Citation Nr: 1752672 Decision Date: 11/16/17 Archive Date: 11/22/17 DOCKET NO. 01-00 173A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUE Entitlement to service connection for diabetes mellitus, type 2. WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD W. R. Stephens, Associate Counsel INTRODUCTION The Veteran had active duty service from September 1982 to June 1987, October 1988 to April 1989, and January 1991 to April 1991, with additional periods of active duty for training (ACDUTRA), inactive duty for training (INACDUTRA), and time served in the United States Air Force Reserves. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2000 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO), which denied service connection for diabetes mellitus. The Veteran testified at a Board hearing before two of the undersigned Veterans Law Judges in September 2002 and April 2008. He also testified at a January 2001 hearing before RO personnel. Transcripts of those hearings are associated with the claims file. One of the two hearing judges is no longer active and the panel is disbanded. This case has a long procedural history, which was extensively detailed in the Board's previous decision in March 2013. This matter was most recently before the Board in July 2015, when the Board denied service connection for diabetes mellitus. The Veteran appealed that decision to the United States Court of Appeals for Veterans Claims (Court), which resulted in a February 2017 Memorandum Decision remanding the matter back to the Board. FINDINGS OF FACT Diabetes mellitus, type 2, was not manifest in service or his periods of ACDUTRA, or to a compensable degree within one year of service and is unrelated to service. CONCLUSION OF LAW Diabetes mellitus, type 2, was not incurred in or aggravated by service or ACDUTRA, and may not be presumed to have been incurred in service. 38 U.S.C.A. §§ 101, 1110, 1112, 1113, 1131, (West 2014); 38 C.F.R. §§ 3.6. 3.303, 3.307, 3.309 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. VA's Duty to Notify and Assist Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). II. Service Connection Diabetes Veterans are entitled to compensation if they develop a disability "resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty." 38 U.S.C.A. § 1110 (wartime service), 1131 (peacetime service). To establish entitlement to service-connected compensation benefits, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service -the so-called 'nexus' requirement." Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). 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). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). Diabetes mellitus is identified as a "chronic" disease under 38 U.S.C.A §1101 and 38 C.F.R. § 3.309(a). "For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "Chronic." When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim." 38 CFR 3.303 (b). In the context of Reserve or National Guard service, the term "active military, naval, or air service" includes active duty, any period of active duty for training (ACDUTRA) during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in line of duty, and any period of inactive duty training (INACDUTRA) during which the individual concerned was disabled or died from an injury incurred or aggravated in line of duty. 38 U.S.C.A. § 101 (21), (24); see also 38 C.F.R. § 3.6. Diseases or injuries incurred or aggravated while performing ACDUTRA are eligible for service connection. 38 U.S.C.A. §§ 101 (24), 106, 1110, 1131. In other words, when a claim is based on a period of Reserve or National Guard service, it must be shown that the individual concerned became disabled (or died) as a result of a disease or injury incurred or aggravated in the line of duty on Reserve ACDUTRA/INACDUTRA or during Federalized National Guard service. The presumption of soundness under 38 U.S.C.A. § 1111 does not apply when a claimant, Veteran or otherwise, has not been examined contemporaneous to entering a period of active service here, the period of active duty for training. See Crowe v. Brown, 7 Vet.App. 238, 245 (1994) (holding that the presumption of sound condition "attaches only where there has been an induction examination in which the later-complained-of disability was not detected" (citing Bagby v. Derwinski, 1 Vet.App. 225, 227 (1991))). In the absence of such an examination, there is no basis from which to determine whether the claimant was in sound condition upon entry into that period of service on which the claim is based. Smith v. Shinseki, 24 Vet. App. 40, 45 (2010). A pre-existing disease or injury will be presumed to have been aggravated by service only if the evidence shows that the underlying disability underwent an increase in severity; the occurrence of symptoms, in the absence of an increase in the underlying severity, does not constitute aggravation of the disability. See Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002); 38 C.F.R. § 3.306 (a). Analysis The Veteran contends that, had his blood sugar level been tested in June 1997 (specifically during his period of ACDUTRA from June 6 