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.

JAMA Forum: What Accounts for the Reduction in Obesity Rates for Preschool Children?

Lawrence Gostin, JD

Lawrence Gostin, JD

In a widely publicized study, Centers for Disease Control and Prevention researchers reported a statistically significant recent downward trend in obesity prevalence among US preschoolers in 18 states, based on data from 2008-2011. These findings have been followed by research published in JAMA showing a significant decline over the last decade in obesity prevalence among children aged 2 to 5 years. Although the media reported a dramatic 43% decline (calculated as a relative difference), the absolute difference was much more modest (a 5.5% decline from 14% in 2003-2004 to just over 8% in 2011-2012).

In other age groups, obesity rates remained at historic highs (and increased among women aged 60 years or older). Yet, the news reports signaled, perhaps prematurely, major advances in the fight against obesity.

To be sure, preschool children are an important demographic, as overweight in young children is a good predictor of weight status and obesity-related health problems in adulthood. And there is some indication that nutrition is trending in the right direction, with children consuming fewer calories in 2010 than they did a decade before. Importantly, eating fewer carbohydrates (including sugars) drove the calorie decline.

Assuming the data reflect a real advance in the fight against overweight and obesity, what might account for the reduction? And what policies might be most effective going forward?

Clearly, shifting something as complex as nutrition and physical activity is difficult, requiring engagement of a variety of stakeholders, including government, industry, civil society, and media. Personal behavior changes occur as people incorporate healthy habits into their daily lives.

Existing within a federalist system, US policies on nutrition and physical activity occur at the national, state, and local levels. Nationally, the nutritious foods promoted by the Special Supplemental Nutrition Program for Women, Infants, and Children (popularly known as WIC) have been selected to closely (although not fully) align with recommended dietary guidelines. At the same time, national initiatives, such as First Lady Michelle Obama’s Let’s Move program, have focused public attention on childhood obesity. Federal policies, however, are imbued with detrimental political influences, including agriculture and school policies reflecting the interests of industry rather than those of children. The farm bill subsidizes unhealthy products such as corn (think high-fructose corn syrup) rather than fruits and vegetables, and the school lunch program counts pizza (think tomato sauce) and french fries (think potatoes) as vegetables.

There is so much more that the federal government could do to improve childhood nutrition, and there is no area more important to address than the marketing of junk foods to children. As the Institute of Medicine pointed out, companies aggressively market unhealthy foods to children and adolescents, not only in television, but also on the Internet, through video games and in other digital platforms. Yet there are few, if any, rules against targeting these impressionable young minds. Companies’ voluntary measures are inadequate, and industry leaders claim it is really the responsibility of parents to monitor what their children are watching.

Most innovation is taking place at the state and local level, through such measures as nutrition and physical activity standards for early care and education. It makes sense to have states and cities act as “laboratories” to try, and to evaluate, new approaches. In fact, many federal initiatives either draw on (or, sadly, even undermine) creative local initiatives. New York City banned trans fat years ago, but the US Food and Drug Administration (FDA) only recently proposed that it might do so nationally. New York similarly introduced menu labeling—a concept then adopted in the Affordable Care Act (ACA). However, because the ACA sets a uniform national standard, it also preempts more stringent local labeling requirements, thus undermining innovation.

More recently, the FDA proposed altering food package labels. The proposed regulation—even if very late in coming—helps to clarify such things as serving size and added sugars. But it fails miserably in doing what is really needed: mandating food companies to provide prominent, comprehensible front-of-package labels. The United Kingdom encourages food companies to label their products with a voluntary “traffic light” system, which uses a vivid red label to flag excess fat, saturated fat, sugar, and salt content, with amber and green labels indicating medium and low levels of these nutrients, respectively. Prominent and clear labeling incentivizes industry to formulate healthy foods. What company wants to have 4 glaring red lights on the front of their package?

Municipal programs to improve nutrition have far outpaced federal action. The National Salt Reduction Initiative (NSRI) is a New York City-led public-private consortium of more than 90 health agencies and associations. Companies in the program voluntarily pledged to reduce sodium by 20% in overall sales within a given food category (eg, canned soup) by 2014. This still left ample room for high-sodium foods provided the producer offset these with low-sodium alternatives within the product category.  Many companies have joined NSRI, with 21 of them meeting sodium checkpoints in 2012.

