Citation Nr: 21003166 Decision Date: 01/19/21 Archive Date: 01/19/21 DOCKET NO. 13-15 308 DATE: January 19, 2021 ORDER Entitlement to service connection for diabetes mellitus, type II due to contaminated water at Camp Lejeune is denied. Entitlement to service connection for amputation of the right leg below the knee, secondary to diabetes mellitus, type II is denied. FINDINGS OF FACT 1. The Veteran had no less than 30 days of service at Camp Lejeune and is presumed to have been exposed to contaminants in the water supply. 2. The preponderance of the evidence is against finding that diabetes mellitus, type II began during active service, or is otherwise related to an in-service injury or disease, to include as due to contaminated water at Camp Lejeune. 3. The Veteran is not service-connected for diabetes mellitus, type II such that entitlement to service connection for amputation of the right leg below the knee as secondary to diabetes mellitus, type II is not warranted. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for diabetes mellitus, type II due to contaminated water at Camp Lejeune have not been met. 38 U.S.C. §§ 1101, 1110, 1131; 38 C.F.R. §§ 3.303, 3.307, 3.309. 2. The criteria for entitlement to service connection for amputation of the right leg below the knee, secondary to diabetes mellitus, type II have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1981 to February 1985. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an October 2011 rating decision issued by a Department of Veterans Affairs (VA) Regional Office. In July 2017, the Veteran testified before the undersigned Veterans Law Judge via a video conference hearing. A transcript is of record. In November 2017, the Board denied the appeal. The Veteran appealed the Board’s decision to the United States Court of Appeals for Veterans Claims (Court). In July 2018, the Court vacated and remanded the appeal for compliance with the instructions in a Joint Motion for Remand (JMR). In January 2019, the Board remand this matter for development consistent with the JMR. There has been substantial compliance with the remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998).   Service Connection 1. Entitlement to service connection for diabetes mellitus, type II due to contaminated water at Camp Lejeune is denied. 2. Entitlement to service connection for amputation of the right leg below the knee, secondary to diabetes mellitus, type II is denied. The Veteran contends his diabetes mellitus, type II is due to contaminated water exposure during service at Camp Lejeune and he also seeks service connection for amputation of the right leg below the knee as secondary to his diabetes mellitus. For the reasons that follow, the Board finds that entitlement to service connection is not warranted. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Additionally, secondary service connection may be granted for a disability that is proximately due to, or aggravated by, a service-connected condition. 38 C.F.R. § 3.310. Effective March 14, 2017, VA amended 38 C.F.R. §§ 3.307 and 3.309 to provide a presumption of service connection for certain diseases based on exposure to contaminants present in the water supply at Camp Lejeune. The amendment defines “contaminants in the water supply” as the volatile organic compounds trichloroethylene (TCE), perchloroethylene (PCE), benzene and vinyl chloride that were in the on-base water-supply systems located at United States Marine Corps Base Camp Lejeune, during the period beginning on August 1, 1953, and ending on December 31, 1987. In order to qualify for presumptive service connection under these provisions, there must be evidence of: (1) a diagnosis of one of the enumerated diseases under the new provision 38 C.F.R. § 3.309 (f), (i.e., kidney cancer, liver cancer, non-Hodgkin’s lymphoma, adult leukemia, multiple myeloma, Parkinson’s disease, aplastic anemia and other myelodysplastic syndromes, and bladder cancer), if manifest to a degree of 10 percent or more at any time after service; and (2) service of at least 30 days (consecutive or nonconsecutive) at Camp Lejeune during the period beginning on August 1, 1953, and ending on December 31, 1987. Service records show that the Veteran was stationed at Camp Lejeune between July 1983 through February 1985, for more than the required 30 days. In the October 2011 rating decision on appeal, VA conceded that he is presumed to have been exposed to contaminants in the water supply. A September 2011 VA examination report also reflects current diagnosis of diabetes mellitus, type II and right leg amputation. However, neither are conditions VA has determined to be associated with Camp Lejeune contaminated water. Accordingly, service connection cannot be granted on a presumptive basis under the applicable regulation. 38 C.F.R. §§ 3.307(a)(7), 3.309(f). Regardless of whether a claimed disability is recognized under 38 C.F.R. §§ 3.307 (a)(7) and 3.309(f), a claimant is not precluded from establishing service connection with proof of actual causation. Combee v. Brown, 34 F.3d 1039, 1044-45 (Fed. Cir. 1994). Thus, the question for the Board is whether the Veteran’s diabetes mellitus began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a current diagnosis of diabetes mellitus, and evidence shows that exposure to contaminated water at Camp Lejeune occurred, the preponderance of the evidence weighs against finding that the Veteran’s diagnosis of diabetes mellitus began during service or is otherwise related to an in-service injury, event, or disease. Therefore, the preponderance of the evidence also weighs against finding that entitlement to service connection for right leg amputation is warranted. The Veteran’s service treatment records are silent for complaints of, treatment for, and/or a diagnosis of diabetes mellitus. The Veteran’s February 1981 enlistment and January 1985 separation reports of medical examination reflect normal clinical