Weighing up the risks

Obesity rarely appears on a death certificate as a cause of death but its effects are far more serious and wide-ranging than many of us care to believe or even admit to.

Obesity, like gout and alcoholism, was once the liability of the affluent social classes but today we are beginning to see the results of a remarkable and sustained change in our lifestyle. Over the past 50 years we have in effect completely changed the environment in which we live. To put it another way we have challenged our own metabolisms and been found wanting. Increasing affluence, a more sedentary lifestyle, an ever increasing range of labour saving devices, an abundance of convenience foods, high in sugars and saturated fats, have resulted in, among other things, bulging waistlines.

A huge problem

The price we may have to pay for such a change in attitudes to life has been clearly spelled out for us by the National Audit Office. In a recent report it estimated that obesity accounted for some 30,000 premature deaths a year and perhaps just as worrying some 18 million sick days a year. The cost to the NHS and the economy overall can be counted in billions, and it does not end there ' insurers are acutely aware of the problems they face in providing both death and disability benefits to an increasingly overweight population. On average, deaths linked to obesity have the effect of shortening a person's life expectancy by some nine years.

Walk down any high street and you cannot fail to notice that a growing number of people are carrying those few extra pounds in weight. The percentage of adults who are obese has more than doubled since the mid-1980s. Today it is estimated that about 46% of men and 32% of women are overweight and an additional 17% of men and 21% of women are obese.

Perhaps more importantly there is a wave of obesity moving through the paediatric population ' 13% of eight-year-olds and 17% of 15-year-olds are obese, which if left unchecked will exacerbate an already unhealthy trend. Children are more likely to be obese if one or both parents are obese. This may be partly due to having learnt poor eating habits from their parents.

The terms overweight and obesity tend to be used somewhat indiscriminately these days with a degree of inter-changeability, however we need to understand that medically speaking there are important differences between these two terms. As a measure of a person's build, the body mass index (BMI) is widely used throughout the UK. Put simply the calculation compares the measurement of a person's weight in kilograms divided by the square of their height in metres. The BMI is not without its critics and it does have some limitations. As people come in all sorts of shapes and sizes there is a wide range of BMI's that are considered 'normal'.

Again it does not take into account body frame and what might be termed 'lean mass' which means that some individuals with well developed muscles such as athletes will have some spuriously high readings. The table on the following page highlights the accepted ranges of BMI in adults.

Again, the BMI calculation takes no account of a person's 'waist size'. This measurement has been shown to have added significance in terms of a person's overall risk profile. In short, the heavier you are, the longer you carry the extra weight, and the more the fat is around your waist, the greater the health risk.

Data from national surveys indicates that the growing levels of obesity are not just a UK phenomenon. Overweight people and obesity are increasing in all countries both developed and developing. However, the worrying aspect from an insurer's point of view is that the trend within the UK is particularly high.

Unhealthy balance

In simple terms, weight gain occurs when there is an imbalance between the amount of energy taken into the body from food and the amount expended across our range of daily activities. As underwriters, people will often try to reassure us with the statement that 'being overweight runs in the family' and it is nothing to worry about. It is true that some people do inherit a tendency which makes them more prone to overeat and part of the problem could therefore be described as 'genetic'. However, it is not the case that when a condition is described as genetic it is inevitable that you will suffer from the condition. It is more often lifestyle that determines how your genes will develop.

We do know that carrying even a moderate weight excess of 20 pounds in a person of average height statistically increases their overall mortality risk. Individuals who are obese with a BMI of over 30 have a 50% increased risk of premature death from all causes compared to an individual with BMI reading within the normal range.

In underwriting terms it is the additional risk factors ' something that makes the chances of a condition developing higher than normal ' associated with being overweight that cause insurers their greatest concerns and regularly results in clients being asked to pay additional premiums for their life and disability cover.

The diseases most closely linked to obesity are heart disease, type two diabetes, high blood pressure and osteoarthritis. Unfortunately it is never quite as simple as being able to say one disease, one cause, and one cure. A range of other risk factors such as smoking, stress, social class, lack of exercise and individual susceptibility may also play their part. If we look more closely at the health consequences of being overweight the emerging picture does not make good reading.

In terms of heart disease alone, obesity is a major factor. High blood pressure is twice as common in adults who are obese. A person with a BMI of 30 or above is at four times the risk of precipitating heart problems such as angina or heart attack. Obesity is also associated with higher levels of cholesterol and other lipids in the blood.

The increasing incidence of type two diabetes is another concern. Over 80% of people with diabetes are overweight or obese and it has been shown that even a weight increase of as little as 20 pounds can double the risk of a person developing type two diabetes. The prevalence of obesity among the young is likely to only exacerbate the problem in the future. The NHS spends the equivalent of over £0.5m an hour on treating diabetic patients.

Being overweight or obese is also associated with an increased risk of some types of cancer including colon, gall bladder, prostate, kidney and ovarian.

A constant strain

We cannot afford to overlook the quality of life issues associated with being overweight and which for many people are just as disabling and have been shown to account for a considerable absence from work. Being overweight puts a tremendous strain on the weight bearing joints especially the hips and knees and leads to many mobility problems. Many overweight people are extremely sensitive as to how they are perceived by others and these concerns can manifest themselves in both anxiety and depression.

In short there are a multitude of factors running through the underwriter's mind when evaluating such risks. One of the cornerstones of insurance is that an individual must contribute in accordance with the degree of risk they bring to the fund.

All insurers will have either height and weight tables or a BMI table to which they refer and which reflects their underwriting philosophy, pricing and the class of business they are writing.

Many clients will be overweight but are otherwise healthy. A typical additional mortality loading imposed, where no other risk factors are involved, would be in the order of:

BMI 30 ' 34 + 50% mortality

BMI 35 ' 39 + 75% / +100% mortality

BMI 40 and over + 150 % upwards

Where the person is overweight in conjunction with other risk factors ' such as smoking, adverse family history ' or together with other medical conditions ' such as high blood pressure, heart and circulatory disorders or diabetes ' the extra mortality associated with being overweight plus that of the other impairment is always greater than would be expected by simply adding the two together. Critical illness and other disability-based products have to be treated with a greater degree of caution given the array of disabling complications that being overweight or obese can cause.

As to what might happen in the future, much will depend upon public attitude, future health strategy, continuing education as to the risks involved and individuals' resolve to change certain aspects of their lifestyle. Until then, underwriters will continue to rate and decline people who present heightened mortality and morbidity risks.

A statement made in an old medical journal was hard hitting but contained a big grain of truth: 'one can argue the view that every obese person helps to write their own death certificate'.

Tony Jupp is chief underwriter at Norwich Union Life