News from Medicine

Underwriting the Metabolic Syndrome
What’s the bottom line in terms of underwriting?

What is the “Metabolic Syndrome”?

Dr. Reaven, a Stanford University physician, at the annual meeting of the American Diabetes Association, first described this syndrome in 1988. It is also called:
  • The insulin resistance syndrome
  • The deadly quartet
  • Syndrome X
  • Dysmetabolic syndrome X
  • Reaven syndrome

The syndrome represents a “cluster” of abnormalities that are closely associated with obesity. The collective impact of these abnormalities is an increased risk of both coronary heart disease (CHD) and type 2 diabetes.

The diagnostic criteria for the metabolic syndrome from the National Cholesterol Education Program Adult Treatment Panel III is as follows:

  1. Abdominal Obesity
    1. Men-waist circumference >40 inches
    2. Women-waist circumference >35 inches
  2. Fasting triglyceride level >150 mg/dl
  3. Fasting HDL level
    1. Men <40 mg/dl
    2. Women < 50 mg/dl
  4. Blood pressure >130/85
  5. Fasting glucose level >110 mg/dl
Why are life insurance and LTC companies concerned about the metabolic syndrome?

There are three areas of concern for life and LTC carriers that impact morbidity and mortality:
  1. The increased risk of the metabolic syndrome is greater than the sum of the individual components. This means that the collective impact of the 5 risk factors is greater than simply adding them up. This increased risk synergy is exemplified in a study published in a 2001 issue of Diabetic Care. Isomaa et al reported on 4500 participants in a family study of type 2 diabetes. The metabolic syndrome increased risk of CHD and stroke 3-fold. The risk of death from cardiovascular disease was increased by 5-fold. These findings were in excess of what would be expected by simply adding up the individual components.
  2. The unchecked epidemic of obesity in the United States shows no signs of abating. With 30% of the US population classified as obese and another 34% classified as over weight, carriers need accurate risk assessment tools to predict the adverse impact on morbidity and mortality. About 50-60% of obese persons have the metabolic syndrome. The current estimate is that 47 million Americans are afflicted with this syndrome. The prevalence increases with age, reaching more than 40% for men and women aged 60 and older. This also happens to be the prime customer based for life and LTC insurance.
  3. Clinicians may overlook the “cluster” of abnormalities that point to the metabolic syndrome by focusing on single abnormalities such as diabetes. This puts pressure on life and LTC home office underwriters to make sure they are not overlooking applicants who fit the diagnostic criteria even they have not been officially diagnosed with the syndrome. Although a simple measurement of waist circumference would identify applicants with the body weight component of the metabolic syndrome, very few medical files contain this information.
How do you screen clients who you know or suspect have the metabolic syndrome?

The syndrome is linked to obesity. Any applicant who is over weight needs to be asked the following questions:
  1. What medications is the applicant taking? This will quickly reveal other medical issues that are associated with the client’s weight. Be on the look out for blood pressure, cholesterol and diabetic medications.
  2. Does the applicant have any history of elevated blood pressure? If they have reading above 120/80, have they been told they have high blood pressure? Are they taking medications for it? What is their blood pressure with the medications?
  3. What is their fasting HDL level? Most people know or can find out their “good” cholesterol level with one simple phone call to their health care provider.
  4. What is their fasting triglyceride level? Most people don’t know this number but can easily get it.
  5. What is their fasting blood glucose level? Many people know this number or can easily get it.
  6. Does their waist exceed the maximum for men (40 inches) or women (35 inches)? This is a delicate question that might be best approached using a “greater or lesser” approach. Example: Would you say your waist size is greater or lesser than (state the number)?
What’s the bottom line in terms of underwriting?

It is going to be harder and harder to get preferred and standard rates on overweight clients. There is a definitive move in medicine to identify metabolic syndrome patients and begin aggressive intervention. The first line treatment involves weight reduction and physical exercise programs. There is no quick and easy way to implement this type of treatment. Treatment almost always involves multiple medications with the attendant cost and compliance issues.

Underwriters are aware of these issues and using this information in their risk assessment. The best defense is to know what type of case you have. If your applicant has the metabolic syndrome, then get them the best coverage you can, now. If they are successful in modifying their risk factors, then shop the case for better rates when their policy renews. Either way you are protecting an applicant who is known to be at higher risk for a deadly outcome.