A spoonful of sugar...

when asked to describe what diabetes is, most people would probably reply, 'too much sugar in the blood.' And this is essentially what it is. The term diabetes mellitus is Greek for 'fountain of sugar' and comes from ancient physician's observations that the urine of people with diabetes was sweet ' a diagnosis which in those times relied on the physician actually dipping their finger in and tasting the urine. Nowadays, and fortunately for the modern GP, there are dip-sticks specially designed to test for urine abnormalities.

When food is eaten it is broken down into glucose, a form of sugar, and enters the bloodstream. Insulin, which is a hormone produced by the pancreas, helps glucose move from the blood to the body's cells. Insulin and glucose work together, so that food can be converted into energy by those cells. Diabetes occurs where there is a shortage of insulin, or when the body's insulin does not work properly causing an excess of glucose in the blood.

Diagnosis

There are many different types of diabetes but there are two main types which are seen by the underwriter.

In Type 1 or insulin dependent diabetes mellitus (IDDM) the body's immune system turns against itself and destroys the insulin-producing cells in the pancreas. This results in a complete deficiency of insulin leaving the patient dependent on insulin replacement therapy. Type 1 is usually diagnosed in childhood or prior to adolescence (before the age of 30).

Type 2 or non-insulin dependent diabetes (NIDDM) is caused either by a shortage of insulin or a faulty response to insulin (insulin resistance) which means insulin does not work as well as it should. Treatment is either via dietary methods or oral medication. Insulin may be used in some Type 2 diabetics although they would not be classed as dependent on it.

Type 2 mainly affects people over 40 which is why it is also called maturity or late onset diabetes. Other risk factors including obesity, family history, ethnic factors and previous pregnancy-related diabetes can lead to Type 2 diabetes being diagnosed earlier than this.

The onset of Type 1 diabetes would usually be abrupt with increased thirst and urination as the body tries to rid itself of glucose. There would be extreme tiredness as the body is unable to move glucose efficiently and weight loss would occur as the body breaks down protein and fat stores as an alternative energy supply. Blurred vision may occur as high glucose levels affect the lens shape and, in turn, vision. Fasting blood sugar levels would be tested to confirm the suspected diagnosis and the initial presentation may be severe enough to warrant hospitilisation to treat the symptoms and establish diabetic control.

The onset of Type 2 diabetes is less dramatic and is often picked up in routine urine or blood sugar testing in the absence of any obvious symptoms. In fact, Type 2 often goes undiagnosed with the onset occurring at least four to seven years before diagnosis, by which time around 50% will have signs of complications. Confirmation of diagnosis will include the same methods as for Type 1, although an oral glucose tolerance test may also be used.

Treatment

Treatment of diabetes aims to control blood sugar levels to prevent hyperglycaemia (high blood glucose levels), which is responsible for most of the long-term complications associated with diabetes. These include:

• Large vessel disease ' early atherosclerosis. Studies estimate that people with diabetes are between two and four times more likely to die of heart disease or stroke.

• Small vessel disease can lead to kidney problems. Approximately 25% of those diagnosed with Type 1 diabetes will progress to end stage kidney failure. Retinopathy, where the small vessels of the eyes are affected, will affect 90% of Type 1 diabetics of 20-years duration, if this becomes serious enough it can lead to blindness.

• Neuropathy is the absence of sensation in the soles of the feet and toes which can lead to injury, ulceration and, in the worst cases, to amputation.

It is also very important to maintain good blood pressure and cholesterol levels in diabetes and these will be routinely monitored by the diabetic clinic which the patient will normally attend every six to 12 months. Blood sugar levels will be monitored as will kidney function. Specialised blood tests include glycosylated haemoglobin or HbA1c levels which represent a good measure of diabetic control over a three month period. Excellent control would be where the level falls below 6%, 6% to 8% would indicate fair control, 8% to 10% moderate control and above 10% would indicate poor control. Smoking will increase the risk factors as will obesity.

The underwriter's role

When dealing with diabetes will the underwriter ask the GP to complete a report and also a special questionnaire targeting specific questions to establish how well the condition is controlled and if there are any complications. A medical examination may also be required where the examiner would be asked to check for any sugar or protein in the urine and check blood pressure readings.

Basic ratings will depend on whether it is Type 1 or Type 2, and also the age of the applicant. Additional ratings may be applied if the age at diagnosis was younger than 18 and also will reflect any additional factors such as height, weight and whether the client smokes. Credit may be given for good control as evidenced by HbA1c, blood pressure and cholesterol readings, or ratings may be increased where control is not as favourable.

Due to the potential long-term complications of diabetes and increased incidence of heart attack, stroke and so on. Terms for critical illness, total and permanent disability benefit and waiver of premium benefit would only be considered for best case Type 2 diabetics where diagnosis was made within the last 10 years. The underwriter would demand evidence of excellent control and this may only be for a short-term policy.

For income protection cover, terms may be possible where the diagnosis was made over six months ago but less than 15 years ago and the client is 40 or over. Again, only the better controlled diabetics with no additional risk factors would be accepted and likely ratings would be in the region of those shown in the table.

Where an adviser has a diabetic customer it is recommended that they consult the provider when applying for cover. This could involve making use of any underwriting helpline the life office may operate. An experienced underwriter will be able to give advice on the likely terms available for this and any other condition.

Simon Taylor is a senior life & disability underwriter with Scottish Equitable Protect