Florida Firefighters Lower Health Risks Through Weight Loss Program

By Todd J. Leduc and Sara A. Jahnke

Jobs in the fire and emergency services are demanding both physically and mentally. There is wide agreement that these personnel need to have high levels of wellness and fitness so they are ready to respond at a moment’s notice to the wide range of fire, rescue, and emergency medical calls that transpire daily. Unfortunately, evidence suggests the fire service is plagued with high rates of overweight and obesity,^1-6 low fitness,^3,7,8 metabolic syndrome,^7,9(p200) poor cholesterol profiles, ^7,9,10 and high rates of cancer.^11,12 Evidence also suggests that a number of work-related risk factors associated with fire and emergency services contribute to and increase the risk of poor health including the physiologic strain of firefighting, exposure to particulate matter and airborne toxins, extreme heat, dehydration, shift work, noise, and psychological stress.¹³ Together, these factors have led to cardiovascular events being the leading cause of line-of-duty deaths (LODDs) among United States firefighters annually.¹⁴ Firefighters also experience higher than normal rates of several forms of cancer,^11,12 likely due to exposures. In addition, firefighters experience more than 70,000 injuries annually.¹⁵ As research has begun to explore the impact firefighting has on personnel, increasing attention is being paid to firefighter health.

Figure 1. Percent of Firefighters in Each Weight-Loss Category

5% of body weight lost is considered a clinically meaningful cut-off by national standards. Nearly a quarter of firefighters achieved this in just six months. On average, those who were overweight or obese at baseline lost 2.7% (SD=3.8) of their body weight by follow-up, with an average weight loss of 5.9 lbs. (SD=8.8.lbs.).

Firefighters and Heart Disease

The leading cause of LODDs among firefighters is cardiovascular events, and for every LODD caused by cardiovascular disease (CVD), there are an additional 17 nonfatal cardiac events that occur on duty.¹⁵ CVD-related LODDs are higher among firefighters than on-the-job deaths of similar groups such as police (22%) and other emergency medical service firefighters (11%) or for occupational groups as a whole (15%).¹⁴ Firefighters face several risk factors that put them at increased risk for heart attack and stroke-some are related to the tasks of firefighting and the challenges of working on 24-hour shifts while others are personal risk factors. Many personal risk factors are influenced by work-related tasks and the firehouse environment.

Job-Related Factors

Responding to fire and emergency calls is inherently stressful, as it requires constantly being prepared for responding to a call. Once a call comes in, it requires an extreme level of physical exertion. Research has found that the risk of a cardiovascular event is as high as 136 times greater while fighting a fire than it is during regular station duties.¹⁶ The products of combustion also may be related to the increased risk of CVD, as several chemicals that impact the heart are present during and after fires.17 Shift work has independently been related to CVD because of the interrupted sleep and circadian rhythms, which lead to weight gain, hypertension, and insulin resistance.^18-21 The fire service also has developed unhealthy patterns of eating, and the cultural practices around eating encourage eating large portions of unhealthy foods.¹ The firehouse environment also sometimes encourages poor fitness habits, with high-call volumes making fitness difficult to schedule.

Figure 2. Percent of Participants in Each Risk Category

The percent of those in the obese range decreased from 47.5% at baseline to 40.5% at follow-up. More than a quarter of participants who were obese at baseline ended up in the Overweight category at follow-up. Of those in the Overweight category at the start, 9.3% ended in the Healthy category at follow-up. National estimates of overweight/obesity (BMI >25) in the fire service are estimated to be around 80%.3 At baseline, the rate was 91.6%, suggesting the OWL program motivated those most at risk to engage in the program.

Personal Risk Factors

Like the general population, firefighters across the country fight obesity and weight gain. Research among firefighters estimates the rates of overweight and obesity among firefighters are as high as 73% to 88%,^3,22 which is actually higher than the general population. When obese firefighters are compared to normal-weight firefighters, the impact of their unhealthy body composition is clear.^3,23 Obese firefighters are more likely to suffer from conditions such as hypertension, low high-density lipoprotein (HDL) cholesterol, high low-density lipoprotein (LDL) cholesterol, high triglycerides, lower cardiorespiratory fitness, reduced strength, more frequent fatal cardiac events, and higher risk of injury. Obesity, while influenced by work-related factors (e.g., firehouse eating, circadian rhythms, lack of time for working out), also is related to personal nutrition and fitness practices. Diets high in sugar and processed food and limited physical activity lead to higher rates of obesity and risk among firefighters. Faced with the negative job-related factors that are inherent to firefighting, it is particularly important for firefighters to focus on personal risk factors.

