Friday, August 31, 2012

Albumin/creatinine ratio is a recommended annual screening

The albumin / creatinine ratio ,  is  a recommended annual screening test . This easy urine test helps find people who are at greater risk of developing diabetic kidney disease.  The leakage of albumin from  blood into the urine is caused by damage to  small blood vessels in kidneys.

  albumin/creatinine ratio
         normal                           < 30        ug/mg creatinine
         microalbuminuria         30 to 299 ugm/mg creatinine
         macroalbuminuria        >  or = 300  ug/mg creatinine

The Risk
  Microalbuminuria ( 30 to 299 mg/24 hours ), is a early marker of kidney damage and is also associated with increased risk of cardiovascular disease. The leakage of small amounts of albumin in the urine does not alway mean that a person will progress on to more severe kidney damage.

Those who progress on to Macroalbuminuria ( > 300 mg / 24 hours) are at increased risk of developing kidney failure.

 Early detection and treatment can reduce the risk

#1 Blood Pressure Control as demonstrated in the in the UKPDS demonstrated  that a small reduction in BP 154/87 to 144/82 resulted in  a 34%  relative reduction in small vessel disease (eye and kidney damage) . Other studies have also demonstrated the effectiveness of Blood pressure control in preserving kidney function.
 Kidney Int. 1995 ; 47:1703-1720  ( DCCT study in Type 1 Diabetes )
 New ENG. J. of Medicine 1993; 329: 1456-1462
Am. J.Med 1995; 99: 497-504
Am J kidney disease 2000; 36: 646-661

#2  Glucose control with a target goal of A1c  of  7 . 
      A 1% point ( 8 .4 to 7.4 ) provided a 24 to 30 % relative risk reduction in 2 classic studies.
                   Type 2 Diabetes  UKPDS
                   Type 1 Diabetes   DCCT

#3  Medications
         ACE Inhibitors  are usually the first choice for people with Diabetes . They are excellent for controlling blood pressure , reducing the risk of heart attacks and strokes, and reducing the  risk of developing microalbuminuria. They  also slow the progression of microalbuminuria and macroalbuminuria to more  severe kidney dysfunction.

       There are over 10 different brands of ACE Inhibitors on the market. I have listed a few of the
       common brands. If your BP medication ends in  "pril " it is probable a ACE inhibitor. check with
       your pharmacist.
                  lisinopril ( zestril , prinivil )
                  ramipril   ( Altase )
                  quinipril  ( Accupril )
                  enalapril  ( Vasotec, enalaprilat )

          Tomorrow we will review ARBS ,  Calcium channel blocker and others

Have fun , Be smart check your BP pills and see if you are on a ACE inhibitor
David Calder,MD

Wednesday, August 29, 2012

Albumin/ creatinine ratio, false positives and false negatives

Albumin/ creatinine ratio  - < 30 is a screening test generally associated with normal kidney function.
"Confirmed test " greater than 30  is a marker of increased risk of developing kidney disease.

       One problem with this test is false positives and negatives.

The test may be falsely elevated by high glucose levels , Exercise within the last 24 hours , infection , fever , high blood pressure .
 A recent follow up reports false negatives in 24% of patients with type 1 diabetes  who progressed to more severe kidney damage. The good news is that it was a useful screening tool and provided comfort in 76% of the patients . The high false negative results provides support for a better screening test such as the one we mentioned in yesterdays post. *( reference below)

The American diabets Association 2012 guidelines recommend:
" Because of the variability in urinary albumin excretion , 2 or 3 specimens collected within a 3 to 6 month period before considering a patient crossed one of the diagnostic thresholds "

more on Albumin /creatinine ratios tomorrow.

