It seems that we are reminded on a daily basis about the obesity epidemic, a leading cause of preventable death that afflicts about one third of adults in the United States. Obesity has been increasing at a frightening rate, more than doubling in incidence during the past 30 years, although recent data suggests that the rate of increase may be leveling off.
Obesity is most commonly measured by Body Mass Index (BMI), which is calculated by dividing weight in kilograms by height in meters squared. The calculation of BMI has been simplified by the presence of calculators readily available on the internet. For example, someone who is six feet tall and weighs 200 pounds has a BMI of 27.1.
A BMI of 25.0 to 29.9 is considered to be overweight, and obesity is defined as a BMI of 30.0 or greater.
Obesity increases the risk of heart disease, hypertension, type 2 diabetes, sleep apnea, abnormal lipids, cancer, stroke and numerous other impairments. The distribution of fat in the body helps determine its significance. For instance, excess fat in the abdominal area, which is termed visceral fat, is especially concerning. Visceral fat leads to the release of substances that promote inflammation and many obesity related conditions. These conditions can also include a decrease in pulmonary function and metabolic syndrome.
Even modest amounts of weight loss can significantly improve diseases related to obesity. The benefits are related more to the amount of weight lost rather than the methods utilized, which might include lifestyle changes, weight loss surgery, medications and psychosocial support.
Options for Weight Loss Surgery
Weight loss surgery, which is also called bariatric surgery, has increased in popularity. These procedures are usually performed using a laparoscope. Gastric banding and gastric bypass are the most common bariatric procedures performed in the US.
In gastric banding, an adjustable band is used to restrict the amount of food that can be accommodated by the stomach. In gastric bypass, the size of the stomach available for digestion is decreased which also restricts the amount of food that can be eaten. In addition, part of the small intestine is bypassed, resulting in decreased absorption of food eaten. When compared to gastric banding, gastric bypass is more invasive with a higher rate of early postoperative complications, but results in a greater degree of sustained weight loss.
Young People at Risk
The obesity epidemic also plagues young people. Over 20 million children and adolescents in the US are overweight or obese. As a result, they are experiencing an increased incidence of diseases that traditionally have been attributed to adulthood, such as type 2 diabetes, abnormal lipids, and hypertension.
The field of obesity is an area of active research, and new medical studies are frequently being published, making its underwriting both challenging and exciting.
Applicant One, who is a 52 year old non smoker with a history of obesity, type 2 diabetes, and sleep apnea, underwent successful gastric bypass five years ago with a resultant loss of 65 pounds. Glucose and hemoglobin A1C values have normalized and a recent sleep study showed marked improvement of sleep apnea. The applicant is 5 foot 10 inches tall and weighs 225 pounds, which comes out to a BMI of 32.3. Although the applicant is still considered obese with this BMI, due to the success of the surgery and improvement in the obesity related conditions Standard Plus Non Tobacco is possible.
Applicant Two, who is 38 years old, is 5 feet tall, weighs 250 pounds (BMI is 48.9), and has poorly controlled diabetes. Hospitalization was recently required for elevated blood pressure that caused severe headaches. Prior weight loss attempts were unsuccessful. This applicant is a decline.
Applicant Three is 60 years old, 6 feet tall, weighs 280 pounds (BMI is 38.0) has hypertension and hyperlipidemia that is well controlled with medications, is seen for regular physicals and is compliant with recommended preventative screening. Applicant three can qualify for Standard.
Applicant Four, who is 45 years old, is 5 foot 8 inches tall and weighs 160 pounds (BMI is 24.3). While in his 20s, he weighed 230 pounds (BMI 35.0), but when a colleague suffered from a heart attack, Applicant Four changed his eating habits, began an exercise program and has been able to maintain his current weight for many years. Applicant Four can qualify for Preferred Plus.
You may have witnessed an explosion in the number of diabetic applicants during the past several years.
In 2007, according to the Centers for Disease Control and Prevention, more than 1.5 million adults aged 18 to 79 in the U.S. were newly diagnosed with diabetes. That same year, the National Diabetes Information Clearinghouse counted 23.6 million diabetics in U.S.
With new and improved treatments and new diagnostic techniques, clients appear to have better control than ever before. So, why can’t you get a better rate for your diabetic applicants?
