Diagnosing Obstructive Sleep Apnea is Covered in New Guideline

A new clinical guideline advises that people who are excessively sleepy during the day should be evaluated for obstructive sleep apnea and, if needed, undergo a sleep study. (Image: ©iStock.com/vitapix)

A new clinical guideline advises that people who are excessively sleepy during the day should be evaluated for obstructive sleep apnea and, if needed, undergo a sleep study. (Image: ©iStock.com/vitapix)

People who are unusually sleepy during the day for no apparent reason should be evaluated for obstructive sleep apnea and, if needed, undergo a diagnostic sleep study, according to a new clinical guideline.

Published today in the Annals of Internal Medicine, the guideline from the American College of Physicians (ACP) is based on reviews of peer-reviewed studies published from 1966 through May 2013. The ACP’s review of the medical literature evaluated how effectively different types of sleep tests can diagnose sleep apnea.

In people with obstructive sleep apnea, breathing slows or briefly stops because the airway becomes blocked during sleep. The result is poor sleep and excessive daytime sleepiness. Obesity is the best-documented risk factor, according to the guideline.

“Obstructive sleep apnea is a serious health condition that is associated with cardiovascular disease, hypertension, cognitive impairment, and type 2 diabetes,” ACP President David Fleming, MD, said in a statement. “It is important to diagnose individuals with unexplained daytime sleepiness so that they can get the proper treatment.”

Obstructive sleep apnea affects about 10% to 17% of the US population, according to the ACP. Estimates vary because researchers have used different criteria to define the condition in clinical studies.

Clinical symptoms include unintentionally falling asleep, daytime sleepiness, unrefreshed sleep, fatigue, insomnia, and snoring. For patients with these signs and no other potential causes of obstructive sleep apnea—thyroid disease, gastroesophageal reflux, or other respiratory conditions, for example—the guideline recommends a sleep study.

The preferred type of sleep study is polysomnography conducted overnight with observation in a sleep laboratory. Polysomnography monitors breathing, airflow, brain activity, blood oxygen levels, and certain muscle movements during sleep.

However, polysomnography is expensive and requires specialized equipment and personnel. For patients without access to a sleep laboratory and who don’t have other chronic medical conditions, the ACP recommends portable sleep monitors that can be used at home or in a hospital.

Fleming said diagnosing obstructive sleep apnea is in line with the ACP’s High Value, Cost-Conscious Care Initiative, which addresses providing quality care while reducing unnecessary costs.

“Prior to diagnosis, patients with obstructive sleep apnea have higher rates of health care use, more frequent and longer hospital stays, and greater health care costs than after diagnosis,” he said.

Irregular Work Hours May Increase Diabetes Risk, Study Shows

Working irregular hours may increase the risk of developing diabetes, according to a new study. (Image: ©iStock.com/hoodesigns)

Working irregular hours may increase the risk of developing diabetes, according to a new study. (Image: ©iStock.com/hoodesigns)

A new study adds diabetes to the list of health ailments linked with working irregular hours outside of a usual 9-to-5 schedule.

The findings show that people who’ve ever had shift-work jobs have a 9% increased risk of developing diabetes compared with those who consistently worked daytime hours. The study, published online today in Occupational and Environmental Medicine, also showed that the increased risk was highest, 42%, in people who worked rotating shifts involving daytime, evening, and nighttime hours.

Men who worked irregular hours had a 37% increased risk of developing diabetes compared with 9% for women. The researchers called the sex difference “an interesting phenomenon.” They said the finding “suggests that male shift workers should pay more attention to the prevention of [diabetes], and provides a clue for future study of how the biological mechanisms of shift work and [diabetes] are affected by gender.”

The study is a meta-analysis based on 12 studies involving 226 652 participants, including 14 595 who had diabetes. Despite previous research that linked shift work with increased risks of breast cancer and of heart attack, study results attempting to show an association with diabetes have been inconsistent.

But several physiological clues are known, the study authors noted. “Some studies have shown that insufficient sleep and poor sleep quality may develop and exacerbate insulin resistance,” they wrote. “Evidence from epidemiological investigation has confirmed that shift work is associated with weight gain, increase in appetite, and adiposity, which are major risk factors for [type 2 diabetes].” Irregular work hours may influence diabetes risk by leading to harmful changes in blood pressure and cholesterol levels, they added.

