Citation Nr: 1724776 Decision Date: 06/29/17 Archive Date: 07/10/17 DOCKET NO. 05-22 479 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Entitlement to service connection for type II diabetes mellitus, claimed as due to exposure to non-ionizing electromagnetic radiation. 2. Entitlement to service connection for coronary artery disease, claimed as secondary to type II diabetes mellitus. 3. Entitlement to service connection for impotency, claimed as secondary to type II diabetes mellitus. 4. Entitlement to service connection for skin rash, claimed as secondary to type II diabetes mellitus. 5. Entitlement to service connection for sleep apnea, claimed as secondary to type II diabetes mellitus. 6. Entitlement to service connection for peripheral neuropathy of the bilateral lower extremities, claimed as secondary to type II diabetes mellitus. REPRESENTATION Appellant represented by: Sean A. Kendall, Esq. WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. Van Wambeke, Counsel INTRODUCTION The Veteran served on active duty for training from August 1971 to February 1972, and on active duty from July 1972 to May 1976. He also had a period of service in the Air National Guard after May 1976. This matter comes to the Board of Veterans' Appeals (Board) on appeal from rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in July 2003 and April 2012. The July 2003 rating decision denied service connection for type II diabetes mellitus, coronary artery disease, impotency and skin rash. The Board denied the claims by way of a September 2010 decision, which the Veteran appealed to the Court of Appeals for Veterans Claims. In November 2011, the Court approved a Joint Motion for Remand (JMR) and remanded the issues for the additional development. An April 2012 rating decision denied service connection for sleep apnea and peripheral neuropathy. The Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge in July 2013. A transcript is of record. The claims were remanded by the Board in September 2015 for additional development. FINDINGS OF FACT 1. The most probative evidence is against a finding that the Veteran's current type II diabetes mellitus had its onset during active service, manifested within one year of discharge from service, or is related to active duty service. 2. The most probative evidence is against a finding that the Veteran's current coronary artery disease, impotency, skin rash, sleep apnea, and peripheral neuropathy of the both lower extremities had their onset during active service or are related to active duty service, or that coronary artery disease or peripheral neuropathy were manifested in the year following discharge from service. 3. Service connection for type II diabetes mellitus is being denied, so service connection for coronary artery disease, impotency, skin rash, sleep apnea, and peripheral neuropathy of the both lower extremities as secondary to type II diabetes mellitus is not warranted. CONCLUSIONS OF LAW 1. The criteria for service connection for type II diabetes mellitus have not been met. 38 U.S.C.A. §§ 1110, 1112, 1131, 1137, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2016). 2. The criteria for service connection for coronary artery disease have not been met. 38 U.S.C.A. §§ 1110, 1112, 1131, 1137, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2016). 3. The criteria for service connection for impotency have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.310 (2016). 4. The criteria for service connection for skin rash have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.310 (2016). 5. The criteria for service connection for sleep apnea have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.310 (2016). 6. The criteria for service connection for peripheral neuropathy of the bilateral lower extremities have not been met. 38 U.S.C.A. §§ 1110, 1112, 1131, 1137, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 Under the Veterans Claims Assistance Act of 2000 (VCAA) VA has a duty to notify and assist a claimant in the development of a claim. VA's duty to notify was satisfied by letters in August 2002 (diabetes, coronary artery disease, impotency, and skin rash) and December 2011 (sleep apnea and peripheral neuropathy). See 38 U.S.C.A. §§ 5102, 5103, 5103A (West 2014); 38 C.F.R. § 3.159 (2016); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Concerning the duty to assist, the record also reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran, including service treatment records, post-service treatment records, records from the Social Security Administration, and VA examination reports. The Veteran was afforded a hearing before the Board and a copy of the transcript is of record. There is no allegation that the hearing provided to the Veteran was deficient in any way. Dickens v. McDonald, 814 F.3d 1359 (Fed. Cir. 2016). The Board also notes that actions requested in the prior remand have been undertaken. In this regard, records from the Social Security Administration were obtained. Accordingly, the Board finds that there has been substantial compliance with the prior remand instructions and no further action is necessary. See D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict, compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998)). After a careful review of the file, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a chronic condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b); see also Walker v. Shinseki, 708 F.3d 1331, 1340 (Fed.Cir. 2013) (holding that only conditions listed as chronic diseases in 38 C.F.R. § 3.309(a) may be considered for service connection under 38 C.F.R. § 3.303(b)). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Where a veteran served continuously for 90 days or more during service after December 31, 1946, and diabetes mellitus, cardiovascular disease, or organic disease of the nervous system becomes manifest to a degree of 10 percent within one year from date of termination of such service, such diseases shall be presumed to have been incurred in service, even though there is no evidence of such diseases during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2014); 38 C.F.R. §§ 3.307, 3.309 (2016). Claims based upon exposure to ionizing radiation are governed by two separate regulations, and each provides a separate and distinct basis for establishing service connection based on exposure to ionizing radiation. See 38 C.F.R. §§ 3.309, 3.311 (2016). However, neither of those regulations is applicable in this case. In this regard, although the Court has taken judicial notice that radar equipment emits microwave-type, non-ionizing radiation, see Rucker v. Brown, 10 Vet. App. 67, 69, 71-72 (1997), non-ionizing exposure from radar equipment is not the type of radiation exposure addressed by the VA regulations found at 38 C.F.R. §§ 3.309 and 3.311 (2016). Furthermore, the Veteran does not contend, and the evidence does not establish, that he was exposed to ionizing radiation so as to permit the application of 38 C.F.R. § 3.311. Disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either proximately caused by or proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). The Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate each claim and what the evidence in the claims file shows, or fails to show, with respect to each claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran essentially contends that his diabetes is the result of working near non-ionizing electromagnetic radiation at a radar facility in Turkey. He initially asserted that coronary artery disease and impotence were also a result of this exposure, but during testimony at a July 2013 Board videoconference hearing, it was asserted by the Veteran's attorney that only the claim for diabetes was based on the asserted exposure and that the remaining claims, which include coronary artery disease, impotence, skin rash, sleep apnea and peripheral neuropathy of the bilateral lower extremities, were all based on a secondary theory of entitlement as secondary to the diabetes. In regards to the claim for diabetes, the Veteran asserts that he was told he was pre-diabetic in 1976, after undergoing a physical when he started working at the VA Hospital in Martinsburg within weeks of getting out of service. He contends that he was referred to an eye clinic because of diabetes and that he had been told since 1976 that he had elevated glucose. The Veteran indicates that records from physicals and pre-employment testing are no longer available. See September 2002 VA Form 21-4138; hearing transcript. He testified that he left VA service in 1983 and was seen by his private physician, who ordered blood tests and found elevated blood sugar in 1987. The Veteran's attorney indicated at the videoconference hearing that there was no evidence of a diagnosis of diabetes within one year of the Veteran's discharge from service, so service connection on a presumptive basis was not being offered up as a theory of entitlement. In a September 2002 VA Form 21-4138, the Veteran's wife reported that she had known the Veteran since 1968 and they got married in 1972. She indicated that the Veteran was discharged from service in 1976 and was seen at the Martinsburg VA Hospital a few weeks after discharge, at which time he was told he had elevated glucose levels and advised to use diet and exercise to keep his diabetes