A comprehensive medical screening program is one of the most proactive policies in protecting a firefighters overall health, yet many fire departments are unable to offer them. In today’s tight economic times it is difficult to justify any type of health and wellness program. In fact according to a report issued by the NFPA (October, 2011) 41% of California fire departments had no program to maintain basic firefighter health and wellness. Yet, it is not all the fire departments fault, firefighters are to blame as well. Even with all the education and information available today researchers at Iowa State University discovered that 86% of volunteer firefighters did not know their blood lipid and 47% did not know their blood pressure (Yoo & Franke). The truth be told, the job will kill you and being ignorant will not help. So what can you do to help yourself and your department?
Obesity is an epidemic in our country and the risks associated with it are heart disease, stroke, high blood pressure, and diabetes. The term obesity is used to describe the health condition of anyone significantly above his or her ideal healthy weight. Firefighters are often classified as obese or overweight due to many factors associated with the job (ie. poor nutrition, sleep disruptions, limited physical activity). Researchers at the Bringham and Women’s hospital showed that prolonged sleep restriction with simultaneous circadian disruption decreased the individuals metabolic rate (Buxton, 2012). According to another study (Shift Work, 2012) shift workers were 23 percent more likely to have had a heart attack and 24 percent more likely to have had another cardiovascular problem. Chances of an ischemic stroke were 5 percent greater among those who worked other than daytime hours. People who worked nights faced the biggest risk. Their odds of a cardiovascular problem were 41 percent greater than for daytime workers.
For the most part getting your annual physical is a simple procedure, but are the tests you getting really benefitting you? The NFPA 1582 Standards on Comprehensive Medical Program provides a buffet of tests but it can be overwhelming and costly to offer them all. Other programs utilize the Framingham Risk Score which utilizes a number of scoring systems used to determine an individual's chances of developing cardiovascular disease (Wilson, 1998). Although the scoring system does help predict coronary heart disease it does not predict for stroke, transient ischemic attack (TIA), and heart failure. This could mean that many firefighters could be flying under the radar, or even worse those who were assessed as low risk could still be at risk. Therefore we are really not addressing cardiovascular disease and the risks associated with it.
Most standards of care programs will generally include the following tests:
· Total Cholesterol
· Blood Pressure
· Body Mass Index (BMI)
· Tobacco Use
· ATP III classification
· Framingham Score
Although comprehensive, this does not show us the real picture. In fact according to one program performed by Reno Public Safety, individuals classified as “high risk” were told to lose weight with a standard high carb, low fat protocol, begin an exercise program, or be placed on statins. Individuals with blood glucose over 100 were not classified as pre- diabetic and were overlooked. Values for fasting plasma glucose range from 100-125 are considered pre-diabetic and recent research has shown that some long-term damage to the body, especially the heart and circulatory system, may already be occurring during pre-diabetes.
Utilizing the basic standards of care assessments listed above the Reno Public Safety program classified 1-2% of the population as “high risk”. However this did not reflect what was really occurring. To help create a more realistic picture they decided to include insulin resistance and metabolic syndrome and saw an increase of 25% of their work force classified as sick or at risk.
Insulin resistance is a condition in which cells no longer respond well to insulin. The body responds by secreting more insulin into the bloodstream in an effort to reduce blood glucose levels. Metabolic syndrome is a name for a group of risk factors that occur together and increase the risk for coronary artery disease, stroke, and type 2 diabetes. Research performed at the University of Connecticut showed that a carbohydrate restriction improves glycemic control, insulin levels, triglycerides, and HDL levels even in the absence of weight loss. However, another study in the journal Circulation (2011) showed that both C-reactive protein and LDL cholesterol both increase in a high-protein diet that doesn’t contain adequate fiber.
