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.

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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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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

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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.

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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.

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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.

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Copyright © 2014 American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.