By Jenny Gold
This story was produced in collaboration with 

On a Monday night in December, Lauretta Martin, 47, visited the sleep lab at the National Rehabilitation Hospital in Washington, D.C. for the second time.

On her first visit, Martin, a heavyset woman whose husband reports she is a loud snorer, was diagnosed with sleep apnea. This time, she was being fitted for a CPAP machine, which helps keep a snorer’s airway open throughout the night.

The sleep lab has six testing rooms, each of which looks just like a room at a Holiday Inn, with striped wallpaper, a floral bedspread, framed prints of the seaside and free wifi.

“They have a brochure that says it’s just like being in a hotel room, and it is,” says Martin, sitting on the edge of her bed wearing a pair of soft grey pajamas and watching a football game on her flat-screen TV.

Aside from the two-dozen colorful electrodes taped to her body to monitor her every motion and the scuba-style mask on her face to enhance her breathing, she looked ready for a cozy night of slumber.

In the tech room a few doors down, a professional sleep technician observed her over a video monitor, testing the electrodes and preparing to listen in to the sounds of her sleep.

Snoring was once considered a simple annoyance for bed partners, but there is a growing awareness in the medical community that the grunts and snorts of noisy sleepers can also be a sign of sleep apnea, a condition shown to increase the risk of numerous serious illnesses, including heart disease, stroke and dementia.

Testing can be a lucrative business, and labs have popped up in free-standing clinics and hospitals across the country. Over the past decade, the number of accredited sleep labs that test for the disorder has quadrupled, according to the American Academy of Sleep Medicine (AASM).

Sleep apnea occurs when the muscles in the back of the throat relax, causing an airway obstruction that can stop a person’s breathing for several seconds or even minutes.  It causes restless sleep and sometimes dangerously-low blood oxygen levels.

The disorder can be diagnosed by monitoring a snorer’s sleep patterns, either in an overnight visit to a sleep lab or at home using a portable testing device. It is then often treated with a CPAP machine, which helps keep a snorer’s airway open during sleep.

Sleep apnea has likely gotten more common as the population has grown older and more obese, two major risk factors for apnea, and the National Institutes of Health estimates that more than 12 million Americans suffer from the disorder.  Many are never diagnosed.

“I think the medical community is sort of dropping the ball” on apnea, explains Dr. David Gross, medical director of the sleep lab at the National Rehabilitation Hospital. “It’s just sad when you walk through the hospital and you see these patients with heart failure—the person might be 35 years old, he’s 350 lbs — but no one’s thinking that he has sleep apnea, which he statistically does.”

Dr. David Gross, director of the sleep lab at the National Rehabilitation Hospital in Washington, D.C., analyzes a sleep test (Photo by Jenny Gold/KHN)

He says more than three-quarters of the patients who come to the lab are diagnosed with apnea.

But the testing isn’t cheap: each night at a hospital sleep lab can cost $1,900 and is usually mostly covered by a patient’s health insurance. Some patients, including Martin, end up spending two nights at the lab – one to test for apnea, and the second to try the CPAP machine.

Dr. Fred Holt, an expert on fraud and abuse and the medical director of Blue Cross Blue Shield in North Carolina, says some patients aren’t having basic exams done first and are therefore being prescribed expensive tests they don’t need. Not everyone who snores has a chronic disorder, he notes.

In other cases, Holt says the labs prescribe CPAP machines right away without first suggesting other strategies like losing weight of sleeping on your side, which can also reduce apnea.

“We are spending more and more money on sleep testing and treatment, and like anything else in health care, there are unscrupulous people out there who are more than happy to do testing and treatment that might be of questionable value,” says Holt. “This might be because of naiveté on the part of the physician, or unfortunately, it could be done for the sake of improving the cash flow of one’s business.”

It’s no secret that the sleep business can be lucrative for physicians. A website for Aviisha, a sleep testing company, has a section for physicians showing a picture of a doctor with a stack of money in his lab coat pocket.  And in February, the AASM is offering a seminar on the “business of sleep medicine for physicians” at a golf resort in Arizona.

Dr. Nancy Collop, president of the AASM, says that while many sleep centers offer comprehensive care for sleep disorders, others are largely focused on overnight sleep testing.

“A lot of people have gotten into the sleep business specifically to do that procedure,” she explains. The goal of the AASM’s accreditation process, she says, is to make sure sleep labs are offering more because “many patients may not even need a sleep study.”

Helen Darling, president of the National Business Group on Health, which represents large employers offering health insurance to their workers, says the tests are driving up the cost of premiums.

