Obesity is a serious health concern for the global population as the number of people gaining excess weight increases. Some prevalence patterns can be seen among people, suggesting that job-related factors can be contributing to the development of obesity. The practice gap that will be explored in this literature review is the prevalence of obesity among pilots, the comorbidities associated with this condition and the impact of lifestyle on these issues.
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Current relevant guidelines for this topic are connected to the general health assessment that pilots undergo, either once a year or once in six months, that evaluate their health, risk of cardiac disease, body mass index (BMI), and other relevant metrics. Relevant search questions that relate to the patient problem and gap that were identified for this review of literature are the connection between the specifics of a pilots work, such as being away from home, not being able to cook homemade meals, stress, night shifts or irregular patterns of work, and adverse health outcomes. This paper aims to examine the existing literature on the topic of lifestyle issues connected to the pilots’ work and propose a suitable intervention in the form of self-monitoring.
In total, 20 articles were chosen for this review that describes the specifics of obesity among pilots, comorbidities, and practice approaches used to overcome this issue. This review synthesizes the findings of multiple studies regarding the underlying causes of obesity and common comorbidities among airline pilots, their impact on the overall health, and strategies for addressing the problem. Hence, the process of identifying suitable studies aimed to review prior research regarding the diseases prevalent among airline pilots in China and other countries and locate interventions for addressing these problems, such as cognitive behavioural therapy.
The following databases – MEDLINE, CINAHL, and PubMed, were searched using the keywords such as airline pilots comorbidities, obesity among airline pilots, heat disease management for pilots, obesity interventions, pilots sleep apnoea prevalence. The main focus was on studies that examined human subjects and specifically pilots, to determine a reliable intervention strategy. In general, most articles focused on cardiovascular issues and sleep apnoea, with little research dedicated specifically to the examination of obesity management in the commercial pilots’ population. Table 1 summarises and synthesises the findings of this review, while the subsequent sections will provide a critical analysis and a proposed intervention assessment.
Table 1. Summary of literature review findings (created by the author).
No Author & Year & Country of Study Study design & Setting & Sample/Population Outcome measures Key findings Limitations Comments/Remarks
1 Sykes, Larsen, Griffith, & Aldington (2012);
New Zeeland Comparing medical certification reports of pilots and New Zeeland’s general population
n=595 pilots Disease prevalence and comorbidities The authors argue that the two health issues identified by this study are connected to the specifics of the pilots’ work environment. This study only explored pilots from one specific airline, and the number of records included is small. This study provides a good overview of the factors that may either adversely or positively impact the health of pilots and provides evidence suggesting that some conditions are prevalent among pilots when compared to the general population.
2 Wang et al. (2011);
China (HK) n=115 Chinese males and n=114 white males working as pilots Obesity prevalence in the Chinese population Ethnicity has a role in obesity prevalence as Chinese males were found to have a more significant percentage of body fat. This study examined a relatively small population sample, and more research is necessary to confirm the findings. This research helps determine the specifics of obesity and comorbidities associated with it. This included a population of pilots, which provides insight into the disease prevalence in this population that can be connected to their work.
3 Souza Palmeira & Marqueze (2016); Brazil Cross-sectional study
n=1198 Obesity prevalence within the pilot population Overweight prevalence at 53.7% and obesity at 14.6% Lack of suggestions for mitigating the examined risks in the context of pilots’ work Factors that contribute to gaining excess weight within the pilot population – not having enough sleep of fewer than 6 hours, not exercising at least 150 minutes per week, failure to relax after work.
