Diabetes

Cheryl Joyce, FALU, FLMI, ARA, ACS

Executive Director, Fac Exclusive SUP Solutions

September 9, 2019

Kyle Kilman, FALU, FLMI, ARA, ACS, AIRC

Underwriting Consultant

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What is diabetes?

Statistics

Anatomy

Three major classifications of diabetes

Signs and symptoms

Diagnosing diabetes

Part One

3

Control

Compliance

Complications

Comorbid conditions

Trends in treatment

Part Two

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

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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

Statistics

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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)

Statistics (cont’d.)

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Global Diabetes Prevalence – Top 10 Countries

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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

Global Diabetes Prevalence 2000/Projected 2030

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• Located behind the stomach

• About 6 inches long

• Aids in the digestive process by making hormones and enzymes

• Contains islet cells

Anatomy

Pancreas

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Islets of Langerhans

Alpha Cells – Glucagon

Beta Cells – Insulin

Delta Cells - Somatostatin

Anatomy (cont’d.)

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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

Anatomy (cont’d.)

Glucagon

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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

Anatomy (cont’d.)

Beta Cells and Insulin

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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

Anatomy (cont’d.)

Beta Cells and Insulin

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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

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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

3 Major Classifications of Diabetes

Type 1 DM

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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

3 Major Classifications of Diabetes (cont’d.)

DM Type 2

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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

3 Major Classifications of Diabetes (cont’d.)

DM Type 2

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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

3 Major Classifications of Diabetes (cont’d.)

Gestational Diabetes

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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

Diabetes Classification – Miscellaneous Category

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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 140-199 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

High-Risk Category to Develop Diabetes

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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

Signs and Symptoms

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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

Diagnosing Diabetes

Underwriting Diabetes

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Control

Compliance

Complications

Comorbid conditions

Trends in treatment

Part Two

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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

Diabetic Control

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Laboratory parameters (HgbA1c, fructosamine, urinalysis)

History of hyperglycemic/hypoglycemic episodes

Lipid control

BP control

Weight control

Control Measured

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Normalize blood glucose

Eliminate hypoglycemic and hyperglycemic episodes

Normalize weight (diet and exercise)

Treat co-existing conditions

Monitor and prevent complications

Treatment Goals

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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

Diabetic Compliance

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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

Brittle Diabetes

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Complications occur when a person’s diabetes is not adequately controlled

Acute complications

• Hyperglycemic or hypoglycemic episodes

• Diabetic Ketoacidosis

Diabetic Complications

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Macrovascular complications

• CVA

• Coronary Artery Disease

• Peripheral Vascular Disease

Diabetic Complications

Chronic Complications – macrovascular (large blood vessels) and microvascular (small blood vessels)

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Retinopathy

Nephropathy

Neuropathy

Diabetic Complications

Microvascular Complications

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While the exact mechanisms are unclear, the macrovascularcomplications 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

Macrovascular Complications

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CVA – risk of stroke is 2-4 times higher in diabetics than non-diabetics; 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

Macrovascular Complications

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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

Microvascular Complications

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Gastroparesis

Cataracts and glaucoma

Increased infections

Slow healing of wounds

Foot and leg ulcers

Other Complications

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Comorbid conditions will considerably worsen the prognosis

Examples of comorbid conditions include:

• Obesity

• HTN

• Alcohol excess

• Smoking

• Dyslipidemia

Comorbid Conditions

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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

Trends in Treatment

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Monitoring• Pain-free glucose tests

• Continuous monitoring device

Insulin therapy advances• Implantable pumps

• Insulin inhalers

• Insulin pill

• New insulin

Trends in Treatment (cont’d.)

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Islet cell transplants

Pancreas transplants

Gene therapy

Vaccine

Trends in Treatment (cont’d.)

Case Studies

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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

Case Study 1

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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

Case Study 2

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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 8.1

Case Study 3

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50-year-old male

$250,000

Mechanical contractor

5.6.269

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

Case Study 4

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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

Case Study 4 (cont’d.)

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45-year-old male

5.10.350

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

Case Study 5

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65-year-old male, smoker 1PPD

5.8.245

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

Case Study 6

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Assessing the Diabetic Risk

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

Stay with the Fundamentals plus….

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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

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