Exercise and Diet Should Be Part of Strategic Firefighter Occupational Health Plans

BY DEBORAH L. FEAIRHELLER, CARLY McMORROW, AND MICHAEL S. BRIAN

OCCUPATIONAL HEALTH is an important and very relevant topic today. Strategy decisions are made by public health agencies using knowledge from evidence-based practices. So, it could be argued that we need to understand how tactical population health differs—between times of “peace” and times of “emergency response.” Considering the high risk of cardiac incidents that firefighters face, as communities continue to suffer complex public health emergencies, we need to develop health policy frameworks that are based on cardiovascular disease (CVD) risk reduction.

According to the American Heart Association, almost every adult has at least one cardiac risk factor.¹ Firefighters are known to say “adapt and overcome” because exposure to stress is a part of their career, but the constant exposure to high levels of occupational risk along with traumatic situations that occur during large-scale incidents could contribute to CVD risk even more than we realize.

The link between COVID-19 and heart health continues to be mentioned in the news and in clinical research studies.² Despite this, most strategic decisions and changes in procedure relate to disease transmission risk. The fire service is aware of the increased risk for disease transmission that structural firefighters may face due to close living quarters, transporting patients, and long work schedules.

Since the pandemic has passed, the increased use of personal protective equipment (PPE) and modified policies for disease risk reduction have remained in place in many stations. Due to the lessons learned during the COVID-19 pandemic, the emergency management community is in a different place than it was pre-COVID-19. The Federal Emergency Management Agency has issued new guidance and continues to improve recommendations on hazard incident response and recovery. Emergency response organizations must comply with all state and federal mandates regarding how they ensure a timely response, maintain preparedness, and coordinate department operations during emergency incidents while maintaining equal access to services for all communities.

We do not know how cardiac-related risk differs in firefighters during a large pandemic response compared to nonemergency situations. It also is unknown what the emergency personnel who were actively responding to calls perceived as either needs or as system breakdowns during the pandemic. A “boots on the ground” perspective could provide valuable public health preparedness insight.

Before the pandemic, we published an article on fireengineering.com “The Link Between Work Stress and Blood Pressure.”³ We have continued to measure blood pressure surge with alarm over the years to help the fire service understand where potential risks exist. In fact, we were able to report that the blood pressure response to alarms is much higher during medical calls than during fire calls.⁴

To understand how tactical health differs during times of “peace” and times of “emergency response,” we conducted six-week exercise and diet interventions in two groups of firefighters: pre- COVID-19 and during COVID-19. We wanted to see if exercise and diet would improve blood pressure and perhaps lead to a lower blood pressure surge in firefighters when the alarm sounds. As part of this, we also surveyed the participating firefighters to collect subjective information on their perception of lessons learned from the COVID-19 response. The information from this survey has not been published anywhere and is made available here.

Tactical Circuit Exercise Program

The tactical training was a functional exercise circuit. We ran the study as a six-week intervention where the circuit program was prescribed three times per week and included six stations of exercises, which were each done three times. Firefighters were instructed to complete the workout at their own pace. The stations included the following:

A 40-lb. carry for 100 feet.
A three-minute stair climb.
A 45-second plank pose.
A 20-lb. carry with a fast walk for 100 feet.
Right and left single leg stands for as long as balance was maintained.
A 15-lb. carry up and down 30 stairs.

Firefighters were recommended to complete the circuit at the firehouse using hoseline, fireground tools, or extrication tools as weighted implements instead of actual barbells or kettlebells.

Modified Mediterranean Diet

The modified Mediterranean diet was introduced in an hour-long training session. We provided the firefighters with a diet manual, some serving-size baggies, and a set of plastic serving cups. Each week, the firefighters would meet with a health coach (who was one of the research students) to learn more about diet and get any diet-related questions answered.

For this diet, each food group was given a certain number of required servings, and we tracked the diet using a Mediterranean Diet Score System that we had created. The scoring system gives more points (more importance) to foods that should be consumed more frequently and fewer points (lower importance) to those that should be consumed weekly or limited altogether. We have recently validated this way to score a diet to prove it is effective at tracking a Mediterranean dietary pattern.⁵

Firefighter Health Comparison Pre- and During COVID

Not surprising, we found that firefighters during the COVID-19 pandemic response were more stressed and had a lower impression of their health. On a stress survey where a higher score indicates more stress, firefighters during COVID-19 had an average score of 6.5 compared to the average score of 3.7 in the pre-COVID firefighters (out of seven total points). Separately, when asked on a scale of 1-10 how they rated their health, with 10 indicating very healthy, firefighters during the COVID response estimated only an average of 5.9 while the pre-COVID firefighters stated their health was around an average of 6.5.

Blood pressure was also higher during the pandemic. Firefighters during COVID-19 had a much larger blood pressure response when their pager sounded. During the pandemic, diastolic blood pressure increased 16.7 mmHg when the pager sounded, compared to 8.1 mmHg before COVID-19. Also, during the pandemic, systolic blood pressure increased 22.2 mmHg when the pager sounded, compared to 15.3 mmHg before COVID-19. Because many firefighters are hypertensive, and it has been reported that many do not know their blood pressure,⁶ finding out that the blood pressure increase with pager alarm was higher during the pandemicis concerning. A firefighter who already has high blood pressure could inherently be at extreme risk when working during a pandemic or a large-scale emergency response if proper wellness programming is not encouraged.

