Diabetes update

The purpose of this article is to provide a general update of diabetes with a focus on newer developments that may impact risk assessment. The main reasons for concern about diabetes are the associated microvascular and macrovascular complications. Control of blood glucose levels, primarily assessed by measurement of hemoglobin A1c, has been shown to reduce the occurrence of microvascular complications. In conjunction with control of other risk factors, control of blood glucose levels reduces the occurrence of macrovascular complications. Type 1 diabetes is now known to be an autoimmune disease. For unknown reasons, the patient's immune system destroys its own pancreatic insulin-producing beta cells. The hallmark of type 2 diabetes is insulin resistance, which may be mediated by one of a number of gene defects. At some point, the pancreatic beta cells are unable to compensate for the insulin resistance by increasing insulin secretion. Type 2 diabetes then appears. Prediabetes, encompassing impaired fasting glucose and impaired glucose tolerance, is an important clinical entity that precedes the diagnosis of diabetes in many cases. Diet and exercise are the most important interventions for reducing the progression of insulin resistance to diabetes. Once diabetes develops, medications are matched to pathophysiology.     

Clinical implications of proteinuria

Proteinuria has long been considered a marker for renal disease. New observations are suggesting that proteinuria is also a risk factor for other outcomes as well, such as cardiac events and stroke. This article will review a recommended strategy for proteinuria detection and the associations of proteinuria with the progression of renal disease and cardiovascular disease. It will also review the significance of the development of proteinuria in the elderly population and discuss other common causes of proteinuria apart from those secondary to diabetes and hypertension.     

Screening potential elderly preferred markers: exploratory analysis of Cardiovascular Health Study (CHS) data

The Cardiovascular Health Study (CHS) analyzes risk factors for coronary heart disease and stroke in people age 65 and older. Since CHS is designed to comprehensively study cardiovascular risk factors in an elderly population, it provides a unique opportunity to study the association of risk factors with mortality, as well as morbidity risk. With the growth of the elderly as population and life insurance market segments, the need to more precisely stratify mortality within a standard risk group of the elderly has grown as well. This exploratory analysis assesses medical factors that could be used to improve mortality risk stratification within a "standard" mortality population, using the CHS public use data set. Participants with a personal history of cardiovascular disease, diabetes, or major electrocardiographic abnormalities were excluded from the analysis in order to mimic a standard life insurance selection process. Then, Cox proportional hazards regression was used to study 10 medical risk factors. This model suggested that forced vital capacity >80% predicted, serum creatinine <1.5 mg/dL (133 mcmol/L), hemoglobin >11 g/dL (110 g/L), and serum albumin >3.5 mg/L (35 mmol/ L) are significantly associated (p = 0.05) with favorable mortality. C-reactive protein <1 mg/L is associated with favorable mortality at borderline significance levels (p = 0.09). On the other hand, a family history of cardiovascular disease (MI and/or stroke) and low BMI (<26 kg/m2) are associated with unfavorable mortality in the analysis. Total to HDL cholesterol ratio of <6, presence of supine systolic blood pressure < or = 140 mmHg, and the presence of minor rest electrocardiographic findings were not statistically significant factors in the multivariate model. Further assessment of the predictive value of the "significant" medical factors identified is required in insured lives.     

Mortality in rheumatoid disease

This paper provides an overview of rheumatoid disease from the perspective of its impact on mortality. The term, rheumatoid arthritis, may promote the misconception that this disease is relatively trivial and easily managed; therefore, "rheumatoid disease" is preferred. Numerous long-term studies in many settings have established that significant excess mortality is associated with rheumatoid disease, and that this excess mortality is related to cardiovascular disease deaths. Inflammation in rheumatoid and cardiovascular diseases shares the same biologic mechanisms. Severity of extraarticular disease, decline in functional level, and level of inflammatory activity are associated with increased risk of mortality. Detection and measurement of novel inflammatory biomarkers may provide tools to assess prognosis and to monitor therapy. Close attention to the management of traditional cardiovascular risk factors is essential in these patients. Whether disease modifying antirheumatic drug (DMARD) therapy will reduce all-cause and cardiovascular disease mortality in rheumatoid disease is the subject of ongoing studies.     

T wave lability: a clue for separating the good from the bad, when ugly

Non-specific T wave abnormalities have challenged both the clinician and the insurance medical director for decades. Distinction between pathologic and physiologic T wave changes often requires costly and time-consuming diagnostic studies. The literature is reviewed on the subject of T wave manipulation by the oral administration of both potassium and glucose, introducing the concept of T wave lability. Based on this concept, a simple technique is suggested which, in many cases, can safely, expeditiously and inexpensively distinguish between organic and functional T wave changes. When employed in the investigation of asymptomatic insurance applicants with unexplained T wave abnormalities but no known cardiovascular or renal disease, this technique appears to be sufficiently reliable to classify the risk posed by non-specific T wave changes without resorting to a sophisticated, lengthy and costly cardiovascular investigation.     

Ankle/arm blood pressure index: an insurance perspective

Recent studies conclude that the ankle/arm blood pressure index (AAI) is a useful clinical tool for refining cardiovascular risk classification in the elderly. A reduction in the AAI to 0.9 or less is associated with increased risk for both coronary heart disease and total cardiovascular disease morbidity and mortality, as well as all-cause mortality. This relationship persists after adjusting for traditional risk factors and known cardiovascular disease. AAI will appear more common in attending physician's statements, prompting a need to educate underwriters about this technology. AAI may be of particular interest to insurers dealing in the elderly market, to those with strong physician examiner systems, and in markets where blood or urine tests are not commonly used in underwriting.     

The Metabolic Syndrome and All-Cause Mortality in an Insured Lives Population

Abstract

Metabolic syndrome and its association with mortality have not been studied in insured lives populations. The Swiss Re Study evaluated metabolic syndrome prevalence and associated mortality from all causes and circulatory disease in a cohort of 35,470 predominantly healthy individuals, aged 18–83 years, who were issued life insurance policies between 1986 and 1997. Metabolic syndrome was defined using the National Cholesterol Education Program (NCEP) Expert Panel Adult Treatment Panel (ATP) III guidelines. The NCEP obesity criteria were modified with a prediction equation using body mass index, gender, and age substituted for waist circumference. Adjustments also were made for nonfasting triglyceride and blood glucose values. Risk ratios for policyholders identified with metabolic syndrome were 1.16 (P = .156) for mortality from all causes and 1.45 (P = .080) for mortality from circulatory disease compared with individuals without the syndrome. Risk was proportional to the number of components, or score, of the metabolic syndrome present. Risk ratios for metabolic syndrome score were 1.14 (P < .001) for mortality from all causes and 1.38 (P < .001) for mortality from circulatory disease compared with individuals without metabolic syndrome factors. In both all-cause and circulatory death models, relative risk was highest for the blood pressure risk factor. Based on a modified NCEP definition, increased mortality risk is associated with metabolic syndrome in an insured lives cohort and has life insurance mortality pricing implications.     

Obstructive sleep apnea and cardiovascular disease and mortality: the argument for causality

There is solid evidence linking obstructive sleep apnea (OSA) to cardiovascular mortality. Although it has yet to be scientifically proven that OSA causes cardiovascular disease, many investigators consider it an independent cardiovascular risk factor. Its impact on the cardiovascular mortality risk of a given applicant varies depending upon the severity of the condition, compliance with treatment, and the applicant's specific cardiovascular milieu. This review is aimed at making mortality risk assessment more accurate by describing what is known of the physiologic mechanisms by which OSA may influence cardiovascular mortality and providing an appreciation for the magnitude of this risk. In doing so, an argument supporting OSA as a cause for cardiovascular disease and mortality emerges.     

Stroke--incidence, mortality, morbidity and risk

In the United States, 700,000 strokes, responsible for 165,000 deaths, occur each year. Worldwide, stroke is the 2nd leading cause of death. Stroke is a major health problem; and as the population ages, its significance will grow. This paper reviews the epidemiology of stroke, the identification of modifiable risk factors, and some of the options for intervention that can reduce stroke-related mortality and morbidity. Though the diagnosis and care of stroke patients has improved, mortality resultant from stroke remains significant, with only 50% 5-year survival in some clinical studies. The risk of stroke following a transient ischemic attack (TIA) or initial stroke is also significant-approximately 30% following either event. Stroke severity at onset and patient age are the most important factors for predicting prognosis. Stroke prevention focuses on management of the traditional cardiovascular risk factors especially control of blood pressure and smoking cessation. The role of diabetes and lipid control in stroke prevention continues to be studied. The optimum use of anticoagulation to reduce stroke risk has been explored by the Stroke in Patients with Atrial Fibrillation (SPAF) studies. Carotid endarterectomy is effective in stroke prevention for those with symptomatic carotid obstruction of 70%, but its role in other scenarios is less certain. Antiplatelet drugs continue to be an important therapy for the prevention of recurrent stroke. Centralized stroke centers that specialize in stroke diagnosis and care along with rapidly rendering appropriate treatment can improve mortality and morbidity of stroke by 20%.     

Accounting-based downside risk and expected stock returns: Evidence from China

We document that earnings downside risk contains information on firms' future operating performance and is positively associated with expected stock returns in Chinese stock markets, and the return predictability of earning downside risk mainly comes from its accrual downside risk component. The pricing of earnings downside risk is especially evident among firms with more transparent information environment and stronger governance efficacy, such as large firms, non-high-tech firms, old firms, and firms with high analyst coverage. Lastly, we show that aggregated earnings downside risk and its components at the market level are all significantly and positively associated with subsequent stock market returns, which is consistent with the notion that the accounting-based downside risk measures contain information about future macroeconomic conditions.     

Versicherungsmedizinische Risikobeurteilung von pathologischen Leberwerten und aktuellen Entwicklungen bei der chronischen Hepatitis

Alcoholic liver disease, non alcoholic fatty liver and chronic viral hepatitis have a high prevalence in the German population. They are associated with significantly increased occupational disability and mortality. Elevated levels of GGT or ALT can be found in about 10 % of the general population. Attempts to identify an underlying diagnosis often remain unsuccessful. In selected cases CDT can be helpful to confirm or rule out suspected alcohol-abuse. Recent studies showed that non alcoholic steatohepatitis (NASH) is a potentially severe complication of diabetes and its metabolic precursors. Treatment options for chronic viral hepatitis get more and more sophisticated, but the rates of sustained cure are still unsatisfactory, especially in hepatitis B with negative HBe-antigen and the hepatitis C genotypes 1, 4 and 5. Life long suppression of HBV replication by nucleoside analogues seems to prevent liver cirrhosis, but may become a great burden on health costs. The risk assessment of HBV carriers and of patients with successfully treated viral hepatitis should rely on the expertise of experienced physicians.     

Diabetes mellitus--long time survival

The medical literature of the last decade enables us to estimate survival of diabetics. Insulin dependent diabetic (IDDM) present a 3 to 6-fold mortality and die after age 30, the most frequent causes being end stage renal and vascular diseases. Non insulin-dependent diabetic (NIDDM) mortality is 1.4 to 3.7 times that of non-diabetics. Cardiovascular events and strokes are the major causes of death. Pancreatic carcinoma occurs twice as frequently in NIDDM compared to non-diabetics. Early markers of late severe complications are hypertension and proteinuria. Retinopathy has little influence on morality if other risk factors are considered. Yet, glaucoma and lens changes are associated with three- and twofold mortalities. One of five IDDM with microalbuminuria progresses to overt nephropathy in 5 years. In NIDDM micro-albuminuria predicts cardiovascular disease with a mortality of up to 2 times. Careful treatment of cardiovascular risk factors and of microalbuminuria combined with optimal metabolic control substantially reduces mortality of diabetics.     

Diabetes mellitus and life insurance

A comprehensive review of the literature of diabetes mellitus, its progression and complications is written with respect to the life insurance industry.     

Update on coronary artery calcium imaging

This update of coronary calcium imaging discusses methods of detecting and measuring coronary artery calcium and their correlation to coronary artery disease risk. The value of EBCT to traditional non-invasive cardiovascular tests is compared. A negative EBCT test makes the presence of atherosclerotic plaque, including unstable plaque, very unlikely. Negative EBCT may be consistent with low risk of a cardiovascular event over the next 2-5 years. Conversely, positive EBCT confirms the presence of a coronary plaque. The greater the amount of calcium, the greater the likelihood of occlusive disease, but there is a not a 1:1 relationship and findings may not be site specific. A high calcium score may be consistent with moderate to high risk of cardiovascular event within the next 2-5 years. Limitations and cautions concerning the general use of EBCT for screening are discussed.     

The Book-to-Price Effect in Stock Returns: Accounting for Leverage

This paper lays out a decomposition of book‐to‐price (B/P) that derives from the accounting for book value and that articulates precisely how B/P “absorbs” leverage. The B/P ratio can be decomposed into an enterprise book‐to‐price (that pertains to operations and potentially reflects operating risk) and a leverage component (that reflects financing risk). The empirical analysis shows that the enterprise book‐to‐price ratio is positively related to subsequent stock returns but, conditional upon the enterprise book‐to‐price, the leverage component of B/P is negatively associated with future stock returns. Further, both enterprise book‐to‐price and leverage explain returns over those associated with Fama and French nominated factors—including the book‐to‐price factor—albeit negatively so for leverage. The seemingly perverse finding with respect to the leverage component of B/P survives under controls for size, estimated beta, return volatility, momentum, and default risk.     

Dementia screening using computerized tests

The preclinical phase of dementia usually precedes the clinical diagnosis by many years. Early detection of dementing conditions during this preclinical phase may provide opportunities for treatments that may slow or mitigate progression. Conventional assessment tools usually can only detect dementia when the symptoms are overt and the disease is well-established. Computerized neurocognitive screening tools hold promise for diagnosing dementia in its early phase. The use, performance and development of several computerized screening tools to diagnose and monitor patients with pre-dementias and dementia are reviewed. The ability to accurately assess the presence of dementia clearly has direct relevance to insurance risk assessment and risk management. As new treatments appear, their role in clinical management of dementia patients will increase as well. In a future issue, the differential diagnosis of dementias related to the findings on these screening tools will be reviewed.     

The urinalysis--inexpensive and informative

The urinalysis dates back 6000 years. Information has evolved from tasting it for sugar to computer assisted assessment for the presence of cells and casts. The urine gives valuable information about kidney function in general and the glomeruli in particular. Findings can lead to a diagnosis of various medical conditions, most notable being diabetes mellitus. Proteinuria has many implications, including the presence of systemic disease and the progression of an underlying renal condition.     

C-reactive protein--a screening test for coronary disease?

C-reactive protein (CRP) is one of a number of substances termed "acute phase reactants," biologic substances that appear in the circulation when an active inflammatory process occurs. Although traditionally used to monitor or detect major infectious or inflammatory conditions, elevations of CRP levels within the conventional range of "normals" has been intensively studied as a marker for coronary disease and risk of future coronary events. Sensitive assays that can be performed on a high-volume, commercial basis are now available. CRP appears to be a valuable marker for the prediction of future events in individuals who have known coronary artery disease. CRP has been proposed as a coronary disease-screening test for healthy individuals; however, available data suggest that use of CRP in this context may be premature. This paper reviews published research concerning CRP and the prediction of cardiovascular and total mortality risk, then outlines the current "state of the art" for the application of CRP to the risk assessment process.     

Valuation and Return Dynamics of New Ventures

A dynamic model of a multistage investment project that capturesmany features of research and development (R&D) venturesand start-up companies is developed. An important feature theseproblems share is that firms learn about the potential profitabilityof the project throughout its life, but that technical uncertaintyabout the R&D effort is only resolved through additionalinvestment. Consequently the risks associated with the ultimatecash flows have a systematic component even while the purelytechnical risks are idiosyncratic. Our model captures thesedifferent sources of risk and allows us to study their interactionin determining the value and risk premium of the venture.