Well, that’s a good question and one that many of the world’s sufferers with diabetes are asking. Perhaps a closer look at the disease of diabetes and its long-term consequences may shed some light on why diabetes mellitus remains a complicated and frequently encountered disease.
What is Diabetes Mellitus
Diabetes is a metabolic disorder of insulin production and/or utilization. More simply stated, it’s the body’s inability to utilize glucose. There are two types of diabetes:
Individuals with type I (formerly IDDM, insulin dependent diabetes, juvenile diabetes) produce little or no insulin; in these cases it usually develops before age 30. A known cause is autoimmune destruction of insulin secreting cells in the pancreas. Clinical signs and symptoms include: frequent urination (polyuria), excessive thirst (polydipsia), excessive appetite (polyphagia) and sudden weight loss.
Individuals with type II (formerly NIDDM, non-insulin dependent diabetes mellitus, adult onset diabetes) have intact insulin production but have insulin resistance. It usually develops after age 40 and is often associated with metabolic syndrome — obesity, hypertension and hyperlipidemia. Known causes are life-style, diet, lack of exercise, obesity and a genetic predisposition. Clinical signs and symptoms may be the slow development of many of the aforementioned symptoms or no symptoms at all.
The types vary by the age when diagnosed, by the body’s response to insulin and by treatment plans. Note: gestational diabetes develops during pregnancy and can often resolve after delivery.
What effect does insulin have when it comes to diabetes?
Insulin is an integral part of the metabolism of glucose. It allows the body to transfer glucose from the bloodstream into the cells so that it can be used as energy.
So what’s the big deal? Glucose is our supply of energy, it’s the fuel that allows us to live. But what happens if glucose cannot get out of the bloodstream and into the cell? The first thing to happen is that the level of glucose in the bloodstream begins to rise. As the glucose begins to rise, its eventual passage into the cell will cause damage to the cell and to the very small vessels called capillaries. Think of glucose as sand in the bloodstream, the more sand (glucose) the more damage to the vessels and the end organs, such as: the kidneys, the heart, eyes, the peripheral vascular system and many other systems.
What is the difference between type I and type II diabetes?
In type I diabetes, the individual produces little or no insulin and therefore the body cannot use glucose for energy. Attempting to survive, the body turns to the metabolism of fat tissue as a source of energy. The by-product of burning fat tissue is ketone production. An excess of ketones will cause the body to become acidic, which will lead to a condition called ketoacidosis. If ketoacidosis is left uncorrected it is deadly. Individuals with type I diabetes are treated with insulin injections in order to avoid ketoacidosis. Before 1921 there was no artificially produced insulin. Individuals diagnosed with type I diabetes were destined to live short and very uncomfortable lives.
The discovery of insulin has prolonged millions of lives. Sadly, those with type I diabetes remain at significant risk for early mortality due to associated issues such as infection, gangrene, heart disease, kidney failure, as well as blindness and many others. Current statistics show that those who were diagnosed with type I diabetes mellitus before the age of 10 have a mortality ratio of 9 to 10 times that of non-diabetic individuals.
Accompanying the obesity epidemic afflicting our country has been an increase in the incidence of type II diabetes. Type II diabetes is mediated via insulin resistance, a condition in which the tissues of the body do not respond normally to insulin produced by the pancreas and even though more insulin may be produced to compensate, the body’s metabolic function is still abnormal. Type II diabetes has a strong genetic component, and thus several members of a family may be afflicted.
How is diabetes diagnosed?
For many years diabetes was diagnosed by symptoms: polyuria, polydipsia and polyphagia. This would prompt the doctor to check the urine for glucose. As medicine became more sophisticated, doctors started to check blood (serum) for glucose and standards were set, above which one would be diagnosed as diabetic. There were inherit problems with this method, mainly it required a fasting specimen or elaborate tests to make the diagnosis.
A breakthrough recently took place when hemoglobin A1c, or A1c for short, was accepted as a viable method for the diagnosis of diabetes. Glucose penetrates the red blood cell and the amount of glucose found in the cell reflects the level of glucose in the serum. Because red blood cells survive for approximately 6 to 8 weeks in the body, testing for glucose in the red blood cell will produce a value consistent with the average serum concentration of glucose over a 6 to 8 week period. Further, there is no need for fasting specimens. This is been extremely helpful for the life insurance industry.
