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Robert Goldstone

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MD, FACE, FLMI, board certified internist and endocrinologist, is medical director for SBLI of Massachusetts. He has extensive brokerage and life insurance experience over 30 years with Pacific Life, MetLife Brokerage and Transamerica Occidental Life. Goldstone is board certified in insurance medicine and the inaugural recipient of the W. John Elder Award for Insurance Medicine Journalism Excellence. He was also honored as a fellow of the prestigious American College of Endocrinology and has written monthly for Broker World from 1991 to September, 2021. Goldstone can be reached by ­telephone at 949-943-2310. Emaill: drbobgoldstone@yahoo.com.

Barrett’s Esophagus

Barrett’s esophagus is a relatively common condition in which normal esophageal tissue (which is squamous cell epithelium) is replaced by columnar metaplasia. Up to five percent of people here in the United States will develop this condition but most alarmingly, another five percent may go on to develop esophageal adenocarcinoma. Since cancer of the esophagus has a very poor prognosis, recognition of this condition and early treatment is of paramount importance.

The commonest predisposition to Barrett’s esophagus is GERD—gastrointestinal reflux disease. As time with GERD goes on, the character of the cells change from benign to pre-malignant. Most people who are diagnosed with Barrett’s are looked at for epigastric discomfort, or persistent heartburn. The reflux esophagitis may either be ignored or treated with antacids or proton pump inhibitors. It isn’t until endoscopy is performed that the diagnosis is made—small biopsies of the tissue during this procedure expose the abnormal cells. The difficult part of Barrett’s is that endoscopies aren’t done until the GERD symptoms have been present for a long time or are not responsive to empirical treatment. It makes it so that diagnosis of this condition (or even esophageal cancer) is made late in the course of the disease, when intervention may be too late.

There are many factors that are associated with a higher incidence of Barrett’s. It is more common in males than in females. Generally the affected are over the age of 50, and a family history may be present. It is preceded by a long history of reflux disease, and is more common in smokers. Ulceration or stricture of the esophagus and previous chemotherapy also present an increased risk. It is also common in those who are overweight or have any previous insult or toxicity to the esophagus.

When an endoscope is passed, small biopsies taken during the course of the procedure are examined under the microscope and the diagnosis is made. The risk of cancer is higher when longer portions of the esophagus is involved, and longer time with symptoms is also an increased risk for Barrett’s. Generally the cell transformation is characterized as either low grade or high grade. High grade disease has the highest chance of malignant potential. The diagnosis in any phase is always an indication to have periodic endoscopies to monitor the course of the disease.

Treatment of Barrett’s involves the vigorous use of acid suppressive medications such as proton pump inhibitors or H2 antagonists. If medication does not work, surgery may be indicated to decrease the amount of esophageal reflux. Treatment in these cases is not curative once the changes in tissue have occurred but it does help reduce or eliminate any further change.

Underwriters look to see the biopsy results and the degree of cell changes, how severe these changes are, any complications that might exist, and how long the disease has been present. A small segment of Barrett’s that is being treated may not be ratable. Longer involved segments and longer time that the disease has been present also factor into a rating. Once there is evidence of cancer, Barrett’s generally becomes uninsurable and much more aggressive treatment is involved.

X Doesn’t Always Mark The Spot

An increasingly common occurrence in an emergency room or even in a routine doctor office visit is the diagnosis of chest pain in a woman. An affected female describes quite typical symptoms of angina and significant chest pain, shortness of breath, or central abdominal pain that warrants further investigation. The physician sees a normal or nonspecifically abnormal EKG. The patient may or may not be sent home with reassurance. When it reoccurs, a treadmill is ordered and often positive. A cardiac catheterization is next. No obstructive lesions are seen.

Once, these women would have been lost to follow-up and their next encounter might have been with a heart attack or even sudden death. It is recognized that this condition is now recognized as INOCA (Ischemia and No Obstructive Coronary Artery disease). This is also known as Syndrome X. Here “X” doesn’t mark the spot—in fact the coronary angiogram much more often than not comes up clean. It is estimated that 3-4 million women in the United States have stable INOCA. Knowing what the diagnosis is not only allows treatment of a significant portion of women at risk, but also contributes to a decreased amount of unneeded testing that comes with its own set of complications and adverse effects.

