Diabetes. Cheryl Joyce, FALU, FLMI, ARA, ACS Director. Bill McMillen, ALMI Associate Underwriting Consultant. September 11, 2018

Transcription

1 Diabetes Cheryl Joyce, FALU, FLMI, ARA, ACS Director Bill McMillen, ALMI Associate Underwriting Consultant September 11, 2018

2 Part One What is diabetes? Statistics Anatomy Three major classifications of diabetes Signs and symptoms Diagnosing diabetes 2

3 Part Two Control Compliance Complications Comorbid conditions Trends in treatment 3

4 What is Diabetes Chronic disease in which the body does not produce or properly use insulin, and can lead to serious complications (vascular and neuropathic) and premature death Characterized by inappropriate hyperglycemia and carbohydrate metabolism No cure Cause is a mystery, with genetic and environmental (comorbid) factors, such as obesity and lack of exercise appearing to play roles 4

5 Statistics Seventh deadliest disease in the U.S. Underreported on death certificates because people typically have multiple chronic medical conditions in combination with diabetes Top 10 countries: India, China, U.S., Indonesia, Japan, Pakistan, Russia, Brazil, Italy, Bangladesh Adults with diabetes have heart disease death rates about 2 to 4 times higher than adults without diabetes 5

6 Statistics (cont d.) Estimated 29.1 million people or 9.3% of the U.S. population (children and adults) have diabetes, of which 27% are unaware that they have the disease Approximately 1.25M American children & adults have Type 1 DM Estimated 79 million people are at high risk for developing diabetes Leading cause of blindness, end-stage renal disease and non-traumatic limb amputation $245 billion: Total costs of diagnosed diabetes in the U.S. in 2012 $176 billion for direct medical costs $69 billion for indirect costs (disability, work loss, premature mortality) 6

7 Global Diabetes Prevalence Top 10 Countries 7

8 Global Diabetes Prevalence 2000/Projected 2030 All age groups: estimated 2.8% in 2000 and 4.4% by 2030 Total number with diabetes: 171 million in 2000 to 366 million in 2030 While prevalence is higher in men than women, there are more women with diabetes than men Most important demographic change to diabetes prevalence across the world appears to be the increase in population of people >65 years of age Given the increasing prevalence of obesity, it is likely these numbers underestimate future prevalence 8

9 Anatomy Pancreas Located behind the stomach About 6 inches long Aids in the digestive process by making hormones and enzymes Contains islet cells 9

10 Anatomy (cont d.) Islets of Langerhans Alpha Cells Glucagon Beta Cells Insulin Delta Cells - Somatostatin 10

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12 Anatomy (cont d.) Glucagon Alpha cells make glucagon when blood glucose falls too low Glucagon travels to liver and tells it to release glucose into the blood for energy Elevated glucose in blood stimulates the release of insulin 12

13 Anatomy (cont d.) Beta Cells and Insulin Insulin solely made by beta cells Glucose >70 mg% stimulates release of insulin by beta cells Insulin tells other cells in the body to use glucose for energy and, most important, decreases concentrations of glucose in the blood Facilitates entry of glucose into muscle, adipose and several other tissues 13

14 Anatomy (cont d.) Beta Cells and Insulin Stimulates liver to store glucose in the form of glycogen Promotes some amino acid and triglyceride synthesis in adipose cells (increase glucose yields increase triglycerides) Promotes synthesis of fatty acids in liver and reduces production of glucose in liver 14

15 Glucose and Insulin The idealized diagram shows the following: Fluctuation of blood sugar (red) and the sugar-lowering hormone insulin (blue) in humans during the course of a day, containing three meals Effect of a sugar-rich versus a starch-rich meal is highlighted Source: Wikipedia 15

16 3 Major Classifications of Diabetes Type 1 DM a.k.a., Insulin Dependent Diabetes Mellitus (IDDM), juvenile diabetes (terms no longer used) In adults accounts for approximately 5% of all diabetes Usually presents as a severe, acute illness before the age of 30, but can affect any age Characterized by 80% destruction of beta cells in the pancreas, leading to absolute insulin deficiency Risk factors possibly are autoimmune, genetic or environmental 10-20% will develop other autoimmune diseases such as thyroid disease, pernicious anemia, adrenal insufficiency 16

17 3 Major Classifications of Diabetes (cont d.) DM Type 2 a.k.a., Non-insulin Dependent Diabetes Mellitus (NIDDM), adult-onset diabetes (terms no longer used) Accounts for 90-95% of all diabetes Strong genetic component, with almost 100% concordance in identical twins Typically insidious onset in adult life and associated with obesity, decreased activity and advancing age Involves varying degrees of insulin deficiency; usually begins as insulin resistance where insulin is not used properly 17

18 3 Major Classifications of Diabetes (cont d.) DM Type 2 Still rare, but a rise in diagnosis in children and adolescents (possibly in relationship to rise in obesity) Risk factors are older age (>45), obesity, family history of diabetes, history of gestational diabetes, impaired glucose metabolism, physical inactivity, low HDL, high cholesterol or high triglycerides, and high blood pressure If beta cells are damaged by persistent hyperglycemia, it can lead to a lack of production of insulin, then Type 2 may need to be treated with insulin versus an oral agent 18

