Citation Nr: 21072361 Decision Date: 12/03/21 Archive Date: 12/02/21 DOCKET NO. 16-52 942 DATE: December 3, 2021 REMANDED Entitlement to service connection for diabetes mellitus (DM) is remanded. REASONS FOR REMAND The Veteran served on active duty from August 2004 to January 2006. He appeals an October 2014 rating decision by the Agency of Original Jurisdiction (AOJ). A Board hearing was held in August 2021. A transcript is of record. The Veteran contends that he developed DM as a result of his service-connected back disability and obstructive sleep apnea (OSA). More specifically, that his back disability and OSA rendered him unable to exercise and caused weight gain, which in turn caused his DM. See Board Hearing Tr. at 5. This includes pain medication to treat his back disability, which he stated prevents him from exercising and resulted in weight gain. Id at 6. The Veteran attended an October 2014 VA examination. The examiner concluded that the Veteran's DM was less likely than not proximately due to or the result of the Veteran's service-connected back disability or OSA. See October 2014 VA examination report. While the examiner noted that weight gain and inactivity are known to be some of the contributory factors to developing DM, the examiner failed to provide an opinion regarding whether the Veteran's back disability or OSA aggravated his DM. Id. This is a necessary component for any secondary service connection analysis. See El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013). As such, the October 2014 VA opinion is inadequate, and a remand is required. Further, Precedential VA General Counsel Opinion 1-2017 holds that obesity may be 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). See VAOPGCPREC 1-2017 (Jan. 6, 2017). As explained below, the record contains some evidence discussing a link between the Veteran's service-connected disabilities and obesity. Here, the Veteran's service treatment records (STRs) indicate that his back disability prevented him from physical training (PT) while in the military. See June 1994 STR; see also September 2002 STR. Further, he has been counseled on various occasions that being overweight is a significant factor for developing DM. See, e.g., October 2014 VA examination report; see also March 2009 and January 2010 VA treatment notes. The Board also notes that the Veteran was educated about the side effects of his prescribed psychiatric medication for his service-connected posttraumatic stress disorder (PTSD), which noted both the possibility of increased weight and increased blood sugar to cause diabetes. See December 2013 VA treatment note. Thus, the Board finds that there is evidence of record to reasonably raise the theory of secondary service connection via obesity as an intermediate step. See Garner v. Tran, U.S. Vet. App. No. 18-5865 (Jan. 26, 2021) (providing a list of six non-exhaustive considerations that could give rise to a reasonably raised theory of secondary service connection with obesity as an intermediate step, including obesity as a side effect of medication where the medication is prescribed for a service-connected disability). Therefore, remand is required to obtain a medical opinion regarding whether the Veteran's obesity could serve as an intermediate step between his service-connected disabilities and his DM. The Veteran also testified that he felt sluggish, tired, and had no energy at the end of his tour in Iraq. See Board Hearing Tr. at 3. Thus, as an alternative theory, he contends that these symptoms were an early sign of diabetes that were not yet diagnosed during service. See Board Hearing Tr. at 7. As such, the Board finds that an opinion regarding direct service connection is also necessary on remand. The matters are REMANDED for the following action: 1. Obtain any outstanding private treatment records and/or VA treatment records relevant to treatment the Veteran received for his DM that are not already of record. All obtained records should be associated with the evidentiary record. If any identified records are not obtainable (or none exist), the Veteran and his representative should be notified and the record clearly documented. 2. Thereafter, obtain an opinion from a qualified clinician to determine the nature and etiology of the Veteran's DM. The evidentiary record, including a copy of this remand, must be made available to and be reviewed by the reviewing clinician. It is up to the discretion of the reviewing clinician as to whether a new examination is necessary to provide an adequate opinion. After the record review and examination of the Veteran, if deemed necessary, the reviewing clinician is asked to respond to the following inquiries: (a.) Is it at least a likely as not that the Veteran's DM was incurred in or is otherwise related to active service? In considering this question, the examiner should comment on whether the Veteran's report of feeling sluggish, tired, and having no energy while on active duty was an early indication of the presence of DM? (b.) Is it at least as likely as not that the Veteran's DM was proximately caused OR aggravated by his service-connected back disability, OSA, and/or PTSD? (c.) Is it at least as likely as not that the Veteran's obesity was proximately caused OR aggravated by his service-connected back disability, OSA, and/or PTSD, to include medication used to treat his PTSD or pain medication for his back? (d.) If so, is it at least as likely as not that the Veteran's DM was proximately caused OR aggravated by his obesity? In rendering these opinions, the reviewing clinician is advised that the Veteran is competent to report his symptoms and history. Such reports must be acknowledged and considered in formulating any opinion. If the reviewing clinician rejects the Veteran's reports, he or she must provide an explanation for such rejection. The reviewing clinician is not to improperly discount the Veteran's lay statements or mistakenly rely on an absence of medical evidence in the record to support his or her conclusions. A complete rationale for all opinions should be set forth and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If an opinion cannot be provided without resorting to mere speculation, the reviewing clinician must provide a complete explanation for why an opinion cannot be rendered. In so doing, the reviewing clinician must explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 3. After the above development has been completed, readjudicate the claim. If any benefit sought remains denied, provide the Veteran and his representative with a supplemental statement of the case (SSOC), and return the case to the Board, if otherwise in order. DONNIE R. HACHEY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Katie Poe, 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.