Citation Nr: 21077422 Decision Date: 12/29/21 Archive Date: 12/29/21 DOCKET NO. 17-07 927 DATE: December 29, 2021 ORDER Entitlement to service connection for diabetes mellitus type 2 is granted. FINDING OF FACT Resolving reasonable doubt in the Veteran's favor, his diabetes mellitus type 2 is at least as likely as not related to an in-service injury, event, or disease. CONCLUSION OF LAW The criteria for service connection for diabetes have been satisfied. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Air Force from May 1983 to November 1983, from June 1984 to August 1985, on September 21, 2001, from July 2002 to August 2002, from February 2007 to May 2007, and from September 2008 to February 2009. This matter is on appeal to the Board of Veterans' Appeals (Board) on appeal from a November 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In February 2019 and August 2021, the Board remanded the matter to the Agency of Original Jurisdiction (AOJ) for additional development, and it has since returned for appellate review. The August 2021 Board remand instructed the AOJ to obtain an addendum VA medical opinion addressing whether the Veteran's diabetes was caused by or the result of his active duty service, to include as due to exposure to toxic chemicals during his service in the Southwest Asia Theater of Operations. The Board finds that there was substantial compliance with the remand directives as a September 2021 VA medical opinion was obtained addressing the issue in question. See Stegall v. West, 11 Vet. App. 268 (1998). 1. Service Connection for Diabetes Mellitus Type 2 The Veteran contends that his diabetes was caused by his active duty service, to include as due to exposure to toxic chemicals while deployed to Southwest Asia. See February 2017 Substantive Appeal. Generally, to establish service connection, a claimant must show: (1) a present disability; (2) an 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. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303; see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Board concludes that the Veteran has a current disability that is related to his active duty service. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). A November 2016 VA examination report shows the Veteran has a current diagnosis of diabetes mellitus type 2. Thus, the question becomes whether the current disability is related to service. On this question there are probative opinions in favor of and against the claim. A review of the service personnel records show that the Veteran was deployed to Iraq from February 2007 to April 2007, and from September 2008 to January 2009. Service treatment records show complaints related to an exposure to smoke from burning trash and feces during an August 2007 post deployment health assessment. During a May 2009 post deployment health assessment, the Veteran reported being exposed to inhalation of smoke from burn pits, oil fires, and industrial pollution. The Veteran submitted an August 2012 private medical opinion by Dr. B.H., who evaluated the Veteran's diabetes mellitus type 2. Dr. B.H. noted that the Veteran is overweight but not significantly obese and did not have a history of diabetes mellitus in any of his family members. Dr. B.H. noted that the Veteran had a history of exposure to dioxin and dioxin-like compounds from smoke inhalation that was a result from his service in Iraq. Dr. B.H. explained that dioxin exposure is recognized as a contributing factor for the development of diabetes mellitus type 2. Dr. B.H. concluded that the Veteran's diabetes mellitus type 2 is at least as likely as not caused by his exposure to dioxin. The Board finds this opinion probative as it was made by a medical professional with consideration of the specific facts in this case. The Veteran submitted another private medical opinion in March 2013 from Dr. K.T., a physician who had treated the Veteran. Dr. K.T. reported that the Veteran was diagnosed with diabetes mellitus type 2 in June 2012 and was deployed to Iraq in 2007 where he was exposed to toxic chemicals from open burn pits. Dr. K.T. noted that the Veteran thinks his diabetes could be secondary to the exposure to the toxic chemicals. However, Dr. K.T. reported that he was not willing to make that determination but left open the idea that such exposure could be a cause of his diabetes. The Board does not afford probative weight to this opinion as the Dr. K.T. did not provide a clear conclusion with a supportive rationale. The Veteran presented for a VA examination in November 2016, at which time he was interviewed by the examiner who also reviewed the pertinent medical history and performed an examination. The examiner opined that the Veteran's diabetes mellitus type 2 is less likely as not caused by or a result of burn pit exposure. In support of this conclusion, the examiner explained that diabetes mellitus type 2 is a disease with a clear and specific etiology and diagnosis. Some