Citation Nr: 1735451 Decision Date: 08/25/17 Archive Date: 09/06/17 DOCKET NO. 11-04 037 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for diabetes. 2. Entitlement to service connection for fatigue, to include as secondary to service-connected posttraumatic stress disorder (PTSD) with bipolar disorder. 3. Entitlement to service connection for memory loss, to include as secondary to service-connected posttraumatic stress disorder (PTSD) with bipolar disorder. 4. Entitlement to service connection for lethargy, to include as secondary to service-connected posttraumatic stress disorder (PTSD) with bipolar disorder. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD R. Connally, Associate Counsel INTRODUCTION The Veteran, who is the appellant in this case, had active service in the U.S. Army from September 1983 to July 1987 and from September 1989 to January 2003. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a March 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. In May 2016, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge (VLJ); a transcript of the hearing is associated with the claims file. The Board previously considered this appeal in August 2016, and remanded this issue for further development in order to schedule a VA examination. That development was completed, and the case returned to the Board for further appellate review. The August 2016 Board decision also contained remand directives for the issues of entitlement to service connection for fatigue, memory loss, and lethargy. Those issues have since become service-connected and there is no longer any pending adverse determination for the Board to adjudicate. The matter will be dismissed below. FINDINGS OF FACT 1. The Veteran has a current diagnosis for diabetes. 2. The Veteran did not experience symptoms of diabetes while in service. 3. Symptoms of the diabetes were not chronic in service, were not continuous since service, and were not shown to a compensable degree within one year of service. 4. The current diabetes is not related to service or a service-connected disability. 5. In a November 2016 rating decision, the RO granted the Veteran's service-connection claims for fatigue, memory loss, and lethargy. CONCLUSIONS OF LAW 1. The criteria to establish service connection for diabetes have not been met. 38 U.S.C.A. §§ 1110, 1112, 1113, 1131, 5107(b) (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2016). 2. The appeal of the Veteran's claims of entitlement to service connection for fatigue, memory loss, and lethargy have become moot by virtue of a November 2016 rating decision granting the benefits, and there remains no matter in controversy for which the Board has jurisdiction. 38 U.S.C.A. §§ 7104(a), 7105(d)(5) (West 2014). (CONTINUED ON NEXT PAGE) REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection for Diabetes The Veteran contends that she is entitled to service connection for diabetes mellitus, type II, as a direct result of her time in service or that it was aggravated by her service-connected disabilities. Specifically, the Veteran asserts that her diabetes had its onset during her active duty service due to her weight fluctuation caused by her service-connected hypothyroidism and her PTSD. She has also claimed that her diabetes is a result of environmental hazard exposures while serving in the Gulf War. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. § 1110, 1131 (West 2014); 38 C.F.R. § 3.303(a) (2016). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). A disability that is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). A claim for secondary service connection requires competent medical evidence linking the asserted secondary disorder to a service-connected disability. See Velez v. West, 11 Vet. App. 148, 158 (1998); Wallin v. West, 11 Vet. App. 509, 512 (1998). Where a service-connected disability aggravates a nonservice-connected condition, a veteran may be compensated on a secondary basis for the degree of disability over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet. App. 439, 448 (1995). Where a Veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, including diabetes, to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. While the disease need not be diagnosed within the presumptive period, it must be shown-by acceptable lay or medical evidence-that there were characteristic manifestations of the disease to the required degree during that time. Diabetes mellitus is a "chronic disease" listed under 38 C.F.R. § 3.309(a); therefore, the presumptive service connection provisions of 38 C.F.R. § 3.303(b) based on "chronic" symptoms in service and "continuous" symptoms since service are applicable to the service connection claim for diabetes. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). With a chronic disease shown as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. For the showing of a chronic disease in service, there is a required combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive. When all the evidence is assembled, 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 a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; not every item of evidence has the same probative value. When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 2014); 38 C.F.R. § 3.102 (2016). The Court has held that an appellant need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. See Gilbert, 1 Vet. App. at 53. The Court has also stated, "It is clear that to deny a claim on its merits, the evidence must preponderate against the claim." Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert. First, the Veteran has a current diagnosis for diabetes. VA treatment records from July 2005 indicate that an initial diagnosis for diabetes was rendered at this time. VA treatment records since July 2005 show continued medical care for diabetes, but do not relate the disability to service. Next, service treatment records do not show any signs or symptoms for diabetes during either period of service. In other words, the record does not support that the condition was diagnosed during service. However, an in-service incident alone does not mandate that service connection be granted. The in-service incident must be shown to cause the current diabetes, or to have caused chronic or continuous symptoms of diabetes to a degree of 10 percent or more within one year of service to be presumed as incurred in-service. As diabetes is a chronic disease under 38 C.F.R. § 3.309(a), the Board will consider whether the Veteran had chronic symptoms in service or continuity of symptomatology since service have been shown. After a review of the evidence, both lay and medical, the Board finds that the weight of the evidence demonstrates the Veteran did not experience symptoms of diabetes in service and did not exhibit a required combination of manifestations sufficient to identify the disease entity or sufficient observation to establish chronicity at the time to warrant presumptive service connection under 38 C.F.R. § 3.303(b). Furthermore, the weight of the evidence shows that the Veteran's symptoms of diabetes since service have not been continuous since discharge or within one year thereof to warrant presumptive service connection. Id. First, regarding chronic symptoms in service, the Board finds that the Veteran was not treated for diabetes in service. The absence of treatment records for diabetes during service does not establish chronic symptoms during this time. However, there is more than just lack of treatment in this case. Records since this time reflect that the Veteran did not show symptoms of diabetes until July 2005. Therefore, she did not experience chronic symptoms of diabetes during service. Accordingly, in order to establish service connection on a presumptive basis the Veteran must demonstrate a continuity of symptomatology. Next, the Board finds that the weight of the evidence demonstrates the Veteran did not experience continuous symptoms of diabetes to a degree of 10 percent or more within one year of service to be presumed as incurred in-service. On VA examination in May 2003, the Veteran affirmatively denied any history of diabetes and her glucose levels did not reveal any abnormalities. Furthermore, the Veteran was not diagnosed with diabetes within one year of discharge from her last period of service as VA treatment records do not show a diagnosis for diabetes until July 2005; two and a half years after service separation. A July 2010 statement from a VA physician states that the Veteran's diabetes "came on within a year of her discharge from the military service." However, this statement is unsubstantiated by post-service medical evidence as there are no clinical findings of diabetes until July 2005. Additionally, the record does not indicate that the Veteran received treatment for diabetes during service or that she actually received treatment within the first year following service separation. Therefore, diabetes was not shown within the first year of discharge and the presumptions under 38 U.S.C.A. § 1112 and 38 C.F.R. §§ 3.303, 3.307, and 3.309 do not apply. As such, the criteria for presumptive service connection have not been met. The Board further notes that the Veteran has a known clinical diagnosis and accordingly the provisions of 38 C.F.R. § 3.317 do not apply. Nonetheless, diabetes is currently shown and the evidence reflects a possible in-service event of environmental hazard exposures while serving in the Gulf War or a possible relationship between the service-connected disabilities and diabetes. The next question is whether there is a causal relationship between the current complaints and the in-service event. After a review of all the evidence, both lay and medical, the Board finds that the weight of the evidence is against a finding of a nexus between the Veteran's current diabetes and service or a service-connected disability. At the May 2016 Board hearing, the Veteran testified before the undersigned that she was told this disorder may be caused or aggravated by her service-connected hypothyroidism or the sleep problems associated with the PTSD. She further alleged that the condition was directly related to the weight gain and sleep issues she experienced during service. She also said it was a result of environmental hazard exposures while serving in the Gulf War. The Veteran stated that she noticed a correlation between her impaired sleep habits and elevated blood sugar readings. On VA examination in September 2016, the examiner noted the Veteran's glucose level found in her service treatment records from 1998, 2002, and 2003. These readings ranged from 88 to 97. In 2004, VA treatment records showed a glucose level of 106 and in February 2005, glucose was measured as 101. The examiner pointed out that in