Have fun , Be Smart and remember Diabetes care is a winnable  game of numbers
David Calder,MD

* Development and Progression of Renal Insufficiency With and Without Albuminuria in Adults With Type 1 Diabetes in the Diabetes Control and Complications Trial and the Epidemiology of Diabetes Interventions and Complications Study
Molitch ME, Steffes M, Sun W, Rutledge B, Cleary P, de Boer IH, Zinman B, Lachin J, Epidemiology of Diabetes Interventions and Complications Study Gro - Diabetes Care (2010)

Bottom Line: Of these, 20 (24%) had AER <30 mg/24 h at all prior evaluations, 14 (16%) had developed microalbuminuria (AER 30-300 mg/24 h) before they reached stage 3 chronic kidney disease, and 54 (61%) had macroalbuminuria (AER >300 mg/24 h) before they reached stage 3 chronic kidney disease.Macroalbuminuria is associated with a markedly increased rate of fall in eGFR (5.7%/year vs. 1.2%/year with AER <30 mg/24 h, P < 0.0001) and risk of eGFR <60 ml/min/1.73 m(2) (adjusted hazard ratio 15.3, P < 0.0001), whereas microalbuminuria had weaker and less consistent effects on eGFR.Macroalbuminuria was a strong predictor of eGFR loss and risk of developing sustained eGFR <60 ml/min/1.73 m(2).However, screening with AER alone would have missed 24% of cases of sustained impaired eGFR.
Affiliation: Northwestern University, Chicago, Illinois, USA.
Abstract: This multicenter study examined the impact of albumin excretion rate (AER) on the course of estimated glomerular filtration rate (eGFR) and the incidence of sustained eGFR <60 ml/min/1.73 m(2) in type 1 diabetes up to year 14 of the Epidemiology of Diabetes Interventions and Complications (EDIC) study (mean duration of 19 years in the Diabetes Control and Complications Trial [DCCT]/EDIC).Urinary albumin measurements from 4-h urine collections were obtained from participants annually during the DCCT and every other year during the EDIC study, and serum creatinine was measured annually in both the DCCT and EDIC study. GFR was estimated from serum creatinine using the abbreviated Modification of Diet in Renal Disease equation.A total of 89 of 1,439 subjects developed an eGFR <60 ml/min/1.73 m(2) (stage 3 chronic kidney disease on two or more successive occasions (sustained) during the DCCT/EDIC study (cumulative incidence 11.4%). Of these, 20 (24%) had AER <30 mg/24 h at all prior evaluations, 14 (16%) had developed microalbuminuria (AER 30-300 mg/24 h) before they reached stage 3 chronic kidney disease, and 54 (61%) had macroalbuminuria (AER >300 mg/24 h) before they reached stage 3 chronic kidney disease. Macroalbuminuria is associated with a markedly increased rate of fall in eGFR (5.7%/year vs. 1.2%/year with AER <30 mg/24 h, P < 0.0001) and risk of eGFR <60 ml/min/1.73 m(2) (adjusted hazard ratio 15.3, P < 0.0001), whereas microalbuminuria had weaker and less consistent effects on eGFR.Macroalbuminuria was a strong predictor of eGFR loss and risk of developing sustained eGFR <60 ml/min/1.73 m(2). However, screening with AER alone would have missed 24% of cases of sustained impaired eGFR.

Tuesday, August 28, 2012

What is your albumin/creatinine ratio ?

I was scanning one of the ADA websites and noticed the abstract of an article discussing a new technique for identifying people at risk for developing kidney disease .This reminded me of a sometimes overlooked test, albumin/creatinine ratio  

Albumin/creatinine ratio  is one of the recommended routine test for people with Type 1 and type 2 Diabetes test  . This test is an early indicator of increased risk for developing kidney disease . Confirmed levels over 30 microgram/ mg creatinine will trigger the efforts for improved glucose management , aggressive blood pressure control and the use of medications called ACE inhibitors

Definitions to know

Albumin/ creatinine ratio -   spot urine test - goal <30 
                                      confirmed test > 30 suggest microalbuminuria
Microalbuminuria-              24 hour urine collection- 30 to 300 mg albumin/24hours 
                                      increases the risk of progressing to macroalbuminuria 

Macroalbuminuria =          24 hour urine collection > 300 mg/24 hour
                                     increases the risk of progressing to more severe kidney damage

Tomorrow I will review a few of the studies discussing the treatment of a "confirmed " test result over 30 microgram/ mg of creatinine.

