Citation Nr: 21005714 Decision Date: 02/02/21 Archive Date: 02/02/21 DOCKET NO. 17-16 801A DATE: February 2, 2021 ORDER Entitlement to service connection for diabetes mellitus, type II, to include as secondary to the service-connected posttraumatic stress disorder (PTSD) and alcohol use disorder, is denied. FINDING OF FACT The Veteran’s diabetes mellitus was not incurred during service; any current diabetes mellitus, type II, is unrelated to service and was not caused or aggravated by the service-connected PTSD and alcohol use disorder. CONCLUSION OF LAW The criteria for service connection for diabetes mellitus, type II, to include as secondary to service-connected PTSD and alcohol use disorder, are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from June 1991 to January 1992. In October 2019, she testified at a Board of Veterans’ Appeals (Board) hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. In January 2020, the Board remanded this case for additional development—to include a VA medical opinion to determine the etiology of the Veteran’s diabetes mellitus. That medical opinion was obtained in January 2020. The Board will, thus, proceed with adjudication of this issue. Service Connection for Diabetes Mellitus, Type II The Veteran contends that her diabetes mellitus is related to her military service. Alternatively, she contends that her diabetes mellitus was caused or aggravated by her service-connected PTSD and alcohol use disorder. See Board hearing transcript at 11. Specifically, she testified that she self-medicated with alcohol to treat her PTSD, which caused or aggravated her diabetes mellitus. Id. VA compensation may be granted for disability resulting from disease or injury incurred in service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. To establish a right to compensation for a present disability, 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 also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). For certain chronic diseases, such as diabetes mellitus, a presumption of service connection arises if the disease is manifested to a degree of 10 percent within a year following discharge from service. 38 C.F.R. §§ 3.307, 3.309. Although the disease need not be diagnosed within the presumptive period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. Service connection may be granted for a condition on a “secondary” theory of entitlement if the condition is shown to have been caused or aggravated by a condition for which service connection has already been established. See 38 C.F.R. § 3.310. The term “aggravated” in this context means that, although the secondary condition was not caused by the service-connected condition, the secondary condition was chronically worsened by the service-connected condition. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). After careful review of the evidentiary record, the Board finds that the evidence is against the claim for service connection for diabetes mellitus. In this regard, the Board acknowledges that the Veteran has a current diagnosis of diabetes mellitus, type II, as reflected on a January 2020 VA examination report. However, the evidence of record fails to establish the in-service incurrence of this disability. In particular, the Veteran’s service treatment records (STRs) are silent for treatment, symptoms, or a diagnosis, of diabetes mellitus. At the January 2020 VA examination, the examiner diagnosed the Veteran with diabetes mellitus, type II. She noted that this disability started in 2005 and negatively opined, based on information reviewed, that it is less likely than not that the Veteran’s current diabetes mellitus is related to service events or injuries. The examiner explained that the evidence of record reveals no ongoing treatment records for diabetes and that enlistment, treatment records, and separation evaluations are negative for diabetes mellitus-related issues. The examiner concluded that direct service connection cannot be established at this time. Accordingly, based on a review of the evidence of record, the Board finds that entitlement to service connection for diabetes mellitus, type II, is not warranted because the evidence fails to show a causal relationship—i.e., a nexus—between the claimed in-service disease or injury and the current disability. In making this determination, the Board finds that the medical evidence does not show a nexus, and the Veteran’s statements regarding onset and continuity of symptoms are not supported by the evidence of record. Her STRs do not reflect any symptoms related to diabetes mellitus. Post-service treatment records also do not show any significant complaints of, and treatment for, diabetes mellitus until approximately 13 years after she left service. The absence of post-service findings, diagnoses, or treatment for more than a decade after service is one factor that tends to weigh against a finding of continuous symptoms after separation. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (holding that the Board may weigh the absence of contemporaneous medical evidence as one factor in determining credibility of lay evidence, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence); see also Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (the passage of many years between discharge from active service and the medical documentation of a claimed disability is one factor to consider as evidence against a claim of service connection). As the record indicates that the Veteran’s diabetes mellitus did not manifest until 2005, many years after active service, service connection is not warranted on a presumptive basis. 