Diabetes is a major public health challenge in industrialized and developing countries, the study authors noted. “By the year 2025, the number of cases of type 2 diabetes mellitus will have increased by 65% to reach an estimated 380 million individuals worldwide,” they wrote.

 

Author Insights: Overtreatment of Diabetes in Elderly Patients Remains Underrecognized

Patrick O'Malley, MD, MPH of the Uniformed Services University of the Health Sciences in Maryland, speaks about overtreatment of diabetes among elderly patients.

Patrick O’Malley, MD, MPH of the Uniformed Services University of the Health Sciences in Maryland, speaks about the overtreatment of diabetes among elderly patients.

The primary goal of treatment for diabetes, as for many chronic conditions, is to lower rates of death and complications from the disease. But an equally important goal in medicine, one recognized over 2 millennia ago, is to “do no harm,” and sometimes this balance between help and harm can be difficult to accomplish.

In this week’s issue of JAMA, a theme issue on diabetes, a viewpoint discusses the overtreatment of diabetes in certain patient populations—that is, the overuse of blood sugar–lowering medications to the point at which average blood sugar levels may be too low and cause more harm than benefit. The authors refer back to a study published about 6 months ago in JAMA Internal Medicine, in which researchers looked at administrative data from a large population of Veterans Affairs patients and found surprisingly high rates of overtreatment.

The JAMA Internal Medicine study focused on patients with diabetes who were most susceptible to hypoglycemia (low blood sugar) caused by diabetes overtreatment, which included patients older than 75 years of age, those who had poor kidney function, and those who had a diagnosis of cognitive impairment or dementia. Overtreatment among these patients was defined as having a hemoglobin A1c (HbA1c) level (a measure of average blood sugar values over a 3-month period) that was less than 6.0% (roughly corresponding to a blood sugar of 126 mg/dL), less than 6.5% (blood sugar of 140 mg/dL), or less than 7.5% (blood sugar of 154 mg/dL).

The researchers found that rates of overtreatment were 10.1% for HbA1c less than 6.0%, 25.2% for HbA1c less than 6.5%, and 44.3% for HbA1c less than 7.0%. However, no information on actual rates of hypoglycemia or the complications thereof (such as emergency department visits or hospitalizations) was collected.

Author Patrick O’Malley, MD, MPH, discusses his views on the implications of this study with news@JAMA.

news@JAMA: The study showed that 44% of VA patients with diabetes and risk factors for serious hypoglycemia may be getting overtreated to some degree. In your article, you state that these results are “sobering.” Why do you think overtreatment happens so often?

Dr O’Malley: In general, overtreatment is a multifactorial issue related to the culture of care. In medicine, physicians always want to do something, to take something, such as a blood sugar value, from abnormal to normal. We rely on clinical evidence for these treatment goals, but sometimes, in the absence of good clinical evidence, we must instead rely on biologic plausibility, and extrapolate data from one population to another. This extrapolation often happens with the elderly, who are not included as participants in many clinical trials on which many general clinical guidelines and recommendations are based. That’s why overtreatment tends to happen in the elderly, not just for diabetes, but for other diseases as well.

Another issue is the use of quality metrics, or A1c in the case of diabetes, with the notion of “lower is better” driving this culture of aggressive care. The VA system in particular is very good at driving such quality metrics to success, which probably leads to higher rates of overtreatment. It’s basically a case of good intentions and good systems gone awry.

news@JAMA: It seems that since elderly individuals are underrepresented in several of the major diabetes trials, evidence on the benefits vs harms of intensive glucose control might be difficult to interpret, and the ideal A1c level for elderly people is still a mystery. Is there a bottom line that can be drawn from these studies?

Dr O’Malley: Yes, the bottom line is that for anyone who has a life expectancy greater than 15 years, an A1c goal of less than 7 is reasonable. For all other people, which includes elderly individuals as well as younger individuals with multiple comorbidities and lower life expectancies, an A1c goal of less than 7 might be more harmful than beneficial. Providers should be tailoring A1c goals to the individual, and life expectancy should be a major part of that equation.

news@JAMA: For individuals with a life expectancy of less than 15 years, what is a reasonable A1c goal? Is there an upper limit?

