Difficulties in predicting the long-term implications of diabetes means underwriting the condition needs careful consideration. Emma Gregson explains
It is easy for those who do not have direct contact with diabetes to underestimate the size and impact of the condition. 1.4 million people in the UK are diagnosed with diabetes each year, and at least the same amount are unaware they have the condition. Diabetes affects infants, children and adults of all ages and although currently incurable, it can be treated successfully.
Diabetes happens when there is a shortage of insulin within the body, or the insulin produced does not work properly. The food we eat is broken down into glucose to produce energy and it is insulin that breaks down the glucose.
Insulin is a hormone produced by the pancreas. It helps glucose enter cells where it can be used as fuel by the body. Glucose comes from the digestion of starchy and sugar/sweet foods. When an inadequate amount of insulin, or insulin that does not work correctly, is produced, the liver produces more glucose than usual but the body cannot process it into energy.
After this happens, the body breaks down the stores of fat and protein to release even more glucose, which still cannot be turned into energy. The unused glucose passes into the urine, which is why people with untreated diabetes urinate a lot, become very thirsty and may lose weight.
If the condition is untreated or poorly controlled, a fatal condition called Ketoacidosis can occur. This results in vomiting, dehydration and coma. It is therefore imperative that the diabetic achieves control of their blood glucose and blood pressure levels to be as close to normal as possible and maintain a healthy lifestyle.
There are many types of diabetes, but for the purpose of this article we will concentrate on the two main types that underwriters encounter:
Insulin dependant or IDDM
This form of diabetes means there is a complete insulin deficiency due to the insulin producing cells in the pancreas being destroyed by the immune system. The body is permanently dependant on insulin replacement treatment.
The patient has to track insulin levels daily in order to inject themselves with the amount of insulin that the body requires. Insulin cannot be taken orally because the digestive juices in the stomach destroy it. Most patients take two to four injections per day.
IDDM is usually diagnosed in childhood or young adulthood before age 30. The symptoms are usually excessive thirst, weight loss, excessive urinating, blurred vision and extreme tiredness. Fasting blood sugar levels are tested to confirm diagnosis.
Non-insulin dependant or NIDDM
Sometimes referred to as 'late or maturity onset' diabetes, this type usually affects people aged 40 plus and occurs when the body no longer responds normally to its own insulin and/or a shortage of insulin occurs. Usually, those affected are predominantly over 40, overweight, do not exercise very much, have a family history of the condition, are African American/ Hispanic/native American or are women who have given birth to very large babies.
Generally, treatment is exercise, weight loss, strict diet, sometimes medication and occasionally insulin, although they are not insulin-dependant. There are several types of tablets that can be prescribed. Some help the pancreas to produce more insulin, some help the body make better use of the insulin produced and others slow down the speed at which the body absorbs glucose from the intestine.
There may be no obvious symptoms, so it can go undetected for a few years and eventually be discovered during routine urine or blood sugar tests by which time, approximately 50% of cases will have complications. Confirmation of diagnosis is usually by testing fasting blood sugar levels or an oral glucose tolerance test.
Complications
Unfortunately it is very difficult to predict the long-term implications of having diabetes as so much depends on how well the condition is controlled, any complications that occur and adverse family history. Good control comes from understanding the condition with strict adherence to treatment and a healthy diet. If good control is achieved and maintained, any serious complications can be delayed, but with poor control the patient is likely to encounter complications earlier. The most severe of complications include:
• Diabetic retinopathy - this is a disorder of the retina, which can lead to impaired vision and in some cases cause blindness.
• Cataracts - these can cause blindness.
• Diabetic neuropathy - this is a disease of the peripheral nerves that usually affects legs and feet. There may be weakness, numbness and a loss of sensation that can lead to injury, ulcerations/ gangrene and amputations.
• Diabetic nephropathy - this is kidney disease and in advanced cases can cause renal failure.
• Hyperlipidaemia - this is elevated levels of cholesterol and diabetics have to be particularly careful that they remain as normal as possible, as cholesterol is the concentration of fats in the blood that can accelerate the development of fatty plaques on the inner walls of the arteries. This can lead to heart disease or stroke.
Emma Gregson is life & disability underwriter for Scottish Equitable
Facts and figures
• Three in 100 people in the UK suffer from diabetes with an equal number being unaware they have the condition (75% of all diagnosed cases being non-insulin dependant).
• According to the International Diabetes Federation, 194 million people worldwide suffer from the condition and it is estimated that 330 million people will be affected by 2025.
• The World Health Organisation states that diabetes is projected to become one of the world's main disablers and killers within the next 25 years.
• The Department of Health reports that approximately 10% of NHS hospital inpatient resources are used for diabetes care. Diabetic complications increase the NHS costs more than five-fold.
• Men and women are generally affected equally.
• Uncontrolled diabetes is the most common cause of blindness in working people and second only to trauma in being responsible for leg amputations.
• 25% of those diagnosed with insulin dependant diabetes will progress to end stage kidney failure.
• The risk of cardiovascular death is three times greater in people with diabetes than those without it.
• People with non-insulin dependant diabetes have the same risk of a heart attack as those without diabetes who have already had a heart attack.
• Diabetes has been a recognised condition for over 3,500 years.
• 'Diabetes' is Greek meaning siphon - to pass through- and 'Mellitus' is Latin for honeyed. It refers to the major symptom of diabetes being sugar in urine.
Sources: The International Diabetes Federation - www.idf.org; The World Health Organisation - www.who.int/en; Diabetes Uk - www.diabetes. org.uk; the beehive - www.thebeehive.org/health/contests/diabetes
Underwriting implications
In order for an underwriter to assess the suitability of the applicant, a report and a specific diabetes questionnaire is requested from the client's doctor. Most patients have checks every six to 12 months to measure blood pressure, cholesterol, blood sugar and kidney function as well as a specialised blood test called Glycated Haemoglobin (HbA1c), which indicates the level of control over a longer period of time, rather than the daily blood glucose level tests, which can vary. This information helps the underwriter to establish the patient's attitude to and control of their condition as well as indicating any associated complications. Occasionally, a medical examination may be required and the examiner will be required to check sugar and protein - an indicator of kidney disease - within the urine and take blood pressure readings.
Any life cover premium loadings applied depend on whether the client is Type 1 or 2 plus the ages at the time of application and diagnosis. For Type 1, the older the client when diagnosed, the less likely they are to have complications and the mortality rates for those diagnosed under 30 are significantly higher. The underwriter will consider a multitude of aspects such as build, smoking, alcohol consumption and associated complications before any additional ratings may be applied.
An additional loading may be added for poor control, however credit can be given for good control if it can be proved by HbA1c, blood pressure and cholesterol tests. Due to the long-term complications of diabetes, critical illness, total and permanent disability benefit and waiver of premium can only be considered for Type 2 diabetics with evidence of optimum control, for a short policy term. Income protection can be considered, but with a premium loading where diagnosis was over six months ago but less than 15 years ago and the client is over the age of 40. Again, we require evidence of optimum control, co-operation with their GP/diabetic clinic and there are no additional risk factors.
