Effect of 2-Week Nightly Moderate Hypoxia on Oral Glucose Tolerance in Individuals With Type 2 Diabetes
Phase: NA
Conditions: Type 2 Diabetes
Sponsor: Pennington Biomedical Research Center

 
 
 
 
 
EFFECT OF 2-WEEK NIGHTLY MODERATE HYPOXIA ON GLUCOSE 
TOLERANCE IN INDIVIDUALS WITH TYPE 2 DIABETES 
(SLEEPDIABETES) 
 
 
NCT02513641 
 
 
Document Upload Date: October 11, 2019 
Latest IRB Approval Date: September 6, 2017 

PBRC# 2015-018
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EFFECT OF 2-WEEK NIGHTLY MODERATE HYPOXIA ON GLUCOSE 
TOLERANCE IN INDIVIDUALS WITH TYPE 2 DIABETES
(SLEEPDIABETES)
PI: Eric Ravussin, Ph.D 
Medical Investigator: Frank Greenway, M.D.
BACKGROUND AND SIGNIFICANCE
Hypoxia in obese adipose tissue (AT) plays an important role in the development of 
whole-body insulin resistance by inducing local inflammation and the release of pro-
inflammatory cytokines (reviewed in [1]). Detrimental effects of hypoxia are also evident in the 
altered glucose metabolism induced by sleep apnea, a condition characterized by intermittent 
and short hypoxic episodes [2, 3]. However, there are conflicting reports about the effects of 
altitude hypoxia on insulin action and glucose uptake [4]. 
Short-duration (4 hours) of exposure to moderate hypoxia has been shown to improve 
transient insulin sensitivity in type-2 diabetics [5], and more prolonged exposure was shown to 
increase whole-body glucose turnover and utilization in healthy subjects [6]. Exposure to 
hypoxic environments has also been shown to increase both whole-body glucose fluxes in 
healthy males and glucose uptake in human and murine skeletal muscle [7]. Controlled studies 
at altitude following acute exposure to hypoxia during exercise have reported improved 
carbohydrate metabolism, including increased glucose oxidation, reduced fasting insulin and 
glucose, and higher fluxes of glucose [8]. In addition, Cartee at al. reported enhanced insulin- 
independent translocation of glucose transporters by hypoxia during exercise [9]. Living at 
altitude in hypoxic conditions is associated with a lower prevalence of impaired fasting glucose 
and type 2 diabetes, as compared to low altitude [10]. 
Exposure to hypoxia has also been advocated as a possible therapeutic aid against 
obesity [11], hypoxia being known to reduce energy intake and to affect protein synthesis [12]. A 
highly publicized study showed reduced rates of obesity at high altitude [13]. Moreover, hypoxia 
has been shown to be beneficial as a complement to exercise in healthy non-obese [14], obese 
[15, 16] and athletes [17-19] to improve skeletal muscle function. 
We have provided the first evidence that intermittent, nightly exposure to moderate 
hypoxia was beneficial in improving insulin sensitivity in healthy obese patients and, therefore, 
lowers the risk of developing type 2 diabetes [20]. Benefits included reduced fasting glucose 
levels and improved whole-body (skeletal muscle) and hepatic insulin sensitivity. Whether such 
intermittent hypoxia improves glucose metabolism in people with type 2 diabetes is unknown.
Reasons for the Protocol Modification and its Safety Implications:
The safety aspects and history of this protocol deserve further comment. It is important 
to the concept of using a hypoxia tent to treat diabetes to use as a home treatment. Although 
the degree of hypoxia generated by the tent was not a safety concern to the FDA, there was 
concern that safety would be compromised if the hypoxia of sleep apnea was added to the 
hypoxia of the tent. The initial approach to eliminating this safety concern in the study was to 
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ensure that the participants did not have sleep apnea. Although this is one way to eliminate the 
threat of sleep apnea-associated hypoxia, it has been very hard to identify these individuals.  
Another way to eliminate sleep apnea-associated hypoxia is to treat the sleep apnea 
with C-PAP, the standard way in which sleep apnea is treated. C-PAP is a continuous pressure 
administered by mask and adjusted to be sufficient to keep the airway open during sleep. The 
C-PAP essentially draws air from the surrounding environment and creates the pressure to keep 
the airway open using a fan. Therefore, the C-PAP machine could be put in the hypoxia tent 
with a cord extending to a wall socket outside the tent to power the machine. In this way the C-
PAP would draw in hypoxic air from the tent, but would also insure that additional hypoxia would 
not occur due to the C-PAP eliminating the sleep apnea. 
