"Tackling Sleep Problems in Athletes"

Players With Large Body Mass at Risk

By: Mike Bederka

For former professional football player Vyto Kab, one of his toughest opponents came far from the stadium field. It came in the bedroom, trying to score some winks instead of touchdowns.

"It was a Saturday night, and I had to play the next day," Kab remembers back to his times with the Detroit Lions in the 1980s. "I was rooming with a big defensive lineman who was one of the few 300-pounders who played during my time.

"He snored like a buzz saw," the tight end recalled distinctly. "It was so bad that I ended up sleeping in the bathtub in order to get a good night's sleep. This guy snored so loudly I would have slept anywhere."

Not surprisingly, Kab ended up getting another roommate, but this experience stayed with him after he hung up his helmet. He entered the sleep field and became one of the investigators on a study released earlier this year that offered surprising results on the high incidence of sleep-disordered breathing (SDB) among professional football players.1

The issue of sleep in athletes desperately needs to be tackled, said Allan M. Levy, MD, associate team physician for the New York Giants football team. It's the "last frontier" when working with athletes to improve performance and health, he noted, and it should become a concern for players, coaching and training staffs, and sleep professionals.

"We've changed their diets, changed their training habits and changed their strength programs," Dr. Levy said. "We've changed everything but their sleep habits."

Now, with some scientific evidence to back physicians up, that might become a bigger priority.

SUPER BOWL STUDY

A few days before the Tampa Bay Buccaneers trounced the Oakland Raiders 48-21 in Super Bowl XXXVII, a study came out in the New England Journal of Medicine that described a dangerous finding.1

After receiving disease-specific questionnaires and subjective sleepiness scales from 302 professional football players from eight National Football League teams (mean age, 25.52.7 years), the researchers evaluated 52 with overnight polysomnography. They found a prevalence rate of 14 percent for SDB — that's nearly five times higher than noted in previous studies of similar-aged adults.

The prevalence among heavier players (offensive and defensive linemen) soared to 34 percent. Linemen accounted for 85 percent of the cases of SDB, and they had the largest neck circumference (19.10.9 inches) and highest body-mass index (36.62.6). Also, systolic blood pressure (12911 mm Hg vs. 1229 mm Hg) and diastolic blood pressure (849 mm Hg vs. 778 mm Hg) were significantly higher in the linemen than in all the other players (P<0.01).

"The thing most striking about this study is that apart from the size of the players you would not expect young, healthy, athletic males to have such a prevalence of sleep-disordered breathing," said study lead author Charles George, MD, professor of medicine, University of Western Ontario, London, Canada.

Dr. Levy concurred. "We have to change the way we're thinking about (SDB)."

With SDB, the body's metabolism isn't operating as efficiently as it can. So in addition to the effects of excessive daytime sleepiness, players have an increased chance of developing hypertension, which is a risk factor for premature cardiovascular disease. "The league wants to do everything it can to prevent a 25-year-old from having a heart attack on the field," Kab said.

The results from this study don't just have implications for professional football players, Dr. George said. It also affects men of similar size and age whose physical health may not be as good as the athletes tested, as well as the swarms of aspiring young people training to play football in the NFL someday.

"There are probably 40,000 to 400,000 college players working to that level. And you could probably increase further that number by order of magnitude if you include high school people. This is the tip of the iceberg."

Body builders, large wrestlers and athletes who participate in field events in track sometimes have significant sleep apnea, too.

"Having a big neck is an important risk factor, whether it's fat or muscle," said Shawn Youngstedt, PhD, assistant project scientist in the psychiatry department at the University of California, San Diego. Research shows both fat and muscle buildup in the neck contribute to narrowing of the airway, resulting in SDB.

BEYOND SDB

In addition to high levels of SDB, the professional football player study also identified an unsuspecting person who had idiopathic hypersomnolence and several others with restless legs syndrome.

"Professional athletes' bodies are at such a high caliber of conditioning that a lot of times their underlying disorders in sleep get masked over because they're operating at such an efficient level," said Kab, who's now co-managing director of SleepTech Consulting Group, Kinnelon, New Jersey. "When you're not looking for something, it's often seen as something else."

Also, athletes with relatively delayed body clocks might suffer from chronic sleep deprivation if they persistently get up early for practice, Dr. Youngstedt said.

"I would recommend if someone has a delayed body clock, advance it with bright light, or if they have to do two workouts, have the second one at night instead of in the morning," said Dr. Youngstedt, who has authored several studies on sleep and athletes.

