Archives of Environmental & Occupational Health

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Health-related quality of life in pilots of a Chinese

commercial airline

Tiebing Liu, Bing Qiu, Chuanyin Zhang, Mingzhao Deng, Zhaohui Liang &
Yanmin Qi

To cite this article: Tiebing Liu, Bing Qiu, Chuanyin Zhang, Mingzhao Deng, Zhaohui Liang &
Yanmin Qi (2020): Health-related quality of life in pilots of a Chinese commercial airline, Archives of
Environmental & Occupational Health, DOI: 10.1080/19338244.2020.1863765

To link to this article: https://doi.org/10.1080/19338244.2020.1863765

Published online: 23 Dec 2020.

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ARCHIVES OF ENVIRONMENTAL & OCCUPATIONAL HEALTH
https://doi.org/10.1080/19338244.2020.1863765

Health-related quality of life in pilots of a Chinese commercial airline

Tiebing Liua
, Bing Qiua
, Chuanyin Zhangb, Mingzhao Dengb, Zhaohui Liangb, and Yanmin Qia
a
Civil Aviation Medicine Institute, Civil Aviation Medicine Center, Civil Aviation Administration of China (Civil Aviation General
Hospital), Beijing, People’s Republic of China; bAviation Hygiene Management Division, China Southern Airlines Company Limited,
Guangzhou, People’s Republic of China

ABSTRACT ARTICLE HISTORY

Health-related quality of life (HRQOL) is currently an important issue in the medical industry. Received 26 March 2020
However, data on HRQOL in commercial airline pilots are lacking. This study aimed to inves- Accepted 6 December 2020
tigate HRQOL and its related factors in a sample of commercial pilots. A purposive sample
KEYWORDS
of 373 participants was recruited from a Chinese Commercial Airline. The median (IQR) score
HRQOL; physical activity;
for physical health, psychological health and social relationship were 64.3 (75–53.6), 62.5 pilots; time-zone flights
(70.8–54.2) and 75 (75–58.3), respectively. The mean (SD) score for Environment was 62.2
(16). After controlling for demographics, the multiple linear regression analyses showed that
physical activity, fruit intake and vegetable intake were positively correlated with HRQOL
score (p < .05), while time-zone flights, smoking, alcohol drinking and being dyslipidemic
showed a negative correlation with HRQOL score (p < .05). Healthcare providers should con-
sider time-zone flights, behavioral factors and dyslipidemia when planning related health
promotion and disease prevention programs for commercial pilots in the future.

Introduction It is currently thought that the assessment of the state

The civil aviation industry has developed rapidly on a
global scale. With the rapid development of the avi-
ation industry, the pilots of Chinese commercial air-
lines are in short supply. The health of pilots is
closely related to aviation safety since nearly 70% to
80% of fatal aviation accidents are resulted from
human error.1
It is well known that flying across multiple time
zones can result in the disruption of the circadian
rhythm. Circadian rhythms are observed in a variety
of physiologic functions, such as body temperature,
sleep and wakefulness, hormone levels, and perform-
ance and behavior. Long term exposure to circadian
disruption can lead to a range of health issues, includ-
ing sleep disorders, obesity, metabolic disorders, type
II diabetes, gastrointestinal dysfunction, compromised
immune function, cardiovascular disease, mood and
social disorders, and increased cancer risk,2,3 which
can endanger flight safety in serious cases. For
example, cardiovascular disease accounts for 50% of
all pilot licenses declined or withdrawn for medical
reasons in Western Europe, and is the most common
cases of sudden incapacitation in flight.4
of health should include both objective and subjective
aspects. Measuring health-related quality of life
(HRQOL) is probably the most frequently used method
of subjective health assessment in chronic illnesses, as it
adequately reflects the burden of the disease. Therefore,
HRQOL is an important component in assessing peo-
ple’s health5 and it is a multidimensional concept that
includes domains of physical health and functioning,
mental health, social functioning and general well-being.
The World Health Organization Quality of Life: Brief
Version (WHOQOL-BREF) assesses HRQOL in four
domains including physical health, psychological health,
social relationships and environment.6
To our knowledge, there are extremely few published
studies that have evaluated health-related quality of life
(HRQOL) and related factors in commercial pilots. For
that reason, through this study, we sought to explore
HRQOL and its related factors among civilian pilots.
Methods
Subjects
This was a cross-sectional study. A purposive sample
of 373 pilots was recruited from a Chinese

CONTACT Bing Qiu camc_ph@qq.com Civil Aviation Medicine Institute, Civil Aviation Medicine Center, Civil Aviation Administration of China (Civil
Aviation General Hospital), Beijing 100123, People’s Republic of China.

Tiebing Liu and Bing Qiu contributed equally to this work.
ß 2020 Taylor & Francis Group, LLC
2 T. LIU ET AL.

Commercial Airline. The study protocol was Data analysis

reviewed and approved by the Ethics Committee of
the Civil Aviation General Hospital and was per-
formed in accordance with the ethical standards laid
out in the 1964 Declaration of Helsinki, and
informed consent was obtained from each subject.
After signing informed consent, participants were
asked to answer a questionnaire. Participant inclu-
sion criteria included (a) the ability to communicate
in Chinese, (b) pilots currently working for the
Commercial Airline and (c) the willingness to par-
ticipate in this study. All subjects passed a manda-
tory annual physical examination. Foreign and
retired pilots and those who failed to receive the
necessary checks or questionnaires were excluded.
All questionnaires were collected and inspected by
trained researchers.
Demographic questionnaire
The demographic questionnaire included questions
regarding demographics, work-related characteristics
and disease information. Demographic data included
age, education, height, weight, smoking status, alcohol
consumption status, vegetable and fruit intake, salty
taste and pluck intake. Work-related questions col-
lected data on length of service and time-zone flights.
Disease information included the presence of a diag-
nosis of hypertension, dyslipidemia and diabetes. The
amount of physical activity per week was determined
using a single question asking about the number of
days per week moderate physical exercise of at least
30 min was performed.
The mean value, frequency and percentages of general
information, health behaviors and other variables were
calculated. For comparing subgroups with respect to
HRQOL scores, the Student t-test and the Analysis of
Variance (ANOVA) test were used if the dependent
variables had a normal distribution and showed vari-
ance homogeneity in the subgroup; otherwise, the
Mann–Whitney U test and Kruskal–Wallis H-test
were used. Meanwhile, the bivariate linear regression
was used to reveal the correlation between the
HRQOL scores and potential influencing factors. A
multiple linear regression analysis model was used for
the control of potential confounding factors. All the
variables that were found to be significant in the
bivariate analysis and all those considered to be of
interest for the study were included in the model. The
statistical analyses were conducted using Stata, statis-
tical software (version 12.0, StataCorp, USA).
Statistical tests were two-sided and p < .05 was consid-
ered statistically significant.
Results
Characteristics of the study population
The socio-demographic and clinical characteristics
of the participants in our study were presented in
Table 1. Out of 398 pilots invited to participate in the
study, 373 consented to participation (response rate 
93.7%). All subjects were male, and the mean age was
34.5 years (SD 7.9 years; median 32 years; IQR
39–29 years; Range: 21–58 years). The mean BMI were
23.8 kg/m2 (SD ¼ 2.2 kg/m2). The median length of
service was 7 years (IQR: 17–4 years). Of 398 pilots,

