OSA & BMI: Obstructive Sleep Apnea & Body Mass Index

**This article is the authors opinion-only, not medical advice**

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I am not an AME or any kind of doctor. I am a fitness professional and advocate, as well as a commercial airline pilot. In 2015, the FAA implemented that AMEs conduct mandatory screening for obstructive sleep apnea (OSA) risk during our flight physicals. This subject gained interest after a 2008 fatigue related incident wherein both pilots fell asleep at the controls and overflew their destination. The NTSB then set OSA in its gunsights after the captain was diagnosed with severe obstructive sleep apnea. In 2013, the NTSB and the FAA cracked down hard, at first stating that any pilot with a “body mass index of 40 or greater would be evaluated for OSA.” They cited that a pilot who is a victim of OSA may be “flying with the performance-equivalent of having blood-alcohol content of .06-.08%  – the legal measure of intoxication.” Body Mass Index is the quickest and most broadly used (but most inaccurate) way to screen for obesity and OSA.* The FAA quickly backed off of this strict enforcement standard after pushback from the pilot union. Here is where we are today: At this point, the AMEs are simply instructed to look for any symptoms/risk-markers of OSA, and insomnia in general, to include obesity but also sleep hygiene. Seventy percent of clinically obese people (BMI of 40 or greater) suffer from OSA, according to the NTSB.

Obstructive sleep apnea, clinically speaking, is a condition where one’s breathing is literally obstructed, reduced or even cut-off completely while sleeping; to the point where they wake-up briefly in order to start breathing again, though they do not remember waking up at all. Those who suffer from this condition are literally being deprived of oxygen. With OSA this occurs repeatedly, up to 15 to 30 awakenings per hour, so that the victim never enters the deep or restorative sleep phase. The obstruction is typically adipose tissue accumulation in the respiratory passages caused by excessive weight gain, as well as genetic factors such as a soft-palate, large tongue and/or age. Sleeping on one’s back, where gravity is a factor can further exacerbate the closure. So, the two biggest risk markers are obesity (which currently also means a BMI or 30 or greater) and snoring. However, many pilots do not even realize they snore excessively unless they sleep next to someone. Body mass index is a very rudimentary way to determine obesity because it is the ratio of one’s weight in kilograms, divided by the square of their height in centimeters. Though the FAA uses a BMI of 40 as the trigger for OSA risk, clinically speaking, a BMI of 30 or greater is considered obese.

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The problem is that this BMI formula/method does not take into account body-composition.  How much of one’s body weight is lean-body mass vs. how much is fat mass or adipose tissue? Therein lies the inaccuracy, which is why it is good that AMEs are now instructed by the FAA not to assess OSA risk based on BMI alone, but also to interview their pilot patients about their sleep quality and to look for other physiological markers, such as type-2 diabetes and blood-pressure, which are also markers of OSA. For now, we are stuck with BMI as the primary screening method, since performing an actual body-composition analysis, or body-fat test is too time-consuming, requires special training, and is ideally conducted in a hydrostatic dunk-tank.

Photo by Jed Smith

If you think you might suffer from sleep-apnea, there are a lot of easily recognizable symptoms already mentioned above. Additionally, consider these: constant drowsiness any time you sit still, being overweight (but especially with an apple-shape or distended abdomen), your sleeping companion constantly telling you to stop snoring or to rollover in bed, you are insulin-resistant or already suffer from type-2 diabetes, you never remember your dreams, or you have high blood-pressure. Beyond falling asleep at the controls (to which pilots are already prone due to constant jetlag-inducing flight scheduling and circadian disruption), those in the OSA risk group are also at risk for stroke, heart-arrhythmia, heart-attack, hypertension and memory loss. All of this is further compounded when you factor in a snapshot of many of our typical monthly flight scheduling, and the circadian disruption it inherently causes (legal by Part 117 rest standards).  Many times we do it to ourselves because pilots are so productivity-driven and we think we can sleep adequately in the back of a plane or in a crashpad bunk. The best strategy you can implement to begin lowering your risk and curing your OSA, is to first to consult a medical professional and sleep specialist for evaluation. There are many medical treatments, such as oral appliances, dental appliances (to keep your airway open ergonomically), CPAP (continuous positive airway pressure) machines, and even surgical interventions. But, if you want to avoid all of this drama and associated time out of the cockpit (from being medically grounded), simply take charge of your life and start losing weight (fat) by altering your lifestyle through diet and exercise. It works well most of the time and it’s free!

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SOURCEAero Crew News, October 2017
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Max Wettstein

Max Wettstein is an Airbus 320 Captain at JetBlue Airways based in Long Beach, CA and has been a pilot for JetBlue for 14 years. Prior to JetBlue, Max was a pilot in the US Navy, for 10 years, flying E-2C Hawkeyes and King Airs. Max is also a fitness professional, appearing on the cover of Men’s Health and other fitness magazines over 20 times, is a published fitness author, consultant and Personal Trainer. Max currently runs a holistic health & travel fitness blog. Max was the initial fitness & health contributor for the pilot cadre at JetBlue for 5 years before corporate took over. As a longtime advocate of holistic health and longevity, Max has made a commitment to researching every occupational health hazards we pilots and aircrew face while flying the line, from long term sitting to jet lag, to radiation exposure. Max also specializes in designing quick, high-value, body weight-only workouts, that can be performed anywhere while on the road, even in your hotel room or the hotel stairwell. Max has the unique background of both airline travel life along with cutting edge fitness, and has learned how to make both work as synergistic careers and as his lifestyle. In his free time when Max isn’t flying the Airbus or on set of a fitness infomercial, Max is usually surfing with his family, skateboarding, or playing beach volleyball in Encinitas, CA.

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