Figure 3. Systolic Measure of Blood Pressure, Percent Within Category

Firefighters and Cancer

Given all the chemicals firefighters are exposed to, it is not surprising that there is concern about firefighters and cancer. Several departments have reported large groups of firefighters all developing cancer around the same time. Studies that have reviewed the literature on firefighters and cancer have found that several types of cancers occur more frequently among firefighters than the general population, including the following:^11,12,24

• Multiple myeloma
• Non-Hodgkin’s lymphoma
• Prostate cancer
• Testicular cancer
• Skin cancer
• Malignant melanoma
• Brain cancer
• Rectal cancer
• Buccal cavity and pharynx cancer
• Stomach cancer
• Colon cancer
• Leukemia
• Malignant mesothelioma
• Kidney cancer
• Bladder cancer
• Esophageal cancer
• Intestinal cancer
• Lung cancer
• Laryngeal cancer

It is believed that the increased risk for these cancers comes from the countless chemicals in the air during and after a fire, even once the smoke has cleared. To better understand the exposure risks firefighters face, Underwriters Laboratories conducted a live burn while monitoring the particulates in the air in its lab. The study found the presence of several gases and particulates, including known carcinogens, were exceedingly present during and after the fires. Most (more than 97%) of the particulates gathered during the burn and overhaul were so small they were invisible to the naked eye.

These risks are increased by the types of products that now burn in a house fire. Synthetic products generate more than 12 times the particles that result from burning natural wood-based products. Carcinogens get into the body through several means including inhalation and through the skin, particularly when they are clinging to gear, gloves, and hoods. In addition to exposures, personal risk factors like food choices, smoking, smokeless tobacco, and alcohol use increase the risk of developing cancer. Firefighters need to be vigilant about minimizing the risks they face.

Firefighters Health Research

After 9/11, there has been an increased understanding of the health challenges firefighters face. To understand these risks, the Department of Homeland Security began funding research on the health and wellness of firefighters through its Fire Prevention and Safety’s Research and Development grant mechanism in 2005. Since its inception, the program has developed a number of lines of research covering health risks on a range of topics including sleep, risk for injury, cardiovascular risk factors, rehab, hydration, and health interventions.

Consistently, scientists have found that overweight/obesity is one of the most significant health concerns facing the fire service. Rates of overweight/obesity (Body Mass Index (BMI)>25) among firefighters are even higher than those of the general population. Many firefighters have metabolic syndrome, and obese firefighters exhibit low cardiorespiratory fitness. ^2,3,22,25 As noted previously, there are a number of occupational risk factors that make firefighters susceptible to weight gain, making health and wellness even more important for this group.

Figure 4. Diastolic Measure of Blood Pressure, Percent Within Category

For example, the rate of injury among firefighters (more than 70,000 injuries each year) is high compared to other types of occupations. Although some injuries can be expected because of the risk firefighters have to take, others are influenced by personal factors. The most common types of injury for firefighters are musculoskeletal injuries such as strains and sprains.26 When studies have looked at what predicts these injuries, the only factor that has predicted injury was obesity: Those who are obese are more than five times more likely than their healthy weight peers to have an injury.²⁷ These injuries result in nearly $1,700/year in excess injury-related absenteeism costs for Class I and II obese firefighters.² Obesity also was found to put firefighters at increased risk for poor cardiovascular outcomes and was related to poor cardiorespiratory fitness.²⁵

Fuel to Fight (F2F) Study

As part of its research portfolio, the Federal Emergency Management Agency (FEMA) Assistance to Firefighters Grant Program funded scientists at the Center for Fire, Rescue & EMS Health Research (CFREHR; EMW-2009-FP-001971) to examine the nutrition environment in the fire service as well as the impact of wellness programs on fire departments. This national cohort study was conducted in 20 departments of varying sizes and locations. Departments were matched based on whether they had implemented key components of the International Association of Fire Fighters/International Association of Fire Chiefs (IAFF/IAFC) Wellness Fitness Initiative²⁸Wellness Fitness Approach (WFA) Departments vs. Standard Departments and compared on a number of health parameters. Given their interest in health and wellness, the Broward Sheriff’s Office of Fire Rescue (BSOFR) volunteered to be a study site and was selected to participate. Scientists from CFREHR visited the department on two occasions for data collection. Two battalions were randomly selected for participation, and three houses from each battalion were then selected. Random selection increases the chances that the end sample will be representative of the department as a whole. For those who participated, the scientific team collected information on a number of self-report domains as well as height, weight, body fat (using foot-to-foot bioelectric impedance), blood pressure, pulse, 24-hour food recalls, and lipid panels. The study was well accepted by BSOFR; nearly all firefighters were offered the opportunity to participate in the study.