to June 22), diabetes would have been diagnosed. The Veteran also contends that his diabetes mellitus is related to his period of active service in the Gulf War, from January 1991 to April 1991. Service treatment records indicate that glucose was tested, through urinalysis, in December 1988. The results were normal. A March 1994 examination report reveals that the Veteran had high cholesterol, and that he denied a family history of diabetes. A July 1997 laboratory report also indicates that the Veteran had high cholesterol. A June 28, 1997 memorandum reveals that the Veteran had an 'incomplete medical requirement,' meaning that all labs, examinations, and tests were not accomplished and reviewed in a timely manner. This memorandum instructed the Veteran to schedule a physical examination. An aircrew summary report indicates that the Veteran was moved to Aircrew Training due to an overall Q-3 rating during his recurring evaluation on June 29, 1997. The Veteran was removed from flying status on October 24, 1997. A March 2000 memorandum reveals that the Veteran was found medically disqualified for continued military duty by reason of non-insulin dependent diabetes mellitus, poorly controlled. A December 1997 private medical record indicated that the Veteran reported abdominal cramps, diarrhea, fever, and chills. A subsequent December 1997 private treatment record revealed that the Veteran's blood glucose level was 361. A March 1999 private treatment record indicated that the Veteran's mother had diabetes. The Veteran was afforded a VA examination in July 1999. The examiner noted that the Veteran's glucose level was 322, and diagnosed the Veteran with uncontrolled type 2 diabetes mellitus. The examiner did not provide an opinion as to the relationship between the Veteran's diabetes and his active service or ACDUTRA. In a December 1999 letter, the Veteran's private physician opined that he could not rule out the possibility that the Veteran's diabetes was related to his service in Operation Desert Storm in late 1990 and early 1991. The Veteran underwent a second VA examination in February 2001. The examiner noted that the Veteran's glucose was 199, and diagnosed the Veteran with insulin-dependent diabetes mellitus. The examiner stated that it was difficult to determine the onset date of the Veteran's diabetes, without reviewing the Veteran's medical records. At the September 2002 Travel Board Hearing before one of the undersigned Veterans Law Judges, the Veteran testified that his diabetes could have and should have been detected earlier if his blood sugar levels had been tested every year. The Veteran testified that his blood sugar level was so high upon his initial diagnosis, that it surely would have been high in June 1997, his period of ACDUTRA. In April 2003, the examiner who conducted the February 2001 VA examination reviewed the Veteran's claims file and past VA examination reports. The examiner also noted that the only record available for review from the Veteran's claims file was a May 1999 note that indicated the Veteran was told he had increased blood sugar in November 1997. The examiner stated that no labs were found and nothing in the Veteran's record indicated a diagnosis of diabetes mellitus. The examiner then opined that the Veteran's diabetes was related to his military service. The Veteran was afforded an additional VA examination in August 2004. The Veteran reported that he was initially diagnosed with diabetes in 1998. The examiner noted that the Veteran's glucose level was 220, and diagnosed him with diabetes mellitus. The examiner noted that the claims file was reviewed, as well as the April 2003 examiner's opinion, and stated that he could not give a determination about whether the Veteran's diabetes was related to service. The examiner explained that it depended upon whether the Veteran was on active duty or in the Reserves. The Veteran was afforded a Central Office Hearing in April 2008 before an additional Veterans Law Judge. The Veteran testified that he was diagnosed with diabetes in November 1997. Additionally, he reported that he served his two-week annual tour in June of 1997 and that blood work performed at that time revealed high cholesterol and high blood pressure, causing him to be taken off flight status. The record contains numerous documents from the Air Force Reserves. These records indicate that the Veteran was called to ACDUTRA from June 6 to June 22, 1997. There are no records indicating any duty in November 1997, when the Veteran was told he had high blood sugar, or in December 1997, when the Veteran was diagnosed with diabetes. The Veteran contends that he served a weekend of INACDUTRA in both November and December 2007. As noted, only a disability arising from an injury incurred in or aggravated during a period of INACDUTRA is compensable under VA regulations. The Veteran's diabetes mellitus is a disease and not an injury; therefore, further consideration of whether it was diagnosed during a period of INACDUTRA is not necessary. The Veteran submitted a January 2010 independent medical evaluation. The physician referenced the