Table 1. Sociodemographic and clinical characteristics of

WHOQOL-BREF participants (N ¼ 373).
The Chinese version of WHOQOL-BREF7 which con- Characteristics Values
Age, years, Median (Range) 32 (21–58)
sisted of 26 items in four domains was chosen for the BMI, kg/m2, Mean ± SD 23.8 ± 2.2
present study. The 26 original items included two Physical activity, days, Median (IQR) 2 (3–1)
Length of service, years, Median (IQR) 7 (17–4)
items on overall HRQOL and general health (the gen- Salty taste, n(%) 148 (39.9)
eral facet on health and overall HRQOL). The remain- Pluck, n(%) 107 (28.8)
Smoking, n(%) 129 (39.3)
ing 24 items, on a five-point scale, could be classified Alcohol drinking, n(%) 141 (38.0)
into four domains: physical health (7 items), psycho- Fruit intake, n(%) 246 (67.0)
Vegetable intake, n(%) 302 (81.0)
logical health (6 items), social relationships (3 items) Hypertension, n(%) 26 (7.0)
and environment (8 items). Each of the 26 items was Dyslipidemia, n(%) 71 (19.3)
Diabetes, n(%) 4 (1.1)
assigned value scores of 1 to 5. The score for each Overweight, n(%) 170 (45.6)
domain was transformed into a linear scale from 0 to Obesity, n(%) 11 (2.9)
Physical health, Median (IQR) 64.3 (75–53.6)
100, with low scores indicating poor HRQOL. A Psychological health, Median (IQR) 62.5 (70.8–54.2)
domain was treated as missing when over 20% of its Social relationship, Median (IQR) 75 (75–58.3)
Environment, Mean ± SD 62.2 ± 16
items were missing.
 ARCHIVES OF ENVIRONMENTAL & OCCUPATIONAL HEALTH 3

Table 2. Distribution of responses (%) in the mainland Chinese WHOQOL-BREF (N ¼ 373).

1 2 3 4 5
Items Very poor Poor Average Good Very good
Q1 General QOL 4(1.1%) 24(6.4%) 188(50.4%) 132(35.4%) 25(6.7%)
Q2 General health 5(1.3%) 44(11.8%) 151(40.5%) 146(39.1%) 27(7.2%)
D1: Physical
Q3 Pain and discomfort 89(23.9%) 69(18.5%) 75(20.1%) 65(17.4%) 75(20.1%)
Q4 Dependence medication 69(18.5%) 72(19.3%) 45(12.1%) 43(11.5%) 144(38.6%)
Q10 Energy and fatigue 1(0.3%) 22(5.9%) 93(24.9%) 165(44.2%) 92(24.7%)
Q15 Mobility 0(0.0%) 3(0.8%) 79(21.2%) 171(45.8%) 120(32.2%)
Q16 Sleep and rest 10(2.7%) 42(11.3%) 129(34.6%) 158(42.4%) 34(9.1%)
Q17 Activities of daily living 0(0.0%) 5(1.3%) 107(28.7%) 215(57.6%) 46(12.3%)
Q18 Working capacity 0(0.0%) 4(1.1%) 75(20.1%) 227(60.9%) 67(18.0%)
D2: Psychological
Q5 Positive feelings 2(0.5%) 25(6.7%) 109(29.2%) 171(45.8%) 66(17.7%)
Q6 Spirituality, religion and personal beliefs 2(0.5%) 17(4.6%) 88(23.6%) 170(45.6%) 96(25.7%)
Q7 Thinking, learning, memory and concentration 1(0.3%) 11(2.9%) 99(26.5%) 178(47.7%) 84(22.5%)
Q11 Body image 1(0.3%) 15(4.0%) 131(35.1%) 137(36.7%) 89(23.9%)
Q19 Self-esteem 0(0.0%) 9(2.4%) 89(23.9%) 204(54.7%) 71(19.0%)
Q26 Negative feelings 1(0.3%) 12(3.2%) 79(21.2%) 190(50.9%) 91(24.4%)
D3: Social relationships
Q20 Personal relations 0(0.0%) 10(2.7%) 104(27.9%) 212(56.8%) 47(12.6%)
Q21 Sex 5(1.3%) 17(4.6%) 111(29.8%) 191(51.2%) 49(13.1%)
Q22 Practical social support 2(0.5%) 4(1.1%) 90(24.1%) 225(60.3%) 52(13.9%)
D4: Environment
Q8 Safety 1(0.3%) 10(2.7%) 89(23.9%) 182(48.8%) 91(24.4%)
Q9 Home environment 7(1.9%) 32(8.6%) 144(38.6%) 134(35.9%) 56(15.0%)
Q12 Financial resources 39(10.5%) 53(14.2%) 157(42.1%) 103(27.6%) 21(5.6%)
Q13 Information 3(0.8%) 32(8.6%) 153(41.0%) 147(39.4%) 38(10.2%)
Q14 Recreation and leisure 6(1.6%) 63(16.9%) 147(39.4%) 125(33.5%) 32(8.6%)
Q23 Physical environment 6(1.6%) 23(6.2%) 122(32.7%) 186(49.9%) 36(9.7%)
Q24 Access to health care 5(1.3%) 27(7.2%) 126(33.8%) 180(48.3%) 35(9.4%)
Q25 Transport 13(3.5%) 43(11.5%) 130(34.9%) 154(41.3%) 33(8.8%)