Dr O’Malley: There’s not a whole lot of great evidence to support a specific upper limit, but in general, a blood glucose consistently over 200 is where people start running into problems with immune system dysfunction and increased risk of infections. This corresponds to an A1c of about 9.

news@JAMA: What can doctors and hospital systems do to address the issue of overtreatment?

Dr O’Malley: On a systems level, we have to be smarter about choosing metrics, and smarter about individualizing metrics to individual patients—older patients should have different metrics than younger ones. On an individual physician level, we should strive to be less pharmacologically oriented, especially in the elderly. There is a lot that therapeutic lifestyle changes can achieve. We also tend to be overly aggressive with monitoring, ordering A1c tests too frequently, and telling our patients to check blood sugars four times a day. Checking blood sugars three times a week is plenty for most stable patients with diabetes.

news@JAMA: What about for patients who might be skeptical or resistant toward the idea of withdrawing or decreasing the intensity of care?

Dr O’Malley: It’s true that this might be a major barrier, as patients are sometimes reluctant to do this, or confused as to why the same doctor who told them to intensify their diabetes control is now telling them to scale back. This is why it’s so important to have a trusting and invested doctor-patient relationship.

Sometimes as doctors, in an effort to stay as up to date and proactive as possible, we change our culture toward treatment before the evidence is truly there, and this ends up harming patients, wasting resources, and engendering distrust among patients toward their physicians and the healthcare system as a whole. Another example of this is what happened with hormone replacement therapy for menopausal women back in the ’90s—we were so quick to act on the benefits of hormone replacement before the long-term evidence was available and then realized it was actually more harmful than beneficial.

news@JAMA: Is there anything else you think patients should be aware of in terms of diabetes overtreatment?

Dr O’Malley: Patients should realize that in general, no medical therapy is perfect, and every therapy has risks. In the case of diabetes, patients should be aware of just how serious and life-threatening hypoglycemia can be. It’s important to educate them about this.

Task Force Backs Screening Women for Gestational Diabetes Late in Pregnancy

A US task force recommends routinely screening women for gestational diabetes after 24 weeks of pregnancy. Image: MayaMoody/iStock.com

A US task force recommends routinely screening women for gestational diabetes after 24 weeks of pregnancy. Image: MayaMoody/iStock.com

All pregnant women should be screened for gestational diabetes but not until the pregnancy has passed the 24th week, according to a new recommendation from the US Preventive Services Task Force (USPSTF) published today in the Annals of Internal Medicine. In 2008, the task force had found insufficient evidence to support routine screening for gestational diabetes in women.

About 6% of pregnant women in the United States develop symptoms of diabetes during pregnancy. In certain populations, particularly minority populations, the rate can be as high as 25%. If left untreated, gestational diabetes increases the risk of poor outcomes for mother and child. Women with gestational diabetes may develop life-threatening preeclampsia, and the fetus may grow unusually large, leading to a complicated delivery and possible injury to the newborn. To avert these problems, nearly all (96%) US pregnant women are currently screened for this condition so that their blood sugar levels may be managed, if needed.

Women who are identified as having gestational diabetes may be advised to increase physical activity, make dietary changes, and monitor their glucose levels. If those steps don’t improve the condition, medications may be prescribed. The USPSTF in 2008 found inadequate evidence to support screening for gestational diabetes before or after 24 weeks, despite the widespread adoption of screening. Other prominent groups such as the American Academy of Family Physicians, the American Diabetes Association, and the Endocrine Society recommend screening after 24 weeks.

But the USPSTF’s new review of the evidence found enough evidence to support the benefits of screening for gestational diabetes after 24 weeks, and the task force has updated its recommendation accordingly. The review did not find sufficient evidence to support screening before 24 weeks, but the report notes that there may be specific circumstances in which a physician may choose to do so. For example, if a woman has risk factors that place her at greater risk, such as obesity or a family history of gestational diabetes, her physician may want to consider earlier screening.

