## Section F. Endocrine Conditions

#### Overview

+------------+---------------------------------------------------------+
| #          | > This section contains the following topics:           |
| #### In th |                                                         |
| is Section |                                                         |
+------------+---------------------------------------------------------+

  ------------ ---------------------------------------------- ------------
  Topic        Topic Name                                     See Page

  22           Diabetes Mellitus                              4-F-2

  23           Thyroid Conditions                             4-F-6

  24           Exhibit 1: Examples of Rating Decisions        4-F-8
               Involving the Complications of Diabetes        
               Mellitus                                       
  ------------ ---------------------------------------------- ------------

#### 22. Diabetes Mellitus

+------------+---------------------------------------------------------+
| ##### In   | > This topic contains information about diabetes        |
| troduction | > mellitus, including                                   |
|            |                                                         |
|            | -   the symptoms of diabetes mellitus                   |
|            |                                                         |
|            | -   evaluating the extent of disability caused by       |
|            |     diabetes mellitus                                   |
|            |                                                         |
|            | -   the complications of diabetes mellitus              |
|            |                                                         |
|            | -   rating complications of diabetes mellitus, and      |
|            |                                                         |
|            | -   consideration of hypertension as secondary to       |
|            |     diabetes mellitus.                                  |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### C    | > December 29, 2007                                     |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### a.   | > The cardinal symptoms of uncontrolled diabetes are    |
|  Symptoms  |                                                         |
| of Diabete | -   polyuria (excessive urination)                      |
| s Mellitus |                                                         |
|            | -   polydipsia (excessive thirst)                       |
|            |                                                         |
|            | -   polyphagia (excessive hunger)                       |
|            |                                                         |
|            | -   weakness, and                                       |
|            |                                                         |
|            | -   loss of weight.                                     |
|            |                                                         |
|            | > The presence of sugar in the urine is characteristic  |
|            | > of, but not essential to, a diagnosis of diabetes     |
|            | > mellitus.                                             |
|            | >                                                       |
|            | > ***Notes***:                                          |
|            |                                                         |
|            | -   A diagnosis of diabetes mellitus cannot be made     |
|            |     from glycosuria alone, as this may result from      |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   a low renal threshold for sugar, or                 |
|            |                                                         |
|            | -   excessive ingestion of sugar.                       |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   Persistent hyperglycemia, a blood sugar of 170 mg   |
|            |     per 100 cc blood after 12-hour fast, and glycosuria |
|            |     may be secondary to                                 |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   hyperthyroidism                                     |
|            |                                                         |
|            | -   dyspituitarism                                      |
|            |                                                         |
|            | -   pregnancy                                           |
|            |                                                         |
|            | -   apoplexy                                            |
|            |                                                         |
|            | -   cerebral trauma, or                                 |
|            |                                                         |
|            | -   severe infections.                                  |
+------------+---------------------------------------------------------+

Continued on next page

22\. Diabetes Mellitus, Continued

+------------+---------------------------------------------------------+
| ##         | > Diabetes mellitus is not seriously disabling if, on a |
| ### b. Eva | > diet sufficient to maintain the weight and strength   |
| luating th | > of the claimant, the                                  |
| e Extent o |                                                         |
| f Disabili | -   blood sugar can be kept within normal limits, and   |
| ty Caused  |                                                         |
| by Diabete | -   urine is sugar free.                                |
| s Mellitus |                                                         |
|            | > As diabetes mellitus progresses                       |
|            |                                                         |
|            | -   it become more difficult to control, even with      |
|            |     insulin                                             |
|            |                                                         |
|            | -   complications develop which increase the degree of  |
|            |     disability, and                                     |
|            |                                                         |
|            | -   increasing limitation of activity due to unstable   |
|            |     blood sugar levels limits employability.            |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ###        | > The complications of diabetes mellitus may include,   |
| ## c. Comp | > but are not limited to                                |
| lications  |                                                         |
| of Diabete | -   arteriosclerosis, including peripheral or cardiac   |
| s Mellitus |     complications                                       |
|            |                                                         |
|            | -   cataracts, and                                      |
|            |                                                         |
|            | -   secondary hypertension.                             |
|            |                                                         |
|            | > ***Notes***:                                          |
|            |                                                         |
|            | -   Most hypertension that develops in diabetics is     |
|            |     essential, primary hypertension and not due to      |
|            |     diabetes.                                           |
|            |                                                         |
|            | -   Even in the incipient stage, diabetic nephropathy   |
|            |     is associated with renal hypertension, which is the |
|            |     most common cause of the hypertension that results  |
|            |     from diabetes nephropathy, and is manifested by     |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   persistent microalbuminuria, which is characterized |
|            |     by urinary excretion of 150-500 mg of protein/24    |
|            |     hours, and                                          |
|            |                                                         |
|            | -   overt proteinuria, which is characterized by        |
|            |     urinary excretion of greater than 0.5 mg protein/24 |
|            |     hours.                                              |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   Renovascular hypertension, a type of secondary      |
|            |     hypertension, is responsible for less than two      |
|            |     percent of all cases of hypertension and is         |
|            |     sometimes (but not always) due to arteriosclerosis  |
|            |     that may be caused by diabetes.                     |
|            |                                                         |
|            | > ***Reference***: For more information on considering  |
|            | > hypertension as secondary to diabetes mellitus, see   |
|            | > [M21-1MR, Part III, Subpart iv,                       |
|            | > 4.F.22.e](../pt03_sp04_ch04_secF#III.iv.4.F.22.e).    |
+------------+---------------------------------------------------------+