4 Dai, Luo, Hu, Ma, Weng (2018); China (HK) Literature review N/A Pilots are subjected to work conditions leading to fatigue that can be a factor resulting in severe health impairment. No practical examination of the issue. Fatigue and stress can be significantly contributing to the health issues in the examined population, requiring a psychological intervention
5 Nicol et al. (2019); The United States Review of the current cardiovascular disease standards in the aviation N/A This article provides a cohesive review of the aviation work standards and work conditions in which the pilots perform their day to day tasks and outlines the prevalence of cardiovascular diseases. Reviews current approaches to cardiovascular disease management among pilots without using a sample population Pilots are at high risk of developing cardiovascular conditions, and lifestyle is an essential factor in their development
6 Stefanescu, Zainea, & Hainarosie (2014) Review of best practices in diagnosing sleep apnea N/A Sleep apnoea is a factor that severely affects the health state of flight crews It does not test the theory using a real-life sample Sleep apnoea is connected to obesity and can be managed through weight reduction
7 Hood, Corsica, Cvengros, & Wyatt (2013); The United States Behavioural weight loss intervention. n=40 N/A A positive association between self-monitoring, weight loss, and sleep apnea management Small sample size The authors focused on the relationship between sleep apnea and weight loss.
8 Raynor, Thomas, Cardoso, Wojtanowski, & Foster (2019);
The United States Observational study
n=60 N/A Self-monitoring improves the outcomes of obesity treatment. Small population sample Obesity is associated with a large variety of foods consumed.
9 Hood & Nakers, Kleinman, Corsica, & Katterman (2014);
The United States Pilot study
N=22 N/A Self-monitoring improves adherence to the dietary recommendations and management of sleep apnoea interventions. Sample size and missing data Lifestyle interventions can be used to address multiple comorbidities.
10 Xanthopoulos, Berkowitz, Tapia (2018);
The United States Lifestyle intervention
n=81 N/A Management of weighing is a practical approach to addressing sleep apnoea Small sample size Lifestyle modification can be used to address both sleep apnoea and obesity.
11 Christaki et al. (2013);
Greece Observational study
N=34 The intervention group lost more weight (0.86 kg) when compared to the control (0.78 kg). Muscle relaxation and berating exercise help decrease stress. Sample size requires more research f similar techniques. Association between stress management and obesity was proven by the authors.
12 Burke, Wang, Sevick (2011); Systemic literature review of articles published from 1993 till 2009 N/A Methodological limitations result in a need to conduct more research on the topic of self-monitoring. Methodology Although all of the examined studies highlight a link between weight loss and self-monitoring, the majority have a small sample size or duration.
13 Cao et al. (2019);
The United States n=30 Heart rate variability affects performance and increases during manoeuvres or with a change in CO2 levels. Pilots are subjected to high levels of stress during their work. Small sample size This study helps understand the specifics of pilot day to day work.
14 Lord & Conlon (2018);
The United States Overview of nursing practice guidelines when working with airline pilots N/A Cardiovascular diseases are the primary cause of license denial in airline pilots; however, no interventions targeting the causes of the issue are currently present. A limited number of examined studies The authors outline the responsibilities of nurses that work with airline pilots in associating with a high prevalence of cardiovascular conditions
15 Chen et al. (2016); China (HK) Observational study
n=303 Metabolic syndrome prevalence 38% of the examined pilots had metabolic syndrome No direct relationship between the cause of the metabolic syndrome and the prevalence is examined It is unclear whether the high prevalence of metabolic syndrome is a result of airline work.
16 Bhat, Verma, Pant, & Singh Marwaha (2019);
India Observational study
n= 1185 N/A A BMI above 23 is a risk factor for hypertension and cardiovascular diseases. The relationship between cardiovascular disease and obesity is proven.
17 Caldwell et al. (2009);
The United States Research article N/A Fatigue is highly prevalent among airline pilots, both commercial and military, and it affects the quality of sleep and cognitive abilities. The article is an overview, and no subjects were tested to prove the hypothesis. Fatigue is an important element that affects people’s health, and airline pilots are often subjected to high levels of fatigue.