38 C.F.R. §§ 3.307, 3.309. Service connection is also not warranted on a direct basis, as there is no medical evidence of any in-service incurrence or relationship between the currently diagnosed diabetes mellitus, type II, and service. Similarly, the Board finds that the evidence does not establish a continuity of symptomatology and, therefore a nexus, as diabetes mellitus is a chronic disease. See 38 C.F.R. § 3.309. As previously stated, the Veteran’s post-service treatment records indicate that the earliest evidence indicating a manifestation of diabetes mellitus was in 2005 – many years after she left service. The Board finds that the VA examiner’s findings and the lapse of approximately 13 years between the Veteran’s separation from active service and the first clinical evidence of her diabetes mellitus are probative evidence that weigh heavily against her claim for service connection. The VA examiner reviewed the Veteran’s claims file and considered the Veteran’s report of symptoms and medical history. The VA medical opinion is probative because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). While the Veteran contends that her diabetes mellitus is related to service, the Board finds that, as a lay person, she is not competent to offer such an etiological opinion. The etiology of diabetes mellitus is a complex medical question that is not capable of lay observation and is not the type of medical issue for which a lay opinion may be accepted as competent evidence. As a lay person, the Veteran does not have the education, training, and experience to offer an opinion as to the onset or etiology of such condition. See Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010) (recognizing that in some cases, lay testimony “falls short” in proving an issue that requires expert medical knowledge). Accordingly, the Veteran’s lay statements in this regard are not competent or probative evidence supporting her claim. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau, 492 F.3d at 1376-77. Accordingly, the Board concludes that service connection is not warranted for diabetes mellitus, type II. Although the evidence of record shows that the Veteran currently has a diagnosis of this disorder, the evidence alone is not sufficient to establish that this disability has a causal connection to her active service. As such, the Board concludes that the preponderance of the evidence is against this claim. The Board has considered the applicability of the benefit-of-the-doubt doctrine. However, that doctrine is not applicable in the instant appeal as the preponderance of the evidence is against the claim. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). Regarding the Veteran’s contention that her diabetes mellitus, type II, is proximately due to, or aggravated by, her service-connected PTSD and alcohol use disorder, the Board notes that service connection is not warranted on a secondary basis. As an initial matter, the Board notes that the Veteran has been service-connected for PTSD and alcohol use disorder as of January 2011. At the January 2020 VA examination, the Veteran reported that her diabetes mellitus first manifested in 2005 – years prior to her PTSD diagnosis. The January 2020 VA examiner negatively opined that it is not likely that the Veteran’s diabetes mellitus was aggravated beyond its natural progression by PTSD and alcohol use disorder. As rationale, she explained that diabetes mellitus, also known as type II diabetes, non-insulin dependent diabetes, or adult onset diabetes, is a condition that affects people in adulthood. She noted that diabetes mellitus is a disorder that is characterized by high levels of glucose in the blood, which occurs due to an increase in the resistance of the body to insulin. The examiner indicated that there are many factors that can lead to diabetes mellitus, or at least that can exacerbate this type of diabetes. However, she noted that PTSD is not a known risk factor. She also stated that a reply would be based on mere speculation since a review of the records reveals numerous contributing risk factors for the Veteran’s history of elevated blood sugars. The examiner emphasized that there is no direct pathophysiologic relationship between diabetes mellitus and PTSD. Regarding the Veteran’s claim that her diabetes mellitus developed secondary to extensive ethanol alcohol (ETOH) use for self-medication of her PTSD, the examiner explained that ETOH can lead to temporary blood glucose spikes but is insufficient to be the sole etiology of diabetes mellitus alone. The examiner noted that diabetes mellitus is secondary to the gradual and progressive development of insulin resistance which develops over a prolonged period of time from overall poor dietary choices. She stated that insulin resistance leads to pre-diabetes and eventually diabetes. The examiner explained that to state the Veteran’s diabetes mellitus is solely secondary to her ETOH consumption for PTSD would be far-fetched. She concluded that there are too many lifetime contributing risk factors and that to extrapolate such a conclusion would ultimately rely on mere speculation. In considering the foregoing evidence, the Board finds that the Veteran’s diabetes mellitus, type II, is not proximately due to, or was aggravated by her service-connected PTSD and alcohol use disorder. As such, service connection for diabetes mellitus, type II, to include as secondary to service-connected PTSD and alcohol use disorder is not warranted. In so finding, the Board observes the January 2020 VA medical opinion that attributes the Veteran’s diabetes mellitus to numerous contributing risk factors that led to her history of elevated blood sugars. The examiner noted that there is no direct pathophysiologic relationship between diabetes mellitus and PTSD and that, while extensive ethanol alcohol can sometimes lead to temporary blood glucose spikes, it is insufficient to be the sole etiology of diabetes mellitus, type II. Accordingly, the Board finds that this VA medical opinion is highly probative because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. See Nieves-Rodriguez, supra. The Board has considered the Veteran’s lay assertions that her diabetes mellitus, type II, was proximately due to, or aggravated by, her service-connected PTSD and alcohol use disorder. However, her assertions are not supported by the clinical evidence of record. See Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). Accordingly, for these reasons, the Board finds that service connection for diabetes mellitus, type II, as secondary to service-connected PTSD and alcohol use disorder must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim for secondary service connection, that doctrine is not applicable. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, supra. THERESA M. CATINO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Trowers, 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.