We have come to appreciate many risk factors for excess mortality at ages 65 and over. Some are the same as those in younger people, while others–like cognitive impairment and frailty–are mainly associated with older ages.
No one disputes that high cholesterol, obesity and current cigarette smoking are markers for an increased risk of heart attacks and other vascular events. All three are components of every insurer's cardiovascular risk profile and guidelines for determining who gets "preferred risk" coverage.
Clinical and epidemiological studies of geriatric subjects show an insidious "flip side" to these risk components that has not, as yet, been factored into most underwriting assessments. Taken together, they constitute what may be called "the sinister trio," as shown in the chart.
Many studies show a diminishing impact of high cholesterol on mortality risk at older ages. In fact, the risk associated with cholesterol, using actuarial parlance, becomes steeply U-shaped, with low readings being at least as significant as those above normal.
What defines "low" cholesterol?
Most would agree that a reading less than 160 mg meets this criterion. Moreover, the adverse impact accelerates at lower levels. Even more worrisome is a cholesterol level that is falling in the absence of dietary or pharmaceutical intervention that would cause this to occur.
We currently use "build" (height in relation to weight) and body mass index (a mathematical calculation) to define underweight, normal weight, overweight and obesity. Like cholesterol, weight also has a U-shaped relationship to mortality, and at older ages, the lower end of the spectrum takes on added prominence.
Some people are underweight throughout their lives. In such cases, still being at roughly the same degree of underweight late in life is not an issue.
However, underwriters often do not know the applicant's weight history and must use current weight and any acknowledged weight loss or gain as the benchmarks. In this context, there is no question that being underweight is much less favorable than normal weight. In fact, studies show that persons (especially females) with mild to moderate obesity have better mortality than those who are underweight.
