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Literature Review Report

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 addressed by this review is the lack of an obesity management program that would help pilots manage their weight more effectively and reduce the likelihood of developing comorbidities.

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Another problem that should be addressed through this literature review is the lack of knowledge regarding obesity, its dangers, and management of the clinic’s staff, which obstructs them from diagnosing patients who have weight management issues and advising them regarding proper interventions. This review proposes introducing a behavior change program that leverages behavioral change practices such as self-monitoring, goal setting, and breathing exercises.

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. According to the Centre for Health Protection (2019), in Hong Kong, approximately 29% of individuals aged from 15 to 84 have a BMI of over 25, presented in Figure 2 and Figure 3 presents WHO statistics for the worldwide population (“health facts for Hong Kong,” n.d.). The relevant statistics regarding obesity are presented in the Appendix as Figure 3 and Figure 4, which suggest that there is an overall increase in the number of individuals with general and abdominal obesity in China when comparing the data from 2004 and 2011.

The Hong Kong government recognizes the importance of weight management since they introduced the Towards 2025 program that aims to teach the citizens healthy behaviors, such as diet and regular exercise (“Towards 2025,” 2018; “Change for health,” n.d.). The following guide by the government of Hong Kong, titled “Healthy Eating” will be used to teach pilots the eating behaviors that can help them control their weight (“Eating healthy,” 2019).

Additionally, some downloadable materials describing healthy eating will be used in this intervention, including FDA’s, Dietary Guidelines for Americans, and CDC’s information (“The food pyramid – A guide to a balanced diet,” n.d.; “Nutrition education resources and materials,” n.d.; “Center for Nutrition Policy and Promotion (CNPP),” n.d.; “Dietary guidelines for Americans,” 2010; “Division of nutrition, physical activity, and obesity,” n.d.; “Center for health protection,” n.d.; “Restaurant,” n.d.).

Hence, both the literature review, governmental organizations, and the intervention program suggest that the current population and the pilots, in particular, suffer from being overweight or obese. Additionally, the EatSmart campaign features advice on how to choose healthy options and what specific foods should be incorporated into one’s diet (“About the campaign,” n.d.). Therefore, there are a variety of resources that can be used by clinical specialists to help their patients.

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Literature Search

In total, 28 articles were chosen for this review that describes the specifics of obesity among pilots, comorbidities, and practice approaches used to overcome this issue as can be seen in Figure1. 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 Hong Kong and other countries and locate interventions for addressing these problems, such as behavioral change.

The following databases – MEDLINE, CINAHL Complete, and PubMed were searched using the keywords such as airline pilots comorbidities, obesity among airline pilots, heart disease management for pilots, obesity interventions, pilots sleep apnoea prevalence, diabetes, aircrew. 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 synthesizes the findings of this review, while the subsequent sections will provide a critical analysis and a proposed intervention assessment.

Figure 3. Search and selection process (created by the author).

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. A significant issue that is connected to obesity is diabetes and its primary risk factor – metabolic syndrome. According to Sharma, Chandrashekar, and Singh (2016), 33.3% of pilots in India have metabolic syndrome, which can lead to diabetes and obesity. Excess weight is associated with several comorbidities and risk factors for pilots, including an increased chance of having hypertension that can lead to the development of cardiovascular diseases (Bhat, Verma, Pant, & Singh Marwaha, 2019). Heart disease prevalence is monitored particularly by airline medical examinations as this factor is vital for ensuring flight safety.

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 are 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 excess weight and associating their work environment with this issue is necessary. 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).

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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, Corsica, Cvengros, and Wyatt (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.

The design of this intervention is based on the evidence of researchers that suggest focusing on physical activity levels and nutrition specifics as to the primary determinants of a person’s health.


The literature review confirms that pilots are at a high risk of being either overweight or obese, which is 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. Behavioral change 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 behavioral change is proposed since the technique is easy to learn and can be implemented by the pilots without a need to monitor their behavior continuously, which aligns with the nature of the nursing practice. Raynor, Thomas, Cardoso, Wojtanowski, and Foster (2019) state that “self-monitoring of dietary intake is believed to be a critical behavior 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.