It will be evident to any thoughtful observer that a major reason for expanding waistlines, especially among children, is larger portion sizes—with the biggest culprit being super-sized sugary drinks. Although a 12-ounce soda was considered “king-size” in 1950, it is now marketed as a child portion. A large Coca-Cola at McDonald’s is 32-ounces, whereas 7-Eleven’s “Double Gulp” contains 50 ounces, 600 calories, and no nutritional value. Yet, the only effort to date to curb portion size was the controversial limit on the sale of large sugar-sweetened beverages in New York City, imposed in 2012 by then-Mayor Bloomberg. The program, however, was unpopular, and the courts have thus far struck it down as mayoral overreach. Yet, creative policies to reduce portion sizes are critical to future success.

If one were to choose a single intervention that would be most likely to work, it might be taxation. Research suggests that even a relatively modest tax on sugary drinks, candy, and other decidedly unhealthy products might reduce consumption. Economic incentives, and disincentives, are powerful motivators of human behavior.

So what are the most important policies for the future to ensure that the decline in preschool obesity is a real trend that will stand the test of time? The truthful answer is that we do not know. But this much is nearly certain: if society were to adopt a suite of policies, sustained over a long period, the culture of overeating would change.

Look at tobacco as a model. It is nearly impossible to say which particular intervention worked in reducing prevalence so dramatically over the last several decades—taxes, laws ensuring smoke-free areas, package labeling, advertising bans, public education, and more. What we do know is that a broad range of policies can transform public perception, and ultimately human behavior. It can be done if there is a political will.

First Lady Michelle Obama recently announced a package of new obesity prevention measures under the Healthy, Hunger-Free Kids Act of 2010: a revamped version of the nutrition label on packaged food, new rules restricting junk food marketing in schools, and the expansion of a pilot program to feed nutritious meals to hungry children in need. From July 1, more than 22 000 schools that serve mainly low-income children will be eligible to serve free school meals to all students. Should these programs progress as planned, it would at least put the United States on the road to healthier, fitter children—a wonderful investment in our future.


About the author: Lawrence O. Gostin, JD, is University Professor and Faculty Director, O’Neill Institute for National and Global Health Law, Georgetown University Law Center, and Director of the World Health Organization Collaborating Center on Public Health Law and Human Rights. His most recent book is Global Health Law (Harvard University Press).

About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.

New Insights Into Genes and Obesity Point to Possible Targets for Treatment

New research reveals association between body mass index and levels of DNA tagging of certain genes. Image: Jeff Morin/iStock.com

New research suggests that body mass index is linked to differing levels of DNA methylation in the HIF3A gene. Image: Jeff Morin/iStock.com

Researchers have found that potentially modifiable chemical tagging of a particular gene is associated with obesity in humans, a finding that underscores the complex roots of obesity involving interactions among lifestyle, genetics, and the environment.

Certain genes such as leptin can play a role in obesity, and the increasing use of whole-genome analysis has uncovered dozens of other genes that might contribute to the problem. In mice, studies have also shown that chemical tagging of some genes is linked with obesity. Such tagging, which is influenced by factors in the environment (including the diet), is part of a phenomenon known as epigenetic modification, which affects how genes are expressed by cells. A common type of epigenetic modification is DNA methylation, the reversible addition of a chemical methyl group to parts of DNA. While one’s genetics are predetermined and remain mostly unchanged throughout life (unless a spontaneous mutation occurs), one’s epigenetics are highly dynamic.

Now, a new study released yesterday in The Lancet reveals that DNA methylation of a specific gene involved in oxygen metabolism and energy expenditure in humans appears to be highly linked to body mass index (BMI) in a large population of Europeans.

Scientists at the University of Leicester in England performed genetic analyses on blood samples from 459 individuals of European origin and looked for associations between levels of methylation on various DNA segments and BMI. After searching through the entire DNA sequence, they found 3 segments on 1 gene, HIF3A, which had differing levels of DNA methylation that were significantly correlated with BMI, even after adjustment for other potentially confounding variables.

The researchers found that for every 10% increase in methylation level of these 3 segments of DNA—on a scale from 0 (no methylation) to 100% (full methylation)—BMI increased from 3.2% to 7.8%. In other words, in this particular population, for every 10% increase in HIF3A methylation level, there was an average BMI increase of 0.87 to 2.12 kg/m2.

