The TRIFECTA
THE TRIFECTA: otherwise known as METABOLIC SYNDROME
The not-so winning combination of abnormal lipids, hypertension
and obesity.
The Long Term Care
International Forum 2013
Our Presenters
Dr. Bruce Margolis, Medical Director - Genworth
Pam Jackson, LTC Underwriting Manager – New York Life
Joe Furlong, Associate Director, Claims - RGA
Our goal is to provide a comprehensive
look at Metabolic Syndrome
to include
an in-depth medical review,
underwriting concerns
and what we see on the claims side.
Metabolic Syndrome
A Medical Perspective
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May 9, 2013
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NOTICE: This document contains confidential, non-public company
information. Further distribution of this document is strictly prohibited.
Company Confidential
©2012 Genworth Financial, Inc. All rights reserved.
Metabolic Syndrome – What Is It?
“Metabolic syndrome (MetS) is a multiplex
risk factor that arises from insulin
resistance accompanying abnormal adipose
deposition and function. It is a risk factor
for coronary heart disease, as well as for
diabetes, fatty liver, and several cancers.”
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Downloaded 4/8/13 – http://emedicine.medscape.com/article/165124-overview
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Metabolic Syndrome – Clinically Defined
ATP III (Adult Treatment Panel) (3 or more of the following)
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– Waist circumference >40 inches in men; >35 inches in women
– Serum triglycerides >150 mg/dl
– Blood pressure >130/85 mmHg
– HDL cholesterol <40 mg/dl in men and <50 mg/dl in women
– Serum glucose >110 mg/dl
WHO
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– Diabetes, IFG, IGT or insulin resistance and at least two of the following criteria:
• Waist –to-hip ratio >0.90 in men or >0.85 in women and/or BMI >30
• Serum triglycerides >150 mg/dl or HDL cholesterol 35 mg/dl in men and 39 mg/dl in
women
• Blood pressure >140/90 mmHg
• Urinary albumin excretion rate >20µg/min or albumin-to-creatinine ratio >30 mg/g
Grundy SM, et al. Circulation. 2004;109:433)
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Metabolic Syndrome – In Other Words
Abdominal obesity
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Atherogenic dyslipidemia
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Raised blood pressure
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Insulin Resistance + glucose intolerance
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Proinflammatory state [elevated C-reactive protein (CRP)]
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Prothrombotic state [increased plasma plasminogen activator inhibitor
(PA-1) and fibrinogen]
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Grundy SM, et al. Circulation. 2004;109:433)
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Metabolic Syndrome
Increased risk for:
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– Cardiovascular disease
• Coronary artery disease
• Cerebrovascular disease (stroke)
• Peripheral artery disease
– Diabetes
– Polycystic ovarian syndrome
– Fatty liver
– Gallstones
– Asthma
– Sleep disturbance
– Some cancers
Grundy SM, et al. Circulation. 2004;109:433)
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From: Prevalence of the Metabolic Syndrome Among US Adults: Findings From the Third National Health and
Nutrition Examination Survey
JAMA. 2002;287(3):356-359. doi:10.1001/jama.287.3.356
Figure Legend:
Data are presented as percentage (SE).
metabolic syndrome_LTCIF_2013
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From: Prevalence of the Metabolic Syndrome Among US Adults: Findings From the Third National Health and
Nutrition Examination Survey
JAMA. 2002;287(3):356-359. doi:10.1001/jama.287.3.356
Figure Legend:
Data are presented as percentage (SE).
metabolic syndrome_LTCIF_2013
Est 47 million in US with Metabolic
Syndrome
10
Cardiometabolic Risk
Despres JP, Lemieux, I. Nature 2006;444:881
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Obesity – Metabolic Syndrome Link
Primary
Metabolic
Disturbance
Intermediate
Vascular Disease
Risk Factor
Intravascular
Pathology
Clinical
Event
Insulin Resistance
Hypertension
Dyslipidemia
Overnutrition
Atherosclerosis
• Coronary arteries
Hyperglycemia
• Carotid arteries
Hyperinsulinemia
• Cerebral arteries
• Aorta
Inflammation
Impaired
Fibrinolysis
• Peripheral arteries
Hypercoagulability
Endothelial
Dysfunction
Despres JP, Lemieux, I. Nature 2006;444:881
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CVD
Role of Adipose Tissue
Goossens, GH. Phys & BehavI 2008;94:206
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Adjusted relative risk
Abdominal Obesity and CVD Risk
Men Women
<95
<87
95-103 87-98
>103
Waist circumference (cm)
Dagenais GR et al, 2005
metabolic syndrome_LTCIF_2013
>98
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From: The Metabolic Syndrome and Total and Cardiovascular Disease Mortality in Middle-aged Men
JAMA. 2002;288(21):2709-2716. doi:10.1001/jama.288.21.2709
Figure Legend:
RR indicates relative risk; CI, confidence interval. Curves for men with vs without the metabolic syndrome based on factor analysis (men in the
highest quarter of the distribution of the metabolic syndrome factor were considered to have the metabolic syndrome). Median follow-up (range)
for survivors was 11.6 (9.1-13.7) years. Relative risks were determined by age-adjusted Cox proportional hazards regression analysis.
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Metabolic Syndrome and CVD Mortality
Malik S, et al. Circulation 2004;110:1245
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Hazard Ratio
CVD Mortality and MetS Risk Factors
Malik S, et al. Circulation 2004;110:1245
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Metabolic Syndrome - Treatment
Weight Loss
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Blood pressure control
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Lipid control
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Exercise
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Medication?
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Cumulative incidence (%)
Prevention of Diabetes
Placebo (n=1082)
Metformin (n=1073)
Lifestyle (n=1079)
40
30
Risk Reduction
31% by metformin
58% by lifestyle
20
10
0
0
1
2
3
Years from randomization
The DPP Research Group. NEJM;2002:393
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4
CVD and Long Term Care Claims
Source: Society of Actuaries LTC Experience Committee Fifth Intercompany Report – November 2007
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The Bottom Line
WHAT YOU CAN’T CHANGE
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Your Genes
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WHAT YOU CAN CHANGE
Your Lifestyle
Your Lifestyle
Your Lifestyle
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Summary
Metabolic Syndrome is a group of risk factors that result from insulin
resistance and excess adipose tissue
This results in an environment if increased for diabetes and
cardiovascular disease
There is excess mortality and morbidity related to the metabolic
syndrome
The best treatment is prevention with a healthy lifestyle including a
balanced healthy diet and regular exercise and no smoking
Medication may be useful when lifestyle measures are inadequate
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Underwriting
Concerns
The Trifecta 2013 Long-Term Care International Forum
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Underwriting Concerns
What does this mean in terms of underwriting?
What is the risk?
How big is the risk?
What has claims experience taught us?
The Trifecta 2013 Long-Term Care International Forum
Underwriting Concerns
What is required to determine eligibility?
 Full medical records, labs required
 Does the client require medication?
 Is he/she compliant ?
 Are there associated risk factors?
Sedentary lifestyle?
Does the client have other LTC policies?
The Trifecta 2013 Long-Term Care International Forum
Underwriting Concerns
Then what?
 Establish the risk by looking at the whole picture
 High Risk? Moderate Risk? Low Risk?
 Limit the benefits if necessary
The Trifecta 2013 Long-Term Care International Forum
Underwriting Concerns- Case Study #1
Scenario:
56 year old female
5 ft 4 in, 192 lbs – BMI 33
Metabolic syndrome documented in the medical records
BP 128/72 stable
Lipids wnl for several years
Stable HTN
Compliant with all medications
Nonsmoker
Started working out 24 months ago
No history of diabetes, stroke
The Trifecta 2013 Long-Term Care International Forum
Underwriting Concerns
Case Study #1
Risk=Moderate
The Trifecta 2013 Long-Term Care International Forum
Underwriting Concerns- Case Study #2
Scenario
62 Female
5 ft 1, 210 lbs – BMI 39.7
Metabolic syndrome documented in the medical records
Blood pressure stable on three meds
Lipids harder to control, but near normal
Insulin resistance, diet controlled
Not always compliant
Smoker
Remote history of a TIA
The Trifecta 2013 Long-Term Care International Forum
Underwriting Concerns
Case Study #2
Risk=High
The Trifecta 2013 Long-Term Care International Forum
Claims Observations
Claims Observations
We don’t see claims with a diagnosis of Metabolic Syndrome.
It does not normally cause a claimant to go on claim.
Claims are the result of the acute events that are
precipitated by Metabolic Syndrome.
Mainly, Stroke, Myocardial Infarction
and complications from Diabetes.
Claims Observations
Column1
Respiratory,
5.3
Digestive, 1.8
Alzheimer's,
20.7
Arthritis, 10.7
Stroke, 10.7
Cancer, 9.9
Circulatory, 9.8
Injury, 9.8
Mental, 5.6
Nervous
system, 6.6
20.5% of claims due to Stroke and Circulatory Diagnoses
Data from 2011 SOA LTC Experience Study #6
Claims Observations
A little more than 20% of claims are due to Stroke
and Circulatory System disorders.
Combined, these causes are equal to the
claim experience we see on Alzheimer’s claims.
We cannot make a direct correlation between
Stroke/Circulatory System disorders
and Metabolic Syndrome in the data but we can infer
that it played a role in a number of these claims.
Claims Observations
The window of opportunity for recovery from
the after-effects of a stroke is limited.
Proper rehabilitation is crucial.
Once paralysis and/or cognitive deficits are
stabilized, there is a small chance that
ADL or Cognitive function will improve.
Close monitoring during the early stages of rehabilitation
is essential to ensure continued eligibility.
Claims Observations
Co-Morbidities
Co-Morbidities are inherent with Metabolic Syndrome
which adds another level of difficulty
when assessing possible length of claim.
Cardiovascular disease, along with diabetes,
can lead to longer claims.
Especially if diabetic neuropathy develops.
Claims Observations
Co-Morbidities
Obesity and diabetes are also complicating
co-morbidities when dealing with hip fractures
and other musculoskeletal claims.
Rehabilitation can be more challenging,
can take longer and obesity and diabetes can have a negative
effect on the ultimate functional capacity of the claimant.
The Trifecta
Summary
As you can see…
Metabolic Syndrome is a condition that is:
• Difficult to manage for the physician
• Challenging to evaluate from an underwriting perspective
• Can be a costly contributing factor at claim time.
And, as with horse racing,
a favorable outcome on The Trifecta is a long shot.
The Trifecta
Questions?
Thank you for your attention.