remarks section of a compensation and pension exam inquiry, where the glucose level of 367 in an in-service report was questioned. Such glucose level was diagnostic of diabetes mellitus. Since the Veteran's blood glucose laboratory reports were missing from his claims file, this indirect record showing a glucose level of 367 in service was significant and supportive of his conclusion that it was at least as likely as not that the Veteran's currently diagnosed diabetes mellitus had its origins in service. Additionally, the physician noted that the Veteran reported that at times he had abnormal thirst and occasional blurred vision while on active duty. Both excessive thirst and blurred vision were symptoms of diabetes mellitus. Although the Veteran was not diagnosed with diabetes mellitus until December 1997, at which time he had a blood glucose level of 361, based on his in-service symptoms (excessive thirst and blurred vision) and the noted in-service glucose level of 367, it was his opinion that it was at least as likely as not that the Veteran's currently diagnosed diabetes mellitus had its origins in service. In March 2010, the Board requested an expert medical opinion from a VHA specialist to determine the etiology of the Veteran's diabetes mellitus. An April 2010 medical opinion was obtained from an Endocrinologist. The physician noted that he reviewed the claims file in its entirety. The physician first discussed the Veteran's service treatment records. The medical examination for service included urinalysis which was negative for glucose. The examiner explained: However, there were no determinations of fasting or random serum glucose levels. Triglycerides were normal in 1985, but were increased in January 1997. Complaints of polyuria/polydipsia, unexplained weight loss, muscle weakness, or unexplained skin infections were not documented in service examination. The first complaint of excessive thirst was to his private physician, Dr. M.F.D., on December 4, 1997. This prompted lab studies including serum glucose of greater than 200, which in combination with excessive thirst met current diagnostic criteria for diabetes mellitus. While his subsequent response to oral medications was sub-optimal, he did not develop ketoacidosis. This confirmed that he had diabetes mellitus type 2 because of substantial insulin resistance, insulin had been required to get adequate control of his hyperglycemia. His hemoglobin A1C at time of diagnosis was 19%. This is extremely high and indicated that substantial hyperglycemia consistent with diabetes mellitus type 2 had to have been present for at least several months prior to December 1997 as the hemoglobin A1C reflected the average blood over the three to four months prior to the measurement. Evidence from a large number of epidemiologic studies of the natural history of diabetes mellitus type 2 indicated that this disease most often develops insidiously and progressively over a period of years. With the more frequent screening of people with serum glucose measurements, we know that the majority of patients with diabetes mellitus type 2 have a prolonged asymptomatic period where their blood glucose is clearly elevated sufficiently to satisfy current diagnostic criteria for diabetes mellitus but do not have any obvious symptoms (even in retrospect). Diabetes mellitus type 2 is not just hyperglycemia. It is associated with a host of metabolic abnormalities as insulin regulates a large number of physiologic processes. This appellant first developed hypertriglyceridemia in January 1997. This was most likely an early manifestation of his diabetes mellitus type 2. Based on current knowledge of the natural history of diabetes mellitus type 2, the examiner concluded that it was at least as likely as not that this Veteran's diabetes mellitus type two began during his period of active service in March 1994. Based on current knowledge of the natural history of diabetes mellitus type 2, the presence of triglyceride elevation starting in early 1997 and length of hyperglycemia as indicated by very high hemoglobin A1C level in December, it was at least as likely as not that his diabetes was present during his active training period from June 5 to June 21, 1997. Severe stresses such as extreme sleep deprivation can accelerate the progression of diabetes mellitus type 2 through activation of "counter-regulatory" hormones, epinephrine, cortisol, glucagon, and immune system hormones such as interferon. However, in his review of documentation in the Veteran's claims file, he did not see any evidence suggesting that his diabetes mellitus increased in severity beyond its natural progress during his active duty for training, particularly during the period from June 5 to 21, 1997. The VHA Endocrinologist expressed that it was at least as likely as not that the Veteran's diabetes mellitus began during his period of active service in March 1994. Unfortunately, there is no documentation of active service in March 1994. The Veteran did have an examination in March 1994, but there is no evidence that he was on active duty at that time. The record indicates