under control. As an initial matter, the Board notes that the Veteran has been diagnosed during the course of the appeal with type II diabetes mellitus, coronary artery disease, impotence / erectile dysfunction, a skin disorder, sleep apnea, and peripheral neuropathy of both lower extremities. Accordingly, the first criterion for establishing service connection has been met. The question becomes whether any of the conditions are related to service and if the diabetes is related to service, whether any of the other conditions are related to the diabetes. Service treatment records show that the Veteran reported an aunt with diabetes during a July 1971 enlistment examination, but the examining physician indicated there were no signs or symptoms in the examinee. Urinalysis completed in July 1971 was negative for albumin and sugar. The Veteran was seen with chief complaint of a rash on the chin in October 1971. The impression was possible impetigo. Also in October 1971, he was seen with sinus problem and nasal congestion. The Veteran again reported an aunt with diabetes during a March 1972 biennial examination, and the examining physician again indicated there were no signs or symptoms in the examinee. Urinalysis completed at that time was negative for albumin and sugar. The Veteran denied skin diseases; pain or pressure in chest; palpitation or pounding heart; heart trouble; high or low blood pressure; cramps in his legs; frequent or painful urination; sugar or albumin in urine; recent gain or loss of weight; neuritis; and frequent trouble sleeping on the March 1972 Report of Medical History. A March 1972 electro-cardiographic record was within normal limits. A March 1972 chest x-ray was normal. The Veteran underwent a physical examination in April 1973, at which time it was noted that lab results were within normal limits and the Veteran denied a history of increased urinary frequency and a history of cardiovascular palpitations. Examination of his skin at that revealed no gross lesions. See clinical records and progress notes. A chest x-ray in August 1973 revealed no significant radiographic abnormalities. The Veteran was assessed with sinusitis in what appears to be July 1975, although the year could also have been 1976 (not during active duty service). Records from the Veteran's period of service in the Air National Guard have also been obtained. During a March 1977 enlistment examination, the Veteran denied pain or pressure in chest; palpitation or pounding heart; heart trouble; high or low blood pressure; cramps in his legs; frequent or painful urination; sugar or albumin in urine; recent gain or loss of weight; neuritis; and frequent trouble sleeping. The examining physician also noted that he denied a family history of diabetes. Examination in March 1977 revealed that urinalysis was negative for albumin and sugar and that chest x-ray was within normal limits. The only defect or diagnosis listed was defective distant and near vision. See reports of medical examination and history. The Veteran again denied a family history of diabetes in December 1978 and May 1979. See Reports of Medical History. The post-service evidence in this case consists of private and VA treatment records. The private records date back to August 1976 and the VA treatment records date back to September 1977 and August 1979. The September 1977 VA record indicates that the Veteran reported a family history of diabetes when seeking ophthalmological treatment for complaint of vision problems. An April 1984 physical examination of drivers indicates that the Veteran denied a health history of cardiovascular disease and diabetes; laboratory findings were negative for sugar and albumin in the urine; electrocardiograph, which is of record, was noted to be within normal limits. The Veteran was seen at City Hospital in October 1985 due to complaints of abdominal discomfort. Lab work notations indicated that urinalysis was negative. An April 1986 physical examination of drivers contained the same findings as that from April 1984 regarding health history and urine laboratory findings. An April 20, 1987, blood chemistry report contains a notation of 167 mg% for sugar. An August 1992 record indicates that pathology of a lesion from the Veteran's groin area was determined to be epidermal necrosis, dermal edema and interstitial acute and chronic dermatitis. A November 1994 record indicates that the Veteran was seen with complaint of sore feet, which had been ongoing for many years. The assessment following physical examination was dermatitis versus tinea pedis. The Veteran was seen in January 1995 with complaints of numbness all over his body; he denied any chest pain at that time. The impression included hypertension and obesity. He was assessed with controlled hypertension, mild diabetes mellitus, and obesity in 1995 (the month is obscured) and hypertension and mild diabetes mellitus in May 1995. The Veteran was admitted to City Hospital on July 30, 1998, after being brought to the emergency room because of loss of consciousness. It was noted that while driving an 18 wheeler, he veered off the road mainly because he was unconscious. The Veteran indicated that he had had several black out spells prior to this one in the year prior and also noted that he had had some episodes of awakening at night time with acute and severe shortness of breath, which lasted only for seconds, which had been occurring over the past year. Echocardiogram, chest x-ray, and electrocardiogram were noted to be normal, as were rhythm strips without evidence of brady or tachyarrhythmia. A sleep study was ordered, which was noted to be grossly abnormal. The Veteran was discharged on August 1, 1998, with pertinent diagnoses of hypertensive cardiovascular disease, obstructive sleep apnea syndrome, diabetes mellitus, and morbid obesity. A multiple sleep latency report and two polysomnography reports are also of record. One comment indicated that the Veteran had episodes of syncope not related to the cardiovascular system and that there was no obstructive cardiomyopathy. The Veteran was admitted to Winchester Medical Center on December 1, 2000, with chief complaint of substernal chest pain, dyspnea and diaphoresis for cardiac catheterization. In pertinent part, he denied any previous cardiac problems or work-up, but indicated he had hypertension and adult onset diabetes mellitus. It was also noted he was obese and that his family history was strongly positive for heart disease, and that both his father and sister had diabetes. The Veteran was discharged on December 2, 2000, with pertinent primary diagnoses of coronary artery disease; hypertension; diabetes; and sleep apnea treated with a continuous positive airway pressure machine. Nerve conduction studies performed in June 2013 at Panhandle Neurology Center, Inc., which were obtained from the Social Security Administration, contain an interpretation of findings most consistent with chronic axonal sensorimotor peripheral polyneuropathy of both lower extremities. Upon review of the record, the Board finds that the first elevated glucose reading shown was in April 1987, and that the first diagnosis of diabetes mellitus was in 1995. As there is no diagnosis of diabetes mellitus show in service treatment records or within one year following discharge from service, competent evidence linking the current condition with service is required to establish service connection. On this question, there are medical opinions both in favor of and against the claim. In a May 2002 letter, Dr. S.A. reports that the Veteran's exposure to "non-iodizing" radiation during his tour of duty in Turkey in 1974-1975 is as likely as not to have contributed to his current medical condition, non-insulin dependent diabetes mellitus. In another May 2002 letter, Dr. S.A. reports that the Veteran is under his care for treatment of diabetes mellitus and was also being treated for coronary artery disease, impotence, and skin rashes; and that it is as least as likely as not that those other conditions are due to the diabetes condition. As no rationale for the basis of these opinions was provided by Dr. S.A., they are not afforded any probative value. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). In a December 2002 letter, Dr. S.A. reported that the Veteran had been under his care for diabetes mellitus and that it is as least as likely as not that the elevated glucose levels reported in 1987 and earlier, within the first year of discharge, was an indication of the diabetes. Dr. S.A. further indicated that this should be conclusive that the diabetic condition, although not given a formal diagnosis, was present. The Board notes that it appears the basis of Dr. S.A.'s opinion was the Veteran's report that he was told he had elevated glucose levels shortly after discharge (pre-diabetic) and the 1987 record showing elevated glucose. In an October 2009 letter, Dr. S.A. reported that the Veteran had been under his care for many years for several medical conditions. It was noted the Veteran had diabetes mellitus and it is as least as likely that he had developed this condition back in the year of 1977 before his discharge. It was Dr. S.A.'s medical opinion that the Veteran was, in fact, a diabetic before discharge. Dr. S.A. reported that the Veteran's blood sugars had been running through the years from 141 all the way to the 400s and that he had been on insulin and medications. The opinion provided by Dr. S.A. that the Veteran developed diabetes before his 1977 discharge from service is not supported by rationale or citation to any of the service treatment records, and suggests a belief the Veteran was still on active duty in 1977, which is not the case. Accordingly, this opinion is not afforded any probative value. Id. The Veteran underwent a VA diabetes mellitus examination in November 2009, at which time his claims folder was available and reviewed. He reported the onset of diabetes mellitus in the late 1980s or early 1990s at the age of 35, and that the condition began with typical symptoms of polyphagia, polydipsia and polyuria and that he was treated for several years with oral medications, diet and exercise with poor to only fair control. The Veteran was noted to be treated for hypertension, but was unsure when it was diagnosed. The Veteran denied symptoms of a skin disorder and skin examination showed no diabetic skin abnormalities. The examiner noted that the earliest fasting blood glucose levels greater than or equal to 126 mg/dL found in the claims file dated back to April 20, 1987. In addition to type II diabetes mellitus, the Veteran was diagnosed with early/mild peripheral sensory neuropathy, as manifest by paresthesias and examination findings of diminished vibratory sensation involving both great toes, which was a complication of diabetes; symptomatic coronary artery disease, which was a complication of diabetes; and symptomatic erectile dysfunction, which was a complication of diabetes. It was the examiner's opinion that type II diabetes mellitus is less likely as not caused by or a result of military service. The examiner explained that there was no documentation of diagnosis or laboratory results which would have led to the diagnosis by current or previous standards within one year of separation from service. The examiner further indicated that although there are a few epidemiological and basic science (non-clinical) studies that suggest there may be an association between non-ionizing radiation and increased rates of type I diabetes mellitus, this is essentially a different disease from the type II diabetes mellitus with which the Veteran was diagnosed. Though the frequencies of electromagnetic radiation (EMR) that have caused concern are similar to that which was produced in abundance at the radar facility near Turkey where the Veteran was stationed between 1974 and 1975, this range of frequencies also includes EMR that we are all exposed to every day of our lives. This exposure includes UHF band television, mobile phones, wireless LAN, and microwave oven emissions, at least some of which was a contributor to the Veteran's total EMR exposure, and even more so in the 21st century than in the latter half of the 20th century. The also examiner stated that there is no conclusive evidence of a cause and effect relationship between exposure to this sort of radiation and development of any human health condition. Additionally, there is no evidence of record that diabetes mellitus affected this Veteran prior to the solitary elevated blood glucose measurement of 162 mg/dL recorded in April 1987. Without any further objective evidence to suggest a change in this Veteran's health status between his separation from military service in May 1976 and this single documented abnormal blood glucose reading in 1987, the examiner could not determine the likelihood that this condition existed, undiagnosed, within one year of separation from service. Similarly, without any service treatment records documenting subjective symptoms or objective signs of the development of diabetes during service, any statement about the chance that this condition developed in this timeframe would be purely speculative. In a November 2011 letter, Dr. S.A. reported it was in his medical opinion that the Veteran's medical conditions of coronary artery disease, obstructive sleep apnea, neuropathy of lower extremities, and diabetes mellitus are closely related to each other. Dr. S.A. reported that sleep apnea doubles the risk of having myocardial infarction. The Veteran underwent several Disability Benefits Questionnaire examinations (DBQs) in September 2012. In pertinent part, the Veteran was diagnosed with type II diabetes mellitus (diagnosed approximately 15 or 20 years ago); erectile dysfunction (diagnosed around 20 years ago); psoriasis; coronary artery disease status post stents, possible inferior infarct age undetermined; and peripheral neuropathy of the bilateral lower extremities (feet) (diagnosed in 2009 and 2012). Also in pertinent part, the Veteran reported he was told he was borderline diabetic in June 1976; and that a rash on his left forearm started when he came back from Turkey and that he had seen a couple of dermatologists and was given creams and medications. The September 2012 VA examiner, an endocrinologist, provided an opinion that the Veteran's diabetes was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The rationale was based on several citations to studies and the examiner's statement that she could not find evidence of onset during military service; that a service lab result from August 20, 1973 showed glucose 100 mg/dL and urinalysis negative for glucose, protein, and ketones; that the Veteran reported the onset around 15 to 20 years ago; that the Veteran reported he was told he was pre-diabetic in 1976, but the laboratory data was not of record; and that service treatment records did not identify diabetes, heart disease, male reproductive disorders, neurological conditions, or skin diseases. The examiner also noted that the previous VA examination indicated the onset was in the late 1980s or early 1990s and that a solitary elevated blood glucose measurement was identified in April 1987 and recorded as 162 mg/dL. The September 2012 VA examiner also provided an opinion that coronary artery disease was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The rationale was based on several citations to studies that discuss risk factors for coronary artery disease, to include smoking, high levels of certain fats and cholesterol in the blood, high blood pressure, high levels of sugar in the blood due to insulin resistance or diabetes, blood vessel inflammation, and plaque buildup in damaged arteries. The examiner also stated that the Veteran was 59 years old, obese, and had/has unhealthy cholesterol levels, diabetes, hypertension, and is sedentary. The September 2012 VA examiner further opined that the claimed impotency was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The rationale was based on the fact that the etiology was more likely multifactorial as the Veteran is obese, has a low normal testosterone level, has diabetes, has problems with cholesterol, has hypertension, and has heart disease. The examiner also cited a website article that discussed common causes of erectile dysfunction. Finally, the September 2012 VA examiner provided an opinion that the claimed skin rash was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The rationale was based on a cited medical article that discussed the risk factors for psoriasis and comorbid conditions. The examiner noted that the Veteran was obese, was taking a beta blocker (Carvedilol), and had comorbid conditions of cardiovascular disease, diabetes and hypertension. In an October 2012 letter, the Veteran's attorney took issue with two of the scientific literature cited by the September 2012 VA examiner in support of the proposition that there is no relationship between diabetes and exposure to electromagnetic radiation. The attorney indicated that one does not address the issue of diabetes and EMF exposure and the other is irrelevant to the question before VA because the study said that EMF radiation is a potential treatment for diabetes as part of a cell implantation process, which has nothing do to with whether EMF radiation is a potential cause of diabetes. The attorney indicates that the examiner's research is inadequate as two studies that have nothing to do with diabetes and electromagnetic radiation were discussed, and favorable studies were ignored. The attorney noted two articles, one entitled "Dirty Electricity Elevates Blood Sugary Among Electrically Sensitive Diabetics and May Explain Brittle Diabetes," by M.H., which was attached to the statement, and the other entitled "An Independent Report Investigating the Criteria Governing the Current Australian Electromagnetic Field Exposure Limits Intended to Limit Adverse Health Effects to Humans," which cites to a New Zealand study that found an increased risk of diabetes from exposure to EMF radiation, in support of the claim. In another October 2012 letter, the Veteran's attorney attached related evidence consisting of an internal Boeing document from the Robert Strom versus Boeing Company lawsuit, which discusses exposure to microwave and radio frequency radiation. An addendum to the opinion provided by the September 2012 VA examiner was obtained in December 2012 because of the additional evidence submitted by the Veteran's attorney that needed review, specifically the article by M.H. The examiner was asked to review all the records and provide an opinion as to the likelihood that diabetes mellitus is related to exposure to electromagnetic fields. The December 2012 