Diabetes has been a longstanding area of interest for life underwriters. The Centre for Disease Control estimates that more than 30 million Americans have diabetes. The numbers appear to be rising, and it’s estimated that as many as 80 million Americans are living with prediabetes – the condition that typically leads to type II diabetes within five years. The numbers are impactful, especially since nearly 1 in 4 people with prediabetes are undiagnosed.
With such prevalence, it’s unsurprising that doctors, and life underwriters, are tracking new treatment options. A new trend has thrown the underwriting scene a bit of a curve ball; using weight loss surgery as treatment for type II diabetes. Rethinking traditional approaches to treatment means underwriters need to develop a new understanding of risk and make other considerations when completing assessments.
I sat down with Dr. Nick Carter, a leading Specialist Laparoscopic Upper Gastrointestinal and Bariatric Surgeon, to better understand how gastric bypass surgery is being used as a treatment for type II diabetes. Dr. Carter has conducted on average, 200 surgeries per year, for the past five years. Of those surgeries, 40% have been performed to reduce BMI related to diabetes. As one of the top surgeons conducting these surgeries in the UK, he has a wealth of knowledge and unmatched expertise on the treatment. You’ll see his insights shared throughout the article as we dive into questions around what this treatment means for the future of underwriting cases with type II diabetes.
Why Does this Topic Matter to Life Underwriters?
Understanding new treatment options is critical for recognizing risks, gauging long-term trends, and meeting client needs. When new treatments are introduced to address predominant diseases like type II diabetes, keeping track of the changes and implications is crucial. The benefits of using gastric bypass surgery as a method for treating type II diabetes offers numerous benefits. “It’s a remarkable thing, a 30-year-old person who has a BMI of 34 with type II diabetes – who would more than likely have a lifetime of living with diabetes- can have surgery and put their diabetes into remission immediately,” explains Dr. Carter. “It has proven to be very beneficial both physically and mentally.” This is a fairly ‘new practice’ in medicine in general, so it may take some time for production underwriting to come across it, but it’s still an important trend to track and it will present unique cases to assess.
What is Type II Diabetes?
Type II diabetes had been previously referred to as non-insulin dependent diabetes, however with such an increased prevalence of uncontrolled diabetes, this had to be adjusted. Often times, uncontrolled type II diabetes does still need to be treated with insulin, or oral medications in addition to insulin. Type II diabetes means that there is chronic hyperglycemia present. People are usually diagnosed with type II diabetes at a later stage in life, but it can be diagnosed at any age. Diagnosis in children is currently on the rise due to increases in childhood obesity. With type II diabetes, the body is not able to utilize insulin produced by the pancreas in the right way.
New Treatments, New Risks
Treatments for type II diabetes have primarily been oral medication and, in some less controlled cases, insulin. Diet has also always played an important role in treatment, as this type of diabetes is related closely to obesity. Often at times, a person with type II diabetes can manage their blood sugar levels with exercise and changes to their diet, regaining control and “curing them” of this disease. Meaning that, if their blood sugars remain low, with an HBA1C of less than 6.1 without medication, they are within normal ranges and are no longer considered a diabetic. Sometimes different clients experience many struggles along the way to attain consistent and controlled blood sugar and weight loss. Nowadays, however, there are new and different types of treatments being used to address type II diabetes.
What is Gastric Bypass Surgery?
Dr. Carter shares that gastric bypass surgery is performed on the stomach to achieve the goal of weight loss. During the procedure, the stomach is cut to the size of a Satsuma and the small intestine is used to connect to this small pouch bypassing the first 2 meters or so of small intestine. With a variety of techniques available, the procedures are individualized to offer the best possible form of treatment to each client. After the surgery is completed, the stomach’s volume is reduced. Its altered response to food results in physiological changes that identify the procedure as a success.
Who is Gastric Bypass Surgery Suitable for?
