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Risk Factors for Cardiovascular Disease, Metabolic Syndrome and Sleepiness in Truck Drivers

Abstract

Background:

Truck driver sleepiness is a primary cause of vehicle accidents. Several causes are associated with sleepiness in truck drivers. Obesity and metabolic syndrome (MetS) are associated with sleep disorders and with primary risk factors for cardiovascular diseases (CVD). We analyzed the relationship between these conditions and prevalence of sleepiness in truck drivers.

Methods:

We analyzed the major risk factors for CVD, anthropometric data and sleep disorders in 2228 male truck drivers from 148 road stops made by the Federal Highway Police from 2006 to 2011. Alcohol consumption, illicit drugs and overtime working hours were also analyzed. Sleepiness was assessed using the Epworth Sleepiness Scale.

Results:

Mean age was 43.1 ± 10.8 years. From 2006 to 2011, an increase in neck (p = 0.011) and abdominal circumference (p < 0.001), total cholesterol (p < 0.001), triglyceride plasma levels (p = 0.014), and sleepiness was observed (p < 0.001). In addition, a reduction in hypertension (39.6% to 25.9%, p < 0.001), alcohol consumption (32% to 23%, p = 0.033) and overtime hours (52.2% to 42.8%, p < 0.001) was found. Linear regression analysis showed that sleepiness correlated closely with body mass index (β = 0.19, Raj2 = 0.659, p = 0.031), abdominal circumference (β = 0.24, Raj2 = 0.826, p = 0.021), hypertension (β = -0.62, Raj2 = 0.901, p = 0.002), and triglycerides (β = 0.34, Raj2 = 0.936, p = 0.022). Linear multiple regression indicated that hypertension (p = 0.008) and abdominal circumference (p = 0.025) are independent variables for sleepiness.

Conclusions:

Increased prevalence of sleepiness was associated with major components of the MetS.

Keywords:
Cardiovascular Diseases; Risk Factors; Metabolic Syndrome; Hypertension; Obesity; Sleep Stages

Resumo

Fundamento:

A sonolência de motoristas de caminhão, que pode resultar de diferentes causas, é a principal causa de acidentes com veículos. Obesidade e síndrome metabólica (SMet) estão associadas a distúrbios do sono e fatores de risco primários para doença cardiovascular (DCV). Este estudo verificou a relação entre essas condições e a prevalência de sonolência em motoristas de caminhão.

Métodos:

Este estudo analisou os principais fatores de risco para DCV, dados antropométricos e distúrbios do sono em 2.228 motoristas de caminhão do sexo masculino a partir de informação coletada de 148 paradas efetuadas em rodovias pela Polícia Rodoviária Federal entre 2006 e 2011. Consumo de álcool e de drogas ilícitas e excesso de horas trabalhadas também foram analisados. Sonolência foi avaliada com a Escala de Sonolência de Epworth.

Resultados:

A idade média foi de 43,1 ± 10,8 anos. De 2006 a 2011, observou-se aumento de: circunferências cervical (p = 0,011) e abdominal (p < 0,001); colesterol total (p < 0,001); níveis séricos de triglicerídeos (p = 0,014); sonolência (p < 0,001). Além disso, houve redução de hipertensão (de 39,6% para 25,9%, p < 0,001), consumo de álcool (de 32% para 23%, p = 0,033) e excesso de horas trabalhadas (de 52,2% para 42,8%, p < 0,001). A análise de regressão linear mostrou correlação íntima de sonolência com índice de massa corporal (β = 0,19, Raj2 = 0,659, p = 0,031), circunferência abdominal (β = 0,24, Raj2 = 0,826, p = 0,021), hipertensão (β = -0,62, Raj2 = 0,901, p = 0,002) e triglicerídeos (β = 0,34, Raj2 = 0,936, p = 0,022). Regressão linear múltipla indicou que hipertensão (p = 0,008) e circunferência abdominal (p = 0,025) são variáveis independentes para sonolência.

Conclusões:

Elevada prevalência de sonolência foi associada com os principais componentes da SMet.