VA examiner reported that there was no evidence of diabetes or pre-diabetes in the service treatment records and specifically discussed some of the service treatment records, to include a July 1971 physical that made note of an aunt having diabetes, but indicated there were no signs or symptoms in the examinee; a July 1971 report of medical history that annotated no sugar or albumin in urine; glucose reading on August 20, 1973, of 100 mg/dL with urinalysis was negative for glucose, protein and ketones; an August 20, 1973, chemistry form that annotated glucose of 100 "FBS" (fasting blood sugar); an undated 1973 patient history worksheet annotated the Veteran's positive response to family history of diabetes, but negative response to frequent desire to urinate and to blood in urine; an October 1974 annotation that cleared the Veteran with no medical or dental problems; a March 1977 enlistment examination that noted normal endocrine system, that the examinee denied family history of diabetes, and that urine tests for sugar and albumin were negative; and a December 1978 report of medical history on which the Veteran denied a family history of diabetes. The examiner also reported reviewing private medical records, to include an April 1987 record that identified a solitary elevated blood glucose measurement of 162 mg/dL, without indication as to whether this was fasting or non-fasting serum glucose level, but with notation that if non-fasting, the April 1987 test does not indicate diabetes and if fasting, then a single blood test does not make a diagnosis of diabetes as an abnormal test must be confirmed with a second test. The examiner indicated that there was not enough evidence to determine if the Veteran had or did not have diabetes in 1987, as a single test is insufficient evidence to make such a diagnosis. The examiner further stated that it was suggestive, but not diagnostic, and that nonetheless, 1987 was well beyond the Veteran's term of service. The examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The rationale was based on review of the claims file, references provided by the Veteran's attorney, and relevant medical records and that the generally scientifically accepted and recognized risk factors for type II diabetes mellitus are obesity, genetic predisposition, age, and sedentary lifestyle. The examiner indicated that electromagnetic radiation is not a recognized or generally accepted risk factor or cause of diabetes mellitus; as such, the Veteran's diabetes is not caused by real or imagined EMF exposure between 1970 and 1977, while he was in the military. The examiner was of the opinion that the causes of the Veteran's diabetes mellitus were family history, sedentary lifestyle, obesity and age. The December 2012 VA examiner also commented on the two papers that are presented by the Veteran's attorney in support of the contention that EMF exposure caused the Veteran's diabetes. The first was a document attributed to a court case (Strom v. Boeing) that does not appear to have any other background associated with it. The document itself is not a scientific paper but rather a vague description of the non-ionizing electromagnetic radiation on the hematopoietic (blood) system. Diabetes was not addressed in the article. The second was a paper entitled "Dirty Electricity Elevates Blood Sugar Among Electrically Sensitive Diabetic and May Explain Brittle Diabetes," which does not propose or present a causal relationship between electromagnetic fields and diabetes as it addresses people who already have diabetes. Additionally, the study presented has nothing to do with the types of EMF used in radar tracking facilities. The examiner noted that home computers typically generate an EMF of 60Hz which is extremely low frequency while the radar dishes of the type at Air Station in Turkey operate at a frequency of 432 MHz, which is ultra-high frequency. The examiner further noted that neither had ever been credibly associated as a cause of diabetes. Furthermore, it is the weakest form of academic paper demonstrating anecdotal evidence case studies without any of controls and weakly correlated conjecture. The examiner stated the author of the paper does not control for physical inactivity, physical activity, or the passage of time. While there has been an overall increase of diabetes in the population concurrently with an overall increase in environmental electromagnetic radiation, as the author asserts, there has not been any study showing a causal relationship between diabetes and EMF. Based on this sort of conjecture, it could also be said that an overabundance of environmental plastics cause diabetes or that contrails from airplanes cause diabetes or that polio vaccinations cause diabetes. The examiner noted none of these would be true based on accepted scientific research and research methods. The examiner further stated the more likely cause is that the wondrous advances in agricultural and food sciences and technologies have eclipsed the slow pace of human metabolic evolution as a central cause of the current diabetic epidemic. The ubiquitous EMFs about which M.H. writes are exactly that: ubiquitous, and the Veteran would have exposure to them daily as would a great deal of other people. If a particular EMF were to cause a disease then one assumes that temporal proximity is the most likely antecedent risk(s) for any causal relationship. The Veteran's contended diabetes did not develop until nearly a decade after he left the military. There may be a relationship between watching television and diabetes but the examiner suspected it had to do with being sedentary and not with the television generated EMF. Even the paper provided by the Veteran and his attorney demonstrates only a transient effect of EMFs on people who already have diabetes, not a causal relationship. As to the general assertion that EMF causes diabetes, the examiner stated there is no current generally accepted scientific linkage between electromagnetic field radiation and diabetes mellitus. A PubMed search yielded no scientific paper suggesting remotely that electro-magnetic radiation has a causal relationship with diabetes. A PubMed search for the terms diabetes and electromagnetic fields yielded 52 results. None of these results was an epidemiological study of EMF as a cause of diabetes. Several imply a beneficial effect of EMF on the treatment of diabetes and its complications. Additionally, as to the specific assertion that the Veteran's diabetes could be caused by electromagnetic fields he may or may not have encountered while in the military between the years October 1974 and October 1974 at the Air Station in Turkey, this particular radio station broadcasts at 432mhz (about the same as a ham radio operator). While the possibility of obtaining a thermal burn if standing directly in front of such a transmitter exists, no danger of radiation damage or sickness has ever been demonstrated or proven at such frequencies. The Veteran submitted an opinion provided by Dr. Bash in a June 2013 letter. Dr. Bash reported that as a specialist in the fields of independent medical examinations and diagnoses, he had been asked to evaluate the Veteran's medical records on longitudinal view to determine "if his current rating is correct concerning his diabetes and secondary diabetic neuropathy, retinopathy, Transient ischemic attack (TIA), cataracts, hypertension (HTN)/coronary artery disease, ED [erectile dysfunction], nephropathy and likely cardiomegaly; and glaucoma and sinusitis with primary and/or secondary sleep apnea/CPAP and primary HTN and TDIU as these problems relate to his service in the US Air Force." Dr. Bash reported that he had reviewed the Veteran's relevant and critical medical facts contained in his medical records, testimony, lay statements and personnel records, conducted a 60-120 minute patient clinical interview history to document the effects of his disabilities upon his ordinary activities, imaging-based medical examination, and an in-person history/clinical interview. Dr. Bash also reported advanced training in neuroradiology and radiology. Dr. Bash provided several opinions, some related to conditions not being considered by the Board in this decision. The Board notes that Dr. Bash cited several references at the end of his opinions. The Board also notes that this opinion was also submitted to the Social Security Administration, as it is included in records obtained from that agency. Dr. Bash reports that the Veteran was assigned to military bases around the world; that there is a single solitary elevated blood glucose measurement of 162 mg/dl in 1987; that the Veteran recalled that in 1976, he was told that he was pre-diabetic; that August 20, 1973, urinalysis noted negative glucose; that chemistry SF Form 548 annotated glucose of 100 FBS; and that there was a family history of diabetes. He stated, "[b]ased on this evidence, if patient was pre-diabetic in 1976, it is likely as not that he was pre-diabetic in service." Dr. Bash went on to report that the Veteran had been married to his spouse for 31 years and they were married during his time in service; that his spouse had written a note that described his frequent urination at night during the time when he was in service and that this lay testimony was consistent with his VA medical exam in June 1976 during which the physician