When the researchers then tested 2 separate populations to see if the results could be replicated (1 group of 339 individuals from France and another group of 1789 individuals from Germany), they found that the associations still held true, although they were less strong. They also tested a fourth group of individuals, using either fat tissue or skin tissue rather than blood. They found an even stronger association between BMI and HIF3A methylation level in fat tissue, but no association in skin tissue.

The authors note that because this was a cross-sectional study, no conclusions about causality can be made. However, they said the findings provide a strong foundation for further research to understand the link between epigenetic changes and obesity, and that understanding the role such changes play could “identify novel therapeutic targets” for this widespread condition.

Heart Health Education Efforts May Not Be Reaching Many Hispanic Women

Hispanic women are less likely than non-Hispanic white women to know that heart disease is the leading cause of death among women (Image: robeo/iStock.com).

Hispanic women are less likely than non-Hispanic white women to know that heart disease is the leading cause of death among women (Image: robeo/iStock.com).

Familiarity with heart disease risk factors is associated with improved lifestyle choices, heart health, and overall health. But Hispanic women living in the United States are less aware than their white counterparts of the risk heart disease poses to them and less accurate in estimating their weight—factors that may partially explain why hypertension, diabetes, and obesity affect minority women disproportionately.

The finding appears in the Journal of Women’s Health.

A study using face-to-face questionnaires completed by 382 Hispanic and 301 non-Hispanic white women participating in the Heart Health in Action database at Columbia University Medical Center in New York City found that Hispanic women were less likely than white women to correctly identify heart disease as the leading cause of death among women (27% vs 88%). Hispanic women were also less likely to know the symptoms of a heart attack or stroke compared with white women (58.5% vs 80.8%).

Women were excluded from the study if they were at high risk for heart disease, had a known history of coronary artery disease, had undergone a cardiovascular procedure, were pregnant, or had a history of heart attack or stroke.

Additionally, Hispanic women were less likely than white women (69.4% vs 82.9%) to correctly estimate their weight, and they were far more likely to underestimate it (24.8% vs 5.0%). Among the Hispanic women, those who spoke primarily Spanish or were bilingual were less likely than those who primarily spoke English to correctly identify that heart disease is the leading cause of death among women.

The researchers concluded that effective prevention strategies that target heart disease knowledge and awareness are needed for populations at risk for heart disease. “Persistently low CVD [cardiovascular disease] awareness poses continuing challenges for Hispanic women, health care professionals, and public health officials,” they wrote. “Education about CVD, weight perception, and healthy weight are critical steps in addressing the relationship between obesity and the rise in CVD mortality attributed to it.”

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.

How Much More Does a Healthy Diet Really Cost?

A healthy diet costs about $1.50 more per day than unhealthy food choices, according to a new study. (Image: brookebecker/iStock.com)

A healthy diet costs about $1.50 more per day than unhealthy food choices, according to a new study. (Image: brookebecker/iStock.com)

Conventional wisdom often chalks up poor eating habits to cost. Usually it’s assumed that fresh produce costs more than chips and that lean meats are more expensive than high-fat cuts. Even though the cost of a healthier diet is difficult to quantify, a comprehensive new study puts it at $1.50 per day more than less healthy eating patterns.

“Until now, the scientific evidence for this idea has not been systematically evaluated, nor have the actual differences in cost been characterized,” lead author Mayuree Rao, a medical student at the Warren Alpert Medical School of Brown University, said in a statement.

Rao and colleagues at Brown and the Harvard School of Public Health analyzed 27 studies published since 2000 that evaluated prices for individual foods and healthier or less healthy diets. Their analysis, published online today in BMJ Open, included prices in 10 high-income countries and calculated price differences per serving and per 200 calories for a variety of foods and types of diets.

For example, they compared prices for boneless, skinless chicken breasts with chicken drumsticks, which were considered a less healthy option. Other comparisons included whole grain bread with white bread, low-fat or nonfat milk with whole milk, and chocolate with high or low saturated fat levels.

A healthier diet rich in fruits, vegetables, fish, and nuts cost about $1.50 per day more than a poor diet filled with processed foods, fatty meat, and refined grains, the study showed. The cost difference was greatest for meat: 29 cents per serving and 47 cents per 200 calories more for healthy options.