Texting the Way to Reduced Diabetes Risk

Text messaging can improve awareness about diabetes and ways to reduce risks. (Image: BrianAJackson/iStock.com)

Text messaging may improve awareness about diabetes and ways to reduce risks. (Image: BrianAJackson/iStock.com)

A 14-week text messaging program helped dozens of people in a pilot study become more aware of their diabetes risk and make healthier dietary choices, according to new research.

The pilot was part of the Beacon Community Cooperative Agreement Program, a federally funded initiative to strengthen health information technology use in 17 communities across the country. Today in the Journal of Medical Internet Research, researchers reported results from Detroit and Cincinnati.

Their findings are based on survey responses from 161 participants who completed the 14-week texting program, known as txt4health. Participants received messages on their cell phones offering a type 2 diabetes risk assessment and weekly messages with tips to reduce their risk. Nearly one-third of the participants had a history of diabetes. About half were obese and almost one-third were overweight. Their mean age was 42.4 years, about three-fourths were women, and the group was evenly split between black and white individuals.

At the pilot’s end, 83.2% of participants said they used the program to set physical activity goals, and 60% of those individuals met their goals all or most of the time. About two-thirds reported setting weight loss goals; 25.7% said they met those goals all or most of the time. About half said the program had helped them lose weight.

Participants said the program also helped them to choose healthier foods. About three-fourths said they were more likely to replace sugary drinks with water; have a piece of fruit instead of dessert; substitute a small salad for chips or fries when dining out; buy healthier foods at the grocery store; and eat more grilled, baked, or broiled dishes instead of fried foods.

In addition, all or most of the participants said the text messages were easy to understand and that the program boosted their knowledge about their own risks for diabetes and increased their awareness about their dietary and physical activity habits.

“Text message programs may be a useful tool when used as a component in a broad-based public health campaign,” lead author Lorraine Buis, PhD, of the University of Michigan Medical School, said in a statement.

But she also noted that only 39% of the 1838 individuals who were fully enrolled in txt4health stuck through all 14 weeks. “Sole reliance on this strategy may be cautioned when targeting a general population because the level of individual engagement varies widely,” Buis added.

Patients Continue to Experience Benefits 3 Years After Weight-Loss Surgery for Severe Obesity

Anita P. Courcoulas, MD, MPH, director of Minimally Invasive Bariatric and General Surgery at the University of Pittsburgh Medical Center, and colleagues found that 3 years after undergoing bariatric surgery for severe obesity, patients had, on average, lost a substantial amount of weight and improved on several health measures. (Image: University of Pittsburgh Medical Center)

Anita P. Courcoulas, MD, MPH, director of Minimally Invasive Bariatric and General Surgery at the University of Pittsburgh Medical Center, and colleagues found that 3 years after undergoing bariatric surgery for severe obesity, patients had, on average, lost a substantial amount of weight and improved on several health measures. (Image: University of Pittsburgh Medical Center)

More encouraging data are emerging on the benefits of bariatric surgery in reducing substantial amounts of weight and improving health in severely obese patients, according to a study published by JAMA.

Researchers with the Longitudinal Assessment of Bariatric Surgery Consortium, a multicenter observational cohort study at 10 US hospitals in 6 geographically diverse regions of the country looked at health measures for severely obese patients 3 years after weight-loss surgery. Patients who had undergone Roux-en-Y gastric bypass surgery had lost about 90 pounds, or about 30% of their original weight; those who had undergone laparoscopic adjustable gastric banding lost about 44 pounds, or about 16% of their original weight. The median presurgical weight for both groups was about 284 pounds.

The researchers also found among study participants who had diabetes at the time of surgery, partial remission of the disease occurred in about two-thirds of those undergoing Roux-en-Y bypass and just over a quarter of those undergoing gastric banding. Abnormal blood lipid levels were eliminated in about 62% of patients after Roux-en-Y bypass and in about 27% after gastric banding. Hypertension resolved in almost 40% of patients with Roux-en-Y bypass and in almost 20% of patients with gastric banding.

