Disease of the month: Diabetes

Due to the Nation’s poor lifestyle choices diabetes is becoming ever more common, a disease that carries severe underwriting penalties. Fergus Bescoby explains

The number of newly diagnosed diabetics in the UK continues to rise significantly. This can certainly be linked to the growing obesity rates across the country and possibly to improved screening procedures and more awareness. It is estimated that more than 2.6 million people in the UK have the condition, and up to 750,000 more are believed to have it without realising they do.

The word diabetes is derived from the Greek word meaning ‘a siphon’, aptly named by the 2nd century A.D. Greek physician, Aretus the Cappadocian, due to the excessive passage of urine, which in his mind caused his patients to ‘pass water like siphons’. Mellitus means honey or sweet, and so diabetes mellitus implies ‘a siphoning, or excess of sweet water through the body’.

Diabetes is a common life-long condition where the amount of glucose in the blood is too high due to the body not using it properly. This is because the pancreas does not produce any or not enough insulin or the insulin that is produced does not work properly (known as insulin resistance). Insulin helps glucose enter the body’s cells, where it is used for energy. Glucose comes from digesting carbohydrate from various kinds of food and drink, including starchy foods such as breads, rice and potatoes, fruit, some dairy products, sugar and other sweet foods. Glucose is also produced by the liver.

Contrary as it may sound, eating too much sugar does not cause diabetes, although this might cause obesity which in turn is associated with people who develop type 2 diabetes.
Various types of diabetes and treatments

Type 1 diabetes

Previously known as insulin dependant diabetes mellitus (IDDM) or juvenile diabetes, is a lifelong condition in which the body cannot control the amount of glucose in the blood. This is because the body cannot produce the natural hormone insulin. The subsequent lack of insulin leads to increased blood and urine glucose. The classical symptoms of polyuria (frequent urination), polydipsia (increased thirst), polyphagia (increased hunger), and weight loss are the results.

Type 1 diabetes can be fatal unless treated with insulin. Injection is the most common method of administering insulin although historically insulin pumps and the inhalation of insulin have been tried. Pancreas transplants have been used to treat type 1 diabetes; however, this procedure is currently still at the experimental trial stage.

There is no preventive measure against developing type 1 diabetes. Most people who develop type 1 are otherwise healthy.

Treatment must be continued indefinitely in all cases and although becoming a daily task need not significantly impair normal activities if sufficient patient training, awareness, appropriate care, discipline in testing and dosing of insulin is taken.  Complications may be associated with both low blood sugar and high blood sugar. Low blood sugar may lead to seizures or episodes of unconsciousness and require emergency treatment. High blood sugar may lead to increased tiredness and can also result in long term damage to other organs such as eyes and joints.

The exact cause of Type 1 diabetes is unknown; however, it is thought that it may be triggered by a virus or other autoimmune diseases. There is also evidence which points towards a genetic predisposition.

Type 2 diabetes

Previously known as non insulin dependant diabetes mellitus (NIDDM) or adult-onset diabetes, this is the most common form of diabetes. It is a disorder characterised by high blood glucose in the context of insulin resistance and relative insulin deficiency. Type 2 diabetes is often initially managed by increasing exercise and dietary modification, however, as the condition progresses, medications are typically needed and this will be in the form of anti-diabetic drugs.

It develops when the body fails to produce enough insulin, or the insulin that is produced does not work properly. It usually appears in people aged over 40, although it can appear from the age of 25 in certain ethnic races. It is becoming more common in children and young people of all ethnicities. More than three quarters of people with diabetes have type 2.

The exact cause of type 2 diabetes is also not fully understood, although there are many risk factors that make developing the condition more likely. These include obesity, smoking, excess alcohol, someone suffering from polycystic ovary syndrome, lack of exercise, ethnic origin, age and certain genetic factors.

It is important to mention that the body cells in an obese person become less responsive to the effects of insulin and this can explain why 80% of people who develop type 2 diabetes are overweight or obese. In particular, people who are ‘apple shape’ with lots of fat around the abdomen.

Gestational Diabetes

Gestational diabetes means diabetes that develops for the first time during pregnancy. It occurs in between 3-5% of pregnancies.

During pregnancy the body has to produce extra insulin to meet the baby’s needs, especially from mid-pregnancy onwards. If the body cannot manage this, it will have too much sugar in the blood and may develop gestational diabetes.

Gestational diabetes usually resolves itself after the baby is born, however, if it persists it can be managed by adjusting diet and taking regular exercise. The condition requires medication or insulin injections in about 10-20% of cases. Gestational diabetes is normally resolved after birth when blood sugar levels return to normal; however someone who has had gestational diabetes in the past is more likely to develop type 2 diabetes later in life.

Diabetes Insipidus

Diabetes insipidus is a rare condition where the body cannot retain enough water. It occurs in approximately one in 25,000 people and can affect anyone of any age although it is more common in adults.

It is a disorder in which there is an abnormal increase in urine output, fluid intake and often thirst. It causes symptoms such as urinary frequency, nocturia (frequent awakening at night to urinate) or enuresis (involuntary urination during sleep or ‘bedwetting’). Urine output is increased because it is not concentrated normally. Consequently, instead of being a yellow colour, the urine is pale, colourless or watery in appearance and the measured concentration is low.

Diabetes Insipidus is not the same as diabetes mellitus and although the two share several similarities such as increased urination and thirst, in every other respect, including the causes and treatment of the disorders, the diseases are completely unrelated. Sometimes diabetes insipidus is referred to as ‘water’ diabetes to distinguish it from the more common diabetes mellitus or ‘sugar’ diabetes.

Its cause in simplistic terms is the inability of the kidneys to conserve water which in turn leads to frequent urination and pronounced thirst. Treatment would depend on the actual underlying cause.

Underwriting considerations

• Income protection cover will be declined
  
• SIC/CIC cover will be declined
  
• Life cover can be offered, but the premium will normally be loaded and will depend on the age of the client, date of onset of the diabetes and the control.
  
• The control can be established by obtaining the results of certain blood tests which include fasting glucose, HbA1C and also testing the urine for the amount of glucose present. A very poorly controlled diabetic will not be offered life insurance.
  
• As a general rule, the younger the client is and the longer the duration has been since diagnosis at underwriting stage, the worse the risk is. The immediate risk within 12 months of diagnosis is also high as the control is uncertain and could fluctuate.
  
• Other risk factors will increase the basic loading, for example smoking, high blood pressure, retinopathy, BMI and abnormal lipids.
  
• Certain risk factors will mean cover cannot be offered, these include a history of myocardial infarction, stroke, impaired renal function, advanced retinopathy and peritheral vascular disease.
  
• Someone with a history of gestational diabetes can be accepted at standard rates, providing the glucose levels have normalized post child birth.
  
• Cover can be offered for someone suffering from diabetes insipidus but a small loading may be applied depending on control.

Fergus Bescoby is underwriting development manager at PruProtect