active duty for training from June 26, 1994 to July 9, 1994; July 12, 1994 to July 19, 1994; September 12, 1994 to September 13, 1994; and September 14, 1994 to September 18, 1994. Therefore, in December 2010, the Board requested an addendum medical opinion from the April 2010 Endocrinologist. A December 2010 addendum opinion letter from an Endocrinologist was received by the Board. The doctor expressed his opinion stating that based on current knowledge of the natural history of diabetes mellitus type 2, it was at least as likely as not that the Veteran's diabetes mellitus type 2 began during 1994, as indicated by his original opinion. Additionally, the doctor stated that his opinion had not changed by the fact that an examination occurred in March 1994, when the Veteran was not on active duty. Furthermore he stated that the Veteran was on active duty at other times during 1994. For clarification purposes, the Board noted that the dates the Veteran was on active duty and ACDUTRA were important for deciding whether service connection was warranted. The doctor noted that the Veteran's diabetes began in March 1994, while he was not on active duty and prior to his ACDUTRA for that year. The record shows the Veteran was on ACDUTRA from June 26, 1994 to July 9, 1994; July 12, 1994 to July 19, 1994; September 14, 1994 to September 18, 1994; March 30, 1995 to April 2, 1995; August 28, 1995 to September 9, 1995; April 22, 1996 to May 1, 1996; September 30,1996 to October 3, 1996; June 7, 1999 to June 12, 1999; and June 14, 1999 to June 20,1999. Therefore, an addendum opinion regarding whether the Veteran's diabetes mellitus type 2, which began in March 1994, was aggravated during his subsequent periods of ACDUTRA, was necessary in order to make a decision with respect to the issue on appeal. A January 2012 medical opinion was received from a different VHA medical doctor. The physician referenced the Veteran's initial A1C of 19 percent, which reflected the presence of diabetes for an absolute minimum of three months, but almost certainly for two years, and possibly somewhat longer. As pertaining to this, he agreed with the exposition of the natural history of Type 2 diabetes rendered in the previous expert opinion. This would set the timing of onset before the dates of active duty referenced. The issue of aggravation by further tours of duty was not addressed by any data provided, and therefore he was unable to form an opinion. However, his glucose control improved, due to active treatment, during that time, suggesting lack of aggravation. Additionally, a January 2012 addendum medical opinion was obtained from the original VHA Endocrinologist who had submitted the previous April 2010 and December 2010 expert medical opinions. The examiner stated that based on current knowledge of the natural history of diabetes mellitus type 2, he could not conclude (based on a standard of "at least as likely as not") that the Veteran's diabetes was aggravated (permanently worsened beyond the normal progress of the disease) during any period of active duty for training. The Endocrinologist again stated that severe stresses such as extreme sleep deprivation can accelerate the progression of diabetes mellitus type 2 through activation of "counter-regulatory" hormones, epinephrine, cortisol, glucagon, and immune system hormones such as interferon. However, in his review of documentation in the Veteran's claims file he did not see any evidence suggesting that his diabetes mellitus was increasing in severity beyond its natural progress during his active duty for training. Having reviewed the record and the Court's May 2014 and February 2017 Memorandum Decisions, the Board has again determined that the weight of the competent evidence shows that the Veteran is not entitled to service connection for diabetes mellitus. Although he has a current diagnosis of diabetes mellitus, the existing medical evidence does not show that this condition was manifest in service or is otherwise related to service, to include any period of ACDTURA. Additionally, the evidence does not show that the Veteran's diabetes mellitus was aggravated beyond a natural state of progression during active service or a period of ACDUTRA. The Board has carefully considered the Veteran's assertions that he has diabetes mellitus that is related to his active service. Here, the Veteran is competent to report his observations and relate what he was told by medical professionals. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). With respect to the Veteran's contention that his diabetes is related to his most recent period of active service, from January to April 1991, service medical records do not show any complaints of illness or injury during this period of service. The Board notes, as the Court's May 2014 Memorandum Decision highlights, that the Veteran has stated that he experienced excessive thirst while in service. However, the Board finds such reports to be not credible. In the Memorandum Decision, the Court specifically noted: "The appellant testified at a Board hearing that he was treated for excessive thirst while serving in the Persian Gulf in 1991." The Court was unpersuaded by VA's argument that "any error was not prejudicial because the appellant's statements describing his symptoms made at the hearing and to his doctor are 'inaccurate and contradicted by the record'" because the Board did not make those findings initially and such statements by VA before the Court were therefore post-hoc rationalization. Thus, the claim was remanded in order for the Board to address the Veteran's lay statements regarding excessive thirst and other symptomatology that he may have suffered during military service in 1991 associated with his diabetes mellitus. As an initial point of fact, the Board notes that the September 2002 and April 2008 Board hearings do not contain any testimony by the Veteran regarding "excessive thirst while in the Persian Gulf in 1991." Instead, that testimony is contained in the RO Hearing in January 2001. The pertinent part of that hearing is quoted below: [Pages 3-4] [Veteran's Representative]: Now, were you having any symptoms of diabetes prior to the diagnosis in 1997, such as joint pain, tingling of the feet, excessive thirst, did you have any of those symptoms prior to 1997? [Veteran]: Prior to 1997? [Veteran's Representative]: Yes. [Veteran]: No, sir. [Veteran's Representative]: And just to clarify to the Board, you feel that you had diabetes prior to 1997, is that correct? [Veteran]: I feel I may have had it prior to... [Veteran's Representative]: ...OK. Now, you also indicated to me prior to the hearing that you feel that your diabetes may have been a result of your service in the Persian Gulf? [Veteran]: Yes, sir. [Veteran's Representative]: Can you describe to the Board why you feel that way? [Veteran]: Well, we had a briefing, I can't remember if it was from members of the VA, or just members of my main, to report to the VA, and let the VA know if you had any symptoms, unusual symptoms that you normally don't have, that you feel that may be connected to what happened in the Persian Gulf. [Pages 6-7] [RO Personnel]: In 1991, three months or so, in 1991, and during that time, you didn't at least didn't know you had any symptoms, is that correct? [Veteran]: If I experienced anything during that time, it just might have been excessive thirst, which I had been treated to. [RO Personnel]: OK, and the diabetes was first diagnosed in 1997, is that correct? [Veteran]: ...Yes, sir. [RO Personnel]: But before it was diagnosed, you would have had some symptoms, I mean this like that, how long before that? [Veteran]: Well, the only thing I experienced before that time sir, was I thought was a stomach virus, but I had excessive weight loss. [RO Personnel]: How was that found, were you just there for a regular medical checkup with a doctor or did you actually go complaining of some symptoms? [Veteran]: I just went complaining of the stomach virus, which I thought I had, and then he tested me, and then about a week later, he let me know that I did have diabetes. [RO Personnel]: And then this was in 1997? [Veteran]: Ninety-seven. In light of the Court's May 2014 Memorandum Decision, the Board reviewed the entire record with regards to the Veteran's lay statements, including any and all written correspondence and argument submitted by the Veteran and/or his representatives, and the Veteran's testimony at the two Board hearings in September 2002 and April 2008. The Board finds that all of the Veteran's other lay statements of record and his other testimony before the Board are void of any statements regarding excessive thirst during his period of service in the Persian Gulf in 1991, as well as void of any other assertions of other symptomatology suffered during his period of service in the Persian Gulf in 1991 which could possibly be associated with his diabetes mellitus. In addressing the Court's May 2014 Memorandum Decision regarding his lay statements, particularly his lay statements that he suffered from excessive thirst while in the Persian Gulf in 1991, the Board notes that the Veteran was unequivocal in his denial of any symptomatology suffered during his 1991 Persian Gulf service while being questioned by his representative, including whether he suffered from excessive thirst. The Veteran, when later asked by the RO hearing officer, whether he suffered any symptomatology associated with his diabetes while in the Persian Gulf in 1991, was equivocal with regards to whether he suffered any symptomatology at that time. He stated that if he were to have suffered any symptoms at that time it would have been excessive thirst. These statements cannot be and the Board does not interpret the plain reading of those statements to mean that he did, in fact, suffer excessive thirst during his period of service in 1991. When further questioned by the RO hearing officer as to his symptoms at any time prior to his diagnosis in 1997, the Veteran was again unequivocal in his testimony that the only symptom he suffered prior to diagnosis was excessive weight loss, which at that time he was attributing to a potential stomach virus and not to diabetes; moreover, that excessive weight loss