7.0% of participants were diagnosed with hyperten-
sion, 19.3% with Dyslipidemia, 1.1% with Diabetes,
48.5% with overweight/obesity, 39.3% smoked and
38.0% drank alcohol.
The median (IQR) scores for physical health, psycho-
logical health and social relationship were 64.3 (75–53.6),
62.5 (70.8–54.2) and 75 (75–58.3), respectively. The
mean (SD) score for Environment was 62.2 (16).
WHOQOL-BREF questionnaire
For overall and general health-related questions, more
than 90% of the participants responded as average to
very good. As far as physical health, psychological
health, social relationship and environmental domains
were concerned, most of the participants responded as
poor to very good except a few responding as ‘very
poor’ for physical health. Table 2 depicted the distri-
bution of responses (%) for WHOQOL-BREF, and
Table 3 showed the scores of pilots according to the
impact factors of HRQOL in pilots.
Bivariate associations between independent
variables and quality of life
Analysis of the relation between the sociodemographic
and psychosocial characteristics of the participants
and the health-related quality of life (HRQOL) com-
ponents were presented in Table 4. The results of uni-
variate linear regression showed that physical activity,
fruit intake and vegetable intake were positively linked
to the psychological health, social relationships and
environmental health domains of HRQOL. Time-zone
flight, salty taste, smoking and being dyslipidemic
were negatively associated with the physical health
domain. Salty taste and being dyslipidemic were nega-
tively associated with the psychological health domain.
BMI, salty taste, pluck intake and being dyslipidemic
were negatively associated with the social relationship
domain. Salty taste and alcohol drinking were nega-
tively associated with the environment domain.
Multivariate linear regression
The results of multivariate linear regression were pre-
sented in Table 5. After adjusting for the other covari-
ates in the model, physical activity was associated with
psychological health and environmental health
domain. Time-zone flights, smoking and vegetable
intake were associated with the physical health
domain. Similarly, fruit intake was associated with the
social health domain and alcohol drinking was associ-
ated with the environment domain. Being
4 T. LIU ET AL.

Table 3. Scores of pilots according to the impact factors of HRQOL in pilots.