Have fun , Be smart and review your albumin/creatinine ratio
David Calder,MD

Urinary Proteomics for Early Diagnosis in Diabetic Nephropathy

  1. Peter Rossing3
+Author Affiliations
  1. 1mosaiques diagnostics GmbH, Hannover, Germany
  2. 2Austin Health, Heidelberg, Australia
  3. 3Steno Diabetes Center, Gentofte, Denmark
  4. 4Department of Endocrinology & Diabetes, St Vincent's Hospital & University of Melbourne, Fitzroy, Australia
  5. 5BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, U.K.
  1. Corresponding author: Petra Zürbig,


Diabetic nephropathy (DN) is a progressive kidney disease, a well-known complication of long-standing diabetes. DN is the most frequent reason for dialysis in many Western countries. Early detection may enable development of specific drugs and early initiation of therapy, thereby postponing/preventing the need for renal replacement therapy. We evaluated urinary proteome analysis as a tool for prediction of DN. Capillary electrophoresis–coupled mass spectrometry was used to profile the low–molecular weight proteome in urine. We examined urine samples from a longitudinal cohort of type 1 and 2 diabetic patients (n = 35) using a previously generated chronic kidney disease (CKD) biomarker classifier to assess peptides of collected urines for signs of DN. The application of this classifier to samples of normoalbuminuric subjects up to 5 years prior to development of macroalbuminuria enabled early detection of subsequent progression to macroalbuminuria (area under the curve [AUC] 0.93) compared with urinary albumin routinely used to determine the diagnosis (AUC 0.67). Statistical analysis of each urinary CKD biomarker depicted its regulation with respect to diagnosis of DN over time. Collagen fragments were prominent biomarkers 3–5 years before onset of macroalbuminuria. Before albumin excretion starts to increase, there is a decrease in collagen fragments. Urinary proteomics enables noninvasive assessment of DN risk at an early stage via determination of specific collagen fragments.
  • Received March 20, 2012.
  • Accepted May 30, 2012.
Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. See for details.

Friday, August 24, 2012

Diabetes care is just a game of numbers that you can win

Most people with and without diabetes will tell you that  Diabetes management is complicated.
I don't believe that rumor.
  We know what the risk factors  for complications are !  Just numbers
  We have treatment goals proven to reduce the risk !       Just numbers
  We have effective tool tools for reducing the risk !
  You do not have to understand the number to correct it !
         Repetition , Discussion and Time will solve that problem
  The tools are available today in your doctors office ! Just ask . 
 Doc, will you help me reach my goal for  _________ ?
  The studies we have discussed over the last few days supports the idea that the treatment of diabetes is not complicated and you do not have be perfect to be a winner


Diabetes care is not complicated !  It is just a game of numbers !   A game you can win !
The Steno -2 study simplified the task to 3 primary numbers " goals" and demonstrate the additive effect of fixing the numbers.

Two out of the 3 , blood pressure and lipids , can be corrected by just taking a pill (or pills ).

Heart disease is the primary cause of death and disability for people with diabetes. Reducing LDL cholesterol and lowering blood pressure have the most effect in reducing vascular disease , glucose control has the least. Glucose control , lowering the A1c to 7 , is most effective for reducing the risk for eye, nerve and kidney damage

The 3rd one , A1c , involves taking medication plus managing food intake

The Steno - 2  study also demonstrated that most of us are not always successful with food management and weight. The study found that most  participants gained weight and increased their waist circumference over the 13 years of the study. This is to be expected because most of our medications to lower glucose levels are associated with weight gain except  the GLP 1 agonist , exenatide( Byetta , Bydureon ) and liraglutide ( Victoza).

