Citation Nr: 20056480 Decision Date: 08/26/20 Archive Date: 08/26/20 DOCKET NO. 15-36 831 DATE: August 26, 2020 ORDER Service connection for diabetes mellitus, type II, claimed as secondary to service-connected right knee disability, is denied. Service connection for hypertension, claimed as secondary to service-connected right knee disability, is denied. FINDINGS OF FACT 1. Diabetes mellitus, type II, is not caused or aggravated by service-connected right knee disability. 2. Hypertension is not caused or aggravated by service-connected right knee disability. CONCLUSIONS OF LAW 1. The criteria for service connection for diabetes mellitus, type II, have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 2. The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 13, 1977, to May 23, 1977. This matter comes before the Board of Veterans’ Appeals (Board) from a rating decision issued in April 2015 by a Department of Veterans Affairs (VA) Regional Office. In July 2018, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the record. In April 2020, the Board remanded the case for additional development and it now returns for further appellate review. 1. Entitlement to service connection for diabetes mellitus, type II, claimed as secondary to service-connected right knee disability. 2. Entitlement to service connection for hypertension, claimed as secondary to service-connected right knee disability. As an initial matter, the Board notes that the Veteran does not claim, nor does the evidence suggest, that his diabetes mellitus, type II, and hypertension are directly related to his military service. In this regard, his service treatment records are negative for any complaints, treatment, or diagnosis of such disorders and they did not manifest until many years after separation from service. Robinson v. Shinseki, 557 F.3d 1355, 1361 (2008). Rather, the Veteran contends that, as a result of an in-service injury to his right knee, for which he is service-connected, he experienced pain, stress, and an inability to exercise, which, in turn, led to diabetes mellitus, type II, and hypertension. Thus, he claims that service connection for such disorders as secondary to his service-connected right knee disability is warranted. In this regard, service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 U.S.C. § 1131; 38 C.F.R. § 3.310(a). 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 (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Further, service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38 C.F.R. § 3.310(b). As an initial matter, the Board notes that the record reflects that the Veteran has current diagnoses of diabetes mellitus type II and hypertension as of June 2008 and November 2002, respectively, as evidenced by treatment records from the Texas Department of Criminal Justice. Furthermore, he has been service-connected for a right knee disability as a result of an in-service injury in 1977, and has competently reported pain and stress, and functional impairment associated with such disability that limits his ability to exercise. Consequently, the remaining inquiry is whether the Veteran’s service-connected right knee disability caused or aggravated his diabetes mellitus type II and/or hypertension, to include as a result of pain, stress, and an inability to exercise. In this regard, the Board remanded the case in April 2020 in order to obtain an opinion addressing such inquiries. In doing so, the Board noted that obesity may act as an “intermediate step” between a service-connected disability and a current disability that may be service-connected on a secondary basis under 38 C.F.R. § 3.310(a). VAOPGCPREC 1-2017. In order to show secondary service connection is warranted under such a theory, a veteran must show (1) that his service-connected disability caused him to become obese; and, if so (2) whether the obesity as a result of the service-connected disability was a substantial factor in causing his claimed condition, and (3) whether the claimed condition would not have occurred but for obesity caused by the service-connected disability. Id. The Board further observed that the United States Court of Appeals for Veterans Claims (Court) held that such extension of service connection through obesity as an intermediary step may also be considered on the basis of aggravation. See Walsh v. Wilkie, No. 18-0495, 2020 U.S. App. Vet. Claims LEXIS 295. Thus, in June 2020, a VA examiner reviewed the entirety of the evidence of record and opined that the Veteran’s diabetes mellitus, type II, is less likely than not proximately due to, the result of, or aggravated by the Veteran’s service-connected right knee disability. In this regard, he noted that his diabetes and service-connected right knee disability are separate entities, and there is no evidence to support an orthopedic condition worsening blood sugar levels. The examiner further opined that the Veteran’s hypertension is less likely than not proximately due to, the result of, or aggravated by the Veteran’s service-connected right knee disability. In this regard, he noted that, while the medical literature supports pain and stress as a cause of acute fluctuations in blood pressure, such has not shown that pain and stress is a cause of chronic and sustained hypertension. Rather, the examiner stated that hypertension is multifactorial and related to renal, vascular, and neurohormonal systems. Furthermore, he noted that, while the record reflected a diagnosis of chronic kidney disease, stage 3, there was no evidence of kidney damage due to nonsteroidal anti-inflammatory drugs (NSAID) usage for the right knee disability prior to the diagnosis of hypertension. As relevant to both disorders, the examiner opined that it is less likely than not that the Veteran’s right knee disability is the sole cause of his obesity. While he noted that obesity is a risk factor for both diabetes mellitus, type II, and hypertension, such is multifactorial, to include genetics, physical inactivity, sedentary lifestyle, diet, and metabolic and cardiovascular conditions. Furthermore, while orthopedic conditions can cause pain that prevents high impact activity, there are multiple activities and other strategies that can be used to prevent weight gain and obesity. Therefore, he concluded that, while medical literature supports obesity as a risk factor for diabetes and hypertension, it is less likely than not that his service-connected right knee disability is the cause of the Veteran’s obesity and, therefore, a nexus had not been established. The Board affords great probative weight the June 2020 VA examiner’s opinions as they considered all of the pertinent evidence of record, to include the statements of the Veteran and his medical records, and provided a complete rationale for the opinions offered. Moreover, the examiner offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion); 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”). Furthermore, there is no medical opinion to the contrary of record. The Board also considered the Veteran’s assertions as to the etiology of his diabetes and hypertension; however, as a lay person, he does not have the requisite training and experience necessary to address such complex medical matters. 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 etiology of such disorders involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship and, thus, may not be competently addressed by lay statements. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (explaining that while the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Accordingly, the Veteran’s opinion as to the etiology of his diabetes and hypertension is not competent evidence and, consequently, is afforded no probative weight. Based on the foregoing, the Board finds that the Veteran’s diabetes and hypertension are not caused or aggravated by his service-connected right knee disorder. Consequently, service connection for such disorders are not warranted. In reaching such determination, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claims for service connection for diabetes and hypertension. As such, that doctrine is not applicable in the instant appeal, and the Veteran’s claims must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). A. JAEGER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Waite The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.