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FITNESS ON THE FLYHealthy Air Travel
by Christopher G. Berger, Ph.D., ACSM-HFS
LEARNING OBJECTIVE
Readers of this article can expect to learn more about staying healthy
when they fly as commercial airline passengers. Modern air travel can
be stressful physically and psychologically, but good strategies for
contending with these stressors have been developed. Many U.S.
airports provide services that keep travelers healthy ‘‘on the fly.’’
Key words:Aviation, Physical Activity, Transportation, Sedentary Behavior, Stressor
Think for a minute about the last time
you traveled as an airline passenger. Did
you stand in long lines waiting to board
your aircraft? Did you spend a lot of time seated
during the flight? Did you arrive at your destina-
tion tired and hypohydrated? If you answered
‘‘yes’’ to any of these questions, you may be
wondering if modern air travel can be healthy.
The purpose of this article is to address the
issue of healthy air travel in two parts. The first
part will educate you on some of the common
health-related problems associated with flying.
The second part shares information about U.S.
airports and the services they offer to keep you
physically active and healthy when you fly.
This information was gathered
by the ACSM Task Force on
Healthy Air Travel (TFHAT).
Contact information for this
working group can be found in
the Recommended Readings
section at the end of this article.
HEALTHY AIR TRAVEL:WHY DOES IT MATTER?
Current data (5) from the U.S.
Department of Transportation
(USDOT) show that there were
nearly 739 million air travel
passenger boardings during 2013. In fact, the
USDOT predicts that boardings will increase
progressively to more than a billion during
2027. During a similar time frame (by 2030), it
also is estimated that the prevalence of obesity
in the United States will increase by 33% (3).
What these two forecasts crudely suggest is that
air travel will grow more popular in conjunc-
tion with a rise in hypokinetic disease.
Although modern air travel is safe for the
majority of flyers, healthy air travel topics
routinely make the news. Have you ever gotten
questions from clients about deep vein throm-
bosis (DVT) (‘‘economy class syndrome’’),
luggage bin injuries, airplane air quality, radia-
tion exposure, jet lag, or the effect of air travel on
sport performance? With all of the flying that is
done in the United States, it should not be
surprising that people wonder about these issues
and the connection to their personal health.
One way to address these issues is to think
again about the last time you traveled as an
airline passenger. Stressors that were imposed
on you during that trip may have occurred
preflight (departure), in-flight, and post-flight
(arrival) stressors. The following three sections
explain these stressors and suggest ways for
coping with them.
Viktor Cap/iStock/ThinkstockA
18 ACSM’s HEALTH & FITNESS JOURNALA | www.acsm-healthfitness.org VOL. 18/ NO. 6
Copyright © 2014 American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
Preflight (Departure) StressorsFrom the time you arrive at the airport until your airplane takes
flight, you can think of the psychological and physical stressors
that you experience during ‘‘preflight’’ or before ‘‘departure.’’
Psychological stressors associated with preflight vary widely.
Examples include anxieties involving the purpose of the trip
(competition, bereavement), fear of flying, and long lines.
These will not be addressed in this article. Physical stressors
associated with preflight are more limited and involve
anatomical and physiological effects on the body. Examples
include toting luggage, rushing to a departure gate, and perhaps
even spending the prior night away from home. Another
preflight stress involves nutrition and the inaccessibility of
adequate healthy foods and beverages for fueling sport
performance and travel itself. Many of these preflight stressors
contribute to travel fatigue.
Some preflight stressors are more serious. Scuba diving is a
good example. Data (4) from the Professional Association of
Diving Instructors (PADI) suggest that nearly a million entry-
level and continuing education diving certifications were issued
worldwide during 2013. Many popular dive sites involve access
by commercial air travel. Given the popularity of scuba diving
and the likely involvement of air transportation, participants
should be advised that the two activities are incompatible. The
reason for this is because scuba diving imposes relatively high
barometric pressures on the diver in conjunction with the
breathing of compressed gases. During postdive air travel,
tissue and blood gases (particularly nitrogen) diffuse, form
bubbles, and instigate ‘‘decompression sickness.’’ Common
symptoms include severe joint and muscle pain, numbness,
headache, and other neurological problems. Decompression
sickness can be fatal. Decompression sickness is rare when
proper dive protocols are followed, but divers commonly are
recommended to avoid flying for at least 24 hours after a dive.