Controlling food intake is also a more time consuming game of numbers

Controlling food intake  concepts are not that complicated.
   *  It is not what we eat .  The problem is how much of what we eat .  PORTION Size !!!!
   *  BEING CONSISTENT  day to day with our food intake , especially Carbohydrates.

The " Dash diet " has simplified food management to a numbers game.
     ( please see my post  from May 19 , 2012 and March 1, 2012 -Simple ideas that work)
 An 1800 calorie diet converted to numbers

                     fruit   vegetables    dairy    grains     meat      nuts/ beans    fats    sweets
servings          4          4                3         7             1.5             0.5              2         0.5

Just numbers !!!  
 Click on the previous post below to review

Dash Diet, Simple Ideas That Work

My first road trip with the Dash diet as my passen...

The Dash Diet - My first 2 month Experience

Small improvements have a big impact
One other thing the classic studies ( DCCT, UKPDS , Cards , Heart Protection Study , Steno-2 )
revealed is that you do not have to be perfect, you just have to do a little better, to be a winner in 

little changes in BP and A1c can have Big a impact...

Treating multiple risk factors is additive

"Opportunity " to just do your best is successful ...

Headline- good news for people with type 2 diabete...

How can I delete this ? update final version

Have fun , Be smart and play to win
David Calder,MD

Monday, August 20, 2012

How can I delete this ? update final version

Yipes! This  was published by accident . It is an a  outline draft of my initial thoughts for a talk I am giving to a local American Diabetes association group . Initially i spent time trying to delete it and then decided to leave it because it may produce a comment or two. Remember this is an outline and not complete.    Dr Calder

         Who is responsible for your health care ?
                                  answer.           I am.

What is your greatest fear ?Blindness  ?kidney disease ? amputation ? neuropathy  
What is the most common cause of death and disability ?
Heart disease & stroke is the most common cause for death and disability in patients with diabetes
                        You may say diabetes is to complicated .
                                          I will let my doctor worry about it 
               Diabetes is not complicated
              It is just a game of numbers
              It is a game you can win

The tools to correct these numbers is available today in your doctors office . Getting those tools into your hands is not difficult.  
* Know what the risk factors are ( just numbers)
* Know the target goals for these numbers that will reduce your risk of complications 

You do not have to understand the test , that will come with time and repetition.
* Have your doctor help you set treatment goals because one size does not fit all

* Follow and record your lab test
 *Any number that is not at your selected target is a reason to talk with your doctor.

                      Just ask the right question  .
                       Doc, can you help me reach my goal ?

                                Diabetes is just a game of numbers.  
                             It is a game that allow you to be less than perfect and still win
                              The Big 3 

               Fix the numbers and you will preserve your good health
                        What if you fix one?     What if you fix more  ? 

# 1 Fix  A1c   -   Effects
                            Small vessel disease _YES  
                            Cardiovascular disease _  ? maybe
There is good evidence that lowering your A1c by 1 % point ( with a target goal of 7 ) will significantly reduce the risk of developing small vessel  disease by about 25 to 30 %

There is also evidence that trying to achieve a near normal A1c of < 6 shows further improvement but is associated with higher mortality and hypoglycemia. ACCORD

 Higher sugars especially post prandial are associated with with increased CV risk
 Producing evidence that glucose control prevents CVD is limited. 
 UKPDS Ns reduction in risk of CV disease except in pts. taking meformin
    10 year followup intensive care pts, had a 15 to 33% reduction in the risk of MI
  DCCT 17 year followup 42 % reduction in CV events and 57 % reduction in stroke

We do not have to be perfect to win . Small changes have a big effect
 How close do you have to get to 7 to show benefit ? 
  Mean A1c in UKPDS 7.4          Steno-2 study 7.8            DCCT 7.4

