By JoNel Aleccia Health writer
msnbc.com
updated 6/14/2009 12:26:56 PM ET 2009-06-14T16:26:56

Truck driver Kenneth Armstrong is a big guy with a bigger problem.

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At age 55, he stands 5-foot-11 and weighs 308 pounds, which doctors say helps to explain why he’s been diagnosed with severe obstructive sleep apnea, a dangerous disorder that puts him at high risk for health problems — and falling asleep at the wheel.

“It was mild, but has worsened as I have gotten older,” says Armstrong, a Michigan man who weighed 190 two decades ago, but gradually has put on pounds.

Fortunately for Armstrong — and the people on the road around him — his employer Swift Transportation Corp. of Phoenix is one of a small but growing number of trucking firms that voluntarily screen drivers at risk for sleep apnea and then pay to treat and monitor them for the potentially life-threatening condition.

Armstrong, for instance, wears a mask hooked to a machine that inflates his airways and restores his oxygen levels every night as he sleeps in his rig.

“I feel that I’m a much better and safer driver because of this CPAP,” he said, referring to the continuous positive airway pressure machine.

But that’s the exception, not the rule, according to sleep scientists at Harvard University, who have renewed a call for federal rules requiring mandatory testing of obese drivers. They say research shows there’s a strong link between fat drivers and sleep apnea and that screening could help prevent truck crashes that kill more than 5,200 people and injure more than 100,000 each year in the U.S.

“It’s a major public health issue and it’s becoming more common with the obesity epidemic,” said Dr. Stefanos N. Kales, medical director of employee and industrial medicine at the Cambridge Health Alliance in Cambridge, Mass.

Kales, who is also an assistant professor at Harvard Medical School and the Harvard School of Public Health, is the senior author of a study published this spring in the Journal of Occupational and Environmental Medicine. It’s the latest to find that obesity is a strong predictor for sleep apnea, and that many drivers are likely to underreport symptoms or to fail to follow through on sleep study referrals and treatment.

“Screenings of truck drivers will be ineffective unless they are federally mandated or required by employers,” said Kales, who studied more than 450 commercial drivers working for more than 50 firms.

New federal rules for obese truckers?
Regulators with the Federal Motor Carrier Safety Administration have been considering for more than a year new rules that would require screening for drivers whose body mass index — a metric based on weight and height — exceeds 30, the baseline for obesity.

A BMI of 30 means 221 pounds for a 6-foot man. Kenneth Armstrong’s BMI equals 43. Researchers estimate that more than 40 percent of commercial drivers have a BMI of 30 or higher. BMI calculator

But the FMCSA has yet to act on the January 2008 recommendation by a medical review board, which frustrates groups representing victims of trucking accidents, who say that fatigue in general and sleep apnea in particular are under-recognized threats on the road.

“A driver is impaired by fatigue long before he falls asleep,” said Jeff Burns, a lawyer representing the Truck Safety Coalition, a safety advocacy group.

“Every time I’m in the vicinity of a large truck on the highway, I believe my life is in danger. I give trucks a very wide berth,” added Burns, who is a member of the Injury Board, a legal advocacy group.

Trucking industry officials reject such comments as scare tactics, noting that the number of truck and bus accidents has held steady at about 161,000 annually for several years, despite more miles traveled, according to figures from the U.S. Department of Transportation.

They argue that obesity is only one of many indicators of sleep apnea and that safety standards should be based on driver performance, not body size.

“There is no direct relationship between a person’s body weight and his ability to drive an 18-wheel truck,” said Tom Weakley, director of operations for the Owner-Operator Independent Drivers Association, which represents about 160,000 drivers. “Show me where that’s a better predictor than a person’s driving record.”

Sleep apnea is a disorder that causes a person’s airways to collapse during sleep, cutting off breathing dozens — or even hundreds — of times a night. Because sufferers wake over and over, they’re never fully rested and their bodies are chronically deprived of oxygen. That can cause health problems ranging from heart disease to diabetes and symptoms that include daytime sleepiness and a tendency to nod off during normal activities.

“It can be a microsleep for few seconds,” said Kales. “That can be enough to throw a truck off the road.”

In such cases, the results can be devastating.

  • In May 2005, a Kansas mother and her 10-month-old child were killed when a truck collided with their sports utility vehicle, according to a report by the Government Accountability Office. The driver had been diagnosed with severe sleep apnea, but he went to another doctor who issued a medical certificate because the driver didn't disclose his condition.
  • In July 2000, a Tennessee Highway Patrol officer died when a truck struck his police car as he guarded a highway work zone, the GAO said. The patrol car exploded on impact. The driver of the truck had previously been diagnosed with sleep apnea and had had a similar crash three years earlier, when he struck a patrol car in Utah.  

