Citation Nr: 21015052 Decision Date: 03/16/21 Archive Date: 03/16/21 DOCKET NO. 08-18 107 DATE: March 16, 2021 ORDER Entitlement to service connection for diabetes mellitus type II is denied. FINDINGS OF FACT 1. Diabetes mellitus type II was not incurred in service, did not manifest to a compensable degree within one year of service separation, and symptoms of diabetes mellitus were not both chronic in service and continuous since service separation. 2. Diabetes mellitus type II is not related to exposure to contaminated water at Camp Lejeune. 3. The Veteran’s diabetes mellitus type II is not secondary to his service-connected disabilities. CONCLUSION OF LAW The criteria for entitlement to service connection for diabetes mellitus type II are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty from October 1981 to May 1985, and from December 1985 to February 1989. The Veteran’s claim for service connection for diabetes mellitus type II comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2007 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The appeal was remanded in May 2017 and November 2018 for a medical opinion. The undersigned Veterans Law Judge held a hearing on this issue in March 2020 and remanded the appeal in May 2020 and December 2020 for a new VA opinion. The Board finds that the requested development has been completed. Entitlement to service connection for diabetes mellitus 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). Certain chronic diseases will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. The Veteran contends in statements and Board hearing testimony that that diabetes mellitus type II is due to obesity caused by his service-connected disabilities. During the March 2020 hearing, the Veteran testified that due to his knee disabilities in service, he was unable to complete daily runs or complete physical fitness tests, and his disabilities stopped him from getting exercise. He was placed on limited duty. He reported that he was not tested for diabetes in service, but was told by his physician, Dr. H. in 1990 that he had prediabetes, and in 1991 he was diagnosed with diabetes. The Veteran felt that his injuries in service caused him to gain weight and that this contributed to diabetes. Alternately, he contends that his diabetes is related to exposure to contaminated water at Camp Lejeune. The Veteran has current diabetes mellitus type II shown by VA and private treatment records. Service treatment records, to include a separation examination report, do not identify any symptoms, treatment, or complaints related to diabetes mellitus. A March 1989 treatment report showed a glucose of 140. A June 1989 VA treatment record indicated that the Veteran’s medical history was negative for diabetes mellitus. A note on the Veteran’s May 1993 lab work from Cassidy Medical Group indicated that a diabetic diet was recommended. Treatment records from Dr. H. show that in the Veteran had increased glucose levels in January 1995 and was advised to be on a weight-reducing diabetic diet. An April 2003 treatment note identified a history of diabetes diagnosed at age 33 (which would be in approximately 1996) after the Veteran had surgery for patellar tendon repair. An April 2018 letter from Dr. A.D. included a review of the Veteran’s medical records. Medical records showed random glucose levels ranging between 87 and 187 between April 1989 and September 1991. The Veteran gained a significant amount of weight on active duty with records stating that he weighed 135 pounds at entry in 1981 and 185 pounds at separation in 1989. No glucose test results were available during active service. He opined, therefore, that it was feasible that the weight gain experienced by the Veteran during active duty was related to his inability to exercise due to service-connected conditions. He stated that the Veteran was diagnosed with diabetes in 1991, two years after separation and was begun on metformin at that time. Given the short time interval between separation and his diagnosis of diabetes mellitus type II, he opined that it was more likely than not that the Veteran was “prediabetic” at the time of his separation. The weight of the evidence shows that diabetes mellitus was not chronic in service, did not manifest to a compensable degree within the one-year presumptive period post-service, and was not noted in service with attributable continuity of symptomatology. Diabetes mellitus was not shown in service. Dr. A.D. identified a 1991 diagnosis of diabetes mellitus, two years post-service. Post-service treatment records that are of record, identified a recommendation of treatment with a diabetic diet starting in 1993. While Dr. A.D. opined that it was more likely than not that the Veteran was “prediabetic” at the time of his separation, the Board finds that being prediabetic is not equivalent to having a diagnosis of diabetes mellitus nor did diabetes mellitus manifest to a compensable degree within one year of service as no diagnosis or treatment was rendered during the presumptive period. VA and private treatment records show the Veteran was not diagnosed with diabetes mellitus until at least 1991, two years after his separation from service and outside of the applicable presumptive period. Service connection may be granted on a direct basis; however, the preponderance of the evidence is against finding that a medical nexus exists between the Veteran’s diabetes mellitus and any in-service injury, event or disease, to include exposure to contaminated water at Camp Lejeune. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303. The weight of the evidence is against finding that diabetes mellitus was incurred in service. A December 2017 VA examiner opined that the Veteran’s diabetes mellitus type II was less likely than not caused by or a result of his exposure to contaminated water at Camp Lejeune. He reasoned that the preponderance of the medical literature regarding Camp Lejeune contaminated water failed to demonstrate a cause and effect association for diabetes mellitus, citing a large volume of research on the long-term health effects on individuals who served at Camp Lejeune. A July 2020 VA examiner also opined that the Veteran’s diabetes mellitus was less likely than not incurred or caused by exposure to contaminated water at Camp Lejeune. The examiner noted the Veteran’s treatment history, stating that his non-fasting glucose levels recorded prior to 1991 and a fasting glucose of 97 in 1991 did not qualify him for a diagnosis of diabetes although he was started on metformin. He noted that a diagnosis of diabetes mellitus requires a fasting blood glucose of greater than 125, a 2 hour post prandial glucose level of greater than 140, a random blood glucose of greater than 300, or 2 separate HgB A1c results taken three months apart which were elevated above normal. He also cited research with regard to chemicals found in the drinking water at Camp Lejeune, but found that there was no association identified between the exposure to those chemicals and the later development of type II diabetes mellitus. The Board finds that the VA opinions are probative and the rationale provided in the December 2017 and July 2020 VA opinions is adequate, considered the Veteran’s medical history, and included sound reasoning based on cited research. Therefore, the weight of the evidence shows that diabetes mellitus was not incurred in service and is not related to exposure to contaminated water from Camp Lejeune. The preponderance of the evidence is against finding that diabetes mellitus is proximately due to or the result of, or aggravated beyond its natural progression by service-connected disability. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). While, the April 2018 opinion from Dr. A.D. shows that “it was feasible” that the weight gain experienced by the Veteran during active duty was related to his inability to exercise due to service-connected conditions, this opinion is too speculative to provide a nexus between the Veteran’s weight gain and his service-connected disabilities or service. See 38 C.F.R. § 3.102; Stegman v. Derwinski, 3 Vet. App. 228, 230 (1992) (evidence favorable to the veteran’s claim that does little more than suggest a possibility that his illnesses might have been caused by service radiation exposure is insufficient to establish service connection); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) (medical evidence which merely indicates that the alleged disorder “may or may not” exist or “may or may not” be related, is too speculative to establish the presence of the claimed disorder or any such relationship). Consequently, the opinion is of little probative value. The weight of the evidence shows that diabetes mellitus was related in part to his obesity; however, the evidence does not establish that his obesity was in turn, due to service-connected disability. The Board notes that May 2018 VA examination had the wrong dates of service and the wrong docket number listed, thus, the opinion has not been considered as it is not clear that the examiner reviewed the correct record in conjunction with the Veteran’s examination. An August 2020 examination did not adequately discuss the facts of the Veteran’s case with regard to physical impairments shown to be due to his service-connected disabilities. Thus, that opinion is also not probative. (Continued on the next page)   The Board finds that the January 2021 opinion was based on the correct facts as shown by the record, and is probative. While the January 2021 VA examiner found that the etiology of the Veteran’s diabetes mellitus, was related to his obesity and a positive family history of diabetes mellitus, the examiner opined that the Veteran’s obesity was less likely than not proximately due to or a result of his service-connected disabilities. The examiner reasoned that obesity was multifactorial in origin, caused by interactions between genetic and environmental influences. The examiner noted the presence of knee pain shown by the record and partial restriction in activities shown by the medical record in 1993. The examiner found that inadequate physical activity was one aspect that could contribute to weight gain, but found that eating patterns and caloric intake, and as the Veteran was recommended to be on a diabetic diet, was a significant factor in his weight gain. The Veteran’s genetic factor, with a strong family history of diabetes was also involved. The examiner found, therefore, that the Veteran’s service-connected disabilities did not contribute most significantly to the development of diabetes. The Board finds that the May 2018 VA opinion is adequate and outweighs the more speculative private opinion from Dr. A.D. provided in April 2018. For these reasons, the weight of the evidence is against finding that the Veteran’s obesity, which was one factor contributing to the development of diabetes mellitus, was due to or the result of his service-connected disabilities. For the reasons discussed above, the Board finds that the preponderance of the evidence is against the Veteran’s claim for service connection. K. Parakkal Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Christine C. Kung 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.