Application of Self-Monitoring in a Practical Setting

Even though 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 guide the food choices that can improve the pilot’s BMI.

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Goal Setting

This step can be done upon the initial examination of the patient in the clinic when he or she is examined for license renewal. Most scholars, such as Raynor et al. (2019) and Burke, Wang, and Sevick (2011), as well as national guidelines, agree that the BMI of over 25 is unhealthy. Hence, it is recommended that the nurse consults pilots with a BMI of over 25 to take advantage of the lifestyle modification program. To facilitate a successful change, the nurse can help set an initial goal of reducing excess weight by 5% to 10% for six months. The emphasis should be on setting targets for food intake and activity levels that align with the specifics of pilots’ work – frequent traveling, working in shifts, staying away from home, and not cooking.

Stress Management

Since the introduced intervention addresses the behavior of pilots and their work conditions, it is necessary to address the main issues of their daily work as well. As suggested by Caldwell et al. (2009), stress is an essential factor that subjects pilots to varied health disparities. Breathing exercises can help reduce stress levels, which will affect both the overall well-being of the pilots and will help them adhere to their goals. One exercise that can be introduced by a nurse is a slow inhale and slow exhale repeated several times, which help focus and reduce blood pressure.


The concept of self-rewards emerged as a support mechanism for conducting interventions in behavioral change strategies. Self-rewards or self-incentives are a promise of rewards in the future if a particular target is reached or if a behavior change was successful (Andalcio, 2018). Self-rewards are commonly used by people aiming to achieve a significant behavioral change. This approach allows one to leverage intrinsic motivation since the reasons for losing weight can differ. The findings of the literature review suggest that this method should not be used on its own but only in combination with other behavioral change instruments.


Autonomy is the key factor that will help improve weight management among pilots. The collaboration among Aviation Medical Examiners, multidisciplinary specialists, nurses, and patients can lead to a significant improvement in an individual’s BMI. Pilots should be educated on the dangers of high BMI and strategies for healthily losing weight. One aspect of this intervention is connected to the Dunning Kruger, which can be described as an illusion of knowledge in a particular area (Fritz, 2019). In the context of obesity, the pilots who undergo examination in the clinic can be informed about their excess weight, and they may possess some general knowledge regarding the strategies for reducing weight, such as eating healthy foods and increasing activity levels.

However, weight loss and maintenance is a more complex issue and as stated by the United States National Heart, Lung and Blood Institute (NIH) (n.d.), it requires a behavioral change, which is a complicated matter. It is possible that pilots will not present accurate information when reporting on their daily food intake or time of exercise. However, this is not the goal of this strategy since the aim is to focus their attention on the observation, recording, and reporting of the eating patterns that will help reduce the calorie intake.

The issue of adherence can be addressed by utilizing the benefits of modern technology, since the majority of pilots have smartwatches, allowing them to monitor some health-related factors and setting up notifications that will remind them to perform a physical exercise or eat regularly. In addition, pedometers, accelerometers, metabolic devices, and software that monitors behavior can be used.


Substantial weight loss is an issue that requires a long-term intervention and a change in how a person decides their day-to-day life. The primary limitation of the explored literature is the fact that all the studies that focus on modifying lifestyle to reduce excess weight and obesity comorbidities did not examine long-term outcomes of the solutions. For instance, reviews by Raynor et al. (2019) and Hood et al. (2013), examined subjects over less than six months, suggesting that more research is necessary to establish a long-term strategy for weight management within the pilot population. This leaves a significant gap in the monitoring process since more clarity is needed to define how weight can be managed and sustained over long periods.

In addition, some evidence suggests that a unified approach to weight loss, including a specific diet or a specified number of exercise hours per week, is not practical when helping a diverse population lose weight. It is because Cheng et al. (2016) suggest that each individual reacts differently to foods and factors such as metabolic rate have a significant impact on the outcomes of healthy behaviors. Hence, a nutrition approach suitable for one individual may not provide similar benefits for another.

This behavior intervention aims to mitigate this issue since the pilots will be discussing their weight management efforts, concerns, and behaviors affecting their health with a nurse, and goals and recommendations will be tailored to suit their lifestyle. However, the majority of the examined studies use one approach for all participants. While this is consistent with the nature of research work, the authors fail to account for the outcomes of people who did not lose weight during their studies, leaving a large number of uncertainties. Also, it is unclear if all the participants complied with the study design and adhered to the recommendations of researchers, which can be an essential element of understanding why people fail to lose weight.


Overall, this literature review confirms that pilots are at a high risk of gaining excess weight, and self-monitoring is proposed as an easy to implement and effective intervention. In general, the findings of the literature suggest that airline pilots are at a high risk of developing diabetes, cardiovascular diseases, obesity, and sleep apnea due to work conditions.

Figure 2. Obesity rates in Hong Kong (“Obesity”, 2019 ).
– BMI over 25;
– normal BMI;
– obese.
Figure 3. Obesity worldwide (“Obesity and overweight,” 2018).
– BMI over 25;
– Obese;
– normal BMI.

Table 1. Summary of literature review findings (created by the author).

No Author & Year & Country of Study Study design & Setting & Sample/Population Aim of the study/article Key findings Limitations Comments/Remarks
1 Caldwell et al. (2009);
The United States Qualitative
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.
2 Houston, Mitchell & Evans (2011);
United Kingdom Quantitative design, retrospective cross-sectional study
N=14,379 Examination of the prevalence and risk factors of cardiovascular disease, including obesity and diabetes, in the population of commercial pilots The findings suggest that pilots have a lower prevalence of hypertension when compared to the general population. The authors cite the healthy worker effect, which is the prevalence of healthy people in the general population, which was used as a comparison with the pilots. This study examined risk factors such as diabetes, hypertension, age and BMI to evaluate which one affects the development of cardiovascular issues.
3 Burke, Wang, Sevick (2011); Qualitative
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.
4 Wang et al. (2011);
China Quantitative
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.
5 Choi & Kim (2013);
Korea Quantitative
Controlled clinical trial
n= 326 BMI, cholesterol levels The group of pilots that received dietary consultations had a 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.
6 Das, Petruzzello, Ryan (2014); The United States A qualitative review of wellness programs for transportation workers N/A The model developed by the authors can be used to incorporate physical activity into the daily lives of transportation employees. This is a theoretical framework, and the authors did not conduct an experiment to support their recommendations, although they are based on previous studies. This article argues that in occupations such as aircrew work, specific attention should be dedicated to physical activity. The authors provide suggestions regarding how pilots can increase their levels of physical activity with consideration of their work specifics.
7 Hood & Nakers, Kleinman, Corsica, & Katterman (2014);
The United States Quantitative
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.
8 Stefanescu, Zainea, & Hainarosie (2014)
The United States Qualitative
Review of best practices in diagnosing sleep apnea N/A Sleep apnoea is a factor that severely affects the health state of flight crews Does not test the theory using a real-life sample Sleep apnoea is connected to obesity and can be managed through weight reduction
9 Hartma-Boyce et al. (2014); The United Kingdom Systematic review
n=37 Conduct a systemic analysis of behavioural management programs. The review of randomized control trials revealed that behaviour management, counting caloric intake, and communication with nutrition specialists was associated with more significant weight loss. This review focused on a specific type of weight management strategy. Management of behaviour is found to be critical for weight loss.
10 Valek, Greenwald & Lewis (2015);
The United States Article Review existing evidence for health promotion models Penders health promotion model is discussed in relation to obesity. Doe not test the suggestions through a study. Nurses should use a holistic approach when working with obese patients.
11 Sharma, Chandrashekar, Singh (2016);
India Quantitative
Cross-sectional descriptive study
N=210 Evaluate the prevalence of the metabolic syndrome in military aircrew The population of Indian aircrew pilots as a 33.3% prevalence of the metabolic syndrome, which can lead to diabetes and obesity Apart from the small sample size, this study focuses only on Indian aircrew. The metabolic syndrome is a significant risk factor for type 2 diabetes and abdominal obesity. This study does not outline why pilots may have a high prevalence of metabolic syndrome. However, it highlights the need to address this risk factor.
12 Souza Palmeira & Marqueze (2016); Brazil Quantitative

