Sleep Medicine Reviews 13 (2009) 247–248
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Sleep Medicine Reviews
journal homepage: www.elsevier.com/locate/smrv
GUEST EDITORIAL
Managing jet lag
In her admirable review of recent trends in jet lag,1 Professor
Arendt states ‘‘Jet lag has never been completely defined, although
anyone who has suffered from this problem has no difficulty in
identifying their personal symptoms.. However the major
complaints are poor sleep, daytime fatigue and poor performance.’’
Whilst these statements are not in dispute, it has been shown2–4
that, whereas individuals’ perception of jet lag seems to include
‘‘increased fatigue’’ at all times of the day, other symptoms depend
to some extent upon the time of assessment: in the morning, the
assessment is dominated by poorer sleep the previous night;
during much of the waking day, lack of motivation and the ability
to concentrate become important factors; and in the evening, the
perception of jet lag tends towards a lack of readiness for sleep.
One implication of these findings is that future studies of ‘‘jet lag’’
will need to consider the time of day when assessments are
made as well as the several components of jet lag. Related to this,
two questionnaires that address different aspects of jet lag have
been devised.4,5
Even though lack of sleep and general fatigue are components of
jet lag that are common to nearly all trans-meridian travellers,
there seems little doubt that some travellers suffer (or complain!)
more than others, and to help those who are most affected must
be an aim of advice that is given to alleviate jet lag. As stated in Are-
ndt’s article,1 there is some evidence that morning types have body
clocks that run faster than the average for the population as a whole
(tau is less than the average of 24.2 h) and that evening types have
clocks that are slightly slower than average. Intuitively, therefore,
those who are ‘‘morning-types’’ or ‘‘larks’’ (tending to sleep earlier
and preferring to be active in the earlier part of the day) should be
at an advantage when travelling to the east and at a disadvantage
when travelling westwards. By contrast, ‘‘evening-types’’ or
‘‘owls’’ (those tending to sleep later and preferring to be active in
the later part of the day) should be at an advantage when travelling
to the west and at a disadvantage when travelling to the east.
However, currently, there are no data that have tested these
hypotheses adequately.
The concept that tau might affect an individual’s chronotype as
well as ease of adjustment to a time-zone transition directs atten-
tion towards the genetic basis of the body clock. It is in this context
that the recent work on effects of polymorphism of the PER3 gene
in humans is of such interest. The finding that those possessing the
5/5 variant tended not only to be extreme morning types but also to
suffer more as a result of sleep loss raises a problem for such trav-
ellers. On the one hand, they might expect their body clock to
adjust more easily to an eastward shift; on the other, they will
need to take great care to minimise sleep loss and its negative
effects. Clearly, much more work is required in this area, including
1087-0792/$ – see front matter Ó 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.smrv.2008.10.001
studies of those with the 4/4 variant (extreme evening types) as
well as comparisons of the suitability of those with the 5/5 or 4/4
variant for shift work, particularly early morning and night shifts.
One of the ways to minimise jet lag is to promote adjustment
of the body clock to the new time zone. As Arendt states,1 light expo-
sure and avoidance coupled with melatonin ingestion, both manip-
ulations being performed at appropriate times, is currently believed
to be the best way to achieve this. However, many of those studies
that have been performed to date in the field are difficult to interpret
due to interference from other factors in the new time zone; closer
control of these factors – exposure to the natural light–dark cycle,
in particular – is required (see recent review, Ref. 6).
When attempting to devise schedules for promoting adjustment
to a new time zone, two further problems are soon encountered.
The first is the need to be able to assess accurately (and on a daily
basis and in the field) the phase of the individual’s body clock, since
the times of light exposure and melatonin ingestion are critically
dependent upon this. So far, assessing the phase of the body clock
has proved difficult. Reliable markers of the body clock (core
temperature and plasma melatonin, for example) are often difficult
to measure directly and mostly affected by environmental influ-
ences (the sleep-activity cycle and bright light, respectively, in
the cases of core temperature and melatonin). Assessment of the
urinary metabolite of melatonin is suggested in the article as an
alternative. However, one problem common to any marker of the
body clock is that measurements need to be taken at frequent
and regular intervals if clock phase is to be established. (It hardly
needs mentioning that variables that are easy to measure repeat-
edly, heart rate, for example, are very poor markers of the body
clock!) As stated in the review,1 solving the problem of assessing
the phase of the body clock remains a priority.
The second problem that is encountered when attempting to
devise schedules for promoting adjustment to a new time zone is
deciding whether the body clock should be advanced or delayed.
For all flights to the west, a delay of the body clock is advised, and
for all flights to the east of 8 or less time zones, a phase advance;
the problem is that, for flights to the east across more than 8 time
zones, some individuals phase advance whereas other adjust by
phase delay (sometimes called ‘‘antidromic’’ as opposed to the pre-
dicted ‘‘orthodromic’’ adjustment). In their study of 85 travellers
across 10 time zones eastwards, Waterhouse et al.7 found that 41%
of the sample adjusted by phase delay and 27% by phase advance;
for the remaining 32%, the circadian rhythm appeared to break up
so that it was not possible to measure a directional response.