Palavras-chave:
Doenças Cardiovasculares; Fatores de Risco; Síndrome Metabólica; Hipertensão; Obesidade; Fases do Sono

Introduction

Traffic accidents are an important external cause of death associated with significant social costs. In 2010, Brazil had 320,000 road accidents, of which 35.1% occurred in the Southeastern region and 20.4%, in São Paulo State11 Departamento Nacional de Infraestrutura e Transporte - DNIT. Anuário estatístico das Rodovias Federais 2010: acidentes de trânsito e ações de enfrentamento ao crime. [Citado 2012 mar10 ]. Disponível em: http://www.dnit.gov.br/rodovias/operacoes-rodoviarias/estatisticas-deacidentes/anuario-2010.pdf
http://www.dnit.gov.br/rodovias/operacoe...
. Cargo vehicles accounted for over 30% of those accidents, although only 9% of the national vehicle fleet is composed of cargo vehicles22 Secretaria dos Transportes: Governo do Estado de São Paulo. [Notícias - Internet]. São Paulo: Secretaria dos Transportes. [Citado 2012 mar 10]. Disponível em: http://www.transportes.sp.gov.br/v20/noticias/imprime_noticia.asp?cod=2105
http://www.transportes.sp.gov.br/v20/not...
.

Several variables have been shown to associate with car accidents33 Connor J, Norton R, Ameratunga S, Jackson R. The contribution of alcohol to serious car crash injuries. Epidemiology. 2004;15(3):337-44.

4 Li MC, Brady JE, DiMaggio CJ, Lusardi AR, Tzong KY, Li G. Marijuana use and motor vehicle crashes. Epidemiol Rev. 2012;34:65-72.

5 Stutts JC, Wilkins JW, Scott Osberg J, Vaughn BV. Driver risk factors for sleep-related crashes. Accid Anal Prev. 2003;35(3):321-31.
-66 Smolensky MH, Di Milia L, Ohayon MM, Philip P. Sleep disorders, medical conditions, and road accident risk. Accid Anal Prev. 2011;43(2):533-48.. Connor et al33 Connor J, Norton R, Ameratunga S, Jackson R. The contribution of alcohol to serious car crash injuries. Epidemiology. 2004;15(3):337-44. have shown that drinking alcohol before driving was responsible for approximately 30% of car crash injuries.33 Connor J, Norton R, Ameratunga S, Jackson R. The contribution of alcohol to serious car crash injuries. Epidemiology. 2004;15(3):337-44. A recent meta-analysis has shown nearly 3 times more vehicle crash risk associated with marijuana44 Li MC, Brady JE, DiMaggio CJ, Lusardi AR, Tzong KY, Li G. Marijuana use and motor vehicle crashes. Epidemiol Rev. 2012;34:65-72.. Stutts et al55 Stutts JC, Wilkins JW, Scott Osberg J, Vaughn BV. Driver risk factors for sleep-related crashes. Accid Anal Prev. 2003;35(3):321-31. in a population-based case-control study have reported that drivers in sleep-related crashes were more likely to work multiple jobs, night shifts, or other unusual work schedules. Overtime work, a night shift, unusual work schedule, and ≥ 60 hours per week were associated with sleep-related crashes55 Stutts JC, Wilkins JW, Scott Osberg J, Vaughn BV. Driver risk factors for sleep-related crashes. Accid Anal Prev. 2003;35(3):321-31..

Smolensky et al66 Smolensky MH, Di Milia L, Ohayon MM, Philip P. Sleep disorders, medical conditions, and road accident risk. Accid Anal Prev. 2011;43(2):533-48. reviewed the potential contribution of several prevalent medical conditions on sleep disorders and on traffic crash risk66 Smolensky MH, Di Milia L, Ohayon MM, Philip P. Sleep disorders, medical conditions, and road accident risk. Accid Anal Prev. 2011;43(2):533-48.. Obesity and metabolic syndrome (MetS) are prevalent among truck drivers77 Marqueze EC, Ulhôa MA, Moreno CR. Irregular working times and metabolic disorders among truck drivers: a review. Work. 2012;41 Suppl 1:3718-25.,88 Mohebbi I, Saadat S, Aghassi M, Shekari M, Matinkhah M, Sehat S. Prevalence of metabolic syndrome in Iranian professional drivers: results from a population based study of 12,138 men. PLoS One. 2012;7(2):e31790. and relate to poor dietary habits and reduced physical activity.

Obesity was associated with some critical security events. Obese truck drivers of heavy commercial vehicles had a 55% higher risk of crash as compared with those with normal weight99 Anderson JE, Govada M, Steffen TK, Thorne CP, Varvarigou V, Kales SN, et al. Obesity is associated with the future risk of heavy truck crashes among newly recruited commercial drivers. Accid Anal Prev. 2012;49:378-84.. Obese truck drivers had higher prevalence of fatigue and risk of involvement in vehicle accidents1010 Wiegand DM, Hanowski RJ, McDonald SE. Commercial drivers' health: a naturalistic study of body mass index, fatigue, and involvement in safety critical events. Traffic Inj Prev. 2009;10(6):573-9.. Obese drivers involved in vehicle accidents also have higher mortality rate as compared with non-obese drivers1111 Zhu S, Layde PM, Guse CE, Laud PW, Pintar F, Nirula R, et al. Obesity and risk for death due to motor vehicle crashes. Am J Public Health. 2006;96(4):734-9..

Obesity and MetS are closely related conditions. MetS is characterized by abdominal obesity, hypertension and metabolic blood alterations, in particular increased blood glucose levels and worsening lipid profiles1212 Grundy SM, Brewer HB Jr, Cleeman JI, Smith SC Jr, Lenfant C; American Heart Association; National Heart, Lung, and Blood Institute. Definition of metabolic syndrome: Report of the National Heart, Lung, and Blood Institute/American Heart Association conference on scientific issues related to definition. Circulation. 2004;109(3):433-8.. Obesity and MetS are strongly associated with obstructive sleep apnea (OSA)1313 Malhotra A, White DP. Obstructive sleep apnoea. Lancet. 2002;360(9328):237-45., which is an important cause of excessive daytime sleepiness in truck drivers and an important factor associated with accidents1414 Powell NB, Chau JK. Sleepy driving. Med Clin North Am. 2010;94(3):531-40.,1515 Ward KL, Hillman DR, James A, Bremner AP, Simpson L, Cooper MN, et al. Excessive daytime sleepiness increases the risk of motor vehicle crash in obstructive sleep apnea. J Clin Sleep Med. 2013;9(10):1013-21..

This study analyzed the associations of cardiovascular risk factors, alcohol, and illicit drugs with sleepiness and vehicle accidents.

Methods

This is a cross-sectional survey on the major cardiovascular risk factors and sleep disorders in 2228 male truck drivers from 148 road stops made by the Federal Highway Police from 2006 to 2011 during the “Commands of Health” program directed to the health of truck drivers carried out once a year on a specific day.

The program is conducted throughout the national territory. Truck drivers were invited to participate and accepting demographic and laboratory data were collected. The response rate was almost 100%. Rare drivers (< 0.5%) refused to participate in the program. All drivers in the study were individual cases, and the likelihood of including the same driver twice in the study was zero.

The interview was conducted and anthropometric data collected by students of nursing or other professions related to human health under the supervision of graduate nurses by using a standard questionnaire. Point‑of‑care testing was used to analyze the serum levels of glucose, triglycerides and total cholesterol. The demographic data analyzed included personal (age, sex, marital status, ethnicity, educational level, socioeconomic class, neck and abdominal circumferences, and body fat) and occupational information (type of employment, length of daily working hours, driving hours, and sleepiness), as well as self-reported drug use. Amphetamines, marijuana, cocaine and benzodiazepines were the drugs questioned to drivers.