Incidentally, decompression sickness is only one type of
‘‘barotrauma,’’ which is a term used to describe a range of
problems involving gas pressure effects on the body. Passengers
traveling by air soon after sustaining a concussion, dental
procedure, or eye or gastrointestinal surgery, as well as those
with sinus congestion, have physiological preflight stressors
that may precipitate barotrauma. Physician clearance is
encouraged for affected travelers. Physicians can be instru-
mental in working with an airline to arrange compressed
oxygen and other services for the individual traveler and sports
team alike.
In-Flight StressorsThe cabin of a modern airliner is not pressurized to sea level. In
fact, even aboard a new jet like the Boeing 787, cabin altitudes
range from 5,000 to 8,000 feet (1,524 to 2,438 m) during flight
(1). What this produces is a lowered partial pressure of oxygen,
which, in conjunction with the very dry air drawn into the cabin
at altitude, may contribute to both serious (hemoglobin oxygen
saturation issues) and not-so-serious (bloody noses, dry skin)
in-flight problems for flyers.
Most people need not be concerned about relatively low partial
pressures of oxygen. Readers are encouraged to study the ‘‘Useful
Tips for Airline Travel’’ advisory recommended at the end of this
article. Concerns about supplemental oxygen for travel should be
expressed to a physician. Problems associated with dry cabin air
can be solved by hydrating frequently with water, fruit juices, and
sports beverages. Dry nasal passages benefit from inexpensive
nonaddicting saline nasal sprays or gels.
Deep vein thrombosis (DVT), oftenmistermed ‘‘economy class
syndrome,’’ is perhaps the in-flight malady most often addressed
by the news media. DVT is associated with long-term sitting or
immobility during flight (1,6). Despite the attention and questions
that surround air travel and DVT, quite a few myths remain
about this condition.
DVT is the formation of a blood clot in the deep large-
diameter veins of the body. More commonly, DVT affects the
lower extremities and is characterized by swelling, pain, or
tenderness in the leg that worsens with standing or movement.
Skin on the affected extremity also may be discolored. DVT is
not necessarily life threatening but what can happen is that the
blood clot that forms can break apart and travel to the lungs. If
that happens and the clot blocks blood flow, a pulmonary
embolism is formed, which can damage the lungs. Symptoms of
pulmonary embolism include shortness of breath and chest pain.
One reason that DVT has been associated with air travel is
because lack of movement (prolonged sitting) and compression of
the (lower) extremity blood vessels are risk factors in its
development. These conditions do not present themselves
exclusively to the ‘‘economy class’’ air traveler and could pose
problems even for those who travel by train or play BINGO in a
church hall. Aside from immobility and blood vessel compression,
it is unclear if other air travel-related factors (lower barometric
pressures, O2 partial pressures) contribute to DVT development.
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VOL. 18/ NO. 6 ACSM’s HEALTH & FITNESS JOURNALA 19
Copyright © 2014 American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
There are two strategies that the fitness professional can
undertake to address DVT risk. The first is to educate clients.
The U.S. National Heart, Lung, and Blood Institute identifies
several risk factors for DVT that include a history of DVT,
extremity trauma, older age, overweight, and smoking (6).
Fitness professionals also should work in conjunction with a
client’s physician to encourage physical activity during travel.
This includes walking, taking breaks from sitting, and leg
exercises. In-flight leg exercises are easy to perform. Have the
client plant his or her heels on the floor and then elevate the
toes to produce a brief stretch of the calf muscles. This
movement then should be alternated with an elevation of the
heels with the toes pressed to the floor. These movements
encourage blood flow to the calf muscles. Compression
stockings during long-distance flights also have been suggested
to help reduce the incidence of DVT (1).