  #2 Fix Lipids especially LDL  -    Effects 
                                                           Small Vessel Disease ? maybe
                                                           CVD__  YES
 reduce LDL
          CARDS Baseline 129  mg/dl  lipitor 10 -Prevents 1 CV event /37 pts./1000 treated for 4 years
                           stroke reduced 48% , coronary Bypass graft 31% acute MI 36%

            LDL mean in 75% was 93  mg/dl    25% was 64

           Heart Protection Study 
           40 mg zocor will lower LDL by about 38 mg/dl  to 58 mg/dl and reduce the risk of developing
           CVD by about 25% regardless of age , sex or initial LDL level . 

When the data was corrected
           for other variables , zocor reduced the risk compared to controls  by about 1/3 rd. treatment for 5
           years will prevent 70 to 100/1000 from having a CV event
   #3 Fix Blood Pressure -Effects
                                            Small vessel disease _ yes
               reduce BP 154/87  to  144/82 
               24 % reduction in all risk
               44% reduction in stroke
              data supports that lowering S  BP below  140 is beneficial and there is no 
              incremental benefit in reducing BP beolw 120

                        Fix all 3
      Treating multiple risk factors is additive!

          Results  50% reduction in relative risk or a 20 % reduction in absolute risk
        Steno-2 study  
               goals                at 7.8 years achieved
       A1c    <6.5                   7.9 vs 9
       SBP <130/80              131
       LDL chol                      83 vs 126
What about the other six ? residual risk Raise HDL , decrease triglycerides , lose weight, reduce waist , circumference exercise

               The Sleeper       sleep apnea

     who snores or has a bed partner that snores
     37 % of type 2  have sleep apnea
     10 % of type1    ''

Diabetes management is more than just glucose control

- Risk factor management can prevent heart disease and stroke  and small vessel disease 
- set goals  for lab test with your doctor 
-record those goals track your own lab 
-Any test not reaching your agreed goal is a reason to talk to your doctor
-you do not have to understand the test initially 
- understanding will come with repetition and time

Friday, August 17, 2012

"Opportunity " to just do your best is successful in diabetes care

Treating multiple risk factors is additive

Effect of a Multifactorial Intervention on Mortality in Type 2 Diabetes
Steno-2 -Study
N. England Journal of Med. 2008:358:580-591

Today we will  look at the goals and imperfect results achieved. Yesterday we looked at the benefits of these people just given the opportunity to just do their best .        

   Treatment goals                baseline test        results at 7.8 years                 results at 13 years
                                                                       ( intensive treatment ended)             ( continued observation ended )
                                                                           (intensive )    (conventional)                   (intensive )   ( conventional )
A1c               < 6.5                     8.4 to 8.7             7. 5            9                              7.8          8

Systolic BP   <130                   147mmhg           131            146                          140         146

Diastolic BP   <80                            85               73               78                             74           73

cholesterol      <200                   205- 224           150            202                           175          175

LDL Chol.      <70                   115 - 132               80             132                            75            80

Triglycerides   <150                  200 - 270           150            260                           150           150

waist size
          men     <40 inches                      41              42. 5           44                             44            43
     women     <35 inches                      39              42               42                             44            45

  Losing weigh and reducing waist circumference failed for almost everyone in both groups.

 Achieving an A1c of <  6.5  was successful in about 18% of the intensive treatment and 10% of the conventional treatment patients. 

 There is little doubt that managing food and trying to correct our blood sugars to target goals, while  avoiding low blood sugars, consumes the bulk of time spent dealing with this disease each day . This also means that many of us  will fall short of the recommended goals. Don't be discouraged , just do your best .

Effort Counts
This study demonstrates the value of our imperfect efforts controlling blood glucose combined with the easer task of  taking  " statins " and  blood pressure pills will reduce the risk developing small and large vessel disease. 