occurred in 1997 a week prior to diagnosis and not in 1991. Finally, insofar as the Veteran's January 2001 statements can be read to state that he did suffer from excessive thirst while in the Persian Gulf in 1991, the Board finds those statements to be not credible. First, after review of the Veteran's service treatment records, the Board notes that those records are void of any treatment for excessive thirst at any time during his periods of service, particularly during his 1991 period of service. Moreover, the Veteran's equivocalness of his statements in contrast to his definitive "No, sir" answer to his representative weighs against a finding that the Veteran actually suffered from and was treated for excessive thirst during his period of service in the Persian Gulf in 1991. See Caluza v. Brown, 7 Vet. App. 478, 511 (1995), aff'd per curium, 78 F.3d 604 (Fed. Cir. 1996) (when determining whether lay evidence is satisfactory, the Board may properly consider internal consistency, facial plausibility, consistency, with other evidence submitted on behalf of the Veteran, and demeanor of witness (if hearing held)); Buchanan v Nicholson, 451 F.3d 1331 (Fed Cir. 2006) (lack of contemporaneous medical records does not, in and of itself, render lay testimony not credible. As a finder of fact, the Board may weigh the absence of contemporaneous medical records when assessing the credibility of the lay evidence). Thus, the Board finds that the Veteran did not state in his January 2001 testimony that he suffered from any diabetes symptoms during his Persian Gulf service in 1991, only that if he did suffer from any symptoms it would have been excessive thirst. The Board therefore finds that the Veteran's lay statements do not indicate that he suffered from any symptomatology associated with diabetes mellitus during his 1991 period of Persian Gulf War service, and that his statements are not credible insofar as they can be read to state that he did, in fact, suffer from and receive treatment for excessive thirst while in the Persian Gulf in 1991. His statements to his representative's and the RO hearing officer's questioning in this matter are an unequivocal "No, sir." Insofar as the Veteran's testimony in January 2001 indicates that prior to his diagnosis in 1997 that he had excessive weight loss which was attributable to his diabetes, the Board notes that the Veteran specifically indicated that this symptom occurred in 1997, approximately a week before diagnosis of his diabetes was made, and was not present in 1991 during his Persian Gulf service. With respect to the medical evidence of record, the Veteran's private physician stated in December 1999 that he could not rule out a relationship between the Veteran's diabetes and his period of active service in 1991. However, the physician did not provide a medical nexus opinion. Considered in its full context, the physician's statement lacks probative value because it is an opinion of mere possibility and not probability. See Stegman v. Derwinski, 3 Vet. App. 228, 230 (1992) (the Court found evidence favorable to the Veteran's claim that does little more than suggest a possibility that his illnesses might have been caused by service radiation exposure is insufficient to establish service connection). Additionally, the private physician's statement is also of little probative value because he failed to state a rationale as to why he believed the Veteran's diabetes mellitus was related to his period of active service. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (stating that a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two). Further, the opinion of the April 2003 VA examiner that the Veteran's diabetes was related to his "military service" also lacks probative value. The VA examiner stated that the only records available for review were past VA examinations and a note from May 1999, indicating the Veteran had high blood sugar in November 1997. In addition to the lack of evidence supporting the VA examiner's opinion, the opinion lacks probative value because of its vagueness. The examiner stated that the Veteran's diabetes was related to his "military service." There is no indication as to whether the examiner was providing a relationship between the Veteran's disability and his latest period of active service, or between the Veteran's disability and a period of ACDUTRA. Additionally, as noted above, the examiner's opinion is of little probative value because it failed to state a rationale as to why he believed that the Veteran's diabetes was related to his period of active service. Nieves-Rodriguez, 22 Vet. App. 295(2008). The Federal Circuit has determined that a significant lapse in time between service and post-service medical treatment may be considered as part of the analysis of a service connection claim. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). In this case, the medical evidence does not show the presence of diabetes until over 6 years after separation from active service. This is a factor the Board has considered in deciding the claim. There is no probative medical evidence of record demonstrating a relationship between his diabetes and his period of active service from January to April 1991. The Board will now address the Veteran's contention that his diabetes mellitus was present in June 1997, during his period of ACDUTRA. As noted, the Veteran contends that a simple blood glucose test performed in June 1997 would have led to a diagnosis of diabetes at that time. The Veteran's medical records from his time with the Air Force Reserves do not contain any complaints of illness or injury for the month of June 1997. Further, while the Veteran contends that his diabetes should have been discovered at that time, it appears from the record that the Veteran did not appear for a scheduled physical examination, and thus had an incomplete medical requirement. It also appears that the examination which revealed high cholesterol and high blood pressure was performed on June 29, 1997; as noted, the Veteran's period of ACDUTRA extended from June 6 to June 22 of 1997. As noted above, with respect to the Veteran's period of ACDUTRA from June 6 to June 22 of 1997, there was no entrance examination made contemporaneous with his period of active service beginning on June 6, 1997. The presumption of soundness under 38 U.S.C.A. § 1111 does not apply when a claimant, Veteran or otherwise, has not been examined contemporaneous to entering a period of active service - here, the period of ACDUTRA. See Crowe v. Brown, 7 Vet.App. 238, 245 (1994) (holding that the presumption of sound condition "attaches only where there has been an induction examination in which the later-complained-of disability was not detected" (citing Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991)). In the absence of such an examination, there is no basis from which to determine whether the claimant was in sound condition upon entry into that period of service on which the claim is based. Smith v. Shinseki, 24 Vet. App. 40, 45 (2010). Thus, the Veteran is not presumed sound upon entry to this period of ACDUTRA. Prior to his period of ACDUTRA from June 6 to June 22 of 1997, the Veteran underwent a periodic examination in March 1994. The April 2010 VHA Endocrinologist noted that the Veteran first developed hypertriglyceridemia in January 1997. However, this was most likely an early manifestation of his diabetes mellitus type 2. Based on current knowledge of the natural history of diabetes mellitus type 2, the Endocrinologist concluded that it was at least as likely as not that this Veteran's diabetes mellitus type two began in March 1994, when the Veteran was not on active duty. Accordingly, the Board finds that the Veteran's diabetes mellitus was a pre-existing condition as to his period of ACDUTRA from June 6 to June 22 of 1997. As the presumption of soundness does not apply, the evidence must establish that aggravation of the Veteran's diabetes mellitus occurred during service. As stated above, 38 U.S.C.A. § 1153 contains a presumption of aggravation when it is shown that a pre-existing disorder underwent an increase in disability during service. The April 2010 VHA Endocrinologist noted that severe stresses such as extreme sleep deprivation can accelerate the progression of diabetes mellitus type 2 through activation of "counter-regulatory" hormones, epinephrine, cortisol, glucagon, and immune system hormones such as interferon. However, in his review of the documentation in the Veteran's claims file, he did not see any evidence suggesting that the Veteran's diabetes mellitus was increased in severity beyond its natural progress during his active duty for training, particularly during the period from June 5 to 21, 1997. Additionally, the January 2012 VHA physician opinion noted that the Veteran's glucose control improved, due to active treatment, during that time, suggesting lack of aggravation. In a January 2012 addendum, the VHA Endocrinologist concluded that based on current knowledge of the natural history of diabetes mellitus type 2, he could not conclude (based on a standard of "at least as likely as not") that the Veteran's diabetes was aggravated (permanently worsened beyond the normal progress of the disease) during any period of active duty for training. Therefore, based on the evidence of record, the Board finds that the evidence of record does not support a finding that the Veteran's diabetes mellitus increased in severity during his periods of ACDUTRA, in particular from June 6 to June 22 of 1997. While the Veteran submitted a January 2010 independent medical evaluation, this evaluation is of little probative value. In his opinion, the physician referenced the remarks section of a compensation and pension exam inquiry, noting a glucose level of 367 in an in-service report. The physician concluded that although the Veteran was not diagnosed with diabetes mellitus until December 1997, at which time he had a blood glucose level of 361, based on his in-service symptoms (excessive thirst and blurred vision) and the noted in-service glucose level of 367, it was his opinion that it was at least as likely as not that the Veteran's currently diagnosed diabetes mellitus had its origins in