of the factors that increase the risk of diabetes mellitus include obesity, positive family history, specific racial and ethnic groups, female gender, and conditions associated with insulin resistance. The examiner noted that the Veteran is obese as his BMI is greater than 31. Further, the examiner noted that the articles submitted by the Veteran are not peer reviewed studies and are essentially news articles and represent individual opinions. The Board finds this opinion highly probative as it was made by a medical professional with consideration of the specific facts in this case and after examination of the Veteran. An addendum VA medical opinion was obtained in December 2017 where the examiner opined that the Veteran's diabetes mellitus type 2 was less likely than not proximately due to or the result of the Veteran's service-connected condition. In support of this opinion, the examiner explained that obesity is a major factor for diabetes, a condition that is directly related to the Veteran's obesity. The examiner noted that the Veteran's service connected conditions do not preclude all forms of exercise. The examiner noted that obesity is due to decreased caloric expenditure with increased caloric intake, which is a choice. The examiner noted that the Veteran's prescribed medications do not cause obesity, such as mometasone furoate which is an inhaled corticosteroid and does not act systematically. The examiner explained that the Veteran has a diagnosis of diabetes and not glucocorticoid hyperglycemia. Another addendum opinion obtained in October 2019 was provided addressing aggravation where the examiner opined that the Veteran's diabetes mellitus type 2 is less likely as not aggravated by the service-connected asthma, medication for asthma, or exercise restrictions. In support of this opinion, the examiner explained that the Veteran's asthma does not preclude all forms of exercise as a person can still walk or exercise in a pool in place of strenuous physical exercise like running. The examiner noted that the Veteran was known to be on Asmanex which is an inhaled corticosteroid but does not act systematically to affect diabetes. (Continued on the next page) Most recently, the Veteran presented for a VA examination in September 2021, at which time he was interviewed by the examiner who also reviewed the pertinent medical history and performed an examination. The examiner opined that it is likely that the toxin exposure the Veteran experienced while deployed in Southwest Asia triggered an autoimmune reaction that led to the Veteran developing diabetes mellitus type 2 with bilateral lower extremity diabetic peripheral neuropathy and erectile dysfunction. In support of this conclusion, the examiner discussed the various articles such as a report about how veterans deployed to Southwest Asia were exposed to high levels of particulate matter and burn pits, and how there may be a likely nexus between diabetes mellitus type 2 and such exposure. The examiner also took into consideration prior opinions addressing the Veteran's obesity and the development of his diabetes. The examiner opined that the prior opinions are moot because the preponderance of data supporting the nexus between a specific exposure event in Southwest Asia and the development of diabetes would not be diminished if obesity were a contributing factor to the development of diabetes as the two are not mutually exclusive. The Board finds this opinion highly probative as it was made by a medical professional with consideration of the specific facts in this case and after examination of the Veteran. The opinion is also supported by other evidence of record. For example, the examiner took into consideration the Veteran's service records and the relevant medical literature of record. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran's current diabetes mellitus type 2 is related to his active duty service. In that regard, the August 2012 private opinion was supportive of the Veteran's diabetes claim as due to exposure to burn pits. While the November 2016 VA examiner explained that the likely cause of the Veteran's diabetes was obesity and not exposure to smoke from burn pits, another VA examiner in September 2021 considered the same facts and determined that the Veteran's diabetes was a result of exposure to burn pits. The latter examiner considered and discussed the relevant medical literatures, and provided a sufficient rationale that is favorable to the Veteran. Notably, the September 2021 VA examiner discussed the prior opinions about obesity, and still concluded that toxin exposure is the likely cause of the Veteran's condition. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for diabetes mellitus type 2 is warranted, and the claim is granted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. D. Martz Ames Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Mathew 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.