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.
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.
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.
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.
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.