The two most common causes of Syndrome X are coronary microvascular dysfunction and vasospasm of the epicardial arteries. The coronary catheterization shows relatively clean coronary arteries, and the condition may be treated more as an inconvenience than a medical condition of concern. More recent studies of patients with INOCA/Syndrome X however show an elevated risk of cardiac events. These include acute angina and coronary syndrome, stroke, hospitalization, and sudden death. A high percentage show no demonstrable cardiac lesions responsible.

When very small coronary vessels are deprived of blood flow, the occurrence of angina (a heart’s cry for help as it is being inadequately perfused with oxygen) is just as telling as a larger more demonstrable heart attack. Vasospasm (when the arteries go into spasm and do not permit adequate blood flow) show similar signs and symptoms. Either way, whether smaller vessels are affected or even “kinked,” the results are the same. At this point modification of all risk factors becomes necessary to minimize symptoms and to prevent progression into more severe forms of obstructive disease.

There is now more specific testing for coronary microvascular disease and vasospastic coronary symptoms. Called CFT (coronary function testing), it involves the use of vasoactive infusions with chemicals such as adenosine and acetylcholine. Nitroglycerin is also used to diagnose nonepithelial dependent microvascular dysfunction. If the diagnosis is unclear, PET scanning, cardiac magnetic resonance and Doppler echocardiography is also employed. At times, empiric therapy is also used—this is a doctor’s high clinical suspicion of this condition followed by what would be the treatment if that were the case. Those with contraindication or allergies, which prevent full testing, may make the diagnosis if successful response to treatment is observed with therapy.

Underwriters look for as much information as they can get from testing, since the diagnosis and treatment are not always clear-cut. All cardiac testing, successful modifications of risk factors, nature of treatment, and frequency of symptoms are considered. When the diagnosis is clear and the time between events is greater than six months to a year, standard insurance is possible. When poor cardiac follow-up or risk factor modification is not optimal, a policy may be rated to account for this. With Syndrome X, knowing that the disease has been diagnosed even when a catheterization is negative and that “X” doesn’t always mark the spot is more than half the battle.

Impaired Risk Life Underwriting: Past, Present and Future

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In 1987, Ronald Reagan was finishing what might be later referred to as an “impaired” presidency, the Minnesota Twins won their first World Series, and we were entering what would become the Renaissance of Impaired Risk Underwriting as a force to be reckoned with. I was practicing Internal Medicine and Endocrinology, and was looking to use my knowledge outside of the nine dots. After leaving practice to start my Insurance Medicine career at Transamerica, I was presented with an opportunity to ride the wave of an up and coming business—impaired risk underwriting—at MetLife Brokerage. It was easy to see that the opportunities would be enormous.

Impaired risk was just turning the corner from being the stepchild of underwriting to becoming one of the most profitable areas of many companies’ business. It would need a shepherd to lead it and explain it to actuaries who felt it left too much to chance and conceivably led to innumerable early claims. A business whose experience dictated its rates and predictions, there just was not enough experience to draw proper conclusions from and, as a result, many imperfect conclusions were arrived at. Companies entering the field had more than enough cases to choose from, since they were not the cup of tea for most established insurers.

It was expensive for a company to take in every case, and certainly to underwrite them all, many of which had no chance of becoming a traditional or even a nontraditional case. Brokers and agents would prospect among those whose medical situations were “different” and “Papers” were born. With papers, medical information would be gathered by the field with the promising ones promoted to full underwriting. Unfortunately papers could be incomplete, missing important sections germane to the accurate assessment of risk, and used as examples as to why the concept could not work. Truthfully, it only needed people with a vision of the future to show that it could.

Impaired risk cases generally had more to underwrite with than any others did. Their medical records were complete and often exhaustive. The testing they came in with gave more information on how to more accurately predict life expectancy than came in on younger individuals. Impaired risks, due to the difficulty in obtaining insurance, were more willing to go out and obtain additional tests or information that made an underwriter much more comfortable that he or she could make a health prediction. Reasons for insurance were quite clear, whether they attempted to shield inheritances for their families, use existing tax law to their advantage, or designed to best protect their businesses. The pieces to the puzzle were there. What was needed was a dedicated group in each company to put them together.

Enter actuaries, who began to collect more and more information, especially on impaired lives, to make more accurate life expectancy predictions because the data was now there. Enter medical directors, who brought in so much information because they had been in practice themselves and knew how to read an APS. While early physicians joined a company just to answer underwriters’ questions on a medical condition, physicians who were now business trained were looking for ways to place cases and to take advantage of medical progress and evolving medical trends. And enter more educated underwriters, ones who not only learned medicine well enough to use the medical data they were given but to ask the right questions to see what was profitable and if they had an advantage over other competing companies, whether medical or financial.

There were other headwinds that helped impaired risk underwriting gain a strong foothold in an insurance company’s mix of risk. Older people were an incredible source of potential business who were not being tapped for fear of early claims or a lack of understanding of their medical health conditions. The elderly as an important risk market was a key realization—they had the money, and now could be underwritten more accurately than ever before. People were living longer thanks to advances in medical techniques and technology and, as such, claims were paid out later than anticipated with insurers investing the money. Interest rates, even dropping ones from the murderous conditions of 1981, had enough to compensate for the occasional blip in underwriting experience in a given year.

It was a golden age in impaired risks, and there were shops all over doing well to prove it. But then something changed. As with life in general, many somethings changed. Emphasis on cost and automation thinned down insurers. Life insurance was being made to be sold directly as a commodity to interested people, as easy as filling out an application and getting approval while traveling on a plane. Younger people needed less requirements, which meant less doctors and underwriters to employ, and as such simplified issue. The key was no longer accuracy but convenience and quick time to issue. Genetic testing made risk prediction possible even at younger ages. Tools such as facial recognition, credit reports, business patterns and zip codes were now added to an application. Taking in the most standard and preferred issues in a law of large numbers setting meant less could go wrong and the pool could adequately compensate for a mistake. It takes less money, less time, more use of automation, and of course fewer people. Products which produce no money or interest make insurers work to be leaner and meaner, and much more limiting tax laws also take out a large slice of the population who made up an important part of the impaired risk business. Less requirements also means fewer doctors to read and interpret them; the American Life Insurance Medical Directors Association, which totaled 900 members when I started, is barely over 200 today.

Then why do I have such confidence this business will be back, and even stronger than ever? The older uninsured and impaired part of the population is again becoming the largest uncovered one for insurance, and will evolve again as a key and important market. Cases are becoming complicated enough that they will not be amenable to simplified underwriting. Attempts to use non-medical factors in underwriting will prove to be inaccurate. For the first time since 1945 life expectancy has actually dropped in the United States, and the existence of COVID and future epidemics like it will leave less healthy people in the world to insure.

Life is not getting easier, as our overtaxed hospitals and health care system remind us each day. More people are presenting out of the stream of simplified issue and decreasing requirements. While this population is young now it will age quickly, and the results of estimating life expectancy without medical records, necessary testing and increasing results of unhealthy lifestyles and pandemic living will again fill the pool of those needing our help and life insurance. It is my prediction that impaired risk underwriting will again rise, and in the not too distant future. It is too important not to.

Life Expectancy And The New Underwriting

For the first time in many of our lifetimes, life expectancy in the United States has declined. Not only did it just not go up as much as we expected—it actually declined. The fall of 1.5 years in 2020 from 78.8 years to 77.3 was the steepest decline since World War II, and the last time actual life expectancy was so low was in 2003 according to the National Center for Health Statistics. That last year of significant decline was in 1943, when the United States was at war and the presumed drop was accountable to casualties during that time.

The pandemic that consumed most of 2020 would be the obvious culprit to account for this drop, and yet it is unlikely that life expectancy will recover in 2021 to pre-pandemic levels. As the new COVID-19 delta variant has proved, the pandemic was not just a limited time event. Especially in areas where vaccination rates have not reached herd immunity protection, we could see yet a further decline in life expectancy. An interruption in the services that caused life expectancy to increase has not only caused many chronic health conditions to worsen, but these effects will be seen in all likelihood throughout an individual’s lifetime. This effect will carry on to actuarial estimates of life expectancy, and cause changes not only in actual underwriting but in pricing assumptions as well.
The pandemic itself in the United States has taken the lives of nearly 600,000 people and counting. Obviously all this life lost was not priced into life expectancy nor into expected premiums and death claims paid out. The effects however of illness and limited access to health care has not only had deleterious effects on general health but is also in effect a “pay it forward” type of scenario. Any condition that has worsened for lack of proper directed health care has caused permanent effects on many individuals that are likely to result in shorter life spans than would otherwise have been expected. The effects therefore go on and on.

Take diseases such as hypertension, hypercholesterolemia, heart disease and diabetes as examples. Hospitals and doctors were so taxed taking care of the acute problems associated with COVID-19, expected health care for conditions that cause ongoing morbidity and mortality was neglected. So called “elective surgeries” were cancelled. Those surgeries deemed non-essential at that moment in time allowed chronic conditions to progress and affect people’s future health in general. Diabetes and heart disease not properly controlled will not have caused an acute increase in mortality over the year or two in question but are likely to have caused changes resulting in lower overall survival over the longer term. Effects of COVID-19 virus in many survivors may have weakened heart and lung function on a permanent basis going forward. The long term effects of what may be a short term pandemic can go on for years and years to come.

Other effects of the pandemic have caused changes to overall health and survival that are much more difficult to measure. Prolonged isolation and stress have profound effects on well-being and self-care. Stress, changes in diet and healthy exercise routines, and missed appointments for follow-ups are impossible to quantitate. Drug use, increased alcohol consumption, poor eating habits and grief from the loss of loved ones increase the prevalence of atherosclerosis, heart disease, cirrhosis and chronic liver disease. Not working and living in suboptimal conditions due to a lack of income also shepherds along with it poorer health and higher short-term morbidity rates which can lead to premature mortality.

Insurers in the last few years have begun the push to accelerated underwriting according to previous experience as well as for convenience with a minimal amount of requirements in order ease the path toward putting insurance in force. Can an insurer now so confidently waive APSs or blood work that was pushed aside in the underwriting process? Can an insurer likewise predict future health based on the effects of the pandemic? Will experience ratings have to be altered because for the first time planning for increased life expectancy thanks to good self-care and advances in medical care can no longer be confidently priced in? Who will bear the burden of the increased amount of premature benefits paid out and the settled death claims far sooner than what was planned for?

Experience plays out into the future, and what was predicted for over the years based on the law of large numbers and expectations for gains in life expectancy can no longer be assumed. The COVID-19 pandemic that was hoped to be over by this time has been extended by the prevalence of the delta variant. The fact that the United States can barely get over 50 percent of its population vaccinated (far less in certain endemic areas) makes the future almost impossible to fully appreciate. In a system where experience is a key predictor in how insurance is obtained and priced, the future of underwriting has become far less able to be planned for, and the “new underwriting” may be just beginning.

The Law Of Large Numbers

Simply stated, the law of large numbers in probability and statistics states that as a sample size grows, its mean gets closer to the average of the entire population. Insurers (in particular reinsurers) have been gathering data now for decades, and advances in informatics has made this data more easily acceptable and interpretable. The more similar the cases that are tabulated and studied are, the closer insurers can get to a probability that is predictable.

Impaired risk cases are outliers. They do not generally conform to the law of large numbers because there are so many variables involved. The many different diseases and complications of multiple factors on overall health make them more difficult to predict. The interactions between health impairments and how different combinations may lead to different outcomes makes this task even harder. Impaired risk has always been the segment of business that required the most hands-on part of risk assessment and the most experience in dealing with it profitably.

Until now, there has been an acceptable amount of “error” (for lack of a better term) in pricing impaired risks. Advances in medicine and treatment led to a progressively longer average life expectancy than actuaries were pricing for. There was less informed competition in impaired risk offers and higher risks were priced for, in excess of what the market allows today. The ability to spend more underwriting dollars in acquiring information (such as APSs, additional blood work and studies, and confirmatory visits to specialists) is becoming more and more limited. The pricing of impaired risk business has had to be more accurate than ever before.

Other things work against impaired risk continuing to be a profit center for many companies. Unexpected epidemics (such as COVID-19) exposed the already vulnerable to a source of mortality that was unexpected and completely unpriced for, as they were the more susceptible population to such disease exposure. The average life expectancy took a step backwards in the last few years, which was unplanned for. Money that could have been made up in investment yield and income has proved harder than ever for insurers to rely on. Taking on more uncertainty in risk assessment was not in insurers projections.

Cheaper and more accelerated underwriting does not lend itself well to impaired risk. Data based and predicted methods, which work so well with younger ages and fewer medical variables, is becoming a mainstay of the underwriting process. Placed applications have increased in the younger age group where fewer requirements are the norm. There is growth in the market for relatively affordable and smaller policies. Essentially actuaries are relying on the fact they can better price risk the more lives they can spread risk over.

A change in staffing is also making things more difficult for impaired risk case placements. Physicians who had been dealing with substandard cases for years are retiring and the replacement is generally a much less experienced resource with a background in informatics or genetics. Cases being accepted are more often those where a decision can be made on more minimal underwriting requirements. Doctor to doctor contact and the collecting of medical information at a cost to the insurer is being minimized. These are the backbone to bringing on a potentially profitable impaired risk case, and that backbone is being de-emphasized.

Whether this change in the way of doing business turns out to be permanent or whether it is just another way of doing business that exists only for the immediate future is an open question. Too many non-medical factors (yields, investments, demand, and a return to increased life expectancy) are just complete unknowns even in the immediate future. Working within the present though is most important. It requires a good existing relationship with underwriters, the preparation of a substandard file in even more detail than ever before and often the obtaining of APSs and supporting information well in excess of what a broker or agent has done before. Most likely however is that impaired risk will find its place in the sun again in the future when the market requires it, and it will take doing the existing business more carefully and completely than ever before in the interim. It too will have its place in the law of large numbers.

The Need For A Follow-Up

Many applications have APS trails that read like a suspense novel. There is a medical condition, oftentimes a serious one, that has an intervention, and the trail ends. Perhaps it is a chronic condition, with unknown degree of control or stability that leaves no clue as to the present status. Maybe even a serious cancer condition that is treated with surgery, chemotherapy or radiation that does well at first, but no clue exists over what is happening in the present. The case will need closure, and that closure is best off anticipated by obtaining a follow-up or current status report with the application.

Underwriters get one chance at obtaining all the information they need in order to make a binding decision on risk. If a material fact is discovered after a policy is issued, unless it was fraud or a lack of disclosure, there is not a second chance to make a different decision. As long as all sources are disclosed, the underwriter has the responsibility of following up on the information that may be available. As such, it is not a good idea to leave a company guessing as to what might be happening. It generally will not be in a client’s favor unless current information is involved.

Gastrointestinal bleeding is one such example. The threshold for screening colonoscopy has been dropped in age to 45, and with good reason. Many cancers and pre-cancers are found early enough to be successfully treated with the newer guidelines. Therefore, if there is a complaint of blood in the stool, or a positive guaiac or Cologuard test for occult blood, the story does not end if the insured feels well, or the bleeding “stops” without a follow-up. It is necessary to know if there is an underlying pathology or the problem had a temporary reason that successfully resolved. Which often requires a doctor follow-up for the case to proceed.

A recent case that presented with a small “non-malignant” tumor in the heart that was successfully treated when a stent was used to approach the tumor without having to surgically open the chest to take the growth out. It was a delicate procedure as the tumor invaded one of the valves in the heart. At that point the surgery was deemed “successful” but the information available ended there. Was the tumor completely removed? Was the stent taken out of the heart or left in permanently? Was the valve functioning properly post-operatively, and was the valve and the rest of the heart intact and disease free? All this was information that was needed to go further, but no notes as to follow-up were available.

Neurologic disease pretty much always needs a current status available to the underwriter. Diseases like Parkinson’s can be stable or progress relentlessly. If the underwriter does not know the course of the disease and how stable (or unstable) it has been, no decision he or she makes can be a favorable one. Diseases like multiple sclerosis can have long periods of stabilization, or may have plateaus and periods of degeneration that can have serious disability. Demonstrating stability not only in the past but in the current can lead to a placeable offer on a case. The continuous follow-up information is crucial to the assessment of risk here.

Oncology cases are particularly sensitive to current follow-up. Cancer treatments can be successful or subject to long periods of remission. However for someone who has had cancer but provides no follow-up on the current results of treatment, it is impossible to be sure a recurrence hasn’t preceded the current application for insurance. Many cancers such as breast and hematological malignancies have rates of recurrence that persist long after initial treatment. Whether it is the oncologist or regular internist that provides current follow-up, it is still necessary for the case to proceed.

Finally, all the information that has succeeded any acute event must be followed up on. If there is a dangerous sign or symptom that an insured has sought treatment for but there is no current status or details of resolution, you’re leaving an underwriter the necessity of guessing what the worst possible outcome could be. Since underwriters have uniformly been exposed to the worst possible outcomes, their imagination may not be pretty. An underwriter will often have to postpone or delay a decision to wait on a proper follow-up, and the delays never help case placement. Anticipate and provide what is needed in advance, as accompanying information on follow-up submitted with the underwriting medical information leads to a smoother and very often more successful process.

Underwriting After Cancer

Advances in medical therapy have led to not only increased longevity after the diagnosis of cancer but in many cases an actual cure. Normal life expectancies are more often the case now after definitive cancer treatment, and extension of life after other cancer treatments are now reasonable expectations. Which cancers are most amenable to favorable underwriting and which may not be as favorable to long term survival are ultimate challenges for insurers. There are of course many different factors in making these estimations.

