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Workplace
Original research
Prevalence and predictors of obesity among women in the fire service
  1. Sara A Jahnke,
  2. Christopher Kaipust,
  3. Nattinee Jitnarin,
  4. Brittany S Hollerbach,
  5. Maria D H Koeppel,
  6. Christopher K Haddock,
  7. Walker S C Poston
  1. Center for Fire, Rescue, and EMS Health Research, NDRI-USA, Inc, Leawood, Kansas, USA
  1. Correspondence to Dr Sara A Jahnke, Center for Fire, Rescue, and EMS Health Research, NDRI-USA.Inc, Leawood, USA; sara{at}hopehri.com

Abstract

Objectives Firefighter health has received a great deal of increased attention over the past decade, but most work has been specific to men in the fire service due to small numbers of women, likely due to challenges with recruitment and retention of women in the fire service. While findings suggest men in the fire service struggle with high rates of overweight and obesity due to a number of occupational challenges, limited data are available on large samples of women firefighters.

Methods Using snowball sampling techniques, we conducted an online survey of both career (N=2,398) and volunteer (N=781) women firefighters.

Results Rates of obesity for both career (15.4%) and volunteer (31.6%) women firefighters were not only lower than men in the fire service (33.5% career and 43.2% volunteer), but also lower than the general population (41.1%). Women career and volunteer firefighters who engaged in heavy physical activity were less likely to be obese. Being a racial or ethnic minority firefighter was associated with being obese, as was serving more than 20 years in the fire service.

Conclusion Findings highlight that women firefighters have been successful in overcoming the occupational risks, such as a challenging nutrition environment, inconsistent schedules, limited time for fitness, and the metabolic impact of shift work, that put firefighters at increased risk for obesity.

  • firefighters
  • women
  • public health

Data availability statement

Data are available upon reasonable request. Data are available upon request. Please contact corresponding author for the data.

https://doi.org/10.1136/oemed-2021-107590

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    Key messages

    What is already known about this subject?

    • Firefighter health has received a great deal of increased attention over the past decade, including examining rates of obesity.

    • While findings suggest men in the fire service struggle with high rates of overweight and obesity due to a number of occupational challenges, limited data are available on large samples of women firefighters.

    What are the new findings?

    • We examined rates of obesity using data from an online survey of both career (N=2398) and volunteer (N=781) women firefighters.

    • Rates of obesity for both career (15.4%) and volunteer (31.6%) women firefighters were not only lower than men in the fire service (33.5% career and 43.2% volunteer), but also lower than the general population (41.1%).

    How might this impact policy or clinical practice in the foreseeable future?

    • Findings from the study suggest some of the health, wellness and training approaches women in the military pursue, including more structured physical training regimens, might be applicable for the fire service environment.

    • Due to the need for high levels of fitness to respond to fire and rescue activities, focusing on ways for all firefighters to maintain their fitness and a healthy weight are key prevention strategies.

    • These results suggest safe, heavy physical activity may be an important component to future obesity prevention strategies.

    Introduction

    Male firefighters in the US fire service evidence high prevalence rates of overweight and obesity among both career and volunteer services (33.5% and 43.2%, respectively).1 In fact, the prevalence of overweight and obesity combined (79.5% in career and 78.4% in volunteer firefighters) is higher than males in the general US population (73.7%).2 This situation is likely due to a number of occupational risk factors including a challenging nutrition environment, inconsistent schedules, limited time for fitness and the metabolic impact of shift work.3 4

    While several studies have examined the relationship between obesity and health among men in the fire service, there are limited data on women firefighters, likely due to their extremely low numbers nationally and difficulty accessing the population.5 While other first responder groups, such as law enforcement, non-fire based emergency medical services (EMS), and the military have been successful recruiting women into their ranks (estimated 14%–16%),6 7 the fire service continues to have extremely low numbers of women (estimated 3.5%–5.1% of all firefighters).8

    Because firefighting is such a strenuous occupation, maintaining high levels of wellness and fitness has become a priority for firefighters and fire departments.9 10 Existing data demonstrate that obesity among men firefighters is significantly related to disability,11 injury4 12 13 and death.14–16 Understanding the prevalence and predictors of obesity among men in the fire service has been useful in directing prevention efforts, prioritising health concerns and supporting advocacy efforts. However, whether women in the fire service evidence similar patterns to men has yet to be explored. Therefore, the current study was designed to determine the prevalence and predictors of overweight and obesity among a large cohort of women in the fire service.