Another very important screening that should be incorporated into every program is the amount of inflammation within your body. Researchers at the University of California - San Francisco (O’Donovan, 2012) showed that small, traumatic exposures over a lifetime or career will boost inflammation in the body. Individuals with higher levels of inflammation within their body tend to have an increased risk of having a heart attack. New England Journal of Medicine , (Ridker, 2002) concluded that CRP outperforms LDL cholesterol as a predictor of cardiovascular risk and is a better predictor of cardiovascular events (heart attacks, strokes, bypass surgery, or angioplasty) than other inflammatory markers (Ridker, 2000). It should be noted that people who have metabolic syndrome often have low levels of inflammation throughout the body.
The role of fat or lipoproteins area constant theme when discussing CVD, and there are many different types and each plays a different role on the body. The most common is cholesterol and is often associated with CVD. Many firefighters have heard of High density lipoprotein cholesterol (HDL-C) often termed the “good” cholesterol, low density lipoprotein cholesterol (LDL-C) is usually termed the”bad” cholesterol, and triglycerides. Recently, many researchers have been looking into the importance of LDL-particle size (small LDL-P). LDL-P measures the actual number of LDL particles. It appears that LDL-P may be a stronger predictor of cardiovascular events than LDL-C. Low LDL-P is a much stronger predictor of low risk than low LDL-C. In fact, about 30 – 40% of those with low LDL-C may have elevated LDL-P. Therefore you can have low LDL-C but still be at risk for CVD, particularly if your LDL-P is elevated. There is an inverse correlation between blood levels of triglycerides and particle size. Thus, the higher your triglycerides, the higher the number of small LDL particles. Conversely, the lower your triglycerides, the higher the number of larger, fluffy protectiveLDL- particles (McNamara, 1992).This may explain why so many patients who suffer a heart attack do not have elevated levels of LDL-C. Patients with high levels of triglycerides and low HDL-C are likely to have high LDL-P despite normal or low LDL-C. This could be a typical patient with the metabolic syndrome. Studies indicate that these patients may actually benefit most from low carbohydrate diets (Kraus, 2006).
In addition to the other tests the Reno Public Safety program had screened 196 individuals for LDL-P, this additional screen determined that 92% or 180 officers were actually at high risk for CVD, leading us to believe there is a large correlation between insulin resistance, systemic inflammation, and LDL-particle size. To help firefighters understand their health screenings a basic self assessment model was developed to help identify their current level of risk. These assessments are to help identify if you are at risk and in no way a means to diagnose CVD. Use this screening model to help create a more proactive approach to your health and always be under the care of a health care provider. Make sure to get your annual physicals and ask your doctor for the tests associated with the chart. Remember, it’s the job that increases the chances of CVD and the only way to combat it is to know the FACTS!
NFPA, (October 2011). Third Needs Assessment of the U.S. Fire Service, CA, Fire Analysis and Research, Quincy, MA.
Yoo, H.L., Franke, W.D.,(August, 2009) Prevalence of cardiovascular disease risk factors in volunteer firefighters. Department of Kinesiology, Iowa State University.J Occup Environ Med.;51(8):958-62.
D'Agostino, Vasan, Pencina, Wolf, Cobain, Massaro, Kannel. (May, 1998). A General Cardiovascular Risk Profile for Use in Primary Care: The Framingham Heart Study. 12;97(18):1837-47
Shift work and vascular events: systematic review and meta-analysis (July, 2012) BMJ 2012;345:e4800 doi: 10.1136/bmj.e4800
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Ridker, P.M., Hennekens, C.H., Rifai, N., Buring, J. E., Cook, N.R., (March, 2000). C-Reactive Protein and other markers of inflammation of cardiovascular disease in women. New England Journal of Medicine
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Krauss, R.M., Blanche, P.J., Rawlings, R.S., Fernstrom, H.M. Willliams, P.T. (September, 2006) Separate effects of reduced carbohydrate intake and weight loss on atherogenic dyslipidemia. Americna Journal of Clinicial Nutrition. ;84(3):668.