endocrine evaluations. The Veteran also denied a history of related symptoms on his February 1981 enlistment and January 1985 separation reports of medical history. Post-service, the Veteran’s VA and private treatment records reflect treatment for diabetes mellitus and amputation status of the lower limb below the knee. See, e.g., November 2014 VA treatment record. A February 2010 private treatment record notes that the Veteran had been non-compliant with diabetes treatment for several years. However, a September 2011 VA treatment record notes the Veteran was recently diagnosed with diabetes mellitus, type II in February 2011. In October 2010, the Veteran submitted “Contaminated Drinking Water at Camp Lejeune, North Carolina” and “Camp Lejeune Historic Drinking Water,” which provide background information on Camp Lejeune contaminated water, including that Trichloroethylene (TCE) was one of the contaminating compounds. In November 2011, the Veteran submitted “Trichloroethylene,” an article by the Environmental Protection Agency (EPA), which notes endocrine effects in humans have been reported with exposure to trichloroethylene. The Veteran underwent a VA examination in September 2011. The VA examiner opined that the Veteran’s diabetes is less likely than not caused by exposure to Camp Lejeune contaminated water because review of the medical literature and appropriate websites fail to reveal any proven or even strongly associated relationship between exposure to Camp Lejeune contaminated water. During his July 2017 Board hearing, the Veteran testified that he was not diagnosed with diabetes in service. See July 2017 Board hearing at 7. In consideration of the JMR, the Board remanded the appeal in January 2019 to obtain additional medical records as well as medical nexus opinion. The RO requested medical records from Dr. J.B., the Barnes Jewish Hospital and Barnes Rehab in December 2019 and June 2020. The office of Dr. J.B. indicated in a July 2020 letter that no records were available for the Veteran. The other two medical facilities did not respond. The Veteran was informed of the RO’s development efforts and the lack of evidence received in letters sent in December 2019, June 2020 and July 2020. In compliance with the remand directives, an addendum opinion was obtained in August 2020. The VA examiner, a physician, opined that the Veteran’s diabetes mellitus is less likely than not caused by or a result of his exposure to Camp Lejeune contaminated water. The examiner noted that the endocrine system is a chemical messenger comprising feedback loops of the hormones released by internal glands of an organism directly into the circulatory system, regulating distant target organs. The examiner further noted that few studies in humans or animals have examined endocrine effects of tetrachloroethylene exposure. To this point, the examiner noted data are limited to a study of prolactin levels in humans exposed occupationally and histopathology examination of the pituitary glands in rats exposed for 13 weeks or adrenal glands in rats and mice exposed for 2 years. He further noted that cortical and medullary hyperplasia of the adrenal glands is the only adverse effect noted in the available studies. The examiner noted that type 2 diabetes mellitus consists of an array of dysfunctions characterized by hyperglycemia and resulting from the combination of resistance to insulin action, inadequate insulin secretion, and excessive or inappropriate glucagon secretion. He indicated that the etiology of type 2 diabetes mellitus appears to involve complex interactions between environmental and genetic factors. He also noted that, presumably, the disease develops when a diabetogenic lifestyle (i.e., excessive caloric intake, inadequate caloric expenditure, obesity) is superimposed on a susceptible genotype. He noted that the body mass index (BMI) at which excess weight increases risk for diabetes varies with different racial groups; however, about 90 percent of patients who develop type 2 diabetes mellitus are obese. Yet, he also noted that a large, population-based, prospective study has shown that an energy-dense diet may be a risk factor for the development of diabetes that is independent of baseline obesity. He then noted that some studies suggest that environmental pollutants may play a role in the development and progression of type 2 diabetes mellitus, but the major risk factors for type 2 diabetes mellitus are the following: age greater than 45 years; weight greater than 120 percent of a desirable body weight; family history of type 2 diabetes in a first-degree relate (e.g., parent or sibling); Hispanic, Native American, African American, Asian American, or of pacific islander descent; and history of previous impaired glucose tolerance or impaired fasting glucose; hypertension or dyslipidemia. The examiner noted that the literature review identified several diseases other than diabetes mellitus for inclusion based on evidence of positive associations in epidemiological studies and subsequent evaluation of the literature on the health effects of chlorinated and aromatic solvent exposures identified additional diseases for inclusion based on evidence of positive associations in epidemiological studies but there is no conclusive evidence in the literature linking exposure to chlorinated and aromatic solvents to diabetes mellitus. The examiner noted that the Veteran was based at Camp Lejeune for nearly 2.5 years between 1982 and 1985 and was diagnosed with diabetes mellitus in 2010. The records reflect the Veteran had a history of poor compliance with treatment for his diabetes, and had vascular complications known to be associated with poor compliance with diabetes mellitus that resulted in him having the right below the knee amputation. The examiner explained that while there are multiple medical conditions linked to the exposure of chlorinated and aromatic solvents found in the water at Camp