Overall study findings were that inclusion of a health and wellness program has significant effects for the departments that implement them.29 Firefighters in WFA departments were significantly less likely to be obese than those in standard departments and were five times more likely to achieve the levels of fitness necessary for firefighting. In addition, firefighters in departments with a wellness focus were less likely to smoke and had higher job satisfaction than their peers. Overall, the study highlighted benefits of implementing a wellness program at the individual and department levels.

CFREHR scientists reported department level data back to department administration, and the results for BSOFR were troubling. Not only were rates of overweight and obesity high, but they were higher than those found in the fire service in general. Of the firefighters measured, nearly a quarter had systolic hypertension, and approximately the same number evidenced diastolic hypertension. Findings highlighted the extreme need of BSOFR personnel for health intervention. Published articles on this study are available at http://www.biomedcentral.com/1471-2458/13/805 and http://www.cdc.gov/pcd/issues/2014/14_0091.htm.

BSOFR’s Response: Obesity Weight Loss (OWL) Program

In June 2013, Chief Todd Leduc was tasked with managing BSOFR’s newly created Division of Health and Wellness. Armed with the F2F department level results, he met with BSO’s Director of Risk Management Victor Marrero. They discussed the health risks facing firefighters, the status of their department, and opportunities for intervention. What resulted was a plan for the Obesity Weight Loss (OWL) program to be funded by the savings generated by the Risk Management’s newly created workers’ compensation department. The intervention was designed to proactively address the most significant risk factor firefighters face-weight-as a means of decreasing injury-related costs and improving firefighter health risk overall.

Program Structure

The OWL program was a departmentwide competition to focus on health, wellness, and weight loss. Station teams were formed to compete on how much weight they could lose over a six-month period; $25,000 was the prize incentive. Key components of the OWL program were developed to be sensitive to the needs of the personnel, to capitalize on department culture, and to engage community stakeholders. Personnel choosing to participate enrolled after risk management and fire rescue staff visited each station to explain the program. Risk Management personnel provided baseline weigh-ins. Risk Management became the “lead dog” for the OWL program, and its Safety and Loss Prevention section was tasked with taking the lead in the weigh-in process and keeping the records of all the participants’ starting and ending weights. They, in fact, weigh in all 395 OWL participants: beginning, middle, and ending.

The program was designed to be a strictly voluntary program, which eliminated union and department “red tape.” Key to program success was the collaboration among leadership, labor, and risk management. Sheriff Scott Israel consistently promoted the program as important to his philosophy of staying safe. Local 4321 and its E-Board also bought into the program and encouraged member participation. Not only did they support the program, but they also joined in the weight-loss challenge, and some of its members were the biggest weight losers! Having the buy-in and support of these individuals who were willing to lead by example set both the tone and precedent for program success.

Marketing

The program was marketed widely to personnel throughout BSOFR. Weekly messages promoting team competition and encouraging weight loss were sent to all personnel. In addition, program incentives were provided to personnel to keep the program and its goals visible. At baseline, each participant was provided with a T-shirt with the OWL logo; a gym bag with a logo was given at the three-month point (both were provided by 1-800-Board Up).

Community Collaborations

Through creative collaborations with local organizations and businesses, BSOFR was able to provide a number of resources to personnel such as the following:

• Coventry Health Care of Florida provided, through a partnership, a contracted exercise physiologist and nutrition educator for fire station-based nutrition education, body composition screening, and cardio step testing.
• Baptist Health South Florida provided station-based health fairs that included education/coaching, blood pressure, cholesterol, glucose, and body composition screenings. No-cost cardiac calcification screenings were also offered to participants.
• Whole Foods Market provided station-based healthy cooking and eating demonstrations as well as gift baskets.
• Gatorade provided station-based sports fuel and nutrition education.
• Weight Watchers offered participants discounted membership fees to help in weight-loss management.
• BSOFR’s health carrier pledged $1 for every pound that was lost.
• BSOFR’s excess workers’ compensation insurance carrier contributed an additional $2,500.
• Participants also were offered discounted hydrostatic body composition screenings.

