By Charlie Morasch
The low-key meeting was in a hotel conference room on a January day in Salt Lake City, UT. About 30 audience members watched amid all the fanfare of a small-town city council proceeding.
Before them, however, were five medical doctors poised to set a precedent: withholding millions of commercial driver licenses until professional truck drivers prove that their body weight doesn’t interfere with their ability to sleep.
The Federal Motor Carrier Safety Administration’s Medical Review Board on Jan. 28 called for all CDL-holders with a body mass index of 30 or greater to be required to take a sleep disorder test to determine whether they have sleep apnea. Sleep apnea is a disorder that can cause the throat to partially close and that can awaken people multiple times at night.
The recommendation could have sweeping implications for America’s truckers.
A 5-foot-10-inch tall man who weighs 210 pounds registers 30.1 on the BMI scale and is therefore considered “obese,” according to the Mayo Clinic’s body mass index calculator.
At the Jan. 28 meeting, Dr. Barbara Phillips, a former chairman of the drug company-funded National Sleep Foundation, ushered the FMCSA’s Medical Review Board through the recommendation process in only a few minutes. Then she made a landmark claim.
“The data do indicate the more you weigh, the more likely you are to crash,” she said, slowing to enunciate each word.
Phillips, who directs a sleep medicine program at the University of Kentucky Good Samaritan Hospital in Lexington, KY, didn’t go on to list the National Sleep Foundation’s millions of dollars in annual contributions from pharmaceutical companies and at least one C-PAP manufacturer.
The logic behind the board’s recommendation went as follows:
- tired truck drivers are more likely to be in a crash;
- drivers with sleep apnea may not sleep as well as drivers without sleep apnea;
- obesity has been linked to sleep apnea; therefore
- truckers with certain body mass indexes should be referred by their physicians to have an overnight sleep apnea test before being approved to obtain or renew their CDLs.
The FMCSA has not yet acted on the Medical Review Board’s recommendation. Agency spokesman Duane DeBruyne said officials can choose to ignore the recommendation, alter the recommendation or adopt it. FMCSA has no timetable for considering whether to adopt the BMI/apnea recommendation, DeBruyne told Land Line.
“This is strictly an advisory body; they can’t make policy,” DeBruyne said.
Inside the numbers
The proposed crackdown on truckers comes during a time of remarkable weight gain among Americans. Fire departments are reporting 25 percent increases in emergency calls from obese patients, requiring many to order oversized gurneys with frames that support up to 1,600 pounds.
But trucking regulators want those increased pounds to come at a price for professional truck drivers.
To reach its conclusion, FMCSA’s Medical Review Board looked at a selection of research studies that link vehicle driver safety to sleep apnea. The board hired two teams of consultants to study the effect sleep apnea has on the ability of truck drivers to drive safely. The consultants also studied obesity’s influence on sleep apnea.
However, neither of those consulting groups issues recommendations. An entirely different panel issued the recommendations based upon the other consultants’ review of the data.
The consultants used 17 studies to examine whether patients with sleep apnea have an increased risk of crashes. Only two of those studies involved commercial vehicle drivers. The studies were rated low to moderate quality.
Of the two studies including commercial vehicle drivers, one actually relied on crash data to be self-reported. That study, performed by Riccardo Stoohs in 1994, was discredited specifically by FMCSA in a 2002 sleep apnea study performed at the University of Pennsylvania.
To answer whether certain risk factors increased crash risks, the consultants reviewed 252 possible studies, and excluded all but 10 of those. Of the 10 they relied on, only three took BMI into account.
In short, the FMCSA Medical Review Board hand-picked a few studies they believed would show sleep apnea makes truck drivers safety risks. Drivers with body mass indexes of 30 (clinically obese) and larger were automatically a crash risk.
John Siebert of the OOIDA Foundation said the Medical Review Board’s reliance on studies involving automobile drivers ignores the discrepancy of experience between those who drive trucks or four-wheelers, equating personal vehicle drivers who often drive 10,000 to 15,000 miles with professional truck drivers who often drive 110,000 miles plus per year.
“Eventually the key questions stop even addressing highway safety and wander off looking at different treatments for obstructive sleep apnea,” Siebert said.
Dr. John McElligott – who co-founded a chain of truck stop medical clinics for truck drivers – said he hasn’t found an overnight diagnostic sleep study that costs less than $2,000. The minimum cost for a two-night study would be about $3,500, McElligott told Land Line.
McElligott’s clinics offer a $1,200 sleep apnea diagnosis through a portable device that attaches to a portable machine to provide “continuous positive airway pressure,” commonly referred to as a CPAP machine. Similar at-home diagnosis machines were considered by the Medical Review Board’s consultants, who decided for the time being to instead recommend overnight clinic-hosted sleep studies.
The expense and time constraints that patients must deal with for the overnight sleep studies discourage many from being tested, McElligott said. Tying truckers down for one to two nights at a specific sleep lab is bad for their business, he said.
“You’re stuck for two nights, and most drivers can’t afford to be stuck for two nights,” McElligott said.
Proper weight loss, use of a CPAP machine and time can help a patient overcome apnea’s sleep attacking symptoms, McElligott said.
But the medical review board didn’t agree.
FMCSA consultants found three studies that considered whether use of CPAP lowered a driver’s crash risk. All three studies showed that, in fact, drivers who used CPAP machines lowered their crash risk, with two of the three showing those drivers’ risk to be cut back to “normal” risk levels.
The consultants, however, decided that a “lack of agreement” between the studies made more study of the CPAP question necessary.
Tightening the belt
Despite the Medical Review Board’s designation as an advisory body, the board does carry considerable influence over FMCSA – trucking’s largest regulator.
FMCSA could decide to adopt the BMI-sleep study recommendation later this year, or after the next U.S. president takes office, Melissa Theriault, OOIDA associate director of government affairs, told Land Line.
If the BMI test is adopted, physicians who work with truck drivers aren’t sure the medical community is prepared to deal with an onslaught of new sleep studies.
Dr. Kingman Strohl has helped thousands of truck drivers navigate federal red tape after they had sleep apnea diagnosed.
Strohl is director of the Center for Sleep Disorders Research at Louis Stokes Cleveland VA Medical Center and professor of medicine at Case Western Reserve University. Many military veterans are truck drivers, of whom about one-third are borderline obese, he said.
“We take a lot of pride in treating truck drivers for sleep apnea and getting them back into full employment,” Strohl told Land Line.
Physicians and governments around the world have sought ways of reducing sleepiness among motorists and truckers, Strohl said, with mixed results.
Sleep apnea is relatively easy to diagnose, treat and usually neutralize the symptoms of, Strohl said. “One-size-fits-all” standards don’t accurately predict sleep apnea, he said, although the affliction’s likelihood increases with weight, age and male gender.
Europe has blended screening and diagnoses of sleep apnea without tying the condition to CDL renewal, Strohl said, while Australia has emphasized a cooperative agreement with drivers to educate them on ways to self-identify sleep conditions.
One size does not fit all
At $2,000 per sleep study and at least a third of the estimated 6 million logbook keepers clinically obese, such a rule could mandate billions in revenue for companies who perform sleep studies. More importantly, Strohl said, sleepiness and apnea can’t be explained with a simple weight test.
Setting a BMI threshold of 30 “is excessively low,” considering that many patients won’t possess a single symptom or precursor for sleep apnea. Instead, Strohl suggested that regulators look at setting the BMI threshold at 40 or 45, when patients would be heavier and a link with sleep apnea likely would be stronger.
The government should improve education and screening of sleep apnea, Strohl said, rather than tie down CDL requirements.
“We get to the point where we have to educate the drivers on what the rules are, and we have to pay attention to the rules and therefore don’t pay attention to what the trucker needs,” Strohl said. “That puts physicians and truckers in an odd position where they’re trying to conform to some rule rather than trying to improve health.”
Strohl already can envision tens of thousands of Ohio CDL-holders annually needing overnight sleep tests, and additional waivers from doctors.
They’ll be competing in an already crowded field of clients.
Among the VA population, patients typically have a 90-day period to complete referrals for procedures like sleep studies, Strohl said. Wait lists to get into those studies, however, often stretch to six months.
“Are we under any obligation to do the testing earlier and then kick out or refuse somebody else to be tested because somebody else needs a medical referral?” Strohl asked.
Studies mostly of noncommercial drivers have shown a link between untreated sleep apnea and sleepiness, and researchers have tied increased sleep apnea risk to larger drivers of all vehicles, Strohl said.
The link between increased body size and safe driving hasn’t been as clear, he said.
“The predicted value – that is the strong cause-and-effect relationships – is not there with enough certainty to be able to convince the general public that this is well known,” Strohl said.
It’s possible that simple increased body mass alone could add to a driver’s crash risk, he said.
“But what do they propose to do about that relationship?” Strohl asked. “I would think they’d just try to pitch new weight-loss treatment and not necessarily have people tested for sleep apnea. I think everybody should know their BMI – but I don’t know that a BMI of 29.9 is any different than 30.1.”
Defining truckers’ safe-driving abilities by BMI may not be the end.
The Medical Review Board’s panel made another recommendation likely to strike fear in more truckers than mandatory self weigh-ins by the DOT.
The board’s panel said FMCSA should build a national database of medical records for professional truck drivers – an ominous suggestion at a time when individual truck drivers already face miles of red tape, competitive disadvantages with larger companies, and privacy concerns when it comes to Uncle Sam being responsible for personal health records.
In a matter of minutes in that Utah hotel room, there proved only one group of professionals apparently asleep at the wheel. LL