Robert Goldstone

Hematuria is the finding of blood in the urine. It can either be quite obvious where blood is visible to the naked eye, or microscopic, where only a urinalysis picks up the findings (asymptomatic microscopic hematuria). Large amounts of blood can create a smoky reddish brown appearance to the urine, while microscopic hematuria may appear as completely normal. Often the timing of the blood in the urine can diagnose where it is coming from: If blood is noted at the start but then disappears, it’s more likely to be at the urethra (or additionally the prostate gland in a male). If noted uniformly from start to finish in the stream, it is more likely to be the kidneys, bladder or ureter as a primary source.

Kidney stones, tumors anywhere in the urinary tract or of the prostate, trauma, inflammation of the kidney due to glomerulonephritis (with many and varying etiologies) and polycystic kidney disease are some of the many causes that have to be ruled out in the face of a finding of hematuria. More benign findings such as contamination from a menstrual period, a urinary tract infection, a bladder infection, or even a prostate infection can all account for blood in the urine. Most initial testing looks for benign disease unless there is a known etiology, a large amount of blood, or risk factors for malignancy. A referral to a specialist usually then depends on which way the decision tree is leaning.

Microscopic hematuria is usually found incidentally on a urinalysis as part of a physical exam or even an insurance examination with a routine blood and urine collection. If a dipstick test is positive for blood and there are three or more red blood cells per microscopic high power field, assessment for urinary tract infection, assessment of benign causes such as menstruation, vigorous exercise, recent procedure to the urinary tract, or history of kidney stones is developed. When casts of cells as well as protein are also found, a referral to a kidney specialist (nephrologist) often ensues for a more detailed systemic workup.

When there are risk factors for malignancy, assessment is first made as to whether the risk is low or there is a history of renal insufficiency or sensitivity to radiation or contrast dye. Ultrasound and non-contrast CT is often done to evaluate the urinary tract, and a urologist is often involved at this point. When malignancy risk is higher and there are no sensitivities to testing, a CT is done and the urologist gets involved earlier, as cystoscopy may be the next step.

Microscopic hematuria is a little harder to evaluate and pinpoint a cause. While in patients with gross hematuria the malignancy rate can be close to 30 percent and full investigation is started right at the onset, closer to 5 percent of microscopic hematuria has a malignant cause, and when the individual involved has no pain and the urine looks clear to the naked eye, workups are often postponed or avoided. After screening, repeating the urines at prescribed time intervals, and treating obvious causes such as infection, still half the diagnoses for microscopic hematuria remain unknown. Continued follow-up, imaging and cystoscopy are done when the hematuria continues after all benign or treatable conditions are ruled out. When urinalyses are done over years and the hematuria disappears, the cause is overwhelmingly often benign.  If the hematuria persists, a full repeat evaluation should be considered within three to five years of the initial evaluation.

Hematuria is difficult for underwriters to assess in the absence of a known cause. A case will be postponed until malignancy is definitely ruled out. When the finding is stable and no family history of kidney disease,  renal failure or glomerulonephritis is obtained, a standard issue is possible. Preferred issues are difficult when the finding persists but the cause is never found, and assessment has to be thorough and prolonged without a positive finding for this to be considered.

In the letter world of hepatitis, B and C are most well known as causing severe and potentially fatal liver injury. But what about hepatitis A virus (HAV)? HAV is one of the world’s most common viral infections, and even though a vaccine given to school age children helps to limit the occurrence of the disease, it is the cause of more than half of the reported cases of viral hepatitis in the United States, and it has significant morbidity.

Hepatitis A is an RNA viral infection shed in the stool and usually spread by food contaminated with fecal matter. It can also be contracted from contaminated water, through personal contact with others infected with the disease, spread in day care centers from child to child, and even through sexual contact. Since hepatitis A has a very long incubation period (approximately 28 days from exposure to the onset of symptoms), it is often hard to trace back to a particular source. More than one-half of the cases never have a specific, identifiable risk factor found.

Onset of the disease is quite dramatic, with fever, nausea, vomiting, diarrhea and jaundice (yellow skin). Headache, weight loss, dark urine and abdominal pain develop as the liver is affected. Symptoms are generally more intense with age, and younger children are less affected than older individuals. Hepatitis A is most contagious two weeks before and one week after symptoms begin, and recurrences are not uncommon.

It is generally not possible to differentiate the individual types of hepatitis from their clinical presentation alone. Even viral infections, drugs, toxins and bacterial and parasitic infections may present with similar pictures. Diagnosis is made by the detection of serum immunoglobulin M (IgM) anti-HAV antibodies. The test is available in most clinical laboratories. Sometimes administration of the hepatitis A vaccine can cause a false positive result, so it’s an important question to ask when the disease seems mild but the testing comes up positive.

Thankfully, hepatitis A is a self-limiting infection in most cases—complications are generally most severe after age 50. One in six affected people may have a relapse, but unlike other forms of hepatitis such as B and C, there is no chronic state. Inflammation of blood vessels, anemia, kidney failure and pancreatitis can occur during the acute phase. There is no treatment for the virus except supportive care, and most all cases subside, even those with relapse. Older individuals should be watched more carefully for complications, and children should not return to school until fever and jaundice have subsided.

The CDC has authorized a vaccine for children, who get a series of immunizations between the age of one and two. Those traveling into areas where hepatitis A is common should receive the vaccine as well. An immunoglobulin that gives passive immunity for up to three months may also be coadministered in adults.

Almost all cases of recovered hepatitis A can be issued at best rates without any problem. Those who have had a recurrence or in whom liver function tests remain abnormal must be fully evaluated, as the more dangerous hepatitis B and C may coexist, or other liver problems and inflammations may cause separate mortality and morbidity and require ongoing treatment.

Osteoporosis affects nearly eight million women and two million men in the United States, and its incidence is only increasing as the population ages. It is a metabolic bone disorder in which a progressive decrease in the density of bones weakens them and makes fractures more likely. Instability and loss of strength in the aging process causes falls which, combined with weakened bones, can cause fractures, resulting immobility, and sharp increases in both morbidity and mortality.

Most people reach a bone mass and strength peak between the ages of 25 and 30. From this point forward bone resorption and remodeling causes changes in the actual bone structure. The body draws calcium from the bones in ongoing ways to support such essential body functions as heart contraction, muscle strength, blood clotting, nerve responses and countless other necessary metabolic functions. Calcium is absorbed when needed and then replaced in the bones when the level in the body is too high by means of a constant feedback system through various hormones that are either stimulated or suppressed depending on body requirements. These changes happen every minute of every day and react to body needs.

After awhile, more bone is broken down than is remodeled, as the process of aging proceeds. The density of bones decreases slowly, and if the body is unable to maintain an adequate amount of bone formation, the bones lose density and become increasingly fragile. This process leads to osteoporosis. Peak bone mass is determined by many factors which include gender (females are more affected than males), genetics, exercise and nutrition. While men lose bone in a linear fashion as they age, females suffer a rapid loss right after menopause, when the sudden loss of estrogen (which is bone protective) is lost. That loss, along with a more haphazard process of bone remodeling, increases susceptibility to osteoporosis at this time in life going forward.

Osteoporosis is defined by measured bone mass. Measured bone density within one standard deviation of average is considered normal. Osteopenia is a condition in which bone mineral density is between 1 and 2.5 standard deviations below the reference value of normal.

Osteoporosis is defined as 2.5 or greater standard deviations below normal, and severe osteoporosis is diagnosed by fragility fractures (meaning those from mechanical forces that would not usually cause damage).

To this point we’ve defined primary osteoporosis. Secondary osteoporosis results not only from normal aging but secondary to other systemic diseases. These include chronic kidney failure, endocrine disorders such as diabetes, thyroid and parathyroid disorders, and those where body nutrition is compromised. Medications such as corticosteroids or anti-epileptic drugs, when administered chronically, likewise increase the risk of osteoporosis.

Most X-rays don’t show bone loss until at least 40 percent of bone mass has been lost. Bone mineral density is better and more accurately measured with a scan called a DEXA scan, which uses double energy X-ray absorptiometry. The National Osteoporosis Foundation recommends testing for all men over 70 and females over the age of 65 at least once, although earlier testing may be done in those with chronic disease or medication administration which facilitates osteoporosis or a history of fracture at an earlier age not commensurate with the trauma that caused it. Females with surgically induced menopause (when uterus and ovaries are removed) have a sudden drop in hormone levels and are candidates for earlier testing as well.

As it is a silent disease without symptoms in earlier phases, osteoporosis is under­­diagnosed, under­reported and under­treated. Those at higher risk of osteo­porosis or with apparent bone density loss diagnosed by X-ray or DEXA scan should supplement their diet with 1,000-1,200 mg calcium and 800 IU vitamin D daily. Other medications are reserved for more severe cases. Increased physical activity, especially weight-bearing activities, smoking cessation, and limited alcohol consumption are also helpful. Osteoporosis is generally a condition that doesn’t require an insurance rating unless there are repeated fractures or incomplete recovery from same, or a marked decrease in stability and everyday function. Osteoporosis, particularly progressive and untreated, contributes to impaired mobility and is a leading cause of mortality in older ages.

While most of us may not know of an active case of tuberculosis in our own circle, to say it is still a global health problem would be putting it mildly. The National Institute of Allergy and Infectious Disease estimates that up to a third of the world’s population may be infected with mycobacterium tuberculosis and that 10 million new cases are diagnosed each year. Additionally, the Center for Disease Control (CDC) states that there is a 5-10 percent lifetime risk of progression from inactive to active disease. Certainly this is no goodbye to tuberculosis prevalence.

While the incidence is far less, percentage-wise, in developed countries such as the United States, a 15 percent increase in occurrence was reported to the CDC during the HIV epidemic of the late 80s and early 90s. The incidence still is significant in the general population due to immigration to the United States from high-incidence countries, from illicit drug use, and among those in the rapidly expanding health care field. People who have inactive or latent tuberculosis generally don’t feel ill, so the only evidence of infection is a positive screening test, often during an application for employment or as part of school screening.

Tuberculosis enters the body primarily through the lungs. Therefore, the lungs are the major site of infection, although tuberculosis can exist in the bones, lymph nodes, and virtually any place in the body. As mentioned, it usually exists in a dormant or latent form. When progressive, constitutional symptoms such as weight loss, fever, night sweats and malaise occur. Chronic cough is the most common pulmonary symptom. Blood in the sputum can be a more advanced sign, and on physical examination chronic illness is very apparent.

One problem in eradicating tuberculosis is erratic standards for diagnosing the disease. Cost containment often limits testing to high risk populations and is not offered to those likely to refuse treatment. A positive tuberculosis skin test indicates exposure to the disease, but the risk of treatment and side effects often exceeds the potential benefit in older individuals and those who have not converted from negative to positive in a recent time frame. Tuberculosis is proved by isolating the bacillus, and a chest x-ray, sputum and culture confirm the diagnosis.

Once discovered, tuberculosis should be treated immediately. Isoniazid (INH) is the primary drug  of choice, and as the disease is a tough one to eradicate often requires between six and nine months of continuous treatment. Many other medications have been developed, and  unfortunately, strains of drug-resistant disease have emerged. The toughest cases are those in people who are immunosuppressed (such as from HIV infection) and the elderly, where reactivation occurs after many years of dormancy and the immune system isn’t as active as at younger ages in fighting the disease. Treatment failure occurs not infrequently since most do not keep up taking the medication for the long period necessary to completely inactivate the disease.

Most cases of completely treated disease or positive skin testing with no evidence of active infection can be issued at standard. Preferred status is reserved for those with follow-up testing that shows no evidence of disease and no history of any immune system disorder. Those with active disease or who are in the midst of treatment are generally postponed.

Resources:

 Centers for Disease Control and Prevention (CDC). Recommendations for use of an isoniazid-rifampin regimen with direct observation to treat latent Myco­bacterium tuberculosis infection. MMWR Morb Mortal Wkly Rep. 2011; 60(48): 1650-53.

 National Institute of Allergy and Infectious Diseases. Tuberculosis (Tb). www.niaid.nih.gov/topics/tuberculosis/Understanding/Pages/overview.aspx.

Fibromyalgia is a tough diagnosis even for the experienced physician. A disorder of musculoskeletal pain throughout the body that is not explained by another systemic or rheumatologic disorder, its discomfort must persist at least three months. It’s also known as fibrositis, myofascial pain syndrome, chronic pain disorder and muscular rheumatism. After osteoarthritis, it is the second most common rheumatic disorder and is estimated to occur in up to 5 percent of the population.

Fibromyalgia was historically a diagnosis of exclusion. After other systemic diseases were ruled out, fibromyalgia became the diagnosis by default. Originally published almost 25 years ago, the diagnostic criteria emphasized chronic widespread pain with a series of tender or trigger points. As these are far more common in women, the diagnosis criteria led to almost exclusively female incidence. Now the criteria are more symptoms-based, and the estimate has been lowered to about two out of every three cases being in women. While most common between the ages of 30 and 50, fibromyalgia can develop at any age, even in childhood, and there is no predominant culture or ethnic group.

Fibromyalgia is considered a disease of pain regulation. Centralized pain can be documented as early as adolescence and is experienced in different regions of the body at different times. There are different central nerve patterns of pain that don’t respond to treatment or to surgery on specific trouble spots. The pain is mostly along with muscles and ligaments and very common in the back, hips, neck, and shoulders. There can be multiple tender points on the exam. Headaches, generalized fatigue, and sleep disorders often accompany this disease. Thankfully, a certain level of relief from these symptoms can be relieved through the use of something like Nutra CBD olie, or over the counter medication. Doing this before it has a chance to get any worse could be particularly useful.

Fibromyalgia also has other characteristics that help in an earlier diagnosis. Family members may have a history of chronic pain, and genetic factors have been reported. Environmental factors that are stressors involving acute pain can be ones such as chronic fatigue syndrome, viral infections, or even psychological stress. About 50 percent are genetic and 50 percent environmental when twin studies are evaluated.

The diagnosis of fibromyalgia is made on history and physical exam. Fibromyalgia is best suspected in those with multifocal pain that has no specific explanation. Often blood tests ruling out systemic illness or autoimmune vascular diseases have to come back negative before settling on the diagnosis. There is no specific lab test for fibromyalgia. Widespread pain that is present for three months or more without another disorder that would explain it best fits the diagnosis of this disease.

Treatment for fibromyalgia remains difficult. Medication such as antidepressants may help, as they aid in disrupting pain cycles. Gabapentin, given in seizure disorders but also in chronic neurologic pain, is also used with varying degrees of success. A newer, yet popular option from people who have tried it, is the use of medical cannabis and CBD oil UK. These products have been known to effectively help people who suffer from chronic pain, like fibromyalgia, as well as insomnia, fatigue, and depression. Plus, they can also help someone relax and feel calmer which is great for those bad days. These capsules, that you can find somewhere similar to Every Day Optimal CBD, (https://www.everydayoptimalcbd.com/product-category/capsules-pills/), may be able to help relieve some of the symptoms of this condition until you are able to find a more permanent solution. Education, cognitive behavioral therapy, and exercise all have shown positive benefits. Straight pain medication has shown to be of only transient benefit and may sometimes even worsen the symptoms.

In underwriting, chronic pain is the major factor. Associated depression, accidents, overuse of drugs and alcohol, and effects of constant emotional stress all play into risk assessment. Those who tolerate the disease well and have stable working and medication histories can qualify for preferred issue. When mobility, employment history, medication overuse or psychological conditions are associated with fibromyalgia, rating is centered on the specific associated problems and their prognosis.

“You can never be too rich or too thin.” This quote is attributed to the Duchess of Windsor, Wallis Simpson. It was enough perhaps to cause King Edward VIII to abdicate his throne for her, but studies are showing that while you may never be “too rich,” being too thin can be hazardous to your health.

Well known are the adverse consequences of obesity. The higher incidences of heart disease, cancer, stroke, hypertension, diabetes and countless other co-morbidities have doctors always encouraging patients to lose weight. But there is a point at which being chronically or significantly underweight can also pose risks. Putting aside the category of eating disorders such as anorexia and bulimia, which are well recognized causes of mortality. Of course, there is great importance in learning about these eating disorders, and there are helpful places where you can learn about bulimia and anorexia nervosa treatment. For now, we ask the question, what risks could be the result of being too thin?

The good news with underweight is that most people up until middle age have no problems with a slighter than normal build, especially if it is lifelong and not associated with a chronic disease. The protective value appears to wear off over time until, at age 65, chronic problems may set in. Underweight is associated with fertility issues in both men and women. There appears to be a “critical mass” necessary for proper ovulation and sperm production. Thinner also means less dense and more brittle bone structure; this can lead to spinal conditions like kyphosis, which can be treated with services like Medical City Kids Orthopedics but for obvious reasons, are best to avoid. There’s also an increased risk of type 2 diabetes, higher fats in the blood (perhaps from more rapid metabolism) and a higher risk (according to the Journal of Public Health) of accidents and depression. This also assumes that underweight does not occur because of poor or improper nutrition which also carries its own set of risk factors for the body.

Those who are chronically underweight also have problems with low blood count (anemia), particularly if nutritional. As the body ages, there is an increased risk of fall and fracture, since supporting tissue for the bones is limited. A rapid metabolism may have other primary causes, such as hyperthyroidism or diseases with increased bone turnover. An increased susceptibility to infection and a compromised immune system have also been reported.

Underweight is measured according to universally available BMI (body mass index) charts calculated through height and weight measures. Underweight is generally associated with BMI between 18.5 and 19 (normal BMIs are between 19 and 25). In more recognizable terms, a woman 5’9″ or more is considered underweight if she is under 112 pounds; 5’2″, under 90 pounds. These are extrapolated to use for men (6’1″, 126 pounds might be considered pathologic in a male, extremely slim but acceptable in a female), and in those under the age of 20. Low mortality is actually found between the normal to 10 percent underweight until older ages, when illness or loss of musculature makes it more of a risk factor.

Most concerning is a loss of weight from normal to underweight. Poor nutrition and eating disorders are more common in the young, but cancer is a particularly dreaded cause as age increases. Intestinal malabsorption, endocrine disorders such as diabetes or hyperthyroidism, depression and even alcohol abuse are common causes of decreasing weight in adults. Someone’s weight-loss diet which is going too well or perhaps even too easily may also have a less desirable cause associated with it. Resorting to a properly managed dietary plan, consuming foods rich in vitamins, nutrients, and minerals, and even additionally relying on nutritional supplements like Nucific Bio-X4, could help in the long run. But before opting for a particular supplement, remember to consult a physician, or read up the product reviews, check their ingredients (for example, Bio X4 ingredients), read up what the peers have to say about the product, its side effects, and more.

Insurers look for a current height and weight, documentation of any changes in the last year and reasons for that change, and any complications that may be associated with the loss of weight, such as chronic infections, loss of appetite or falls. An unintended weight loss must have all causes investigated before insurance consideration is given. Those who are underweight but active and fit without any concurrent disorders may be given better than standard issue.

Colon cancer is the third most common cancer in the United States, and the second most lethal. There has been a lot of progress in reducing deaths from colorectal cancer (CRC), both in improved treatment and through early and effective screening. When colon cancer is diagnosed at younger ages, however, it generally has a poorer long-term outcome, particularly in the hereditary types. Thus, earlier than normal screening procedures have to be the rule.

Most everyone is now familiar with the American Cancer Society guidelines for early detection of CRC. Beginning at age 50, men and women considered to be at average risk are recommended to have a flexible sigmoidoscopy every 5 years and a colonoscopy every 10 years. A rectal digital examination with every physical exam by the doctor on a yearly basis is also advocated. These are not easy or comfortable exams, but they have made a big difference in the early detection and treatment of colon cancer.

How about people under the age of 50? More than 10 percent of CRC cases and almost 20 percent of rectal cancers are now diagnosed in younger individuals, and the incidence and mortality are increasing right alongside. Why is this happening? Researchers are postulating that one cause is a higher obesity rate and a concurrent higher rate of diabetes, both found to be significant in increasing CRC risk. But another and maybe key reason is the absence of screening at younger ages. Without a protocol of necessary recommended testing, people over 50 are having cancers and pre-cancers found earlier and removed at completely curable stages. Cancers in younger age groups are allowed to grow unchecked so that when they are found it is at a much more advanced stage.

Both inherited and sporadic cases of CRC arise from adenomatous polyps. It’s a slow process and may take five years for a polyp to transform into significant cancer. When screening is early on in the process, the growths are removed in precancerous stages. When allowed to develop on their own, they can become large and deadly. Villous adenomas are the most common of these, with up to 50 percent having foci of cancer.

Of biggest concern are the early appearing and hereditary forms of colorectal cancer. The growths themselves lack the characteristics of normal tissue (anaplastic) and grow more quickly, as well as a spread or metastasize to other organs. Major syndromes are familial adenomatous polyposis (FAP) and hereditary non-polyposis colorectal cancer, or Lynch syndrome. In FAP, polyps develop in the teenage years and a cancer diagnosis may occur before the age of 40. The risk of extraintestinal cancers is also increased. These cancers may have already spread beyond and through the colon when a diagnosis is made. Telling symptoms, such as rectal bleeding, blood in a bowel movement, abdominal pain, and change in the character of stools may already be a later presenting sign in these cases. If any of these symptoms begin to affect you, a colorectal surgeon may be required to help you return to full health.

The key to successful treatment of colon cancer at younger ages is to take a good history and screen earlier in high-risk individuals. A family history of colon cancer before the age of 60 or in two or more first-degree relatives at any age indicates a candidate for early screening. Those who either have a diagnosis of FAP or Lynch syndrome, or who have inflammatory bowel disease (such as ulcerative colitis or Crohn’s) must be screened earlier, either at 40 years of age or 10 years earlier than the youngest age at CRC diagnosis for any first-degree relative. These cancers caught early are very amenable to successful treatment, and time is of the essence.

Many people usually take things CBD during their treatments to avoid the strong symptoms of vomiting and pain that can be caused by chemotherapy. It has helped people so much that when someone recovers from cancer and stopped taking the treatments they have started to Buy CBD Gummies wholesale and other products to sell their own white-label products to other sufferers of cancers. This is just a little way that people can give back to their community in a big way but with minimal effort.

Most people who have cured colon cancer or cancer treated with complete removal at early stages in a polyp will get standard insurance. Those cases in which there was metastasis, an aggressive type of cancer noted at the time of treatment, or an invasion of cancer through the wall of the colon may have a postponed time, followed by a diminishing flat extra until a cure is likely. Familial syndromes are usually treated with the more drastic step of complete removal of the colon and/or rectum, and even then maybe declined if the risk for recurrence or of another extraintestinal cancer is too high.

Celiac disease is an autoimmune disorder of the gastrointestinal tract that is driven by exposure to dietary gluten. Gluten is a storage protein in barley, wheat and rye, and thus difficult to avoid. It was once thought to be rare, but studies estimate that up to one in 300 people may have a form of this disorder. And it is not new—rather, it is being diagnosed more frequently and with more certainty today. It is common in North America and Europe, and especially in those of European and Middle Eastern descent.

Celiac disease is inheritable and genetic. Two specific histocompatibility antigens, HLA-DQW2 and HLA-DR3 are specifically linked. It is characterized by chronic inflammation of the mucosa of the small intestine, and eventually causes small areas in the intestine to atrophy. This in turn leads to malabsorption and prominent symptoms. Celiac disease can run the gamut from being a minor inconvenience to severely affecting people and may develop at any age. As with many autoimmune diseases, it is two to three times more common in women, and people who have other autoimmune diseases such as thyroid problems or diabetes are more prone to developing celiac disease.

Early on, celiac disease doesn’t have a lot of specific symptoms. Diarrhea and flatulence are probably the most common two, but they are intermittent and don’t show a lot of physical findings on a doctor’s exam. As time passes, symptoms become more prominent, with abdominal pain, bloating, malabsorption and significant discomfort. The diagnosis is best made with a high index of suspicion. While iron deficiency, folate deficiency, weight loss and some electrolyte abnormalities may occur during the course, generally both doctor and affected individual are led to diagnostic suspicion by relating it to foods they have eaten. Lactose intolerance is usually the number one suspected problem, but when withdrawal of milk products doesn’t seem to solve the problem, celiac disease needs to be suspected.

The diagnosis of celiac disease is made through the use of serologic tests, a biopsy of the small bowel on endoscopic exam, and the reaction to the withdrawal of gluten containing substances. The serologic testing doesn’t always make the diagnosis on its own, and the biopsies are needed to confirm. Early in the disease neither test may be definitive and empirical treatment with a gluten-free diet has to be instituted. While symptom relief may occur rapidly, the testing and microscopic changes may take 6 to 12 months to reverse post institution of the diet.

So what is a gluten-free diet? Grains that must be avoided are wheat, barley, malt and rye. This is no easy task, given that these make up the majority of the American diet. The internet is an excellent source of listings of foods that are gluten-free, and much newer packaging, particularly in health food stores, makes this more obvious. However, this can get significantly more expensive, and dining out is always an unknown. Meats, vegetables, fruits and dairy products are gluten-free, making this one way to differentiate this from lactose intolerance. Generally it is advisable to get testing anyway, as conditions like irritable bowel syndrome, reflux and flatulence improve with a gluten-free diet, and a definitive diagnosis by biopsy is still the way to go.

When the diagnosis of malabsorption is uncertain, insurers will wait for a cause to be determined. Most people with mild to moderate celiac disease are insured standard, with only the severe, more stubborn cases causing problems. More than 90 percent of people with celiac disorder improve significantly with a gluten-free diet, but compliance is difficult and the control needed to monitor food intake religiously is not easy, especially in a convenience-oriented world. 

They’re everywhere now-on the front of retail counters to all over the internet. E-cigarettes are advertised as the safer, more socially acceptable and convenient alternative to smoking. The use of e-cigarettes has increased not only among smokers but the Centers for Disease Control and Prevention also notes their greatly increased use by school-age children who were previously non-smokers. The aesthetics of e-cigarettes is something that encourages people to begin using these products, without thinking about the health impacts. Other alternative methods like nicotine gum, patches, and pouches (such as these) have been used to quit smoking, over the years, and it still remains unknown how impactful e-cigarettes can be to health and if they even provide the same service as older smoking remedies.

So how “healthy” are e-cigarettes, and do they pose a risk similar to traditional smoking?

E-cigarettes, which can come in the form of something like this Pockex Vape are usually battery-operated devices with both a mouthpiece and two interlocking tubes made of either metal or plastic. Models may have an LED light at the tip to simulate active smoking or indicate that the device is active. The first part contains the battery and the attached part a cartridge that has a heating element and a liquid. This liquid is usually a substance that contains and dissolves nicotine. Upon being inhaled, the nicotine liquid vaporizes into a mist. Some preparations don’t contain nicotine and may have flavored mists such as chocolate or cherry. Each cartridge has the capacity to simulate approximately one to two packs of cigarettes via puff volume.

The potential benefits of e-cigarettes to traditional smoking have some merit. First, they do not contain tobacco and, as a result, the number and intensity of smoking related diseases is decreased. They are also considered a socially acceptable means of inhaling nicotine without the high penetration of secondhand smoke distributed by traditional tobacco products. Many also promote the use of e-cigarettes as a means of smoking cessation.

The other side of the coin-particularly in insurance pricing but also in the general, overall health of e-cigarettes users-is that they are not without drawbacks.

First of all, most e-cigarettes deliver a potent dose of nicotine. Nicotine releases epinephrine, which charges the sympathetic nervous system. It raises heart rate, increases blood pressure, increases cardiac output and constricts blood vessels.

Second, the factors in play all combine to lead to conditions such as long term hypertension (high blood pressure) and secondarily to arrhythmias of the heart and congestive heart failure. There is also increased risk of stroke.

Third, and perhaps equally problematic, FDA studies of the more commonly available products show impurities in the solutions, such as tobacco-specific nitrosamines and polycyclic aromatic hydrocarbons. Each of these is carcinogenic, although certainly less so than the levels that are found in cigarette smoking. The addictive substance in cigarettes is nicotine, and delivering it in an e-cigarette rather than a traditional product doesn’t erase that effect on the body.

Two other problems involve long term potential effects of the introduction of e-cigarettes. First, younger and younger people are being introduced to this product. Despite lower carcinogen potential, delivering blasts of nicotine and carcinogenic substances to teenage bodies produces potential long term damage at younger ages. This leads to nicotine dependence in previously non-smoking individuals. Second, the crossover between using e-cigarettes and using traditional cigarettes is quite high, and some of the tobacco risk is additive.

At present, e-cigarette users are treated as smokers, especially if their specimens contain measurable nicotine. While the FDA works to standardize and control specifications for a uniform public health standard for all the non-regulated products that exist, long term safety is still unknown, as is the potential to create new smokers among youths who are introduced to e-cigarettes as a “safe” alternative to tobacco products.

It is always nice to know that the top clinical research centers in the nation are continually working to update their treatment guidelines. The American College of Cardiology (ACC), along with the American Heart Association (AHA) and the Center for Disease Control (CDC) have updated their clinical practice guidelines for cardiovascular disease as of November 2013. How do their findings affect our knowledge of disease prevention, and how do they relate to underwriting?

Certainly not news but reiterated by the AHA were healthy lifestyle guidelines. Activity levels should be for an active lifestyle (at least 30 minutes of walking or exercise daily) and maintaining a normal weight. Generally this assigns to a body  mass index (BMI) of between 22 and 25. Though technically overweight, most with a BMI of between 26 and 28 also did quite well in the heart studies, so long as they were physically active. Those looking to maintain their cardiovascular health may want to consider checking out the customer reviews of energy renew to see whether dietary supplements are the way to go for improving their health and wellness.The majority of build tables in life insurance underwriting are generous with regard to standard mortality (a bit more strict with preferred criteria) and take this into account.

All the committees came out as extreme advocates of the use of statin drugs to lower cholesterol levels. While a common joke is that cardiologists would like statins added to the water supply, the 2013 Report on Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Disease in Adults was quite clear. High intensity statins appear to reduce cardiovascular risk in primary and secondary prevention populations across all ranges of triglyceride levels. The thinking that omega 3 fatty acids and fibrate drugs were useful adjuncts is now thought to be non-additive to statin drugs alone in the process, which simplifies therapy.

Most of our insurance tables are based on total cholesterol and ratio of total cholesterol to HDL (the “good” fraction). As a result, newer drugs thought to raise good cholesterol were studied relative to mortality. Although HDL is still a good marker for increased atherosclerotic risk, the panel found that the drug of choice for people with increased cardiovascular risk and low HDL levels was (you guessed it)-statins. None of the trial data suggested the use of other adjuncts for therapy.

So what are accepted numbers? And who gets treated? Those with clinical atherosclerotic heart disease, LDL (“bad” cholesterol) over 190, those with diabetes, and those with calculated scores by the American Heart Association over 7.5 percent.

Again, in insurance underwriting, lower is always better. Standard mortalities are generally with cholesterol/HDL ratios under 6.5 to 8, and total cholesterol less than 240. Preferred criteria (now that there are multiple classes of preferred, there is often multiple risk stratification with cholesterol) prefer the total cholesterol under 190 and ratio under 4.5. And in clinical practice, if there are other diseases that are associated with cardiovascular disease (such as diabetes, heart attack or kidney failure, for example), lower is even better, with some guidelines preferring total cholesterol (on treatment) below 130 and LDL (bad cholesterol) measurements under 70. With the treatment of choice: statins.

Of course, the presence of any additional factors can worsen risk. When there is high blood pressure, ratable build, an abnormal EKG, or diabetes for example, the coronary heart disease risk is multiplied. It makes high or even high normal cholesterol more important to underwriting and evaluation of increased risk.

In all cases, treatment is not considered an additional risk factor but rather a blessing, as lowered levels equate to lower mortality risk.