“This is a good example of something where we have technology, we have financial incentives to use more of it then we have historically done, you have enough problems including a growing obesity epidemic, and you sort of put together the so-called perfect storm for driving up overuse and health care cost,” Darling says.

She says doctors should focus instead on common-sense approaches to sleep apnea, like losing weight, before turning to expensive testing and medical devices.

Another option are home sleep tests, which costs less than a fifth of the cost of a lab test, and are considered effective for most patients. Medicare began paying for home sleep tests in 2008, but the tests have had only modest growth.

“I believe lab tests, as opposed to the home tests, are being wildly overprescribed,” says Mike Backus, senior vice president of American Imaging Management, a subsidiary of Wellpoint.

Right now, he says, 99 percent of the sleep tests given to Wellpoint patients are done in the lab, but “it should be 70 percent at home and 30 percent in the lab.”

Backus adds that the majority of patients who are diagnosed with apnea and then given CPAP machines stop using them within the first year.

Some insurers, including Wellpoint, are changing the way they pay for sleep testing to curb the costs. Many now require a special pre-authorization. They also ask the doctor whether a patient qualifies for a home sleep test instead of one at the lab.

Those changes are now widespread among Massachusetts insurers and are having an effect on the sleep industry in the state.

Dr. Lawrence Epstein, the chief medical officer of Sleep Healthcenters in Massachusetts, says the labs have already experienced a 20 percent drop in the number of patients coming in for testing.

While the past decade was focused on industry growth, he says it’s “now going to be about consolidation and provision of better quality, more efficient care.”

Sleep Healthcenters has shut down three of its 15 sleep labs, and more closures may be on the way. Epstein says the company is focusing more on “sleep wellness,” including treating and managing sleep disorders, and less on testing.

The key, he explains, is to become more efficient without decreasing access to care for patients who need it.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

Chef Eric has struggled to manage his weight his entire life, and blogs on the Swedish website about food, his weight loss journey, eating in public, and more.

Dr. Richard Lindquist, a specialist with Swedish’s Weight Loss Services, provides some holiday eating tips to help you avoid those extra calories.

Spiced Hot Toddy

Serves 6 — 5oz drinks

Ingredients:

• 1 quart Light Soy milk
• 1 vanilla bean — split with seed scraped out
• 2 cinnamon sticks
• 1 TBSP honey
• 1 whole Nutmeg

Preparation:

1. Place soy milk w/vanilla bean and cinnamon sticks in sauce pan, bring just to simmer, insuring not to boil. Remove from heat. Add honey.
2. Allow the spices to steep for 10 minutes.
3. Transfer all the ingredients to a French press and press all spices down to the bottom.
4. Froth the toddy by carefully pumping up and down on the press, divide among 6 tea cups
5. Grate fresh Nutmeg over the Toddy, serve immediately.

Nutritional Information:

• 100 calories
• 1.5 grams of fat
• 6 grams of protein
• 12 grams carbs

Green Tea & Rosemary Sparkler

Makes 1 — 12 oz serving

Ingredients:

• 1 bag – Favorite Green Tea
• 2 inch stalk of Lemongrass (can substitute a lemon wedge)
• 1 stem of rosemary — small sprig removed from the top reserved
• 4 oz hot water
• 8 oz favorite sparkling water
• Ice cubes (optional)
• Artificial sweetener (optional)

 Preparation:

1. Steep the tea bag in the 4 oz of hot water with the lemongrass and the rosemary. Remove the teabag after 3 minutes let the herbs remain until the water reaches room temperature.
2. Strain tea into a tall glass over ice and sweetener (optional)
3. Add the 8 oz of bubbly water and a sprig of rosemary for garnish

Nutritional Information:

• 0 calories

By Michelle Andrews

Jackie Risley, before and after her bariatric surgery (Photos provided by Risley)

As obesity among young people continues to rise, a growing number of clinicians and researchers say that weight-loss surgery may be their best chance to take off significant weight and either correct or avoid conditions like diabetes and heart disease, which often go hand-in-hand with obesity.

But although health plans frequently cover bariatric surgery in adults, insurance coverage for the procedure in patients under age 18 is spotty.

Experts in pediatric obesity say that caution is warranted and that insurers shouldn’t just rubber-stamp such surgery in adolescents.

But they say emerging research may lead to more coverage for young people.

Anyone who has ever been on a diet—and there are many of us—knows that there are sensible ways to lose weight. These include balanced diets, exercising and realistic goals.