Postflight (Arrival) StressorsMuch of the commotion that contributes to preflight stress
repeats itself postflight or on arriving at the destination. This
can be particularly challenging to the fitness or sport
professional who travels with a team. Connections get missed,
luggage gets lost, carry-on bags fall out of their bins, and ears
fail to ‘‘pop.’’ Although many of these stressors influence the
travel experience, the most significant postflight stress is jet lag.
Jet lag is a legitimate physiological problem with symptoms
that include insomnia, daytime sleepiness, concentration
problems, and gastrointestinal or menstrual cycle disruptions.
The key to minimizing and treating jet lag is to define it
correctly. Consider the following example. Lufthansa routinely
runs a nonstop flight from Frankfurt, Germany, to Luanda, Angola,
in southern Africa. The flight covers more than 4,000 miles
(6,571 km) for a duration of just over 8 hours. Bearing in mind
that passengers on this flight experience the same preflight and
in-flight stressors just described, it is conceivable that many
making this journey would arrive in Africa fatigued, irritable,
and perhaps even a little sore. Passengers might blame jet lag
and head to a hotel for some sleep. Is this jet lag though?
Technically, no.
Jet lag is defined accurately as a disruption of the body’s
circadian rhythm in conjunction with travel across at least one
time zone. Jet lag develops because the traveler’s internal ‘‘body
clock’’ temporarily is asynchronous with the destination time.
Even an 8-hour flight from Europe to southern Africa may not
produce jet lag because (in the above example) there is no time
difference between Frankfurt and Luanda. Because no time
zones were crossed during this flight, there is no circadian
disruption. There is no jet lag. What then accounts for the
fatigue, irritability, and soreness?
‘‘Jet stress’’ probably is the better term to use when
describing fatigue associated with air travel that crosses fewer
than one or two time zones. The distinction between jet lag and
jet stress is important because methods for treating jet lag may
involve changes in diet, complicated sleep cycle adjustments,
and medications. Methods for treating jet stress involve simpler
attentions to its symptoms.
For jet stress, symptoms can be alleviated by planning the trip
carefully to include healthy meals and exercise. Sleep deficiencies
that accrue before travel can aggravate jet stress symptoms, so it is
important to be well rested before air travel. Because jet stress can
be psychological, it is important to develop realistic expectations
for travel whether it is for business or pleasure. Travelers should be
vigilant about limiting work and social activities in an effort
to accommodate the stress of travel. Physiological symptoms
described in the previous two sections of this article can be
treated as already described.
Many of the methods used to address jet stress alleviate
symptoms of jet lag too, but jet lag is a somewhat more serious
issue because it can be difficult to ‘‘resynchronize’’ the body clock
especially if the trip is of long distance but of short duration.
Travelers anticipating jet lag commonly are recommended to
adjust sleep habits to the destination quickly. For example, if it is
daytime at the destination, avoid sleeping in-flight. It is often
helpful for the traveler to set his or her watch to the local time of the
destination on boarding the outbound flight. For every time zone
crossed, athletes are encouraged to budget 1 day for adjustment
but, again, this may not be possible for trips of short duration.
Other treatments for jet lag include light therapy (1). Bright light
minimizes the sensation of sleepiness so it can be used to help
travelers adjust to destination time. Melatonin or benzodiazepine
and nonbenzodiazepine drugs may be prescribed to facilitate
sleep (1).
Jet stress and jet lag are temporary postflight stressors.
Eventually, frequent flyers develop unique coping mechanisms
for jet stress and jet lag. Some international airlines make this a
little easier to do. For example, British Airways publishes a ‘‘jet
lag calculator’’ on its Web site (2) that can be used to advise on
the proper course of jet lag treatment given the distance (time
zones crossed) and direction (eastbound or westbound) flown.
HOW DO AIRPORTS FACTOR INTOHEALTHY AIR TRAVEL?
Note from the first part of this article that departure, in-flight,
and postflight stressors often have one factor in common:
movement restrictions. There is a lot of sitting and immobility
with modern air travel.
In 2012 and 2013, the TFHAT wanted to address flying and
sedentary behavior so a survey was put together with a simple
question in mind: What opportunities exist at airports to keep
people physically active during travel?
To answer this question, the TFHAT made a list of U.S. large-
hub airports (Figure 1) as defined by the USDOT. Brainstorming
sessions among TFHAT members identified 26 airport services
20 ACSM’s HEALTH & FITNESS JOURNALA | www.acsm-healthfitness.org VOL. 18/ NO. 6
Fitness on the Fly
Copyright © 2014 American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
felt to be conducive for physical activity (Figure 2). These
services were organized under five broad categories that included
physical activities, conveniences, disability resources, guidance
programs, and safety measures. Because certain airport amenities
are only available to passengers willing to pay a fee, efforts were
made to list only those amenities that would generally be
available to the flying public. For example, only members of the
U.S. military and their dependents are eligible to use airport
United Service Organizations (USO) facilities. These facilities,
along with those for airline club members or airport employee
service centers, may make it easier for users to enjoy airport
physical activities because they often offer places to store carry-on
items, procure refreshments, or shower during travel V but
they are not available to most flyers.
Readers using Figure 2 to plan physical activity during travel
should remember that airport amenities change frequently.
There is a general trend toward improved airport services and
healthy flying, but it is always a good idea to double-check
airport Web sites for up-to-date information on amenity
availability. With that in mind, readers may be surprised to
find out what airports have available. Consider these examples:
Travelers through Ronald Reagan Washington National Airport
(DCA) who find themselves delayed also will find themselves just a
few steps from the Mount Vernon Trail that goes on for miles and
connects with several other greenways in the area. Gravelly Point
(notorious for excellent plane spotting) and Arlington National
Cemetery are along theway.AlthoughDCAusually does not serve as
an international hub, some fresh air andbright lightwhen trailwalking
could combat jet lag in conjunction with transcontinental flights.
On the west coast, a traveler using the San Diego
International Airport can take advantage of a path that runs
along San Diego Bay at Spanish Landing Park nearby. San
Diego’s near-perfect year-round climate also tempts cyclists
because it is possible to bike to the airport safely. Bicycle
lockers (four bikes each) at Terminal 1 are free after a $25 key
deposit and sign-up process, and there are bike racks located at
Figure 1. U.S. Air Traffic Hubs. The U.S. Department of Transportation has identified 25 cities with ‘‘large’’ airline hub operations. The ACSMTask Force on Healthy Air Travelused this map to generate a list of airports and their amenities linked to physical activity and personal health. Note the geographic diversity of ‘‘large’’ hub airports.
VOL. 18/ NO. 6 ACSM’s HEALTH & FITNESS JOURNALA 21
Copyright © 2014 American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
Terminal 1. Racks at Terminal 2 are expected to be installed by
the time this article goes to press.
Many large-hub airports in the United States provide
physical activity opportunities in other ways. For example,
both terminals of MinneapolisYSt. Paul International Airport
(MSP) offer easy access to the Metro Transit light rail system.
The Blue Line (Hiawatha) runs frequently from the airport to
downtown Minneapolis where there is an ample number of
parks, pedestrian paths, and bikeways. Even a short 3-hour
layover in MSP gives travelers plenty of time to enjoy an hour
outdoors. In the western United States, Salt Lake City
International Airport boasts the Wingpointe Golf Course, an
18-hole course open during the season from sunrise to sunset.
Although these are some of the more exciting examples of how
one could incorporate physical activity into the flying experience, it
also is possible to engage in exercise without leaving the airport
simply by walking the terminals themselves. Most of the large-hub
airports listed in Figure 2 are expansive enough to accrue 1,000 to
2,000 steps just by walking from one gate to another using gate
numbers and airport maps as guides. Several airports listed in
Figure 2 have spent thousands of dollars on art work to fascinate
flyers along the way. For example, Hartsfield-Jackson Atlanta Inter-
national Airport installed remarkable stone carvings from Zimbabwe
in the pedestrian corridor of the Transportation Mall, located
between the T Gates and Concourse A. Overhead signage also has
been installed to guide walkers on distances, which typically range
from 900 to 1,000 feet (274 to 305 m) from one terminal to the next.
‘‘AIR TRAVEL’’ DOES NOT HAVE TO MEAN‘‘INACTIVITY’’
The purpose of this article was to address the issue of healthy
air travel by identifying some of the common stressors
Figure 2. U.S. Airports and Physical Activity. In 2012/2013, the ACSM Task Force on Healthy Air Travel evaluated airports using Web site information, visits, andother sources to compile this list of airport attributes that are consistent with physical activity opportunities. Features are classified on the basis of five broadcategories. Note that some attributes are common everywhere, whereas other features are unique to an airport.
22 ACSM’s HEALTH & FITNESS JOURNALA | www.acsm-healthfitness.org VOL. 18/ NO. 6
Fitness on the Fly
Copyright © 2014 American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
associated with flying and provide examples of how physical
activity can be incorporated into travel. You are encouraged to
visit the Web site for TFHAT and share your ideas about how air
travel can be healthy!
AcknowledgmentThe author thanks Valery Kellen for assistance with data collection.
References1. AerospaceMedical Association.Medical guidelines for airline travel (2nd ed).
Aviation, Space, and Environmental Medicine [Internet], 74(5), Section II,2003 [cited 2014 Sep 20]. Available from: http://www.asma.org/asma/media/asma/Travel-Publications/medguid.pdf.
2. British Airways. Jet Lag Calculator [Internet] [cited 2014 Sep 20]. Availablefrom: http://www.britishairways.com/travel/drsleep/public/en_us#.
3. Finkelstein EA, Khavjou OA, Thompson H, et al. Obesity and severeobesity forecasts through 2030. Am J Prev Med. 2012 Jun;42(6):563Y70.
4. Professional Association of Diving Instructors (PADI). WorldwideCorporate Statistics 2014 [Internet] [cited 2014 Sep 20]. Available from:http://www.padi.com/scuba/about-padi/PADI-statistics/default.aspx.
5. U.S. Federal Aviation Administration. FAA Aerospace Forecast FiscalYears 2014Y2034 [Internet] [cited 2014 Sep 20]. Available from: http://www.faa.gov/about/office_org/headquarters_offices/apl/aviation_forecasts/.
6. U.S. National Heart, Lung, and Blood Institute. Explore Deep VeinThrombosis [Internet] [cited 2014 Sep 20]. Available from: http://www.nhlbi.nih.gov/health/health-topics/topics/dvt/.
Recommended ReadingsAerospace Medical Association. Useful Tips for Airline Travel [Internet].
Available from: http://www.asma.org/asma/media/asma/Travel-Publications/HEALTH-TIPS-FOR-AIRLINE-TRAVEL-2013-Trifold.pdf.
American College of Sports Medicine Task Force on Healthy Air Travel[Internet]. Available from: http://www.exerciseismedicine.org/onthefly.htm.
Berger C. A healthy altitude: are you taking a winning approach to travelfatigue? Sports Med Update. 2002;16(1):32Y9.
Disclosure: The author declares no conflicts of interest and
does not have any financial disclosures.
Christopher G. Berger, Ph.D., ACSM-HFS,
is an exercise physiologist at Arizona State
University. He has been an HFS-certified
member of the American College of Sports
Medicine since 1998 and a CSCS-certified
member of the National Strength and
Conditioning Association since 2002. He
chairs the ACSM Task Force on Healthy Air Travel and is
currently working toward a student pilot certificate from the
FAA. To date, Dr. Berger has flown as an airline passenger over
500 times.
Krisztian Miklosy/iStock/ThinkstockA
BRIDGING THE GAP
Modern air travel often is stressful, but it need not beunhealthy. By understanding some of the physical stressorsof air travel in terms of preflight, in-flight, and postflightproblems, you and your clients can travel more comfortablyin the future. U.S. large-hub airports are making itincreasingly easier to stay fit when you fly. By takingadvantage of these amenities, you and your clients can lookforward to healthy air travel.
VOL. 18/ NO. 6 ACSM’s HEALTH & FITNESS JOURNALA 23
Copyright © 2014 American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.