GUEST COLUMNIST Amy J. Khan, MD, MPH National Medical Director – Concentra TotalCare A comprehensive and insightful overview of the health and productivity issues facing commercial drivers and the trucking industry was provided by Dr. Khan of Concentra during the American Trucking Association’s Health and Safety Expo held in Nashville, TN , in September 2008. Highlights from this presentation are included in this article.
Amy J. Khan, MD, MPH
National Medical Director – Concentra TotalCare
A comprehensive and insightful overview of the health and productivity issues facing commercial drivers and the trucking industry was provided by Dr. Khan of Concentra during the American Trucking Association’s Health and Safety Expo held in Nashville, TN , in September 2008. Highlights from this presentation are included in this article.
Driver Health Status
Compared to the rest of the US population, commercial drivers are disproportionately affected by weight problems with up to 90% reported as overweight or obese compared to two thirds of US adults. In fact, compared to workers from other occupational categories, commercial drivers rank among the highest in obesity rates. This increase in obesity has fueled the increased risk and expression of related chronic disease and musculoskeletal injury. For example, obese workers have four-fold greater risk of hypertension. Similarly, the risk for diabetes and sleep apnea is greatly increased among obese persons compared to those with normal weight. Lastly, large physical size can potentially compromise a driver’s functional capacity to safely and comfortably operate a commercial vehicle and can impact the severity or recovery of musculoskeletal injuries.
Lifestyle, poor dietary habits such as consumption of high caloric fast food, sugary soft drinks and high fat snack foods, limited physical activity, long work hours and chronic lack of sleep due to inconsistent domicile and irregular or rotating shifts frequently characterize the lives of many commercial drivers. These characteristics place them at increased risk for weight problems, diabetes, heart disease and other chronic illness. In addition, more than half of commercial drivers report regular tobacco use which increases their risk for heart disease, stroke, lung disease and cancer.
Sleep apnea represents a particular concern for commercial drivers and increased risk to driver and public safety from motor vehicle crashes if this condition is not recognized or treated. Published reports have estimated rates of moderate to severe sleep apnea to range from 10 to 16% among the commercial driver population. Strongly associated with obesity, sleep apnea also creates a risk for impaired glucose metabolism, contributing to the risk for developing glucose intolerance, insulin resistance, and diabetes. Among sleep apnea patients, over three quarters complain of both excessive daytime sleepiness and cognitive impairments, and half report personality changes. As a group, sleep apnea patients’ risk of motor vehicle collisions is increased two to seven-fold thereby representing a significant potential liability to employers of commercial drivers.
In addition to the health risk issues noted above, commercial drivers tend to be older on average than other members of the US workforce. This represents an additional risk for chronic disease as older persons are more likely to have health issues such as hypertension and other chronic illness (as a factor of aging) compared to younger persons.
Trucking Industry Issues
In the United States, federal regulations governing transportation safety require commercial drivers to meet behavioral and health standards as assessed through a periodic medical certification (see http://www.fmcsa.dot.gov/.) Whereas commercial drivers in good health may be qualified for two years, Department of Transportation (DOT) regulations disqualify commercial drivers with Stage 3 hypertension, uncontrolled diabetes or untreated sleep apnea. In many cases, those with poorly managed medical conditions or evidence of worsening health status may have qualification time restricted and be required to return for medical re-evaluation at shorter intervals. Inadequately controlled or advanced medical conditions may lead to permanent medical disqualification of a driver.
Due to the increased health risks and disease burden of the potentially eligible driver population, employers of commercial drivers are increasingly challenged by the costs associated with more frequent qualifying exams for drivers with certain health risks that are mandated by federal regulation. These costs combined with the increase in non-occupational health care costs in general represent in increasing financial burden to employers. In addition, loss of productivity driven by obesity is well documented as these workers typically incur higher rates of disability and absenteeism. Frequent driver turnover and related costs for recruitment and training represent an additional issue for employers of commercial drivers.
Improving Health Status
In an effort to improve driver health, reduce health costs, increase productivity and retain drivers in their workforce, evidence has shown that employers can benefit from acommercial driver wellness program that implements health improvement activities targeted to the risks of their commercial drivers. For example, a JOEM report[i] published last year demonstrated a more than 50% reduction in uncontrolled blood pressure among hypertensive drivers (from 40.7% at baseline to 17.2% at follow up) after a health awareness and hypertension management program was implemented for 6 months. The improvement in blood pressure was consistent across all subgroups defined by diabetes, obesity, and use of antihypertensive medication.