Since it has been shown by Foster GD et al. [24] that 86% of overweight and obese 
diabetic subjects have sleep apnea, we feel that, in addition to including subjects without sleep 
apnea, we should include patients with sleep apnea controlled on C-PAP. Both of these groups 
of patients will be protected from any additional hypoxia associated with sleep apnea that would 
add to the safe hypoxia generated by the tent, but including the group with sleep apnea 
controlled on C-PAP will allow us to enroll and complete the study which has only enrolled one 
patient in over a year when limiting those studied to those without sleep apnea.  
HYPOTHESIS AND AIMS
Aim: To determine the effect of 2-week overnight sleep in moderate hypoxia on glucose 
tolerance in participants with type 2 diabetes.
Hypothesis: Exposure to moderate hypoxia (2400 m altitude) for 14 consecutive nights in 
obese, type 2 diabetic subjects will improve glucose tolerance
Primary endpoint: Results from the 75 g oral glucose tolerance test (OGTT) assessed by 
different statistical approaches including:

Traditional area under the curve (glucose and insulin)

Repeated measures mixed effect model

Matsuda Index

Kahn's calculation of indices of insulin sensitivity and insulin secretion
Exploratory endpoints: Fasting plasma fructosamine and hemoglobin A1-C as well as daily 
body weight
SUBJECTS
We plan to have n = 10 completers.
Inclusion criteria:
-
Aged 20-65 yrs
-
Have a BMI < 55 kg/m2
-
Body weight 450 lbs or less
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-
Have either been diagnosed with type 2 diabetes, or 125 mg/dl < Fasting Blood Sugar < 
200 mg/dl, or hemoglobin A1-C ≥ 6.5%
-
Non-smokers
- 
Weight stable over the previous 3 months (< 3 kg fluctuation)
-
Known diagnosis of sleep apnea and ownership of a continuous positive airway pressure 
(C-PAP) device that must be worn throughout the nights spent in the tent
-
If no known presence of sleep apnea, be willing to spend one night in a sleep laboratory 
(Louisiana Sleep Foundation) to assess presence of sleep apnea
Exclusion criteria:
-
Diagnosed with T2DM ≥ 15 years ago
-
Pregnant Women
-
Current insulin treatment
-
Treatment with sulfonylureas or glitinides
-
Treatment with a GLP-1 agonist
-
Any other diabetes medication other than an oral agent is exclusionary unless otherwise
            cleared by medical investigator.
-
Chronic Obstructive Pulmonary Disease (COPD)
-
Congestive heart failure
-
Prior severe cardiovascular events such as stroke or myocardial infarction
-
If treated for T2DM with other oral agent, no change in the treatment for 1 month before 
the study and the duration of the study
-
Previously known diagnosis of sleep apnea without ownership of a continuous positive 
airway pressure (C-PAP) device or agreement to use owned CPAP device during the 
nights spent in the tent
- 
Presence of sleep apnea following a positive home sleep test (HST), or have unsafe 
oxyhemoglobin saturation levels (less than 78%) during a one night sleep monitoring 
assessment conducted at the Louisiana Sleep Foundation without ownership of a 
continuous positive airway pressure (C-PAP) device or agreement to use owned C-PAP 
device during the nights spent in the tent
-
History of high altitude sickness
-
History of altitude sickness
-
Does not have access to a bed or sleeping surface equivalent to or smaller than a 
Queen size mattress.
RECRUITMENT
Potential participants will be recruited through the PBRC website, e-mails, flyer distribution, and 
word-of-mouth. Individuals will call or e-mail the Recruitment Core at PBRC and will undergo a 
phone screen to answer a series of yes or no questions regarding their age, gender, body 
weight and height, changes in body weight during the last month, presence of disease, and 
smoking status. Eligible individuals will be scheduled for their screening visit at the PBRC 
Outpatient Clinic.