The following cardiovascular risk factors were assessed: smoking, dyslipidemia, diabetes, hypertension, sedentary lifestyle and obesity. The percentage of body fat was calculated using the formula: % of body fat = 495/(1.0324-0.19077(log(waist-neck))+0.15456(log(height)))-450 (log10)1616 Hodgdon JA, Beckett MB. Prediction of percent body fat for U.S. Navy men from body circumferences and height. Report No. 84-11. San Diego, CA: Naval Health Research Center. Available from: Naval Health Research Center, 1984. (Report nº 84-11).. Neck, abdominal, and waist circumferences above normal limits were defined as values ≥ 40 cm, ≥ 102 cm, and ≥ 109 cm, respectively1717 Pinto JA, Godoy LB, Marquis VW, Sonego TB, Leal CF, Artico MS. Anthropometric data as predictors of Obstructive Sleep Apnea Severity. Braz J Otorhinolaryngol. 2011;77(4):516-21.. The obesity risk factor was defined according to body mass index (BMI) (kg/m22 Secretaria dos Transportes: Governo do Estado de São Paulo. [Notícias - Internet]. São Paulo: Secretaria dos Transportes. [Citado 2012 mar 10]. Disponível em: http://www.transportes.sp.gov.br/v20/noticias/imprime_noticia.asp?cod=2105
http://www.transportes.sp.gov.br/v20/not...
), using the following scale: normal (BMI ≥ 18.5 to < 25), overweight (BMI ≥ 25 to < 30) and obese (BMI ≥ 30)1818 World Health Organization. (WHO). Obesity: preventing and managing the global epidemic. Report of a WHO Consultation. Geneva, World Health Organization, 2000 Technical Report Series, n. 894. Geneva; 2000. (Technical Report Series nº 894).. Smokers were classified as current versus non-current smokers. Hypertension was diagnosed when systolic blood pressure > 140 mmHg, diastolic blood pressure > 90 mmHg, or if antihypertensive medication was being used1919 Sociedade Brasileira de Cardiologia; Sociedade Brasileira de Hipertensão; Sociedade Brasileira de Nefrologia. [VI Brazilian Guidelines on Hypertension]. Arq Bras Cardiol. 2010;95(1 Suppl):1-51.. Dyslipidemia was diagnosed in individuals with total cholesterol ≥ 240 mg/dL, triglycerides ≥ 200 mg/dL, low-density lipoprotein (LDL) cholesterol ≥ 130 mg/dL or in individuals using lipid-lowering medications2020 Santos RD; Sociedade Brasileira de Cardiologia. [III Brazilian Guidelines on Dyslipidemias and Guideline of Atherosclerosis Prevention from Atherosclerosis Department of Sociedade Brasileira de Cardiologia]. Arq Bras Cardiol. 2001;77 Suppl 3:1-48.. Diabetes was diagnosed in individuals with fasting glucose ≥ 126 mg/dL or casual plasma glucose ≥ 200 mg/dL as well as in individuals receiving hypoglycemic medications2121 American Diabetes Association. Diagnosis and classification of Diabetes Mellitus. Diabetes Care. 2006;29(Suppl 3):S43-8.. Sedentary lifestyle was diagnosed qualitatively by self-reported absence or presence of any additional leisure physical activity unrelated to regular working hours.

Sleepiness was assessed using the Epworth Sleepiness Scale with a cutoff score > 102222 Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep. 1991;14(6):540-5..

The Ethics Committee of the University of São Paulo Medical School approved this study (research protocol n°539/13).

Statistical analysis

Comparison of percentages and linear regression analysis were used for the statistical analysis of each variable (BMI, diabetes, hypertension, overtime, illicit drugs, alcohol, smoking, hypercholesterolemia, sleepiness, waist circumference, body fat, and triglycerides). All variables were dichotomized and analyzed as a percentage of the presence of the altered variable for each year. Using sleepiness as the dependent variable, linear multivariate regression analyses were performed using diabetes, illicit drug and alcohol use, hypercholesterolemia, hypertriglyceridemia, and abdominal circumference as independent variables. The same analysis was made for vehicle accidents as the dependent variable and diabetes, illicit drug and alcohol use, hypercholesterolemia, hypertriglyceridemia, sleepiness, and abdominal circumference as independent variables. The significance level adopted for the statistical tests was 5% (p < 0.05). The statistical analyses were performed using the SAS program for Windows (Statistical Analysis System version 9.2, SAS Institute Inc., 1989-1996, Cary, NC, USA).

