliance, not strict compliance, is required. Dyment v. West, 13 Vet. App. 141 (1999), aff'd, Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002); Stegall v. West, 11 Vet. App. 268 (1998). Dr. S.K.'s opinion was deemed to relate to dioxin exposure as opposed to benzene exposure. The August 2007 VA physician's opinion was summarized as finding that the aforementioned journal article does not support benzene exposure causing type II DM. This article once again was recognized as concerning type I DM instead of type II DM. No other articles were mentioned, but it was otherwise noted that elevated body mass index is a risk factor for developing type II DM and that the Veteran developed his type II DM after gaining 40 pounds when he quit smoking. His lack of a family history was acknowledged, but his weight was found to be causative. In sum, there are many factors for discounting Dr. S.K.'s opinion. It accordingly is not persuasive. There is an important factor for discounting the opinion of the August 2007 VA physician. Indeed, a medical opinion is not persuasive if it is not supported by a rationale. Nieves-Rodriguez, 22 Vet. App. at 295; Stefl v. Nicholson, 21 Vet. App. 120 (2007). However, the November 2011 VA primary care staff physician's opinion is persuasive because there are no factors for discounting it. This opinion indeed is the most persuasive evidence. It is adequate in that it includes sufficient detail so that the determination made herein is fully informed. Barr, 21 Vet. App. at 303. Significantly, it is supported by other evidence. First, the Veteran reported to the November 2011 VA primary care staff physician being told by his VA primary care doctor that he had type II DM due to chemical exposure since his family history is negative. It was noted that there was no documentation of what was said to him. A lay person's account of what a medical professional purportedly told him, in any event, is not competent medical evidence. Robinette v. Brown, 8 Vet. App. 69 (1995). Yet, there is an April 2005 VA treatment record which contains the text of a letter sent to the Veteran from a nurse practitioner. This nurse practitioner relates no awareness of any potential for service connection for his type II DM, since he did not serve in the RVN, unless it manifested during his service. Second, scientific sources have found benzene to be associated with an increased risk of certain cancers. VA Revised Training Letter 11-03. They have not found benzene to be associated with an increased risk of type II DM. The conclusion of the journal article entitled "Benzene - A Review of the Literature from a Health Effects Perspective" that it could not be determined that benzene exposure is associated with DM, whether type I or type II, is reiterated. The same is true of an Internet article submitted by the Veteran in October 2006, since it is a summarization of the information presented in this journal article. The above discussion shows that the preponderance of the evidence is against the Veteran's entitlement to service connection for type II DM under all applicable theories of entitlement. As such, the benefit of the doubt is inapplicable. The benefit sought further is denied. ORDER Service connection for type II DM is denied. ____________________________________________ THERESA M. CATINO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs