As the number of overweight people in the UK continues to increase, Karen Anderson explains how underwriters view obesity and its related health risks
Almost two thirds of adults in the UK are currently classed as overweight. If this trend continues, one in three people will be obese by 2020 and obesity will soon overtake smoking as the number one preventable cause of premature death.
Another great concern is obesity in young children, which has doubled since the mid-80s with almost 8.5% of six-year olds and 15% of 15-year olds now classed as obese. By looking at the rapid rise of increased weight it can be predicted that by 2020 over half of all children will be classed as obese. And using these predictions it is believed that the current generations of children may be the first for over a century for whom life expectancy will fall.
Mortality
Obesity is generally described as being 20% or more above the recommended body weight for an individual's height. For insurance purposes, obesity is based on mortality studies and average weights in the insured population. For mortality, the range of increased weight that is acceptable at standard rates is relatively wide, since the extra mortality for being overweight in the absence of related risks is small. However, the situation is different for disability and critical illness (CI) benefits.
Obesity can be determined by measurement of height and weight expressed as the body mass index (BMI) defined as weight in kilograms, divided by the square of the height in metres. The ideal BMI range for a man is 20.1 - 25.0, with a value in excess of 30 being defined as obesity. The ideal BMI range for a woman is 18.7 - 23.8, with obesity equalling a value in excess of 28.6.
The fundamental cause of obesity is always the consumption of energy in excess of requirements, although several other factors may contribute to its development such as genetic factors, psychological factors, endocrine disorders such as hypothyroidism and injury or disease affecting the hypothalamus. Environmental factors also have a strong influence and include lifestyle behaviour such as food choices and a person's level of physical activity.
Morbid obesity is when a person is excessively overweight, defined broadly as a body weight of at least 60% more than ideal body weight. Morbid obesity has severe effects on the cardiovascular and respiratory systems and greatly increases mortality and morbidity. It is particularly associated with coronary artery disease, hypertension, stroke, diabetes, high cholesterol, respiratory diseases, certain types of cancer and osteoarthritis. It rarely responds to medical treatment and treatment by diet alone usually fails. Drastic surgical measures are often used such as jaw wiring (dental splinting), gastric stapling, gastric balloon insertion, gastric bypass and most commonly intestinal bypass.
Obesity has long been associated with increased morbidity and mortality risks, in particular heart disease, stroke and type 2 diabetes. The British Heart Foundation estimates that around 5% of coronary heart disease deaths in men and 6% in women are due to obesity. Obesity is also linked to increased risks of certain cancers. Cancer Research UK has suggested that one in eight cancer deaths in the UK is caused by obesity. The table below illustrates the estimated increased risk of developing associated disease with obesity. These figures come from an international study and compare the likelihood of an obese individual developing the disease compared to an individual in the normal range.
Appetite suppressants
The table below shows that obesity impacts a woman's health more than a man's, which could be the possible cause of the recent shrinking differential between male and female life emerging in continuous mortality investigations. In terms of extra mortality it has been shown that the risk of death for someone with a BMI of 30 is about 50% higher than for someone with a healthy BMI, and with a BMI over 30 the risk more than doubles.
Reduction in calorie intake is the primary method of treatment, though most overweight people fluctuate in weight and will often regain any lost weight. Long-term success in moderate obesity is poor, with an overall success rate of no more than 10-20%. Drugs can be used to treat obesity along with a dietary regime but cannot be used as a substitute.
There has been some concern regarding the use of appetite suppressants due to the reporting of pulmonary hypertension in people taking these drugs. There has then been further reporting of valvular heart disease and abnormal echocardiograms have been reported, with mitral and/or aortic regurgitation being shown in people who have previously been treated with these drugs. This is when the previously mentioned surgical methods may be used, but there can be a large number of post-operative complications, including liver disease.
The good news is that losing a small amount of weight can reduce the chances of developing heart disease or stroke. Reducing weight by 10% can decrease the chance of developing heart disease by improving how the heart works, blood pressure and levels of blood cholesterol and triglycerides. Studies show that health can be improved by losing as little as 10 to 20lbs.
Karen Anderson is a life & disability underwriter at Scottish Equitable
Underwriting implications
It is common practice for insurance companies to increase premiums for certain products based on elevated BMI measurements. These ratings can differ but in general the following guidelines are common.
When a person has a BMI of 30, which is when a person will be considered obese, the insurance company will generally not rate for life cover, CI cover or for income protection (IP) unless there are other risk factors such as hypertension or diabetes.
When an individual reaches a point of morbid obesity, terms will not be available for protection benefits. This means that a BMI of over 45 will generally be declined for life cover and a BMI over 40 will generally be declined for CI and IP. A person with a BMI below 30 will obtain standard terms, and between 30 and 45 could obtain rated terms.
When a person has confirmed that they are overweight on their application form, it is standard practice to obtain a medical examination with either an independent company or with their own GP. This allows the underwriter to assess their weight along with blood pressure, past/current medical history and family history.
If a person also discloses that they have either had medical treatment or have used appetite suppressants we will also obtain a GP report in order to assess pre-treatment weight and current weight, and also if any complications have occurred as a result of this treatment. When considering what terms to offer an overweight person, the underwriter also pays close attention to smoking status, family history, blood pressure and cholesterol levels, as a combination of many factors can prove to be a high risk.
Facts and figures
• The economic cost of obesity to the NHS is £3.3bn - £3.7bn per year.
• Factoring in the costs associated with individuals who are overweight, these costs increase to £6.6bn - £7.4bn.
• Obesity is strongly associated with life threatening illnesses such as type 2 diabetes, coronary heart disease and cancer.
• Over 80% of people with diabetes are overweight or obese.
• People who are 20% overweight are eight times more likely to suffer from high blood pressure than someone of normal weight.
• Rates of type 2 diabetes, previously know as adult onset diabetes, have tripled in the last 30 years, which is largely due to increase in obesity.
• Obesity in pregnancy is associated with a higher risk of death for both the baby and the mother and can also raise the blood pressure of the mother by 10 times.
• Obesity in pregnancy is associated with an increased risk of birth defects such as spina bifida.
• Greater than normal operative risks exist should a need for surgery arise.
• Rehabilitation from injury or disabling illness is problematic.
• Reactive depression may be a feature perhaps due to body image or the stringent measures used to attempt to lose weight.
• It is estimated that 18,000 sick days a year are lost due to obesity.
• 21% of women are obese, 32% of women are overweight.
• 17% of men are obese, 46% of men are overweight.
• 28,000 heart attacks caused by coronary artery disease are directly attributable to obesity.
• A weight gain of 20lbs doubles your risk of heart disease.
• Strokes are twice as common in obese people.
• Coronary artery disease is more than twice as common in obese men under 45, than in men of normal weight.
• One in four overweight children are showing early signs of type 2 diabetes.
• Woman gaining more than 20lbs from age 18 to midlife double their risk of post-menopausal breast cancer, compared to women whose weight remains stable.
• Nearly 50% of all breast cancers occur in obese women.
• For every 2lb increase in weight, the increase of arthritis increases by about 10%.
• On a plus note being overweight protects against osteoporosis.
Sources:
National Audit Office
British Heart Foundation
The National Institute of Health