Nearly one in three drivers has sleep apnea
Sleep apnea increases the risk of an accident by two to seven times, and up to 20 percent of truck crashes are estimated to be caused by drivers who fall asleep, Kales said.

Prevalence studies suggest that up to 28 percent of commercial drivers have mild to severe sleep apnea. That works out to as many as 3.9 million of the roughly 14 million commercial drivers licensed in the United States, Kales indicated.

It’s a much higher than rate than for the general population, where an estimated 4 percent of men and 2 percent of women between the ages of 30 and 60 in the U.S. have sleep apnea, according to the American Sleep Apnea Association. Overall, about 18 million Americans have the problem, although only about 10 percent of sufferers actually are diagnosed.

In the survey Kales led, 456 commercial drivers from 50 companies were studied for 15 months. During that time 78 drivers, or 17 percent, met screening requirements for sleep apnea. They were older and more obese, with higher average blood pressure. Of the 53 drivers referred for sleep studies to test for apnea, 33 did not comply and were lost to follow-up, researchers said. The remaining 20 were all confirmed to have sleep apnea, but, after diagnosis, only one driver complied with treatment.

It’s not clear when the FMCSA will take up the issue of screening obese drivers.

“We are taking the Medical Review Board’s recommendations under thoughtful advisement, and supplementing those recommendations with additional research in order to develop sound regulatory proposals,” Candice Tolliver, an agency spokeswoman, responded in an e-mail.

But neither Tolliver nor Dr. Mary D. Gunnels, director of the agency's office of medical programs, responded to questions about a timeline, or about why sleep apnea doesn’t appear on the agency’s list of pending agenda items.

However, critics and supporters of the agency say the reason for the long lag is clear: Officials are leery of any proposal that could affect, or even idle, 40 percent of the truckers on the road. Costs for conducting sleep studies, paying for equipment and monitoring drivers could cripple independent truckers or small firms, said Weakley, of the independent truckers' association.

Link between obesity and crash deaths isn't clear
“Until you can show a direct relationship between sleep apnea and deaths on the road, they can’t do anything about it,” he said. “It won’t fly.”

The American Trucking Associations, a group representing some 38,000 members, is more circumspect. Christie Cullinan, director of workplace and fleet safety, said the organization recognizes that sleep apnea is a public safety issue and that the group supports the idea of guidance to detect and correct the problem.

After all, the average cost of a large truck crash involving a fatality is $3.6 million, FMCSA figures show. A crash with injuries costs nearly $200,000. And the average cost of all large truck crashes is about $91,000.  

Still, any guidance has to be the right guidance, Cullinan said.

“I don’t think there’s a CEO that doesn’t know that screening for sleep apnea banks your safety dollars,” she said. “But there’s a balance that needs to be met.”

As it stands now, sleep apnea screening is left to a single, easily dodged question on a certification exam, Kales and others said. As his study showed, many drivers simply ignore referrals for sleep studies, or they ignore the treatment. Some resort to “doctor-shopping,” seeking certifiers who will overlook sleep apnea. That’s primarily because they’re afraid of losing their licenses, people on all sides of the issue agree.

“Truckers have quite a fear of disclosing that they get sleepy when they drive because it might mean their livelihood,” said Wendy Sullivan, vice president of Precision Pulmonary Diagnositics, a Houston company that created a sleep apnea screening tool used by at least two trucking firms that have started testing their drivers.

One trucking firm, Schneider National Inc. based in Green Bay, Wis., became an industry leader on the issue after a pilot project begun in 2003 showed that screening drivers reduced crashes, cut liability costs, increased retention — and trimmed employee health expenses by more than $500 a month.

Now, the firm screens all of its 15,000 drivers and treats and monitors the 1,400 or so diagnosed with sleep apnea, said Don Osterberg, Schneider’s vice president of safety and driver training.

You're going to feel better and you're going to be safer’
“We want to remove those barriers,” he said. “Come forward, let us help you get treated for this. You’re going to feel better and you’re going to be safer.”

But officials at Schneider and Swift Transportation, the firm Kenneth Armstrong works for, acknowledge that change will come slowly, despite danger, unless it’s mandated.

“The science speaks for itself. We know there’s an issue out there,” said Scott E. Barker, vice president of safety, recruiting and driver services for Swift, which launched its pilot project this year. “I believe there’s going to be regulation. We’re just trying to get out ahead of it.”

Armstrong said he tries to do his part to inform fellow truckers about the benefits of sleep apnea detection and treatment. In the meantime, he's starting work on losing weight.

“I tell them, ‘Get it done,’” he said. “You can’t treat sleep apnea like a bad haircut, that time will solve it. It won’t solve itself.’”

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