Results

The clinical and laboratory data of 2228 truck drivers from road stops conducted by the Federal Highway Police from 2006 to 2011 are shown in Table 1. The mean age was 43.1 ± 10.8 years. From 2006 to 2011, an increase in neck (7.5% to 13.9%, p = 0.011) and abdominal circumferences (19.8% to 52.8%, p < 0.001), total cholesterol (4.4% to 13.7%, p < 0.001), triglyceride plasma levels (25.8% to 39.1%, p = 0.014), and sleepiness (4.9% to 14.7%, p < 0.001) was observed (Figure 1). In addition, a reduction in hypertension (39.6% to 25.9%, p < 0.001), alcohol consumption (32% to 23%, p = 0.033) and overtime hours worked (52.2% to 42.8%, p < 0.001) was also observed. The data obtained regarding body fat (56.1% to 62.4%, p = 0.395), smoking (20.3% to 17.7%, p = 0.192), hyperglycemia (14.9% to 11%, p = 0.267), and illicit drug use (5.5% to 8.1%, p = 0.127) were similar to the data analyzed from previous years. The linear regression analysis showed that sleepiness was closely correlated with BMI (β = 0.19, Raj2 = 0.659, p = 0.031), abdominal circumference (β = 0.24, Raj2 = 0.826, p = 0.021), hypertension (β = -0.62, Raj2 = 0.901, p = 0.002), triglycerides (β = 0.34, Raj2 = 0.936, p = 0.022). Vehicle accidents showed correlation with only BMI (β = 0.21, Raj2 = 0.807, p = 0.024). Linear multiple regression indicated that hypertension (p = 0.008) and abdominal circumference (p = 0.025) are independent variables for sleepiness, and no independent variable was found for vehicle accidents.

Table 1
Clinical and laboratory data of truck drivers from road stops conducted by the Federal Highway Police from 2006 to 2011
Figure 1
Linear regression results of the variables from 2006/2007 to 2011.

Discussion

Our study showed that increased sleepiness was associated with the major components of the MetS. Increased abdominal circumference and hypertension were independently associated with sleepiness. It is well known that our population is becoming increasingly obese2323 Rtveladze K, Marsh T, Webber L, Kilpi F, Levy D, Conde W, et al. Health and economic burden of obesity in Brazil. PLoS One. 2013;8(7):e68785., and based on data from our study we observed the same trend in truck drivers. Weight gain is often associated with some degree of hypertension, diabetes, dyslipidemia, and, thus, MetS.

Recently, Hirata et al2424 Hirata RP, Sampaio LM, Leitão Filho FS, Braghiroli A, Balbi B, Romano S, et al. General characteristics and risk factors of cardiovascular disease among interstate bus drivers. Scientific World Journal. 2012;2012:216702. found an increased prevalence of hypertension, obesity, hyperlipidemia, and hyperglycemia in bus drivers. These findings were related to lifestyle, such as poor dietary habits and low physical activity2525 Pasqua IC, Moreno CR. The nutritional status and eating habits of shift workers: a chronobiological approach. Chronobiol Int. 2004;21(6):949-60.. Sleepiness in these subjects may be related to some factors, such as overtime work, poor sleep quality, illicit drug and alcohol intake and obesity. Overtime work accounted for approximately 22% of road accidents and associated with higher mortality rate as compared with other causes2626 Garbarino S. [Sleep disorders and road accidents in truck drivers]. G Ital Med Lav Ergon. 2008;30(3):291-6.. Nevertheless, in our study, overtime work remained constant during the study period.

Alcohol intake and illicit drugs are known to be two important factors associated with sleepiness. We observed a reduction in the percentage of alcohol consumption in our truck drivers and the percentage of illicit drug use remained unchanged during the period analyzed suggesting minor, if any, influence of these variables on the expressive increase of sleepiness in our study. Poor sleep quality and obesity are closely related.

It is well known that drowsiness results from OSA, an important factor in this obese population and in subjects with MetS2727 Moreno CR, Carvelho FA, Lorenzi C, Matuzaki LS, Prezotti S, Bighetti P, et al. High risk for obstructive sleep apnea in truck drivers estimated by the Berlin questionnaire: prevalence and associated factors. Chronobiol Int 2004;21(6):871-9.,2828 Hartenbaum N, Callop N, Rosen IM, Phillips B, George CF, Rowley JA, et al; American College of Chest Physicians; American College of Occupational and Environmental Medicine; National Sleep Foundation. Sleep apnea and commercial motor vehicle operators: Statement from the joint task force of the American College of Chest Physicians, the American College of Occupational and Environmental Medicine, and the National Sleep Foundation. Chest. 2006;130(3):902-5..

Moreno et al2929 Moreno CR, Louzada FM, Teixeira LR, Borges F, Lorenzi-Filho G. Short sleep is associated with obesity among truck drivers. Chronobiol Int. 2006;23(6):1295-303. used the Berlin Questionnaire to show that smoking and drug use are independent variables associated with increased risk for OSA in our truck driver population. A low risk for OSA was associated with some degree of exercise.

Another study on Brazilian truck drivers indicated that less than 8 hours of daily sleep, age > 40 years, glucose levels > 200 mg/dL, cholesterol levels > 240 mg/dL, snoring, and hypertension are independent factors associated with obesity2929 Moreno CR, Louzada FM, Teixeira LR, Borges F, Lorenzi-Filho G. Short sleep is associated with obesity among truck drivers. Chronobiol Int. 2006;23(6):1295-303.. Some of these factors are components of the MetS. Xie et al3030 Xie W, Chakrabarty S, Levine R, Johnson R, Talmage JB. Factors associated with obstructive sleep apnea among commercial motor vehicle drivers. J Occup Environ Med. 2011;53(2):169-73. also showed that a BMI ≥ 30, hypertension, and diabetes are independently associated with OSA in commercial motor vehicle drivers. In our study, central obesity and hypertension are associated with sleepiness. These changes are likely related to the poor dietary habits, due to the high-calorie meals consumed by truck drivers at highway restaurants, and the lack of physical activity, consequent to overtime work. Nevertheless, the number of car accidents did not change during the study period. This finding may be the result of some improvements to the infrastructure and logistics of the transport system3131 Agencia Nacional de Transportes Terrestres (ANTT). Relatórios anuais. Brasília; 2008/2013. [Citado em 2014 jun 10]. Disponível em http://www.antt.gov.br/index.php/content/view/4880/Relatorios_Anuais.html#lista
http://www.antt.gov.br/index.php/content...
. However, improvements to truck drivers’ health may have an important impact on cargo vehicle accidents.

A recent health survey of U.S. long-haul truck drivers showed that 83.4% were overweight/obese, 57.9% experienced sleep disturbances, and approximately 40% reported cardiovascular disease concerns3232 Apostolopoulos Y, Sönmez S, Shattell MM, Gonzales C, Fehrenbacher C. Health survey of U.S. long-haul truck drivers: work environment, physical health, and healthcare access. Work. 2013;46(1):113-23.. An additional study of long-haul truck drivers indicated increased cardiovascular disease mortality in those drivers younger than 55 years3333 Robinson CF, Burnett CA. Truck drivers and heart disease in the United States, 1979-1990. Am J Ind Med. 2005;47(2):113-9.. This is a key age group in our truck driver population. The incidence of cardiovascular disease in men has significantly increased from that age onward. Therefore, this is a key group for implementing preventive interventions.

The main limitation of this ecological study was that we performed the statistical analysis based on a percent of the yearly grouped variable instead of the individual subject data. Because we used the percent data indicative of the presence or absence of a particular variable, we could not quantify the intensity of each variable. Other study limitations were: accuracy of point-of-care testing used to analyze the serum levels of glucose, triglycerides and total cholesterol. A common problem in studies with this design is the reverse causality that can mask the effects of some investigated associations. Residual confounding and selection bias are variables that may have influenced our results.

Conclusion

Increased sleepiness was associated with the major components of the MetS. The implementation of preventive measures, such as improvement in eating habits and physical activity, regular working times, and better working conditions, may reduce cardiovascular disease in this population. Lifestyle changes and cardiovascular risk factor control may reduce sleepiness and consequently decrease cargo vehicle accidents.

  • Sources of Funding
    There were no external funding sources for this study.
  • Study Association
    This study is not associated with any thesis or dissertation work.

Acknowledgements

To the Department of Legal Medicine, Medical Ethics, Social and Labour Medicine of the University of São Paulo Medical School for funding English language editing of the manuscript, and to the Federal Highway Police Department for data acquisition.

