February 2010 Issue

A Burning Need — Preventing Heart Disease Among Firefighters
By Rita E. Carey, MS, RD, CDE, and Stephanie Berg, MS, ACSM-RCEP, ACSM-CHFS, NSCA-CSCS, NSCA-CPT, ACE-PFT
Today’s Dietitian
Vol. 12 No. 2 P. 44

They spend their days saving lives, but they may not realize the problems ablaze in their own bodies. Firefighters must follow proper fitness and nutrition guidelines to lessen their risk for heart disease.

An important mission of any fire service is to make sure every firefighter comes home alive and well. As a means to this end, personal protective equipment, safety precautions, and teamwork combine to ensure the highest possible survival rate for firefighters working under extremely hazardous conditions.

Unfortunately, up to one half of on-duty firefighter deaths are caused by heart disease, something no amount of protective gear can prevent. Indeed, cardiac arrest is the leading cause of death among firefighters aged 40 to 50. Many factors increase the risk of dying from cardiac arrest in this population, including poor dietary habits, the presence of subclinical or clinical heart disease, and, most of all, the job’s stressful nature.
In 2008, in an effort to mitigate the impact of heart disease on the lives of firefighters, the International Association of Fire Fighters and the International Association of Fire Chiefs partnered to create the Fire Service Joint Labor Management Wellness-Fitness Initiative (WFI). The initiative’s primary purpose is to recognize the unique heart disease risks associated with firefighting duties and set forth fitness and wellness guidelines specific to this population.

Unique Fitness Needs
Physical fitness is important for preventing heart disease and protecting firefighters from injury while on the job. Historically, firefighters have followed fitness guidelines developed for athletes to prevent illness and injury. Recommendations for athletes typically guide individuals to train physically and mentally for peak performance during competition. Unfortunately, the physical demands placed on a firefighter responding to a call are very different from those for which an athlete trains. For example, an athlete knows when his or her competition or event is scheduled and can prepare for the physical and mental challenges associated with competition over time. A firefighter never knows when his or her event will occur—it could be at noon or 3 am—and thus has to approach training in a unique way.

Recognizing the different training needs of firefighters and other emergency service workers, the National Strength and Conditioning Association (NSCA) developed unique exercise guidelines for these populations in a program called NSCA — Tactical Strength and Conditioning. The NSCA classifies public safety personnel (including firefighters and police officers) and military personnel as “tactical athletes,” those who require a unique training approach to be mentally and physically fit for unexpected bursts of extreme physical activity and mental stress. They would optimally train to be in peak condition at all times, unlike a competitive athlete who usually trains to deliver his or her best performance for only a season or a particular event.

When fire personnel fight a structure fire, they often work under strenuous and physically demanding conditions. The specialized gear and self-contained breathing apparatus can weigh up to 75 lbs. The breathing apparatus and personal protective equipment that firefighters wear also significantly impair postural and functional balance and thus can decrease physical performance and increase physical stress during a call.1 In addition, on-duty firefighters can expect to lift, carry, or pull objects weighing 80 to 135 lbs while wearing heavy gear and being somewhat physically constrained.2 All of these factors have a tremendous effect on an individual’s heart rate, as does the mental stress associated with responding to a call.

In a study conducted in 2008, the Orange County Fire Authority found that an initial alarm call caused the heart rates of monitored firefighters to increase to an average of more than 170 beats per minute (bpm).3 Additionally, they found an average rate increase of more than 50 bpm over the resting rate while firefighters were dressing in personal protective equipment. (The goal for a firefighter is to be dressed and ready to leave the station within 60 seconds of hearing the alarm.)

As firefighters arrive on the scene and engage in the strenuous tasks of pulling hose, setting up equipment, fighting the fire, securing ventilation, and search and rescue, heart rates rise again. In 1996, researchers found that the average maximum heart rate during a 40-minute rescue drill rose to 182 bpm.4 Also of note, a firefighter climbing stairs with gear and equipment for five minutes may have a heart rate reaching 95% of maximum effort during the climb.5

Therefore, a firefighter wearing all of his or her gear must be able to cope with extrinsic stressors such as heat and the weight and constraining effects of personal protective equipment, as well as the intrinsic stress produced by confined movement, less-than-optimal balance, and mental pressure. Fortunately, many of the negative effects of these stressful elements can be somewhat mitigated among firefighters who are physically fit, eating right, and living a healthy lifestyle.