    Methods

    Sampling

    The parent study from which these data were derived was originally designed to collect foundational data on the health and safety of women firefighters and to use that data to develop model policy and practice recommendations for fire departments. Primary recruitment for the study occurred through a number of existing networks due to two major factors. The number of women in the fire service is extremely low and a national database of firefighters does not currently exist. As a result, recruitment emails for active women in the fire service (career or volunteer) were sent through the International Association of Fire Firefighters, Women in Fire, and the Center for Fire, Rescue, & EMS Health Research (CFREHR) distribution lists. Additional recruitment techniques included contacting previous participants from the CFREHR studies and posting on the ‘Secret List’, an internationally popular fire service listserv. Finally, snowball sampling was used as participants were requested to share the study with their colleagues and friends. This use of snowball sampling is a common method for small, under-represented populations, and has been used to access women firefighters in previous research.17 The final sample consisted of women firefighters in the USA and Canada.

    Internet survey protocol

    All data collection procedures were approved by the appropriate institutional review board. The informational email included a link to a Qualtrics survey that provided an informed consent document. Once participants indicated consent to participate, they were directed to the online survey. Recruitment and data collection occurred from May 2017 through August 2017. Participants were provided a US$10 Amazon gift card at the completion of the survey.

    Measures

    Personal and occupational demographic information was collected using standard questions (eg, age, marital status, education, income, race, ethnicity, rank, years of service).

    Obesity status. Body mass index (BMI; kg/m2) was calculated by using the participant’s self-reported height and weight. BMI was categorised as underweight (<18.5 kg/m2), normal weight (range, 18.5–24.9 kg/m2), overweight (range, 25.0–29.9 kg/m2) and obese (≥30.0 kg/m2).18 Previous work suggests firefighters are generally accurate in their self-reporting of height and weight, assuaging limitation concerns with using self-reported height and weight.19 Obese firefighters were examined in comparison to the combined underweight, normal weight and overweight firefighters because previous work among male firefighters has shown obese firefighters are at the highest risk for a number of health and safety outcomes, even magnitudes higher than overweight firefighters.11–13

    Fitness. Physical activity was measured using the Self-Report of Physical Activity (SRPA) Questionnaire,20 which provides a self-rating of physical activity over the last 30 days. Participants rated their level of fitness on a scale of 0 (sedentary) to 7 (3 or more hours of vigorous activity per week), and the first two categories were combined for analyses.

    Injury. Women were asked to indicate whether they had incurred an on-duty injury in the past 12 months. Those with one or more reported injury were classified as injured. Questions were based on previous work with the fire service,12 and were not limited to injuries resulting in a worker’s compensation claim or department report. Previous work with women firefighters indicates they are often reluctant to report injuries related to concerns about appearing weak or unfit to do the job based on their gender.21

    Substance use. Tobacco and alcohol use questions were based on the Center for Disease Control and Prevention’s Behavioral Risk Factors Surveillance System questionnaire.22 Tobacco use status (current, former, never) was classified based on responses to questions about whether participants had tried a cigarette, smoked a cigarette in the past 30 days, and smoked more than 100 cigarettes in their lifetime. Alcohol use was dichotomised for those who indicated a binge drinking23 (eg, 4 or more drinks in a 2-hour period) episode in the past 30 days versus those who had not.

    Depression. Depression was measured using the Center for Epidemiological Studies Short Depression Scale,24 which captures relevant behaviours and feelings over the previous week. The measure is highly reliable among the general population (Spearman-Brown, split halves r=0.85) and in-patient samples (r=0.90). Responses were dichotomised by whether participants were in the range of concern for depression or not.

    Post-traumatic symptoms. A modified version of the Trauma Screening Questionnaire25 was used to assess symptoms of post-traumatic stress. Participants were asked to indicate which of 10 symptoms they experienced in the past 12 months related to being on the job. The symptoms included having intrusive thoughts, experiencing upsetting dreams, reliving the experience, physical responses (eg, fast heartbeat, churning stomach), sleep disturbances, irritability or angry outbursts, difficulty with concentration, heightened awareness and feeling jumpy or easily startled. Scores of six or more were considered to be in the range of concern for post-traumatic stress symptoms and was the score used to dichotomise the variable.

    Data analysis

    Descriptive statistics (frequencies, means) were calculated for each variable. Univariate comparisons were made between career and volunteer firefighters using Pearson, χ2 and t-tests. Because significant differences were present between career and volunteer firefighters on all demographic variables, statistical models were conducted separately for career and volunteer women firefighters. Simple logistic regression was conducted to evaluate each demographic variable with obesity among career and volunteer firefighters, separately.

    The association between the outcome obesity, and the exposures SRPA, injury, binge drinking, cigarette use, depression, post-tramautic stress disorder, years of service, minority status, marital status, rank, education and income was evaluated using separate logistic regression models for career and volunteer firefighters. The Hosmer and Lemeshow purposeful model selection strategy26 was used to fit the models based on clinical or statistical significance, or previous literature. Age was removed from the models due to the correlation with years of service. Model fit was explored using the Hosmer and Lemeshow Goodness of Fit test. Model specification, multicollinearity and residual analyses were also explored. The OR, 95% CI and p value (p<0.05) were used to evaluate the results. Statistical analyses were performed in Stata V.15.