Continued on next page

22\. Diabetes Mellitus, Continued

+------------+---------------------------------------------------------+
| ##### d. R | > Evaluate compensable complications of diabetes        |
| ating Comp | > separately unless they are a part of the criteria     |
| lications  | > used to support a 100 percent evaluation.             |
| of Diabete | > Noncompensable complications are considered part of   |
| s Mellitus | > the diabetic process under diagnostic code (DC) 7913. |
|            | >                                                       |
|            | > ***Reference***: For examples of rating decisions for |
|            | > the complications of diabetes mellitus, see [M21-1MR, |
|            | > Part III, Subpart iv,                                 |
|            | > 4.F.24](../pt03_sp04_ch04_secF.xml#III.iv.4.F.24).    |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##         | > Infer the issue of service connection for             |
| ### e. Con | > hypertension as secondary to diabetes mellitus        |
| sideration | > whenever                                              |
|  of Hypert |                                                         |
| ension as  | -   service connection is established for               |
| Secondary  |                                                         |
| to Diabete | ```{=html}                                              |
| s Mellitus | <!-- -->                                                |
|            | ```                                                     |
|            | -   diabetes mellitus, and                              |
|            |                                                         |
|            | -   diabetic nephropathy, and                           |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   the veteran has a diagnosis of hypertension.        |
|            |                                                         |
|            | > Use the table below to determine what action to take  |
|            | > on the inferred claim for secondary service           |
|            | > connection for hypertension.                          |
+------------+---------------------------------------------------------+

+-----------------------------------+-----------------------------------+
| If the medical evidence shows ... | Then ...                          |
+-----------------------------------+-----------------------------------+
| hypertension was diagnosed        | grant service connection for      |
| *after* diabetic nephropathy was  | hypertension as secondary to      |
| diagnosed                         | diabetes mellitus.                |
+-----------------------------------+-----------------------------------+
| -   hypertension was diagnosed    | deny service connection for       |
|     *before* diabetic nephropathy | hypertension as not secondary to  |
|     was diagnosed, and            | diabetes mellitus.                |
|                                   |                                   |
| -   there has been *no* change in |                                   |
|     the treatment of hypertension |                                   |
|     or increase in blood pressure |                                   |
|     readings since diabetic       |                                   |
|     nephropathy was diagnosed     |                                   |
+-----------------------------------+-----------------------------------+

Continued on next page

22\. Diabetes Mellitus, Continued

  -----------------------------------------------------------------------
  e\. Consideration of Hypertension as Secondary to Diabetes Mellitus
  (continued)

  -----------------------------------------------------------------------

+-----------------------------------+-----------------------------------+
| If the medical evidence shows ... | Then ...                          |
+-----------------------------------+-----------------------------------+
| -   hypertension was diagnosed    | obtain a medical opinion to       |
|     *before* diabetic nephropathy | determine if hypertension was     |
|     was diagnosed, *but*          | aggravated by the                 |
|                                   | service-connected (SC) diabetic   |
| -   there has been a change in    | nephropathy.                      |
|     the treatment of hypertension |                                   |
|     and/or an increase in blood   |                                   |
|     pressure readings since       |                                   |
|     diabetic nephropathy was      |                                   |
|     diagnosed                     |                                   |
+-----------------------------------+-----------------------------------+
| no clear indication as to         | obtain a medical opinion to       |
|                                   | determine if hypertension         |
| -   when hypertension was         | developed or was aggravated by    |
|     diagnosed, or                 | the SC diabetic nephropathy.      |
|                                   |                                   |
| -   whether hypertension has      |                                   |
|     worsened since diabetic       |                                   |
|     nephropathy was diagnosed     |                                   |
+-----------------------------------+-----------------------------------+

#### 23. Thyroid Conditions

+------------+---------------------------------------------------------+
| ##### In   | > This topic contains information about thyroid         |
| troduction | > conditions, including                                 |
|            |                                                         |
|            | -   the definition of the term ***hyperthyroidism***    |
|            |                                                         |
|            | -   rating conditions combined with hyperthyroidism,    |
|            |     and                                                 |
|            |                                                         |
|            | -   rating nontoxic adenoma.                            |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### C    | > December 13, 2005                                     |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > ***Hyperthyroidism*** with diffuse goiter is a        |
| a. Definit | > condition caused by excessive functioning of the      |
| ion: Hyper | > thyroid gland.                                        |
| thyroidism |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > Use the table below to rate different conditions      |
| b. Rating  | > determined to be combined with hyperthyroidism.       |
| Conditions |                                                         |
|  Combined  |                                                         |
| with Hyper |                                                         |
| thyroidism |                                                         |
+------------+---------------------------------------------------------+

