1. LIFE SOLUTIONS Not for use with the public. ©2014 Lincoln National Corporation Products issued by: The Lincoln National Life Insurance Company Lincoln Life & Annuity Company of New York THE FUTURE OF JUVENILE UNDERWRITING Steven Cooper, MD AVP & Senior Medical Director Lincoln Financial Group CHOLHUA 2014 LCN-823546-022114

2. LCN-XXXXXX-XXXXXX For agent or broker use only. Not for use with the public. WHAT WE WILL COVER (AND WHY) Northwestern Mutual 2011 underwriting decisions on juvenile applicants age 10 and younger: Asthma - #1 Attention Deficit/Hyperactivity Disorder (ADHD) - #2 BMI - #3 Actually Unknown/Other was #2 and Blank was #3 so I consider myself lucky! LCN-823546-022114

3. LCN-XXXXXX-XXXXXX For agent or broker use only. Not for use with the public. ASTHMA Asthma is a chronic disease of the airways characterized by periods of reversible airflow obstruction These periods constitute asthma attacks or exacerbations Airway inflammation and hyper-reactivity are the factors leading to obstruction Exposure that provoke attacks include exercise; airway infections; airborne allergens (including dust mites) and airborne irritants including cigarette smoke LCN-823546-022114

4. LCN-XXXXXX-XXXXXX For agent or broker use only. Not for use with the public. During an asthma attack, the smooth muscle layer goes into spasm, narrowing the airway. The middle layer swells because of inflammation, and more mucus is produced. In some segments of the airway, mucus forms plugs that nearly or completely block the airway. Merck Manual Home Health Handbook, www.merckmanuals.com AIRWAY CHANGES DURING ASTHMA ATTACK LCN-823546-022114

5. LCN-XXXXXX-XXXXXX For agent or broker use only. Not for use with the public. UNDERWRITING ASTHMA – MORTALITY FACTORS Those with frequent and severe asthma symptoms and evidence of airflow limitation are at greatest risk (although sporadic deaths occur in mild, moderate and severe asthma) In US asthma fatalities are most common in lower income, non-white urban populations Two clinicopathophysiologic profiles exist: 1) Slow onset fatal asthma (80-85% of cases) with progressive symptoms for more than 12 hours and often up to 1-3 weeks 2) Rapid onset fatal asthma with death occurring 2 to 6 hours after symptom onset LCN-823546-022114

6. LCN-XXXXXX-XXXXXX For agent or broker use only. Not for use with the public. Major: Recent history of poorly controlled asthma Prior history of near-fatal asthma Minor: Aeroallergens Aspirin and NSAIDS Exercise Genetic Factors Illicit drugs Menstruation Respiratory viruses Smoking Others FATAL ASTHMA RISK FACTORS LCN-823546-022114

7. LCN-XXXXXX-XXXXXX For agent or broker use only. Not for use with the public. A low FEV1 is associated with an increased risk of asthma exacerbations, and the lower it is the greater the risk (Osborne et al Chest 2007;132:1151 and others) In a prospective study of severe/difficult to control asthma post- bronchodilator FVC < 70% was a predictor of asthma related ED visits and hospitalization (Miller et al Eur Resp J 2006;28:1145) Despite this individuals with fatal or near-fatal asthma may have entirely normal baseline spirometry FATAL ASTHMA – OBJECTIVE MEASURES LCN-823546-022114

8. LCN-XXXXXX-XXXXXX For agent or broker use only. Not for use with the public. ASTHMA DEATHS BY AGE CDC, MMWR, May 4, 2012 /61(17);315 LCN-823546-022114

9. LCN-XXXXXX-XXXXXX For agent or broker use only. Not for use with the public. Factors associated with persistence of asthma into adulthood include severity, atopic conditions (allergic rhinitis, eczema), positive family history and early age of onset (age 5 or under) Would use caution and likely decline coverage to young asthmatic children (< 5 years old) with anything but the most mild, intermittent asthma (such as occasional wheezing with colds) Older children and adolescents who develop asthma after age 5 and who are on inhalers only, with good follow up and no hospitalizations due to their asthma are likely insurable at standard or low substandard rates UNDERWRITING ASTHMA – PRACTICAL APPROACH LCN-823546-022114