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SCREENING
Participants will report to the PBRC clinic after a >10-h overnight fast. The screening visit 
includes an explanation of the purpose of the study, a description of the procedures and the 
reading and signing of informed consent. Volunteers will then complete a brief personal and 
family medical history. Height, weight, waist and hip circumference, vital signs (blood pressure, 
pulse, oral temperature) will be measured. Volunteers will then have an EKG. Subjects with a 
previous sleep apnea diagnosis must possess a C-PAP device and must agree to use the 
CPAP device during the nights spent in the tent; if no C-PAP device is available for usage, the 
subject will not be eligible to participate in the study. If subjects are considered to be eligible up 
to this point, blood will be drawn for a complete blood count, blood chemistry (Chem15), and a 
hemoglobin A1-C as part of the draw. Subjects who do not meet the eligibility criteria will be 
immediately informed in person or by phone. An interview with a trained psychologist will 
identify potential barriers to enrollment into the SLEEPDIABETES study and also barriers to 
have the hypoxia tent system setup at the participant’s home. Only subjects without a previous 
sleep apnea diagnosis and who meet all eligibility criteria will next undergo a two-step process 
to: (1) confirm the absence of sleep apnea (home sleep test, or HST), as well as (2) confirm 
these subjects without a sleep apnea diagnosis exhibit safe oxygen saturation levels (monitored 
sleeping study at the Louisiana Sleep Foundation, a certified sleep laboratory) while sleeping 
under the mild hypoxic conditions denoted by the study. Subjects previously diagnosed with 
sleep apnea and who possess a C-PAP device will not undergo testing at the Louisiana Sleep 
Foundation.
(1) Home Sleep Test (HST): Subjects without a sleep apnea diagnosis will first undergo a home 
sleep test conducted by the Louisiana Sleep Foundation under the direction of Dr. John K. 
Schwab, MD, DABSM, the chief medical director of the Foundation. Subjects will obtain the 
home sleep test from Dr. Schwab and will be given instructions on how to wear the device 
during a single night of sleep. The device will record breathing rates and oxygen saturation 
levels throughout the single night of sleep. After the single night sleep, subjects will be 
instructed to return the device to the Louisiana Sleep Foundation where Dr. Schwab will review 
the sleep data and identify the potential presence of sleep apnea. If the presence of sleep 
apnea is detected, subjects will be immediately informed of their ineligibility to participate in the 
study. If a negative test for sleep apnea is concluded, subjects will next undergo a monitored 
sleep study.
(2) Monitored Sleep Study: Subjects who have a negative test for sleep apnea following a HST 
will next undergo a monitored night of sleep under hypoxic conditions at the Louisiana Sleep 
Foundation. Subjects will arrive at the Louisiana Sleep Foundation on the evening of their 
monitored sleep study. A sleep technician will closely monitor the subject’s oxyhemoglobin 
saturation throughout a single night of sleep under hypoxic conditions (2400 m altitude). 
Hypoxic conditions will be achieved via a hypoxic tent, as previously described and conducted 
at Pennington Biomedical Research Center [20]. Following the technician-monitored night of 
sleep, Dr. Schwab will review the sleep data and provide insight as to the subject’s ability to 
participate in the study given expected oxyhemoglobin saturation levels at 2400 m. Subjects 
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who exhibit <78% oxyhemoglobin saturations, or who display sleep data of safety concern to Dr. 
Schwab, will be informed of their ineligibility to participate in the study. 
If the HST and sleep center monitoring are within safe ranges for study participation following 
evaluation by Dr. Schwab, the participant will officially be accepted into the study and will begin 
baseline testing (Day 0) within weeks and in agreement with schedules. All subjects who have a 
known sleep apnea diagnosis, possess a C-PAP device, and are agreeable to using the C-PAP 
device during the nights spent in the tent will be accepted into the study as well.
EXPERIMENTAL DESIGN
This study includes outpatient and in-home visits and will consist of three periods: 
1) Baseline measures of glucose tolerance (OGTT) and body composition (DXA)
2) Intervention involving 14 night stays in simulated altitude (hypoxic tent in home) 
3) Post-treatment (after 14 nights in hypoxia) measures of glucose tolerance
After screening, subjects will be asked to maintain their usual diet and physical activity levels. 
Baseline: 
A 75-g OGTT will be performed. Body composition will be measured by DXA. Fasting plasma 
fructosamine will also be collected via blood draw. A urine pregnancy test will be performed on 
all females of child-bearing potential prior to the DXA. 