This study also confirms long term followup  finding in the of the UKPDS and DCCT studies ;
a period of intensive control of glucose has a lingering long term effect in reducing the risk of all diabetes complications including cardiovascular disease. More on this tomorrow.

Have Fun , Be smart and just do your best
David Calder,MD

Wednesday, August 15, 2012

Treating multiple risk factors is additive

Effect of a Multifactorial Intervention on Mortality in Type 2 Diabetes
Steno-2 -Study
N. England Journal of Med. 2008:358:580-591

The Conclusion is first today

The overall conclusion of this study is , this target driven multi-risk factor treatment reduced the risk of cardiovascular and microvascular events by about 50 %. You can stop here are read on for more details.  

I recommend that you "google" this  study and look at the actual charts on page 584 and especially the charts on page 587 that provides the actual results achieved in each group. These results may be comforting to you in your struggles with this disease.

Small improvements in known multiple risk factors maintained over a few years have a major  lasting impact on the risk of developing all of the complications of diabetes, especially heart disease.

  160 patients with type 2 diabetes with microalbuminuria received either intensive multifactoral  therapy or conventional treatment for 7.8 years. The intensive management portion of the study ended and both groups were observed for an additional 5.5 years for a total of 13.3 years. the primary end point was death from any cause. All patients were offered intensive treatment after the initial 7.8 years of the study

Patients were divided into 2 groups

Intensive - therapy group
Involved a combination  of medication and focused behavioral modification including specific goals 
These targets included :  
           A1c <6.5  ,
           Total cholesterol < 175mg/dl( 4.5 mm/l) ,
           Triglyceride level < 150 mg/dl ( 1.7mm/l) and 
           Blood pressure < 130/80

The conventional treatment group received treatment consistent with Danish medical association

                                        intensive treatment group                    conventional treatment group
Macrovascular disease           number  of patients                           number of patients
Total Number who died                  24                                                       40
      Cardio vascular deaths                9                                                       19                                                      
      cancer                                          2                                                        5
      other conditions                         13                                                      16
Strokes                                              7                                                       30
Heart attack                                       7                                                       35
Coronary artery bypass surgery         8                                                      14
amputation                                       10                                                       32

Microvascular disease progression was reduced
progressed to end stage
kidney disease                                 1                                                           6
Retinopathy                                    39                                                        52
neuropathy                                      42                                                        45


Previous studies of individual risk factor treatments of blood pressure and lipids reduced the relative risk of cardiovascular events by about 25 %. 

This study demonstrated that the benefits of treating multiple risk factors is additive.
This study demonstrated a 59 % relative risk reduction  and a 29%reduction in absolute risk  for developing cardiovascular disease. 

Most effective  and least effective treatments
The use of statins and blood pressure medications  followed by aspirin and glucose lowering drugs seem to have the most impact on the reduction of cardiovascular risk. More of the patients in the intensive treatment group received metformin which could have effected the overall risk. The number of people who stopped smoking was about the same in both groups. Exercise measured in minutes /week was better in the conventional treatment group. 
Weight and waist circumference increased in both groups

This data suggest that we are pretty good at taking our pills and not as good at controlling our  food intake.

Actual treatment goals achieved
    Group                                                  intensive                 conventional 

 A1c less that 6.5                                       18%                        10 %
 Cholesterol less than 175 mg/dl            80%                        75%
 Triglycerides less than 150 mg/dl          78%                       50 %
 systolic blood pressure less than 130    22%                       15%

Tomorrow I will review the actual treatment results achieved on each of these risk factors.

Have Fun , Be Smart  and remember , any improvement is better than no improvement
David Calder,MD

Monday, August 13, 2012

Headline- good news for people with type 2 diabetes

Headline - good news for people with type 2 diabetes

 Diabetes treatments result in a 50% risk reduction for developing;
 microvascular disease ( eye , nerve and kidney damage) and
 macrovascular disease ( heart attacks and strokes ).

Details tomorrow. Home work ,  please click on the links below and review these 2 post from July .

