Obesity and eating disorders affect a huge proportion of society. Christina Sharples looks at the growing problem and asks how insurers rate these conditions
Obesity has reached a point where it is claiming 30,000 lives annually in England. Statistics show that many adults in England are overweight and around one in five are obese. Obesity is usually described as being 20% or more above the recommended body weight. People who are described as being morbidly obese tend to be at least 60% more than their ideal body weight.
Being obese or overweight substantially increases the risk of hypertension, cholesterol disorders, type two diabetes, coronary heart disease, stroke, gallbladder disease, osteoarthritis, sleep apnoea and respiratory problems. Morbid obesity has even greater health implications and greatly increases mortality (death) and morbidity (sickness). Permanent response to medical treatment is rare and treatment by diet alone usually fails.
In some cases of severe obesity, surgical measures such as jaw wiring, gastric stapling, gastric balloon insertion, gastric bypass and, most commonly, intestinal bypass are used. These procedures carry risks in themselves and are not usually advised on people aged over 50 due to meta-bolic complications and post-operative morbidity. There are a high number of post-operative complications, the most common being liver disease, which can be progressive and result in liver failure.
From an underwriting perspective, the main points to consider are:
• Current height and weight.
• Current blood pressure.
• Any complications.
Obviously, all this information will not be available at the time of proposal, therefore, it is usual practice to ask the client to attend a medical or paramedical to assess the above. This is also common practice as weight details are often significantly under-disclosed at proposal stage.
Ratings for overweight clients will depend on which height and weight charts the insurer is using. Some insurers use older charts which are slightly more lenient than the latest guidelines. Ratings for critical illness will usually be slightly higher than the life risk due to the increased incidence of heart attack, stroke and so on associated with being overweight. Ratings for sickness insurance are again higher due to the increased morbidity risk.
Interestingly, if the applicant is over 55 the rating would be slightly lower than the same height and weight rating for an applicant under 55.
An example of a rating would be someone who is five foot, five inches and weighs 17 stone. This would attract a loading of +75% on life cover, +100% on critical illness and +150% on income protection.
Generally where an applicant is greater than +100% overweight for life cover the insurer may choose to decline any additional benefits such as critical illness or sickness-related benefits.
Anorexia
On the other side of the scale, eating disorders such as anorexia nervosa and bulimia nervosa also cause serious emotional and physical problems that can have life-threatening consequences. Anorexia is characterised by self-starvation and excessive weight loss. Symptoms include:
• Refusal to maintain body weight at or above a minimally normal weight for height, body type, age, and activity level.
• Intense fear of weight gain or being fat.
• Feeling fat or overweight despite dramatic weight loss.
• Loss of menstrual periods.
• Extreme concern with body weight and shape.
Anorexia often begins with dieting which becomes uncontrolled. Weight loss is accomplished through reduced food intake, vigorous exercise, fasting or laxative/diuretic abuse. Physical manifestations and complications that may occur include cardiac arrhythmia, kidney problems, hypothermia, hypotension, oedema, dental problems, development of lanugo (fine downy hair), gastrointestinal and haematologic disorders (anaemia and a low white cell count). Osteoporosis (thinning bones) is a major problem, and carries an increased risk of developing fractures spontaneously or following minor amounts of trauma.
Individuals suffering from anorexia typically deny the serious medical implications of their malnourished state. It is common for a concerned family member to seek professional help on their behalf as they do not recognise or admit to having this disorder. If individuals seek help, it is usually due to the somatic and psychological sequelae of starvation. Depression is often present.
Bulimia
Bulimia is characterised by a secretive cycle of binge eating followed by purging. It involves eating large amounts of food in short periods of time, then getting rid of the food and calories through vomiting, laxative abuse or over-exercising.
Individuals suffering from bulimia are usually within normal weight range although weight loss may occur. They are likely to have been overweight prior to onset. The binge eating is often triggered by psychosocial stress and it may occur as often as several times per day and is usually done in secret.
Stimulant use in an attempt to subdue the appetite and substance abuse occurs in approximately one-third of individuals with bulimia. There is also an increased incidence of impulsive behaviour, depressive symptoms and mood disorders. Fluid and electrolyte abnormalities, cardiac arrhythmia, gastrointestinal disorders, menstrual irregularities, dental problems and parotid gland enlargement are some physical manifestations and complications that may occur, although these are less prominent than in anorexia.
Both anorexia and bulimia are, by far, more common in females. Treatment for anorexia involves short-term interventions to increase body weight, and long-term therapy to tackle personality and family problems. Treatment for bulimia consists of behavioural therapy and specialist treatment if the condition persists. Anti-depressants are also often prescribed for both conditions.
Compulsive over-eating
Another eating disorder is binge eating or compulsive over-eating. It is characterised by periods of uncontrolled, impulsive or continuous eating beyond the point of feeling comfortably full. Purging is not a feature of this condition, but there may be sporadic fasts or repetitive diets and often feelings of shame or self-hatred after a binge. Depression, anxiety and loneliness can affect individuals who overeat compulsively, which can lead to further unhealthy episodes of binge eating. Body weight can vary from normal to severe obesity. Eating disorders are complex conditions that can arise from a variety of potential causes. Once started, however, they can create a self-perpetuating cycle of physical and emotional destruction. All eating disorders require professional help.
Anorexia and bulimia are not new conditions. A disorder apparently like anorexia nervosa was first written about in 1669, and was recognised as a clinical condition in 1873. Bulimia nervosa was not recognised as a clinical condition until 1979.
In today's society, young women, especially, feel under pressure to conform to the media 's image of the perfect figure. This can result in feelings of inadequacy, which can lead to dieting and eating disorders if taken to the extreme. Other psychological factors that can contribute to an eating disorder are low self-esteem, lack of control in life, depression, anxiety and loneliness. Family and relationship problems, a history of abuse or bullying and difficulty in expressing emotions and feelings can also contribute to eating disorders. Scientists are researching possible biochemical or biological causes of eating disorders. In some individuals with eating disorders, certain chemicals in the brain that control hunger, appetite and digestion have found to be imbalanced. The implications of these findings remain under investigation.
It is difficult to estimate the incidence of eating disorders due to the reluctance of people with these conditions to admit to having a problem. The best estimates suggest that around one young woman in 100 suffers bulimia nervosa and probably somewhat fewer suffer anorexia nervosa. In 1992, the Royal College of Psychiatrists estimated that 60,000 people were receiving treatment for an eating disorder at any one time in the UK. It is now believed the figure is nearer to 90,000, with many more people, especially those with bulimia, who have not been diagnosed. Studies show those most at risk of developing anorexia are between 10-19 years of age, where bulimia was found to primarily affect females aged between 20-39 years.
The underwriting considerations for anorexia are:
• Age at onset and duration.
• Mood or other associated mental/ behavioural disorder.
• Body weight.
• Treatment and compliance.
• Any physical complications.
And for bulimia:
• Duration.
• Treatment.
• Any associated depression or mood disorders.
• Any alcohol or other substance abuse.
Eating disorders are often non-disclosed and where an applicant appears significantly underweight the underwriter may choose to obtain a GP's report even if the proposal form is clean to ensure there is no eating disorder involved.
If there is a current history of anorexia or bulimia the application will be postponed. Where there has been a full recovery with no treatment for six months terms may be possible with a loading. Applicants who have been symptom-free for more than four years should get ordinary rates for life cover.
Christina Sharples is a life and disability underwriter with Scottish Equitable Protect