He knows the tortures of disrupted sleep from personal experience. As a cross-country runner in college, he often couldn't hit the pillow until 1 a.m., even though he had sunrise practice a mere five hours later.

"By the end of the season, I was fried," he said. "If I could have slept a couple hours more every morning, I would have been much better off."

Body clock problems also may result from the transcontinental travels that athletes endure frequently. No scientific evidence shows that jet lag might cause a point guard to miss a free throw or a wide receiver to drop an easy catch, but Dr. Youngstedt said it "seems reasonable" that flying from Los Angeles to New York the night before a game could decrease performance levels. Insomnia brought on by jitters before a big game may exaggerate their altered sleep sessions as well.

And don't think athletes' sleep schedules get any better when they have a little time away from the field. Football players generally arrive at 6:30 a.m. for practice, and they don't get home until dinnertime, Dr. Levy said. Players try to cram everything they need to do in those evening hours because Tuesday is their only true day off.

The result is poor sleep, which could disrupt an important aspect of the nighttime cycle.

"The sleep of athletes is different than the sleep of you and me," Dr. George said. "Because they are exerting themselves and they are subjecting their bodies to more wear and tear, they certainly need time to restore and repair during sleep."

That happens typically in the first third of players' sleep cycles when growth hormone, which is important for tissue repair, is mostly released in the body.

"You must have that portion of sleep in order to repair yourself from any cellular damage during the daytime," Dr. George said. However, this area of study needs to be examined further as does athletes' sleep patterns in general.

FUTURE DIRECTIONS

One direction would be to look at how SDB affects performance. A 1997 pilot study conducted by SleepTech Consulting Group explored this topic briefly. Researchers tested 16 linemen from the Giants for sleep apnea. The 13 diagnosed with the disorder had slower reaction times and lapses in concentration in daytime performance tests when compared to a similarly aged group of controls without sleep apnea.

Dr. George and colleagues plan to conduct a second phase of their research, which could involve up to 16 NFL teams over the course of two years. "It's going to diagnose as well as treat and show their difference in performance as a result of treating their sleep disorders," Kab said.

However, getting these young players to adhere to the standard treatment of continuous positive airway pressure may be a tough opponent.

"You have to remember you're dealing with 22-year-old football players who are making a lot of money," said Kab, who also played with the Giants and the Philadelphia Eagles. "They are worried about what you can do for me now. The long-term benefit is something in the back of their head."

Also, weight loss, which usually is another first-line therapy for SDB, won't work for the bigger-is-better mentality of one of America's bulkiest sports.

"It's a fact of the game," Dr. Levy said. "They need that weight to compete."

Football players' waistlines have bulged in the past 25-plus years. In 1976, no lineman weighed more than 300 pounds. In 1986, only 10 met that mark, but a decade later at least 200 players weighed the big 3-0-0. Figures from last football season state that 338 hit that plateau.

Dr. George remembered a recent quote from a coach talking about a player who tipped the scales at 400 pounds. "I don't care how much he weighs, as long as he can move," the coach said.

Reluctance from the coaching staffs could pose an obstacle to future research. The hardest part of conducting this year's study was getting the players free to do the sleep studies, Dr. Levy said, because the coaches didn't want to do anything to break the players' routines.

However, league officials have gone on the record to support the study and future research in this area.

"We are committed to enhancing our players' health, performance and quality of life both on and off the playing field," said Gene Upshaw, executive director of the NFL Players Association, in a statement. "Through the participation of its players in the study, the NFL and NFLPA have aided in identifying a potentially serious health problem facing its largest athletes.

"Even more significantly," he continued, "as the result of its vision in participating in this groundbreaking study, the league and its players have shed light on a condition that may affect millions of younger men with large body masses, who, like their NFL counterparts, would likely go without the benefit of diagnosis and treatment until much later in life."

Dr. George said he can see a day when sleep questionnaires, sleep diaries and maybe actigraphy will be part of regular sports physicals.

The best means to get professional sports teams to encourage good sleep awareness and hygiene is to go through their medical departments, Dr. Levy said. "You have to get the trainers and doctors to sit with these players and explain to them what sleep is all about."

With that in mind, future research will help score the winning touchdown for everyone involved.

"The only way you're going to get the attention of all the players and all of the teams and their management is to show that we've identified a problem, and if we treat it, we can make their performance better," Dr. George said. "Then, people will buy into it."

REFERENCE

1. George CFP, Kab V, Levy AM. Increased prevalence of sleep-disordered breathing among professional football players. N Engl J Med. 2003;348:367-8.

Mike Bederka is assistant editor of ADVANCE.