Weight Underwriting: Truth or Consequences
Misperceptions abound regarding the true insurability implications of weight. This article will focus in on those issues that matter and explain why.
In which ways can we approach the assessment of weight?
- “Build” (weight in relation to height)
- Body mass index (BMI)—a simple calculation
- Markers for visceral obesity. BMI is an upgrade over “Build.”
Nevertheless, BMI fails to discriminate between bad adiposity (carried in the abdominal region; called “visceral”) and adiposity that does not matter (carried in the hips, back and thigh).
How can we make up for this shortfall in obesity assessment?
To balance the equation, we should be using at least waist circumference (WC) and ideally the waist-to-hip ratio. WC should be measured on every paramedical. It would be even better if they also measured hip circumference, but there has been pushback from paramed companies on this. Bottom line: without factoring visceral adiposity into underwriting, we inexorably overcharge some applicants while under-debiting others. Middle-age cigarette aficionados benefit the most; elderly women get hammered (so to speak).
How is weight status delineated by BMI?
BMI is divided into 6 subsets:
Class I Obesity
Class II Obesity
Are significant impairments prevalent in the obese?
Yes—and the list is as long as the Long Island phone book! Almost every CV risk factor is somehow related to weight. In addition, depression and cancer are more common in obese individuals.
How does obesity impact liver enzymes?
Most obese people have some degree of fatty liver, largely accounted for by nonalcoholic fatty liver disease (NAFLD). Nearly all of them are asymptomatic. Simple fatty liver accounts for a significant share of two-digit ALT elevations on screening blood profiles. When simple fatty liver progresses to nonalcoholic steatohepatitis (NASH), we may find AST elevated as well.
One sinister clue in this setting is an AST-to-ALT ratio > 1.5. In the absence of alcohol excess or NASH, the ALT is almost always proportionally higher than the AST. GGT does not rise beyond the normal limit due to obesity alone, so this would be another matter of concern in this context.
Bottom line: NAFLD is, strictly speaking, a liver condition, but its impact on insurability is greater from a cardiovascular perspective.
What is the overall mortality risk based on weight?
We say it is “J-shaped,” which translates to some excess risk in underweight and then progressively greater adversity starting—more or less—at the threshold for obesity. Beyond mid-life, this configuration becomes “U-shaped” (underweight being as significant as obesity). Then, over age 70, the contour of the mortality curve has been shown to be almost “L-shaped,” which means virtually all of the risk accrues from underweight.
Fact is, in a large medical study, the median BMI associated with a noteworthy increase in mortality at ages 75 and over was greater than 40 in both genders.
Is weight-loss (bariatric) surgery reserved for the morbidly obese?
No. It is now commonly done for Class II obesity and we even see applicants with Class I obesity that have had one of these procedures in the presence of major comorbidities like diabetes.
Does weight-loss (bariatric) surgery favorably impact insurability?
It may if (a) significant weight loss is realized and (b) that loss is more or less sustained going forward. In this setting, presurgical hypertension and diabetes frequently disappear.
How is weight mortality impacted by smoking overall?
In one study, there was little difference between smokers and nonsmokers if BMI was at least 18.5, whereas mortality was 2/3 greater in smokers who were underweight as compared to their skinny non-puffing peers. Overweight/obese current smokers have also been shown to have more abdominal fat than nonsmokers, which is one reason why using WC and the waist-to-hip ratio would help us level the playing field in weight underwriting.
Which is “better” over age 65: weight gain or weight loss?
In the Cardiovascular Health Study, a 5% weight gain did not influence mortality. On the other hand, the equivalent weight loss hiked the death risk 50% in just 3 years.
Which is more significant in the elderly: underweight or weight loss?
Weight loss (by the proverbial “country mile”)!
What is considered a significant weight loss?
Clinical criteria are greater 10+ pounds or over 5% of usual/pre-loss weight. At 10%, one suspects malnutrition or a serious underlying disease such as cancer.
Does the interval of the weight loss matter?
It does. The most disconcerting weight loss in elders occurs within the past 12 months and it is usually progressive rather than stabilized over the majority of this interval.
What if the weight loss is intentional?
All other things being equal, unintended weight loss is more worrisome. One hastens to add, however, that by age 75, the lines blur and many cases of “voluntary weight loss” are in fact little more than wishful thinking!
What are the 10 RED FLAGS when underwriting geriatric weight loss?
In no particular order:
Evidence of frailty (abnormal “Get Up and GO” test, impaired ADLs, etc.)
Any degree of cognitive impairment
New-onset GI symptoms
Resting pulse rate > 100
Low hemoglobin, including “mild anemia” if not clinically investigated
Low (< 140) cholesterol; doubly so if it is falling
Substantially low (< 25) or falling HDL-C
Low serum albumin
Long history of cigarette narcosis; ideally, benchmarked by “pack-years” of consumption (which most insurers still ignore).
By Hank George, FALU CLU, FLMI for NAILBA Perspectives Magazine January/February 2012 issue.