told him that he was borderline diabetic; that his spouse noted his urination problem as she was a shift worker and was up often at night when he would use the restroom; that the Veteran's local doctor at the time, Dr. M., examined his posterior orbital globe during a physical and told him that he had both diabetes and hypertension; that this examination was also shortly after service in 1976; that the posterior globe is a good place to see diabetic and hypertension changes as the retina has exposed blood vessels; that Dr. M. gave the Veteran a verbal diagnosis, thus this should be equivalent to a medical record, as his paper records had been destroyed; and that Dr. M. was unable to write a note about his medical care recollections, however for many decades Dr. M. treated this Veteran for his eyes. It was Dr. Bash's opinion "considering every possible sound medical etiology/principle, to at least the 90 [percent] level of probability" that his current diabetes and secondary conditions of peripheral neuropathy, nephropathy, cataracts, ED and transient ischemic attack arose during his military service. Dr. Bash stated his opinion was based on several reasons, including that the Veteran entered the service fit for duty without any doctor-diagnosed illnesses of diabetes and secondary diabetic neuropathy; he has diabetic-induced secondary peripheral neuropathy and the other conditions listed above as per his medical records and per Dr. Bash's own analysis; he has strong lay evidence of polyuria frequent urination in service and afterward, which is a sign of diabetes; he remembers a medical opinion from an employee health doctor who told him that he had borderline diabetes in 1976 following service; additionally, he remembers his private physician, Dr. M., also told him that he had both diabetes and hypertension based on his 1976 physical; he had cupping of his optic discs on ophthalmology examination in June and September 1977 consistent with glaucoma; diabetes is well-known to cause glaucoma, therefore, his glaucoma cupping in 1977 was likely due to his diabetes as his records do not contain another more likely cause for his cupping or glaucoma; his records post-service show a consistent pattern of worsening diabetes; it was Dr. Bash's opinion that his diabetes started in service due to the supportive lay and medical opinion/testing data contained in his record; he had medical visits for diabetes in 1987 with a sugar level of 167 and on urine testing in 1992, he spilled protein into his urine consistent with the advancing stages of the diabetic-induced nephrotic syndrome likely caused by his long-standing diabetes; his current symptoms per lay statements show chronicity of symptoms; his records do not support another more plausible etiology for his early diabetes and secondary condition; the time lag between service time polyuria and early signs of diabetes and his later more formal diagnosis is consistent with known medical principles and the natural history of this disease; and that this opinion is consistent with the Veteran's subjective lay statements and the objective findings/imagining/tests/diagnoses. Dr. Bash also noted that the opinion was consistent with the opinion of Dr. S.A. and that the listed diabetic secondary complications are consistent with the opinion of the 2009 VA examiner, who simply stated that the Veteran's exposure to radiation did not cause his diabetes, but did not comment on his ophthalmologic examinations or the opinion of his physician immediately post-service. In regards to hypertension, coronary artery disease and ED, Dr. Bash again reported on the 1976 finding of hypertension when Dr. M. examined the Veteran's posterior orbital globe, and again reported on the 1977 ophthalmological examinations that showed disc cupping and narrow arteries before stating that disc cupping and narrow arteries are well described in the literature as signs of hypertension as documented on a cited internet link. It was Dr. Bash's opinion "considering every possible sound medical etiology/principle, to at least the 90 [percent] level of probability" that his current hypertension, coronary artery disease and ED are due to his experiences/trauma during his military service. Dr. Bash state this opinion was based on several reasons, including that the Veteran entered the service fit for duty without any doctor-diagnosed illnesses of hypertension; he has hypertension and well-known secondary complications of coronary artery disease and erectile dysfunction; his narrow optic vessels in service are the first signs of his hypertension; his current symptoms are per the attached lay statements, which show chronicity of symptoms; his records do not support another more plausible etiology for his current cardiac primary and secondary pathology or other risk factors (in or out of service) to explain his problems other than his service-time experiences with hypertension and diabetes; no other physician has made a controverting opinion; and this opinion is consistent with the Veteran's subjective lay statements, the objective findings/imaging tests/diagnoses. In regards to sinusitis with secondary sleep apnea/CPAP, Dr. Bash reports that the Veteran has been married to his spouse for 41 years and they were married during his time in service. His spouse has written a note that describes his frequent sinusitis and frequent nightly loud snoring all while he was in service. His snoring was heard in the next room and his spouse noted this problem at night as she was a shift worker and was up often when he snored during his sleep. Additionally, his diabetes likely caused him to gain weight from about 190 pounds in service to his current 250 pounds (5 foot 10 inches tall). Dr. Bash asked VA to note that excessive weight is also a well-known cause of sleep apnea. It was Dr. Bash's opinion "considering every possible sound medical etiology/principle, to at least the 90 [percent] level of probability" that the Veteran's current sinusitis with secondary sleep apnea/CPAP problems are due to his experiences/trauma during his military service. Dr. Bash stated he based this opinion on several reasons, including that the Veteran entered the service fit for duty without any doctor-diagnosed illnesses; he had sinusitis, snoring and large weight gain likely due to his service induced diabetes; he has been diagnosed with sleep apnea/CPAP; his current symptoms are per the attached lay statements, which show chronicity of symptoms; his records do not support another more plausible etiology for his current sinusitis/snoring with secondary sleep apnea/CPAP pathology or other risk factors other than service induced weight gain in or out of service to explain his problems other than his service time experiences with sinusitis and snoring; the literature supports a positive association both between sinusitis/snoring and weight gain and the development of sleep apnea; the time lag between sinusitis/snoring and weight gain in service and his current sleep apnea diagnosis is consistent with known medical principles and the natural history of his disease as often this disease goes undiagnosed for several years; and this opinion is consistent with the Veteran's subjective lay statements, the objective findings/imaging tests/ diagnoses. In regards to primary hypertension, Dr. Bash reports that the Veteran's diabetes likely caused him to gain weight from about 190 pounds in service to his current 250 pounds (5 foot 10 inches tall). Dr. Bash also reported that excessive weight is a well-known cause of hypertension as each pound of weight adds 10 miles of blood vessels, which adds additional vascular resistance, which in turn causes an increase in blood pressure, and that this is exactly what likely happened to this Veteran. It was Dr. Bash's opinion "considering every possible sound medical etiology/principle, to at least the 90 [percent] level of probability" that his current hypertension problems are due to his service caused diabetes and associated weight gain. Dr. Bash based this opinion on several reasons. These include that the Veteran entered the service fit for duty without any doctor-diagnosed illnesses of hypertension; his narrowed optic vessels in service on eye exam were likely the first signs of his hypertension in service; the literature supports an association between narrow optic vessels and hypertension; additionally, he developed diabetes in service and had weight gain post service; his weight gain likely synergistically contributed to his hypertension, as weight is a well-known cause of hypertension; his current symptoms are per the attached lay statements, which show chronicity of symptoms; his records do not support another more plausible etiology for his current hypertension pathology or other risk factors other than service-time narrow optic vessels and post service diabetes induced weight gain; and this opinion is consistent with the Veteran's subjective lay statements and the objective findings/imaging tests/diagnoses. In a letter received in July 2013, Dr. S.A. reported that the Veteran had been his patient for many years and that Dr. S.A. concurred with Dr. Bash's opinion except for his diagnosis of nephrotic syndrome. The Board sought a Veterans Health Administration (VHA) opinion in December 2013. The requested opinion was provided by Dr. S.Y. in January 2014, who concluded