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.

Weight loss may be voluntary (diet, medication, bariatric surgery) or involuntary. Involuntary loss at older ages is powerfully linked to increased mortality per se, as well as to frailty (which has mortality and morbidity implications).

The prevailing underwriting paradigm for cigarette smoking focuses on current smoking or the interval since quitting.

However, after many years of cigarette consumption, current smoking becomes less of a concern than duration of smoking, expressed in “pack years” (one year of smoking a pack a day is one “pack year”; a year of two packs per day is two “pack years”; and so on).

Most of the association between smoking and mortality is due to the chronic effects of cigarette indulgence. Therefore, knowing the applicant’s smoking history is important in defining risk, especially beyond midlife.

Who would be the better candidate for life insurance: someone who just started smoking at age 65 (yes, this does happen!) or someone who had accumulated 80-plus pack years but quit two years ago at age 63? Clearly, it would be the “ex-smoker.” This is a paradox considering that this newly starting current smoker would be denied the most favorable life insurance rates, whereas, at most companies, the other person would not.

Clearly, life insurers need to start asking proposed insureds who have ever smoked how long they have done so and how much, on average, they smoked per day. This allows underwriters to make rough estimates of the “pack years” and thereby to define the risk better.

When all three components of the sinister trio are linked together, the mortality risk is more than additive.

This is especially important in persons who do not have (or acknowledge, anyway) a history of chronic disease. Think of this trio as a “time bomb” for pathology. Though currently below the threshold of detection by routine screening, it is nevertheless disposed to result in acute circulatory events, cancer and other catastrophic consequences.