Dr. Carter explains that those who are considered obese are the best candidates. A BMI of over 40 is typically the benchmark for obesity. Obesity increases the risk for many comorbid factors, high blood pressure, high cholesterol, sleep apnea, and, our focus, type II diabetes. The possibility to cure type II diabetes with gastric bypass surgery is a relatively new development, but one that early interventions have shown is promising. NICE has now released guidance to say this type of surgery can be considered on Type 2 diabetics with a BMI of 30 and above.
How to Underwrite Someone Who No Longer has Type II Diabetes?
One of many questions that may arise from an underwriting perspective is: how do you underwrite someone who had type II diabetes but does not anymore?
Some might feel this is a different scenario than underwriting someone who had gestational diabetes, even though the same outcome occurs: in both cases the person no longer has any symptoms of diabetes. Despite similar outcomes, gestational diabetes (diabetes brought on in pregnant women) who no longer have symptoms after childbirth is a different situation than a person diagnosed type II diabetic who has ‘cured’ themselves with gastric bypass surgery. It would be interesting to see how some of the existing underwriting manuals recommend handling this assessment. With manuals and reinsurers following the trend of getting slightly more aggressive in rating for diabetes, I would imagine it could be viewed as past history that is no longer present. An example of notes when underwriting a case like this could be what you see below.
How would you handle this sample case?
Below is an example of what notes could look like when underwriting a case like this. How would you handle this case? What would your company guidelines suggest?
To be underwriting such a new medical treatment for diabetes, there are many questions and concerns that come to mind. With any new practice there needs to be an established and methodological way of assessing the risk. There needs to be some form of statistics to base table ratings on. Unfortunately, some factors, such as long-term effects and effectiveness of the treatment, we just may not know until later in the future.
Patient Experience and the Risk of Anorexia
To understand how gastric bypass surgery is being used to treat type II diabetes, Dr. Carter explains the types of procedures being used and new treatment options available.
When discussing trends among the patients he sees for this type of treatment, Dr. Carter shares that “patients who come in with type II diabetes need to fit the NHS (National Health Service) criteria. People with low BMI’s and women consult on the procedure more often, typically because they are more body conscious”. When discussed the risks involved, he explained that “most risks are mediated and mitigated early on, as metabolic surgeons have criteria that extend beyond physical symptoms and qualifications.”
One risk that could arise is anorexia, which is clearly not the goal. “Transitioning from obesity to living with anorexia is rare. It is more common for people who have undergone the surgery to experience adverse effects associated with unstable mental health, body dysmorphia, anxiety, depression, and other types of eating disorders,” he says of the risks of using surgery for treatment. “To mitigate the risk of these developing, there needs to be a thorough psych review done, both pre- and post-surgery. As long as the bypass is tailored accordingly and appropriately, standard, long term risks are more common.”
Early Results and Factors for Success
The early results are encouraging. “In 18 months, the procedure would have paid for itself in terms of the cost of treatment, medications, and appointments necessary to control and manage diabetes on its own,” Dr. Carter explains.
Patients who have chosen the treatment have demonstrated that it offers longevity and a sustainable option for people with type II diabetes. “65% of patients who have had the procedure remain off of all diabetes medication within a year to two years,” Dr. Nick Carter says. “After ten years, remission is approximately 40% with weight regain. Individuals who have a BMI of 27-28, who are off of medication for 1 year, show very good follow up results.”
More data is required to look at long term trends and efficacy across more patients, but the option offers a lot of potential for diagnosed individuals who are mentally, emotionally, and physically prepared to change their lifestyle. Life underwriters should keep an eye on this treatment option and consider how their manuals and policies may be applied or adapted to fit the changing treatment landscape.
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Featured Underwriter: Seema Samad
Seema Joined LOGiQ³ in February 2015 and is responsible for production underwriting. She has 9 years of experience in the life insurance industry, starting her career with a short stint as a tele-interviewer at Manulife, quickly moving on to life underwriting roles. Seema’s background as a registered practical nurse has been an asset to her career in underwriting. She studied Nursing at Conestoga College and is an active member with the College of Nurses of Ontario.