Lead author Anita P. Courcoulas, MD, MPH, director of Minimally Invasive Bariatric and General Surgery at the University of Pittsburgh Medical Center, discusses her team’s findings.

news@JAMA: Why did you do the study?

Dr Courcoulas: Our focus was to look at the durability of weight and health changes after bariatric surgery in a carefully studied, heterogeneous population with a high degree of follow-up.

news@JAMA: These patient populations had different results based on the procedure performed. Why is that?

Dr Courcoulas: Our study didn’t specifically address the potential mechanisms of weight change, nor was it designed to make head-to-head procedure comparisons. In our study, both bypass and banding did lead to substantial weight loss at 3 years that compares favorably to the modest weight loss resulting from lifestyle intervention alone. The weight loss after banding was less than reported in previous studies and not as large as the weight loss after bypass. This may be a function of patient, provider, and/or many other factors and deserves further attention.

news@JAMA: Given that Roux-en-Y bypass appears to outperform gastric banding, why not have everyone who needs bariatric surgery receive the bypass?

Dr Courcoulas: There are patients who come to see a bariatric surgeon who are not comfortable with bypass because of the anatomical changes they will undergo, so banding is appealing for those still wanting help to lose weight.

news@JAMA: So is bariatric surgery the best option for severely obese individuals looking to lose weight and improve health measures?

Dr Courcoulas: The extreme heterogeneity in outcomes we found highlights the need to better understand factors contributing to individual differences in weight loss results. It would make sense if one of the important variables in determining how much weight one will lose and how well that weight loss is maintained is lifestyle modification—how do you make the most of an operation to help enhance those results? Even so, longer-term follow-up is needed to determine the durability of the weight and health improvements we observed.

Bariatric Surgery Achieves Long-term Diabetes Remission in Some Patients, Study Shows

Roux-en-Y gastric bypass surgery is more likely than other bariatric surgical procedures to reverse diabetes in obese patients who have the condition, according to a new study. (Image: JAMA, ©AMA)

Roux-en-Y gastric bypass surgery is more likely than other bariatric surgical procedures to reverse diabetes in obese patients who have the condition, according to a new study. (Image: JAMA, ©AMA)

Bariatric surgery can reverse type 2 diabetes for more than 5 years in some obese patients who have the condition, according to new research.

The study, published online today in the Annals of Surgery, followed up 217 obese patients with type 2 diabetes for a median of 6 years after they had bariatric surgery. Patients had 1 of 3 bariatric procedures: 162 had Roux-en-Y gastric bypass surgery, in which the size of the stomach is permanently reduced; 32 had gastric banding, which uses an adjustable band to narrow the opening from the esophagus to the stomach; and 23 had sleeve gastrectomy, in which much of the stomach is removed.

Overall, patients lost 55% of their excess weight and half of the patients had a complete or partial remission of their diabetes after the median 6-year follow-up period. Specifically, 24% of patients had a complete remission of their diabetes with a blood sugar level of less than 6% without diabetes medications. The American Diabetes Association (ADA) recommends a blood sugar level no higher than 7%.

An additional 26% of patients had a partial remission of their diabetes, and 34% had improved glycemic control. Cardiovascular risk factors decreased by 25%. Diabetic neuropathy improved in 53% of patients and stabilized in 47%.

The investigators also found that patients who had long-term weight loss, were diagnosed with diabetes less than 5 years before their surgery, and had gastric bypass surgery rather than the other 2 procedures were most likely to have sustained diabetes remission.

However, 19% of patients who achieved full or partial remission had a recurrence of their diabetes. Even so, those patients had improved glycemic control and cardiovascular risk factors compared with their status before surgery. The investigators noted that 75% of patients who had a recurrence still met the ADA goal of blood sugar levels less than 7%.

“Only about half of diabetics in the United States currently have acceptable control of their blood glucose level,” lead investigator Stacy Brethauer, MD, a bariatric surgeon at the Cleveland Clinic Bariatric and Metabolic Institute, said in a statement. “This study confirms that [Roux-en-Y gastric bypass surgery] can offer durable remission of diabetes in some patients and should be considered as an earlier treatment option for patients with uncontrolled diabetes.”