service. However, there were no determinations of fasting or random serum glucose levels in service, as noted by the April 2010 VHA Endocrinologist, despite the private physician's report of reading of 367. There were several physical examinations during service that included urinalysis. Sugar was negative throughout examinations in February 1982, May 1985, March 1988, June 1988, January 1990, March 1994, and January 1997. Therefore, the premise for the January 2010 independent medical opinion is not supported by the evidence of record. Additionally, the physician cited to an examination inquiry report, not an actual medical record, which is an insufficient basis to conclude such glucose reading ever existed. After review of the record, the Board concludes that the reading of a glucose level of 367 while in-service does not exist. In sum, there is no reliable evidence linking the Veteran's diabetes mellitus to service. The contemporaneous records establish that there were no credible or documented manifestations of diabetes in service, there were no manifestations of diabetes within one year of separation, and diabetes was first manifest many years after separation. The Board finds the contemporaneous records to be far more probative and credible than the Veteran's report onset and continuity and treatment. Here, diabetes was not "noted" during service within the meaning of section 3.303(b). Service treatment records do not show a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. Furthermore, the evidence does not establish that diabetes was manifest to a compensable degree with one year of separation. 38 C.F.R. §§ 3.307; 3.309. Rather, the examinations during the pertinent time frame were normal. Furthermore, diabetes was not incurred in or aggravated during a period of ACDUTRA. 38 U.S.C.A. §§ 101 (24), 106, 1110, 1131. As noted, the presumptive provisions do not apply to ACDUTRA. Lastly, the Board notes that the Veteran has also submitted an article from an unknown source regarding the risk of chronic multi-symptom illness (CMI) in Veterans who served in the Gulf War. This article states that Veterans with CMI have a higher incidence of metabolic syndrome, which increases the risk of coronary heart disease, diabetes, and cirrhosis of the liver. Service connection may be established for a chronic disability resulting from an undiagnosed illness which became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War or to a degree of 10 percent or more not later than December 31, 2016. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317 (a)(1)(i). In addition to certain chronic disabilities from undiagnosed illness, service connection may also be given for medically unexplained chronic multi-symptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) that is defined by a cluster of signs and symptoms, as well as for any diagnosed illness that the VA Secretary determines by regulation warrants a presumption of service connection. The Board notes that the Veteran has not been diagnosed with CMI, nor does he allege that he suffers from a chronic disability resulting from an undiagnosed illness. Therefore, the provisions of 38 C.F.R. § 3.317 are not applicable in this case. The Board has also considered the provisions of 38 C.F.R. § 3.307(c). No presumptions may be invoked on the basis of advancement of the disease when first definitely diagnosed for the purpose of showing its existence to a degree of 10 percent within the applicable period. This will not be interpreted as requiring that the disease be diagnosed in the presumptive period, but only that there be then shown by acceptable medical or lay evidence characteristic manifestations of the disease to the required degree, followed without unreasonable time lapse by definite diagnosis. Symptomatology shown in the prescribed period may have no particular significance when first observed, but in the light of subsequent developments it may gain considerable significance. Cases in which a chronic condition is shown to exist within a short time following the applicable presumptive period, but without evidence of manifestations within the period, should be developed to determine whether there was symptomatology which in retrospect may be identified and evaluated as manifestation of the chronic disease to the required 10-percent degree. This provision applies to qualifying service of sufficient length. As with section 3.303, the regulation requires positive evidence during the presumptive time frame. The regulations require symptoms or manifestations during the presumptive period, rather than a diagnosis. Here, during the presumptive period, there were no identified symptoms or manifestations and this case has been fully developed. For these reasons, the Board finds that a preponderance of the evidence is against the Veteran's claim, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Consequently, the Board finds that service connection for diabetes mellitus is not warranted. ORDER Entitlement to service connection for diabetes mellitus, type 2 is denied. ____________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs