Citation Nr: 1546790 Decision Date: 11/04/15 Archive Date: 11/10/15 DOCKET NO. 11-26 446A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUE Entitlement to service connection for type 1 diabetes mellitus, claimed as secondary to service-connected posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Illinois Department of Veterans Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Carsten, Counsel INTRODUCTION The Veteran had active service as a member of the National Guard from September 1990 to March 1991; January 1995 to November 1995; and January 2003 to September 2003. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois, which in pertinent part, denied service connection for type 1 diabetes mellitus. In April 2014, a hearing was held before the undersigned Veterans Law Judge (VLJ) sitting at the RO. In September 2014, the Board remanded the appeal for further development. In August 2015, the Board requested a medical opinion from the Veterans Health Administration (VHA). See 38 C.F.R. § 20.901 (2015). The opinion was received in September 2015. The Board acknowledges that the Veteran was not provided a copy of the opinion and given an opportunity to respond. Considering the favorable decision herein, the Veteran is not prejudiced by any lack of notification. See Bernard v. Brown, 4 Vet. App. 384 (1993). This is a paperless appeal and the Veterans Benefits Management System (VBMS) and Virtual VA folders have been reviewed. FINDING OF FACT The preponderance of the evidence shows that it is at least as likely as not that the Veteran's type 1 diabetes is proximately due to or caused by service-connected PTSD. CONCLUSION OF LAW The Veteran's type 1 diabetes mellitus is secondary to service-connected PTSD. 38 U.S.C.A. § 1110 (West 2014); 38 C.F.R. §§ 3.303, 3.310 (2015). REASONS AND BASES FOR FINDING AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) In light of the favorable decision herein, a detailed discussion as to how VA satisfied the duties to notify and to assist is not required. See 38 U.S.C.A. §§ 5103, 5103A (West 2014); 38 C.F.R. § 3.159 (2015). Analysis In general, service connection will be granted for disability resulting from injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Where a Veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, service connection will be presumed for certain chronic diseases, including diabetes, if manifest to a compensable degree within one year after discharge from service. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2014); 38 C.F.R. §§ 3.307, 3.309(a) (2015). Presumptive periods do not apply to periods of active duty training and inactive duty training. See Biggins v. Derwinski, 1 Vet. App. 474 (1991). Service connection may be granted on a secondary basis for a disability that is proximately due to or the result of a service-connected condition. 38 C.F.R. § 3.310(a). Service connection is also possible when a service-connected condition has aggravated a claimed condition, but compensation is only payable for the degree of additional disability attributable to the aggravation. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In October 2006, VA amended 38 C.F.R. § 3.310 to incorporate the Court's decision in Allen except that VA will not concede aggravation unless there is medical evidence showing the baseline level of the disability before its aggravation by the service-connected disability. 38 C.F.R. § 3.310(b). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. See 38 U.S.C.A. § 5107(b) (West 2014); 38 C.F.R. § 3.102 (2015). Initially, the Board notes there is no indication that the Veteran's diabetes manifested during a period of active military service or within one year following discharge from his 2003 period of active duty. Service connection on a direct basis or as a chronic presumptive is not warranted, nor does the Veteran contend as such. Rather, he asserts his type 1 diabetes is secondary to service-connected PTSD. The Veteran is currently service-connected for PTSD, rated as 30 percent disabling. During the April 2014 Board hearing and in various statements, the Veteran reports that he was diagnosed with PTSD in the fall of 2003. He had trouble sleeping with a poor diet and alcohol consumption resulting in significant weight gain. He had symptoms of diabetes in 2005 and in early 2006 was seen in the emergency room for severe stomach pain and diagnosed with diabetes. A May 2008 letter from Dr. T. D., an endocrinologist, states that the onset of the Veteran's diabetes was 2 years prior. The Veteran was started on oral agents but blood sugars were still elevated. He suspected the Veteran had type 1 diabetes (which may be LADA - latent autoimmune diabetes of adults). The physician recommended that he start on insulin therapy. In a March 2014 statement, the Veteran's endocrinologist stated that the onset of diabetes was clearly in 2006 and he believed it represented type 1 (insulin-dependent) diabetes mellitus. In November 2014, Dr. C. H. submitted a statement in support of the Veteran's claim, which was accompanied by medical literature. He noted that he first met the Veteran in September 2014 when he presented to establish care as his previous physician was no longer practicing. The physician stated that his synopsis was based on that visit, review of limited old records, and research on the subject. He discussed pertinent medical history and noted that the Veteran was diagnosed with autoimmune diabetes 2-3 years following his service abroad. The physician indicated that prior to meeting the Veteran, he was not familiar with an association between PTSD and diabetes, but he had found literature suggesting that there was. In pertinent part, the physician stated: I have learned that diabetes is more prevalent in patients with [PTSD] in general, and, in one particular study, combat veterans with [PTSD] had a greater risk of autoimmune diabetes. There are several studies showing a significant increase in rates of autoimmune disease in general in veterans with [PTSD]. Similar increases in Type 1 diabetes in children has been documented in geographical regions where children have