OWL Outcomes

Of the 664 sworn firefighters at BSOFR, 60% (395 firefighters) chose to participate in the program, which started on 10/1/13 and finished six months later on 3/31/14. A mid-program weigh-in was completed on 1/6/14 to gauge program progress. At the three-month weigh-in (immediately after the holidays), two teams had collectively gained weight; however, by follow-up, all teams had lost weight.

• OWL participants lost 2,361 pounds.
• Of all the participants with baseline and follow-up data, 70.7% lost weight during the OWL trial and 15.4% did not gain weight.
• OWL participants lost an average of 5.8 lbs. (SD=8.9 lbs.) with changes in weight ranging from 61 lbs. lost to 17 lbs. gained.
• By comparison, the average firefighter gains between 1 and 3.4 lbs. per year. In the PHLAME (Promoting Healthy Lifestyles: Alternative Models’ Effects) lifestyle intervention study, heralded as a success in the fire service, the active intervention arms of the study actually gained weight over the year.30

Fuel 2 Fight Health Comparisons

Data for waist circumference and blood pressure for OWL participants are limited to follow-up data and cannot be compared directly to the Baseline Fuel 2 Fight data. Health parameters with available data from OWL Follow-up and Fuel 2 Fight are outlined in Figure 4-6.

Hypertension

Rates of hypertension for both systolic and diastolic measures (Stages 1 and 2) were lower among OWL participants than for Fuel 2 Fight participants (Figure 4).

OWL Feedback

Overall, BSOFR leadership and personnel positively received the OWL program. The program was perceived as being successful in increasing a focus on health and wellness and its relationship to readiness. Individualized feedback seemed beneficial in helping individuals understand their personal risk while the team competition motivated positive peer pressure to achieve healthy outcomes.

Some challenges existed in program implementation. It was suggested that having some individual incentives beyond the team prizes would be beneficial. Some perceived the six-month time frame to be too long. The time frame was chosen as a means of not only setting but also maintaining a health focus for an extended period. Challenges also existed to weigh-ins, since they took place over a 10-day period. Some felt they had an unfair disadvantage because they were weighed at the beginning of the period instead of at the end. Despite these considerations, the program was hailed as a significant success!

Figure 5. Percent of Firefighters at High Risk by Waist Circumference

Future Directions

Based on the initial success of the OWL program, a similar program is underway with the Department of Detention personnel. For BSOFR personnel, 50 firefighters who weighed 250 pounds or more were identified. Approximately 20% of this group gained weight over the program period. Others took the program as an opportunity to make a concerted effort to lose weight; one person lost more than 40 pounds. This group overall lost an average of 19.4 pounds per participant, for a total of 970 pounds, indicating they, in general, welcomed the opportunity for weight loss.

Evidence suggests that this group of personnel is at extremely high risk for poor health outcomes and injury. Current plans include an OWL II program aimed at further assisting these firefighters who are at the greatest risk for injury and cardiovascular events. Potential future directions include a voluntary program with an incentivized participation model. The program may provide resources (e.g., dietician, peer fitness trainer, accountability tracking such as a Fitbit); a medical exam to establish a baseline risk assessment, and additional support for making and achieving goals. The specific plan is under development in collaboration with health and wellness experts and health care partners.

References

1. Haddock C, Poston WSC, Jahnke SA. Addressing the Epidemic of Obesity in the United States Fire Service. Greenbelt, MD: National Volunteer Fire Council; 2011. Available at: http://tkolb.net/tra_sch/FireTruckCrashes/2012/FF_ObesityStudy.pdf. Accessed September 10, 2013.

2. Poston WSC, Jitnarin N, Haddock CK, Jahnke SA, Tuley BC. Obesity and injury-related absenteeism in a population-based firefighter cohort. Obes Silver Spring Md. 2011;19(10):2076-2081. doi:10.1038/oby.2011.147.

3. Poston WSC, Haddock CK, Jahnke SA, Jitnarin N, Tuley BC, Kales SN. The prevalence of overweight, obesity, and substandard fitness in a population-based firefighter cohort. J Occup Environ Med Am CollOccup Environ Med. 2011;53(3):266-273. doi:10.1097/JOM.0b013e31820af362.