June 2005, the Veteran's A1C was elevated to 9.30, and in July 2005, her glucose was 179, which was when she was formally diagnosed with diabetes. The VA examiner also reported that while the Veteran did gain weight during service, her diabetes did not manifest until approximately two years after leaving service when she also had gained an additional 34 pounds after leaving service. The examiner also found that the medical literature does not support any toxin exposure related to onset of diabetes two years after leaving service. The examiner found that there was no evidence of the Veteran's service-connected hypothyroidism worsening her diabetes since she was stable on her Synthroid dose and has noted improved control with her gradual normalization of BMI. The examiner further reported that the Veteran's diabetes was not worsened by her PTSD, specifically her sleep issues. The examiner explained that the medical literature supports the normalization of her BMI through improvement in lifestyle/diet changes as associated with improved management of diabetes. An independent medical opinion was obtained in April 2017. The examiner noted the Veteran's contentions that her claimed diabetes is related to and/or aggravated by military service, and/or service connected PTSD, to include sleep issues associated with PTSD, and/or hypothyroidism, and/or weight gain during service as well as reports of exposure to various toxins in the Persian Gulf. The examiner opined that it is less likely than not that the Veteran's diabetes had its onset in service, manifested to a compensable degree within one year of service separation or is due to or the result of an in-service disease or injury. With regard to the Veteran's claim of weight gain during service as related to her diabetes, the examiner reasoned, "Although the Veteran's weight fluctuated throughout her active duty period of service, the overall gain was approximately 10 pounds. Concurrently, the active duty and presumptive period medical records were negative for complaints, signs and symptoms of, diagnosis, treatment, injury and/or events related to diabetes." In addition, the examiner explained, "Pathophysiologically, hyperinsulinemia and insulin resistance are pervasive features of obesity, increasing with weight gain and diminishing with weight loss. Therefore, it is as least as likely as not that obesity and insulin resistance relate to the impairment of insulin action..." The examiner pointed out that the Veteran had gained approximately 34 pounds after service separation by the time she was diagnosed with diabetes. However, the Veteran recently decreased her weight, which the examiner noted also resulted in lower A1C and glucose levels. As a result, the examiner concluded that it is at least as likely as not that the Veteran's current metabolic condition, diabetes, and body mass are responding to appropriate care and diet, to include weight loss and medication. Regarding the Veteran's claim of toxin exposure causing her diabetes, the examiner opined that it is less likely than not that the Veteran's diabetes is related to toxin exposure. The examiner reasoned, "the Department of Veterans Affairs, military medicine, endocrinology, occupation medicine and internal medicine literature lack sufficient objective medically-based, clinical evidence to support a nexus between reports of exposure to various toxins in the Persian Gulf and a subsequent diagnosis of diabetes..." Next, regarding the Veteran's claim that her hypothyroidism caused and/or aggravated her diabetes, the examiner commented that hypothyroidism "is an autoimmune disorder causing glandular destruction and hormone deficiency, to include changes in the production of thyroxine (T4) and/or triiodothyronine (T3)." However, "The possibility of hypothyroidism should be considered, but it is an uncommon cause of obesity." Nonetheless, the examiner concluded, "the Department of Veterans Affairs, military medicine, endocrinology and internal medicine literature lack sufficient objective medically-based, clinical evidence to support a nexus between hypothyroidism and subsequent diagnosis of Diabetes Mellitus, Type II." Additionally, the examiner reported that the Department of Veterans Affairs, military medicine, endocrinology and internal medicine literature "lack sufficient objective medically-based, clinical evidence to support the diabetes as due to, the result of or has been aggravated by the Veteran's service connected hypothyroidism because the two metabolic diseases are independent and separate conditions effecting different glandular moieties and functions." Lastly, the examiner opined that the Veteran's diabetes is less likely than not due to, the result of, or was aggravated by her PTSD and specifically the sleep issues associated with the PTSD. The examiner reasoned that the DSM-5 criterion "lacks supportive objective and/or subjective based clinical evidence to support a nexus between PTSD and the development of diabetes." Furthermore, the examiner explained, "...the Department of Veterans Affairs, military medicine, mental health and internal medicine literature lack sufficient objective medically-based, clinical evidence to support the diabetes as due to, the result of, or has been aggravated by the Veteran's service-connected PTSD with or without sleep issues." The examiner then commented that these medical conclusions