Heart Disease and On-Duty Deaths
An on-duty death is recorded when a firefighter dies while physically at work or within 24 hours of responding to a call for an organized fire department.6 In 2006, the Centers for Disease Control and Prevention (CDC) conducted a study on fatalities among volunteer and career firefighters. The study analyzed data collected by the U.S. Fire Administration from 1994 to 2004 (after omitting deaths resulting from the attacks on the World Trade Towers in 2001). Researchers at the CDC determined that over 10 years, 610 volunteer and 368 career firefighters died while on duty. The CDC then analyzed the causes of these deaths and discovered that one half of the deaths among the volunteer group and 39% among career firefighters were caused by heart attacks. The median age of death was 47 for volunteers and 44 for career firefighters. In other words, cardiac arrest was the leading cause of fatalities for both groups in the 10 years studied.

The researchers later discovered that cardiovascular episodes among firefighters primarily occurred during specific activities: fire suppression, alarm response and return, and physical training.7 For reasons described previously, a firefighter might work continually at 90% to 95% of maximum heart rate while engaged in fire suppression activities. Consequently, the demands on a firefighter’s cardiovascular system during physical work are vastly greater than what the average individual or even athlete experiences while exercising at an intense rate. If subclinical or established vascular disease is present in a firefighter’s blood vessels, the stress and pressure exerted within the arteries can break open both stable and unstable plaque, potentially triggering a heart attack or stroke.

A Wellness Initiative
It is critically important that firefighters practice and maintain healthy behaviors throughout their careers. The Fire Service Joint Labor Management WFI promotes a heart-healthy diet, weight control, regular fitness training, and abstention from smoking. This initiative recommends that all fire departments, both volunteer and career, establish a comprehensive wellness program that includes medical and fitness exams, behavioral (mental) health interventions, fitness training, and injury/medical rehabilitation. Unfortunately, participation in this initiative is voluntary, and nearly 70% of fire departments in the United States lack programs that promote fitness and health.8

Encouraging fire departments to mandate annual fitness and health exams is one way to ensure that more individuals receive the information and training they need to protect themselves from heart disease. Mandated exams can provide an opportunity to address individual modifiable risk factors and are a way to catch any preexisting or emergent heart condition and offer aggressive treatment as needed. After all, knowledge often encourages individuals to adopt lifestyle changes. If firefighters understand their health status and disease risk more fully, they may be motivated to adopt a healthier lifestyle and a beneficial training program that will prevent both cardiovascular disease and cardiac death.

Adopting a wellness initiative requires buy-in from both administration and staff. One or more individuals in a department may initially decide to promote a wellness/fitness program, but support from all parties and funding must be secured before the idea can be advanced. Grants are often available for districts without funding to establish the WFI through the U.S. Fire Administration, which is now a division of the Department of Homeland Security. Visiting and gathering information about programs in other districts can help engender support from administration and staff. Generally, a presentation to the fire district board of directors is required before it can be adopted.

Once support and funding are secured, a strategic plan to put the WFI into practice is needed. Small or volunteer departments may not have the manpower or enough funding to initiate the entire program at once. In these situations, implementing a program gradually may be the better approach.

Stephanie Berg, a firefighter with the Central Yavapai Fire District (CYFD) in Prescott Valley, Ariz., had the opportunity to establish the WFI in her fire district. When Berg was hired as a full-time firefighter in 2004, the assistant fire chief was interested in implementing the WFI in the district. He relied on Berg, an exercise physiologist, to help put the initiative into action. After visiting fire departments in Phoenix that had the program in place, they prepared a proposal, which the district board of directors accepted.

Over the course of two years, Berg developed and monitored fitness exams for every firefighter, engineer, captain, and support/administrative staff member in the district. At that time, testing was conducted in the cardiac rehabilitation and adult fitness gym at the local hospital. After securing funds to place fitness equipment in each station, Berg was able to conduct fitness testing within CYFD facilities. With the help of additional funding from the CYFD, she and three of her coworkers went to school to obtain certification as peer fitness trainers through the American Council on Exercise. Today, peer fitness trainers in the district monitor staff during biannual fitness testing and act as important resources in helping the entire district reach fitness goals.

Once the physical fitness portion of the WFI was under way, the medical component was reviewed, and medical physicals were scheduled following the WFI’s guidelines. A local dietitian planned and presented nutrition classes, held during large staff meetings and individually with three- to four-man crews. Overall, the process was not easy, but persistence, compromise, the support of administrators, and help from coworkers ultimately enriched the program and now support its continued growth.

Less Latitude for Unhealthy Behaviors
Nutrition goals for firefighters include following heart-healthy eating behaviors both at work and at home and maintaining a healthy weight. Obesity is significantly associated with dyslipidemia and elevated blood pressure, triglycerides, and glucose levels.9 Many individuals who are overweight can live for years without undo complications from these clinical risk factors. But unfortunately, there is less latitude for unhealthy behaviors for firefighters. As mentioned earlier, firefighters are exposed to extreme work conditions that require their hearts to work at near-maximum capacity for extended periods of time. Excess body fat increases the heart workload and amplifies heat stress by preventing efficient heat dissipation during exercise. In addition, obesity increases the caloric expenditure required to perform firefighting tasks such as climbing ladders and stairs and may well increase the risk of injury incurred while performing those tasks.10

Firefighters and other emergency response personnel regularly work to protect others from harm. The physical and emotional stressors of their jobs can take a tremendous toll on their health, and nothing underscores this better than the statistics for death from cardiac arrest in the firefighter population. Because they are at extreme risk for heart disease, they need to take extra steps and precautions to stay healthy. Diets that control weight and blood lipids, stress and behavioral management, and specialized fitness training are essential and likely go beyond measures required for the general population to stay healthy. Firefighters may need to learn that their needs are different before they are willing to make lifestyle changes. After all, they are paid to physically and mentally perform at their peak level. However, unlike a prize sought by professional athletes, the ultimate trophy for firefighters is to return home alive and healthy.

— Rita E. Carey, MS, RD, CDE, is a clinical dietitian and diabetes educator at Yavapai Regional Medical Center and the Pendleton Wellness Center in Prescott, Ariz.

— Stephanie Berg, MS, ACSM-RCEP, ACSM-CHFS, NSCA-CSCS, NSCA-CPT, ACE-PFT, is a certified strength and conditioning specialist and certified personal trainer, a registered clinical exercise physiologist and certified and health and fitness specialist, and a peer fitness trainer. She is employed by Central Yavapai Fire District and also works as an exercise physiologist at Yavapai Regional Medical Center.


1. Punakallio A, Lusa S, Luukkonen R. Protective equipment affects balance abilities differently in younger and older firefighters. Aviat Space Environ Med. 2003;74(11):1151-1156.

2. Gledhill N, Jamnik VK. Characterization of the physical demands of firefighting. Can J Sport Sci. 1992;17(3):207-213.

3. Contreras M, Espinoza N. What is firefighter fitness? Presentation given at: Firehouse World Conference; February 2008; San Diego, Calif.

4. Smith DL, Petruzzello SJ, Kramer JM, Misner JE. Physiological, psychophysical, and psychological responses of firefighters to firefighting training drills. Aviat Space Environ Med. 1996;67(11):1063-1068.

5. O’Connell ER, Thomas PC, Cady LD, Karwasky RJ. Energy costs of simulated stair climbing as a job-related task in fire fighting. J Occup Med. 1986;28(4): 282-284. 

6. Centers for Disease Control and Prevention. Fatalities among volunteer and career firefighters — United States, 1994-2004. MMWR Weekly. 2006;55(16):453-455.

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8. Kales SN, Soteriades ES, Christophi CA, Christiani DC. Emergency duties and deaths from heart disease among firefighters in the United States. N Eng J Med. 2007;356(12):1207-1215.

9. Byczek L, Walton SM, Conrad KM, Reichelt PA, Samo DG. Cardiovascular risks in firefighters: Implications for occupational health nurse practice. AAOHN J. 2004;52(2):66-76.

10. International Association of Fire Fighters. The Fire Service Joint Labor Management Wellness-Fitness Initiative, 3rd ed. Washington, D.C.: International Association of Fire Fighters; 2008.