    Age-standardised rates for obesity were computed for our sample for US women firefighters only for comparison with the most recent age-adjusted sample of the women in the USA27 and in the Department of Defense (DoD).28 StatsDirect Statistical Software V.2.7.8 was used to compute the age-standardised rates via the direct method,29 which allows comparisons of prevalence rates from populations or samples with different underlying age distributions that may confound comparisons across samples or populations.

    Results

    Sample

    A total of 3179 women completed the demographic questions (2398 career, 781 volunteer; 3017 USA, 162 Canada). Demographic characteristics of the participants are presented in table 1. Women firefighters were, on average, nearly 40 years old (career 39.4 years, volunteer 37.1 years). Career firefighters had more years of service on the job (13.3 years) compared with volunteers (9.6 years). Most were non-Hispanic Caucasian women (85.3% career, 91.2% volunteer) which is similar to men in the fire service.30

    View this table:
    Table 1

    Characteristics of women firefighters in the sample

    Obesity prevalence

    As shown in figure 1, the average BMI among participants was 25.9 (SD=4.4) kg/m2 for career firefighters and 27.9 (SD=6.1) kg/m2 among volunteers. Almost half (48.8%) of career firefighters were in the healthy or underweight range of BMI while 15.4% fell in the obese range (figure 2). Over one-third (38.3%) of volunteer firefighters were in the healthy range while nearly a third (31.6%) fell in the obese range.

    Figure 1
    Figure 1

    Body mass index of woman firefighters.

    Figure 2
    Figure 2

    Per cent under or normal weight, over weight and obese women firefighters.

    Demographic correlates of obesity

    The ORs for obesity from simple logistic regression models for each demographic variable, for career and volunteer firefighters, are presented in figure 3. These models examined firefighters who are obese in comparison to the combined category of under/normal/overweight firefighters to identify those most at risk for poor personal and occupational health and safety. For career women, age, years of service, racial minority, rank, and income were significantly associated with obesity. For volunteer women, years of service, rank, and education were significantly associated with obesity.

    Figure 3
    Figure 3

    Demographic correlates of obesity.

    Predictors of obesity

    For both career and volunteer firefighters, frequent heavy physical activity of at least 30 min/week was inversely associated with obesity (table 2). For volunteer women firefighters, recreational physical activity of at least 1 hour/week was also inversely associated with obesity (OR=0.49, 95% CI 0.25 to 0.95). Career women firefighters who served for 20–29 years were more likely to be obese (OR=1.75, 95% CI 1.09 to 2.79), and the magnitude of the association increased after 30 years of service (OR=2.65, 95% CI 1.30 to 5.39). Racial minority career women were also 63% more likely to be obese than Caucasian women (OR=1.63, 95% CI 1.11 to 2.40).

    View this table:
    Table 2

    Predictors of obesity among women career and volunteer firefighters

    Age standardisation

    Age-standardised obesity prevalence among career (17.2%) and volunteer (32.8%) US firefighters was lower than the rates for US adult women (41.1%27). However, when age was standardised to women in the military, US career firefighters and US volunteer firefighters had substantially higher rates of obesity than women in the DoD, 17.2% and 32.3% versus 10.3%.28

    Discussion

    The findings highlight the generally low prevalence of obesity for women career (15.4%) firefighters compared with men in the career (33.5%)3 fire service. Obesity was more common among volunteer firefighters, with nearly one-third (31.6%) of women in the obese range compared with career firefighters. This may be a result of differing recruitment techniques, department standards and time commitments for volunteer firefighters. Still, these rates are lower than men in the volunteer fire service (43.2%).1 While data about male firefighters indicate the fire service serves as an obesogenic environment,3 this does not seem to hold true for women firefighters. It could be that women in the fire service are not as integrated into the environment as men, or it could be due to the extra pressure women report feeling to perform given the male-dominated environment.21 Future research should examine what protective factors women experience that lead to their low prevalence of obesity compared both to men firefighters and women in the civilian population. An additional look at social and environmental differences between volunteer and career women firefighters in regards to physical health would be beneficial given the difference in obesity rates between the two groups.

    Rates of obesity were lower than the US population for women when age standardised. However, when compared with an age-standardised match to women in the military, the rates of obesity were higher. It is possible some of the health, wellness and training approaches women in the military pursue, including more structured physical training regimens, might be applicable for the fire service environment as well given similar needs in terms of physical readiness. A recent systematic review examined randomised clinical trial exercise interventions that measured efficacy on health and lifestyle outcomes.31 Results indicated workplace interventions can improve health outcomes among firefighters. However, none of the articles identified in this review had a gender-based focus and women are often excluded from these studies due to the low number of women in the fire service; future investigations should examine tailoring health promotion interventions with a specific focus on women firefighters.

    Women career and volunteer firefighters who engaged in heavy physical activity for at least 30 min/week were significantly less likely to be obese, and the magnitude of the association increased in protection as the duration of heavy physical activity increased. This provides further evidence for the interplay between fitness and obesity in the fire service.1 Due to the need for high levels of fitness to respond to fire and rescue activities,32 focusing on ways for all firefighters to maintain their fitness and a healthy weight are key prevention strategies. These results suggest safe, heavy physical activity may be an important component to future obesity prevention strategies.

    Behavioural health concerns were not related to obesity in the current analysis, which is consistent with the findings of men in the fire service.12 Firefighting is a stressful occupation where high rates of behavioural health issues are a concern due to both chronic and acute stressors.33 34 In addition to the standard risks of firefighting, discrimination, and harassment of women firefighters also is common.35 Previous work has shown that level of discrimination and harassment are significantly related to poor physical and mental health outcomes among women firefighters.35 Future research should examine obesity prevalence and behavioural health modifiers.

    Injury over the past year was not related to obesity in the current sample. Previous work has found a significant relationship between obesity and injury among men in the fire service.15 16 However, the relationship has traditionally been found when measuring obesity by measured height and weight, body fat or waist circumference. While self-reported height and weight tend to be relatively accurate among firefighters,19 our past work shows that BMI does tend to underestimate the proportion of firefighters who are obese based on high body fat percentage, which is likely a better predictor of injury risk. Further, there is evidence that obesity modifies the association between health behaviours and injury among men firefighters,36 which could occur among women firefighters. Future research should examine differing methods of obesity classification among women in the fire service to see if patterns mirror those found among men.

    Among career firefighters, those who reported being racial or ethnic minorities were 63% more likely to be obese than their Caucasian peers. This is not consistent with data from male firefighters1 that finds similar rates of obesity regardless of race or ethnicity. It is possible that women who are of racial or ethnic minority status and in the fire service may have particularly challenges maintaining their health and wellness given the intersectionality, but future research is needed to further elucidate the relationship. Career firefighters who have more than 20 years of service were more likely to be obese than those with less than 10 years of service. The magnitude of association increased for those with more than 30 years of service. This result aligns with previous research among male firefighters which found an annual weight gain of 0.5–1.5 kg/year.37

    While the current results highlight several important findings, limitations do exist and should be acknowledged. Clearly, a population-based sample would be preferable to the snow-ball sampling approach used in this study. However, a number of issues made population-based sampling unfeasible such as the lack of a national database of women firefighters and low census of women in any given department. As databases of women in the fire service are developed, it is important to expand this area of work. The cross-sectional nature of the data also limits interpretation of directionality and our ability to make causal inferences. Future cohort studies can examine incident relationships between variables.

    Additionally, limitations concerning measurement should be acknowledged. The current study did not account for the severity of injury, which may limit physical activity, and contribute to an increased BMI during the time of data collection. It is also necessary to acknowledge the self-reported nature of the participants’ height and weight, which was used to calculate their BMI, a method that we have used previously and correlates well with measured BMI among male firefighters.19 Given the widespread location of participants, a standard and objective measure of height and weight was not feasible. Lastly, because the prevalence of obesity was greater than 10% in both career and volunteer women firefighters, using the OR to approximate the risk ratio may have resulted in an overestimation of the risk ratio.38

    Despite the limitations, the current study has a number of strengths. It is the first study to document the rate of obesity and fitness among a large, national sample of both career and volunteer women firefighters. While snowball sampling is acknowledged to be the best sampling to estimate prevalence, couching the questions related to obesity and fitness into a more general survey benefits the sample in that it does not just pull for those interested in obesity and fitness and likely makes the findings more generalisable. Overall, the data provide a strong foundation for future research and as a general point of reference for the fire service. Future research also should examine other first responder groups such as law enforcement and EMS personnel to see if results are similar for women in those services as juxtaposed to men.

    Data availability statement

    Data are available upon reasonable request. Data are available upon request. Please contact corresponding author for the data.

    Ethics statements

    Patient consent for publication

    Ethics approval

    The Institutional Review Board of NDRI-USA approved of the study protocol and procedures for this project.

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    Footnotes

    • Contributors All authors have contributed to the design, analysis and drafting the manuscript, and have approved this submitted version. SAJ is the guarantor and accepts full responsibility for the finished work, the conduct of the study, had access to the data, and controlled the decision to publish.

    • Funding The current study was funded by FEMA’s Assistance to Firefighters Research & Development Grant EMW-2015-FP-00847.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.