"Will lowering my blood sugar more help me prevent 

Good News! Risk factor management works..

Have Fun , Be smart and remember diabetes management is more than just glucose control
David Calder,MD

Saturday, August 11, 2012

High Blood Pressure " Our remedies oft in ourselves do lie"

Controlling high blood pressure

                                     " Our remedies oft in ourselves do lie"
                                                    Shakespeare, All's well that ends well 

I have attached a list of common undone/partially done things on our intending to do list that  interfere with our efforts to control Blood Pressure

Weight reduction         ->     lose 11 pounds and lower your systolic BP 2.5 to 10 mmhg
(if over weight)

Follow the Dash diet     ->     and lower your Systolic BP 8 to 14 mmhg

Reduce sodium intake  ->     and lower your systolic BP 2 to 8 mmhg
    ( 2.4 grams of sodium )
    ( or 6 grams of sodium chloride )

Regular exercise            ->     and lower your systolic BP 2 to 9 mmhg
   ( walk 30 minutes /day )    

Limit alcohol intake      - >     and lower your Systolic BP 2 to 4 mmhg
 ( 1 ounce ethanol ,
    24 Ounces of beer   or
    10 ounces of wine )

I have attached links to previous post that are related to the above subject

little changes in BP and A1c can have big a impac...

My favorite diet ideas including the DASH diet

Dash Diet, Simple Ideas That Work

Have fun ,Be Smart and remember little changes in our life style helps preserve our good health
David Calder,MD

Friday, August 10, 2012

Do you have Obstructive Sleep Apnea ? Take the test .

What is obstructive Sleep apnea ?
    Obstructive sleep apnea occurs when the muscles in the back of the throat relax and allow other structures including the tongue to partially block the air way.

 Could you have Obstructive sleep apnea (OSA )?
    Suggestion . Put a check mark by symptoms you ( or your spouse ) has and don't hesitate to  discuss the possibility with your doctor.

  early clues 
    _    Your snoring disturbs others especially your spouse
    _    Your spouse wears ear plugs when going to bed
    _    Your spouse complains  of loud snoring punctuated by periods of silence

    _     Snoring is the loudest when you sleep on your back and goes away when you turn to your side

    _     Daytime drowsiness  when driving , having to struggle to keep your eyes open  when driving.
           Falling asleep at a stop light ? Intense desire to sleep when driving ? Going to sleep while driving ?

    _     Falling asleep when reading ?

    _     unusual fatigue 

    _     Unusual symptoms such as Vasovagal attacks ( fainting ) or unexplained transient ( Usually less
           than 1 minute) attacks of  atypical nausea , sweating and weakness that can occur in any position
           at any time.

    _     recent onset of heart rhythm problems           

    _     If  you have high blood pressure
    _     If you are overweight ( up to 70 % of obese people have OSA )
    _     If you have Diabetes ( OSA is 3 times more common )
    _     If you are a NFL football player (estimated up to 14% have OSA )
    _     If you are a NFL lineman (estimated up to 34% have OSA )
    _     If you have heart disease ( 30 to 50% may have OSA ) 
    _     If you have a thick neck, 
                       Women > 15 inches ( 38 cm)
                       Men      >  17 inches ( 43 cm )
    _      If have consistent nasal congestion at night and on awaking
    _      If you are over age 65 (OSA is 3 times more common)
    _      If you are black ,hispanic , asian or pacific islander 
    _      If you have a family history of sleep apnea
    _      If you smoke 
    _      If you are post menopausal
    _      If you don't believe you have Sleep Apnea when your doctor suggest you may have it.
             I had 15 of the above symptoms and did not believe my doctor when he suggested it as a 
             possible cause for my symptoms

     I have attached below some of my other recent post discussing sleep apnea

     Have Fun , Be Smart , the screening test for sleep apnea is easy and the treatment is amazing
     David Calder,MD