that with the very minimal available information from the 1970s and the lack of relevant laboratory results, it was very difficult to conclude with precision whether the Veteran had diabetes during or within one year after discharge from service. Dr. Y. indicated that it is unlikely exposure to EMF is the cause of his diabetes based on the current knowledge and cited medical literature on PubMed, which did not provide any evidence that diabetes can occur secondary to exposure to EMF. Dr. Y. also indicated that if laboratory data prior to May 1977 was available, presumptions could be made but without them, it was not possible to make a comment or give an opinion. Clarification of the opinion provided in January 2014 was requested in May 2014 because the Veteran had submitted multiple articles he believed supported the conclusion that his EMF exposure caused his diabetes and that one of the articles suggested dirty electricity elevated blood sugar among electrically sensitive diabetics. It was requested that the articles submitted by the Veteran be reviewed and whether they changed the conclusion that EMF is unlikely to have caused the Veteran's diabetes, with explanation as to why. An addendum opinion was obtained from Dr. S.Y. in June 2014. Dr. Y. noted that she was not an expert on environmental medicine or forensic pathology and that a person with knowledge about electromagnetic field may be able to clarify better. Dr. Y. did note that American Diabetes Association, World Health Organization, and International Federal of Diabetes did not connect electromagnetic fields as a cause of diabetes mellitus at present; that electromagnetic hypersensitivity (EHS) is an ill-defined term to describe the fact that people who experience health symptoms in the vicinity of electromagnetic fields (EMF) regard them as causal for their complaints, but that up to now, most scientists assume a psychological cause for the suffering of electromagnetic hypersensitive individuals; that there was no literature on PubMed to connect a causal relationship between EMF and diabetes; and that EMF us used in treating diabetic neuropathy, with citation to three sources. In regards to the article submitted by the Veteran on dirty electricity elevating blood sugar among sensitive diabetics, Dr. Y. noted that the article was from Canada in 2008 and warranted large scale studies; that no new studies had been published; and that the publication introduced a term called type 3 diabetes and explains high sugars in medical centers and exposure to electronic equipment at home. Dr. Y. again concluded that with the very minimal available information from the 1970s and the lack of relevant laboratory results, it was very difficult to conclude with precision whether the Veteran had diabetes during or within one year after discharge from service; and again noted that if laboratory data prior to May 1977 was available, presumptions could be made but without them, it was not possible to make a comment or give an opinion. Dr. Y. indicated that her conclusions should be based on current literature accepted with causal relationship accepted by clinical medicine; that current evidence does not support the effect of EMF in causing diabetes, but that does not mean what future science could hold; and that environmental experts may be able to help in that area. The Board sought an independent medical opinion in February 2015 and the opinion was obtained that same month. Dr. B.A.D. at Wayne State University School of Medicine reported that the Board's question of whether the Veteran's diabetes mellitus is etiologically related to his exposure to electromagnetic waves in service would be broken down into two components. First, what are the possible causes for the development of diabetes mellitus in the Veteran and second, is there a causal relationship between exposure to electromagnetic waves and the development of diabetes mellitus. Dr. D. reported that the Veteran's medical record includes a multitude of entries starting as early as 1971. Many of these entries relate to eye examinations for the purpose of correction of refraction errors. Dr. D. indicated that it is customary during eye examinations for the providers to inquire about diabetes and obtain a diabetes history from the patient. This was consistently done with the Veteran and there was consistent evidence that the Veteran had a family history of the presence of diabetes mellitus. Dr. D. further notes that this was documented repeatedly by several physicians in their progress notes as well as by the Veteran himself when during pre-visit surgery, the box indicating the presence of family history of diabetes was checked as affirmative. Dr. D. noted that it was interesting that following discharge from military service, progress notes in the 1990s started labelling the Veteran as obese and that his weight increased from 190 pounds in 1977 to 230 pounds in 2012. In addition, he developed problems with hyperlipidemia as evidenced by documented serum lipoproteins. In this Veteran with family history of diabetes mellitus and increase in weight and lipoprotein blood levels, the development of diabetes mellitus is most likely related to these factors than exposure to electromagnetic waves. Dr. D. went on to state that given this opinion about the possible predisposing factors for diabetes mellitus in this patient, one may still wonder whether the electromagnetic field exposure may have aggravated or accelerated or is in some way related to the development of diabetes in this patient. Dr. D. explained that the evidence linking electromagnetic waves to diabetes is weak. Proponents of this hypothesis present case reports of diabetics who had significant changes in their glucose blood levels when in the proximity of a computer. The proponents do not present any evidence from controlled experiments that would be acceptable scientific evidence of such an association. Furthermore, the studies show that diabetic control may be worsened by exposure to electromagnetic waves. The studies do not show that diabetes develops de novo following exposure to these waves. One study which supports the hypothesis that these waves may aggravate diabetes clearly states that: "long and continuous exposure to relatively high intensity electromagnetic field may count as a mild stress situation and could be a factor in the development of depressive state or metabolic disturbances. Although we should stress that the average intensity of the human exposure is normally much smaller than in the present experiment." Dr. D. noted that even proponents of the hypothesis believe that the contribution of these waves to stress (and possible metabolic disorders) is minimal. In addition, several studies show that exposure to these waves may, in fact, have a positive impact on the outcome of diabetic complications such as wound healing and neuropathy (with cite). Dr. D. noted that a recent survey from Germany reports that there is significant discordance among physicians as to whether exposure to these waves may have a detrimental effect on human physiology (with cite). Dr. D. concluded by noting that the contention that electromagnetic waves cause diabetes is not supported by scientific data that are based on randomized controlled studies or even less rigorous scientific evidence. On the other hand, the Veteran has other factors that are known to be linked to the development of diabetes mellitus. Consequently, it was Dr. D's opinion that it is less likely than not (less than 50 percent probable) that the Veteran's diabetes mellitus is etiologically related to his exposure to EMF in service. In an April 2015 letter, the Veteran's attorney took issue with the February 2015 opinion obtained by the Board because it failed to take into account the history provided by the Veteran of diabetes after service. The attorney states that Dr. Bash's opinion, on the other hand, specifically cites to the lay evidence in support of service connection. The attorney urges the Board to disregard the February 2015 opinion because it does not take into account the lay evidence and it does not provide a rationale to discount the lay evidence. However, the Board does not find the lay assertions, upon which the opinions by Dr. Bash and by Dr. S.A. are based, to be credible. Both the Veteran and his wife have alleged that the Veteran was told he was pre-diabetic shortly after his discharge from service, that he has had elevated glucose levels since his discharge from service, and that he experienced frequent urination during and since service. They have also asserted that the Veteran suffered from frequent urination during and subsequent to service, which Dr. Bash has asserted is a symptom of diabetes. The Board acknowledges that the Veteran's post-service medical evidence from 1976 is reportedly unavailable; however, other records during the subsequent years following service do not corroborate the assertions made by the Veteran and his wife in pursuit of this claim for benefits. In this regard, on the March 1977 Report of Medical History prepared for enlistment in the Air National Guard, the Veteran denied having or having a history of sugar or albumin in urine or frequent or painful urination. Physical examination revealed a urinalysis that was negative for albumin and sugar. On Reports of Medical History dated in December 