The specific health promotion activities provided to the commercial drivers in the report cited above included 1) a personal health education session consisting of a five to ten minute consultation by a health specialist following their regular qualifying exam; 2) a health marketing campaign that included placement of health promotion materials at work and mailed home that reinforced the importance of optimal blood pressure control, healthy lifestyle practices, treatment compliance and factors impacting commercial driver certification; 3) access to follow up blood pressure monitoring and facilitated referral for follow up medical care including provision of suggested “Ask your doctor” questions for drivers to pose to their treating provider; and 4) tools for employers, unions, and clinicians that reinforce hypertension awareness.
Obesity screening and related risk reduction counseling are recommended by the United States Preventive Services Task Force (USPSTF). This clinical preventive service could easily be offered during the certification/recertification exam process for commercial drivers. Noninvasive body measurements would be obtained to identify chronic disease risk and include determination of body mass index (BMI) and waist circumference, both independent risk factors for development of cardiovascular disease and diabetes. An additional set of focused screening tests could also be provided to identify persons at risk for sleep related problems such as sleep apnea or those with tobacco use problems.
Given obesity’s association with increased morbidity and mortality, providing guidance and support to improve dietary practices, increase physical activity, and reduce or prevent weight gain can potentially avert future co-morbidity from associated hypertension, diabetes or sleep apnea. Population-based screening and referral for ongoing lifestyle support interventions can help reduce related health care and disability costs, as well as reduce the need for more frequent DOT reexaminations, due to improved health status of commercial drivers.
Key to Effective Interventions
A Truck Driver Wellness Program targeted to your commercial drivers can assist your driver population in staying healthy both on the road and at home. These programs reinforce the message that good health is essential not only for ones wellbeing, but also for the wellbeing of the family and the community. Whereas it is true that the vast majority of commercial drivers will pass their DOT certification and re-certification medical exam, those at risk for future illness often don’t know it but can be identified early to prevent future disease through modification in lifestyle practices or timely referral for medical evaluation.
An effective Commercial Driver Wellness Program should be multi-component and offer sufficient intensity and duration to realize the maximum benefit to the employee and employer return on investment[ii]. Essential components of a successful Commercial Driver Wellness Program includes the following elements:
· Health Risk Screening and Education – evidenced-based screening and counseling on risk factors for sleep apnea, diabetes, blood pressure and tobacco use problems. Attention to diet, physical activity, weight management, sleep hygiene and personal accountability for health behaviors are stressed and clinical practice guidance provided that reinforces lifestyle change and link to timely medical care.
· Ongoing Health Promotion – guided by the risk factor burden of the trucking industry employee population, health messaging and coordinated health awareness campaigns keep recommended lifestyle practices top of mind. Workplace and environmental support for selecting healthy nutritional options and increasing physical activity for drivers are emphasized.
· Targeted Lifestyle Support – topic-focused educational sessions such as for weight management or diabetes care may be offered via web-based meetings with a focus on building skills and confidence to make and sustain healthy behaviors.
· Personal Health Coaching – offered to participants to support improved health practices such as tobacco cessation. Through active engagement, personal responsibility and confidence is enhanced to make recommended lifestyle changes.
· Effective Incentives – requires an understanding of the workforce demographics, employee benefits and health management objectives to promote participation.
Health management efforts to improve the recognized health and safety risks of commercial drivers are essential especially in light of the workforce characteristics and economic challenges faced by the trucking industry today. By leveraging current requirements for medical certification exams, targeted health improvement programs can be delivered in a cost effective and convenient manner to minimize downtime and ensure commercial drivers are back in their vehicle in a timely manner. Through innovative use of incentives, periodic check ins, web-based tools and telephonic touch points, ongoing support and specific interventions can successfully support healthy lifestyle practices and reduce disease risk among commercial drivers.
Dr. Khan serves as the National Medical Director for Concentra’s TotalCare program, an integrated suite of services for employers and their workforce that includes health promotion, disease prevention, occupational health and primary care. Prior to joining Concentra, Dr. Khan served six years at the Centers for Disease Control and Prevention identifying at-risk populations, measuring disease burden, and disseminating disease prevention recommendations. In addition, she has over a decade of health management experience in her prior role as Assistant Physician-in-Chief at Kaiser Permanente in Northern California where she directed a multidisciplinary behavioral health service line serving workers and their dependents impaired by substance-use problems. Specialty boarded in Internal Medicine, General Preventive Medicine & Public Health, and Addiction Medicine, Dr. Khan is an expert in population health, behavioral change and integrated clinical care. Her background gives her broad knowledge of cost effective solutions that improve health while reducing overall health care costs. Dr. Khan earned her BA in chemistry from Albion College, her MD from Wayne State University School of Medicine and her MPH from Johns Hopkins Bloomberg School of Public Health. For more information about how Concentra’s TotalCare services can help improve health, reduce costs and enhance productivity, visit: www.concentratotalcare.com.
 J Occ Env Med Medicine 2008;
 Am J Prev Med 2005;29(