According to the American Diabetes Association, A1c values between 5.7 and 6.4 may indicate a pre-diabetic condition. A1c values greater than 6.5 are considered diagnostic for diabetes.
Some people may have type II diabetes for several years before it’s discovered and complications may already be present before the diagnosis is made. Diabetes can cause many complications, some of which are kidney damage (nephropathy), eye damage (retinopathy), nerve damage (neuropathy), coronary artery disease, cerebral vascular disease, peripheral vascular disease, abnormal lipids and liver disease.
Fortunately, all is not lost. Medicine has made significant progress in the treatment of diabetes. Diabetic diets are evolving almost daily. Implantable devices to monitor glucose levels and administer the correct amount of insulin are evolving. Animal studies on implantable insulin-producing-cells are shaping up to have real promise for a possible cure, or at least gain a better level of control for the diabetic patient. Insulin is now produced using recombinant DNA, eliminating allergic reactions, common with insulin harvested from animals.
Until we can take advantage of this new and exciting science, diabetics need to continue to monitor their diets, exercise, blood pressure control, glucose levels and maintain compliance with their medications to help reduce diabetes’ effects.
Diabetes is on a path to becoming a worldwide epidemic.
Currently there are approximately 24 million diabetic sufferers in the U.S. and approximately 10 million still undiagnosed. It is estimated that by the year 2030 there may be as many as 34 million diabetics in the U.S. alone. Help your diabetic applicants by gathering as much pertinent information as possible on their disease. This will enable the underwriter to properly assess the risk and provide the most appropriate offer. Let’s take a look at some possible scenarios.
Applicant One is a 57 year old male diagnosed with type II diabetes three years ago. He is seen every six months by his primary care doctor and his average A1c is 6.8. His build is favorable with a body mass index of 27. One year ago he was diagnosed with hypertension and his blood pressure is well maintained on Lisinopril. He also smokes an occasional celebratory cigar, less then 12 per year. This client appears well followed, and if the rest of his risk factors are also as well controlled and his urinalysis is negative for cotinine on exam, this client may receive an offer as good as Standard Plus.
Applicant Two is a 62 year old male diagnosed with type II diabetes ten years ago. His A1c is 8.1, and his creatinine level is 1.5. His blood pressure is well maintained and he had a normal favorable stress test last year. Approximately six months ago an ulceration on his right leg was discovered and continues to be followed by his primary care doctor. This client is a poor candidate for insurance due to his uncontrolled A1c, impaired renal function and the unhealed ulceration on his leg. Coverage would be declined.
Applicant Three is a 40 year old female diagnosed with type I diabetes 10 years ago. She has mild peripheral neuropathy and her A1c is under 6.5. She has a family history of early coronary disease. She was found to have hyperlipidemia and was prescribed a statin with her most recent labs showing a cholesterol/HDL ratio 4.5, HDL 65 and an LDL 90. Although this client has added risk factors for coronary disease, along with her diabetes, she is managing them well and can expect a mild rating, perhaps as good as Table 2.
Dave Murphy, Sales Vice President, gets agents thinking about how they are demonstrating respect for their clients and prospects. As an independent financial professional, you ask people to trust you to guide them with their money. Are you returning the favor?
To get more done in less time, slow down, says innovation expert Daniel Burrus. It may sound counterintuitive, but doing so allows you to identify issues before they become problems, avoid tunnel vision, and embrace the big picture.
“One problem that exists in the here and now is many organizations’ tunnel-like focus on execution. Your attention to the immediate moment blinds you to most everything else.”
In the past clients who have wanted to cover a long term care need, almost always used a traditional long term care policy. The client would pay their annual premium and if he or she needed long care, the policy would pay out a daily or monthly benefit. It was the most efficient way to obtain the needed coverage. The issue that some clients had with this solution was that they received nothing if there was never a need for care. Also, the premium was not guaranteed. Increases in premiums were possible and came to fruition.
Some Advantages of Using a Hybrid LTC Policy:
Guarantees with premium, death benefit, and in some instances return of premium
Your client will receive a benefit whether they live, die, or quit
It is really just a re-positioning of an asset that is earmarked for long term care planning and acquiring leverage for that need