been exposed to war. In [PTSD] patients, there are alterations in the hypothalamic-pituitary axis and cortisol level as well as higher T-cell counts and decreased natural killer cell activity. This suggests a relationship between [PTSD] and autoimmune disease in general, as well as diabetes specifically. These data are mostly taken from observational studies and some in larger numbers than others, but they certainly raise the possibility of a causative relationship between [PTSD] and autoimmune diabetes. In regard to [the Veteran], I understand that his [PTSD] is considered to be a result of his service abroad. If one believes the emerging literature and agrees that [PTSD] does increase the risk of autoimmune disease and diabetes specifically, then I think one has to consider that [the Veteran's] [PTSD] more likely than not played a role in his development of autoimmune diabetes. As I am not an expert in [PTSD] or its relationship to autoimmune disease, I would encourage review of the literature when evaluating [the Veteran's] appeal. The Veteran underwent a VA examination in January 2015. The examiner set forth pertinent history and following physical examination and review of the record, opined that the claimed condition was less likely than not proximately due to the Veteran's PTSD. In support of this opinion, the examiner stated: Though there is research based findings of PTSD patients with stress and anxiety developing autoimmune diseases, so far there is no conclusive clinical evidence to prove in PTSD patients, causing diabetes mellitus type I in PTSD patients considering early symptoms of PTSD, to include lethargy, insomnia, binge eating, weight gain, anxiety, depression, as well as medication use. The examiner further stated that retrospectively it appears the Veteran's diabetes could be type 1 as diagnosed by his endocrinologist. He also stated: Auto immune disease with auto antibodies is considered as a etiology for Diabetes Mellitus type I. Current ongoing research studies and epidemiology studies findings for autoimmune diseases in Veterans particularly with PTSD depression and Anxiety causing autoimmune disorders including diabetes mellitus type 1, appear to be credible, but not proven with certainty in clinical practice. As concerns aggravation, the examiner stated that the Veteran's diabetes was treated appropriately and was not aggravated beyond the natural progression by the PTSD. He also stated that it was not possible to determine the cause for weight gain without mere speculation as it can be caused by multiple factors. The examiner indicated that he discussed the case with another VA physician who agreed with the opinion. He further referenced the November 2014 private statement and accompanying medical literature. In March 2015, the Veteran's spouse submitted a statement wherein she indicated she believed that his PTSD and associated problems caused his diabetes. The Board acknowledges that the spouse is a registered nurse. She does not, however, provide any supporting rationale for her statement and it appears it is offered in her capacity as a lay person and not as a medical professional. Thus, the statement is not considered probative as concerns etiology. On review, the January 2015 VA opinion is inadequate in that it appears to be based on the absence of conclusive clinical evidence. Similarly, the November 2014 private opinion is not adequate because it is speculative in nature. Accordingly, neither of these opinions is considered probative. In September 2015, the Board received a VHA opinion. The physician discussed the Veteran's medical history and noted: There are several theories related to the cause of type 1 diabetes. One theory, called the beta-cell stress hypothesis suggests that certain "stressors" cause increased insulin demand, leading to beta cell stress, which then may lead to an autoimmune reaction in genetically susceptible individual, and the onset of type 1 diabetes (citations omitted). In the last 2 decades, psychological stress has been postulated to be one of the factors contributing to the beta cell stress theory, leading to type 1 diabetes. This theory refers to some laboratory data suggesting dysregulation in the function of the immune system under stress. ... The examiner went on to discuss various studies and noted: Most studies on this topic point to a correlation between mental stress and the risk of type 1 DM, but given the observational nature of those studies, a definitive causal relation cannot be established. Furthermore, these correlations were all shown in children and there is no similar data in adults. Finally, no studies directly evaluated the correlation between PTSD and type 1 diabetes. However, at least 2 of the studies showed a connection between exposure to war and T1 DM, and many of the types of stressful life events studied are probably no more stressful than PTSD. Consequently, I suspect that a similar correlation between PTSD and T1 DM would be seen if such a study were to be performed. This however would still not establish causality, but we need to keep in mind that causality in this setting might be impossible to prove, since a clinical trial on this topic would be extremely difficult - if not impossible - to design and execute. With the available evidence, I think that it is at least as likely as not that the Veteran's type 1 DM is proximately due to or the result of service-connected PTSD. In this case, the cause of the Veteran's current type 1 diabetes may never be known to a certainty. The VHA opinion, however, provides a positive nexus and is considered highly probative. That is, the opinion was provided by an endocrinologist and was based on a review of the claims folder with consideration of relevant theories of causation and citation to applicable studies. The record does not contain probative evidence to the contrary and service connection for type 1 diabetes is warranted. See 38 C.F.R. § 3.102 (2015). ORDER Service connection for type 1 diabetes mellitus, claimed as secondary to service-connected PTSD, is granted. ____________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs