Citation Nr: 21022214 Decision Date: 04/15/21 Archive Date: 04/15/21 DOCKET NO. 10-23 536 DATE: April 15, 2021 ORDER Entitlement to service connection for diabetes mellitus type II, to include as due to the Veteran’s service connected acquired psychiatric disorder, is denied. FINDING OF FACT The Veteran’s diabetes mellitus was not secondary to (caused or aggravated by) his service-connected acquired psychiatric disorder and was not otherwise related to an in-service injury or disease. CONCLUSION OF LAW The criteria for service connection for diabetes mellitus due to service or service-connected disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active military service from October 1972 to June 1973. Sadly, the Veteran passed away in November 2015. The Veteran’s surviving spouse has been substituted for purposes of processing the claims on appeal. This matter comes before the Board of Veterans’ Appeals (Board) from the August 2009 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously before the Board in October 2019 and was remanded for further development. Entitlement to service connection for diabetes mellitus type II, to include as due to service connected acquired psychiatric disorder Prior to his death, the Veteran contended that his diabetes was caused by his service connected acquired psychiatric disorder and its associated medications. 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 question for the Board is whether the Veteran had a disability that was proximately due to, or the result of, or was aggravated beyond its natural progress by service-connected disability. The Board concludes that, while the Veteran had a disability, the preponderance of the evidence is against finding that the Veteran’s diabetes was 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). As noted above, this matter was previously before the Board in October 2019. At that time, the Board found the Veteran’s March 2015 VA examination inadequate and directed the Agency of Original Jurisdiction (AOJ) to obtain an opinion regarding the etiology of the Veteran’s diabetes. Specifically, the examiner was asked to address whether it is at least as likely as not that the medication taken for the Veteran’s acquired psychiatric disability caused the Veteran’s obesity; whether that subsequent obesity was a substantial factor in causing the Veteran’s diabetes; and, if the Veteran’s diabetes would not have occurred but for the obesity caused by the Veteran’s acquired psychiatric disability and associated medication. Subsequently, in September 2020, a VA opinion was obtained. The examiner noted that per the medical literature, both body mass index (BMI) and exercise levels are important risk factors for type II diabetes and that the weight of the medical literature does not support schizophrenia in and of itself as being causal of diabetes. The examiner noted that the Veteran was first noted to be diagnosed with schizophrenia in a November 1982 discharge summary. Additionally, private treatment records noted that the Veteran was diagnosed with type II diabetes in January 2001. At the time of his diabetes diagnosis, the Veteran’s weight was noted to be 375 pounds with a BMI of 51.6. The examiner stated that prior to 1972, the available evidence supports the Veteran’s weight as being elevated to a BMI above the normal range. Prior to the Veteran’s diabetes diagnosis, the examiner noted that the Veteran was on numerous medications to treat his acquired psychiatric condition, with all anti-psychotic medications stopping in July 1986 and not resuming until January 2004. The examiner explained that although medical literature does show that some of these medications can be associated with weight gain, the Veteran had a BMI in the over-weight range prior to starting these medications. Additionally, even after the Veteran stopped taking these medications in July 1986, he continued to gain weight. The examiner stated that the medical records show that the Veteran gained 119 pounds in the time frame extending from a few months before these types of medications were stopped (in July 1986) until his diabetes diagnosis in 2001. Additionally, the examiner noted that the Veteran’s medical records note eating habits that support an elevated BMI (December 2005 treatment note states “[the Veteran] continues to snack heavily” and a February 2010 treatment note states “guess I should not be eating so much bread and pasta”). The September 2020 examiner also referenced an October 2011 VA doctor note that states that the Veteran’s diabetes is directly related to his morbid obesity, which is in turn more likely than not related to his antipsychotic medications. However, the September 2020 examiner explained that it is unknown what data the October 2011 VA physician based this opinion on, or if the physician had access to the Veteran’s earlier treatment records, as discussed above, or if the physician recognized the Veteran’s weight gain after he was off anti-psychotic medications for a long period of time. Therefore, the Board finds the October 2011 VA opinion not probative as is does not provide an adequate rationale or appear to take into account all of the facts in this case. Ultimately, the September 2020 examiner opined that it is less likely as not that medication taken for the Veteran’s acquired psychiatric disability caused the Veteran to become obese. Thereby, the questions regarding whether the Veteran’s obesity was a substantial factor in causing the Veteran’s diabetes and whether the Veteran’s diabetes would not have occurred but for this diabetes, were not answered. The examiner also opined that the Veteran’s diabetes was not aggravated beyond its natural progression by the Veteran’s service connected acquired psychiatric disorder. Additionally, the examiner stated that a baseline level of severity of the Veteran’s diabetes (prior to aggravation) could not be established. The examiner explained that the Veteran’s weight actually declined from 375 pounds to 264 pounds from January 2001 to October 2014, respectively, before increasing again prior to his death. However, the Veteran was also noted to have fluid retention issues towards the end of his life, which the examiner noted can result in significant weight gain. The examiner stated that the Veteran’s hemoglobin A1c was noted to fluctuate after his diabetes diagnosis but did not appear to correlate with the Veteran’s weight or his anti-psychotic medication use. Therefore, the examiner opined that it is less likely than not that the Veteran’s diabetes was aggravated by his service connected acquired psychiatric medication. The Board acknowledges that prior to his death, the Veteran believed that his diabetes was proximately due to or the result of the medication taken for his service-connected disability. However, the Veteran and Appellant are not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of anatomical relationships. Therefore, it is outside the competence of the Veteran and Appellant in this case because the record does not show that they had the skills or medical training to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the September 2020 VA medical opinion. Therefore, the Board finds that entitlement to service connection for diabetes, on a secondary basis, is not warranted. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Appellant’s claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107 (b). MICHAEL MARTIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Mountford, 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.