Intervention: Nightly exposure to hypoxia
Over the following 14 nights, participants will sleep under a tent simulating an altitude of 2400m 
(~7500 ft) for 7-12 hrs each night depending on their usual sleep pattern in their bedroom. Each 
participant will be informed that their partner or household member, or any other individuals, are 
prohibited from entering or sleeping in the tent.
Post treatment measurements:
After the 7th night of hypoxic sleep, participants will come to the Pennington Biomedical clinic to 
provide a fasting blood sample to measure glucose and insulin. We will also collect information 
of the quality of their sleep under the hypoxic tent.
The morning of the 14th exposure to hypoxia, participants will come to the Pennington 
Biomedical clinic facilities in a fasting state to perform a post intervention assessment. 
Approximately 15 min after arrival, a 75-g OGTT will be performed. Fasting plasma 
fructosamine and hemoglobin A1-C will also be collected via blood draw.
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Table 1. Schedule of Procedures 
Screening
Sleep 
Screening
(HST & Sleep 
Study)
Baseline
(Day 0)
Mid- 
Intervention 
(Day 7)
Post-
Intervention
(Day 14)
Health questionnaire
X
Body weight
X
X
X
X
Vital signs*
X
Electrocardiogram
X
Blood draw
X
X
  X
X
Oral glucose tolerance test
X
X
Body composition by DXA
X
Urinalysis
X
Urine Pregnancy Test
X
Oxyhemoglobin saturation**
X
     * blood pressure, pulse, oral temperature
        ** Only performed on subjects without previous sleep apnea diagnosis. Time between 
screening and sleep screening, as well as sleep screening and baseline testing (Day 0), will 
vary depending on scheduling at Pennington Biomedical and the Louisiana Sleep Foundation.
METHODS AND PROCEDURES
Urine and blood.
At screening, 9.5ml of blood will be collected for CBC, Chem15 panel, and hemoglobin A1-C 
analysis. Urine will also be collected at screening for urinalysis. Approximately 39.5 mL of blood 
will be taken at baseline, and 41.5 mL of blood will be taken at post-intervention for the OGTT, 
fructosamine, and hemoglobin A1-C analysis. Archives (~10 mL; serum and plasma) will be 
collected at baseline, mid-intervention, and post-intervention for future analysis. Following the 
7th night spent in the hypoxic tent, ~2 ml of blood will be drawn for plasma glucose and insulin 
concentrations. A total of approximately 122.5 mL (approx. 8.5 Tbl.) of blood will be taken.
Vital signs
Vital signs will be measured while the subject lying on a bed. Body temperature (sublingual) will 
be measured using an electronic thermometer (Sure Temp 679, Welch Allyn) and blood 
pressure using a manometer (Baumanometer. W.A. Baum Co., Inc. USA). Heart rate will be 
measured by radial arterial pulse for 60 seconds. 
Overnight exposure to hypoxia (simulated altitude)
Pennington staff will visit the participant’s home and setup the hypoxic tent system. This person 
will also instruct participants on how to use the equipment. Participants will spend 14 
consecutive nights in the “altitude tent”, with the simulated altitude being set at 2400m over sea-
level. Hypoxia will be obtained by nitrogen dilution of the ambient air in an airtight tent (Hypoxico 
Inc., NY). Briefly, ambient air is filtered and a small part of the oxygen removed before the 
modified air is flushed in the airtight tent. Altitude is mimicked by lowering the oxygen content 
rather than reducing the atmospheric pressure. However the physiological stimulus is 
comparable and has been used in multiple studies involving different populations. This altitude 
corresponds approximately to the altitude of most mountain resorts and of Mexico City, one of 
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the largest metropolises in the world. It has been chosen because it is within the range of the 
altitudes eliciting a physiological response to hypoxia, and has been proven to be safe in obese 
patients during a 1-week exposure [11]. 
Oral glucose tolerance test  
Glucose tolerance will be assessed using an oral 75 g oral glucose tolerance test (OGTT).   