Lejeune during the time the Veteran was stationed there, there is no evidence that diabetes mellitus is associated with or a direct cause of being exposed to Camp Lejeune contaminated water. He indicated the Veteran has other risk factors known to be associated with diabetes mellitus, including a family history, age over 45 years, and history of hypertension. Thus, the examiner concluded that it is less likely that his diabetes mellitus is related to or caused by his exposure to Camp Lejeune contaminated water. The examiner also opined that the Veteran’s below the knee ambulation was related to complications of his diabetes and most likely accelerated by lack of appropriate medical care. An addendum opinion was obtained in November 2020. The examiner specifically noted review of the articles submitted by the Veteran in October 2010 and November 2011. The examiner noted that both articles address the historical concentrations of trichloroethylene and other chemicals in drinking water at the U.S. Marine Corps Base at Camp Lejeune, which were sufficiently elevated to raise potential health concerns. The examiner noted that the EPA article mentions that liver, kidney, immunological, endocrine, and developmental effects have also been reported in humans; however, there is no supportive data providing a causal link with diabetes mellitus and Camp Lejeune contaminated water. Finally, the examiner noted that neither of the articles reviewed offer evidence that trichlorethylene is a cause of type II diabetes mellitus. After a review of the evidentiary record, the Board finds the preponderance of the evidence weighs against finding that entitlement to service connection for diabetes mellitus, type II is warranted. VA and private treatment records show the Veteran was not diagnosed with diabetes mellitus until many years after separation from service. While the Veteran may be competent to report having experienced some symptoms of diabetes mellitus after service within a presumptive period, he is not competent to provide a diagnosis in this case or to determine that these symptoms were manifestations of his currently diagnosed diabetes mellitus. The issue is medically complex, as it requires knowledge of the interaction between multiple internal organ systems in the body and interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Similarly, while lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, the potential relationship between the Veteran’s diabetes and his exposure to Camp Lejeune contaminated water is complex in nature and falls outside the realm of common knowledge of a lay person. Jandreau, 492 F.3d at 1377 n4. There is no indication that he possesses the medical knowledge to attribute his diabetes to Camp Lejeune contaminated water. Therefore, while the Veteran is competent to describe his symptoms and the research he has undertaken, he is not competent to opine on the complex medical question of whether his exposure to Camp Lejeune contaminated water caused his diabetes. Thus, the Board finds that the Veteran’s lay evidence is insufficient evidence to establish etiology. Consequently, the Board gives more probative weight to the competent medical evidence of record, specifically the August 2020 and November 2020 VA opinions provided by a physician. The Board finds the VA opinions are the most probative evidence of record, because they are based on an accurate medical history and provided a detailed and cogent explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). To the extent the medical treatise evidence was offered to provide a nexus between the Veteran’s diabetes mellitus and his in-service exposure to Camp Lejeune contaminated water, the Board acknowledges that medical treatise evidence can, in some circumstances, constitute competent medical evidence, especially when combined with an opinion of a medical professional. 38 C.F.R. § 3.159(a)(1); Sacks v. West, 11 Vet. App. 314, 317 (1998). However, generic information in a medical journal or treatise is normally too general and inconclusive to constitute the sole basis for establishing a medical nexus to a disease or injury. Mattern v. West, 12 Vet. App. 222, 227 (1999). The articles provided by the Veteran show that trichloroethylene exposure may have effects on the endocrine system, but they are not specific to the facts of his case, do not explicitly address diabetes, although it is acknowledged that diabetes is a disorder of the endocrine system, and are not combined with an opinion of a medical professional. The articles are general in nature and do not specifically provide a correlation between the Veteran’s diabetes and exposure to Camp Lejeune contaminated water and have not been specifically related to the Veteran’s particular circumstances by a medical professional. Thus, these treatises are afforded little probative weight. As service connection for diabetes mellitus, type II has been denied herein, service connection for amputation of the right leg below the knee as secondary to diabetes mellitus, type II is not warranted. The medical evidence, including the August 2020 VA opinion clearly shows the amputation is directly attributable to diabetic and related vascular complications. Because the Veteran has not raised, and the record does not reasonably raise, entitlement to direct service connection, the Board will not consider entitlement to direct service connection. See generally See Robinson v. Mansfield, 21 Vet. App. 545, 552-56 (2008). In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine; however, as the preponderance of the evidence is against the claim, the doctrine is not applicable. Accordingly, service connection for diabetes mellitus, type II and amputation of the right leg below the knee is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). D. JOHNSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M.Aoughsten, Associate Counsel 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.