19 3 Major Classifications of Diabetes (cont d.) Gestational Diabetes Occurs in 2-10% of all pregnancies, possibly due to metabolic stress Characterized by glucose intolerance Immediately after pregnancy 5-10% of women with gestational diabetes will be diagnosed with Type 2 diabetes Women who have had gestational diabetes have a 35-60% chance of developing diabetes in the next 10 to 20 years 19

20 Diabetes Classification Miscellaneous Category Any disease or condition that damages the pancreas can lead to secondary diabetes Possible causes of beta cell destruction are conditions such as hemochromatosis, pancreatitis and cystic fibrosis Endocrine disorders, which cause counter-insulin hormonal states, i.e., Cushing s, acromegaly, hyperthyroidism or pheochromocytoma, can predispose an individual Genetic conditions such as Down s syndrome, Turner s and Huntington s Chorea Drug-induced with diazides, steroids, synthroid or phenytoin Also can be induced by ischemic disease 20

21 High-Risk Category to Develop Diabetes a.k.a., Impaired Glucose Tolerance (IGT), Impaired Fasting Glucose (IFG), Pre-diabetes Raises risk of developing Type 2, heart disease and stroke Defined by higher than normal glucose levels, but not high enough to be classified as diabetes IGT is a condition in which the blood sugar level is mg/dl after 2 hours following an oral glucose tolerance test IFG is a condition in which the fasting blood sugar level is 100 to 125 mg/dl after an overnight fast 21

22 Signs and Symptoms Frequent urination Excessive thirst Unexplained weight loss Extreme fatigue Frequent skin, gum or bladder infections Blurred vision Slow to heal cuts/bruises Tingling/numbness in hands or feet Extreme hunger 22

23 Diagnosing Diabetes A1c >6.5 is now recommended for the diagnosis of diabetes; A1c levels of 6.1 to 6.5 are at high risk to develop DM A1c does not require fasting or timed blood samples Relatively unaffected by acute stress when compared to glucose Fasting plasma glucose (FPG) and 2-hour plasma glucose (2HPG) can still be used to diagnose, but all results and lab tests should be reconfirmed Can be used to manage and treat diabetes 23

24 Underwriting Diabetes

25 Part Two Control Compliance Complications Comorbid conditions Trends in treatment 25

26 Diabetic Control Degree of control is an important predictive factor in determining the onset and outcome of complications To gain a mortality benefit from good control, it is important to maintain good control over a long period, not just in the last few months before assessment for insurance purposes 26

27 Control Measured Laboratory parameters (HgbA1c, fructosamine, urinalysis) History of hyperglycemic/hypoglycemic episodes Lipid control BP control Weight control 27

28 Treatment Goals Normalize blood glucose Eliminate hypoglycemic and hyperglycemic episodes Normalize weight (diet and exercise) Treat co-existing conditions Monitor and prevent complications 28

29 Diabetic Compliance Short-term and/or long-term complications may develop because a person is either uncooperative with suggested management/therapy or is receiving substandard care Ideal compliance includes annual assessment of neurological, cardiovascular and renal function as well as routine eye exams Watch for recent description of brittle diabetes or frequent insulin reactions 29

30 Brittle Diabetes Definition Occurs in a patient whose life is constantly disrupted by episodes of hyper- or hypoglycemia, whatever their cause (less than 1% of diabetics) Usually episodes of either hyperglycemia or hypoglycemia not mixed Occurs more frequently in women More complications and most likely related to poorer metabolic control 30

31 Diabetic Complications Complications occur when a person s diabetes is not adequately controlled Acute complications Hyperglycemic or hypoglycemic episodes Diabetic Ketoacidosis 31

32 Diabetic Complications Chronic Complications macrovascular (large blood vessels) and microvascular (small blood vessels) Macrovascular complications CVA Coronary Artery Disease Peripheral Vascular Disease 32

33 Diabetic Complications Microvascular Complications Retinopathy Nephropathy Neuropathy 33

34 Macrovascular Complications While the exact mechanisms are unclear, the macrovascular complications are the cause of death in about 75% of diabetics; elevated glucose, lipids and blood pressure play a role in this control of these is a crucial treatment goal 34

35 Macrovascular Complications CVA risk of stroke is 2-4 times higher in diabetics than nondiabetics; stroke was noted on 16% of diabetes-related death certificates for ages 65 and older CAD heart disease noted on 68% of diabetes-related death certificates for ages 65 and older; adults with diabetes-related heart disease have death rates 2-4 times higher than adults without diabetes PVD more than 60% of non-traumatic lower limb amputations occur in diabetics 35

36 Microvascular Complications Retinopathy related to diabetes is the most significant cause of adult blindness in the non-elderly; incidence is significantly higher with A1c s >6.5 Nephropathy seen in longstanding diabetics of >15 years duration; end-stage renal disease in 30% of Type 1 diabetics and 20% of Type 2 diabetics; in 2008 there were more than 200,000 people in the U.S. with ESRD due to diabetes on chronic dialysis or with a kidney transplant; when macroalbuminuria or microalbuminuria is present, there is an increased risk of CAD Neuropathy 60-70% of diabetics have mild to severe forms of nervous system damage; the risk is increased with ^BMI, smoking, hypertension and ^triglycerides 36

37 Other Complications Gastroparesis Cataracts and glaucoma Increased infections Slow healing of wounds Foot and leg ulcers 37

38 Comorbid Conditions Comorbid conditions will considerably worsen the prognosis Examples of comorbid conditions include: Obesity HTN Alcohol excess Smoking Dyslipidemia 38

39 Trends in Treatment Traditional treatment protocol for all diabetics diet and exercise and weight loss are key components Help lose weight Lower blood sugar Helps cells accept insulin more efficiently Type 1 insulin treatment Type 2 oral meds; insulin if not responsive to these 39

40 Trends in Treatment (cont d.) Monitoring Pain-free glucose tests Continuous monitoring device Insulin therapy advances Implantable pumps Insulin inhalers Insulin pill New insulin 40

41 Trends in Treatment (cont d.) Islet cell transplants Pancreas transplants Gene therapy Vaccine 41

42 Case Studies

43 Case Study 1 35-year-old female $500,000 Accountant Diabetes age 7 at onset Current labs A1c 6.6, fructosamine 1.5 and fasting BS 120; HOS negative APS: A1c s in history two years prior: 7.0; 7.7; 7.5; began insulin pump one year ago with follow-up A1c 6.5 Checks blood sugar 2 times per day Dad died of an MI at age 57 43

44 Case Study 2 50-year-old male In school to become a pastor, completion expected next year Past foreign travel to South Africa to visit friends, no future plans Current Fructo 3.2, fasting glucose 169, A1c 10.7, ALP 143, Trigs 355, Chol/HDL 6.6 HOS Glu 0.02 No medical history admitted, hasn t seen an M.D. in 5 years Admits to being told he had elevated blood sugar, and he should just watch it; told agent he d be seeing doctor next week Follow-up papers show newly established patient, new DM, Rx: Avandia; hyperlipidemia, ECG neg 44

45 Case Study 3 39-year-old male Born in India DMII dx d 5 years prior Current A1c 9.1, Fructo 2.2 HOS #1 Prot 47, MALB 10, RBC 5, MALB/Creat.034, P/C.16 HOS #2 Glu >1.0, Prot 61, MALB 23.2, RBC 5, MALB/Creat.12, P/C.34 HOS #3 Glu.66, Prot 27, MALB 7.7, RBC 5, MALB/Creat.12, P/C.34 A1c 2 years prior

46 Case Study 4 50-year-old male $250,000 Mechanical contractor Age onset 43; found while hospitalized for anterior MI Current meds: Glucophage, Avandia, Insulin 70/30, Zestril, Lipitor, Aspirin MI followed by PTCA 8 years ago, then redone one month later and finally CABGX1 2 months after that Chest pain 5 years ago and Cath showing patent LIMA to LAD but LVEDP of 45 with occasional chest pain since GERD occasionally with Prilosec prn Erectile dysfunction 46

47 Case Study 4 (cont d.) Nausea after heavy meals Peripheral foot numbness A1cs over 4 years average between 8 and 9 Exam A1c at 7.9 Tough work schedule with indiscriminate diet adherence noted Occasional anxiety noted with Xanax prn Goes to primary care, endocrinologist and cardiologist regularly 47

48 Case Study 5 45-year-old male Was insulin-dependent DM Gastric bypass 6 months prior Current A1c 7.5 Using oral meds and continues to adjust dosage Metabolic syndrome noted prior to bypass, current lipids favorable HTN 140/90 on Rx Lisinopril 2 ETOH daily Credit problems 48

49 Case Study 6 65-year-old male, smoker 1PPD DM dx d 1 year prior to application HTN BPH with TURP Erectile dysfunction noted Current A1c 6.5 HOS P/C.31 MALB 4.9 History of chest pain; Thallium from 6 months prior essentially negative for ischemia 49

50 Assessing the Diabetic Risk Stay with the Fundamentals plus. Know relevant Risk Factors for Diagnosis of and progression to End Organ Disease in Diabetes. Know the Duration of diabetes Understand the Medications most importantly, their contraindications Know the individual Control parameters Recognize the Complications Assess the Co-Morbidities 50

51 Diabetes Risk The Good, The Not So Good FAVORABLE Apply Tx Fundamentals: Diet, Exercise, Medication Regular Check Ups (2x-4x per year) Stable/Near normal HgbA1c s SMBG (1x - >4x per day) No Diabetes Complications No/Few Co-Morbidities (under control) Older age in >65 age group Aggressive Lipid Control Low NT pro BNP UNFAVORABLE Check ups outside of care directives None or very infrequent SMBG Weight Gain & Inactivity Recurrent Hypoglycemia/Ketoacidosis Regular Excursions of Blood Glucose Evidence of CAD with minimal follow-up Complacency in Treatment Regimen 51

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