Subjects will be studied after an overnight fast. An intravenous line will be placed and one 
baseline sample will be drawn at -5 minutes. The subjects will then consume a 75 g glucose 
beverage within 5 minutes. Blood samples will be collected at 30, 60, 90, and 120 to measure 
serum glucose, insulin, and free fatty acid concentrations.  Whole body insulin sensitivity will be 
calculated using the Matsuda insulin sensitivity index (10,000/square root of [fasting glucose x 
fasting insulin] x [mean OGTT glucose x mean OGTT insulin]). We will also assess insulin 
secretion as described by Dr. SE Kahn. In brief, the early insulin response during the OGTT, 
also known as the insulinogenic index is calculated as the ratio of the change in insulin to the 
change in glucose concentrations from 0 to 30 minutes.  The oral disposition index (DIo), a 
measure of b-cell function is calculated as [∆ insulin0-30min/∆ glucose0-30min] x 1/fasting 
insulin.  Complementary to the glucose response, we would also monitor the changes in the 
blood FFAs as a measure of the adipose tissue capability to suppress lipolysis in response to 
insulin.  So, it can be used as a marker of insulin sensitivity in terms of adipose tissue.  We will 
calculate the insulin sensitivity index for blood FFAs by the formula: ISI (ffa) = 2/(INSp × FFAp) 
+ 1), where INSp and FFAp indicate insulinemic and blood FFA areas, respectively, of the 
person under study recorded during the OGTT.
DXA scan
Dual X-Ray absorptiometry (DXA) scans will be performed using the GE iDXA whole-body 
scanner to assess body composition. The protocol requires that participants lie on a table 
wearing a hospital gown and no metal containing objects, while the scanner emits low energy X-
rays and a detector passes along the body. The scan takes 10 minutes and the radiation dose is 
less than 1 mrem, equal to about 12 hours of background radiation. Fat mass is calculated from 
weight (kg) on a scale and % body fat and fat-free mass by subtracting fat mass from total body 
weight (kg).
Sample size. This is a pilot study to test the impact of mild hypoxia in participants with type 2 
diabetes. We therefore did not perform a power analysis.
Data analysis
Data will be expressed as mean +/- SE. Values before and after exposure to hypoxia will be 
compared using the paired Student’s t test or a Wilcoxon rank signed test. Despite the pilot 
nature of this study, the results may be published as a short communication depending on the 
potential changes in insulin sensitivity.
Data collection, storage and confidentiality
All results will be kept in locked file cabinets and restricted-access computers. All of these will 
be kept separate from records with names and other personal information. The only people who 
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will know that these patients are research participants are members of the research team. No 
information about them, or provided by them during the research, will be disclosed to others 
without their written permission, except if it is necessary to protect their rights or welfare (for 
example, in case of injury or emergency care), or if it is required by law. When the results of the 
research are published or discussed in conferences, no information will be included that would 
reveal the identity of these patients. Participants will be identified by codes when the data 
gathered in this procedure is presented or published. Authorized representatives of the National 
Institutes of Health may need to review records of individual participants. As a result, they may 
see their name; but they are bound by rules of confidentiality not to reveal the patients’ identity 
to others.
RISK/BENEFIT ASSESSMENT
The known risks, inconveniences or side effects involved in this study are the following:
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Procedure
Risk
EKG
There are no risks associated with this test. There is a small 
possibility there may be some redness or irritation if you happen to 
be allergic to the adhesive on the electrodes.  
Body composition by 
DXA
The amount of radiation used for this procedure is very small.  The 
radiation dose for this scan is equivalent to the radiation you are 
naturally exposed to in the environment in less than one day.  Scans 
will not be performed on any subject who is pregnant, and all 
females should inform the DXA technologist if there is any 
possibility that they are pregnant.    
Blood Draws
Bruising, bleeding, pain, infection. These will be minimized by using 
trained phlebotomists with sterile techniques.
Sleeping under 
hypoxia (simulated 
altitude ~ 2400m)
Some patients may feel a slight discomfort and feeling of 
claustrophobia while sleeping in an airtight tent. Participants will be 
free to exit the tent if they feel claustrophobic. There should not be 
any risk associated to sleeping at altitudes <2500m since: (1) 
those participants with diagnosed sleep apnea will wear a C-PAP 
device while sleeping under the tent to maintain airway pressure, 
and (2) those participants with suspected sleep apnea or 
participants that showcase unsafe oxygen saturation levels during 
the single night stay throughout testing at the Louisiana Sleep 
Foundation will be excluded. Recent reviews suggest an 
acclimatization process for higher altitudes [21, 22]. Acute altitude 
sickness may nonetheless be experienced by some volunteers, 
with symptoms as headache, anorexia, and nausea, which might 
however be transient [21]. High altitude pulmonary edema is very 
unlikely at such altitude, being known to occur at much higher 
altitudes and with exercise [23]. However, we will exclude 
participants with high altitude sickness and monitor for altitude 
sickness by asking participants about symptoms (which usually 
happen in the first 6-24 hours) such as headache, nausea, 
vomiting, dizziness, insomnia, loss of appetite and dyspnea. 