4. Soteriades ES, Hauser R, Kawachi I, Liarokapis D, Christiani DC, Kales SN. Obesity and Cardiovascular Disease Risk Factors in Firefighters: A Prospective Cohort Study. Obes Res. 2005;13(10):1756-1763. doi:10.1038/oby.2005.214.

5. Soteriades ES, Hauser R, Kawachi I, Christiani DC, Kales SN. Obesity and risk of job disability in male firefighters. Occup Med Oxf Engl. 2008;58(4):245-250. doi:10.1093/occmed/kqm153.

6. Tsismenakis AJ, Christophi CA, Burress JW, Kinney AM, Kim M, Kales SN. The obesity epidemic and future emergency responders. Obes Silver Spring Md. 2009;17(8):1648-1650. doi:10.1038/oby.2009.63.

7. Baur DM, Christophi CA, Tsismenakis AJ, Jahnke SA, Kales SN. Weight perception in male career firefighters and its association with cardiovascular risk factors. BMC Public Health. 2012;12(1):480. doi:10.1186/1471-2458-12-480.

8. Durand G, Tsismenakis AJ, Jahnke SA, Baur DM, Christophi CA, Kales SN. Firefighters’ physical activity: relation to fitness and cardiovascular disease risk. Med Sci Sports Exerc. 2011;43(9):1752-1759. doi:10.1249/MSS.0b013e318215cf25.

9. Donovan R, Nelson T, Peel J, Lipsey T, Voyles W, Israel RG. Cardiorespiratory fitness and the metabolic syndrome in firefighters. Occup Med. 2009;59(7):487-492. doi:10.1093/occmed/kqp095.

10. Burgess JL, Kurzius-Spencer M, Gerkin RD, Fleming JL, Peate WF, Allison M. Risk factors for subclinical atherosclerosis in firefighters. J Occup Environ Med Am CollOccup Environ Med. 2012;54(3):328-335. doi:10.1097/JOM.0b013e318243298c.

11. LeMasters GK, Genaidy AM, Succop P, et al. Cancer risk among firefighters: a review and meta-analysis of 32 studies. J Occup Environ Med Am CollOccup Environ Med. 2006;48(11):1189-1202. doi:10.1097/01.jom.0000246229.68697.90.

12. Youakim S. Risk of cancer among firefighters: a quantitative review of selected malignancies. Arch Environ Occup Health. 2006;61(5):223-231. doi:10.3200/AEOH.61.5.223-231.

13. Soteriades ES, Smith DL, Tsismenakis AJ, Baur DM, Kales SN. Cardiovascular disease in US firefighters: a systematic review. Cardiol Rev. 2011;19(4):202-215. doi:10.1097/CRD.0b013e318215c105.

14. CDC. Fatalities among volunteer and career firefighters-United States, 1994-2004. MMWR Morb Mortal Wkly Rep. 2006;55(16):453-455.

15. Karter MJ, Molis JL. US Firefighter Injuries-2011. National Fire Protection Association, Fire Analysis and Research Division; 2012. Available at: http://www.tkolb.net/FireReports/2012/2011FF_Injuries.pdf. Accessed August 29, 2013.

16. Kales SN, Soteriades ES, Christophi CA, Christiani DC. Emergency duties and deaths from heart disease among firefighters in the United States. N Engl J Med. 2007;356(12):1207-1215. doi:10.1056/NEJMoa060357.

17. Fabian T, Borgerson JL, Kerber SI, et al. Firefighter Exposure to Smoke Particulates. Underwriters Laboratories; 2010. Available at: http://www.ul-mexico.com/global/documents/offerings/industries/buildingmaterials/fireservice/WEBDOCUMENTS/EMW-2007-FP-02093%20-%20Executive%20Summary.pdf. Accessed February 28, 2013.

18. Elliot D, Kuehl K. The effects of sleep deprivation on fire fighters and EMS personnel. Fairfax, VA: International Association of Fire Chiefs; 2007. Available at: http://www.iafc.org/files/progssleep_sleepdeprivationreport.pdf. Accessed January 30, 2014.

19. Esquirol Y, Bongard V, Mabile L, Jonnier B, Soulat J-M, Perret B. Shift work and metabolic syndrome: respective impacts of job strain, physical activity, and dietary rhythms. Chronobiol Int. 2009;26(3):544-559. doi:10.1080/07420520902821176.

20. Lowden A, Moreno C, Holmbäck U, Lennernäs M, Tucker P. Eating and shift work-effects on habits, metabolism and performance. Scand J Work Environ Health. 2010;36(2):150-162. doi:10.5271/sjweh.2898.

21. Puttonen S, Härmä M, Hublin C. Shift work and cardiovascular disease-pathways from circadian stress to morbidity. Scand J Work Environ Health. 2010;36(2):96-108.

22. Kales SN, Polyhronopoulos GN, Aldrich JM, Leitao EO, Christiani DC. Correlates of body mass index in hazardous materials firefighters. J Occup Environ Med Am Coll Occup Environ Med. 1999;41(7):589-595.

23. Clark S, Rene A, Theurer WM, Marshall M. Association of body mass index and health status in firefighters. J Occup Environ Med Am Coll Occup Environ Med. 2002;44(10):940-946.

24. Daniels RD, Kubale TL, Yiin JH, et al. Mortality and cancer incidence in a pooled cohort of US firefighters from San Francisco, Chicago and Philadelphia (1950-2009). Occup Environ Med. 2013:oemed-2013-101662. doi:10.1136/oemed-2013-101662.

25. Baur DM, Christophi CA, Kales SN. Metabolic syndrome is inversely related to cardiorespiratory fitness in male career firefighters. J Strength Cond Res Natl Strength Cond Assoc. 2012;26(9):2331-2337. doi:10.1519/JSC.0b013e31823e9b19.

26. Jahnke SA, Poston WSC, Haddock CK, Jitnarin N. Injury among a population based sample of career firefighters in the central USA. InjPrev J IntSoc Child AdolescInj Prev. 2013.doi:10.1136/injuryprev-2012-040662.

27. Jahnke SA, Poston WSC, Haddock CK, Jitnarin N. Obesity and incident injury among career firefighters in the central United States. Obes Silver Spring Md. 2013. doi:10.1002/oby.20436.

28. International Association of Fire Firefighters (IAFF). Wellness Fitness Initiative: Departments. Available at: http://www.iaff.org/hs/wfiresource/departments.html. Accessed February 13, 2014.

29. Poston WS, Haddock CK, Jahnke SA, Jitnarin N, Day RS. An examination of the benefits of health promotion programs for the national fire service. BMC Public Health. 2013;13(1):805. doi:10.1186/1471-2458-13-805.

30. Elliot DL, Goldberg L, Kuehl KS, Moe EL, Breger RKR, Pickering MA. The PHLAME (Promoting Healthy Lifestyles: Alternative Models’ Effects) firefighter study: outcomes of two models of behavior change. J Occup Environ Med Am Coll Occup Environ Med. 2007;49(2):204-213. doi:10.1097/JOM.0b013e3180329a8d.

TODD J. LEDUC, MS, CFO, CEM, MIFirE, is a 25-year veteran of and the chief of health & safety for Broward County (FL) Fire Services. He is the secretary of the International Association of Fire Chiefs (IAFC) Safety, Health and Survival Section and a peer reviewer for professional credentialing designation and agency accreditation with the Center for Public Safety Excellence. He has been published and speaks extensively on fire service leadership and safety and is on the editorial board for a number of publications. In 2013, he was awarded the 2013 IAFC Gary Briese Safety Award and was named the Center for Public Safety Excellence Ambassador of the Year; in 2014, he was honored by the IAFF Local 4321 for leadership on firefighter health and safety issues.

SARA A. JAHNKE, PhD, is the director of the Center for Fire, Rescue and EMS Health Research at the National Development and Research Institutes, Inc. She completed her doctorate in psychology with a health emphasis at the University of Missouri-Kansas City and the American Heart Association’s Fellowship on the Epidemiology and Prevention of Cardiovascular Disease. She was the principal investigator of two large-scale studies of the health and readiness of the U.S. Fire Service, funded by the Department of Homeland Security, and a qualitative study of health and wellness with a national sample of fire service representatives from the American Heart Association. She is the principal investigator of a study on the health of women firefighters, funded by the National Heart Lung and Blood Institute at the National Institutes of Health. In addition, she has had published research on health behaviors of military personnel and qualitative and quantitative articles in the areas of obesity, tobacco, and health behaviors.