10. LCN-XXXXXX-XXXXXX For agent or broker use only. Not for use with the public. ADHD ADHD is not new; enhanced awareness due to rapidly advancing research may make it seem like it is Prevalence in US in children is 3-7%. It is associated with psychiatric co- morbidity in approximately 50-60% of cases (learning disorders, depression, anxiety and antisocial personality disorder among others) Name is misleading; problem is not lack of attention but rather too much attention to non-relevant stimuli 3 basic forms listed in DSM IV: Attentional; Hyperactive/Impulsive and Combined Executive Functioning is disturbed by the neurotransmitter imbalance of ADHD; among the areas most commonly distorted are flexibility, organization and planning LCN-823546-022114

11. LCN-XXXXXX-XXXXXX For agent or broker use only. Not for use with the public. ADHD Executive function is a major task of the frontal lobes Functional MRI studies support decreased activation of areas of frontal lobe during certain tasks in children with ADHD A 10-year study by NIMH demonstrated that brains of children and adolescents are 3-4% smaller than those of children without disorder Catecholamines are the main neurotransmitters in frontal lobe, and the main targets for medication used to treat the disorder LCN-823546-022114

12. LCN-XXXXXX-XXXXXX For agent or broker use only. Not for use with the public. World health organization study of children with ADHD in 10 countries (Lara et al Biol Psychiatry 2009 Jan 1;65(1):46-54) An average of 50% of children with ADHD continued to meet DSM-IV criteria as adults Persistence was related to: Symptom profile – attentional plus hyperactive/inattentive (OR* = 12.4) Symptom severity (OR = 2.0) Co-morbid major depressive disorder (OR = 2.2) High co-morbidity (> 3 child/adolescent disorders in addition to ADHD) (OR = 1.7) Paternal (but not maternal) anxiety mood disorder (OR = 2.4) Parental antisocial personality disorder (OR = 2.2) *OR = Odds Ratio, the odds that an outcome will occur given a particular exposure compared to the odds of the outcome occurring in the absence of the exposure ADHD – PERSISTENCE IN ADULTS LCN-823546-022114

13. LCN-XXXXXX-XXXXXX For agent or broker use only. Not for use with the public. UNDERWRITING ADHD – MORTALITY FACTORS There is no clear correlation between ADHD itself and increased mortality ADHD is a risk factor for developing conduct disorders, oppositional- defiant behavior and substance abuse – presence of any of these increases risk Suicide risk is increased through worsening of comorbid conditions such as conduct disorder and depression Adolescent risk-taking behavior may persist into adulthood Medication for ADHD – What is Risk? LCN-823546-022114

14. LCN-XXXXXX-XXXXXX For agent or broker use only. Not for use with the public. One often sees articles in the popular press regarding the dangers of stimulant medication for ADHD 1999 study published in Pediatrics found that pharmacologic treatment of adolescents with ADHD was associated with an 85% reduction in risk for substance abuse This is an important fact to keep in mind when considering the inherent risk of medications themselves In 2011 the FDA released a safety update indicating that a large study of children with ADHD treated with stimulant medication did NOT have an increase in adverse cardiac events There is a black-box warning for Strattera (a non-stimulant ADHD drug) regarding increased suicide risk ADHD TREATMENT RISKS LCN-823546-022114

15. LCN-XXXXXX-XXXXXX For agent or broker use only. Not for use with the public. Since the presence of conduct disorder or oppositional-defiant behavior, as well as substance abuse, are the main factors associated with increased mortality, would use caution in underwriting pre-adolescents with ADHD The adolescent with ADHD who has no evidence of conduct disorder, oppositional-defiant behavior or substance abuse, and who is compliant with medication and follow up visits, is likely a standard risk The presence of other psychiatric disorders or neurologic issues will add co-morbidity and increase mortality, and may require an additional rating depending on type and severity UNDERWRITING ADHD – PRACTICAL APPROACH LCN-823546-022114

16. LCN-XXXXXX-XXXXXX For agent or broker use only. Not for use with the public. CHILDHOOD OBESITY The term obesity wasnt as well defined in pediatric literature until recently; it was usually used interchangeably with overweight Obesity now defined as > 95 th % of BMI-for-age in 2-19 year olds; overweight is 85-94 th % In children < 2 years old overweight is weight-for-length at or above 95 th % LCN-823546-022114

17. LCN-XXXXXX-XXXXXX For agent or broker use only. Not for use with the public. Prevalence of Overweight Among Children and Adolescents: United States, 1999-2000. (2002). National Center for Health Statistics, Centers for Disease Control and Prevention Website LCN-823546-022114

18. LCN-XXXXXX-XXXXXX For agent or broker use only. Not for use with the public. http://www.cdc.gov/diabetes/statistics/incidence/images/fig2.gif WHY THE CONCERN? LCN-823546-022114

19. LCN-XXXXXX-XXXXXX For agent or broker use only. Not for use with the public. The evidence would strongly suggest that the answer is YES Serial data from NHANES (National Health Examination Survey) shows that the increasing prevalence of obesity/overweight in adults is matched by similar trends among children and adolescents The correlation is higher in obese adolescents but is present at younger ages and lower BMIs as well DO OBESE CHILDREN BECOME OBESE ADULTS? LCN-823546-022114

20. LCN-XXXXXX-XXXXXX For agent or broker use only. Not for use with the public. Hypertension DM Fatty liver Sleep Apnea PCOS Pseudotumor cerebri Orthopedic issues CHILDHOOD OBESITY – COMORBIDITIES LCN-823546-022114

21. LCN-XXXXXX-XXXXXX For agent or broker use only. Not for use with the public. Overweight/obese children and adolescents who do not develop hypertension or DM are at risk of developing these as adults The risk of adult co-morbidities is increased in obese adolescents even if the obesity does not persist (Must, et al NEJM 1992:327:1350-5) Abdominal obesity leads to insulin resistance which leads to metabolic syndrome Hypertension, lipid abnormalities, DM and CAD are consequences of metabolic syndrome PEDIATRIC OBESITY – ADULT RISKS LCN-823546-022114

22. LCN-XXXXXX-XXXXXX For agent or broker use only. Not for use with the public. Studies have shown an increase in certain cancers with as little as an increase of BMI of 5 (Biro & Wien Am J Clin Nutr 2010;91(suppl):1499S- 1505S) Men – Esophageal cancer (RR* = 1.52) Thyroid cancer (RR = 1.33) Colon cancer (RR = 1.24) Renal cancer (RR = 1.24) Women – Endometrial cancer (RR = 1.59) Gallbladder cancer (RR = 1.59) Esophageal cancer (RR = 1.51) Renal cancer (RR = 1.34) *RR = Relative Risk, a measure of the risk of a certain event happening in one group compared to the risk of the same event in another group CHILDHOOD OBESITY AND CANCER LCN-823546-022114

23. LCN-XXXXXX-XXXXXX For agent or broker use only. Not for use with the public. Several factors thought to be at play in terms of the increased cancer risk Dietary – Increased fats, decreased fruits/vegetables Decreased activity levels Decreased Vitamin D levels CHILDHOOD OBESITY AND CANCER LCN-823546-022114

24. LCN-XXXXXX-XXXXXX For agent or broker use only. Not for use with the public. Primary prevention through lifestyle and environmental interventions is considered the best approach for addressing worldwide cancer risk (Danaei et al Lancet 2005;366:1784-93) and may be best approach to obesity epidemic as well Health care providers need to address this in a fashion that does not encourage eating disorders (Patton et al BMJ 1999;318:765-8) Comprehensive programs that promote increased activity and decreased television viewing time are helpful School programs that promote increased physical activity and improve diet behaviors can be successful (Brown et al Obes Rev 2007;8:127-30) Parental involvement! CHILDHOOD OBESITY - PREVENTION LCN-823546-022114

25. LCN-XXXXXX-XXXXXX For agent or broker use only. Not for use with the public. In his 2008 article in JIM Dr. Dan Zimmerman of Northwestern Mutual concludes that pediatric overweight adversely affects mortality rates; the exact extent and degree have yet to be determined (J Insur Med 2008;40:204-209) Although it is now 5 years later, we do not yet have all the answers Seems safe to say that one needs to be very cautious in underwriting overweight children and especially adolescents; those who qualify as obese are most likely uninsurable due to the significant future mortality risk to which they are subject CHILDHOOD OBESITY – PRACTICAL APPROACH LCN-823546-022114

26. LCN-XXXXXX-XXXXXX For agent or broker use only. Not for use with the public. Any question? THANK YOU FOR YOUR ATTENTION LCN-823546-022114