Also, it was interesting for us to see that the exercise and diet intervention improved these blood pressure responses in only six weeks. After following the Mediterranean diet and completing six weeks of tactical circuit exercise, firefighters had a smaller blood pressure increase when the pager sounded.

Figure 1 shows the amount that blood pressure would rise. The solid bars represent the measured amount before the intervention. The open bars represent the measured amount after the intervention. In every single comparison, the open bars are lower than the solid bars—suggesting that the exercise and diet intervention reduced the risk that firefighters are exposed to. These lower blood pressure surges when the alarm sounds could mean that firefighters are at less risk of cardiac events. It seems that the exercise and diet improved their health.

*shows where the level was significantly lower after the exercise and diet.

We are the first researchers to measure these blood pressure surge levels when the pager alarm sounds, and we are the first ever to compare these blood pressure responses between times of “peace” and times of “emergency response.”

Perception of Preparedness

We sent out a survey to ask about the perception of preparedness for the emergency response during the COVID-19 pandemic. The firefighters who completed the survey were certified to run medical calls as an EMT or paramedic (60% yes) and worked at fire stations staffed by paid crew (80% yes). When asked, “What do you feel could have helped to better prepare your station for the COVID-19 response?” the responses were as follows:

55.6% more funding.
55.6% more community education.
44.4% more stress and resilience support.
44.4% better collaboration between state agencies and fire command.
44.4% improved communication between command and state agencies.
11.1% training in contagious disease.

Additionally, firefighters felt they lacked adequate information to feel safe and commented on things like there should be strategies for the following:

Better notification if a patient had COVID-19 after they dropped the patient off at the hospital (potential unknown exposures).
More transparency.
Better communication of information.

They also commented that the stock of PPE was insufficient, supplies and cleaning solutions should be improved, and they lacked proper PPE at times. Firefighters also wished for more staffing assistance because staffing was often short due to illness, exposure, or quarantine.

How Is This Helpful?

This evidence-based data can inform strategic decisions for healthcare models during future large-scale emergencies. CVD risk is inherent in society and especially in emergency service workers. If exercise and diet reduce blood pressure and lower the blood pressure spikes that occur when the pager alarms sound, then occupational health plans should include exercise and diet programming. Interestingly, though, when asked what they felt their fire station needed to be better prepared for a large-scale response, the comments did not address firefighter fitness or diet. They mainly focused on improvements in communication, education for the community, stress and resilience skills, and higher quality and amount of PPE.

Cardiac incidents remain the leading cause of line-of-duty death in firefighters. Anything that we can do to reduce risk, especially during incident response, should become policy. As the emergency management community continues to improve guidance on hazards, it is our hope that wellness programming is part of the plan.

What Can You and Your Station Do?

Implement wellness programs now. Encourage each other to discuss diet and exercise. Reach out to professionals for advice. Track what you eat, increase fruit and vegetable consumption, and decrease processed snack foods. Small steps and little changes pay off. If these habits can become the mainstay for the fire service, lives could be saved.

Acknowledgments: We would like to thank the firefighters who participated in this study and the research assistants who helped with data collection.

Funding: This work was supported by the American Heart Association Grant 19AIREA34450151(Feairheller).

REFERENCES

Virani, Salim, et al. “Heart Disease and Stroke Statistics-2021 Update.” Journal of the American Heart Association, vol. 143, no. 8, 27 Jan. 2021, bit.ly/3XZlDn6.
Graham Elliot, et al. “Firefighters and COVID-19: An Occupational Health Perspective.” Journal of Occupational and Environmental Medicine, 16 Jun. 2021, bit.ly/4h3YoBd.
Carty, Megan, et al. “The Link Between Work Stress and Blood Pressure.” Fire Engineering, 1 Feb. 2020, bit.ly/3NgsQud.
Rynne, Paige, et al. “Blood Pressure Responses are Dependent on Call Type and Related to Hypertension Status in Firefighters.” Blood Pressure, 2023, bit.ly/3BPJHBl.
Reeve, EH, et al. “Validation of a Mediterranean Diet Scoring System for Intervention Based Research.” Journal of Nutritional Medicine and Diet Care, 2021, bit.ly/3XXczPL.
Risavi, Brian, and Jason Staszko. “Prevalence of Risk Factors for Coronary Artery Disease in Pennsylvania (USA ) Firefighters.” Prehospital and Disaster Medicine, Feb. 2016, bit.ly/3XZBja2.

DEBORAH L. FEAIRHELLER, Ph.D., FACSM, USAW-L1, has worked as a volunteer firefighter in the Philadelphia (PA) and the Durham (NH) areas. She is a certified firefighter and rescue technician. She is director for the HEART laboratory and is an assistant professor at California State University in San Marcos. Her clinical research examines the relationships between cardiac risk factors, blood pressure responses, and lifestyle. As an experienced firefighter, she has a vested interest in getting the fire service physically active and improving cardiac health.

CARLY McMORROW was a graduate student and the graduate assistant for the Clinical Cardiac Program at the University of New Hampshire. She was the lead author on an extensive review of the literature in blood pressure responses in firefighters. She was a previous student researcher in the HEART lab, working on the exercise and diet intervention during the COVID-19 pandemic.

MICHAEL S. BRIAN, Ph.D., is a collaborating researcher and an assistant professor at the University of New Hampshire. His research interest is in studying the cardiometabolic disease process and improving health outcomes through exercise and lifestyle modifications. He has expertise in metabolism, 24-hour blood pressure regulation, and the relationship of obesity to blood vessel health.

Exercise and Diet Should Be Part of Strategic Occupational Health Plans