References

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    Connor J, Norton R, Ameratunga S, Jackson R. The contribution of alcohol to serious car crash injuries. Epidemiology. 2004;15(3):337-44.
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    Li MC, Brady JE, DiMaggio CJ, Lusardi AR, Tzong KY, Li G. Marijuana use and motor vehicle crashes. Epidemiol Rev. 2012;34:65-72.
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    Stutts JC, Wilkins JW, Scott Osberg J, Vaughn BV. Driver risk factors for sleep-related crashes. Accid Anal Prev. 2003;35(3):321-31.
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    Marqueze EC, Ulhôa MA, Moreno CR. Irregular working times and metabolic disorders among truck drivers: a review. Work. 2012;41 Suppl 1:3718-25.
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    Mohebbi I, Saadat S, Aghassi M, Shekari M, Matinkhah M, Sehat S. Prevalence of metabolic syndrome in Iranian professional drivers: results from a population based study of 12,138 men. PLoS One. 2012;7(2):e31790.
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    Malhotra A, White DP. Obstructive sleep apnoea. Lancet. 2002;360(9328):237-45.
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    Powell NB, Chau JK. Sleepy driving. Med Clin North Am. 2010;94(3):531-40.
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    Ward KL, Hillman DR, James A, Bremner AP, Simpson L, Cooper MN, et al. Excessive daytime sleepiness increases the risk of motor vehicle crash in obstructive sleep apnea. J Clin Sleep Med. 2013;9(10):1013-21.
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    Hodgdon JA, Beckett MB. Prediction of percent body fat for U.S. Navy men from body circumferences and height. Report No. 84-11. San Diego, CA: Naval Health Research Center. Available from: Naval Health Research Center, 1984. (Report nº 84-11).
  • 17
    Pinto JA, Godoy LB, Marquis VW, Sonego TB, Leal CF, Artico MS. Anthropometric data as predictors of Obstructive Sleep Apnea Severity. Braz J Otorhinolaryngol. 2011;77(4):516-21.
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    Santos RD; Sociedade Brasileira de Cardiologia. [III Brazilian Guidelines on Dyslipidemias and Guideline of Atherosclerosis Prevention from Atherosclerosis Department of Sociedade Brasileira de Cardiologia]. Arq Bras Cardiol. 2001;77 Suppl 3:1-48.
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    American Diabetes Association. Diagnosis and classification of Diabetes Mellitus. Diabetes Care. 2006;29(Suppl 3):S43-8.
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    Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep. 1991;14(6):540-5.
  • 23
    Rtveladze K, Marsh T, Webber L, Kilpi F, Levy D, Conde W, et al. Health and economic burden of obesity in Brazil. PLoS One. 2013;8(7):e68785.
  • 24
    Hirata RP, Sampaio LM, Leitão Filho FS, Braghiroli A, Balbi B, Romano S, et al. General characteristics and risk factors of cardiovascular disease among interstate bus drivers. Scientific World Journal. 2012;2012:216702.
  • 25
    Pasqua IC, Moreno CR. The nutritional status and eating habits of shift workers: a chronobiological approach. Chronobiol Int. 2004;21(6):949-60.
  • 26
    Garbarino S. [Sleep disorders and road accidents in truck drivers]. G Ital Med Lav Ergon. 2008;30(3):291-6.
  • 27
    Moreno CR, Carvelho FA, Lorenzi C, Matuzaki LS, Prezotti S, Bighetti P, et al. High risk for obstructive sleep apnea in truck drivers estimated by the Berlin questionnaire: prevalence and associated factors. Chronobiol Int 2004;21(6):871-9.
  • 28
    Hartenbaum N, Callop N, Rosen IM, Phillips B, George CF, Rowley JA, et al; American College of Chest Physicians; American College of Occupational and Environmental Medicine; National Sleep Foundation. Sleep apnea and commercial motor vehicle operators: Statement from the joint task force of the American College of Chest Physicians, the American College of Occupational and Environmental Medicine, and the National Sleep Foundation. Chest. 2006;130(3):902-5.
  • 29
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Publication Dates

  • Publication in this collection
    27 Oct 2015
  • Date of issue
    Dec 2015

History

  • Received
    23 Mar 2015
  • Accepted
    06 Aug 2015
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