#Obesity and #Health in the #North #American #Fire #Service

There are more than 1 million firefighters throughout the #USA and #Canada who are exposed to multiple dangers as they perform their vital duties protecting our communities. The current virtual issue in Occupational Medicine highlights selected #firefighter research published over the last 6 years in the journal. These papers reflect the three highest priority health concerns of the current North American Fire Service: #cardiovascular disease (CVD), #cancer and #behavioural health issues. While each of these three issues seems discrete and disconnected, there are important ways in which these very different problems interrelate. Each challenge is connected in some way to the obesity epidemic and to the predominant fire service culture, which includes inadequate physical activity (PA) and suboptimal fitness levels and too often, a reliance on over-eating, binge drinking and oral tobacco for stress-relief. Nonetheless, firefighters are making substantial progress in combating these health issues by implementing comprehensive wellness programmes and gradually changing their culture in positive ways.

It has long been a goal of the fire service to decrease firefighter injury and fatalities. However, firefighting is inherently dangerous, and many of its hazards—including high levels of thermal and cardiovascular stress, exposure to toxins and carcinogens, and psychological stress and trauma—can only be partially mitigated by engineering/administrative controls and personal protective equipment. Nonetheless, promoting a healthier fire service with more fit resilient lifestyles has the potential to improve wellness among firefighters, and decrease the risks of CVD, cancer and behavioural health issues.

Sudden cardiac death (SCD) is the single most frequent cause of duty-related fatalities, accounting for almost half of all fatalities [1–3]. With rare exception, firefighter SCD occurs among firefighters with underlying coronary heart disease (CHD) and/or cardiomegaly [3]. Importantly, obesity and obesity-related conditions such as metabolic syndrome (MetS) and sleep apnoea are associated with an increased risk of both CHD and cardiomegaly. Additionally, obesity is strongly correlated with lower levels of PA and insufficient cardiorespiratory fitness (CRF) levels, which increase the risks of future CVD. Lipsey et al. evaluated the prevalence of MetS components, CRF levels and their association in a cohort of both career and volunteer firefighters in Colorado. The researchers found that approximately 10% of this sample of Colorado firefighters had MetS and nearly half had CRF levels that were inadequate as defined by current medical standards for firefighters [4]. Furthermore, Baur et al. found that low CRF among asymptomatic firefighters was associated with higher risk of electrocardiographic and autonomic abnormalities during maximal exercise stress testing and recovery [5]. Consistent with the above, obesity has been shown to negatively affect fitness, MetS, left ventricular hypertrophy/cardiomegaly, incident CHD and on-duty CHD events in the fire service [3,6–8]. Unfortunately, research has consistently found that about 40% of firefighters are obese [3,9].

Cancer is another increasingly important health concern in the North American Fire Service accounting for 27% of all-cause, lifetime mortality among US firefighters with growing evidence of a significant relationship between firefighters’ occupational exposures and cancer [10]. Although firefighting as an occupation appears to convey about a 15% increase in the risk of death from cancer [10], obesity also increases the risk of many cancers by as much as 30–80% [11]. Thus, while recent efforts to improve cancer screening among firefighters [12] and to minimize and mitigate their occupational exposures to carcinogens are very appropriate, it is also crucial to emphasize lifestyle measures such as maintaining a healthier weight, better quality nutrition and avoiding tobacco use as additional strong defences against cancer.

While not a new problem, recent research has brought increasing attention to behavioural health issues in the fire service, including substance abuse, post-traumatic stress and suicide. In many jurisdictions firefighters are responsible for rescue operations, hazardous materials management, responding to natural disasters and domestic attacks, and providing emergency medical services. A common saying in the fire service is that ‘Your worst day is our everyday’ [13]. Not surprisingly, research suggests that regular exposure to these traumatic events may have a negative psychological toll on firefighters’ mental health [13]. Although many firefighters are remarkably resilient, research suggests that a considerable number suffer negative psychological consequences from their experiences. Research has documented increased rates of depression, post-traumatic stress disorder and substance abuse, including oral tobacco and binge drinking [13–15]. Piazza-Gardner et al. assessed the quantity and frequency of alcohol consumption among career firefighters. As observed in the study, firefighters’ drinking levels exceeded those of the general adult population, including college students, suggesting that firefighters represent an at-risk drinking group [16]. Similarly, Haddock et al. reported high rates of binge drinking among firefighters in their study, yet they also found that those who drank alcohol in moderation had the most positive health and safety attributes [15].

There are multiple efforts underway to change the fire service culture from within, and these efforts are to be applauded. Some of the most effective examples of promoting improved health outcomes occur when fire service organizations partner with research programmes [17]. For example, the IAFF/IAFC Wellness Fitness Initiative has long sought to involve subject matter experts and clinicians to devise an evidence-based programme to support firefighters [18], while the Firefighters’ Cancer Support Network incorporates research findings and implements education programmes aimed at behaviour changes, which can decrease firefighters’ occupational exposures [19]. Feeding America’s Bravest is another evidence-based intervention that uses the latest science to promote healthy Mediterranean eating habits among firefighters [20].

One major obstacle to culture change through health promotion programmes has been cost concerns from administrators who consider only the upfront costs, rather than the return on investment. Beyond CVD and cancer, which have costly consequences, obesity has been associated with an increased risk of on-duty death from traumatic causes in the fire service [8] and is also linked to increased risks of injury and disability in the fire service with increased costs [18]. Thus, findings of Kuehl et al. [17] in this issue documenting the economic benefits of a wellness programme that reported reduced injury rates and decreased costs with a beneficial return on investment are of major import [17].

In conclusion, North American firefighters are a unique occupational group who commonly work under dangerous conditions, and in so doing, face several serious potential health issues. Research findings and national fire service priorities both suggest that the greatest challenges facing the health and survival of firefighters include CVD, cancer and behavioural health issues. Importantly, cultural change, including the adoption of healthy behaviours, can help to address all three issues. Changes in the fire service culture to improve firefighters’ health and wellness are necessary, including: discouraging tobacco use, reducing binge eating, avoiding excessive drinking, promoting wellness and fitness programs, encouraging good nutrition, maintaining healthy weights, and combating stress and increasing resiliency.

This article was published as an introduction to a collection of papers (https://academic.oup.com/occmed/pages/Health_in_the_North_American_Fire_Service) concerning Health in the North American Fire Service, a special virtual issue of Occupational Medicine.