After a diagnosis of cancer, insurance postponement is the rule to better assess the degree of treatment and response to the therapy. Generally, this is done for a certain amount of years, and the clock begins not after diagnosis of the problem but after therapy is fully completed. There has to be definitive treatment for the cancer, otherwise the case remains a decline. There is a flat extra rating period after a certain amount of time, where an extra premium is charged until the risk of cancer recurrence equates to a standard mortality. At a certain point the insured’s mortality equals that of a standard premium and the flat extra falls off.

With many cancers the risk of recurrence is early in the process, and those for example which were amenable to complete removal are insured earlier and with shorter periods of added premium. Some however pose a risk of late residual mortality even after complete and radical treatment is accomplished. Breast cancer is one of those examples—there are recurrences even well after treatment and as such the added flat extra may persist for quite an extended time. Some types that are more notorious for adverse late outcomes may require a permanent flat extra for the duration of the policy to cover a possible cancer recurrence.

Not all cancers of a certain body organ or system are looked at or are rated equally. Each cancer is different and requires a specific focus on individual variables. Cancer cell type is important, as some types are more aggressive than others. The more the cells resemble the normal architecture of the organ involved, the better they do treatment-wise. Those that have wild growth, or anaplastic types, have poorer prognoses. The spread of the cancer is taken into account—those that spread to additional tissue or are larger in size have a different outcome than smaller more limited ones. Cancer is staged differently depending on whether it limits itself to the specific area or invades local musculature and lymph nodes. Cancer that has spread to other organs (metastatic) does the least well. Cancer may recur even after long indolent periods—even after 10 to 20 years of disease free periods.

Some malignancies are called indolent ones—they are not curable but are still compatible with many years of life. Leukemia (such as chronic lymphocytic leukemia), certain types of non-Hodgkin’s lymphoma, and skin disease which may eventually metastasize to organs (such as mycosis fungoides) may have very extended periods of survival. Those are insured at times with permanent ratings, because the risk of the cancer having adverse mortality is forever present. These types of cancers have to be looked at individually and ratings may gravitate to the side of caution because the underlying problem is perpetually present.

Second cancers are generally insured with higher ratings. The body’s immune system is key to cancer resistance and the appearance of a second malignant growth may signify an additional problem. Likewise, the long-term effects of cancer treatment may have to be taken into account. High dose chemotherapy and radiation treatments may have a beneficial effect on the primary cancer process but other body organ systems may fail over time due to the burden of treatment as cancer treatment affects all cells, not just diseased ones.

The key to insuring those with cancer rests on full staging information, confirmation of definitive treatment, and a lack of recurrence. Patient compliance and regular doctor follow-up is necessary in all of these instances—without them, estimates of survival and insurance offers are rarely possible.

Hypothyroidism: Often A Silent Disease

Hypothyroidism is estimated to be present in over one percent of the population and up to five percent over the age of 60. While hypothyroidism is easily diagnosable through laboratory testing, most lab panels do not include it as a routine test. Many carry this diagnosis with overt symptoms, but most are asymptomatic particularly when the disease is mild. When advanced, it may cause symptoms that may lead to a medical emergency.

The thyroid gland controls the metabolic rate in the body. When body metabolism slows, both mental and physical sluggishness can develop. Particularly in older individuals, hypothyroidism can be mistaken for just the “normal” process of aging. However, blood pressure, heart function and fluid regulation may be adversely affected, and prompt treatment is required to restore normal body function.

Mild hypothyroidism generally escapes detection on a physical exam without a screening panel that includes thyroxine and thyroid stimulating hormone measurements (T4 and TSH). Patient complaints include weight gain, tiredness, weakness, mild shortness of breath on exertion, joint pains, and even reported depression. Further questioning may reveal cold intolerance, joint pains, myalgias, and prolonged bleeding from menstruation. While an enlarged thyroid gland may be part of the picture, hypothyroidism can occur without this finding. As hypothyroidism progresses, findings of high blood pressure, cardiac failure and significantly delayed reflexes become part of the picture.

Hypothyroidism is much more often than not a primary disease of the thyroid gland itself. Those treated for the opposite problem (hyperthyroidism or an overactive thyroid) may slip into hypothyroidism as a consequence of the treatment itself. Autoimmune disease, particularly a condition known as Hashimoto’s thyroiditis, causes the gland to gradually fail and not produce the necessary thyroid hormone needed by the body. Iodine deficiency (particularly in parts of the world where iodine is not supplemented into foods like bread and salt) and cases due to pituitary failure (secondary hypothyroidism) are less common causes.