And then there are reckless ways to shed pounds—fads and diet aids that promise rapid weight loss, but often recommend potentially dangerous practices.

These include HCG weight-loss products marketed over-the-counter (OTC) that are identified as “homeopathic” and direct users to follow a severely restrictive diet.

The Food and Drug Administration (FDA) is advising consumers to steer clear of these “homeopathic” human chorionic gonadotropin (HCG) weight-loss products.  They are sold in the form of oral drops, pellets and sprays and can be found online and in some retail stores.

FDA and the Federal Trade Commission (FTC) have issued seven letters to companies warning them that they are selling illegal homeopathic HCG weight-loss drugs that have not been approved by FDA, and that make unsupported claims.

(For the list of manufacturers, distributors and products—and more information about FDA’s concerns about HCG—visit www.fda.gov/hcgdiet.)

HCG Makes Big Claims

HCG is a hormone that is produced by the human placenta during pregnancy.

Products that claim to contain HCG are typically marketed in connection with a very low calorie diet, usually one that limits calories to 500 per day.

Many of these popular HCG products claim to “reset your metabolism,” change “abnormal eating patterns,” and shave 20-30 pounds in 30-40 days.

“These products are marketed with incredible claims and people think that if they’re losing weight, HCG must be working,” says Elizabeth Miller, acting director of FDA’s Division of Non-Prescription Drugs and Health Fraud. “But the data simply does not support this; any loss is from severe calorie restriction. Not from the HCG.”

HCG is approved by FDA as a prescription drug for the treatment of female infertility, and other medical conditions. It is not approved for weight loss.

In fact, the prescription drug label notes there “is no substantial evidence that it increases weight loss beyond that resulting from caloric restriction, that it causes a more attractive or ‘normal’ distribution of fat, or that it decreases the hunger and discomfort associated with calorie-restricted diets.”

HCG is not approved for OTC sale for any purpose.

A Potentially Dangerous Diet

Living on 500 calories a day is not only unhealthy—it’s hazardous, according to FDA experts. Consumers on such restrictive diets are at increased risk for side effects that include gallstone formation, an imbalance of the electrolytes that keep the body’s muscles and nerves functioning properly, and an irregular heartbeat.

Shirley Blakely, a nutritionist at FDA’s Center for Food Safety and Applied Nutrition, echoes concerns about such restrictive diets. They can be dangerous, she says, and potentially fatal.

Very low calorie diets are sometimes prescribed by health care professionals for people who are moderately to extremely obese as part of medical treatment to lessen health conditions caused by obesity, like high blood pressure.

But even then, strict—and constant—medical supervision is needed to ensure that side effects are not life threatening, says Blakely.

Without medical oversight, consumers on very low calorie diets may not be getting enough vitamins, minerals and—most critically—protein.

“In general, the reference (average) calorie level is 2,000,” says Blakely. “If you want to lose weight, reduce your daily intake by 500 calories. Over the course of a week, that equals 3500 calories, which is the loss of a pound. Gradual weight loss is the way to do it.

Story Started Decades Ago

Miller explains that HCG was first promoted for weight loss in the 1950s. “It faded in the 1970s, especially when it became apparent that there was a lack of evidence to support the use of HCG for weight loss,” she says.

The diet has become popular again and FDA and FTC are taking action on illegal HCG products. “You cannot sell products claiming to contain HCG as an OTC drug product. It’s illegal,” says Brad Pace, team leader and regulatory counsel at FDA’s Health Fraud and Consumer Outreach Branch. “If these companies don’t heed our warnings, they could face enforcement actions, legal penalties or criminal prosecution.”

Elisabeth Walther, a pharmacist at FDA, explains that the agency does not evaluate homeopathic drug products for safety or effectiveness, and is not aware of any scientific evidence that supports homeopathy as effective.

However, those that meet certain conditions set by FDA can be marketed. A reference document called the Homeopathic Pharmacopoeia of the United States lists active ingredients that may be legally included in homeopathic drug products.

“HCG is not on this list and therefore cannot be legally sold as a homeopathic medication for any purpose,” Walther says.

FDA advises consumers who have purchased homeopathic HCG for weight loss to stop using it, throw it out, and stop following the dieting instructions. Harmful effects should be reported online to FDA’s MedWatch program or by phone at 800-FDA-1088 (800-332-1088) and to the consumer’s health care professional.

This article appears on FDA’s Consumer Updates page, which features the latest on all FDA-regulated products.

Dec. 6, 2011