+----------------------------------+-----------------------------------+
| If hyperthyroidism is combined   | Then ...                          |
| with ...                         |                                   |
+----------------------------------+-----------------------------------+
| predominant heart disease        | rate the condition as             |
|                                  | hyperthyroid heart disease under  |
|                                  | DC 7008, if doing so would result |
|                                  | in a higher evaluation than using |
|                                  | the criteria for hyperthyroidism  |
|                                  | under DC 7900.                    |
+----------------------------------+-----------------------------------+
| psychiatric manifestations       | consider the psychiatric          |
|                                  | condition in the overall          |
|                                  | evaluation under DC 7900.         |
|                                  |                                   |
|                                  | ***Rationale***: There is a       |
|                                  | tendency for psychiatric          |
|                                  | manifestations to occur where     |
|                                  | hyperthyroidism is present.       |
+----------------------------------+-----------------------------------+

Continued on next page

23\. Thyroid Conditions, Continued

+------------+---------------------------------------------------------+
| ##         | > A nontoxic adenoma or tumor of the thyroid may be     |
| ### c. Rat | > rated zero percent, 20 percent, or higher, if other   |
| ing Nontox | > organs are affected.                                  |
| ic Adenoma | >                                                       |
|            | > ***Note***: Since the thyroid influences the general  |
|            | > rate of metabolism, growth, and development, disease  |
|            | > of the thyroid may affect other vital organs and      |
|            | > interfere with their functions, resulting in higher   |
|            | > evaluations which should be evaluated under the       |
|            | > diagnostic code for the particular organ involved.    |
+------------+---------------------------------------------------------+

#### 24. Exhibit 1: Examples of Rating Decisions Involving the Complications of Diabetes Mellitus

+------------+---------------------------------------------------------+
| ##### In   | > This exhibit contains three examples of rating        |
| troduction | > decisions involving the complications of diabetes     |
|            | > mellitus.                                             |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### C    | > December 13, 2005                                     |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### a.   | > ***Situation***: The veteran has noncompensable       |
|  Example 1 | > complications of diabetes mellitus but does not have  |
|            | > ketoacidosis or hypoglycemic reactions.               |
|            | >                                                       |
|            | > ***Result***: Do not evaluate the diabetes mellitus   |
|            | > at 60 percent simply because noncompensable           |
|            | > complications are present. Assign a 40 percent        |
|            | > evaluation if there is a requirement of insulin,      |
|            | > restricted diet, and regulation of activities.        |
|            | > Include the noncompensable complications under DC     |
|            | > 7913.                                                 |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### b.   | > ***Situation***: The veteran's diabetes mellitus is   |
|  Example 2 | > controlled by insulin, restricted diet and careful    |
|            | > regulation of activities. In addition, there is       |
|            | > diabetic peripheral neuropathy ratable at 10 percent. |
|            | >                                                       |
|            | > ***Result***: Rate the diabetes mellitus at 40        |
|            | > percent, and separately evaluate the compensable      |
|            | > complication in accordance with the note under DC     |
|            | > 7913.                                                 |
+------------+---------------------------------------------------------+

Continued on next page

24\. Exhibit 1: Examples of Rating Decisions Involving the Complications
of Diabetes Mellitus, Continued

+------------+---------------------------------------------------------+
| ##### c.   | > ***Situation***: The veteran underwent a              |
|  Example 3 | > below-the-knee amputation due to complications of     |
|            | > diabetes mellitus. In addition                        |
|            |                                                         |
|            | -   his basic diabetes mellitus requires                |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   more than one daily injection of insulin            |
|            |                                                         |
|            | -   restricted diet, and                                |
|            |                                                         |
|            | -   regulation of activities                            |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   his episodes of ketoacidosis require weekly visits  |
|            |     to the diabetic care provider, but                  |
|            |                                                         |
|            | -   there is no progressive loss of weight and          |
|            |     strength.                                           |
|            |                                                         |
|            | > ***Result***: Evaluate the diabetes mellitus at 100   |
|            | > percent and grant Special Monthly Compensation (SMC)  |
|            | > (k) for anatomical loss of a foot. Since the below    |
|            | > the knee amputation is secondary to diabetes          |
|            | > mellitus, and is considered a compensable             |
|            | > complication (in lieu of progressive loss of weight   |
|            | > and strength) to warrant the 100 percent evaluation,  |
|            | > it would be pyramiding to assign a separate 40        |
|            | > percent evaluation for the amputation.                |
|            | >                                                       |
|            | > ***Note***: If compensable complications are not      |
|            | > considered in reaching the 100 percent evaluation,    |
|            | > they may be separately evaluated.                     |
+------------+---------------------------------------------------------+