Thyroxine (T4) and triiodothyronine (T3) are the body’s main active thyroid hormones. These levels are decreased in hypothyroidism. Because sometimes body proteins and other metabolic states cause abnormal binding to proteins and may affect the measured values, the best value for diagnosing hypothyroidism is TSH, or thyroid stimulating hormone. Think of the process as a feedback loop. The pituitary gland in the brain is the thyroid-regulating center. When thyroid levels are low, a signal from the pituitary tells the gland to produce more thyroid hormone, and TSH rises. The hormone charged with this is TSH. An elevated TSH level is the signal that more hormone is needed or the body’s supply is less than adequate. This combined with low thyroid hormone measurements make the diagnosis. When the cause is secondary (the pituitary is failing), both thyroid hormone and TSH levels may be simultaneously low, but then other pituitary hormones are likely low and the diagnosis is made through those coincidentally low values.

Untreated hypothyroidism, particularly in the older population, can become quite serious. Myxedema coma, the most severe form of hypothyroidism, may cause severe body decompensation. Heart disease, lowered blood pressure, subnormal body temperature and decreased heart rate can become life compromising. Additionally, myxedema is difficult to treat and must be done under monitored conditions with extreme caution. Dementia may also occur, and this condition has to be differentiated from prolonged low thyroid levels. Hormone replacement may reverse these changes.

Treatment of most cases of hypothyroidism can be accomplished with simple thyroid hormone supplementation in the form of a daily oral medication. T4 (Synthroid) may be taken once a day with excellent results, and sometimes combinations of T4 and the more active thyroid metabolite T3 are used. Proper dosage is established by blood testing and monitoring of TSH and symptoms. As different people have a different thyroid set point, the dosage is not a uniform dose for each individual.

Most underwritable thyroid disease is not ratable, with preferred status available to most all who do not have accompanying disease and who take their medication regularly. Hypothyroidism becomes ratable with diseases such as uncontrolled hypertension or cardiac abnormalities. Again, well-monitored replacement therapy is a key to the best result.

The Limitations Of Hemoglobin A1c

When assessing glycemic control in the majority of our applicants, hemoglobin A1c is the gold standard for assessing glucose control over an intermediate period of time. It controlled for many of the “I had a bad diet yesterday,” “It was a tough weekend,” or “Except for last week I ate perfectly.” Yet there are circumstances when hemoglobin A1c may be an unreliable value. As such, there are other ways of getting a fair picture of glucose control.

Hemoglobin itself is the molecule within red blood cells that carries oxygen to the body tissues. A small part of the hemoglobin has sugar attached to it, and this is measured as the hemoglobin A1c. The amount of hemoglobin A1c is dependent on the level of sugar in the blood—higher sugar levels mean higher hemoglobin A1cs. As the red blood cell in the body has a life of about 120 days, a blood measurement may find a red cell that is 119 days old or one that may be a day or two old. That average in-between (of approximately 8 weeks) correlates to the hemoglobin A1c.

A random blood sugar is truly the measurement only at the exact time the blood is drawn, and represents a moment in time. Sugar in the urine sample may or may not correlate to the degree of glucose control in the body at a given moment. Fructosamine, also used by our testing labs, measures average glucose in the two to three week range. In clinical practice, a doctor uses random blood sugars, fasting bloods and a short term measure of control (such as fructosamine) to guide medication therapy. For insurance purposes, hemoglobin A1c provides a much better guide to intermediate and longer term control and allows assessment of the effectiveness of blood sugar control that excuses a day or even a week or two of non-compliance.

Many conditions that modify red blood cell production, destruction or influence the life span of the red cell will alter A1c measurements. Those include chronic renal disease (with shortened red cell life) that may decrease the A1c level, chronic liver disease (which may increase or decrease the level), and the absence of a spleen, where there is decreased red cell turnover due to an increased red blood cell life span (as there is no spleen to serve as a filter for removing abnormal or old cells). Iron deficiency anemia increases hemoglobin A1c as a reduced red blood cell turnover prolongs the survival of the cells. Hemolytic anemia does the opposite with reduced RBC turnover prolonging RBC survival. And all bets are off in pregnancy, where hemoglobin A1c may be increased later in the pregnancy but decreased early on.

Sometimes people with different hemoglobins can have completely different A1c measurements. Sickle cell anemia, thalassemia and many variants found in ethnic populations can provide strikingly different results that have little if anything to do with the degree of sugar control. The results are multifactorial and can depend on the type of hemoglobinopathy and/or anemia that exists. Even simple Vitamin B12 and folate deficiencies in the diet may increase hemoglobin A1c by reducing the turnover of cells and prolonging the red blood cell survival.

When hemoglobin A1c values are off and don’t correlate to the true clinical picture in an applicant or patient, there are other tests used to get a more accurate picture. Serum fructosamine (as mentioned previously) is a circulating glycated protein (mostly albumin) that is independent of hemoglobin abnormalities. It is more related to the half-life of albumin (about 17-20 days) and as such gives a very accurate but shorter period of control measurement of two to three weeks. Glycated albumin also gives a good 14-21 day measure of glycemic control but has limitations in those with any albumin problem (like liver disease or thyroid dysfunction). Capillary blood glucose and continuous blood glucose monitoring are both quite effective but generally limited to clinical practice in those who have an established diabetes diagnosis and are assessing the degree of control diet and medication may bring.

As insurance laboratory blood testing can now run both fructosamine and hemoglobin A1c on the same sample, there are less problems with assessment of glucose control that an underlying blood abnormality may disguise. Severe conditions in body physiology and disease are usually quite obvious (like kidney or liver failure) by other clinical and laboratory testing and can differentiate a hemoglobin A1c abnormality quickly. Thankfully though the measures used now in our laboratory assessment of blood sugar control provide us an accurate means for an underwritable situation and accurate assessment of blood sugar control.

Carotid Artery Stenosis

Carotid artery stenosis is a narrowing or constriction of any part of the carotid arteries, generally caused by atherosclerosis. One of the body’s largest arteries, the common carotid artery is the one you can generally feel pulsations of on each side of your neck. It comes off of the aorta and divides into the internal carotid artery (which supplies blood to the brain) and the external carotid, which supplies the face. The area where it divides is a common site for atherosclerosis, which is a buildup of plaque that narrows the vessel or provides the tendency to rupture and shoot through the bloodstream.

In most cases the cause of carotid artery stenosis is a degeneration of the wall of the artery, usually from fatty or cholesterol deposits. Sometimes the plaque is stable, and causes a narrowing of the blood flow through the brain and face. Other times, a part of the plaque may break off and travel through the circulation to the brain or other body organs. When the emboli shut off blood flow to a given cerebral area, a TIA (if it is temporary) or a full blown stroke can ensue.

The characteristic signs of carotid stenosis are a bruit (rumbling sound) over the carotid artery or the end result—a TIA or stroke. In those with risk factors (high cholesterol, HTN, obesity, diabetes) carotid artery screening may be done in the absence of a precipitating event. This has become quite controversial as we will discuss shortly. A Doppler ultrasound can determine the extent and the degree of the stenosis. Cerebral angiograms were a diagnostic tool but are used less frequently now with the advent of very sensitive MRI and MRA (angiogram) testing.

Treatment is generally aimed at the prevention of problems, including strokes and other complications of atherosclerosis. Anticoagulants (blood thinners like Coumadin or Eliquis) may be given as well as antiplatelet drugs to retard clotting. Surgery (usually a carotid endarterectomy), an open removal of carotid plaque, has been less used because of the risks of preoperative angiography and surgery, however angioplasty and stenting are still the main procedure used for significant symptomatic carotid stenosis.

Recently the USPSTF (US Preventative Services Task Force) reviewed evidence for screening for carotid artery stenosis in asymptomatic individuals and gave it a “D” or unnecessary recommendation. They focused on cost of testing relative to positive findings, false positive testing requiring further work-up which proved to be negative, and potential harm from the angiography, surgery and other interventions. Their position is very controversial, especially in those who have been spared potential life threatening stroke or sudden death.

Prognosis of carotid artery stenosis depends on the degree of stenosis and the contributing co-morbid conditions that may cause progression not only in the carotid arteries but in other major blood vessels in the body. With stenosis less than 50 percent there is a small risk of stroke. At 70 percent or higher the risk becomes quite significant and intervention becomes a consideration (surgical or medical). Risk factor modification such as lowering blood pressure, using cholesterol lowering drugs, smoking cessation and weight loss are important preventative steps.

Most applicants will be rated with stenosis over 50 percent or if significant stenosis has occurred at younger ages (less than 50 for example). Aggressive medical therapy and intervention may be credited in these circumstances. When TIA, stroke or carotid intervention has occurred, the ratings increase. As mentioned active risk modification and close doctor follow-up is necessary, as carotid artery dissection (tearing) and major stroke are distinct causes of mortality.