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About Diabetes
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Special thanks to Banner Life.
Diabetes is a syndrome characterized by hyperglycemia (high
blood sugar) in which there is an inadequate amount of insulin
for the needs of the body (type-10) or the insulin that is
produced is ineffective (type-2). Symptoms of diabetes include
frequent urination, excessive thirst, extreme hunger, unusual
weight loss, increased fatigue and blurry vision.
The Centers for Disease Control estimates that in the United
Stated diabetes affects 18.2 million people or 6.3 percent of
the population. Of this group, nearly a third are undiagnosed.
Insurance testing discovers some of them
The diagnosis of diabetes is made based on the presence of an
elevated fasting plasma glucose of 126 mg/dl or higher, random
plasma glucose of at least 200 mg/dl with suggestive symptoms or
an abnormal glucose tolerance test (table 1). The oral glucose
tolerance test (OGTT) is the gold standard for diagnosing
diabetes and is performed by measuring blood glucose levels
after ingesting a glucose rich drink.
The diagnosis of diabetes is made if the plasma glucose level is
200 mg/dl or higher two hours after the drink. Hemoglobin A1c is
a test that is very familiar to most involved in underwriting
life insurance. It is used mainly to evaluate the level of
control of diabetes for the past few months.
Several studies validate its use in diagnosing diabetes at
values of 6.0 and higher. There is convincing evidence that
overall mortality begins to increase at levels of HbA1c above
5.0 even in non-diabetics.
Table 1: Diagnostic Criteria for Diabetes
|
Criteria |
Pre-Diabetes or
Impaired Glucose Tolerance |
Diabetes |
|
Fasting plasma glucose |
110 to 125 mg/dl |
> 126 mg/dl |
|
Random ptesma glucose |
|
> 200 mg/dl and symptoms
of diabetes |
|
2Hr plasma glucose on
OGTT |
140 to 199 mg/dl |
> 200 mg/dl |
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|
Type-1 Diabetes is caused by
autoimmune destruction of the beta
cells of the pancreas causing
absolute insulin deficiency. Those
with type-1 diabetes are prone to
other autoimmune disorders such as
Hashimoto's thyroiditis, pernicious
anemia, and Addison's disease.
Intensive therapy with parenteral
(subcutaneous injection) insulin is'
the mainstay of therapy for type-1
diabetes and the goal is to maintain
HbA1c close to normal (6.0 to 7.0).
The side effects of this type, of
therapy are hypoglycemic (low blood
sugar) reactions and weight gain. In
cases that are difficult to manage,
use of an insulin pump reduces the
incidence of hypoglycemia.
Type-2 Diabetes is a disorder
characterized by varying
combinations of defects in beta
cell secretion of insulin and
insulin resistance. More than 80
percent of diabetics in the United
States have type-2 diabetes. Type-2
diabetes has a strong genetic
component. An affected individual
has a 25 percent probability of
having an affected parent. Metabolic
syndrome and impaired glucose
tolerance are precursors to
diabetes
TType-2 diabetes is a progressive
disorder and is a major risk factor
for cardiovascular disease. The
prevalence of obesity, hypertension
and elevated lipids is high in
type-2 diabetes. Since
cardiovascular disorders and kidney
disease cause most of the deaths
(table2), the goal of therapy is
prevention of these diseases.
Reducing blood sugar and
maintaining HbA1c as close to normal
as possible is the first step. As
most patients with type-2 diabetes
are obese, they require a weight
reducing diet. A loss of 10 to 20
pounds lowers glucose levels and
alleviates symptoms. Daily exercise
improves control of blood sugar by
improving the effectiveness of
insulin. Risk of a future myocardial
infarction in diabetics with no
history of CAD is similar to
non-diabetics who have already had a
myocardial infarction. Consequently,
reducing LDL to less than 100 mg/dl
and raising HDL are integral
components of therapy. If the
fasting glucose level continues to
be above 140 mg/dl, one or two
anti-diabetic oral medications are
prescribed. If the blood sugar
control is inadequate with oral
medications, insulin therapy is
added. Optimal blood pressure
control and judicious use of
medications, such as ACE (angiotensin
converting enzyme) inhibitors or
ARBS (angiotensin receptor
blockers), can help protect the
kidney.
Gestational diabetes mellitus (GDM)
is a form of glucose intolerance
that has onset or first recognition
during pregnancy. The diagnosis of
GDM is made using the usual
diagnostic criteria for diabetes.
Maternal complications of GDM
include hypertensive disorders such
as toxemia and increased incidence
of cesarean delivery. During
pregnancy, treatment to keep blood
sugar level normal is essential to
prevent complications to the fetus.
After delivery 5 to 10 percent will
continue to have diabetes. Women
with COM have a 50 percent chance of
developing diabetes over the ensuing
10 years.
Insurance testing for diabetes
The aim of testing is to detect
undiagnosed cases and determine the
level of control in those with known
diabetes. In the past the industry
has not put much emphasis on
detecting undiagnosed cases. Given
the rising incidence of diabetes,
continuing on this path is not
prudent.
BBlood glucose and fructosamine
testing are performed on all
applicants for life insurance and
HBA1c is analyzed on those forty and
older. The urine is tested for
microalbumin on all applicants with
a history of diabetes or those
discovered on insurance testing to
have diabetes. Blood glucose is
unreliable as a diagnostic test for
diabetes in the insurance testing
environment due to processing
problems. Although inexpensive,
screening with fructosamine is
unreliable as it misses many cases.
HbA1c, in addition to being a
dependable screening test for
diabetes, has the added benefit of
measuring blood sugar control in
those with known diabetes.
Performing HbA1c and microalbumin
testing early in the underwriting
process facilitates appropriate
pricing of risks and expeditious
issuing of cases.
Table 2: Complications of Diabetes
That Cause Increased Mortality
|
Complicationsfont> |
Impact |
|
Heart Disease |
Leading cause of
diabetes-related death. Death rate is 2 to 4 times that
of those without diabetes. |
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Stroke |
Risk of stroke is 2 to 4
times that of those without diabetes. |
|
HBP |
70+% of adults with
diabetes have hypertension. |
|
Kidney Disease |
Leading cause of kidney
failure, accounting for 44% of cases. |
Underwriting diabetes is a complex
process. It begins with assessing basic debits for
diabetes for age of onset and the type of diabetes. Then
additional debits or credits are assigned for blood sugar
control (HbA1c levels), CAD risk factors such as LDL (bad)
cholesterol, CRPfC-reactive-protein), HDL (good)
cholesterol, weight, blood pressure and microalbumin. Net
debits or credits are used to modify the basic rating. The
presence of complications such as proliferative retinopathy
and neuropathy would warrant additional debits. For a given
age of onset, the best rates are given to those diabetics
without complications, low or absent microalbumin and good
long-term control of HbA1c and cardiac risk factors. Such an
applicant, with diabetes onset at age fifty or older, could
be classified as standard plus.
Related Information
Diabetes Care
About
Diabetes
Application
underwriting your life insurance policies
Determine your
underwriting classification
Decision chart
could help you decide the type of life insurance to purchase
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