The investigators noted that the daily $1.50 price difference totals $550 per year. “For many low-income families, this additional cost represents a genuine barrier to healthy eating,” they wrote. However, they estimated that annual US health care costs linked with unhealthy eating total $393 billion, or $1200 per person.

Long-Awaited Prevention and Treatment Guidelines for Heart Disease Published

Four new guidelines give primary care physicians direction as they help their patients reduce their risk of developing heart disease. (Image: JAMA, ©AMA)

Four new guidelines give primary care physicians direction as they help their patients reduce their risk of developing heart disease. (Image: JAMA, ©AMA)

Much-anticipated national guidelines for reducing most risk factors associated with cardiovascular disease have finally been released—with one exception. Updated guidelines for addressing hypertension, which had been expected to be available earlier this year, are not yet available.

The released guidelines focus on healthy lifestyles, atherosclerotic cardiovascular risk assessment, blood cholesterol management, and obesity.

The healthy lifestyles and risk assessment guidelines are new. The cholesterol management guideline is the first update since 2004. The obesity guideline is the first update of the original document, published in 1998.

Each guideline was created by expert panels convened by the National Heart, Lung, and Blood Institute, which handed over governance, management, and publication of the guidelines last June to the Obesity Society (for the obesity guideline) and to the American Heart Association and the American College of Cardiology along with the Obesity Society for the others.

Guideline for a Healthy Lifestyle
The healthy lifestyle guideline stresses eating a generally heart-healthy diet and engaging in physical activity as key elements for preventing heart attacks, strokes, and other cardiovascular diseases. The guideline’s recommendation on diet doesn’t endorse any specific eating plan, such as the Mediterranean diet; instead, it calls for primary care physicians to develop heart-healthy dietary plans based on the individual patient’s caloric requirements and personal and cultural food preferences, with additional tweaks to account for other medical conditions, such as diabetes.

The healthy lifestyle guideline also calls for a reduction in salt (sodium) consumption but doesn’t endorse a target level, such as limiting sodium intake to 1500 mg/d as advocated by the American Heart Association and others. Regarding physical activity, the guideline advises moderate or vigorous aerobic exercise, such as brisk walking, for an average of 40 minutes 3 or 4 times a week.

Guideline for Cardiovascular Risk Assessment
Previously, cardiovascular risk assessment focused only on coronary heart disease, but the new guideline includes stroke. This is intended to improve overall cardiovascular risk assessment, particularly for women and blacks, who are at much greater risk for stroke then white men.

The guideline promotes risk assessment methods for atherosclerosis-related risk factors that are easily ascertained by a primary care physician, such as age, cholesterol levels, blood pressure, smoking, and diabetes.

Cholesterol Guideline
The cholesterol guideline emphasized reducing low-density lipoprotein cholesterol (LDL-C), the “bad” cholesterol, but doesn’t set a specific target. Instead, the guideline authors recommended moderate- or high-intensity statin therapy for 4 groups:

• Patients with cardiovascular disease
• Patients with an LDL-C level of 190 mg/dL or higher
• Patients with type 2 diabetes who are between 40 and 75 years of age
• Patients with an estimated 10-year risk of cardiovascular disease of 7.5% or higher who are between 40 and 75 years of age

The 10-year risk threshold is a lower percentage than currently used and could lead to a doubling of statin use in the adult US population, from 15% to about 30%.

Guideline for Addressing Obesity
The obesity guideline recommends weight reduction— with a goal of losing 5% to 10% of one’s body weight within 6 months—through a nonspecific reduced-calorie diet, increased physical activity, and adoption of behavioral strategies introduced by a trained professional, who should meet in person with the patient 2 or 3 times a month for 6 months.

The guideline also said that bariatric surgery may provide significant health benefits for patients with a body mass index (BMI) of 40 or higher or a BMI of 35 or higher along with 2 other cardiovascular risk factors.

What About the Hypertension Guideline?
Not included in the rollout of the 4 guidelines was the hypertension guideline, which hasn’t been updated since 2003 and had been expected to be ready for release this summer. American Heart Association President Mariell Jessup, MD, said at a press conference last week that she wasn’t sure when the hypertension guideline would be published but that like the guidelines released today, it will be based on a similar approach, performed by an expert panel.