Adverse events will be monitored throughout the study, and 
participants with acute altitude sickness will be withdrawn from the 
study. 
Risk Classification: The study risk can be classified as moderate since we have already used 
this same paradigm in 8 participants with obesity (see reference #20) and we will exclude all 
potential participants with congestive heart failure, prior cardiovascular events such as stroke or 
myocardial infarction and those with diagnosed sleep apnea and lack a C-PAP device to wear 
throughout the nights spent in the tent.
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Minimizing Risks: All study procedures will be monitored by the investigators and/or the 
medical investigator of the study to minimize potential risks and discomforts to study subjects. 
Research participants will be immediately withdrawn from the study upon evidence of any 
serious adverse event. 
Eligible subjects without a previous sleep apnea diagnosis will undergo an extensive two-step 
sleep evaluation, involving a home sleep test as well as a monitored sleep test at the Louisiana 
Sleep Foundation, to identify the presence of sleep apnea as well as closely monitor and 
evaluate oxyhemoglobin saturation levels during a single night sleep at 2400 m in the hypoxic 
tent, respectively. Sleep data will be thoroughly evaluated and assessed on a subject-by-subject 
basis by the chief medical director of the Louisiana Sleep Foundation to ensure the upmost 
safety precautions are taken. Only those subjects who exemplify safe oxyhemoglobin saturation 
levels during both sleep evaluation tests will be allowed to enroll in the study.
Eligible subjects with previous sleep apnea diagnosis who possess a C-PAP device will be 
required to use the C-PAP device throughout the nights spent in the tent. 
Adverse Event Reporting: Adverse event monitoring will occur at mid-intervention (Day 7) and 
post-intervention (Day 14) visits, and participants will be instructed to call the study coordinator 
(Dr. Kara Marlatt) at the onset of any abnormal effects (headache, nausea, vomiting, dizziness) 
between visits. 
Data Safety Monitoring Plan. Drs. Ravussin and Greenway will be responsible for monitoring 
the data, assuring protocol compliance, and conducting safety reviews after completion of the 
first participants and then every 6 weeks. During the entire study, Dr. Greenway will monitor 
adverse events and determine if they are attributed to the study procedures. If any of those 
adverse events are suspected to be related to study procedures, they will be immediately 
reported to the PI and the IRB.  
Such study has already been conducted in 8 participants with obesity and identified a 20% 
improvement in insulin sensitivity.
Potential Benefits: There is no direct benefit to the volunteers but knowledge may be gained 
that will benefit others. Participants will, however, receive some information about their health. 
Payment for Participation: If participant completes all 14 days of the study, they will receive 
$350 for the time spent in the clinic. Conversely, if the participant completes the mid-intervention 
visit (Day 7) but does not complete the post-intervention visit (Day 14), the participant will 
receive $175. And finally, if the participant enrolls in the study but does not complete the mid-
intervention visit (Day 7) or beyond, the participant will receive $50. This compensation is in line 
with all the other studies conducted at the Pennington Biomedical Research Center and will be 
mailed within 4 weeks of study completion.
Financial Obligations of the Subjects: None
Emergency Care and Compensation for Research-Related Injury: No form of compensation 
for medical treatment is available from the Pennington Biomedical Research Center. In the 
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event of injury or medical illness resulting from the research procedures the research volunteer 
will be referred to a treatment facility. The Pennington Biomedical Research Center is a 
research facility and provides medical treatment only as part of research protocols. Should a 
volunteer require medical treatment, community physicians and hospitals must provide them to 
him/her.
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Appendix (see below on pages 13 and 14)
The Food and Drug Administration (FDA) has reviewed this submission and responded to our 
request for a risk determination for the proposed study. FDA has determined that this proposed 
clinical investigation is a non-significant risk (NSR) device study because it does not meet the 
definition of a significant risk (SR) device under § 812.3(m) of the investigational device 
exemptions (IDE) regulation (21 CFR 812).  See FDA letter attached.
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Voss, J.D., et al., Lower obesity rate during residence at high altitude among a military 
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Wiesner, S., et al., Influences of normobaric hypoxia training on physical fitness and 
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