Cross-sectional study

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.
13 Chen et al. (2016); China Quantitative
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 the metabolic syndrome is a result of airline work.
14 Khodaveisi, Omidi, Farokhi, & Soltanian (2017)
Iran Quantitative examination, quasi-experimental study
N=108 Demographics, construct’s of Pender’s health promotion program (HPM), and nutrition habits. The differences in nutrition behaviour before and after intervention were significant in the experimental group, suggesting that HPM helps educate patients regarding the importance and specifics of healthy nutrition. This study emphasises the improvement of nutrition behaviour for obese individuals, without dedicating attention to weight reduction. The authors used an HPM to design an intervention for obese individuals. The suggestions can be incorporated into the pilot intervention.
15 Mendis and Balasuriya (2017);
Shri-Lanka Quantitative
N=100 Determine the prevalence of dyslipidaemia among the pilots of the Shri-Lanka air force pilots In this study, the lipid profile of pilots was examined in association with diseases such as diabetes and heart disease. Out of 100 participants, 79% had abnormalities in their lipid profile. This study examined air force pilots, limiting the scope of the investigation. Dyslipidaemia is a significant health risk factor, and it is prevalent among pilots.
16 Gibson & Saninbury (2017);
Australia Article Present several strategies for improving adherence. This paper discusses strategies for improving adherence to nutrition the other weight loss guidelines. This is not a quantitative study. Level of adherence is the main factor that determines the success of the intervention.
17 Melendez-Torres et al. (2018); The United Kingdom Systematic review
n=20 Evaluate the ten most effective and ten least practical weight management approaches The authors highlight the fact that supportive relationship between patients and providers is crucial for weight loss. The authors were unable to assess the quality of the studies adequately. Support from healthcare providers, clear guidelines and direction for participants.
18 Barret, Begg, O’Halloran & Kingsley (2018) Systematic review
n=1949 Investigate the impact of cognitive-behavioural therapy (CBT) and motivational interviewing (MI) on weight loss. This review of randomized controlled trials suggests that weightloss outcomes are slightly improved if CBT and motivational interviewing are integrated into the intervention. This review suggests that further studies should be conducted to determine the impact of CBT and MI. Although this review suggests a moderate impact of MI, it showcases that interventions using MI are more successful when compared to others.
19 Dai, Luo, Hu, Ma, Weng (2018); China Qualitative
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
20 Xanthopoulos, Berkowitz, Tapia (2018);
The United States Quantitative
Lifestyle intervention
n=81 N/A Management of weighting is a practical approach to addressing sleep apnoea Small sample size Lifestyle modification can be used to address both sleep apnoea and obesity.
21 David & Cassin (2018);
The United Kingdom Qualitative review Examine motivational interviewing The authors provide suggestions for conducting motivational interviews with obese individuals, using a case study. This is not a quantitive study, which presents evidence. This paper presents a case study and discusses the implications and specifics of motivational interviewing, which is helpful for the intervention.
22 Lord & Conlon (2018);
The United States Qualitative
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
23 Gupta, Coates, Dorrian, & Banks (2018)
The United States Qualitative
Narrative review N/A Shift work burdens the employees and adversely affects the 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
24 Nicol et al. (2019); The United States Qualitative
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 its development
25 Raynor, Thomas, Cardoso, Wojtanowski, & Foster (2019);
The United States Quantitative
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.
26 Cao et al. (2019);
The United States Quantitative
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.
27 Bhat, Verma, Pant, & Singh Marwaha (2019);
India Quantitative
Observational study
n= 1185 N/A A BMI above 23 is a risk factor for hypertension and cardiovascular diseases The observational nature of the study requires further investigation into the relationship between cardiovascular disease and obesity. Relationship between cardiovascular disease and obesity is proven.
28 Semlitsch et al. (2019); United States, Unites Kingdom, Australia, Germany. Systematic review
n=19 Examine PubMed and WHO recommendations on obesity management. Most articles employed a multidisciplinary team and managed obesity as a chronic condition. This review only focused on high-income English speaking countries and Germany. This systemic review suggests a multidimensional approach, including physical activity, nutrition intervention and behavioural change.

Figure 4. Obesity trends in China (Zhao, Su, Wang, Wang, & Zhang, 2018).

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