18 Choi & Kim (2013);
Korea Controlled clinical trial
n= 326 BMI, cholesterol levels The group of pilots that received dietary consultations had lower BMI and cholesterol levels upon the second examination. It is not clear how the proposed intervention will affect the lifestyle outside a clinical setting. Providing dietary advice has a beneficial effect on pilots, suggesting that merely advising on better food choices and diet management decreases the risks of obesity development.
19 Causse, Chua, & Remy (2019); An observational study in a clinical setting
n=61 Measuring the performance of pilots of different age groups The performance of pilots is connected to a variety of factors, including their health and age Limited sample size The ageing of the global population suggests the need to address various conditions associated with age. Obesity and its comorbidities can be developed in the pilot population, and to ensure that older pilots can work and intervention is necessary.
20 Gupta, Coates, Dorrian, & Banks (2018). Narrative review N/A Shift work burdens the employees and adversely affects their eating behaviour. No real-life examination based on subject research This article confirmed that pilots could gain excess weight because of the nature of their work
This literature review aims to investigate the existing gap, which is the prevalence of obesity-related comorbidities in airline pilots and the best practice to help them manage their diet and reduce weight. Overweight is associated with a number of comorbidities and risk factors for pilots, including an increased chance of having hypertension that can lead to the development of cardiovascular diseases (Bhat et al., 2019). Heart disease prevalence is monitored particularly by airline medical examinations as this factor is vital for ensuring flight safety.
It is a common belief that pilots are more healthy and dedicate more attention to their health when compared to the general population. It is because they undergo routine health examination and regular screenings for potential disorders (Sykes et al., 2012). Hence, the dependence on good health as the central aspect that allows pilots to work is considered to be the primary motivating factor to lead a healthy lifestyle, which can be leveraged when developing an intervention. Additionally, Sykes et al. (2012) identify the main environmental factors that can cause increased comorbidities in this population, which are the sedentary nature of the job, bad eating habits due to the inability to eat at home, and increased alcohol consumption.
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This provides an understanding of the fact that pilots suffer from work conditions that subject them to the development of unhealthy eating habits. Sykes et al. (2012) aimed to explore the question of health by comparing the general population of people in New Zeeland and pilots self-reported medical examination records. In general, it was concluded that pilots had issues in two domains – skin cancer prevalence and kidney disease. Although this study did not specifically explore the issue of obesity and comorbidities, it provided an assessment of several conditions that are a direct result of the pilot’s work.
Another issue is the need to be concentrated and work under stressful conditions. The findings of Cao et al. (2019) suggest that the environment that commercial pilots work in subjects them to significant pressure, as proved by the increase in the heart rate variability during the flight simulations.
Other aspects, such as the CO2 levels inside the cabin, are also affecting the health of these individuals, suggesting that a pilot-specific examination is required to address the health concerns of this population. Souza Palmeira and Marqueze (2016) found that aspects such as working night shifts are more likely to contribute to the prevalence of obesity in this population. Among the lifestyle factors that also contribute to this risk is exercising less than 150 minutes per week, having difficulties relaxing, and not getting enough sleep on the weekends, which is consistent with findings from some other studies.
Understanding why pilots are likely to have access weight and the associating of their work environment with this issue is necessary. One of the maladaptive mechanisms that arise as a response to stress is overeating, which can be an issue with pilots subjected to continuous stress at work (Christaki et al., 2013). Hence, the intervention should address this mechanism and modify it to help mitigate both the stress and negative eating patterns.
Caldwell et al. (2009) argue that fatigue may be the core issue affecting airline pilots as the work conditions often do not allow them to have sufficient sleep. Apart from this element having an impact on the overall performance and risk of errors, this may be the cause of health issues. An important factor is the lack of ability to address the problem since a modification of airline policies can be completed only on a governmental level. Hence, interventions should target strategies that pilots can implement themselves.
Obesity itself is a severe problem, but one should note that it often leads to a variety of problems. Another issue is the connection between different conditions, since Xanthopoulos, Berkowitz, Tapia (2018) state that sleep apnoea is associated with a decrease in the quality and quantity of sleep, resulting in more stress, and is “associated with intermittent hypoxemia, hypercapnia, arousals and sleep fragmentation” (p. 109).
Hence, by addressing one issue, this intervention will be able to improve multiple aspects of a pilot’s well-being. Sleep apnea is among the primary comorbidities that arise as a result of being overweight. Hood et al. (2013) state that 70% of individuals with obesity are also diagnosed with sleep apnoea. The authors confirm that losing weight has a positive effect on mitigating the symptoms of sleep apnoea and other common diseases, such as increased heart disease risk.
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In general, the findings of the literature suggest that airline pilots are at a high risk of developing cardiovascular diseases, obesity, and sleep apnoea due to work conditions. Since their work requires them to stay away from home for long periods of time and has a stressful nature, the psychological implications of the lifestyle change will be considered. One of the methods used in cognitive-behavioural therapy (CBT) is self-monitoring, which implies recording a particular activity. The primary modifiable risk factor is lifestyle and attitudes towards the work conditions, such as the ability to manage stress and monitor food intake when away from home.
The literature review confirms that pilots are at a high risk of being either overweight or obese, which subjected to comorbidities associated with these disorders. Ethnicity also contributes to these factors as Chinese males are more likely to be obese when compared to other populations (Wang et al., 2011). These findings suggest a need to develop an intervention that would target the lifestyle of these pilots and how they approach the difficulties, such as not eating at home and irregular sleep patterns associated with their work.
Stress reduction strategies can be beneficial for this population as their work is connected to high responsibility and a need to be highly attentive, which can cause issues when not working. CBT can be used to address the issue of obesity and allow pilots to be more aware of their eating patterns and stress management. Self-monitoring as part of CBT is proposed since the technique is easy to learn and can be implemented by the pilots without a need to monitor their behaviour continuously, which aligns with the nature of the nursing practice. Raynor et al. (2019) state that “self-monitoring of dietary intake is believed to be a critical behaviour for successful weight loss” (p. 147).
An important element is the fact that the authors report the need to consistently but not comprehensively monitor the food intake, which simplifies the process. Hence, the pilots can be taught simple techniques for recording what they eat during a day, without a need to explicitly state the details, which should contribute to the weight loss process and improvement of the overall health.
Application of Self-Monitoring in a Practical Setting
The review of literature provides an understanding of the issues that arise as part of the work as a pilot. Despite the fact that these employees are subjected to medical examinations either once a year or once in six months, which allows them to renew their license, many non-life-threatening conditions prevail in this population. This intervention proposes to implement self-monitoring, which can be combined with goal setting and stress management through breathing exercises as the key elements.
These measures address the key issues of the pilot population, help either mitigate the risk or manage obesity and its comorbidities and contribute to the overall well-being. During the examinations, a nurse can explain how to evaluate personal food intake, what is a good target for calories, and which foods should be avoided to a pilot, based on his or her health assessment.
This intervention offers pilots to use of a notebook and a pen to record their food intake throughout the day. No specific knowledge is necessary; however, a primary education on the calorie intake based on the BMI can be provided by a nurse, with suggestions for healthy eating options. As proven by the studies conducted by Raynor et al. (2019), self-monitoring, even if performed inconsistently, provides a potential for reducing the daily energy intake in subjects. This also can help reduce the variety of foods consumed by individuals, which is also associated with weight gain. Choi and Kim (2013) also provide an understanding of the need to educate pilots regarding healthy dietary choices that they can make to improve their health.
Different studies perform varied self-monitoring techniques, including using paper notebooks or technology to record the daily intake of food. However, an essential element of this intervention is the need to provide guidance regarding the food choices that can improve the pilot’s BMI. Overall, this literature review confirms that pilots are at a high risk of gaining access to weight and self-monitoring is proposed as an easy to implement an effective intervention.
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