Citation Nr: 21040510 Decision Date: 07/05/21 Archive Date: 07/05/21 DOCKET NO. 17-04 314 DATE: July 5, 2021 ORDER Entitlement to service connection for diabetes mellitus, type II, to include as secondary to service-connected hypertension is denied. FINDING OF FACT The Veteran's diabetes mellitus, type II, did not manifest during active duty service, is not related to any incurrence of active duty, and is not caused or aggravated by hypertension. Diabetes was first demonstrated over 1 year following separation from service. CONCLUSION OF LAW The criteria for service connection for diabetes mellitus, type II (hereinafter diabetes), to include as secondary to hypertension have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served honorably in the U.S. Navy from February 1974 to February 2004. The Veteran underwent a VA examination in October 2016 in which the examiner opined that the Veteran's current diabetes is less likely than not the result of his service-connected hypertension. However, this opinion was issued prior to the Veteran's January 2017 submission of relevant medical journal articles supporting a causal relationship between diabetes and hypertension, and the case was accordingly remanded in October 2018 for another VA examination to assess the medical journal articles submitted. As the requested development has been completed, the case is now before the Board again for review. Service connection, generally. Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009). Service connection may be established on a secondary basis for a disability that is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to 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. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439 (1995) (en banc), reconciling Leopoldo v. Brown, 4 Vet. App. 21 (1993), and Tobin v. Derwinski, 2. Vet. App. 34 (1991). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Service connection for some chronic diseases, including diabetes, may be presumed to have been incurred in service if manifested to a compensable degree within 1 year following separation from qualifying service. 38 U.S.C. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Entitlement to service connection for diabetes mellitus, to include as secondary to service-connected hypertension. The Veteran contends that his current diagnosis of diabetes mellitus was caused by his hypertension, for which he was awarded service connection in July 2004. The Veteran's service treatment records are silent for any treatment for, diagnosis of, or symptoms related to diabetes. Following the October 2018 remand, the Veteran was afforded additional VA examinations and opinions. On October 2019. This examiner stated that Veteran's diabetes was less likely than not incurred during his military service, based on the Veteran's service treatment records (STRs) being negative for a diagnosis of diabetes mellitus. The examiner cited the Veteran's retirement examination, which indicated a glucose level that was within normal limits. A review of the Veteran's VA outpatient treatment records indicated that treatment for elevated glucose began in 2011, about 7 years after he retired. The examiner also stated that the Veteran's diabetes was less likely than not aggravated by his service-connected hypertension. No baseline could be determined. The examiner stated that the Veteran's A1c levels, documented in his VA treatment records, indicated satisfactory glycemic control between 2012 and 2019. There is no evidence that the Veteran's diagnosis of hypertension aggravated his ability to maintain satisfactory glucose levels. In addition, it is important to point out that the risk factors previously described by Dr. C.W. include body mass, diet, and activity. The examiner opined that it is not uncommon for people who develop hypertension to also develop diabetes, as stated, because of "common biological traits", such as genetic predisposition, and because of lifestyle issues, diet, and activity, which contribute to obesity. The foregoing opinion was followed by a January 2020 addendum again reviewing the articles and noting the "common biological traits." There was no recorded change from the earlier opinion. Another VA medical opinion was completed in June 2020. This examiner also stated that it was less likely than not that the Veteran's diabetes was caused by his hypertension. The examiner stated that the medical literature submitted by the Veteran in support of his claim, written by Dr. C.W., are not peer-reviewed articles and appear to be blogs and statements as written by the doctor on a website. Therefore, in the view of this examiner, there can be a significant limitation on relying on these blogs for the purpose of validating this claim, and they should be afforded limited probative weight. Analysis The articles reviewed by both examiners do mention that diabetes and hypertension are "closely related disease" and that the two are likely to occur together "simply because they share a common set of risk factors" which include body mass, diet, and activity level." Therefore, it is possible that diabetes and hypertension can commonly coexist in an individual due to the presence of these risk factors. However, the Board finds probative the medical examiners' contention that diabetes and hypertension in this case are comorbidities that are correlated rather than causally linked. The medical evidence in this case does not corroborate a conclusion that hypertension would be the cause of diabetes for the Veteran. As noted in the opinions diabetes is caused by insulin resistance and relative impairment insulin secretion, which is at the level of the pancreas organ. Hypertension is a disease characterized by increased arterial pressure, which itself does not cause diabetes to occur. The medical examiners' review of the peer-reviewed medical literature proffered by the Veteran have not revealed or demonstrate that diabetes can occur secondary to hypertension; hypertension itself is not recognized or established as a risk factor for development of diabetes. In sum, applying the findings and evidence to the appropriate legal standards, service connection for diabetes mellitus type II is not warranted under any theory. Finally, secondary service connection for diabetes as related to hypertension is not warranted as there is no medical nexus shown. 38 C.F.R. § 3.310. The VA examiners' opinions, proffered after review of the file and consideration of the medical research on the subject, were against the claimed connection, and is given dispositive weight on this point. To summarize then, diabetes was not shown in service and was not demonstrated within one year of service separation. Moreover, the preponderance of the medical evidence shows that the hypertension did not cause or aggravate the diabetes, based on the medical opinions of record. As such, service connection is not warranted; as there is no doubt to resolve, the benefit of the doubt rule is inapplicable. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. MICHAEL D. LYON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Omosegbon, Babalakin O. 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.