1978 and May 1979 he denied any change in his physical health and denied taking medications. On the physical examination of drivers conducted by Dr. M. in April 1984 and April 1986, the Veteran denied a personal health history of diabetes. Both examinations showed laboratory findings were negative for sugar and albumin in the urine. Moreover, the October 1985 record from City Hospital showed urinalysis was negative. It seems unlikely that Dr. M. would have been willing to formally certify that the Veteran had no history of diabetes and was not suffering from diabetes when examining him in 1984 and 1985, had the Veteran, in fact, been suffering from pre-diabetes and/or diabetes since 1976. Also, the file includes records from Dr. M. dating from August 1976. There is no mention of diabetes or elevated blood sugar until the August 1986 entry, nor mention of testing for such. Had the Veteran been pre-diabetic in 1976 and told to be such by Dr. M. as alleged, it is likely that records over the immediately following years would reflect repeated testing to monitor the condition. See AZ v. Shinseki, 731 F.3d 1303 (Fed. Cir. 2013) (recognizing the widely held view that the absence of an entry in a record may be considered evidence that the fact did not occur if it appears that the fact would have been recorded if present). In weighing credibility, VA may consider interest, bias, inconsistent statements, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza v. Brown, 7 Vet. App. 498 (1995). Here, the recollections of the Veteran and his wife as to when he was advised he was diabetic/pre-diabetic and symptoms of frequent urination during and following service are being provided 30 years after service, and in furtherance of the claim for monetary benefits. As their recollections are inconsistent with medical evidence significantly more contemporaneous to service, with the Veteran's own reports on reserve Reports of Medical History, and with medical records dating prior to his first elevated blood sugar in the mid 1980's, the Board does not find their assertions to be credible. See Buchanan v. Nicholson, 451 F.3d 1331, 1336-1337 (2006) (the lack of contemporaneous medical records, the significant time delay between the affiants' observations and the date on which the statements were written, and conflicting statements of the veteran are factors that the Board can consider and weigh against a veteran's lay evidence); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (VA cannot ignore a Veteran's testimony simply because the Veteran is an interested party; personal interest may, however, affect the credibility of the evidence). Turning to the medical opinions of record, Dr. S.A. concluded that it is as least as likely as not that elevated glucose levels reported earlier than 1987, to include within the first year of the Veteran's 1976 discharge from service, were an indication of diabetes. As the record shows no elevated glucose levels during or within the year following service, this opinion is based on the assertion made by the Veteran and/or his wife that has been deemed by the Board to lack credibility. Accordingly, this opinion from Dr. S.A. is afforded no probative value. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (a medical opinion based on an inaccurate factual premise is not probative); see also Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) ("If the opinion is based on an inaccurate factual premise, then it is correct to discount it entirely") (citing Reonal)). As none of the opinions provided by Dr. S.A. on the etiology of the Veteran's diabetes has been afforded any probative value, this leaves the opinions provided by the VA examiners in November 2009, September 2012 and December 2012; by Dr. Bash in June 2013; by Dr. Y. in January 2014 and June 2014; and by Dr. D. in February 2015. The VA examiners all concluded that the Veteran's diabetes mellitus is less likely as not caused by or a result of military service. They each noted the normal lab findings in the evidence during and after service until the noted elevated reading in April 1987 as part of the rationale for the opinion expressed. In addressing whether the reported exposure to non-ionizing electromagnetic radiation caused the Veteran's diabetes, the November 2009 VA examiner acknowledged that there are a few non-clinical studies that suggest there may be an association between non-ionizing radiation and increased rates of type I diabetes mellitus, but this was not the type of diabetes that the Veteran has; the December 2012 VA examiner indicated that electromagnetic radiation is not a recognized or generally accepted risk factor or cause of diabetes mellitus. Each cited sources to support their conclusions. The December 2012 VA examiner's determination that electromagnetic radiation is not a recognized risk factor for diabetes mellitus is substantiated by the opinions provided by Dr. Y. in January 2014 and June 2014, and by Dr. D. in February 2015. Dr. Y. reported that cited medical literature on PubMed did not provide any evidence that diabetes can occur secondary to exposure to EMF and that the American Diabetes Association, World Health Organization, and International Federal of Diabetes did not connect electromagnetic fields as a cause of diabetes mellitus at present. Dr. D. reported that the evidence linking electromagnetic waves to diabetes is weak and that studies do not show that diabetes develops de novo following exposure to these waves. The Board notes that both the December 2012 VA examiner, and the June 2014 opinion from Dr. Y., specifically address the article entitled "Dirty Electricity Elevates Blood Sugary Among Electrically Sensitive Diabetics and May Explain Brittle Diabetes," by M.H., submitted by the Veteran's attorney. The December 2012 VA examiner noted that even the paper provided by the Veteran and his attorney demonstrates only a transient effect of EMFs on people who already have diabetes, not a causal relationship between electromagnetic radiation and the development of diabetes. Dr. Bash provided an opinion in June 2013 that the Veteran's diabetes arose during his military service. This opinion was based on many factors, to include strong lay evidence of polyuria frequent urination in service and afterward, which is a sign of diabetes; that the Veteran remembers being told he had borderline diabetes in 1976 and that he was told he had diabetes in 1976 by his private physician, Dr. M.; and that ophthalmologic examinations in 1977 showed cupping of the optic discs, which is consistent with glaucoma, which is well-known to be caused by diabetes, such that the glaucoma cupping in 1977 was likely due to diabetes. However, as the opinion was based on the lay assertions of the Veteran and his wife that the Board has determined lack credibility, the opinion provided by Dr. Bash is not afforded any probative value. See Reonal and Monzingo, both supra. The Board acknowledges Dr. Bash's assertion that the Veteran had glaucoma caused by his diabetes evident in optic cupping noted in ophthalmologic records going back to 1977. However, such opinion pre-supposes the Veteran had diabetes prior to 1977, which, as noted above is not supported by the record. Moreover, the VA examiner, an ophthalmologist, who conducted an August 2012 VA eye conditions DBQ specifically indicated that the Veteran was only a glaucoma suspect, not that he had glaucoma in either eye, and that this is a genetically determined condition and not due to diabetes. Dr. Bash's conclusion that the Veteran had glaucoma in 1977 is afforded significantly less probative weight than the opinion from an eye specialist who actually conducted a detailed examination of the Veteran's eyes. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (the Board is entitled to discount the weight, credibility, and probity of evidence in light of its own inherent characteristics and its relationship to other items of evidence). In addition to the lack of scientific evidence establishing a link between diabetes and electromagnetic radiation, the opinions provided by the VA examiner in December 2012 and Dr. D. in February 2015 specifically pointed to risk factors the Veteran has other than the alleged exposure to electromagnetic radiation as the more likely cause or causes of the Veteran's diabetes. The December 2012 VA examiner cited family history, sedentary lifestyle, obesity and age; Dr. D. cited family history, obesity, and high cholesterol/hyperlipidemia. The Board notes that Dr. D. specifically cited progress notes starting in the 1990s that labeled the Veteran as obese, and problems with increased lipoprotein blood levels as evidenced by documented serum lipoproteins. These opinions, which are based on a detailed rationale, namely that there is no established evidence that diabetes is caused by exposure to non-ionizing electromagnetic radiation, but that family history, sedentary lifestyle, obesity, age, and high cholesterol/hyperlipidemia, all factors in the Veteran's case, are known risk factors, are afforded high probative value. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion). In sum, the preponderance of the competent, credible, and probative evidence is against a finding that the Veteran had diabetes in service or to a compensable degree within one year following discharge from service, or that such condition is related to active service, to include as a result of non-ionizing electromagnetic radiation. Accordingly, the claim for service connection for diabetes mellitus is denied. The preponderance of the evidence is also against the claims for service connection for coronary artery disease, impotence, skin rash, sleep apnea and peripheral neuropathy of the bilateral lower extremities on a direct basis. As an initial matter, although the Veteran was seen during active duty service with complaints involving his skin and sinuses, the service treatment records are devoid of reference to complaint of, or treatment for, any problems with his heart, impotence/erectile dysfunction, and neuropathy of the lower extremities. Moreover, the Veteran denied pain or pressure in the chest; palpitation or pounding heart; heart trouble; high or low blood pressure; cramps in his legs; recent gain or loss of weight; neuritis; and frequent trouble sleeping during the March 1977 enlistment examination conducted in conjunction with his period of service in the Air National Guard following active duty service. In addition to the foregoing, the Board finds that it was not until many years after the Veteran's May 1976 discharge from active duty service that he began mentioning having problems or receiving treatment for any of these conditions. More specifically, the earliest notation related to skin problems following service was in August 1992; for sleep apnea was in 1998; for coronary artery disease was in December 2000; and for impotence and peripheral neuropathy of the bilateral lower extremities was in November 2009. Given the foregoing, competent evidence linking the current conditions with service is required to establish service connection. The September 2012 VA examiner provided an opinion that coronary artery disease was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The rationale was based on risk factors specific to the Veteran, namely age, obesity, unhealthy cholesterol levels, diabetes, hypertension, and sedentary lifestyle. Dr. Bash, on the other hand, concluded that the Veteran's coronary artery disease is due to his experiences/trauma during service. The rationale was based in large part on Dr. Bash's determination that the Veteran exhibited both hypertension and diabetes during service. Neither hypertension nor diabetes is shown in the service treatment records or diagnosed for many years after service. Given that Dr. Bash's opinion is based on an inaccurate factual premise, the Board attaches significantly greater probative weight to the opinion provided by the September 2012 VA examiner, which was based on review of the medical evidence specific to this Veteran in both the in-service and post-service years. The September 2012 VA examiner provided an opinion that the claimed impotency was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The rationale was based on the fact that the etiology was more likely multifactorial as the Veteran is obese and has a low normal testosterone level, has diabetes, has problems with cholesterol, has hypertension, and has heart disease. Dr. Bash, on the other hand, concluded that the Veteran's erectile dysfunction is due to his experiences/trauma during service. The rationale was based in large part on Dr. Bash's determination that the Veteran exhibited both hypertension and diabetes during service. Neither hypertension nor diabetes is shown in the service treatment records or for many years after service. Given that Dr. Bash's opinion is based on an inaccurate factual premise, the Board attaches significantly greater probative weight to the opinion provided by the September 2012 VA examiner, which was based on review of the medical evidence specific to this Veteran in both the in-service and post-service years. The September 2012 VA examiner provided an opinion that the claimed skin rash was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The rationale was based on risk factors specific to the Veteran, namely obesity, the fact that he was taking a beta blocker (Carvedilol), and comorbid conditions of cardiovascular disease, diabetes and hypertension. This opinion, which stands uncontroverted in the record, is afforded high probative value. See Prejean, 13 Vet. App. at 448-49. Dr. Bash provided an opinion that the Veteran's peripheral neuropathy arose during military service; however, the rationale was based on a determination that it was diabetic-induced and a well-known complication of diabetes, not on any in-service findings of peripheral neuropathy. As such, Dr. Bash did not actually provide an opinion linking the peripheral neuropathy of the bilateral extremity directly to service. In any event, as noted above, Dr. Bash's opinion that diabetes began in service has been afforded no probative weight, and the most probative evidence indicates diabetes was not shown in service. Thus, Dr. Bash's opinion that peripheral neuropathy arose in service from the diabetes is afforded no probative weight. Dr. Bash provided an opinion that the Veteran's sleep apnea was secondary to sinusitis. However, such opinion was based on the Veteran's wife's assertion that he snored loudly at night even during service and since service, and that the Veteran had weight gain due to diabetes. The Veteran is not service-connected for sinusitis. To the extent that Dr. Bash may be trying to establish that the Veteran had symptoms of sleep apnea in service and chronically since then, this opinion is not afforded any probative value. Although the Veteran was seen with complaints related to his sinuses in service, there is no indication that his problems were chronic. While the Veteran's wife is competent to report that he has snored since service, there is no indication from the medical evidence of record that he has had chronic symptoms of sleep apnea since discharge from service. Rather, the evidence associated with the Veteran's initial treatment and diagnosis of sleep apnea indicates that he reported black out spells/loss of consciousness and episodes of night time awakening with acute and severe shortness of breath beginning in approximately 1997. Moreover, the Veteran denied frequent trouble sleeping on the March 1977 Report of Medical History. Thus, to the extent the Veteran or his wife assert he suffered from sleep apnea during and since service, the Board does not find such assertions persuasive. Her recollections are being rendered 30 years after service and are inconsistent with the medical evidence of record. Moreover, while Dr. Bash indicated that the Veteran's diabetes had caused him to gain weight in and out of service, and that excessive weight is also a well-known cause of sleep apnea, the Board notes that the medical evidence associated with the Veteran's initial treatment and diagnosis of sleep apnea indicates that he reported black out spells/loss of consciousness and night time awakening with acute/severe shortness of breath beginning in approximately 1997. Moreover, as explained by Dr. D. in February 2015, it was not until the 1990s that progress notes started labelling the Veteran as obese. As Dr. Bash's opinion was based on the assertions of the Veteran's wife that the Board has rejected as unpersuasive, as well as due to the contention that diabetes caused weight gain, the Board affords the opinion no probative weight. To the extent the Veteran contends that his claimed disabilities arose in and/or are related to service, as a lay person, the Veteran has not shown that he has specialized training sufficient to render such an opinion. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). In this regard, the diagnosis and etiology of his claimed disabilities are matters not capable of lay observation, and require medical expertise to determine. Thus, the Veteran's own opinion regarding the etiology of his current disabilities is not competent medical evidence. The probative medical evidence of record is afforded significantly greater weight than the Veteran's lay assertions. In sum, the preponderance of the competent, credible and probative evidence is against a finding that the coronary artery disease, impotence, skin rash, sleep apnea, and peripheral neuropathy of the bilateral lower extremities were present in service or that coronary artery disease and peripheral neuropathy were manifested to a compensable degree within the year following discharge from service. Accordingly, service connection on a direct and/or presumptive basis is not warranted. Moreover, as service connection for diabetes mellitus is being denied service connection for these disabilities as secondary to type II diabetes mellitus must also be denied. 38 C.F.R. § 3.310. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the probative evidence is against the claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b) (West 2014); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert, 1 Vet. App. at 55-56. ORDER Service connection for type II diabetes mellitus is denied. Service connection for coronary artery disease is denied. Service connection for impotency is denied. Service connection for skin rash is denied. Service connection for sleep apnea is denied. Service connection for peripheral neuropathy of the bilateral lower extremities is denied. ____________________________________________ K. A. BANFIELD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs