Citation Nr: 21011825 Decision Date: 03/02/21 Archive Date: 03/02/21 DOCKET NO. 11-24 261 DATE: March 2, 2021 ORDER Entitlement to service connection for hypertension is denied. Entitlement to service connection for diabetes mellitus, type II, is denied. Entitlement to service connection for intervertebral disc syndrome (IVDS) with bulging discs (low back disability) is denied. FINDINGS OF FACT 1. The Veteran’s hypertension is not secondary to service-connected bilateral foot disability, left knee disability, and dysthymic disorder, to include through obesity as an intermediary step, and is not otherwise related to an in-service injury or disease. 2. The Veteran’s diabetes mellitus, type II, is not secondary to service-connected bilateral foot disability, left knee disability, and dysthymic disorder, to include through obesity as an intermediary step, and is not otherwise related to an in-service injury or disease. 3. No abnormalities related to the low back were noted on the Veteran’s October 1995 entrance examination report. 4. The evidence clearly and unmistakably demonstrates that a low back condition pre-existed the Veteran’s service and was not aggravated during service. 5. The Veteran’s low back condition is not otherwise shown to be associated with his service or the service-connected bilateral foot disability, left knee disability, and dysthymic disorder, to include through obesity as an intermediary step. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension are not satisfied. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for service connection for diabetes mellitus, type II, are not satisfied. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 3. The criteria for service connection for IVDS with bulging discs (low back disability) are not satisfied. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.306, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from July 3, 1996 to August 28, 1996. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from February 2009 and May 2015 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Baltimore, Maryland. The February 2009 rating decision, in relevant part, granted a 50 percent rating for the Veteran’s service-connected dysthymic disorder. The May 2015 rating decision denied service connection for diabetes mellitus, type II, hypertension, obesity, and intervertebral disc syndrome with bulging discs, and denied an increased rating for a left foot disability. The Veteran was issued statements of the case (SOCs) in November 2016. He perfected his appeal with a November 2016 VA Form 9. In an April 2017 statement, he withdrew a request for a Board hearing. See 38 C.F.R. § 20.704(e). A June 2017 Board decision remanded the claims listed on the title page above for further development. The RO issued supplemental SOCs in April 2020 and August 2020. The appeal has now been returned to the Board for adjudication. Additional VA treatment records were added to the claims file following the issuance of the August 2020 SOC. After review, the Board finds that they are not relevant to the service connection claims at issue, as the records relate to the current severity of any treated conditions, rather than the crucial issue of a nexus to service. Thus, adjudication of the claims decided herein may proceed without prejudice to the Veteran. See 38 U.S.C. § 7105. Service Connection The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. The Board will summarize the relevant evidence and focus specifically on what the evidence shows or fails to show as to the claims. See, e.g., Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). When there is an approximate balance of evidence regarding an issue material to the determination of a matter, the benefit of the doubt in resolving the issue shall be given to the claimant. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Service connection may be granted for a disability resulting from injury suffered or disease contracted in the line of duty or for aggravation of preexisting injury suffered or disease contracted in the line of duty. 38 U.S.C. §§ 1110; 38 C.F.R. § 3.303. In addition, service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). In order to prevail on the issue of entitlement to service connection, there must be (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. Hickson v. West, 12 Vet. App. 247, 253 (1999). A veteran seeking service connection must establish the existence of a disability and a connection between service and the disability. Boyer v. West, 210 F.3d 1351 (Fed. Cir. 2000). In general, VAOPGCPREC 1-2017 concludes that obesity per se is not a disease or injury for purposes of 38 U.S.C. § 1110 and therefore may not be service connected on a direct or secondary basis. See VAOPGCPREC 1-2017. The Board is bound by the General Counsel’s opinion as Chief Legal Officer of the Department. 38 U.S.C. § 7104(c). However, VAOPGCPREC 1-2017 also recognizes 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). Additionally, in Walsh v. Wilkie, 32 Vet. App. 300 (2020), the Court held that aggravation of obesity by service connected disability must be addressed as well. Service connection may also be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disease or injury. 38 C.F.R. § 3.310(a). In order to establish entitlement to service connection on a secondary basis, the evidence must show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Id. Finally, service connection may be granted for certain chronic diseases if manifested to a degree of 10 percent or more within one year of separation from active service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Hypertension, diabetes mellitus, and arthritis are included in the list of chronic diseases under 38 C.F.R. § 3.309(a). However, the Veteran served less than 90 days, thus he is not entitled to consideration of the presumptions under 38 C.F.R. § 3.307 in this case. The Board has the authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other evidence. Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997). 1. Entitlement to service connection for hypertension. The Veteran contends that he gained weight due to service-connected disabilities, and as a result of that weight gain, he now has hypertension. The Veteran underwent physical examination upon his entrance to the service. The October 1995 Report of Medical Examination measured a blood pressure reading of 120/80. The Veteran’s weight was 203 pounds. In July 1996, his weight was 208 pounds. The Veteran separated from the service in August 1996. In September 1996, his blood pressure measured 129/66, 153/71, and 116/67. His weight was 198 pounds. In October 1996, his blood pressure was recorded at 122/62, with weight of 210 pounds. He was deemed to be within normal limits by a physician. In January 1997, the Veteran’s blood pressure reading was 122/62 and his weight was 237 pounds. In October 1999, his blood pressure was measured at 120/80 with weight at 276 pounds. A June 2001 VA treatment note documented newly diagnosed hypertension. The Veteran underwent VA examination in conjunction with his present claim in May 2015. Based upon the Veteran’s report, the examiner noted a 2001 diagnosis of hypertension, unconfirmed by treatment records. She stated that the Veteran’s hypertension is the result of his morbid obesity secondary to inactivity but opined that the obesity is less likely than not caused by or related to the service-connected dysthymia or foot condition. The examiner noted that although the foot condition limited certain physical activities, the Veteran was not prevented from other activities that would help with weight loss, such as swimming. A private medical opinion from Dr. C.B. was received in June 2015. He stated that the Veteran’s hypertension was likely secondary to the service-connected psychiatric condition, including the psychoactive medications that are known to cause weight gain. Dr. C.B opined that there is a 90 percent probability that the Veteran has a service-connected psychiatric condition requiring continuous medication resulting in weight gain. He noted that the Veteran had high blood pressure for many years and that the hypertension was due to medication. In August 2015, a VA medical examiner reviewed the claims file, including the private medical opinion from Dr. C.B. The VA examiner stated that it is impossible to prove that the Veteran developed elevated weight secondary to using medications for mental health issues. He found no documented medical evidence of record that the Veteran’s weight precipitously increased related to onset of use of antidepressants or that his weight gain was aggravated by of use of antidepressants. He stated that Dr. C.B.’s findings included tertiary and quaternary relationship claims which are difficult or impossible to prove or verify with any medical certainty. The VA examiner found them to represent pure speculation. He concluded that the relationships indicated by Dr. C.B. between weight and medication do not represent sound medical judgement at any level of medical practice. The Veteran underwent further VA examination in July 2020. The examiner noted a history of asymptomatic hypertension that was initially diagnosed in 2001. Medications for the condition included daily doses of Losartan and Clonidine. After review of the claims file, the examiner noted a single elevated blood pressure reading that occurred during active duty service. A September 1996 reading was 153/71. He also noted that blood pressure readings were normal in October 1995 and the Veteran did not have a sustained elevated blood pressure reading until 2001. He was then monitored and did not start antihypertensive medications until 2004. The examiner stated that the Veteran did not meet the diagnostic criteria for hypertension during service. He opined that the Veteran’s current hypertension is less likely than not incurred in or caused by the elevated reading during service. The examiner also opined that the current hypertension is less likely than not related to the Veteran’s obesity caused by the service-connected bilateral foot disability, left knee disability, and/or dysthymic disorder. In support of this opinion, he explained that hypertension is a disease caused by narrowing or hardening of the peripheral vasculature either by age or congenitally. There is no correlation between the development of hypertension and bilateral foot disability, left knee disability and/or dysthymic disorder. He also explained that obesity is a condition that can be controlled not just with exercise but with decreased caloric intake and studies have shown that decreased caloric intake is actually superior to exercise in controlling weight. After careful consideration of the evidence of record, the Board finds that service connection is not warranted for hypertension. The evidence of record fails to persuasively show a nexus between the current condition and any in-service incidents or events. The Veteran had an elevated blood pressure reading of 153/71 in September 1996, which did not meet the diagnostic criteria for hypertension. Outside of this single elevated blood pressure reading, his blood pressure was within normal limits during service and for several years thereafter. By the Veteran’s own admission, hypertension was not diagnosed until 2001, approximately five years after his discharge. The July 2020 VA examiner found no nexus to service for the current condition and the record is absent any objective medical evidence supporting a direct relationship to service. Thus, the preponderance of the evidence weighs against a finding that the Veteran’s hypertension manifested during active service or developed as the result of an event, injury, or disease during active service. The Veteran’s central theory for entitlement to service connection for hypertension is secondary service connection. He contends that his hypertension is the result of obesity caused by the service-connected bilateral foot disability, left knee disability, and/or dysthymic disorder. The Board has specifically considered that obesity may be an “intermediate step” between a service-connected disability and a current disability that may be connected on a secondary basis (1) if a previously service-connected disability caused him to become obese or aggravated his obesity; (2) that obesity was a substantial factor in causing secondary disability; and (3) the secondary disability would not have occurred but for the obesity. See VAOPGCPREC 1-2017; Walsh v. Wilkie, 32 Vet. App. 300 (2020). However, there is no persuasive evidence of an intermediate step in this case because there is no persuasive evidence that a service-connected disability led him to become obese or aggravated his obesity or that the Veteran’s hypertension would not have occurred but for obesity caused or aggravated by service connected disability. The weight of the probative evidence reflects that the obesity was not caused or aggravated by disease or injury, rather it was caused by caloric intake. See Marcelino, supra. Treatment records include multiple notes directing the Veteran to engage in physical activity and inviting him to participate in VA’s weight loss program, thus indicating that he was not immobile to the point that activity was not permitted. Weight-gain resulting in obesity by itself, possibly contributing in some respect to disability, does not warrant service-connection. Id. The evidence of record contains multiple medical opinions on this issue. In the case of conflicting medical opinions, the Board must weigh the credibility and probative value of the medical opinions, and in so doing, may favor one medical opinion over the other. See Evans v. West, 12 Vet. App. 22, 30 (1998) (citing Owens v. Brown, 7 Vet. App. 429, 433 (1995)); see also Wensch v. Principi, 15 Vet. App. 362, 368 (2001) (it is not error for the Board to favor the opinion of one competent medical expert over that of another when the Board gives an adequate statement of reasons and bases for doing so). The probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches. Guerrieri v. Brown, 4 Vet. App. 467, 470 (1993). Other factors affecting the probative value of a medical opinion include thoroughness and degree of detail, and a well-reasoned rationale. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000); see also Bloom v. West, 12 Vet. App. 185, 187 (1999). The credibility and weight to be attached to these opinions is within the province of the Board. The Board has considered the June 2015 private opinion from Dr. C.B, which stated that the Veteran’s psychoactive medications often cause weight gain. However, this opinion is afforded little probative value, based on the abstract language and insufficient rationale. Dr. C.B. stated that medications often cause weight gain but did not discuss the specifics of the Veteran’s medical history. Notably, significant weight gain occurred prior to the use of any psychoactive medication. The Veteran denied any medication for psychiatry in an October 2005 VA examination report. During a December 2008 VA examination, he reported use of Ambien and Topomax. Treatment records reflect weight of 198 pounds in September 1996 and 276 pounds in October 1999. Subsequently, weight increased to 294 pounds in June 2001 and 309 pounds in June 2003. The Veteran’s weight is currently approximately 330 pounds. Thus, the majority of the weight gain occurred prior to use of medication for a psychiatric condition, which conflicts with the opinion provided by Dr. C.B. He used specific language to declare a 90 percent probability that the Veteran’s hypertension caused an enlarged heart but did not opine on the etiology of the hypertension with any certainty. For these reasons, the Board does not find the June 2015 private opinion persuasive as to the etiology of the Veteran’s hypertension and any relationship with obesity. The Board affords significant probative value to the VA examination conducted in July 2020. The examiner accurately stated the Veteran’s medical history in regard to hypertension. He opined that the current hypertension is less likely than not related to the Veteran’s obesity caused by the service-connected bilateral foot disability, left knee disability, and/or dysthymic disorder. In support of this opinion, he provided a medical rationale explaining that hypertension occurs from narrowing or hardening of the peripheral vasculature either by age or congenitally. The examiner found no correlation between the development of hypertension and the Veteran’s bilateral foot disability, left knee disability and/or dysthymic disorder. He also explained that obesity is a condition that can be controlled not just with exercise but with decreased caloric intake. The July 2020 VA examiner interviewed the Veteran, reviewed his medical history, and provided fully articulated opinions supported by reasoned analyses. See, e.g., Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303-04 (2008). His opinions did not use speculative language but, rather, provided the degree of certainty required for medical nexus evidence. Accordingly, the July 2020 VA examination report is afforded significant probative value in this case. See Jandreau v. Nicholson, 492 F.3d 1372, 1376 (Fed. Cir. 2007) (noting “the Board retains discretion to make credibility determinations and otherwise weigh the evidence submitted”). The Board also notes that the July 2020 VA examiner’s findings are consistent with the August 2015 VA addendum opinion, which stated that it is impossible to prove that the Veteran developed elevated weight secondary to using medications for mental health issues. The August 2015 VA examiner found no documented medical evidence of record that the Veteran’s weight precipitously increased related to onset of use of antidepressants or that his weight gain was aggravated by of use of antidepressants. He found Dr. C.B.’s findings to represent pure speculation and concluded that the relationships indicated by Dr. C.B. between weight and medication do not represent sound medical judgement at any level of medical practice. For these reasons, the Board places greater evidentiary weight on the July 2020 VA examination report supported by the August 2015 VA addendum opinion. Moreover, treatment records clearly show no causation or aggravation of obesity on account of service connected disability resulting in a substantial factor in causing hypertension and that hypertension would not have occurred but for causation or aggravation of obesity on account of service connected disability. After thorough review of the conflicting medical opinions, the Board finds that the collective VA medical opinions are more probative than the private opinion as they include a detailed supporting rationale, specific language, and accurate medical history. Thus, the more probative VA medical opinions weigh against establishing service connection for hypertension. The Board also considered the Veteran’s lay statements purporting to relate his hypertension to his service-connected bilateral foot disability, left knee disability, and/or dysthymic disorder. Although he is competent to report his symptoms, any opinion regarding whether his hypertension is etiologically related to his weight gain and service-connected disabilities requires medical expertise that he has not demonstrated. See, e.g., Jandreau, 492 F.3d at 1376; Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). The Board also notes that while the Veteran contends that immobility due to his service-connected disabilities caused his obesity, this is contradicted by treatment records recommending that he engage in permissible forms of physical activity and participate in VA’s weight loss program. Thus, while the Board has considered the lay statements of record, they are outweighed in probative value by the objective medical evidence which does not support a nexus as asserted by the Veteran. After careful consideration, the Board concludes that the probative evidence of record weighs against a finding that the Veteran’s hypertension is the result of his service or due to obesity caused or aggravated by his service-connected bilateral foot disability, left knee disability, and/or dysthymic disorder. 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, that doctrine is not applicable. 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53. 2. Entitlement to service connection for diabetes mellitus, type II. The Veteran contends that he gained weight due to service-connected disabilities, and as a result of that weight gain, he now has diabetes mellitus, type II. The Veteran underwent VA examination in conjunction with his present claim in May 2015. The examiner noted a 2010 diagnosis of diabetes mellitus, type II. Treatment included a restricted diet, insulin injections, and prescription medication. Regulation of activities was noted as not required as part of the medical management of the condition. After review of the claims file and examination of the Veteran, the examiner concluded that the Veteran has diabetes as a result of his morbid obesity secondary to activity. She opined that the obesity is less likely than not caused by or related to the Veteran’s dysthymia or foot condition. While acknowledging that the foot condition does make the Veteran limit certain activities, he is not prevented from all activities that would help with weight loss, such as swimming. A private medical opinion from Dr. C.B. was received in June 2015. He stated that the Veteran’s diabetes was likely secondary to the service-connected psychiatric condition, including the psychoactive medications that are known to cause weight gain. He also stated that the Veteran’s excess weight gain due to medication and immobility is the likely cause of his diabetes, as weight gain is a known cause of the disease. Dr. C.B opined that there is a 90 percent probability that the Veteran has a service-connected psychiatric condition requiring continuous medication resulting in weight gain and that the weight gain caused the diabetes. In August 2015, a VA medical examiner reviewed the claims file, including the private medical opinion from Dr. C.B. The VA examiner stated that there is no documented medical evidence of record that the Veteran’s weight gain caused his diabetes. He further explained that there are millions of people with elevated weight who do not have diabetes and that a high component of diabetes is genetic. He stated that Dr. C.B.’s findings included tertiary and quaternary relationship claims which are difficult or impossible to prove or verify with any medical certainty. The VA examiner found them to represent pure speculation. He concluded that the relationships indicated by Dr. C.B. do not represent sound medical judgement at any level of medical practice. The Veteran underwent further VA examination in July 2020. The examiner noted a diagnosis of diabetes in 2001. After review of the claims file and examination of the Veteran, the examiner opined that the diabetes is less likely than not incurred in or caused by service. He found no documentation of diagnosis or treatment for diabetes during service and no symptoms or complaints related to diabetes mellitus. The examiner stated that it was not until 2001 that the Veteran was found to have elevated glucose levels consistent with the criteria for the diagnosis of diabetes mellitus, well after discharge from military service. He also opined that the diabetes is less likely than not to have occurred but for the obesity caused by the service-connected bilateral foot disability, left knee disability, or dysthymic disorder. In support of this conclusion, he explained that the Veteran has developed diabetes which has a known risk factor in patients with obesity and fits the criteria for morbid obesity, which is the likely precursor for his diabetes. However, he further explained that while the Veteran’s bilateral foot and left knee disabilities with dysthymic disorder have decreased his ability to exercise, he still has the conscious ability to decrease his caloric intake and therefore control his obesity despite his orthopedic conditions. The examiner cited clear medical studies showing that decreased caloric intake actually reduces weight and maintains a normal BMI more efficiently than with exercise. The examiner also stated that the Veteran’s obesity is less likely than not a result of the service-connected bilateral foot disability or left knee disability because obesity is not solely caused by inactivity and decreased ability to exercise. The Veteran’s bilateral foot and left knee disabilities have decreased his physical activity, but he has control of his caloric intake despite his disabilities. Studies show that decreased caloric intake is a far more effective and efficient way of maintaining weight and avoiding obesity. After careful consideration of the evidence of record, the Board finds that service connection is not warranted for diabetes mellitus, type II. The evidence of record fails to persuasively show a nexus between the current condition and any in-service incidents or events. By the Veteran’s own admission, diabetes was not diagnosed until over a decade after his separation from service. The July 2020 VA examiner found no nexus between the current condition and service. The preponderance of the evidence weighs against a finding that the Veteran’s diabetes manifested during active service or developed as the result of an event, injury, or disease during active service. The Veteran’s central theory for entitlement to service connection for diabetes is secondary service connection. He contends that his diabetes mellitus, type II, is the result of obesity caused by the service-connected bilateral foot disability, left knee disability, and/or dysthymic disorder. The Board has specifically considered that obesity may be an “intermediate step” between a service-connected disability and a current disability that may be connected on a secondary basis (1) if a previously service-connected disability caused him to become obese or aggravated his obesity; (2) that obesity was a substantial factor in causing secondary disability; and (3) the secondary disability would not have occurred but for the obesity. See VAOPGCPREC 1-2017. However, there is no persuasive evidence of an intermediate step in this case because there is no persuasive evidence that a service-connected disability led him to become obese or aggravated his obesity. The weight of the probative evidence reflects that obesity was not caused or aggravated by disease or injury, rather it was caused by caloric intake. See Marcelino, supra. Treatment records include multiple notes directing the Veteran to engage in physical activity and inviting him to participate in VA’s weight loss program, thus indicating that he was not immobile to the point that activity was not permitted. Weight-gain resulting in obesity by itself, possibly contributing in some respect to disability, does not warrant service-connection. Id. The evidence of record contains multiple medical opinions on this issue. In the case of conflicting medical opinions, the Board must weigh the credibility and probative value of the medical opinions, and in so doing, may favor one medical opinion over the other. See Evans, 12 Vet. App. at 30; see also Wensch, 15 Vet. App. at 368. The probative value of medical opinion evidence is based on the medical expert’s personal examination of the patient, the physician’s knowledge and skill in analyzing the data, and the medical conclusion the physician reaches. Guerrieri, 4 Vet. App. at 470. Other factors affecting the probative value of a medical opinion include thoroughness and degree of detail, and a well-reasoned rationale. See Prejean, 13 Vet. App. at 448-49; see also Bloom, 12 Vet. App. at 187. The credibility and weight to be attached to these opinions is within the province of the Board. The Board has considered the June 2015 private opinion from Dr. C.B, which stated that the Veteran’s psychoactive medications often cause weight gain. However, this opinion is afforded little probative value, based on the abstract language and insufficient rationale. Dr. C.B. stated that medications often cause weight gain but did not discuss the specifics of the Veteran’s medical history. He also stated that the Veteran’s excess weight gain due to medication and immobility is the likely cause of his diabetes, as weight gain is a known cause of the disease. Notably, significant weight gain occurred prior to the use of any psychoactive medication. The Veteran denied any medication for psychiatry in an October 2005 VA examination report. During a December 2008 VA examination, he reported use of Ambien and Topomax. Treatment records reflect weight of 198 pounds in September 1996 and 276 pounds in October 1999. Subsequently, weight increased to 294 pounds in June 2001 and 309 pounds in June 2003. It is currently approximately 330 pounds. Thus, the majority of the weight gain occurred prior to use of medication for a psychiatric condition, which conflicts with the opinion provided by Dr. C.B. He used specific language to declare a 90 percent probability that the Veteran has a service-connected psychiatric condition requiring continuous medication resulting in weight gain and that the weight gain caused the diabetes. However, other than stating that weight gain in general is a known cause of diabetes, he did not provide a sufficient rationale in support of this statement. Without further explanation, the Board cannot determine the reasoning underpinning such opinions. See Nieves-Rodriguez, 22 Vet. App. at 304 (holding, in the context of weighing one medical opinion with another, that “[i]t is the factually accurate, fully articulated, sound reasoning for the conclusion ... that contributes probative value to a medical opinion”). For these reasons, the Board does not find the June 2015 private opinion persuasive as to the etiology of the Veteran’s diabetes and any relationship with obesity. In this case, the Board affords significant probative value to the VA examination conducted in July 2020. The examiner appears to have transposed the date of the diabetes diagnosis from 2010 to 2001. Even with a 2001 diagnosis in mind, the examiner stated that the diagnosis was significantly after the Veteran’s discharge such that it removed any direct link to service. He opined that the diabetes mellitus is less likely than not incurred in or caused by the diabetes mellitus during service. He also opined that the current diabetes is less likely than not related to the Veteran’s obesity caused by the service-connected bilateral foot disability, left knee disability, and/or dysthymic disorder. In support of this opinion, he provided a medical rationale explaining that the Veteran’s obesity is the likely precursor for his diabetes. However, he further explained that while the Veteran’s service-connected conditions have decreased his ability to exercise, he still has the ability to control his obesity despite his orthopedic conditions. The examiner cited clear medical studies showing that decreased caloric intake reduces weight and maintains a normal BMI more efficiently than with exercise. He explained that obesity is a condition that can be controlled not just with exercise but with decreased caloric intake. The July 2020 VA examiner interviewed the Veteran, reviewed his medical history, and provided fully articulated opinions supported by reasoned analyses. See, e.g., Nieves-Rodriguez, 22 Vet. App. at 303-04. His opinions did not use speculative language but, rather, provided the degree of certainty required for medical nexus evidence. Accordingly, the July 2020 VA examination report is afforded significant probative value in this case. See Jandreau, 492 F.3d at 1376. The Board also notes that the July 2020 VA examiner’s findings are consistent with the August 2015 VA addendum opinion, which stated that it is impossible to prove that the Veteran developed elevated weight secondary to using medications for mental health issues. The August 2015 VA examiner found no documented medical evidence of record that the Veteran’s weight precipitously increased related to onset of use of antidepressants or that his weight gain was aggravated by of use of antidepressants. He found Dr. C.B.’s findings to represent pure speculation and concluded that the relationships indicated by Dr. C.B. between weight and medication do not represent sound medical judgement at any level of medical practice. For these reasons, the Board places greater evidentiary weight on the July 2020 VA examination report supported by the August 2015 VA addendum opinion. Moreover, treatment records clearly show no causation or aggravation of obesity on account of service connected disability resulting in a substantial factor in causing diabetes and that diabetes would not have occurred but for causation or aggravation of obesity on account of service connected disability. After thorough review of the conflicting medical opinions, the Board finds that the collective VA medical opinions are more probative than the private opinion as they include a detailed supporting rationale, specific language, and accurate medical history. Thus, the more probative VA medical opinions weigh against establishing service connection for diabetes. The Board has also considered the Veteran’s lay statements purporting to relate his diabetes mellitus, type II to his service-connected bilateral foot disability, left knee disability, and/or dysthymic disorder. Although the Veteran is competent to report his symptoms, any opinion regarding whether his diabetes is etiologically related to his weight gain and service-connected disabilities requires medical expertise that he has not demonstrated. See, e.g., Jandreau, 492 F.3d at 1376; Kahana, 24 Vet. App. at 435. The Board also notes that while the Veteran contends that immobility due to his service-connected disabilities caused his obesity, this is contradicted by treatment records recommending that he engage in permissible forms of physical activity and participate in VA’s weight loss program. Thus, while the Board has considered the lay statements of record, they are outweighed in probative value by the objective medical evidence which does not support a nexus as asserted by the Veteran. After careful consideration, the Board concludes that the probative evidence of record weighs against a finding that the Veteran’s diabetes mellitus, type II is the result of his service or due to obesity caused or aggravated by his service-connected bilateral foot disability, left knee disability, and/or dysthymic disorder. 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, that doctrine is not applicable. 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53. 3. Entitlement to service connection for IVDS with bulging discs (low back disability). The Veteran contends that he gained weight due to service-connected disabilities and as a result of that weight gain, he now has a low back disability. An April 1991 private x-ray revealed spondylolisthesis, L-5 on S-1, with bilateral spondylolysis. A July 1992 pre-service private treatment record shows that the Veteran was treated for neck and back pain. The Veteran was involved in a car accident on July 16 at which time he was in an MTA bus that was involved in an accident. It was noted that the Veteran was thrown about within the bus and apparently struck his head in addition to suffering other injuries. A July 1992 x-ray revealed pars defect at L5 level with very mild spondylolisthesis and no evidence of fracture. The Veteran’s October 1995 Report of Medical Examination conducted upon enlistment is absent any notations of defects or diseases of the back. Service treatment records reflect that the Veteran fell off a bunk and injured his right great toe in July 1996. X-rays revealed osteoblastic changes in the right 2nd metatarsal, which was questionably an old fracture or growth. He was seen multiple times for foot pain. A bone scan demonstrated findings of a stress reaction in the left knee. He was referred for physical therapy. The Veteran underwent VA examination in conjunction with his present claim in May 2015. The examiner noted a 2013 diagnosis of a bulging disc categorized as intervertebral disc syndrome (IVDS). The Veteran complained of lower back pain, with symptoms starting in 1996 when his left foot gave way, injuring his lower back. He was treated with physical therapy at Kernan Hospital. Approximately six years ago, the pain started radiating to the right lower extremity calf. There is no history of surgery. The Veteran stated that the increased back pain caused limited standing, walking, bending, and lifting. After review of the records and physical examination of the Veteran, the examiner opined that it is less likely as not the back condition was incurred in or caused by the low back condition during service. The examiner noted that service treatment records are silent as to a back condition during service, although there are records of physical therapy at Kernan Hospital in April 1991 which are barely legible. A private medical opinion from Dr. C.B. was received in June 2015. He stated that the Veteran’s weight gain is causing secondary degenerative spine disease given his weight of over 300 pounds. Dr. C.B opined that there is a 90 percent probability that the Veteran entered the service fit for duty without any doctor-diagnosed illnesses and that his spine disease is due to weight gain as he weighs over 300 pounds. In August 2015, a VA medical examiner reviewed the claims file, including the private medical opinion from Dr. C.B. The VA examiner stated that there is no documented medical evidence of record that the Veteran’s weight gain caused arthritis in his back. He further explained that there are millions of people who have elevated weight and no arthritis in the back. Conversely, there are also millions of people who are thin and have arthritis in the back. He stated that Dr. C.B.’s findings included tertiary and quaternary relationship claims which are difficult or impossible to prove or verify with any medical certainty. The VA examiner found them to represent pure speculation. He concluded that the relationships indicated by Dr. C.B. between antidepressants, weight gain, and arthritis in the back do not represent sound medical judgement at any level of medical practice. The Veteran underwent further VA examination in July 2020. The examiner noted diagnoses of lumbosacral strain in 1991, lumbar disc herniation in 2013, and lower extremity radiculopathy in 2013. After review of the claims file and examination of the Veteran, the examiner opined that the current low back condition is less likely than not incurred in or caused by service. He found no documentation of injury to the lumbar back during service and noted that the Veteran was evaluated in April 1991, July 1992, and August 1992 for a back injury relating to a motor vehicle collision. The October 1995 enlistment physical was silent for any residual back pain. His separation physical was also silent for any back complaints. A chronic back condition was not diagnosed until February 2013, when the Veteran was found to have lumbar disc herniations with radiculopathy. The examiner also opined that the low back condition is less likely than not proximately due to or the result of the Veteran’s service-connected left foot stress fracture with degenerative arthritis, left knee meniscus tear with degenerative arthritis, and right foot peroneal neuropathy. He explained that lumbar disc herniation is a mechanical instability of the lumbar spine itself resulting in herniation of the lumbar disc, which can lead to radiculopathy. This is a disease that occurs within the spinal column and is unrelated to any disease of the foot or knee. The Veteran’s left foot stress fracture with degenerative arthritis, left knee meniscus tear with degenerative arthritis, and right foot peroneal neuropathy are separate and distinct conditions that have no effect on causing a disc herniation or radiculopathy of the lumbar spine. The examiner also stated that the low back disability, which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. He noted the documentation of lumbar strain as a result of a motor vehicle collision prior to service. The examiner found no documentation of back pain during service and noted that it was not until 2013 that the Veteran was diagnosed with lumbar disc herniation with radiculopathy. The examiner noted a 17-year time lapse between complaints and diagnoses. After careful consideration of the evidence of record, the Board finds that service connection is not warranted for the Veteran’s low back disability. A veteran will be considered to have been in sound condition when examined and accepted for service, except as to disorders noted on entrance into service, or when clear and unmistakable evidence demonstrates that the disability existed prior to service and was not aggravated by service. Only such conditions as are recorded in examination reports are to be considered as noted. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). Although STRs reflect that the Veteran was in a car accident in 1992, the October 1995 entrance examination does not indicate that he had a diagnosis of any low back conditions upon entry into service. His back was deemed normal at that time. Therefore, the Board finds that the presumption of soundness attaches. See 38 U.S.C. § 1111; Doran v. Brown, 6 Vet. App. 283, 286 (1994). Thus, the burden is on VA to rebut the presumption by clear and unmistakable evidence that a low back condition was both preexisting and not aggravated by service. In this case, there is clear and unmistakable evidence that the Veteran suffered a back injury prior to service. A pre-service April 1991 private x-ray revealed spondylolisthesis L-5 on S-1, with bilateral spondylolysis. A July 1992 x-ray revealed pars defect at L5 level with very mild spondylolisthesis and no evidence of fracture. The July 2020 VA examiner opined that the Veteran’s current low back disability clearly and unmistakably existed prior to service. Thus, while there is no evidence of a low back diagnosis on the Veteran’s entrance examination in October 1995, the Board finds clear and unmistakable evidence that a low back condition existed prior to his service beginning in July 1996. The claim now turns upon whether such preexisting low back disability was clearly and unmistakably not aggravated by service (two months). The July 2020 VA examiner opined that the Veteran’s low back disability was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. The Board’s review indicates that symptoms were more severe during periods prior to service than during service or since his discharge, and it was not until many years post-service back pain resurfaced in treatment records. Notably, the Veteran’s statements primarily assert that his back pain is due to weight gain, rather than any aggravation during service. To the extent that the Veteran asserts that his low back disability was aggravated during service, the Board acknowledges that he is competent to testify as to his observations. Jandreau, 492 F.3d at 1376-77. Lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In this case, however, the Veteran does not possess the medical expertise to provide an opinion regarding the etiology of his low back disability, particularly given the multiple etiological options. Where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. West, 12 Vet. App. 460, 465 (1999). Here, the July 2020 VA examiner with medical training and knowledge explained that the Veteran’s current lumbar disc herniations occurred as a result of shifting of the vertebrae, independent from the bilateral foot, left knee, and dysthymic disorders. Thus, the probative evidence of record supports a clear finding that the preexisting low back condition was not aggravated by service. Accordingly, the Board concludes that there is clear and unmistakable evidence that the Veteran’s low back disability preexisted service and was not aggravated during service. The Board notes that the Veteran’s central theory for entitlement to service connection is secondary service connection. He contends that his low back disability is the result of obesity caused by the service-connected bilateral foot disability, left knee disability, and/or dysthymic disorder. The Board has specifically considered that obesity may be an “intermediate step” between a service-connected disability and a current disability that may be connected on a secondary basis (1) if a previously service-connected disability caused him to become obese or aggravated his obesity; (2) that obesity was a substantial factor in causing secondary disability; and (3) the secondary disability would not have occurred but for the obesity. See VAOPGCPREC 1-2017. However, there is no persuasive evidence of an intermediate step in this case because there is no persuasive evidence that a service-connected disability led him to become obese or aggravated his obesity or that the Veteran’s IVDS would not have occurred but for obesity caused or aggravated by service connected disability. The weight of the probative evidence reflects that obesity was not caused or aggravated by disease or injury, rather it was caused by caloric intake. See Marcelino, supra. Treatment records include multiple notes directing the Veteran to engage in physical activity and inviting him to participate in VA’s weight loss program, thus indicating that he was not immobile to the point that activity was not permitted. Weight-gain resulting in obesity by itself, possibly contributing in some respect to disability, does not warrant service-connection. Id. The evidence of record contains multiple medical opinions on this issue. In the case of conflicting medical opinions, the Board must weigh the credibility and probative value of the medical opinions, and in so doing, may favor one medical opinion over the other. See Evans, 12 Vet. App. at 30; see also Wensch, 15 Vet. App. at 368. The probative value of medical opinion evidence is based on the medical expert’s personal examination of the patient, the physician’s knowledge and skill in analyzing the data, and the medical conclusion the physician reaches. Guerrieri, 4 Vet. App. at 470. Other factors affecting the probative value of a medical opinion include thoroughness and degree of detail, and a well-reasoned rationale. See Prejean, 13 Vet. App. 448-49; see also Bloom, 12 Vet. App. at 187. The credibility and weight to be attached to these opinions is within the province of the Board. The Board has considered the June 2015 private opinion from Dr. C.B, which stated that the Veteran’s psychoactive medications often cause weight gain. However, this opinion is afforded little probative value, based on the abstract language and insufficient rationale. Dr. C.B. stated that medications often cause weight gain but did not discuss the specifics of the Veteran’s medical history. Notably, significant weight gain occurred prior to the use of any psychoactive medication. The Veteran denied any medication for psychiatry in an October 2005 VA examination report. During a December 2008 VA examination, he reported use of Ambien and Topomax. Treatment records reflect weight of 198 pounds in September 1996 and 276 pounds in October 1999. Subsequently, weight increased to 294 pounds in June 2001 and 309 pounds in June 2003. It is currently approximately 330 pounds. Thus, the majority of the weight gain occurred prior to use of medication for a psychiatric condition. Dr. C.B. also stated that the Veteran’s excess weight gain due to medication and immobility is causing secondary degenerative spine disease. Dr. C.B used specific language to declare a 90 percent probability that the Veteran has spine disease due to weight gain. However, other than stating that weight gain in general is the cause of the Veteran’s back problems, he did not provide a sufficient rationale in support of this statement. Without further explanation, the Board cannot determine the reasoning underpinning such opinions. See Nieves-Rodriguez, 22 Vet. App. at 304 (holding, in the context of weighing one medical opinion with another, that “[i]t is the factually accurate, fully articulated, sound reasoning for the conclusion... that contributes probative value to a medical opinion”). For these reasons, the Board does not find the June 2015 private opinion persuasive as to the etiology of the Veteran’s low back disability and any relationship with obesity. In this case, the Board affords significant probative value to the VA examination conducted in July 2020. He opined that the Veteran’s low back disability is less likely than not the result of the obesity claimed to have been caused by his service-connected bilateral foot disability, left knee disability, or dysthymic disorder. He explained that the Veteran has lumbar disc herniations that were noted on MRI in 2013. This condition occurs as a result of shifting of the vertebrae causing the vertebrae to shift resulting in symptoms of pain and radiculopathy. The examiner stated that this is an independent condition from his bilateral foot, left knee, and dysthymic disorders. He also noted that although the Veteran has multiple orthopedic conditions which have impeded his ability to exercise and remain physically active, normal weight may be maintained by decreasing caloric intake. The examiner cited clear medical studies showing that decreased caloric intake actually reduces weight and maintains a normal BMI more efficiently than with exercise. He explained that obesity is a condition that can be controlled not just with exercise but with decreased caloric intake. The July 2020 VA examiner interviewed the Veteran, reviewed his medical history, and provided fully articulated opinions supported by reasoned analyses. See, e.g., Nieves-Rodriguez, 22 Vet. App. at 303-04. His opinions did not use speculative language but, rather, provided the degree of certainty required for medical nexus evidence. Accordingly, the July 2020 VA examination report is afforded significant probative value in this case. See Jandreau, 492 F.3d at 1376. The Board also notes that the July 2020 VA examiner’s findings are consistent with the August 2015 VA addendum opinion, which stated that it is impossible to prove that the Veteran developed elevated weight secondary to using medications for mental health issues. The August 2015 VA examiner found no documented medical evidence of record that the Veteran’s weight precipitously increased related to onset of use of antidepressants or that his weight gain was aggravated by of use of antidepressants. He found Dr. C.B.’s findings to represent pure speculation and concluded that the relationships indicated by Dr. C.B. between weight and medication do not represent sound medical judgement at any level of medical practice. For these reasons, the Board places greater evidentiary weight on the July 2020 VA examination report supported by the August 2015 VA addendum opinion. Moreover, treatment records clearly show no causation or aggravation of obesity on account of service connected disability resulting in a substantial factor in causing the back disability and that the back disability would not have occurred but for causation or aggravation of obesity on account of service connected disability. After thorough review of the conflicting medical opinions, the Board finds that the collective VA medical opinions are more probative than the private opinion as they include a detailed supporting rationale, specific language, and accurate medical history. Thus, the more probative VA medical opinions weigh against establishing service connection for a low back condition. The Board has also considered the Veteran’s lay statements purporting to relate his low back condition to his service-connected bilateral foot disability, left knee disability, and/or dysthymic disorder. Although the Veteran is competent to report his symptoms, any opinion regarding whether his low back condition is etiologically related to his weight gain and service-connected disabilities requires medical expertise that he has not demonstrated. See, e.g., Jandreau, 492 F.3d at 1376; Kahana, 24 Vet. App. at 435. The Board also notes that while the Veteran contends that immobility due to his service-connected disabilities caused his obesity, this is contradicted by treatment records recommending that he engage in permissible forms of physical activity and participate in VA’s weight loss program. Thus, while the Board has considered the lay statements of record, they are outweighed in probative value by the VA medical opinions which do not support a nexus as asserted by the Veteran. After careful consideration, the Board concludes that the probative evidence of record weighs against a finding that the Veteran’s pre-existing low back disability is the result of or aggravated by his service or due to obesity caused or aggravated by his service-connected bilateral foot disability, left knee disability, and/or dysthymic disorder. 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, that doctrine is not applicable. 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53. (continued on next page) TANYA SMITH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Jamison, E. 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.