Physical health, Psychological health, Social relationship, Environment,
Variables Median (IQR) Median (IQR) Median (IQR) Mean ± SD
Total 64.3 (53.6, 75.0) 62.5 (54.2, 70.8) 75.0 (58.3, 75.0) 62.16 (15.97)
Age 40 years 64.3 (53.6, 78.6) 62.5 (54.2, 70.8) 75.0 (58.3, 75.0) 61.90 (15.43)
>40 years 60.7 (53.6, 75.0) 62.5 (54.2, 70.8) 75.0 (50.0, 75.0) 62.98 (17.58)
p value .545a .419a .584a .576b
Body mass index <24 kg/m2 64.3 (53.6, 75.0) 66.7 (58.3, 70.8) 75.0 (62.5, 75.0) 63.09 (16.41)
24 kg/m2 64.3 (53.6, 78.6) 62.5 (54.2, 70.8) 75.0 (50.0, 75.0) 61.19 (15.47)
p value .701a .058a .031a .252b
Physical activity 2 days 64.3 (53.6, 75.0) 62.5 (54.2, 70.8) 75.0 (58.3, 75.0) 61.69 (14.99)
>2 days 64.3 (53.6, 75.0) 66.7 (54.2, 70.8) 75.0 (58.3, 75.0) 62.67 (16.99)
p value .941a .117a .379a .553b
Length of service 7 years 67.9 (53.6, 82.1) 66.7 (58.3, 70.8) 75.0 (66.7, 75.0) 62.10 (16.08)
>7 years 60.7 (53.6, 71.4) 62.5 (54.2, 70.8) 75.0 (58.3, 75.0) 62.23 (15.91)
p value .003a .035a .054a .939b
Smoking No 67.9 (57.1, 82.1) 62.5 (58.3, 70.8) 75.0 (58.3, 75.0) 62.19 (14.65)
Yes 60.7 (53.6, 75.0) 62.5 (54.2, 70.8) 75.0 (50.0, 75.0) 60.47 (17.18)
p value .001a .086a .702a .333b
Alcohol drinking No 66.1 (53.6, 78.6) 62.5 (58.3, 70.8) 75.0 (58.3, 75.0) 64.31 (15.88)
Yes 60.7 (53.6, 75.0) 62.5 (54.2, 70.8) 75.0 (58.3, 75.0) 58.87 (15.59)
p value .071a .207a .063a .001b
Fruit consumption <200 g/d 60.7 (53.6, 75.0) 62.5 (54.2, 66.7) 66.7 (50.0, 75.0) 57.88 (13.74)
200 g/d GDDD 64.3 (53.6, 78.6) 62.5 (58.3, 70.8) 75.0 (58.3, 75.0) 64.32 (16.47)
p value .193a .015a .001a <.001b
Vegetable consumption <300g/d 60.7 (50.0, 71.4) 58.3 (54.2, 66.7) 66.7 (50.0, 75.0) 56.03 (15.44)
300 g/d 64.3 (53.6, 78.6) 66.7 (54.2, 70.8) 75.0 (58.3, 75.0) 63.61 (15.77)
p value .011a <.001a <.001a <.001b
Hypertension No 64.3 (53.6, 75.0) 62.5 (54.2, 70.8) 75.0 (58.3, 75.0) 62.10 (16.17)
Yes 66.1 (60.7, 78.6) 66.7 (62.5, 75.0) 75.0 (58.3, 75.0) 62.50 (13.38)
p value .246a .298a .451a .903b
Dyslipidemia No 67.9 (53.6, 78.6) 62.5 (54.2, 70.8) 75.0 (58.3, 75.0) 63.11 (15.89)
Yes 60.7 (50.0, 71.4) 62.5 (54.2, 66.7) 75.0 (50.0, 75.0) 59.24 (15.50)
p value <.001a .021a .025a .065b
Time-zone flights <5 time zones 67.9 (57.1, 82.1) 62.5 (54.2, 70.8) 75.0 (58.3, 75.0) 61.75 (16.39)
5 time zones 57.1 (50.0, 64.3) 62.5 (54.2, 70.8) 75.0 (58.3, 75.0) 63.42 (14.64)
p value <.001a .251a .817a .387b
a
The Student t-test.
b
The Mann–Whitney U test.

Table 4. Univariate linear regression analyses of factors associated with HRQOL in pilots.
Physical health Psychological health Social relationships Environment
Variable Coef 95%CI Coef 95%CI Coef 95%CI Coef 95%CI
Age –0.07 –0.26, 0.13 –0.08 –0.23, 0.07 –0.14 –0.33, 0.06 0.02 –0.18, 0.23
Physical activity 1.01 –0.3, 2.3 1.74


0.77, 2.71 1.56
0.3, 2.83 2.62


1.32, 3.92
BMI –0.17 –0.89, 0.55 –0.49 –1.04, 0.06 –0.98

–1.69, 0.26 –0.49 –1.24, 0.26
Length of service 0.01 –0.16, 0.17 –0.05 –0.18, 0.07 –0.1 –0.27, 0.07 0.04 –0.14, 0.21
Time-zone flights –11.17


–14.58, 7.76 –1.51 –4.25, 1.23 0.26 –3.35, 3.87 1.66 –2.1, 5.42
Salty taste –4.49

–7.63, 1.35 –2.5
–4.91, 0.08 –3.3
–6.48, 0.13 –3.06 –6.38, 0.26
Pluck –2.04 –5.45, 1.38 –2.56 –5.16, 0.05 –3.82
–7.25, 0.4 –4.37
–7.93, 0.8
Smoking –5.83

–9.13, 2.53 –2.36 –4.91, 0.18 –0.44 –3.84, 2.97 –1.72 –5.2, 1.76
Alcohol drinking –3.19 –6.38, 0.01 –1.88 –4.31, 0.55 –2.93 –6.12, 0.27 –5.44

–8.75, 2.14
Fruit intake 2.04 –1.28, 5.37 2.86
0.34, 5.38 5.81

2.51, 9.11 6.44


3.04, 9.84
Vegetable intake 4.98
1.07, 8.89 5.09

2.12, 8.06 7.29


3.4, 11.19 7.58


3.52, 11.64
Dyslipidemia –6.83

–10.72, 2.94 –3.54
–6.51, 0.57 –4.51
–8.45, 0.57 –3.87 –7.96, 0.23
Hypertension 3.42 –2.66, 9.5 1.82 –2.82, 6.47 –2.49 –8.6, 3.62 0.4 –5.98, 6.77
Diabetes –0.02 –15, 14.96 6.99 –4.35, 18.33 5.21 –9.8, 20.21 5.67 –9.86, 21.2

p < .05;

p < .01;


p < .001.

dyslipidemic was associated with physical health and statistically significant negative correlation with
social health domain. HRQOL score (p < .05).
Overall, the multivariate analysis showed physical
activity, fruit intake and vegetable intake were statis-
tically significant (p < .05) positively correlated with
Discussion
HRQOL score, while time-zone flights, smoking, alco- The present study systematically assessed the associ-
hol drinking and being dyslipidemic showed a ation between quality of life (QOL) sores and
 ARCHIVES OF ENVIRONMENTAL & OCCUPATIONAL HEALTH 5

Table 5. Multiple linear regression analyses of significant factors associated with QOL in pilots.
Physical health Psychological health Social relationships Environment
Variable Coef 95%CI Coef 95%CI Coef 95%CI Coef 95%CI
Age 0.11 –0.09, 0.31 –0.04 –0.22, 0.13 –0.11 –0.33, 0.12 –0.06 –0.27, 0.16
Physical activity – – 1.49

0.51, 2.47 0.97 –0.3, 2.24 2.23

0.93, 3.53
BMI – – – – –0.72 –1.55, 0.11 – –
Length of service – – – – – – – –
Time-zone flights –12.71


–16.35, 9.07 – – – – – –
Salty taste –2.69 –5.79, 0.41 –2.51 –5.2, 0.19 –2.9 –6.53, 0.74 – –
Pluck – – – – –1.61 –5.56, 2.34 –3.77 –7.62, 0.09
Smoking –5.26

–8.33, 2.2 –– – – – – –
Alcohol drinking – – – – – – –4.57
–8.2, 0.94
Fruit intake – – 2.28 –0.69, 5.24 5.67

1.88, 9.47 3.87 –0.05, 7.8
Vegetable intake 5.97

2.12, 9.83 2.84 –0.89, 6.56 4.6 –0.16, 9.37 2.96 –1.92, 7.84
Dyslipidemia –4.83
–8.85, 0.81 –3.44 –7.06, 0.17 –4.75
–9.43, 0.06 – –
Hypertension – – – – – – – –
Diabetes – – – – – – – –

p < .05;

p < .01;


p < .001.
– No data.

behavioral factors and time-zone flights with the
Chinese version of the WHOQOL-BREF and investi-
gated the differences in QOL between pilots with and
without time-zone flights using a moderately large
sample. Only male pilots were enrolled in the current
study since female pilots were rare in China. Overall,
after adjusting for the other covariates in the model,
the multivariate analysis showed physical activity, fruit
intake and vegetable intake were positively associated
with QOL. However, time-zone flights, smoking, alco-
hol drinking and being dyslipidemic were negatively
associated with QOL.
In our study, we observed that time-zone flights
were negatively associated with QOL. Time-zone
flights are often accompanied by differences between
in vivo time and external environmental time. During
the transition from preflight to post-flight steady state,
not only will be the state of life affected, but behav-
ioral performance will also be affected.8 The most sig-
nificant character of time-zone flights was jet lag. Like
shift work, jet lag induces circadian rhythm and sleep
disruption.9 One study showed that on trips with
time-zone flights, pilots experience successive non-
24 h day/night cycles, which can lead to sleep and cir-
cadian disruption.10 It is well known that Jet lag is
commonly experienced when travelers cross multiple
time zones.11 Meanwhile, time-zone flights also meant
increased working hours, less rest time, more fatigue
and sleep problems, which have been proven to result
in errors in work.12,13 This should be considered a
serious issue since human error accounts for about
70–80% of all fatal aviation accidents.14
In this study, we observed that smoking was nega-
tively associated with QOL, which was also found
among the English general population and the magni-
tude of the link between smoking and QOL is
determined by the number of cigarettes.15 The most
possible explanation is that low quality of life may be
the result of smoking cigarettes, based on the findings
that substances inhaled in cigarettes have been
reported to be linked to muscular weakness, vitality
loss, muscle disorders and psychological derange-
ment.16 However, due to the cross-sectional nature of
our study, we cannot conclude that smoking was the
reason for poor QOL. It is also plausible that people
with low quality of life are more likely to smoke and
more difficult to quit.
In our study, we observed that alcohol consump-
tion was negatively associated with QOL, which is
similar to one previous study.17 However, the analysis
of the QOL scores by alcohol consumption pattern
suggested the existence of an inverted U-shaped rela-
tionship between the QOL scores and alcohol con-
sumption.18 Specifically, the QOL of moderate alcohol
drinkers was higher than that of nondrinkers and
heavy drinkers. The small association between alcohol
consumption and better physical HRQOL found at
baseline was not apparent after a few years of follow-
up. Medical advice on alcohol consumption cannot be
grounded on its effects on HRQOL.19
In our study, we found that physical activity and
fruit and vegetable intake were positively associated
with the quality of life, which is similar to several pre-
vious studies.20,21 In these studies, physical activity and
fruit and vegetable intake were associated with higher
quality of life scores, higher self-rated health and lower
mortality. Considering the link with possible potential
mechanisms, physical activity and fruit and vegetable
intake have been found to be associated with increased
perceived health and life satisfaction, as well as
decreased high blood pressure among mostly middle-
aged employees.22 Moreover, regular practice of a
6 T. LIU ET AL.
physical activity is an important factor in the preven-
tion of noncommunicable diseases (NCDs).23 Although
this association varies according to the type and inten-
sity of PA and differs across QOL domains.24
Our study has several limitations that need to be
considered. First, as a result of the cross-sectional
study design, we were unable to draw any conclusions
about the causal relationship between time-zone
flights, behavioral factors and chronic diseases. In
addition, this study is mainly aimed at pilots from an
airline, so when the response rate is very high, it can
reflect the pattern of the pilots of the company and
there may be some limitations in the extrapolation of
results. Future work is needed with larger sample sizes
and longer-term studies. Second, due to excessive or
underestimation of the participants’ actual health
behaviors, the results may lack accuracy, with previous
studies suggesting that people tend to overestimate
their physical activity and intake of fruits and vegeta-
bles.25 Third, because of the recruitment strategy,
selection bias might have happened because those
who had a strong motivation to alter their health
behaviors might have registered to participate. Fourth,
in order to simplify the workload of filling in the
form and improve the response rate, we did not col-
lect detailed information regarding time-zone flights
and shiftwork. In the future, further studies should
take more detailed data on the above factors into con-
sideration. Finally, dietary and behavioral habits such
as sleep, physical activity and fruit and vegetable
intake are complex, and the models presented here
probably do not consider all relevant factors. For
example, future research should investigate more com-
plex health factors, such as a high-fat diet, which may
affect the level of physical activity intensity of eating
behavior,26 genetic susceptibility and stable personality
traits.27 Nonetheless, our study has obtained several
constructive outcomes.
Conclusions
Physical activity, fruit intake and vegetable intake are
positively correlated with quality of life. However,
time-zone flights, smoking, drinking and dyslipidemia
are inversely related to the quality of life. Health pro-
viders should consider the above issues when planning
related health promotion and disease prevention pro-
grams for pilots in the future.
Disclosure statement
The authors declare that there is no conflict of interest
regarding the publication of this article.
Acknowledgment
The authors are grateful to the anonymous reviewers for
helpful comments and valuable suggestions and critically
reviewing the paper.
Funding
This study was supported by the National Natural Science
Fund Committee and Civil Aviation Administration of
China Jointly Funded Project (No. U1633130) and the Civil
Aviation Medicine Center (General Hospital) Scientific
Research Fund-funded Project (No.201939)
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