The cause for this phenomenon is unclear, though speculation
exists that it might be related to the individual’s tau and chrono-
type. The advantages of promoting phase adjustment by phase
248 Guest Editorial / Sleep Medicine Reviews 13 (2009) 247–248
delay or advance have been considered elsewhere.3 The schedule
for promoting adjustment of the body clock differs according to
a phase-advance or phase-delay programme, and the need for an
accurate marker of the body clock becomes critical. Whilst the issue
of adjusting by phase delay or advance might pose a problem for
the traveller (and for those offering advice on adjustment), it seems
that it could be used as the basis for an experimental test of the effi-
cacy of schedules designed to promote adjustment by phase
advance or phase delay. Thus, if a trans-meridian flight across 9
time zones to the east is considered, separate schedules to promote
adjustment by phase advance or phase delay could be tested. In
practice, since an accurate assessment of the phase of the body
clock is required, such an investigation would need to be performed
in the first instance in the laboratory rather than the field.
If the general principles by which phase adjustment can be
promoted are known (subject to the provisos just given), many
details are still to be established, as acknowledged in the article.1
Examples of information still required include: the dosage of mela-
tonin before, during and after the journey; the value of melatonin
analogues; the usefulness of drugs to promote sleep without dis-
turbing daytime performance and of drugs to promote wakefulness
without disturbing sleep (bearing in mind that some of these might
be addictive and/or banned); the spectral quality of light for adjust-
ing the body clock most effectively; and the value of light-emission
devices for providing light if this is required during the night.
Perhaps one of the more controversial aspects of the review1 is
the recommendation of attempting to adjust to a new time zone
before the flight itself. While there is much to commend this
approach, in practice, problems might arise. These have been
covered in the article but we stress that the person attempting
this procedure must be fully aware of the extent of the demands
required. For example, for a flight to the east across 8 time zones,
the sleep–wake cycle needs to be adjusted so that sleep is required
between 16:00 h and 24:00 h; for a flight to the west across 8 time
zones, the sleep–wake cycle needs to be adjusted so that sleep is
between 08:00 h and 16:00 h. In effect, the individual needs to
act like a shift worker and will experience the social and domestic
problems experienced by them. In addition, the extent to which
symptoms due to inappropriate phasing of the body clock with
respect to the sleep–wake cycle would be present also is unclear.
This adjustment of the sleep–wake cycle requires light exposure
and avoidance, supported by melatonin ingestion, at appropriate
times. Whilst this is by no means impossible, of course, the natural
light–dark cycle and influences of a predominantly day-orientated
society all hinder such a full adjustment. Partial adjustment might
turn out to be a more acceptable alternative but evidence of the
practicality of such regimes is awaited. In general, athletes and
some travellers might not be prepared to compromise their pre-
flight days with the presence of symptoms similar to shift workers’
malaise. Indeed, the advice of consensus statements for travelling
athletes by the British Olympic Association and the European
College of Sport Science8,9 is that adjustment of 2–3 h for 2–3
days is the maximum to be attempted to avoid interference with
normal training programmes.
For the majority of travellers, the problems caused by jet lag and
the advice to ameliorate its effects will apply comparatively rarely.
By contrast, for frequent flyers and, particularly, aircrew undertaking
long-haul flights on a regular basis, other considerations need to be
taken into account. As well as in animals, there is some evidence
from humans whose body clock is repeatedly shifted by trans-
meridian flights of cognitive and menstrual disorders10–12; in shift
workers too, there is a greater incidence of several disorders
affecting the reproductive, gastrointestinal and cardiovascular
systems.13 Moreover, the advice for promoting shifts of the body
clock would need to be implemented often and over the course of
a sustained period of time, several years. Data are currently not avail-
able with regard to long-term effects of timed light exposure and
melatonin ingestion.14 These data are required before such pro-
grammes of adjustment can be advocated for continual use by trav-
ellers and aircrew (as well as shift workers). It is unlikely that drug
firms and light-box manufacturers will undertake such programmes
of investigation, and other means of funding these programmes
need to be set up to obtain such information.15
Long-distance flights are likely to increase in frequency in the
years ahead. Current knowledge enables a reasonably detailed
rationale to be produced to minimise the effects of these upon
the symptoms of jet lag. The review by Arendt1 outlines these prob-
lems and possible ways to alleviate them, and is a valuable addition
to the literature on the subject. What the review does also is to indi-
cate that far more details are required when possible schemes for
ameliorating jet lag are considered, and that obtaining these will
be a challenge in the times ahead.
References
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assessments of the relationship between jet lag and some of its symptoms.
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Jim Waterhouse*
Thomas Reilly
Research Institute for Sport and Exercise Sciences,
Liverpool John Moores University, Liverpool, UK
 Corresponding author.
E-mail address: waterhouseathome@hotmail.com