were based on a comprehensive review of the Veteran's electronic files, medical evidence from the clinical file, lay statements, CAPRI, and current medical literature. The Board finds this medical opinion highly probative of a negative nexus between the Veteran's current condition and service because they not only contain clear conclusions with supporting data, but also reasoned medical explanations connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). As a result, service connection is not warranted on a direct or secondary basis. In this decision, the Board has considered the Veteran's contentions and lay statements as they pertain to a nexus between current complaints and service. Lay statements may be competent to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan, 451 F.3d at 1331 (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Some medical disorders require specialized training for a determination as to diagnosis and causation; therefore, such issues are not susceptible of lay opinions on etiology, and a veteran's statements therein cannot be accepted as competent medical evidence. See Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) (stating that it "is generally the province of medical professionals to diagnose or label a mental condition, not the claimant"); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis); Jandreau, 492 F.3d at 1377, n. 4 ("sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer"). As a layperson, the Veteran does not have the requisite medical knowledge, training, or experience to be able to render a competent medical opinion regarding the cause of the medically complex disorder of diabetes. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011) (recognizing ACL injury is a medically complex disorder that required a medical opinion to diagnose and to relate to service). Diabetes is a medically complex disease process because of its multiple etiologies, requires specialized testing to diagnose properly and sometimes involves symptomatology that overlaps with other disorders. Woehlaert, 21 Vet. App. at 462 (holding that rheumatic fever is not a condition capable of lay diagnosis). The etiology of the Veteran's current diabetes is a complex medical etiological question involving internal and unseen system processes unobservable by the Veteran. The Board does not doubt that the Veteran is sincere in her belief that her diabetes is related to service. However, there is no evidence of the disability in either period of service or within one year of discharge to warrant service connection on any basis. The current statements, made in connection with her claim for benefits that maintain symptoms of diabetes due to service or a service-connected disability, are inconsistent with previous statements made during service. See Caluza v. Brown, 7 Vet. App. 498, 510-511 (1995) (holding that credibility can be impeached generally by a showing of interest, bias, inconsistent statements, or, to a certain extent, bad character); Pond v. West, 12 Vet. App. 341, 345 (1999) (although Board must take into consideration the Appellant's statements, it may consider whether self-interest may be a factor in making such statements). Based on the above, the Board does not find the Veteran competent to provide evidence of an etiological nexus between her current diabetes and service. As such, there is no competent evidence of record from the Veteran suggesting a causal relationship between the diabetes and service; therefore, the Board attaches greater probative weight to both the September 2016 VA examination and April 2017 independent medical opinions than to the Veteran's lay statements. For the reasons discussed above, the weight of the evidence demonstrates that the Veteran's current diabetes was not incurred in service, may not be presumed to have been incurred therein, and is not otherwise related to service or a service-connected disability. Therefore, the claim for service connection for diabetes must be denied. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application, and the claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Dismissal of Moot Claims As noted in the Introduction above, the RO denied the Veteran's service-connection claims for fatigue, memory loss, and lethargy in an April 2009 rating decision. The Veteran appealed this determination to the Board. However, upon remand by the Board in August 2016, the RO granted the benefits sought in a November 2016 rating decision. The rating decision stated "this rating decision represents, a total grant of benefits sought on appeal for lethargy, fatigue and memory loss. As such, this issue is considered resolved in full." Under 38 U.S.C.A. § 7105, the Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. In essence, a "case or controversy" involving a pending adverse determination to which the Veteran has taken exception no longer exists. See Shoen v. Brown, 6 Vet. App. 456, 457 (1994). Based on the RO's November 2016 determination awarding service connection for fatigue, memory loss, and lethargy, the Veteran's appeal has been granted in full, and there is no longer any pending adverse determination for the Board to adjudicate. The appeal of the Veteran's service-connection claims for fatigue, memory loss, and lethargy have become moot by virtue of the November 2016 grant, and must therefore be dismissed for lack of jurisdiction. See 38 U.S.C.A. §§ 7104(a), 7105(d)(5) (West 2014); see also Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). The Board notes that if the Veteran disagrees with the initial disability rating or the effective date assigned by the RO for the award of service-connection for these disabilities, she may file a Notice of Disagreement with the RO within one year of receiving notice of such determination. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2016). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim and of the relative duties of VA and the claimant for procuring that evidence. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). VCAA notice should be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The RO provided a letter to the Veteran in April 2009, prior to the initial adjudication of the service connection claim on appeal. The letter notified the Veteran of what information and evidence must be submitted to substantiate the claim, including a description of what information and evidence must be provided by the Veteran and what information and evidence would be obtained by VA. The Veteran was also advised to inform VA of any additional information or evidence that VA should have, and to submit evidence in support of the claim to the RO. The content of the letter complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). The notice requirements of the VCAA apply to all elements of a service connection claim, including: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. The Veteran was provided with such notice by the April 2009 letter, including the type of evidence necessary to establish a disability rating and effective dates. Next, VA has a duty to assist a veteran in the development of the claim. To that end, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159; see Golz v. Shinseki, 590 F.3d 1317, 1320-21 (2010) (stating that the "duty to assist is not boundless in its scope" and "not all medical records . . . must be sought - only those that are relevant to the veteran's claim"). Here, service records have been obtained as have records of VA and private treatment. Based on the foregoing, the Board finds that VA has met its duty to assist with regard to records development. The Veteran was afforded a VA examination with respect to this claim in September 2016. During the examination, the VA examiner conducted a physical examination of the Veteran with diagnostic testing, was provided the claims file for review, took down the Veteran's history, considered the lay evidence presented, laid a factual foundation for the conclusions reached, and reached conclusions and offered opinions based on history and examination that are consistent with the record. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4); Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (holding that the Board is entitled to presume the competence of a VA examiner and the adequacy of their opinion). The Veteran appeared at a hearing before the undersigned Veterans Law Judge in May 2016. In Bryant v. Shinseki, the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) essentially requires that any Veterans Law Judge who chairs a hearing fulfill two duties to comply with the above regulation. 23 Vet. App. 488 (2010). These requirements consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Id. During the hearing, the Veterans Law Judge sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked or was outstanding that might substantiate the claim. Accordingly, the Veteran is not shown to be prejudiced on this basis. Moreover, the Veteran has not asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. The actions by the undersigned satisfy the obligations imposed by 38 C.F.R. § 3.103. All necessary development has been accomplished; therefore, appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). In addition to the evidence discussed above, the Veteran's statements in support of the claim are also of record. The Board has carefully considered such statements, and concludes that no available outstanding evidence has been identified. Additionally, the Board has reviewed the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claim. For these reasons, the Board finds that the duties to notify and assist the Veteran in the development of this claim have been met, so that no further notice or assistance to the Veteran is required to fulfill VA's duty to assist. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). As noted in the Introduction, the Board previously remanded this claim in August 2016. The Board instructed the AOJ to schedule the Veteran for a VA examination and then readjudicate the claim on appeal with consideration of the additional evidence associated with the claims folder. Since that time, VA issued a supplemental statement of the case that considered the additional, new evidence. As a result, the Board finds substantial compliance with its previous remand instructions, and has properly continued with the foregoing decision. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting the Board's duty to "insure [the RO's] compliance" with the terms of its remand orders). ORDER Service connection for diabetes is denied. The issues of entitlement to service connection for fatigue, memory loss, and lethargy are dismissed. ____________________________________________ H. SEESEL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs