Health and Wellness 

Guide

for the Volunteer Fire Service

FA-267/January 2004
Mission Statement 

National Volunteer Fire Council 

Mission Statement 

To provide a unified voice for volunteer Fire/EMS organizations. This Mission will be 

accomplished by: 

• Representing the interests of the volunteer Fire/EMS organizations at the U.S. 

Congress and federal agencies. 

• Promoting the interests of the state and local organizations at the national level. 

• Promoting and providing education and training for the volunteer Fire/EMS 

organizations. 

• Providing representation on national standards setting committees and projects. 

• Gathering information from and disseminating information to the volunteer 

Fire/EMS organizations. 

U.S. Fire Administration 

Mission Statement 

As an entity of the Federal Emergency Management Agency, the mission of the United 

States Fire Administration is to reduce life and economic losses due to fire and related 

emergencies, through leadership, advocacy, coordination, and support. We serve the 

Nation independently, in coordination with other Federal agencies, and in partnership 

with fire protection and emergency service communities. With a commitment to 

excellence, we provide public education, training, technology, and data initiatives. 

On March 1, 2003, FEMA became part of the U.S. Department of Homeland Security. 

FEMA’s continuing mission within the new department is to lead the effort to prepare the 

nation for all hazards and effectively manage federal response and recovery efforts 

following any national incident. FEMA also initiates proactive mitigation activities, trains 

first responders, and manages Citizen Corps, the National Flood Insurance Program and 

the U.S. Fire Administration. 

NVFC Health and Wellness Guide i 
ii NVFC Health and Wellness Guide 
Table of Contents 

NVFC AND USFA HEALTH AND WELLNESS GUIDE 

FOR THE VOLUNTEER FIRE SERVICE

TABLE OF CONTENTS

Acknowledgements........................................................................................................... vii 

Executive Summary........................................................................................................... ix 

Programs from Across the Nation................................................................................ ix 

Developing and Implementing a Health and Wellness Program.................................. x 

I. Introduction .....................................................................................................................1 

II. State of Health and Wellness in the Volunteer Fire Service..........................................3 

Overview of Health Concerns of Volunteer Firefighters.............................................. 4 

Cardiovascular Health............................................................................................. 4 

Strains and Sprains.................................................................................................. 5 

Stress Levels ........................................................................................................... 6 

Weight Problems..................................................................................................... 7 

Summary of the Importance of Health and Wellness............................................. 7 

Top Reasons Why Fitness Programs Have Not Worked........................................ 8 

Overview of Major Fire Service Wellness Initiatives................................................... 9 

NFPA Standards.................................................................................................... 10 

IAFC-IAFF Wellness-Fitness Initiative................................................................ 10 

U.S. Air Force Physical Fitness Program ............................................................. 13 

III. Importance of Health and Wellness in the Volunteer Fire Service ............................15 

Cardiovascular Disease............................................................................................... 15 

NVFC Health and Wellness Guide iii 
Table of Contents 

Smoking ................................................................................................................ 16 

Hypertension......................................................................................................... 17 

High Cholesterol................................................................................................... 17 

Obesity .................................................................................................................. 18 

Diabetes................................................................................................................. 18 

Physical Inactivity................................................................................................. 18 

Summary............................................................................................................... 19 

Importance of Improved Strength and Flexibility ...................................................... 20 

Ergonomic--Related Disorders................................................................................... 21 

Cumulative Trauma Disorders.............................................................................. 22 

Back Disorders...................................................................................................... 23 

IV. Volunteer Programs from Across the Nation .............................................................25 

Overview of Current Health and Wellness Programs................................................. 25 

Model Program Elements ........................................................................................... 27 

Caldwell Fire and Rescue, Idaho: Participant Involvement and Facilitators........ 27 

Carroll County, Maryland: Annual Medical Examination ................................... 27 

Gates Fire District, New York: Record Keeping.................................................. 28 

Chesterfield County Fire and EMS, Virginia: Individualized Programming ....... 28 

Update on Programs from Previous Report................................................................ 29 

Valdez Fire Department, Alaska........................................................................... 29 

Plantation Fire Department, Florida ..................................................................... 29 

Flossmore Volunteer Fire Department, Illinois.................................................... 30 

Gates Fire District, New York .............................................................................. 30 

iv NVFC Health and Wellness Guide 
Table of Contents 

Howland Fire Department, Ohio........................................................................... 31 

Chesterfield County Fire and EMS, Virginia ....................................................... 31 

Lacey Fire Department, Washington .................................................................... 31 

IAFC Funded Programs.............................................................................................. 32 

Bernalillo County Fire Department, New Mexico................................................ 32 

Hartford Emergency Services, Vermont............................................................... 33 

Brodhead Fire Department, Wisconsin................................................................. 33 

V. Development of a Health and Wellness Program for Volunteer Fire Departments.....35 

Program Components.................................................................................................. 35 

Regular Fitness Screenings and Medical Assessments......................................... 35 

Fitness Program .................................................................................................... 37 

Behavioral Modification Program ........................................................................ 41 

Educating Membership ......................................................................................... 43 

Screening Volunteer Applicants........................................................................... 43 

Program Administration.............................................................................................. 44 

Health and Wellness Coordinators........................................................................ 44 

Liability Exposure................................................................................................. 45 

Funding Alternatives............................................................................................. 45 

Incentives for Participation................................................................................... 49 

VI. Implementing a Health and Wellness Program ..........................................................51 

Department Planning and Assessment........................................................................ 51 

Creating the Vision ............................................................................................... 51 

Implementation Steps............................................................................................ 51 

NVFC Health and Wellness Guide v 
Table of Contents 

Data Collection, Analysis, and Evaluation ................................................................. 53 

Evaluating Program Effectiveness........................................................................ 54 

Appendix A: Health and Wellness Resources..................................................................57 

Appendix B: Relationship Between Cardiovascular Risk Factors and Physical Fitness..61 

Endnotes.............................................................................................................................81

vi NVFC Health and Wellness Guide 
Acknowledgements 

ACKNOWLEDGEMENTS 

The National Volunteer Fire Council (NVFC) Health and Wellness Project, 

supported by the United States Fire Administration (USFA), was developed to improve 

health and wellness within the volunteer fire service. TriData, a Division of System

Planning Corporation, assisted the NVFC in developing the guide. 

This study of the current state of health and wellness programs would not have 

been possible without the cooperation and assistance of many members of the fire service 

throughout the United States. A number of fire departments are featured throughout the 

guide. The NVFC thanks them for their contributions and insights. 

During this study, the Department of Homeland Security Under Secretary for 

Emergency Preparedness and Response was Michael D. Brown; the USFA Administrator 

was R. David Paulison; the USFA Project Officer was William Troup; and the NVFC 

Executive Director and Project Manager was Heather Schafer. 

NVFC would like to recognize the following individuals for their technical 

assistance with the project: 

• Dr. Denise Smith, Professor of Exercise Science at Skidmore College and 

Research Associate at the Illinois Fire Service Institute, offered many 

hours of technical advice on the guide and its proposed program. Dr. 

Smith was a prime contributor to Chapter III (Importance of Health and 

Wellness for the Volunteer Fire Service) and the author of Appendix B 

(The Relationship Between Cardiovascular Risk Factors and Physical 

Fitness). 

• Mr. Fabio Comana, Exercise Physiologist, Nutritionist, and Wellness 

Director with Club One Pro Services, Inc, assisted in developing the 

proposed program as well as alternatives for motivating firefighters to 

participate in health and wellness programs. 

• Ms. Vicki Runnels, Director of Special Projects at the International 

Association of Fire Chiefs, explained the “Joint-Labor Management 

Wellness Initiative” and offered insight on implementation of a volunteer 

program. 

At TriData, Patricia Frazier was project manager. Ms. Frazier was assisted by 

Jason Reimer and other members of the TriData staff. Philip Schaenman, President of

TriData, provided technical and corporate oversight. 

NVFC Health and Wellness Guide vii 
viii NVFC Health and Wellness Guide 
Executive Summary

EXECUTIVE SUMMARY 

Firefighting is one of the nation’s most dangerous and hazardous jobs, with heart 

attacks, high physical stress levels, sprains, and strains all too common. Of all firefighters 

in the U.S., 73 percent are volunteers.1 The leading cause of on-duty death among these 

volunteers is heart attacks. The leading cause of injuries for all firefighters is overexertion 

and strain. 

The prevalence of cardiovascular illness and deaths and work-inhibiting strains 

and sprains among firefighters illustrates the need for a comprehensive health and 

wellness program in every department. The fire service realizes that health and wellness 

programs benefit individual firefighters and the fire service as a whole; such programs 

can yield safer and more effective action by first responders to emergencies. 

Many organizations have addressed the issue of health and wellness in the fire 

service. The National Fire Protection Association (NFPA) redeveloped and its health and 

wellness standards. Since 1997, several career departments have worked with the 

International Association of Firefighters (IAFF) and the International Association of Fire 

Chiefs (IAFC) on a wellness initiative. To address the issues specific to volunteers, the 

National Volunteer Fire Council (NVFC) developed this guide to health and wellness for 

volunteer fire departments and members. 

Programs from Across the Nation 

The NVFC state directors and alternates identified 16 volunteer departments with 

current experience in health and wellness programs. The departments use many different 

approaches to health and wellness including screenings, examinations, immunizations, 

education, behavioral modifications, and fitness programming. Fewer than half of the 

departments stated that their programs are well received, and ten departments noted fire 

service culture as an impediment to the program. The three greatest problem areas 

identified are lack of funding, lack of well-defined requirements, and the inability to keep 

members motivated. 

As this guide details, budget constraints should not be a major barrier to the 

implementation of a comprehensive program. Many opportunities exist to help reduce or 

eliminate costs, such as developing partnerships. The USFA Assistance to Firefighters 

Grant program is especially effective; grants are available to establish or expand wellness 

and fitness initiatives for firefighting personnel. 

Education is the best option to counter concern among members about increasing 

their time requirements. Understanding the risks and consequences of not participating in 

a health and wellness program is a critical step in creating and implementing a successful 

program. When presented with comprehensive reasons why they should participate, many 

individuals often do so. 

NVFC Health and Wellness Guide ix
Executive Summary

In the 1992 version of this guide, nine programs were featured as case studies. 

They served as models for other volunteer departments, and many of the programs 

featured continue to be viable today. Only one has been substantially reduced from its 

original scope. These case studies, as well as new ones, also look at how to implement 

different program components and address the concerns. 

Developing and Implementing a Health and Wellness Program 

Planning is the most important step in implementing a health and wellness 

program. A vision is needed to provide guidance on how to develop and implement an

individualized departmental program. No model plan exists that will work for all 

departments in all places, but there are model elements and core components that should 

be implemented, including: 

• Regular fitness screenings and medical assessments 

• Fitness program (cardiovascular, strength, and flexibility training) 

• Behavioral modification (smoking, hypertension, diet, cholesterol, 

diabetes) 

• Volunteer education 

• Screening volunteer applicants 

In a program where all of these components are combined, the volunteers pay 

more attention to their personal health and wellness, which will improve the department 

overall. If a department cannot implement the entire program at once, it is far better to 

initiate some of these components than to do nothing. 

A priority to ensure the program is successful is to appoint peer coordinators. The 

coordinators should be the advocates and leaders within the department for the Health 

and Wellness program. The coordinators might come from a steering committee or be

identified by the department leadership. 

Once the components have been selected and the program implemented, health 

and wellness needs to be made a priority if it is to become a part of the volunteer 

firefighter culture. When department leadership and health and wellness coordinators 

actively advocate participation (in both words and actions), volunteers will see that the 

department has identified health and wellness as a priority and will be more likely to 

participate. 

x NVFC Health and Wellness Guide 
Introduction 

I. INTRODUCTION 

Firefighting continues to be one of the nation’s most dangerous and hazardous 

jobs with heart attacks, high physical stress levels, and sprains and strains all too 

common. In the past five years, the fire service has focused its attention on overcoming 

these issues by working to change the service’s culture. The National Fire Protection 

Association (NFPA) has spent much time redeveloping and revamping their health and 

wellness standards, while career departments have been working with the International 

Association of Firefighters (IAFF) and International Association of Fire Chiefs (IAFC) 

on a wellness initiative that began in 1997. 

Volunteer personnel also face similar risks when it comes to health and wellness. 

The nature of member time constraints and tight departmental budgets in the volunteer 

service often inhibits the creation of comprehensive health and wellness programs. 

Implementing a comprehensive health and wellness program could overwhelm

the resources of many volunteer departments. Time, lack of program leadership, and 

insufficient funding pose serious challenges to most departments, which often struggle to 

deliver basic fire suppression capabilities. 

This guide provides the rationale and suggestions for successfully implementing a 

health and wellness program in the volunteer service. It also addresses many common 

roadblocks. The chapters are divided to help volunteer departments develop a program 

from the ground up. 

• Chapter II: State of Health and Wellness in the Volunteer Fire Service 

looks first at current causes for both injuries and deaths in the fire service. 

It then examines current fire service health and wellness programs and 

initiatives, resources for doing them, and why many programs have not 

been sustained. 

• Chapter III: Importance of Health and Wellness in the Volunteer Fire 

Service summarizes in layperson’s terms the science behind firefighter 

major injuries and fatalities. This summary should provide better 

motivation for firefighters to engage in health and wellness programs. 

• Chapter IV: Volunteer Programs from Across the Nation looks at actual 

health and wellness programs and trends in volunteer departments. It 

includes programs from the first edition of this guide, as well as new 

programs that have been developed. 

• Chapter V: Development of a Health and Wellness Program for 

Volunteer Fire Departments gives a step-by-step guide to developing a 

health and wellness program in a volunteer fire department. The chapter 

discusses common roadblocks faced by departments and other strategies to 

deliver a sustainable program.

• Chapter VI: Implementing a Health and Wellness Program brings 

together all of the recommendations presented throughout the guide in 

developing a program. 

NVFC Health and Wellness Guide 1 
Introduction 

This guide ends with two appendices to offer more assistance with program

development. Appendix A includes contact information for departments and resources, 

and additional references. Appendix B examines the relationship between cardiovascular 

risk factors and physical fitness. 

2 NVFC Health and Wellness Guide 
II. State of Health and Wellness in the Volunteer Fire Service 

II. STATE OF HEALTH AND WELLNESS IN THE VOLUNTEER 

FIRE SERVICE 

Every year, statistics show that firefighting is one of the most dangerous 

occupations in the world. Volunteer firefighter fatalities accounted for 56 percent of all 

firefighting-related deaths from 1990-2000. 2

 In 2002, stress was the leading cause of onduty deaths among volunteer firefighters, leading to the death of 26 firefighters. Heart 

attacks were the direct cause of death in 50 percent of on-duty volunteer firefighter 

fatalities.3

 In both nature and cause, stress and heart attacks killed a higher percentage of 

on-duty volunteer firefighters than career firefighters, making clear the need for increased 

emphasis on cardiovascular health, physical fitness, and overall wellness in the volunteer 

service. 

Through the first seven months of 2003, the United States Fire Administration 

(USFA) reported 53 firefighter fatalities. Twenty-eight of those deaths were volunteers. 

Of these volunteer deaths, almost half were heart attacks, while the other half were 

primarily internal traumas.4

 These statistics underscore the health and wellness issues 

being addressed in this guide, and show how current the problem is in today’s volunteer 

fire service.

The occurrence of an injury, its severity, and its outcome are influenced by many 

factors. Without a doubt, the health of the individuals sustaining the injury is one of the 

more important factors. Firefighting consists of periods of low activity punctuated by 

periods of intense, strenuous activity. Good physical condition is a critical component in 

the body’s ability to successfully transition, without injury, between these two activity 

levels. 

Undoubtedly, pre-existing medical conditions affect the health and safety of 

firefighters, including underlying medical diseases as well as physical fitness. The NFPA 

estimates that 82,250 firefighters were injured in the line of duty in 2001.5

 On-duty 

deaths and injuries may have been avoided, or less severe, under the same conditions if 

there was no pre-existing condition. 

Despite the known risks, thousands of volunteer firefighters and emergency 

medical personnel lack rudimentary medical evaluation and overall wellness that can 

ameliorate the physical stress of emergency response. According to the USFA 

publication, A Needs Assessment of the U.S. Fire Service: A Cooperative Study 

Authorized by U.S. Public Law 106-398, only one-fifth of the surveyed departments 

nationwide have a program to maintain basic firefighter fitness and health, such as is 

encouraged by NFPA 1500, Standard on Fire Department Occupational Safety and 

Health Program.

6

The study goes on to report that a large share of firefighters serve as volunteers in 

smaller communities, where most fire departments do not have programs to maintain 

basic firefighter fitness and health. There may be as many as 792,000 firefighters, or 

NVFC Health and Wellness Guide 3 
II. State of Health and Wellness in the Volunteer Fire Service

roughly three-fourths of the estimated total number of U.S. firefighters, without such 

programs. 

Implementing health and wellness programs in the fire service could likely 

prevent volunteer firefighter injuries and deaths. A body of evidence suggests that 

improved lifestyles reduce the risk of injury and death. Many injuries and deaths could be 

reduced by implementation of a health and wellness program in the department. 

Overview of Health Concerns of Volunteer Firefighters 

This section looks at the overall health concerns of volunteer firefighters. A more 

detailed discussion of the benefits of a health and wellness program for firefighters is

provided in Chapter III. The discussion of health concerns is applicable to the fire service 

as a whole. The data presented is primarily from the NFPA. The NFPA death statistics 

broken down by volunteer and career firefighters. Injury statistics encompasses both 

collectively and are not broken down by volunteer and career. 

CARDIOVASCULAR HEALTH

As shown in Figure 1, heart attacks are the leading cause of volunteer firefighter 

fatalities, accounting for 50 percent of firefighter line-of-duty deaths in 2002. The 

number of firefighters, both career and volunteer, who suffer heart attacks while off duty 

remains untallied. The physical demands placed on firefighters can be very high; they 

often must go from a state of deep sleep to extreme alertness and high physical exertion 

in a matter of minutes. Further, they must carry heavy equipment through intense heat 

while wearing heavy protective gear. While many Americans are at risk for heart disease, 

the nature of firefighting requires that firefighters be particularly careful in maintaining a 

high level of physical fitness to combat coronary problems. 

The prevalence of heart attacks is a continuing problem. In 2001, excluding the 

World Trade Center deaths, “heart attacks were the number one cause of [firefighter] 

death.”7

 The USFA Firefighter Fatality Retrospective Study: 1990-2000 analyzed the 

causes of more than 1,000 on-duty firefighter deaths in the United States during the last 

decade of the 20th century and concluded that heart attack remains the leading cause of 

death, accounting for 44 percent of firefighter line-of-duty deaths. Heart disease is also

the leading cause of death in the United States, according to the American Heart 

Association.

4 NVFC Health and Wellness Guide 
II. State of Health and Wellness in the Volunteer Fire Service 

FIGURE 1: VOLUNTEER FIREFIGHTER DEATHS BY NATURE OF INJURY (2002) 8

Burns

8%

Internal Trauma

24% 

Other 

2% 

Asphyxiation

12% 

Drowning

4%

Heart Attack 

50% 

Source: NFPA Journal, July/August 2003: "2002 Firefighter Fatalities."

The cardiovascular state of health and wellness in the fire service is of such 

concern that researchers identified a correlation to the public’s safety. The high-risk 

profile for cardiovascular disease of firefighters should be a national concern.9

 Why 

firefighters should be concerned with cardiovascular disease and other risk factors is 

discussed in Chapter II. 

STRAINS AND SPRAINS

As shown in Figure 2, in 2001, sprains, strains, and muscular pains accounted for 

47 percent of overall firefighter injuries, and was the leading cause of injury.10 In 

addition, 33 percent of fireground injuries were caused by overexertion and strain. 

When the National Fire Protection Association analyzed fireground injury data 

from 1993-1997 and compared the nature of injuries in both moderate and severe injury 

cases, sprains and strains accounted for the highest percentages in both categories.11 Of 

severe firefighter fireground injuries, 30 percent were sprains and strains; of moderate 

and minor injuries, 21 percent were strains and sprains, and 15 percent were general 

pains. 

NVFC Health and Wellness Guide 5 
II. State of Health and Wellness in the Volunteer Fire Service

FIGURE 2: FIREFIGHTER INJURIES BY CAUSE, 2001 

Source: Michael J. Karte

, lifting and carrying 

hoses, pulling or maneuvering hand tools and saws, pulling and lifting property or 

content

ers

s, a frequent source of

pain and complaint among firefighters, and another category of injury falling under 

“ergono

s

ders

.

A majority of the job-related activities in the fire services can be characterized as 

sedentary in nature, e.g., equipment maintenance, building inspections, or public 

Burns

7%

Smoke or Gas

Inhalation

4%

Respiratory Distress

2%

Wound, Cut, Bruise

20%

Other

12%

Thermal Stress

4%

Strain, Sprain,

Muscular Pain

47%

Heart Attack or Stroke

1% Dislocation, Fracture

3%

r, Jr. and Joseph L. Molis, “2001 Firefighter Injuries.” 

In most injury cases, sprains and strains are caused by pulling

s, lifting and moving ladders, and lifting other items. Very often, sprains and 

strains are exacerbated by preexisting conditions, called Cumulative Trauma Disord

(CTDs). CTDs, which fall under the umbrella term “ergonomic-related disorders,” 

include tendonitis and nerve compression, conditions caused by continued, cumulative 

stress to certain joints, tendons, ligaments, and other body parts.12

Other sprains and strains can be worsened by back disorder

mic-related disorders.” Twisting, pushing and pulling, lifting, bending and 

stretching can all cause such disorders, and even such a seemingly mundane action, a

continued sitting, can be a problem. Regardless of the cause, pre-existing back disor

can result in more severe injuries among firefighters, especially in fireground situations

STRESS LEVELS

6 NVFC Health and Wellness Guide 
II. State of Health and Wellness in the Volunteer Fire Service 

education. Active firefighting on the other hand is a tremendously strenuous task. The 

firefighter can be taken from a complete resting state and within minutes be thrust into a 

danger

l can

ations, such as a fire, researchers note that the body responds 

with a number of physiological changes. More adrenaline is released into the 

bloods

besity “the terror within, a threat that 

is every bit as real to America as the weapons of mass destruction.”14 

Some researchers have estimated that more than half of all Americans are 

signific

rage,” writes Fire 

Rescue reporter James O. Page.

t

public safety jobs because physical and emotional 

stress is unavoidable. 

of health and wellness and the needs for developing and

implementing health and wellness programs can be summarized in ten reasons: 

1. Improves heart health: The importance of aerobic exercise cannot be 

nteer

strengthens heart muscle, decreases clotting, and stabilizes the electrical 

ies

2.

3. Helps prevent Type II diabetes: Exercise improves the body's ability to 

regulate blood sugar, preventing Type II diabetes. 

ous, complicated environment where he or she is expected to perform at a 

demanding physical level. 

Firefighters face a potentially deadly combination of stress, heat and high body 

temperature, and dehydration. Repeatedly placing such stresses upon an individua

take its toll. In stressful situ

tream, muscles tense, breathing quickens, and heart rate and blood pressure rise. 

Researchers also note, however, that fit individuals tend to take these physical responses

in stride and with less wear and tear to the body.13

WEIGHT PROBLEMS

Surgeon General Richard Carmona called o

antly overweight. “I believe the American fire service reflects those numbers. 

Among volunteers and fire chiefs, I suspect we exceed the national ave

15

A publication in the Journal of the American Dietetic Association indicates tha

many overweight or obese firefighters may not even realize the potential problem.

16

Physical conditioning is crucial in

SUMMARY OF THE IMPORTANCE OF HEALTH AND WELLNESS

The importance

understated. Heart attacks cause the majority of deaths among volu

firefighters. Regular aerobic exercise helps prevent heart disease, 

activity of the heart. Aerobic exercise slows plaque buildup in the arter

and also helps to normalize blood pressure, especially in people whose 

blood pressure is somewhat elevated. 

Improves heart tolerance: Exercise increases blood volume, which 

improves heat tolerance. Improved heat tolerance will help firefighters 

battle more intense fires.

NVFC Health and Wellness Guide 7 
II. State of Health and Wellness in the Volunteer Fire Service

4. Reduces risk of strains and sprains: Physical activity strengthens th

muscles and joints and other structures like tendons and ligaments that 

help hold the body togethe

e

r. This strengthening decreases the risk of 

strains and sprains; the leading cause of injury for firefighters. 

5. rs often deal with life

and death situations when they respond to an emergency. Taking part in 

nal

fy, and

6. al

s

7. ns metabolic rate: By preventing the loss of metabolically active

muscle tissue, exercise helps prevent the drop in metabolic rate that

8. f stamina, 

strength, flexibility, bone density, and metabolic rate, which all affect an 

9.

r back and increases strength in the 

abdominal and back muscles can help prevent the development of back 

nd

10. Encourages overall healthy lifestyle: As fitness improves, activity 

, such as

.

TOP REASONS 

Despite

are many obsta

addressed if vo

May improve emotional state: Volunteer firefighte

health and wellness programs improves their psychological and emotio

states, which will improve emotional reactions during a life and death 

situation. An improved emotional state also improves self-esteem, sel

efficacy and sleep patterns, thereby reducing depression, anxiet

stress. 

Maintains weight loss: Exercise helps control body weight and is essenti

in any weight loss program. Weight loss is more likely to be maintained if

a person continues to exercise. Weight loss increases stamina, as well a

aerobic abilities, both of which are needed for firefighting. 

Maintai

sometimes accompanies weight loss and the gradual decline in metabolic 

rate that occurs with aging. 

Enhances ability to fight fires: Exercise can slow the loss o

individual’s ability to fight a fire. 

Prevents development of back problems: Maintaining flexibility in the 

muscles of the legs and lowe

problems. Firefighter back problems often develop from lifting hoses a

equipment and moving apparatus. 

becomes easier. Exercise increases stress resistance and improves sleep.

An active lifestyle also encourages other health-promoting habits

avoiding tobacco and alcohol and developing healthy eating habits. 

Besides feeling better, firefighters lower their risk for injury or even death

with more and consistent exercises

WHY FITNESS PROGRAMS HAVE NOT WORKED 

the importance of health and wellness programs for the fire services, there

cles to their inception and implementation. These obstacles must be 

lunteer firefighter health is to be improved. Based on health advocate and 

8 NVFC Health and Wellness Guide 
II. State of Health and Wellness in the Volunteer Fire Service 

former firefighter Michael Stefano’s experience from administering a number of

programs, the following are the five leading reasons for failure: 17 

of the

nually,

the firefighters to

motivate them to change their lifestyles. 

2.

must be taken into account, and the participants must be able to see their 

3. signed

ments, professional consultation should be sought to ensure the 

efficacy and safety of the program.

4.

programs for volunteers should be 

designed around the members’ personal and family time. 

5.

a

er 

Overview f

The fir

its personnel. T partment serves the public, accomplishes 

its missions, and is able to make a difference in the community. By committing to a 

wellness program, the fire department often increases the members' trust. This trust 

enhances every program and each call answered by the fire department. Placing a high

1. Lack of information on risk to self: Many firefighters are not aware

health risks of firefighting and are therefore uninterested in changing their 

condition. With many preventable injuries and deaths occurring an

pertinent health information must be disseminated to

Lack of individual goals: Programs that have failed to outline reasonable 

and specific individual goals are less likely to succeed. Program 

participants who feel they do not accomplish anything drop out. In 

developing any fitness program, the needs and wishes of the participants 

progress. 

Lack of appropriate training: Fitness programs generally are not de

by professionals and thus lack the elements necessary for an effective 

program. While hiring a personal trainer may be too expensive for some

fire depart

Lack of time to devote to the program: Volunteer firefighters already 

donate many hours to the fire service, and few feel they have excess time

to devote to health and wellness. However, firefighter health is too 

important to ignore. Instead, fitness

Lack of motivation: Even firefighters aware of their elevated health risk 

choose not to participate in fitness programs. Lack of motivation is

serious challenge that must be addressed by each fire department. Chapt

IV provides some suggestions. 

o Major Fire Service Wellness Initiatives 

e service's greatest asset is not equipment, apparatus or stations, but rather 

hrough its personnel, the fire de

NVFC Health and Wellness Guide 9 
II. State of Health and Wellness in the Volunteer Fire Service

priority on wellness makes sense for everyone, including fire service personnel, the

taxpayers, and the public served. 

ss

s for a health-related fitness program for fire 

department members who are involved in rescue, fire suppression, emergency medical 

materials operations, and related activities. Implementation of this 

document shall promote the members’ ability to perform occupational activities with 

vigor a

3. An exercise training program that is available to all members 

f any fire department 

occupa al s edical

Requirements for Firefighters and Information for Fire Department Physicians, which 

was rel d in

IAFC-IAFF W

on

artment uniformed personnel. The initiative issued an 

extensive guide, The Fire Service Joint Labor Management Wellness-Fitness Initiative 

ent’s effort. 

in

that it

NFPA Standards 

In August 2000, NFPA released NFPA 1583: Standard on Health-Related Fitne

Programs for Firefighters. As the NFPA states, “The purpose of this standard is to 

provide the minimum requirement

services, hazardous

nd to demonstrate the traits and capacities normally associated with a low risk of

premature development of injury, morbidity, and mortality."18

“The health-related fitness program shall include the following components: 

1. The assignment of a qualified health and fitness coordinator 

2. A periodic fitness assessment for all members 

4. Education and counseling regarding health promotion for all members

5. A process for collecting and maintaining HRFP data”19

When adapted, this standard can be a key component o

tion afety and health program, and is a companion to NFPA 1582: M

ease February 2000.

ELLNESS-FITNESS INITIATIVE

The Fire Service Joint Labor Management Wellness-Fitness Initiative (also 

known as “the 10 Cities Initiative”) is a partnership between the International Associati

of Fire Fighters (IAFF) and the International Association of Fire Chiefs (IAFC) to 

improve the wellness of fire dep

(Second Edition), that may be used to supplement a volunteer departm

Ten U.S. cities and Canadian public professional fire departments participate

the initiative, which was introduced in 1997. The participating departments require their 

membership to participate in the complete program. A key aspect of the program is

be implemented in full, not just selected components. Although developed for career 

10 NVFC Health and Wellness Guide 
II. State of Health and Wellness in the Volunteer Fire Service 

departments, components of the initiative can be adapted to the needs of volunteer 

departments. 

The initiative is based on the premise that the program is non-punitive and 

confidential. If a volunteer firefighter wellness program is to succeed, these same

conditions should apply. According to the IAFC-IAFF initiative manual, “all component 

results are measured against the individual’s previous examination and assessments an

not against any standard or norm.” Additionally, personal records are not released, n

even to the ind

d

ot

ividual’s personnel file. A separate file system should be kept, and the 

information provided only on a need-to-know basis. 

nia)

diana)

ornia)

t (Florida)

to some ogram as well. 

ble 1, the wellness-fitness initiative 

has mu be implemented as a whole. In the 

case of the volunteer service, it would be qu ing to implement all of these at 

once. M

develop

The ten fire departments participating in the program are: 

• Austin Fire Department (Texas) 

• Calgary Fire Department (Canada) 

• Charlotte Fire Department (North Carolina) 

• Fairfax County Fire and Rescue Department (Virgi

• Indianapolis Fire Department (In

• Los Angeles Fire Department (Calif

• Miami-Dade County Fire Rescue Departmen

• City of New York Fire Department (New York) 

• Phoenix Fire Department (Arizona) 

• Seattle Fire Department (Washington) 

All ten of the departments that began the initiative have continued in the program

 degree, and other departments have implemented the pr

Components of the Initiative--As seen in Ta

ltiple components, all of which are designed to

ite challeng

any of the components are discussed in further detail in the chapter on 

ing a model program, later in this guide. 

NVFC Health and Wellness Guide 11 
II. State of Health and Wellness in the Volunteer Fire Service

TABLE 1 : COMPONENTS OF THE IAFC-IAFF INTIIATIVE

Category Components

Medical 

• Body Composit

• Laboratory Tes

fectious Disease Testing

• Physical Evaluation 

ion Evaluation

ts 

• Vision Tests 

• Hearing Evaluations 

• Spirometry 

• EKG 

• Cancer Screening 

• Immunizations and In

• Referrals

• Data Collection

Fitness 

learance

r Exercise 

• Equipment and Facilities 

and Peer Trainers 

losophy 

capabilities, 

• Medical C

• On Duty Time fo

• Exercise Specialists

• Fitness Incorporated into Phi

• Fitness Evaluations (aerobic

flexibility, muscular strength, muscular

endurance) 

• Fitness Self Assessments 

• Exercise Prescriptions

Rehabilitation 

• habilitation

cal Liaison 

s

Need for Re

• Rehabilitation as a Priority

• Establishment of a Medi

• Physical Therapy Service

• Clinical Pathways 

• Alternate Duty 

• Injury Prevention Program

Behavioral

Health

istance

• Tobacco Use Cessation 

grams 

tion 

ent

• Professional Ass

• Nutrition

• Employee Assistance Pro

• Substance Abuse Interven

• Stress Management

• Critical Incident Stress Managem

• Chaplain Services

Peer Fitness Trainers h provides for a peer fitness trainer (PFT) 

certification program. This program helps to identify firefighters who have demonstrated 

the knowledge and skills required to: 

--T e program also

• Design and implement fitness programs

12 NVFC Health and Wellness Guide 
II. State of Health and Wellness in the Volunteer Fire Service 

• Improve the wellness and fitness of their departments 

g wellness and fitness (e.g.,

fitness programs in schools). 

Home s ess trainer (PFT) certification program are 

now available. This certification, developed together by the IAFF, IAFC and the 

Americ

el.

lpful 

on

• Assist in the physical training of recruits 

• Assist the broader community in achievin

tudy materials for the peer fitn

an Council on Exercise (ACE), provides fire department employees with the 

knowledge needed to develop exercise programs for other fire department personn

PFTs will also learn wellness-fitness initiative fitness testing protocols and will be he

in promoting wellness and fitness throughout their departments. For more information

the PFT course, visit http://www.iaff.org/safe/content/PFT. 

U.S. AIR FORCE PHYSICAL FITNESS PROGRAM

Air Force firefighters are also active military personnel, so they must adhere to a 

very strict fitness program. The Air Force Fitness Program considers cardiovascular 

fitness

cling

e

rtment 

of Defense FitSoft and the Fitness Management (FITMGMT) applications to administer 

and ma

kept for each individual. The profile includes 

information such as name, rank, Social Security number, birth month, testing date and 

test sta ement

as the single best indicator of total physical fitness. Air Force firefighters are 

routinely tested through aerobic fitness to evaluate their cardiovascular fitness. This 

testing procedure evaluates the heart rate at the end of a 6 to 8 minute steady-state cy

period. Scores are pass/fail and are determined by the individual's gender and age. Th

Air Force also takes upper body strength and abdominal strength into account.20

FitSoft and Fitness Management--Currently, the Air Force uses the Depa

nage the Air Force Fitness Program. These programs are used by the base-level 

Fitness Program Manager (FPM) to produce rosters and fitness program status reports. 

The FitSoft application collects data and sends it to FITMGMT where the Fitness 

Program Manager can analyze it. 

A profile of fitness data is

tus. From an individual's profile the user can also view the Fitness Improv

Program (FIP), test detail, and data. 

NVFC Health and Wellness Guide 13 
14 NVFC Health and Wellness Guide
III. Importance of Health and Wellness in the Volunteer Fire Service

III. IMPORTANCE OF HEALTH AND WELLNESS IN THE 

VOLUNTEER FIRE SERVICE

Chapter II looked at the state of health and wellness in the volunteer fire service. 

As the statistics showed, heart attacks represented the number one cause of death, while 

sprains and strains represented the number one cause of injuries. This chapter will look at 

why it is important for volunteer firefighters to reduce their risk to these health issues.

Cardiovascular Disease 

Cardiovascular disease (CVD) is the leading cause of death in the United States, 

accounting for approximately one million deaths per year.21,22 Moreover, CVD exacts a 

considerable toll on the fire service, as shown in the previous chapter. 

USFA aims to reduce firefighter deaths by 25 percent by 2005.23 Clearly, the only 

way to achieve this goal is to drastically reduce the number of deaths due to heart attacks. 

A commitment to health and safety requires that the fire service continue to address lineof-duty deaths due to other causes through proper training, adequate resources, etc. This 

section, however, is aimed at improving firefighter health and safety by addressing the 

important health issue of CVD in the fire service. This section outlines the development 

of CVD, the risk factors for developing it, the relative risk associated with different 

values for each risk factor, and the benefits of exercise in controlling risk factors. 

Cardiovascular disease refers collectively to a state of disease in the blood

vessels. If blood vessels become narrowed (i.e., by the buildup of plaque) or obstructed 

(i.e., by a blood clot) then blood, and the oxygen and nutrients it carries, cannot be 

delivered to the vital organs of the body. If blood flow to the heart muscle is impeded, a 

heart attack occurs. The terms coronary heart disease (CHD) or coronary artery disease 

(CAD) describe a specific form of CVD in which the blood vessels supplying the heart 

muscle are blocked. 

When there is an obstruction in a coronary vessel, the tissue below the blockage 

does not get adequate oxygen. If the lack of oxygen (called ischemia) is too severe, the 

heart tissue dies (called an infarction; a myocardial infarction means death of heart 

muscle tissue). Thus, a person who has suffered a myocardial infarction (also called a 

heart attack) has had a portion of the heart tissue destroyed. If the area supplied by the 

blood vessel is very small, the person may recover from the heart attack or may not even 

know that he or she has suffered a heart attack. However, if the area below the occlusion 

is too great, the heart cannot continue to function as an effective pump, and death results. 

Atherosclerosis refers to the disease condition in which plaque builds up in the 

arterial wall causing the size of the vessel opening to become narrower. The initiation of 

atherosclerotic plaque buildup may begin quite early in life; there is strong evidence that 

it begins in the early 20s for many people in developed countries of the Western world. 

Therefore, it is important to think of CVD as a long-term disease that begins early in life, 

although symptoms are often delayed until middle or older age. Also, CVD can reach 

NVFC Health and Wellness Guide 15 
III. Importance of Health and Wellness in the Volunteer Fire Service

advanced stages without overt symptoms. In many individuals, the first sign of CVD is a 

fatal heart attack; thus reinforcing the need for young firefighters to take steps to avoid or 

delay atherosclerosis. It also suggests that all firefighters should seriously address the 

health issues of CVD, even if they are symptom free. 

A health risk factor is a characteristic that is present early in life and is associated 

with an increased risk of developing future disease. A modifiable risk factor is a risk 

factor that can be minimized by diet, exercise, or personal habits. There are several risk 

factors for CVD, including non-modifiable and modifiable ones (see Table 2). The nonmodifiable risk factors include: gender, age, race, and family history. Men are more 

likely to suffer CVD at a younger age than females; thus, being over 45 years is 

considered a risk factor for males and being over 55 years is a risk factor for females. 

Family history is defined as the premature death (before 55 years for males or before 65 

years for females) of a parent or sibling from CVD. 

Modifiable risk factors deserve a great deal of attention because, when they are 

altered, an individual can influence his or her likelihood of developing CVD. There are 

six major modifiable risk factors: smoking, hypertension (high blood pressure), 

hypercholesterolemia (high cholesterol levels), diabetes or impaired glucose tolerance, 

obesity, and physical activity. The more risk factors that an individual has, the greater the 

likelihood he or she will suffer from CVD. 

TABLE 2: RISK FACTORS FOR DEVELOPING CARDIOVASCULAR DISEASE

Risk Factors That 

Cannot be Modified 

Risk Factors That Can be 

Modified 

• Age 

• Heredity 

• Race 

• Gender

• Cholesterol-lipid fractions 

• Cigarette smoking 

• Diabetes mellitus 

• Hypertension

• Obesity 

• Physical inactivity 

SMOKING

Approximately 25 percent of the adult population in the U.S. smokes, and 

approximately one million young people take up the habit each year.24 Cigarette smoking 

accounts for an estimated 430,000 deaths per year in the United States, more than 40 

percent of them due to cardiovascular disease.25 In fact, as early as 1983, the Surgeon 

General established smoking as the leading avoidable cause of cardiovascular disease. 

Thus, quitting cigarette smoking is one of the most important interventions possible to 

decrease the risk of premature death due to CVD. Smoking increases the risk for sudden 

cardiac death, aortic aneurysm, peripheral vascular disease, and stroke. Smoking one 

pack of cigarettes per day doubles the risk of CVD compared to not smoking, and 

16 NVFC Health and Wellness Guide 
III. Importance of Health and Wellness in the Volunteer Fire Service

smoking more than one pack triples the risk.26,27 As the number of cigarettes smoked 

increases, so does the risk of coronary artery disease and stroke. 

HYPERTENSION

Hypertension refers to a chronic, persistent elevation of blood pressure. 

Epidemiological data shows that the risk of death doubles with a systolic blood pressure 

greater than or equal to 140 mmHg and a diastolic blood pressure greater than or equal to 

90, and thus a blood pressure above 140/90 is defined as hypertension. The risk of 

developing CVD increases directly with increasing levels of both systolic and diastolic 

blood pressure. If untreated, approximately 50 percent of patients with hypertension die 

from coronary heart disease or congestive heart failure, another 33 percent die from

stroke, and 10 percent to 15 percent die due to renal failure. 

The primary lifestyle modifications to help reduce hypertension include smoking 

cessation, diet and exercise, with the overall goals of losing weight, increasing physical 

activity levels, and decreasing salt intake. A program of regular aerobic exercise results 

in a decrease of approximately 10 mmHg in systolic and diastolic blood pressure in 

hypertensive individuals.28 Exercise also helps control blood glucose levels and the 

ability of blood vessels to change diameter during exercise. 

HIGH CHOLESTEROL

Blood lipids are comprised primarily of triglycerides and cholesterol. Cholesterol 

and triglycerides are carried in the blood by a lipoprotein molecule. Low-density 

lipoproteins (LDLs), also known as “bad cholesterol”, and high-density lipoproteins 

(HDLs), also known as “good cholesterol”, vary in their densities and in the way they 

transport cholesterol. Elevated levels of triglycerides, cholesterol, and LDL-cholesterol 

are associated with increased risk of CVD. On the other hand, increased levels of HDLcholesterol are associated with a decreased risk of cardiovascular disease. Therefore, 

elevated levels of HDL are desirable. In fact, they represent a positive risk factor for 

cardiovascular disease. 

Elevated levels of cholesterol in young adults greatly increase their risk of 

coronary heart disease later in life. In fact, young men who are in the upper quartile 

(highest 25 percent for cholesterol levels) have a nine-fold increase in risk of heart attack 

compared to men in the lowest quartile (lowest 25 percent).29 The increase in risk of 

cardiovascular disease increases progressively with increasing levels of cholesterol; there 

is a 20 percent to 30 percent increase in risk for coronary heart disease for every 10 mg/dl 

increase in cholesterol.30 Exercise is an important component of any weight loss program 

and weight loss is associated with positive changes in lipid profiles. Furthermore, regular 

aerobic exercise decreases triglyceride levels and increases HDL levels. 

NVFC Health and Wellness Guide 17 
III. Importance of Health and Wellness in the Volunteer Fire Service

OBESITY

Despite what seems to be an obsession with thinness and dieting, approximately 

20 percent of the adult population in the US is obese and another 25 percent to 30 percent 

of the population is overweight.31,32 Obesity is associated with a number of diseases, 

including cardiovascular disease (high blood pressure, dyslipidemia), diabetes, 

gallbladder disease and cancer. Obesity is associated with several other risk factors but it 

does appear that it also exerts an independent influence on the risk of cardiovascular 

disease. 

As excess body weight increases so does the risk of cardiovascular disease.33

There is little or no change in mortality at the lower end of the range (Body Mass Index 

(BMI) less than 25), but as BMI increases above 25, risk increases substantially. Thus, 

each incremental pound gained (once a person is categorized as overweight) is associated 

with additional risk. 

Exercise is an important component of any weight loss program. Studies have 

consistently shown that exercise is particularly effective in maintaining weight loss. 

Additionally, exercise is the best way to lose fat and maintain muscle mass. When a 

person loses weight through exercise alone they lose fat and muscle. On the other hand, a 

person who loses weight through a combination of diet and exercise, losses almost 

exclusively fat weight. 

DIABETES

Diabetes is a metabolic disorder characterized by the inability to use sugar 

(glucose) effectively. Individuals with diabetes have a 300 percent to 500 percent 

increased risk of cardiac events. Furthermore, 75 percent of all deaths among diabetic 

patients are from CVD. The degree of cardiovascular risk is directly related to fasting

blood glucose levels.34 Additionally, individuals who have diabetes along with other risk 

factors are at much higher risk than nondiabetic individuals with the same number of risk 

factors. Diabetes often coexists with other risk factors for cardiovascular disease. In fact, 

the cluster of risk factors has been termed metabolic syndrome X, and includes abdominal 

obesity, hypertension, dyslipidemia, and an inability to effectively use glucose (diabetes). 

Therefore, it is important that persons with diabetes very aggressively control other risk 

factors; they should lose excess body weight, exercise regularly and eat a diet low in 

simple sugars and carbohydrates. 

PHYSICAL INACTIVITY

Physical inactivity is related to several of the risk factors discussed previously. A 

lack of exercise increases an individual’s risk of obesity, hypertension, dyslipidemia, and 

diabetes. However, physical inactivity is also an independent risk factor for 

cardiovascular disease. The risk of CVD in inactive people is about twice that of 

physically active individuals; approximately the same as for hypertension and high 

18 NVFC Health and Wellness Guide 
III. Importance of Health and Wellness in the Volunteer Fire Service

cholesterol.35 In fact, physical inactivity is responsible for approximately 200,000 deaths 

per year in the U.S.36 Numerous studies have shown that CVD mortality is inversely 

related to level of physical activity or fitness.37

SUMMARY

Cardiovascular disease is a major threat to the health and safety of firefighters. To 

stay healthy, and address the risk factors for developing CVD, a firefighter should adopt a 

few healthy lifestyle habits. In short, to reduce the risk of suffering a heart attack or 

stroke it is imperative that firefighters: 

• Do not smoke 

• Follow a regimen of moderate aerobic exercise 

• Eat a balanced diet, avoiding excess saturated fats, excess simple sugars, 

and maintaining normal body weight. 

Table 3 details the recommendations above and indicates the risk factors that are 

influenced by each recommendation. Of particular note is the benefit physical activity has 

on five of the six modifiable risk factors. Imagine the excitement within the fire service, 

indeed the nation, if a medication were developed that could achieve half the benefits that 

we know can be derived from consistent participation in a moderate exercise program!

TABLE 3: RECOMMENDATIONS FOR DECREASING CV RISK FACTORS

Recommendations Risk Factor Influenced 

Exercise Moderately 

• Decreased Blood Pressure 

• Improved Lipid 

(Cholesterol) Profile 

• Decreased Body Fat 

• Improved Glucose 

Tolerance 

• Eliminates Physical 

Inactivity

Eat a Balanced Diet 

• Improved Lipid 

(Cholesterol) Profile 

• Decreased Body Weight

• Improved Glucose 

Tolerance 

• May Decrease Blood 

Pressure 

Do Not Smoke • Smoking 

NVFC Health and Wellness Guide 19 
III. Importance of Health and Wellness in the Volunteer Fire Service

Importance of Improved Strength and Flexibility 

Strength and flexibility training can effectively develop musculoskeletal strength, 

musculoskeletal endurance, and functional movement around the joints and is strongly 

recommended for health, fitness, injury prevention, rehabilitation, and for improving 

one’s overall quality of life. 

Flexibility is the ability to move a joint freely through an entire range of motion. 

As an example, good shoulder flexibility should allow both hands to touch together 

behind your back. It is however, joint specific, varying significantly across joints and 

between individuals. Many factors including joint structure, ligaments, tendons, muscles, 

skin, fat tissue, body temperature, gender, and age all contribute to the range of motion at 

a joint.38 

Many muscular and skeletal problems result from poor flexibility. For adults, this 

is typically the most neglected aspect of a physical fitness program. Most individuals can 

benefit from improved flexibility, regardless of age or gender. With aging, muscles 

shorten (tighten), diminishing the range of motion in a joint, hindering or halting day-today activities and movements. A regular stretching program can help lengthen your 

muscles, maintain or restore flexibility. The benefits of being flexible include: 

• Flexibility decreases risk of injury: Increasing range of motion 

decreases the resistance in various tissues. An individual is therefore less 

likely to incur injury by exceeding tissue extensibility, or maximum range 

of movement of tissues during activity.39

• Flexibility increases physical efficiency and performance: A flexible 

joint has the ability to move farther in its range and requires less energy to 

do so.40

• Flexibility increases tissue temperature: An increase in tissue 

temperature increases circulation, and nutrient transport due to decreased 

joint viscosity.41

• Flexibility increases neuromuscular coordination: An increase in 

coordination, or ease of movement, occurs because of an increase in nerve 

impulse velocity. In attuning the central nervous system to the physical 

demands placed upon it, opposing muscle groups work in a more 

synergistic or coordinated fashion.42

• Flexibility training reduces muscle soreness: Post-exercise stretching is 

extremely effective in reducing localized, muscular soreness, typically 

experienced 12-72 hours after exercise.43

The American College of Sports Medicine, American Heart Association, Centers 

for Disease Control and Prevention, and U.S. Surgeon General's Office consider strength 

training to be an integral part of any comprehensive health program and have defined 

population-specific guidelines.44,45 The benefits of a strength training program include: 

20 NVFC Health and Wellness Guide 
III. Importance of Health and Wellness in the Volunteer Fire Service

• Improved body composition, muscle growth, and metabolism:

Effectively designed strength training programs stimulate muscle growth, 

burning additional calories and lowering the amount of fat on the body. 

All individuals of any age or gender can effectively build muscle. A onepound increase in muscle mass can increase caloric expenditure by 30 to 

50 calories per day. Muscle losses attributed to injury, aging, or inactivity 

can reduce your caloric expenditure by the same amount.46

• Improved physical functioning: The neuromuscular adaptations to 

strength training enable one to perform tasks with less physiological 

stress. Much of the improved efficiency demonstrated with strength 

training is attributed to neural and hormonal adaptations that increase 

neural drive to muscles, improve muscle recruitment and synchronization, 

increase muscle contractile activation and diminish the protective function 

of proprioceptors that limit range, intensity and speed of movements 

around joints.47

• Decreased risk for osteoporosis and osteoarthritis: Weight training will 

increase bone density, of great concern as we age or become postmenopausal. Increased bone density reduces the chances of bone fractures 

and bone degeneration. Additionally, strengthening joints and muscles 

supporting the joints can significantly reduce joint pain and inflammation. 

• Improved flexibility: Optimal musculoskeletal function maintains 

adequate range of motion at all joints. This is of particular importance to 

the lower back region, where lack of flexibility from insufficient activity 

or poor posture increases the risk of chronic low back pain. 

Ergonomic---Related Disorders 

This section has been adapted from the USFA guide: Fire and Emergency 

Medical Services Ergonomics--A Guide for Understanding and Implementing An 

Ergonomics Program in Your Department.

48 This guide is considered to be the foremost 

authority on ergonomic issues in the fire service. 

Ergonomic-related disorders include cumulative trauma disorders and back 

disorders. Alone, these injuries, which are often developed over time as a result of 

uncorrected behaviors, postures, and habits, pose threats. When combined with the rough 

nature of the fireground, with its requirements of increased physicality, strength, and 

agility, ergonomic-related disorders can increase the risk for prolonged injury and can 

risk firefighter lives if untreated. 

Ergonomic-related disorders may often appear minor, but such disorders can 

severely exacerbate fireground sprains and strains and transform moderate injuries into 

more threatening injuries that increase job time lost, and diminishes both dexterity and 

the ability to effectively fight fires. The ergonomic-related disorders discussed in this 

section are often preventable and treatable through a fitness program, behavioral 

NVFC Health and Wellness Guide 21 
III. Importance of Health and Wellness in the Volunteer Fire Service

modification program, and screenings and assessments. Understanding the disorders 

themselves, their risks, and their causes is critical to the design of an effective health and 

wellness program. 

CUMULATIVE TRAUMA DISORDERS

Cumulative trauma disorders (CTDs) can be described as wear and tear on joints 

and surrounding tissue because of overuse. Every joint in the body can potentially be 

affected, but the joints in the lower back and upper limbs are these that receive the most 

injuries. Cumulative disorders accumulate through time. Acute trauma, by contrast, are 

injuries that occur as the result of a onetime event such as a cut or fall. Cumulative 

trauma is also known by a variety of terms, such as musculoskeletal disorders, overuse 

syndrome, or repetitive motion disorders.

Cumulative trauma disorders affect any area of the body where tendons, joints, 

and nerves are found. Most commonly, CTDs target the upper extremities, which include 

all of the anatomical components from the shoulder to the fingers. While acute injuries 

resulting from a single event do occur to the upper extremity, more disorders are 

currently recognized as the cumulative effect of multiple small, often unrecognized, 

repetitive injuries, particularly those for the back. Upper extremity CTDs largely affect 

the origin of muscles (where the muscle attaches to the bone, the tendon, the joints, the 

blood vessels, and the nerves). 

Types of CTDs--While there are several types of CTDs, most CTDs fall into two 

main categories: 

• Tendonitis: Tendons serve as links that connect muscle to bone and come

into play whenever a muscle is used for the motion of a bone structure. In 

some areas of the body, tendons slide through sheaths. As with any other 

moving part, overuse of tendons can cause friction, which in turn causes 

wear and tear and expansion or swelling. When tendons or their sheaths 

swell, there is pain and tenderness, known as tendonitis. 

• Nerve Compression: Nerves are found throughout the body and several 

points exist where it is possible for nerves to be compressed. Pinching of 

nerves is often caused by making certain awkward motions or assuming 

certain postures. Other times, compression can be caused by swelling of 

nearby tendons. 

Risk Factors--There are several on-the-job factors that can increase the risk of 

developing CTDs. The more factors involved and the greater the exposure to each, the 

higher the chance of developing a disorder. Factors of working conditions include: 

• Repetition: Risk increases with number and frequency of motions made 

by a particular part of the body. 

22 NVFC Health and Wellness Guide 
III. Importance of Health and Wellness in the Volunteer Fire Service

• Force: Risk increases with the amount of exertion required for particular 

motions. 

• Awkward postures: Risk increases with positions of the body, which 

deviate from a neutral position; primarily bent wrists, elbows away from

their normal positions at the side of the body, and a bent or twisted lower 

back. 

• Contact stress: Risk increases with excessive contact between sensitive 

body tissue and sharp edges or unforgiving surfaces on a tool or piece of 

equipment. 

• Vibration: Risk increases with exposure to vibrating tools or equipment, 

whether a hand-held power tool or whole-body vibration. 

• Temperature extremes: Risk increases with exposure to excessive heat 

or cold. 

• Stressful conditions: Risk increases with certain stressful situations at 

work or due to the nature of the work. 

BACK DISORDERS

The back is a complex system consisting of several distinct spinal regions. 

Lifting, bending, and twisting motions (on or off the job) can cause severe injury and 

pain. Next to the common cold, back disorder is the reason most often cited for job 

absenteeism. 

Types of Disorders--Pulled or strained muscles, ligaments, tendons, and discs are 

perhaps the most common back problems. Half of the U.S. work force is likely to 

experience back problems at least once during a lifetime. Most back disorders result from

chronic, or long-term, injury rather than from one specific incident. When back muscles 

or ligaments are injured from repetitive pulling and straining, the back muscles, discs, 

and ligaments can become scarred and weakened and lose their ability to support the 

back. This condition makes additional injuries more likely. Types of back disorders 

include: 

• Lumbosacral strain: Caused by overuse of the muscles of the lumbar and 

sacral areas of the back.

• Sacroiliitis: Caused by inflammation from overuse of the lumbar muscles 

of the joints between the lowest and sacral areas of the back, spinal bones 

(sacrum), and the hip bones (ilium). 

• Lumbosacral sprain: Caused by overuse of ligaments in the lumbar and 

sacral areas of the back.

• Postural low back pain: Results from overuse of the lumbosacral 

muscles by maintaining a posture that requires these muscles to work 

beyond their capabilities.

NVFC Health and Wellness Guide 23 
III. Importance of Health and Wellness in the Volunteer Fire Service

• Muscular insufficiency: Occurs when muscles are unable to bear stresses

imposed on them. 

• Herniated disc: Results when the disc that sits between two spinal bones

(vertebrae) bulges from between them.

• Degenerated disc: Results when wear and tear on disc slowly destroys its 

structure. 

Risk Factors--Back disorders are frequently caused by the cumulative effects of 

faulty body mechanics such as: excessive twisting, bending, reaching, lifting loads that 

are too heavy or too big, too far from the body, staying in one position for too long, poor 

physical conditions, and poor posture. Prolonged sitting stresses the body, particularly the 

lower back and the thighs. It may cause the lower back to bow outward if there is 

inadequate support. This abnormal curvature can lead to painful lower back problems, a 

common complaint among office workers. Other risk factors include: 

• Heavy physical work: Information based on workers’ compensation 

claims and insurance data show that low-back pain is more prevalent in 

highly physical jobs; the potential for overexertion injuries is greater. 

• Lifting: Low-back pain is clearly triggered by lifting; the weight, speed, 

duration, and frequency of lifting affect the onset of low-back pain. 

• Bending, stretching, and reaching: Bending in combination with lifting 

appears to be the most common cause for low-back pain; the incident of 

low-back pain also increases with loads held away from the body. 

• Twisting: Lifting in combination with twisting has been implicated in 

low-back pain injuries. 

• Pushing and pulling: Pulling and pushing account for 9 to 18 percent of

all back strains and sprains. 

• Prolonged sitting and standing: Studies show that jobs involving all 

standing or all sitting postures are associated with increased risk for low 

back pain as compared to jobs involving frequent changes in posture. 

• Vibrations: As in other CTDs, vibration is a significant risk factor. 

• Accidents: Traumatic events outside the context of manual lifting, such as 

slipping, tripping, stumbling, or other incidents, which place unexpected 

loads on the back, can contribute to chronic low-back pain. 

Between complications of cardiovascular disease, strains, sprains, and other 

ergonomic related disorders, firefighting is truly one of the most dangerous occupations. 

The demands of volunteer firefighters are very high and require a focus on health and 

wellness. This chapter looked at some of the impacts of not engaging in a health and 

wellness program. 

24 NVFC Health and Wellness Guide 
IV. Volunteer Programs From Across the Nation

IV. VOLUNTEER PROGRAMS FROM ACROSS THE NATION 

Previous chapters of this health and wellness guide have addressed why it is 

important for volunteers and the departments they serve to focus on health and wellness. 

This chapter looks at programs implemented by various volunteer or combination fire 

departments across the country to assess the strengths and weaknesses of each program. 

This assessment or “lessons learned” is a valuable tool for departments that want to 

implement their own program.

Overview of Current Health and Wellness Programs 

The NVFC state directors and alternates identified 16 volunteer departments with 

current experience with health and wellness programs. The departments vary widely in 

type, membership size, and community served. Table 4 shows the diversity of the 

departments discussed in this chapter. 

Most of the programs listed in Table 4 began in the early 1990s and, with one 

exception, remain viable. Less than half of the departments (7 of 16) report a positive 

reception, and 63 percent (10) note fire service culture as an impediment to the program. 

Participation is evenly spread among age groups, but a smaller percentage of women 

participate than men. The three greatest problem areas with the programs are: 

• Lack of funding 

• Lack of well-defined requirements 

• Inability to keep membership motivated. 

The departments use many different approaches to health and wellness including 

screenings, examinations, immunizations, education, behavioral modifications, and 

fitness programming. Fifty-six percent of the departments (9) analyze injury reports to 

customize the health and wellness program to meet the needs of their department. 

Most departments acknowledge that while the time and equipment are available 

for programming, active participation by the members is quite low. For example, fifty-six 

percent (9) of the departments offer training and educational components to improve 

mental and physical health and quality of life, but the utilization is only sporadic. 

NVFC Health and Wellness Guide 25 
IV. Volunteer Programs From Across the Nation

TABLE 4: BACKGROUND OF DEPARTMENTS

Type of 

Department State Population

Number

of 

Stations 

Number

of 

Career 

Number of 

Volunteers

Type of 

Community

Combination NC 800,000 40 700 200 Urban/Suburban

Combination VA 275,000 19 400 150 Suburban/Rural

Volunteer MD 155,654 14 0 600 Suburban/Rural

Volunteer FL 71,000 6 0 189 Suburban

Volunteer NC 70,000 9 0 194 Rural

Combination WA 70,000 7 50 60 Suburban

Volunteer ID 40,000 2 0 50 Rural/Suburban

Combination KY 35,500 3 37 12 Suburban

Combination NY 35,000 3 35 19 Suburban

Volunteer CT 26,500 3 0 86 Urban

Volunteer NY 24,500 2 0 78 Suburban

Volunteer TX 20,000 1 0 55 Rural

Combination OH 17,500 3 42 23 Suburban

Combination IL 13,000 1 9 45 Suburban

Volunteer MO 5,600 2 0 32 Rural

Combination IA 5,000 1 8 28 Rural

Combination AK 4,300 3 8 25 Rural

Seventy-five percent of the departments (12) ensure immunizations for Hepatitis 

B and Tetanus, and provide annual flu shots. Sixty-three percent (10) provide full blood 

laboratory screening and full medical physical examinations, including chest x-ray, stress 

test, EKG, blood pressure, vision, and hearing tests and testing for high-risk cancers. Fire 

departments note that various cancers and heart problems were identified early because of 

the medical exams. 

Ten departments have an exercise facility at each station. Facilities feature 

treadmills and universal weight machines in most cases, and cross-training machines in 

50 percent (8) of the responding departments. 

Less than one-third of the departments (5) test body fat percentages and establish 

a body fat reduction plan. An additional five departments contract with licensed industrial 

hygienists to address specific injury risks, and only two of the programs include peer 

fitness trainers. 

Three-quarters of the departments (12) fund the entire cost of a health and 

wellness program through a variety of sources. The fundraising method most commonly 

used to cover program costs is a local tax. In three other cases, funding is provided either 

directly from the employees or through worker’s compensation. 

26 NVFC Health and Wellness Guide 
IV. Volunteer Programs From Across the Nation

Model Program Elements 

This section discusses the more innovative program approaches that some of these 

departments use with their health and wellness programs. Although not all of the 

components are exactly replicable, they provide benchmarks against which volunteer 

departments can compare their programs. In each example provided, small pieces of 

comparable elements from other departments, discussed in the previous section, were 

included to strengthen the comparable model. 

CALDWELL FIRE AND RESCUE, IDAHO: PARTICIPANT INVOLVEMENT AND 

FACILITATORS

The fitness program developed by Caldwell Fire and Rescue demonstrates the 

importance of participant support and engagement. The firefighters themselves helped 

build the program. Firefighters, as most people, have a greater stake in the success of the 

program when they play an integral role in its development. 

Fitness program participants in Caldwell play the roles of mentors and partners 

for each other. This encourages them to complete their exercises more frequently and 

helps maintain a positive attitude about the program. Other fire departments have chosen 

members of the department to act as peer fitness trainers. These individuals encourage 

full participation, provide guidance in appropriate fitness methods, and serve as a source 

of support. While it is desirable to have peers lead the program, they should be properly 

trained to help deliver a safe program. 

CARROLL COUNTY, MARYLAND: ANNUAL MEDICAL EXAMINATION

Carroll County has a countywide wellness program. Individual fire departments 

elect the degree to which they wish to participate. The program began in 1995, and 

focuses on annual physicals for the firefighters. The program also encourages all 

members to live a healthy lifestyle. The county fire association has an agreement with a 

local general practitioner who gives the firefighters physicals at a reduced rate. 

Each department chief sends a list of department members to the practitioner. The 

doctor’s office then contacts each volunteer and schedules an appointment for their 

annual medical exam. These physicals are paid by the fire department. (Firefighters can 

elect to receive a comparable physical from their own doctor at their own expense.) 

Those who have health problems are declared unfit for duty until they are treated or

cleared. Firefighters with identified health problems are rehabilitated and then returned to 

duty. Firefighters’ records are kept confidential; the department is only notified if there 

are health-related problems that affect fitness for duty. 

One of the major obstacles in implementing the Carroll County annual physical 

program is that some firefighters are concerned about the potential health problems that 

could be detected. It is emphasized to the firefighters that physicals and tests are designed 

to identify problems before they cause death or major impairment. Carroll County has 

NVFC Health and Wellness Guide 27 
IV. Volunteer Programs From Across the Nation

several success stories of firefighters whose lives were saved because of the annual 

physicals. Additionally, no volunteer has had to leave the service as a result of the testing. 

This is vastly preferable to ignoring the possibility of a problem until it begins to affect a 

firefighter’s life. 

GATES FIRE DISTRICT, NEW YORK: RECORD KEEPING

Gates Fire District has a model record keeping program. The District Fire Chief is 

responsible for tracking the progress of each participant and of the program as a whole. 

The program tracks a firefighter’s general health, strength, body composition, endurance, 

and flexibility. An individual can observe the changes over time, which provides 

motivation for further participation in the program. 

The Fire Chief also maintains records of sick leave usage, injury reports, and 

accident reports. Reviewing and analyzing the records show the strengths and weaknesses 

of the fitness program. A decrease in the number of injuries may serve as an impetus for 

more firefighters to participate in the program. 

As program administrator, the Fire Chief schedules the necessary physicals and 

ensures compliance with the program procedures. This organization guarantees that 

everyone receives the necessary medical attention and that everyone participates in the 

program to the same degree. 

An alternative found to be effective elsewhere is to appoint a volunteer health and 

wellness coordinator, who would do what the chief does in this case. Many chiefs are so 

overwhelmed with time demands from managing the fire department that they do not 

have time to administer the program, and often appoint one or two others to do it. This 

does not mean the chief is not involved; rather, he or she is (or should be) the biggest 

advocate for the program to the membership. 

Also, it should be noted that the most effective programs ensure confidentiality of 

each individual member’s health and wellness initiatives. Without it, volunteers might 

not be as forthcoming and less likely to participate. 

CHESTERFIELD COUNTY FIRE AND EMS, VIRGINIA: INDIVIDUALIZED PROGRAMMING

The Chesterfield County program recognizes that not all firefighters are alike. 

Individuals of different ages, sizes, genders, and classifications have different fitness 

needs. The details of the daily fitness routine therefore are determined on a case-by-case 

basis by a professional trainer. The department also uses peer facilitators to tailor the 

health program for each individual. Some of the program’s success stems from this 

guarantee that everyone has an appropriate regimen and achievable goals. 

One of the reasons for using peer facilitators instead of professional trainers is to 

save costs. Professional trainers are costly. Having two firefighters trained and certified 

28 NVFC Health and Wellness Guide 
IV. Volunteer Programs From Across the Nation

might have a high initial cost, but will save money in the long run. The peer facilitators 

may be more effective in encouraging participation. 

Update on Programs from Previous Report 

In the first version of this guide, nine programs were featured as case studies in an 

attempt to help other departments build their programs using the experience of other 

volunteer departments. In this guide, featured programs are presented for the same

reason: they have model elements that could be emulated. But, it also is useful to look 

back at how previous programs grew, or declined in the past several years. 

VALDEZ FIRE DEPARTMENT, ALASKA 

The Valdez Fire Department in Valdez, Alaska, experienced substantial budget 

cutbacks, and subsequent cutbacks to the fire department’s health and fitness program, 

created in 1991. The original non-mandatory program offered a pre-acceptance medical 

examination, follow up evaluations, counseling, and a fitness/exercise program including 

goals for specific members and workouts with free weights and a universal gym with onsite exercise equipment. Participants included members of all age ranges and ranks and, 

at the program’s inception, interest was high. The department paid for a large majority of 

the equipment costs and accompanying computer software, and members funded specific 

programs with their own money, such as exams and the Employee Assistance Program. 

In 2003, department officials considered the program viable with a 60 percent 

departmental participation rate, but acknowledged that the program was not as detailed or 

comprehensive as they had intended, mainly due to organizational downsizing at the 

department and budget cutbacks. The regimen of screenings and testing and availability 

of counseling has been fully implemented, but the program does not include member 

education and contact with specific specialists, such as a hygienist. 

PLANTATION FIRE DEPARTMENT, FLORIDA 

The Plantation Fire Department in Plantation, Florida, created their health and 

fitness program in the early 1990s. The program incorporated a screening and evaluation 

component, which included full blood laboratory screenings, annual flu shots, and 

rehabilitation following injuries. The program also included an educational piece, with

nutrition and weight management, exercise, back care, stress management, and heart 

disease counseling provided to members. The department purchased universal machines 

and stationary bicycles for all stations, and medical examinations were paid by the 

department. 

As of 2003, Plantation Fire Department has pared down its health and fitness 

program, retaining only the benefits that the city provides to its employees, such as the 

use of exercise equipment, by membership, at three city-managed exercise facilities, and 

other medical and testing programs. 

NVFC Health and Wellness Guide 29 
IV. Volunteer Programs From Across the Nation

Plantation Fire Department officials indicated that program’s demise was mainly 

due to its high cost and little interest among membership. In addition, the city already 

provided certain benefits to all city employees and volunteers at no cost or for reasonable 

fees. 

FLOSSMORE VOLUNTEER FIRE DEPARTMENT, ILLINOIS

The health and fitness program at the Flossmore Volunteer Fire Department in 

Flossmore, Illinois, was implemented in 1989, and is described in 2003 by department 

officials as a “moderate” success, with 25 to 30 percent of the total membership 

participating.

The Flossmore program includes pre-acceptance medical screenings and an

exercise and fitness program. The exercise program includes evaluations and testing, 

cardiovascular exercise regimen development and counseling, and fitness and exercise 

equipment that emphasizes cardiovascular exercise over bodybuilding and weight lifting. 

The program has experienced few changes since its inception. Department 

officials say that those members who participate in the program “love it,” and that two 

members who had injuries that required surgery were fortunate that these injuries were

diagnosed during a program-sponsored screening or evaluation. 

GATES FIRE DISTRICT, NEW YORK

Gates Fire District in Rochester, New York, continues to experience success with 

its comprehensive Health and Fitness Program, which began in 1988. The district has 

made improvements to the program, such as adding the services of doctors and an 

occupational health company. District officials report these changes have increased the 

program’s convenience to members. 

Department officials believe that the availability of their program, with equipment 

available at two out of three stations, was the program’s most popular asset among 

members, many of whom work non-traditional hours and cannot schedule time for 

exercise at a limited-schedule gym. 

District officials said that the lack of a formal structure to their health and fitness 

program (a majority of the program’s offerings are voluntary) is the program’s weakest 

point. The district acknowledges that the program would be more effective with peer 

trainers and more one-to-one contact between new program participants and program

veterans. Of the members who discontinued using the program, most said that the 

program was physically difficult and yielded too few results. The district is considering 

changes to their plan based on participant feedback. 

Much of the program’s successes, district officials said, can be measured by what 

did not happen to its members. One member, for example, discovered prostate cancer as a 

30 NVFC Health and Wellness Guide 
IV. Volunteer Programs From Across the Nation

result of his program-related screenings, and others have discovered heart problems that 

would not have been diagnosed without the program’s screening regimen. 

HOWLAND FIRE DEPARTMENT, OHIO 

The Howland Fire Department in Warren, Ohio, has also experienced moderate 

success with its health and fitness program, which it implemented in 1989. Department 

officials report that 75 percent of all members participate in the program in some way, 

and 25 percent of the membership participates three days per week. Department officials 

attribute any lack of interest among members to time constraints and the fact that the 

program is not mandatory. 

The program includes pre-acceptance medical screening, monthly physical fitness 

evaluation, and cardiovascular-focused fitness equipment. To enhance the program, the 

department added a “jump-stretch” program, which focused on low impact stretching 

warm-ups to make members more flexible. Additionally, the department has paid specific 

attention to maintaining the fitness equipment. 

CHESTERFIELD COUNTY FIRE AND EMS, VIRGINIA

Chesterfield Fire Department’s in Chesterfield, Virginia, health and wellness 

program has evolved since its inception in 1978. The department is currently rewriting its 

program, which was originally organized from an academic perspective and placed 

emphasis on jogging and running exercises. Now, the intent is to target issues and needs 

specific to firefighters, such as knee and joint injuries. At the same time, and as a result of 

this rewrite, the department is replacing treadmills--which can exacerbate joint injuries--

with elliptical machines and free weights. 

As the program has evolved, officials at the Chesterfield Fire Department have 

pinpointed the program’s few problems, including member dissatisfaction with 

qualifications requirements for trainers and the lack of participation among some

members. Members prefer that all trainers have qualifying degrees, a requirement which 

is not currently in effect. Participation is not mandatory for the department’s volunteer 

members. 

The department has measured the programs continued success by evaluating the 

seriousness of injuries among members, which the department has estimated as 

decreasing, along with medical costs for treating injuries. Additionally, the department 

reports that the program remains popular, retaining 90 percent of participants after they 

“graduate” from initial program stages. 

LACEY FIRE DEPARTMENT, WASHINGTON

The Lacey Fire Department in Lacey, Washington has increased the breadth and 

scope of its health and fitness program since its inception in the mid-1980s. The 

NVFC Health and Wellness Guide 31 
IV. Volunteer Programs From Across the Nation

department hired a health and safety officer in 2000, and is working with five nearby 

departments to help create health and fitness programs for each of them. 

Most of the department’s 180 members participate in the program. The program’s 

leadership attributed the program’s popularity and high participation rates to its clear 

organization; one person is “in charge” of the program and can communicate directly 

with members about it. 

The program’s only drawback, as indicated by department officials, is the lack of

authority given to the health and safety officer position. 

IAFC Funded Programs 

The IAFC, funded by a USFA cooperative agreement, selected a group of eight 

departments to fund for a best practice project. Three of the programs led to some

innovations and new concepts that are useful to consider when developing a program in 

other volunteer departments. 

BERNALILLO COUNTY FIRE DEPARTMENT, NEW MEXICO

Bernalillo County Fire Department is a combination department with 200 

members. Their program consists of several components discussed in this chapter and the 

following. They require an annual physical exam for all members. For potential 

members, they use a wildland firefighter pack test for screening (uses a timed walk 

around a track carrying a specified amount of weight). They also have improved their 

kitchens in the firehouses to encourage firefighters to cook vs. bringing in fast food. 

Under the IAFC program, they have initiated or are initiating the following for 

both volunteer and career firefighters: 

• Two career employees and one volunteer are certified as peer fitness 

trainers. These peer trainers will document each member’s fitness program 

and measure progress. 

• Influenza vaccinations are on request. 

• Health and wellness classes are held on a regular basis. 

• All members (including volunteers) are expected to work out in aerobic 

activity 30 minutes per duty day. They sign into the exercise room, and 

must notify the shift commander or peer fitness counselor at the start and 

finish of each workout. 

• They plan to measure changes in sick leave usage and on-duty injury 

reports as a result of the program. 

32 NVFC Health and Wellness Guide 
IV. Volunteer Programs From Across the Nation

HARTFORD EMERGENCY SERVICES, VERMONT

Hartford’s combination department serves a population of 10,000. Their 

volunteers are paid on a per-call basis. To increase members’ support, the department 

developed the fitness program working with a group of volunteers and career firefighters. 

Their program centered on being completely voluntary, confidential, and non-punitive. 

Under the IAFC program, they have initiated or are initiating the following 

program components: 

• Two certified peer fitness trainers work with the membership to develop 

individual routines and to keep logs and records. 

• Fitness evaluations are offered to all members. 

• Two paid physical exams are offered; participants were asked to 

voluntarily give data from their physical exam to peer fitness trainers: 

blood pressure, pulse, weight, spirometry (lung capacity), and cholesterol. 

• Health classes, lectures, and relevant literature are also offered, free of 

charge. 

• All members are requested to work out three times per week for 30 

minutes and to login and logout each session. 

BRODHEAD FIRE DEPARTMENT, WISCONSIN

Brodhead Fire Department is a 39-member volunteer department. They have had 

three recent fatalities from heart attacks of active members off-duty. Prior to 

implementing a health and wellness program, they did not have an agility test to screen

members, nor was there a physical fitness program. 

Since implementing the program, Brodhead has seen a 25 percent decrease in 

program participation. The chief of the department said the main reason for the decrease 

in participation is because it is difficult to keep the members motivated. Although they 

have a peer coordinator who is responsible for log up keep and membership motivation, 

the coordinator position is overwhelmed. 

The members who have stayed active in the program state they feel better, have 

better endurance, and can carry out their responsibilities to a higher degree. 

Under the IAFC program, they have initiated or are initiating the following 

program components: 

• Department pays the co-pay portion of a physical exam at the start of their 

new fitness program and one on completion of the start-up program. 

NVFC Health and Wellness Guide 33 
IV. Volunteer Programs From Across the Nation

• Members are encouraged to use a local health club where club trainers can 

design personal workout routines for each member. Club memberships are 

subsidized for the first four months with grant funds. 

• Specialists from local hospitals are invited to speak at training sessions 

every other month on nutrition, body mechanics, stress management, and 

other health issues. Additionally, the department provides volunteers with 

monthly literature on healthy lifestyles. 

• Hepatitis and TB testing/vaccinations are provided by the department. 

• The department requires a minimum of two 30-minute sessions of aerobic 

activity per week, with the hope that members will increase the workout 

time on their own. The aerobic exercise routine is the only mandatory 

component for members. 

34 NVFC Health and Wellness Guide 
V. Development of a Health and Wellness Program for Volunteer Fire Departments 

V. DEVELOPMENT OF A HEALTH AND WELLNESS PROGRAM 

FOR VOLUNTEER FIRE DEPARTMENTS 

The previous chapters examined why health and wellness programs are essential 

and what departments across the nation are doing with their programs. This chapter 

focuses on how a volunteer or combination department can develop a health and wellness 

program of its own. 

The development of a health and wellness program involves both the 

implementation of program components and the establishment of a program

administration and supporting groundwork. This chapter begins with a look at the major 

program components, followed by a discussion of the administration of a health and 

wellness program. Chapter VI brings all of the recommendations together with a step-bystep program implementation guide. 

Program Components 

A comprehensive health and wellness program includes the following 

components: 

• Regular fitness screenings and medical assessments 

• Fitness program (cardiovascular, strength, and flexibility training) 

• Behavioral modification (smoking, hypertension, diet, cholesterol, 

diabetes) 

• Volunteer education 

• Screening volunteer applicants. 

When a program combines all of these components, the volunteers pay more 

attention to their personal health and wellness, which will improve the department 

overall. If a department cannot implement the entire program at once, it is far better to 

initiate some of these components than to do nothing. 

REGULAR FITNESS SCREENINGS AND MEDICAL ASSESSMENTS

Regular screenings and medical assessments are an important foundation for a 

successful, comprehensive health and wellness program. NFPA 1582 provides a set of 

guidelines for medical testing and screening, which simplifies the development of this 

component.

Fitness Screening--Prior to participation in any fitness program, adults should be 

effectively screened in accordance with American College of Sports Medicine (ACSM) 

Guidelines. These guidelines will classify individuals as a low, moderate, or high risk for 

participation in any fitness program. Individuals classified as high risk should be referred 

to a high-risk intervention program, closely supervised by medical personnel. These 

NVFC Health and Wellness Guide 35 
V. Development of a Health and Wellness Program for Volunteer Fire Departments 

individuals will incur the greatest risk for cardiac complication and increased health care 

costs. They may be at risk from the exercise program itself if it is not properly modified 

to their capabilities. 

Individuals classified as moderate risk should only participate in moderately 

strenuous programs without having had a medical exam within the past year. Nor should 

they undergo testing without medical supervision. Individuals classified as low risk can 

participate in an exercise program that can be vigorous in nature or undergo testing 

without medical supervision. 

Annual Medical Examinations--The risks that confront a firefighter necessitate a 

regular evaluation of health and wellness. NFPA 1582 recommends an annual medical 

examination for all firefighters over 40, at least every two years for those 30 to 39, and at 

least every three years for those ages 29 and under. Identifying risks might preclude a 

volunteer from riding for a period of time. In this circumstance, however, the firefighter 

should not take this action as a punishment, but rather be convinced that it is for their 

safety and health as well as for other fire service members and the community. 

The examinations should be standardized for all members. As discussed in the 

previous chapter, Carroll County, Maryland, developed a partnership with a local health 

practitioner who offered a discounted rate and provided standardized examinations for 

volunteers. Such a physician would work with the health and wellness coordinators, in 

addition to the members, providing a much-needed perspective on the condition of the 

membership in that specific department. 

NFPA 1582, Medical Requirements for Firefighters and Information for Fire 

Department Physicians, suggests the following items be reviewed as part of the medical 

examination; any problems identified should be rectified before the firefighter is allowed 

to respond to emergencies:49

• Vital signs--namely, pulse, respiration, blood pressure, and, if indicated, 

temperature 

• Dermatological system 

• Ears, eyes, nose, mouth, throat 

• Cardiovascular system 

• Respiratory system 

• Gastrointestinal system 

• Genitourinary system 

• Endocrine and metabolic systems 

• Musculoskeletal system 

• Neurological system 

36 NVFC Health and Wellness Guide 
V. Development of a Health and Wellness Program for Volunteer Fire Departments 

• Audiometry 

• Visual acuity and peripheral vision testing 

• Pulmonary function testing 

• Laboratory testing, if indicated 

• Diagnostic imaging, if indicated 

• Electrocardiography, if indicated. 

Although having a common practitioner would be ideal for conducting all of these 

tests consistently, some firefighters will want to use their own physician. These 

firefighters should be provided with a common medical examination form, developed by 

the department, to standardize the process and to ensure comparable results. 

FITNESS PROGRAM

A well-designed fitness program should include both physical activity and 

exercise. It is designed to improve individual physical condition and endurance and to 

reduce the risk of heart attacks and other major problems facing firefighters. 

Physical activity is defined as bodily movement produced by the contraction of 

skeletal muscle, which increases energy expenditure--in simple language, moving around. 

Exercise is planned or structured movement, repetitive in nature. It is intended to 

improve or maintain one or more of the following components of physical fitness: 

• Cardiorespiratory fitness

• Muscular strength 

• Muscular endurance 

• Flexibility 

• Body composition. 

Exercise and training programs have now evolved beyond the simple focus of the 

health-related aspects of physical fitness to include the skill-related aspects vital to 

firefighter performance. The fire service has shifted its emphasis to training programs 

that improve the overall quality of life by maximizing the carryover gains from training 

into the activities of firefighting. 

Surveys indicate that about 36 percent of the American population engages in no 

physical activity, and an additional 26 percent undertake insufficient physical activity. 

Nationally, dropout rates for those beginning an exercise program are alarming, reaching 

50 percent or more by the end of the first six months. The reasons are complex and 

multifaceted, influenced by factors associated with each individual, the environment, and 

the stage of behavioral readiness and features of the program itself.50

NVFC Health and Wellness Guide 37 
V. Development of a Health and Wellness Program for Volunteer Fire Departments 

Moderate-Intensity Program--Historically, attention has focused solely upon 

exercise, promoting its benefits and virtues. Recent research, however, has demonstrated 

numerous health benefits associated with regular participation in intermittent, moderateintensity physical activity in addition to exercise. Consequently, the Centers for Disease 

Control and Prevention has amended and expanded their emphasis to include greater 

awareness of participation in physical activity and the quantities and intensities necessary 

to achieve health benefits, which are lower than previously thought to be necessary. This 

does not discount the added benefits of more intense, longer duration exercise. There are 

benefits from increased activity that more people (and firefighters) may be willing to 

maintain. 

According to U.S Surgeon General Richard Carmona: “Significant health benefits 

can be obtained by including a moderate amount of physical activity on most, if not all 

days of the week. Through a modest increase in daily activity, most Americans can 

improve their health and quality of life... Additional health benefits can be gained 

through greater amounts of physical activity. People who maintain a regular regimen of 

activity that is of longer duration or of more vigorous intensity are likely to derive greater 

benefit.” 

Moderate intensity activities are equivalent to walking three to four mph (15 to 20 

minutes to walk a mile). These casual daily activities are the easiest to promote and 

implement and are key to any successful fitness program. 

Figure 3 shows how anyone could increase their physical activity in their daily 

lives even if they do not commit to a regular workout routine. 

38 NVFC Health and Wellness Guide 
V. Development of a Health and Wellness Program for Volunteer Fire Departments 

FIGURE 3: PHYSICAL ACTIVITY PYRAMID 51

Source: Institute for Research and Education, 1996

Some additional examples of moderate activity: 

TV CUT DOWN

Sitting 

Computer

Aerobic Recreational

(20+ minutes) (30+ minutes)

Running, Swimming Dancing, Hiking

Strength 

Flexibility

Raking, Gardening

Leisure 

Activities 

Golf, Bowling

2-3X / WEEK

3-5X / WEEK

FREQUENTLY

Everyday Activities 

Stairs vs. elevators

Park further

Walk the dog 

Walk to mailbox

• Washing/waxing a car (45–60 min) 

• Washing windows/floors (45–60 min) 

• Playing volleyball/touch football (45 min) 

• Gardening or raking leaves (30–45 min) 

• Basketball game (15–20 min) 

• Bike riding (30 min) 

• Moderate-high tempo dancing (30 min) 

• Swimming laps (15–20 min) 

• Brisk walking (30 min). 

Cardiovascular Program--The goals of the cardiovascular portion of the fitness 

program are to improve performance, improve health, prevent injury, decrease the risk of 

heart attack, and increase heat tolerance. The first step is to increase daily activity. Not 

only will this improve health, but it also creates a more positive, active image for 

firefighters in the community. 

NVFC Health and Wellness Guide 39 
V. Development of a Health and Wellness Program for Volunteer Fire Departments 

At the next level, participants could engage in moderate intensity exercise for 30 

or more minutes a minimum of three times per week. This can include such activities as a 

brisk walk or a bicycle ride. Firefighters should set a pace with which they are 

comfortable and increase the pace as they wish. 

As firefighters become comfortable with the moderate level, they could transition 

to a higher intensity exercise. Once again, participants set their own pace. Depending on 

the needs of the individual, this intensity exercise could be performed in a gym, at the 

department, or at home. 

It may be possible to develop partnerships with a nearby fitness center. Then, 

firefighters would have access to a wide range of equipment and fitness expertise. This 

can also benefit the department, as using the fitness center will reduce the time 

commitment for the volunteer coordinator and reduce liability concerns. On the negative 

side, the use of a fitness center may cost more money, be inconvenient for the volunteers, 

and involve more self-motivation. A more detailed discussion about developing 

partnerships is provided later in this chapter under Program Administration. 

Exercising in a department facility can foster a sense of camaraderie among the 

volunteers. Team competitions and participation in community events can also provide 

motivation for greater participation in fitness programs. Cardiovascular exercise can be 

performed in the department with the aid of only a few machines. Treadmills, stationary 

bicycles, elliptical machines, stair climbers, and rowing machines can serve volunteer 

departments adequately. These machines require a modest initial cost, but in the long 

term they may reduce costs of membership fees to fitness centers.52 

Strength Training--The goals of strength training are to protect against injury, 

improve performance, maintain the appropriate body composition and improve health. 

An appropriate strength-training regimen includes a progressive weight lifting and 

calisthenics program. These exercises should be performed two to four times per week, 

working the major muscle groups twice a week. 

A weight-training regimen includes a minimum of one to three sets of six to 12 

repetitions each day at a comfortable weight. Individuals should begin with one set at a 

lower weight level and work up to three sets at a higher weight level. Participants, 

however, need to progress at their own pace. Ideally, the selection of exercises should 

emulate firefighter activities for the weight training to improve job performance. 

A calisthenics routine may include situps, pullups, and crunches plus a selection 

of exercises aimed at strengthening and stabilizing the core muscle group. Here too, 

participants progress at their own pace. 

Weight lifting and calisthenics can be done at a fitness center, in the department, 

or at home. Although a fitness center offers a wide range of strength training machines, 

most departments could provide barbells, dumbbells, Smith presses, and weight stations 

at minimal costs.

53

40 NVFC Health and Wellness Guide 
V. Development of a Health and Wellness Program for Volunteer Fire Departments 

Flexibility Training--The goal of flexibility training is to prevent injuries, 

especially to the lower back. Participants engage in moderate stretching, holding each 

stretch for 10 to 30 seconds. Although stretching is encouraged prior to exercise or 

physical activity, the greatest gains in flexibility are made after exercise, when muscles 

are warm. Therefore, stretching should be done both as a warm-up and after exercise. 

Strength and flexibility go hand-in-hand. Increasing both simultaneously will improve 

firefighter performance and decrease their risk for injury. 

BEHAVIORAL MODIFICATION PROGRAM

Behavioral modification is another core component of a comprehensive health 

and wellness program. Firefighters will want to address any preexisting health conditions 

and personal behaviors that heighten their risks of cardiovascular disease (CVD) or other 

injuries. CVD is by far the leading cause of firefighter deaths in the United States. 

Smoking, hypertension, an unhealthy diet, unmanaged cholesterol, unmanaged diabetes, 

and high blood glucose levels are all contributors to CVD, and each can be modified. 

(See Appendix B for a detailed discussion of the medical physiology of each of these 

contributing factors to CVD.) 

Smoking--Smoking cessation is one of the most important interventions for 

preventing CVD. Smoking cessation reduces the risk of the first heart attack by 65 

percent.54 The strategies to reduce the risk of CVD associated with smoking are 

straightforward: 

• Individuals can attend a smoking cessation program, employ nicotine 

replacement therapy, or discuss medication options with their physician. 

Over-the-counter and prescription medications are available to help 

overcome the smoking addiction. 

• Fire departments can aggressively promote smoking cessation programs 

available through local hospitals and other health agencies and consider 

sponsoring programs for their employees. 

• Fire departments can ban smoking among firefighters at the station. 

• Fire departments can implement regulations that protect firefighters from 

second-hand smoke at the station. 

Hypertension--Strategies to reduce the risk of CVD associated with hypertension 

are varied and often overlapping. The degree of risk and the appropriate interventions 

depend on the degree of hypertension and the presence of additional risk factors. 

Individuals with elevated blood pressure, even high-normal blood pressure, should 

consult with their physician. During the consultation, the physician needs to be made 

aware of the types of job stresses encountered in firefighting. The physician may 

recommend drug therapy to treat hypertension. But lifestyle modifications should also be 

used in conjunction with medication. In fact, lifestyle modifications may be sufficient to 

avoid medication or to prevent the need for medication. 

NVFC Health and Wellness Guide 41 
V. Development of a Health and Wellness Program for Volunteer Fire Departments 

Diet--An appropriate diet is an important factor in the prevention of CVD. In 

general, the three primary objectives of diet modification are: 

• Attaining ideal body weight 

• Ensuring a well-balanced diet high in fruits and vegetables 

• Restricting saturated fats and simple, refined carbohydrates (sugars). In 

general, less than 30 percent of daily calorie intake should be from fats 

(with less than 10 percent of calories coming from saturated fats). 

Cholesterol intake should be less than 300 mg/day. Because of growing 

evidence that omega 3 fatty acids protect against CVD, it is commonly 

recommended that individuals eat fish one or two times per week.55 

Lowering caloric intake is important in weight reduction. A loss of excess body 

fat is associated with decreased blood pressure. A two-pound reduction in body weight is 

associated with a 1.6-mmHg reduction in systolic blood pressure and a 1.3-mmHg 

reduction in diastolic blood pressure. The higher an individual’s blood pressure is the 

higher their risk for CVD.56 

Reducing salt intake is beneficial for individuals with elevated blood pressure. 

Sodium restriction is associated with a decrease in blood pressure in most people.57 Salt 

restriction can be achieved by avoidance of salty foods (e.g., potato chips, olives), by not 

using or restricting the amount of salt while cooking or seasoning foods, and by avoiding 

processed food. Other recommended dietary changes include decreasing alcohol and 

caffeine consumption and increasing fruits, vegetables, and fish in the diet. 

Reducing Cholesterol--As discussed in detail in Appendix B, the risk of CVD is 

heightened with unmanaged cholesterol. In general, the strategies for managing 

cholesterol levels fall into two categories: life-style modification and drug therapy. Drug 

therapy may be necessary for individuals who are at high risk for cardiovascular disease 

(risk factors discussed in Appendix B). If cholesterol levels are a concern, firefighters 

should consult with a physician to see which combination of strategies is right for their 

individual needs. 

The primary lifestyle modifications that affect high cholesterol involve diet and 

exercise, in addition to drug therapy. In all cases, drug therapy should occur in 

conjunction with dietary therapy and increased physical activity. In many instances, drug 

treatment for high cholesterol levels is a long-term treatment strategy, and it is imperative 

that individuals continue to take their medication. Very often individuals will not “feel 

better” when they are taking the medication, but the cardiovascular system is “working 

better.” 

Managing Diabetes and Reducing Blood Glucose Levels--Diabetes often 

coexists with other risk factors for cardiovascular disease. Clustered, these risk factors are 

termed “metabolic syndrome X” and include abdominal obesity, hypertension, 

dyslipidemia, and an inability to effectively use glucose (diabetes). Therefore, a person 

42 NVFC Health and Wellness Guide 
V. Development of a Health and Wellness Program for Volunteer Fire Departments 

with diabetes must very aggressively control other risk factors. A diabetic should lose 

excess body weight, exercise regularly, and eat a diet low in simple sugars and 

carbohydrates. Because of the complexity of the disease, its relationship to heart disease, 

and the difficulty controlling blood glucose levels, a diabetic person should consult 

regularly with a physician about a diet and exercise program and the need for medication. 

EDUCATING MEMBERSHIP

Education is another core component of a comprehensive health and wellness 

program and is an important step to shift the culture of the fire service. Education 

includes health (nutrition and fitness), orthopedic, and ergonomic seminars or workshops. 

Using firefighter interest surveys and determining needs, seminars can be tailored to 

include back care, nutrition, supplements, stress management, resiliency training, diet, 

heart disease, smoking, and injury prevention. Short seminars can be included in the 

department’s regular training or business meetings. 

Some groups or individuals within the community may be willing to conduct the 

seminars at little or no cost. The fire department might find speakers willing to volunteer 

their time to the fire service by contacting the local YMCA, health clubs, college, 

chamber of commerce, or medical community (including hospitals). 

SCREENING VOLUNTEER APPLICANTS

Another component in the health and wellness program is recruiting people with 

good fitness habits. Recruiting healthy individuals to serve as firefighters may reduce 

firefighter fatalities from heart attacks and other medical conditions. Physically fit 

individuals may also be at less of a risk of incurring traumatic injuries. Two examples of 

screening processes are a wildland firefighter pack test (featured in Chapter IV) and a 

candidate physical agility test. Both screening processes look at the challenges that face 

potential firefighters. 

The members of the IAFF-IAFC Wellness/Fitness Task Force developed the 

Candidate Physical Agility Test (CPAT) to establish a non-discriminating, fitness-based 

test for hiring firefighters. The CPAT is administered along with other recruiting and 

mentoring practices. The CPAT is comprised of eight events in which the candidate must 

wear a 50-pound weighted belt. (A belt is used as opposed to structural turnout gear and 

SCBA so as not to give an advantage to experienced firefighters seeking employment.) 

The eight events include: 

• Stair climb (climbing stairs with a 25-pound simulated hose pack) 

• Ladder raise and extension (placing and raising ground ladder to the 

desired floor or window) 

• Hose drag (stretching and advancing hoselines, charged and uncharged) 

• Equipment carry (removing and carrying equipment from fire apparatus to 

fireground) 

NVFC Health and Wellness Guide 43 
V. Development of a Health and Wellness Program for Volunteer Fire Departments 

• Forcible entry (penetrating a locked door, breaching a wall) 

• Search (crawling through dark areas to search for victims) 

• Rescue drag (victim removal from a fire building)

• Ceiling pull (pulling a ceiling to check for and locate fire extension). 

Although the CPAT was designed for recruitment to career departments, it can be 

applied to recruitment of volunteer firefighters as well. 

Program Administration 

The administration of a health and wellness program is crucial to its success. If

the program is not made a priority or is mismanaged, members may refuse to participate. 

On the other hand, proper management and leadership might create a positive culture 

change in the department. 

HEALTH AND WELLNESS COORDINATORS

NFPA 1583 recommends: “The fire department, under the discretion of the fire 

chief, shall appoint a health and fitness coordinator. The health and fitness coordinator 

shall be: 

• “A member of the fire department or an outside agent as designated by the 

fire department.... 

• “Report to the fire chief or the fire chief’s designated representative.... 

• “Be the administrator of all components of the health-related fitness 

program.... 

• “Act as a direct liaison to the fire department’s health and safety officer.... 

• “Have access to appropriate educational materials and/or formal 

certification from a professional organization, relevant educational 

experience, appropriate academic degrees, completion of course work 

relevant to the program components, or attendance at workshops related to 

health and fitness.... 

• “Maintain continuing education requirements”58

In short, coordinators are to be the program’s advocates within the department 

and to be coaches for the volunteers. With proper support from the officers, especially the 

chief, these coordinators could change the health and wellness culture within the 

department. Preferably, coordinators should be trained through an accredited peer fitnesstraining program. They coordinate all program marketing, manage data collection, and 

generate monthly reports for fire department management. 

44 NVFC Health and Wellness Guide 
V. Development of a Health and Wellness Program for Volunteer Fire Departments 

Coordinators should be available for year-round training, programming, and 

consultation. They will need to divide their time between addressing individual program

prescription and training, monitoring performance, task analysis, injury prevention, and 

administration. Depending on the size of the department, multiple coordinators might be 

necessary. 

LIABILITY EXPOSURE

Liability is a major concern of volunteer departments that have health and 

wellness programs, and even a greater concern for those that are looking to start one. 

Although there is no way to eliminate liability, there are ways to reduce it. When creating 

a program, a department should work with its insurance company and its legal counsel or 

the community’s counsel. Insurance companies address these types of concerns every day 

and are generally inclined to offer assistance beforehand to help prevent a claim.

More importantly, departments need to keep in mind the risks that come with not 

implementing a health program. With firefighter injury rates high, and many injuries 

preventable, implementing a program will likely reduce injuries and save departments

money in the long run. 

FUNDING ALTERNATIVES

Creating a full health and wellness program, as outlined in this chapter, could 

prove costly to a department, especially a small budget volunteer organization. There are 

many opportunities to help reduce costs, receive grants to cover expenses, or forge 

partnerships to eliminate costs. This section looks at some of the options and alternatives 

in funding a health program. 

USFA’s guide, Funding Alternatives for Fire and Emergency Medical Services, 

presents a number of ideas for funding different types of programs, including a health and 

wellness program. One might argue that health and wellness of firefighters should be a 

priority and be paid for from the five service’s budget. Since the current budget may be 

inadequate and the probability of its increase politically uncertain, other sources of 

funding may need to be considered. Some ideas include: 

• Fees for service: A way to raise funds for the budget that could be set 

aside for a health and wellness program. 

• Grants: Funding is available from a number of sources that could be 

sought after to help offset the cost of the program. An opportunity that 

each department should look at is the USFA Assistance to Firefighters 

Grant program, which is highlighted later in this section. 

• Interacting and networking: Contact state fire and EMS offices, 

associations, organizations, public officials, or decision makers and make 

sure they recognize the importance of health and wellness in the fire 

service. 

NVFC Health and Wellness Guide 45 
V. Development of a Health and Wellness Program for Volunteer Fire Departments 

• Foundations and corporate donations: Large foundations, community 

service clubs, and corporations often can usually provide funding or inkind donations (such as equipment) if they believe the need is present and 

the program is worthwhile. 

• Partnerships: As discussed in greater detail later in this section, 

partnerships can minimize costs and improve relations in the community. 

• Fundraising: This is always a good option, and one that ensures members 

have invested their time into the health and wellness program. 

Department-sponsored events such as bingo and casino nights or raffles 

that are specifically targeted to raising funds for firefighter health and 

safety are likely to be supported by the community. 

No matter what method employed, each department needs to ensure the programs 

are adequately funded and supported. 

Assistance to Firefighters Grant--This section is from the USFA “2003 Program

Guidance for the Assistance to Firefighter Grant (AFG) Program.”59 The purpose of the 

AFG program is to award 1-year grants directly to fire departments to enhance the safety 

of the public and firefighters with respect to fire and fire-related hazards. This program 

supports departments that lack the tools and resources necessary to protect the health and 

safety of the public and their firefighting personnel with respect to fire and fire-related 

hazards. 

FEMA may award AFG funds for the purpose of establishing or expanding 

wellness and fitness initiatives for firefighting personnel. 

The USFA believes that to have an effective wellness/fitness program, fire 

departments must offer an entry physical examination, an immunization program, and 

periodic health screenings. Accordingly, applicants for grants in this category must 

currently offer, or plan to offer with grant funds, all three benefits in order to receive 

consideration and funding for any other initiatives. After entry-level physicals, annual 

physicals, and immunizations, high priority is given to formal fitness, incident 

rehabilitation, and employee assistance programs. Lower priority is given to stress 

management and illness rehabilitation. 

The AFG maintains that the greatest benefit will be realized by supporting new 

wellness and fitness programs, and therefore, accords higher competitive ratings to those 

applicants lacking wellness/fitness programs over those applicants that already possess a 

wellness/fitness program. As participation is critical to achieving any benefits from a 

wellness or fitness program, AFG gives higher competitive ratings to departments whose 

wellness and fitness programs mandate or provide incentives for participation. 

Eligible expenditures in a wellness and fitness activity for firefighting personnel 

may include the procurement of medical services to ensure that the firefighting personnel 

are physically able to carry out their duties. Purchase of medical equipment is not eligible 

46 NVFC Health and Wellness Guide 
V. Development of a Health and Wellness Program for Volunteer Fire Departments 

under this category. Expenditures to carry out wellness and fitness activities may include 

costs for personnel, physicals, equipment (including shipping), supplies, or other related 

contract services directly associated with the implementation of the proposed activity 

(e.g., health-care consultants, trainers, nutritionists). 

Transportation expenses and fitness club memberships for the firefighters or their 

families are not eligible under the wellness and fitness activity. Other expenses not 

eligible in this area include construction of facilities to house a fitness program such as 

exercise or fitness rooms, showers, etc. Modifications to an existing facility are allowable 

if the modifications involve only the renovations defined in the Final Rule and published 

in the Federal Register (renovations limited to minor interior alterations costing less than 

$10,000). Renovation expenses should be included in the budget as an “other” line-item

expense and explained in the narrative. 

Partnerships and Contracts--Implementing a health and wellness program can be 

both expensive for the fire department and time-consuming for the program coordinator. 

A complete program includes access to fitness machinery, health expertise, medical 

examinations, and inoculations. Many volunteer departments cannot easily afford this 

monetary commitment. Additionally, the program coordinator must have time for 

organizing, implementing, and tracking the various aspects of the program. To meet these 

challenges, fire departments can form mutually beneficial partnerships with outside 

organizations and businesses. 

Some fire departments contract with local gyms, wellness centers, or other 

businesses that specialize in fitness/wellness programs. This provides the firefighters 

access to quality fitness machinery and the expertise of personal trainers and physical 

therapists. Many gyms offer group discounts for fire departments; this can be a relatively 

inexpensive method of providing the necessary space and equipment for fitness training. 

These arrangements can prove to be ineffective however; although fitness facilities may 

be available, many lack the needed support in programming for the firefighters. 

Departments should consider forging agreements with facilities or businesses that will 

offer support in delivering task-specific programming that will prove most beneficial to 

firefighters and the department’s investment. Even departments that use equipment 

within the department can benefit from contracting with a gym for assistance from

personal trainers and physical therapists. Doing so can prevent injury and save time for 

the program coordinator. 

Some fire departments have found that using gyms is inconvenient; firefighters 

have to travel to the gym and exercise on their own time. Accessibility is a major factor 

that needs to be considered when forging partnerships or entering into contracts. If 

volunteers will not travel to the facility, there is little use in the partnership. 

The Stillwater Fire Department has had a physical fitness program since 1982. 

The Stillwater Fire Department and Seretean Wellness Center at Oklahoma State 

University have partnered in offering Stillwater firefighters medical and fitness 

examinations. These services have been provided as part of a physical fitness initiative. 

NVFC Health and Wellness Guide 47 
V. Development of a Health and Wellness Program for Volunteer Fire Departments 

Aggregate data (means and percent changes) have been supplied to management and 

individual results to participants with the underlying impetus of helping firefighters 

achieve and maintain a high level of fitness and health. 

Departments could also form partnerships to provide medical attention to their 

volunteers. Some general practitioners offer discounted annual physicals by contract to 

the departments. In turn, the physician can advertise himself or herself as the physician 

for the local fire department. (The department could give them a certificate to that effect.) 

This is not only a cost-effective method of supplying annual physicals, but it enhances 

better coordination and consistency. Once the doctor has a list of the participating 

volunteers, he or she can contact them to schedule annual physicals. The doctor is then 

responsible for the scheduling and record keeping. The program coordinator need only 

read the doctor’s summary reports to check for compliance. Contracting with a single

doctor’s office also provides a greater degree of uniformity in decisions of fitness for 

duty. 

Partnerships between fire departments and gyms or doctors can be mutually 

beneficial. The departments receive discounted services of a higher quality than they 

could provide internally. The gyms or doctors receive increased business and a positive 

local image. This type of relationship can also be formed on a larger scale. For instance, 

fire departments can contact groups such as the YMCA and the American Heart 

Association to possibly fund and provide services to their fitness programs. Several local 

fire departments may find it beneficial to do this as a collaborative effort. 

A relationship between the fire service and nonprofit organizations and the media 

also can offer opportunities to improve the general health of volunteer firefighters. 

Nonprofits may be able to provide funding sources, equipment, or program guidance. 

Additionally, they can attract the attention of the news media, potentially shedding light 

on the important issue of firefighter health. The current atmosphere of overwhelming 

support for firefighters can thereby be harnessed to improve the condition of the fire 

service. 

There are numerous other possibilities for programs between fire departments and 

nonprofit organizations. For instance, statistics show that heart disease is a leading cause 

of line-of-duty firefighter deaths. The American Heart Association has supported fire 

departments that are trying to reduce their risk of heart disease through programming. 

One way to accomplish this is to challenge firefighters to reach certain goals, such as a 

certain ideal weight or a specific amount of weekly exercise, and then ask the partner 

organization to provide the necessary information and materials. Challenges of this nature 

offer attainable goals and an opportunity for publicity. 

Each department should develop a list of organizations to outreach for assistance. 

The type of organizations to consider contacting include: 

• YMCAs, health clubs, wellness centers 

• Hospitals, medical offices, physical therapists 

48 NVFC Health and Wellness Guide 
V. Development of a Health and Wellness Program for Volunteer Fire Departments 

• Offices of nutritionists or dieticians 

• Colleges and universities (medical centers, health departments, fitness 

centers) 

• National health organizations (e.g., American Heart Association) 

• National service organizations (e.g., Lions, Rotary) 

• Fitness stores (e.g., Sports Authority, bicycle stores) 

• Health stores (e.g., General Nutrition Centers) 

INCENTIVES FOR PARTICIPATION

Participation rates in health programs are largely dependent on the specific 

programs implemented and the participation incentive utilized. A key to increase 

involvement is to provide incentives for volunteer participation. Naturally, the more 

reasons a person has to participate, the more likely they are to not only join, but to 

actively engage in the program. 

Non-incentivized programs generate poor levels of participation, but traditional 

“achievement awards” (e.g., workout equipment, certificates) demonstrate a 20 to 40 

percent participation rate. Financial or personal incentives are most effective. Average 

participation, or utilization rates, for such incentive-based programs average 50 to 60

percent.60 Examples of effective incentives that could be offered include: 

• Cash or gift drawings 

• Schedule priority 

• Choice of firehouse duties 

• Recognition at banquets or meetings 

• Financial rewards for program completion. 

NVFC Health and Wellness Guide 49 
50 NVFC Health and Wellness Guide 
VI. Implementing a Health and Wellness Program 

VI. IMPLEMENTING A HEALTH AND WELLNESS PROGRAM 

Chapter V addressed the components and administration of a model health and 

wellness program for volunteer fire departments. This chapter looks at how to combine 

these components into an effective program and implement the program at the 

department level. 

The most important step in implementing a health and wellness program is 

planning. An effective implementation plan should address two basic areas: department 

planning and assessment; and data collection, analysis, and program evaluation. 

Department Planning and Assessment 

As discussed in Chapter V, the foundation of an effective health and wellness 

program, especially for volunteers, is customizing it to meet the needs of the participants. 

There is no model plan that will work for all departments in all places. There are model 

elements and core components that should be implemented. These elements and 

components were laid out in Chapter V. 

CREATING THE VISION

When implementing a program, a small steering committee needs to first develop 

a vision for the department’s program. When developing the vision for the program, the 

committee should identify the major issues that affect their volunteers and the impact of 

those issues on both the individual and department (some of the issues that affect many, if 

not all, volunteers were discussed in Chapters II and III). It is very important that a 

representative sample of the volunteers is consulted while developing the vision. The 

vision should provide guidance on how to develop and implement an individualized 

program for the department, and so making sure the targeted participants have input is 

critical. 

IMPLEMENTATION STEPS

With a vision developed, the department could begin the program planning, 

implementation, and integration process. The following areas need to be addressed during 

this process:

1. Select health and wellness coordinator(s): As discussed in Chapter V, the 

coordinators should be the advocates and leaders within the department for 

the Health and Wellness program. The coordinators might come from the 

steering committee itself or be identified by the committee while 

developing the vision for the program.

NVFC Health and Wellness Guide 51 
VI. Implementing a Health and Wellness Program 

2. Consult with legal counsel and insurance company: Legal counsel and 

insurance companies could help diminish liability of injury and risk. 

Additionally, some insurance companies may give the department credit 

for implementing a program aimed at reducing the risk of fireground 

injuries and deaths.

3. Select program components: The department should consult with a 

qualified medical or fitness professional in selecting the components, or 

pieces of each component, to ensure the program is customized for the 

needs of the individual department. Departments within older volunteer 

base, for example, most likely will require a different program than a 

department with a mix of young and older volunteers. (All of these 

components are discussed in much greater detail in Chapter V.) 

4. Create a fitness component: The fitness component should address 

cardiovascular fitness, muscular strength and endurance, flexibility, and 

body composition. The fitness component could begin with a simple 

encouragement to increase moderate intensity activities such as walking 

the dog, swimming laps, or playing basketball. Over time, the department 

should provide opportunities for volunteer firefighters to participate in 

more intense workouts whether at the department or a gym. 

5. Create a behavioral modification component: A behavioral modification 

component should include smoking cessation, hypertension and 

cholesterol reduction, and diet modification components. Behavioral 

modification will help to address pre-existing health conditions that 

heighten risks to cardiovascular health. 

6. Include screenings before participating in fitness program: Most experts 

agree that prior to participation in any fitness program, individuals should 

be screened to determine risk and workout needs. 

7. Include a regimen of regular health screenings and assessments: Annual 

physicals for volunteers older than 40, and every other year for those 30 to 

39, and at least every three years for those ages 29 and younger, will help 

identify health risks for firefighting. In several cases, departments that 

have instituted a physical program discovered potentially serious health 

issues, and the problems were corrected before they grew serious. 

8. Educate firefighters about health risks, nutrition, fitness, and other 

wellness topics: Education is one of the most important steps that a 

department can take to help change the health and wellness culture. 

52 NVFC Health and Wellness Guide 
VI. Implementing a Health and Wellness Program 

9. Identify department facility needs: If a department chooses to have the 

fitness equipment in the facility, a review of the space requirements for 

each piece of equipment (including electrical outlets, floor support needed, 

etc.) needs to be completed. Even if a department chooses to partner with 

a gym, the coordinators might want a bulletin board to advertise program

components, a shelf or closet to keep program materials, and a file cabinet 

to hold program files. These facility needs are important and must be 

considered early in the planning process. 

10. Develop the program budget: Creating a health and wellness program will 

most likely prove quite costly, which makes it a challenge, especially for 

smaller volunteer departments. The steering committee, or coordinators, 

should develop a realistic budget that funds the purchase of any start-up 

supplies and equipment; the implemented program components, any 

rewards and incentives, as well as additional funding for unforeseen 

expenditures. 

11. Identify funding sources: Chapter V gives several options to fund a Health 

and Wellness program without draining the department’s general fund. 

Possible sources to cover or diminish costs include grants, in-kind 

donations, foundation or corporation donations, partnerships, or general 

fundraising drive. 

12. Devise marketing strategies for participation: Firefighters must be 

convinced that they should invest their free time and energy into a health 

and wellness program when they are already volunteering time to the 

department. Ideas to consider when developing marketing strategies 

include offering incentives (discussed in Chapter V) and discussing the 

importance of participation (discussed in Chapters II and III).

13. Make health and wellness a priority: Once the components have been 

selected and the program is implemented, health and wellness needs to be 

made a priority to fully integrate the program into the culture of the 

volunteers. If department leadership and health and wellness coordinators 

are actively advocating participation (in both words and actions), the 

volunteers will see that the department has identified health and wellness 

as a priority and will be more likely to participate.

Data Collection, Analysis, and Evaluation 

Once the program is underway, health and wellness coordinators need to 

continuously review the program and make changes as needed. To determine what 

changes are needed, coordinators will need to actively collect data and feedback from

membership on a regular basis. Table 5 looks at different areas that should be evaluated, 

how to collect the data, and what the data states about the program. 

NVFC Health and Wellness Guide 53 
VI. Implementing a Health and Wellness Program 

TABLE 5: HEALTH AND WELLNESS PROGRAM DATA 61

Area Objective Measures / 

Data 

Collection 

Method Data Sources Timing 

Reaction &

Satisfaction

• Accessibility 

• Effectiveness 

• Appropriate 

delivery 

• Perception 

• Willingness 

to participate 

• Attitude

towards 

programs

• Questionnaire /

Surveys 

• Participants • End of 

session 

• End of 

program

Learning

• Comprehension 

• Retention

• Self-test 

scores

• Session 

completion

• Quizzes • Participants • During

sessions 

• End of 

session 

Application &

Implementation

(behavioral 

change impact)

• Completion of 

programs

• Review of

program reports 

• Post-program

participation

• Goal setting

and 

achievement

• Program

adherence 

• Follow-up

questionnaire 

• Observation of 

completed

assignments 

• Participants 

• Coordinators 

• End of 

session 

• End of 

program

• 6 months

post -

program

Application &

Implementation

(fitness impact)

• Volunteers 

regularly working 

out

• Increased

endurance 

• Post-program

participation

• Goal setting

and 

achievement

• Program

adherence 

• Fitness 

screenings 

• Follow-up

questionnaire 

• Observations 

• Participants 

• Coordinators 

• End of 

session 

• End of 

program

• 6 months

post-program

Financial

Impact 

• Decreased claims

• Decreased

absences 

• Decreased

disability 

• Health care 

premiums

• Total hours 

(medical 

leave) 

• Firefighter

observation & 

attendance 

• Overtime costs 

• Administration 

• Shift leaders 

• Chiefs /Asst 

Chiefs 

• Monthly

• Quarterly

Adapted from: The Human Resources Scorecard.

EVALUATING PROGRAM EFFECTIVENESS

This section has been adapted from the USFA Ergonomics Manual, Chapter 10 

“Evaluating Program Effectiveness.” 

In many industries, management frequently assesses the success or failure of a 

program through economic measures: 

• Increased net production (efficiency due to lower number of quality 

control rejects) 

• Reduced incidence of days lost 

• Reduced medical insurance cost 

54 NVFC Health and Wellness Guide 
VI. Implementing a Health and Wellness Program 

• Reduced worker’s compensation cost

• Increased esprit de corps.

As can be seen, all but the first of the items on the above list apply to the 

firefighting and EMS professions. A successful program anywhere must show a 

measurable reduction in injuries, severity of injuries, and work time loss after the 

program is put into place. 

Measuring the effectiveness of health and wellness programs in the fire service 

may require the development of new criteria. In the long term, the effectiveness of a 

health and wellness program may be mostly measured at the local level, regardless of the 

size of the department, by the criteria below. 

Health statistics 

• Reduced injury rate 

• Reduced injury severity 

• Reduced overhead costs

• Reduced medical/workers’ compensation costs 

• Reduced time loss 

Program statistics 

• Increasing participation by membership in all aspects of program

• Number of injuries or illnesses identified by screenings 

• Hours logged by membership in physical fitness 

General 

• Better fitness equipment developed/purchased 

• Improved eating practices 

• Regular health screenings and examinations 

• Regular educational events 

With the data collected and analyzed on a regular basis, department coordinators 

and leadership can make smart choices about the direction, funding level, and impact of 

the program. Every program is a work in progress, and a health and wellness program

will be no different. The key to maintaining a robust health and wellness program is 

adapting to the needs of the volunteers who participate. Analysis of collected data and 

information is the key to the success of any program. 

NVFC Health and Wellness Guide 55 
56 NVFC Health and Wellness Guide 
Appendix A: Health and Wellness Resources 

APPENDIX A: HEALTH AND WELLNESS RESOURCES 

(All contacts listed alphabetically) 

PROGRAM DEVELOPMENT CONTACTS

American College of Sports Medicine. Phone: (317) 637-9200. E-mail: 

publicinfo@acsm.org.http://www.acsm.org. 

Fabio Comana. Phone: (858) 715-6889. Email: Fabio.Comana@ClubOne.com. 

IAFC Wellness Initiative. Vicki Runnels, Special Projects Coordinator, IAFC. (703) 273-

9815. Email: projects@iafc.org. 

National Fire Protection Agency: http://www.nfpa.org. 

National Volunteer Fire Council. Phone: (888) ASK-NVFC. Email: nvfcoffice@nvfc.org. 

Denise Smith, Ph.D. Phone: (518) 580-5389. Email: dsmith@skidmore.edu. 

USFA Assistance to Firefighter’s Grant program: (866) 274-0960. Email: 

usfagrants@fema.gov 

USFA Firefighter Fitness and Wellness Program. http://www.usfa.fema.gov/fireservice/health/health.shtm. 

FIRE DEPARTMENT CONTACTS

Austin Fire Department. 1621 Festival Beach Road, Austin, Texas 78702. Phone: (512) 

469-3604. Contact Jill Craig, Wellness/Fitness Coordinator. (Career)

Bernalillo County Fire and Rescue. 6840 2nd Street N.W., Albuquerque, New Mexico 

87107. Phone: (505) 761-4225. (Combination)

Brodhead Fire Department. 1100 West 3rd Avenue, Brodhead, Wisconsin 5320. Phone: 

(608) 897-2112. (Volunteer)

Caldwell Fire and Rescue. 310 South 7th Avenue, Caldwell, Idaho 83605. Phone: 208-

455-3032. (Volunteer)

Calgary Fire Department. 4124 11th Street, SE, Calgary, Alberta, Canada T2G 3H2. 

Phone: (403) 221-4518. Contact Mike O’Reilly, Fitness Coordinator/ Training Officer. 

(Career)

Charlotte Fire Department. 600 E. 4th Street, Charlotte, North Carolina 28202. Phone: 

(704) 336-5725. Contact Glenn Jones, Physical Fitness Coordinator. (Career)

NVFC Health and Wellness Guide 57 
Appendix A: Health and Wellness Resources 

Chesterfield Fire and EMS. P.O. Box 40, Chesterfield, Virginia 23832-0040. Phone: 

(804) 748-1360. (Volunteer)

Fairfax County Fire and Rescue Department. 4100 Chain Bridge Road, Fairfax, Virginia 

22030. Phone: (703) 246-3970. Contact Lieutenant Pat Morrison, Physical Fitness 

Coordinator. (Career/Volunteer)

Gates Fire District. 2355 Chili Ave., Gates, New York 14624. Phone: (585) 426 – 2720. 

(Volunteer)

Hartford Emergency Services. 812 VA Cutoff Rd., White River Jct., Vermont 05001. 

Phone: (802) 295-3232. (Combination)

Los Angeles County Fire Department. 464 W. 8th Street, Claremont, California 91711. 

Phone: (909) 620-2201. Contact Captain Derek Alkonis, Wellness-Fitness Coordinator. 

(Career)

Miami Dade County Fire and Rescue. 8000 N.W. 21st, Suite 222, Miami, Florida 33122. 

Phone: (305) 593-6100. Contact Orlando Pena, Benefits Director. (Combination)

New York City Fire Academy. Randall’s Island, New York, New York 10035. Phone: 

(718) 999-1946. Contact Lieutenant Kevin Malley, Fitness Program Director. (Career)

Phoenix Fire Department. 10102 North 173rd Avenue, Waddell, Arizona 85355. Phone: 

(602) 535-8235. Contact Captain Scott Peltin. (Career)

Seattle Fire Department. 301 2nd Avenue, South, Seattle, Washington 98104. Phone: 

(206) 386-1777. Contact Kim Favorite, Physical Fitness Specialist. (Career)

National Resources 

DIET

American Dietetic Association http://www.eatright.org

Center for Nutrition Policy and Promotion http://www.usda.gov/cnpp/index.html

Consumer Nutrition Hotline 1-800-366-1655 

DISABILITIES / INJURIES

American Paralysis Association 1-800-225-0292 

American Rehabilitation Association 1-800-368-3513 

American Speech-Language Hearing Association 1-800-638-8255 

58 NVFC Health and Wellness Guide 
Appendix A: Health and Wellness Resources 

Brain Injury Association 1-800-444-6443 

National Easter Seal Society 1-800-221-6827 

DISEASE

Alcohol and Drug Hotline 1-800-821-4357 

American Cancer Society Response Line 1-800-227-2345 

American Diabetes Association 1-800-232-3472 

American Liver Foundation Hepatitis Hotline 1-800-223-0179 

Arthritis Foundation Information Line 1-800-283-7800 

Asthma and Allergy Foundation of America 1-800-727-8462 

CDC National AIDS Hotline 1-800-342-2437 

CDC National STD Hotline 1-800-227-8922 

National Foundation for Depressive Illness 1-800-248-4344 

National Parkinson Foundation, Inc. 1-800-327-4545 

FITNESS

Aerobics and Fitness Association of America 1-800-233-4886 

American College of Sports Medicine 1-800-445-4808 

American Heart Association http://www.americanheart.org

Healthier US http://www.healthierus.gov

NVFC Health and Wellness Guide 59 
60 NVFC Health and Wellness Guide
Appendix B: Relationship Between Cardiovascular Risk Factors and Physical Fitness 

APPENDIX B: RELATIONSHIP BETWEEN CARDIOVASCULAR 

RISK FACTORS AND PHYSICAL FITNESS

Cardiovascular disease (CVD) is the leading cause of death in the United States, 

accounting for approximately one million deaths per year.62,63 CVD also exacts a 

considerable toll on the fire service. As seen in Figure 4, approximately 40 to 45 percent 

of all line-of-duty deaths among firefighters, in most years, are due to heart attacks, 

whereas less than 10 percent are due to burn injuries.64 The United States Fire 

Administration (USFA) and the National Fire Protection Agency (NFPA) record the 

number of deaths and disability of firefighters due to CVD, provided the cardiac event 

occurred while the individual was on duty.65,66 It is difficult to compare the incidence of 

CVD in the fire service with that of the general population. (There currently is 

epidemiological data that indicates rate of CVD deaths in the general population, but 

there is not information for firefighters because no agency collects data on firefighter 

deaths, unless they occur in the line of duty.) 

FIGURE 4: LINE OF DUTY DEATH BY CAUSE67,68,69

0

10

20

30

40

50

60

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

Heart Attack

Burns

Sources: USFA, “Firefighter Fatality Retrospective Study,” April 2002. 

NFPA Firefighter Fatality Reports 2001 and 2002. NFPA Journal July/August 2002, 2003. 

A USFA goal is to reduce firefighter deaths by 25 percent by 2005.70 Clearly, the 

only way to achieve this goal is to drastically reduce the number of deaths due to heart 

attacks. A commitment to health and safety also will require the fire service continue to 

address line-of-duty deaths due to other causes (e.g., accidents, entrapment, thermal 

injuries) through training, the provision of adequate resources, and other measures. 

Firefighters are most effective in their firefighting activities when they possess a 

thorough understanding of the nature of their profession. This appendix provides 

information to firefighters about CVD and the risk factors associated with developing 

NVFC Health and Wellness Guide 61 
Appendix B: Relationship Between Cardiovascular Risk Factors and Physical Fitness 

CVD. The appendix describes the prevalence and progression of CVD including 

occlusion, arhterosclerosis, atheroscleroticl plaque and plaque rupture, and clot 

formation. 

Finally, and perhaps most importantly, this appendix identifies the risk factors for 

CVD including smoking, hypertension (high blood pressure), hypercholesterolemia (high 

cholesterol levels), diabetes or impaired glucose tolerance, obesity, and physical activity. 

The more risk factors that an individual has, the greater the likelihood that he or she will 

suffer from CVD. 

THE PROGRESSION OF CARDIOVASCULAR DISEASE 

Cardiovascular disease refers collectively to a state of disease in the blood

vessels. If blood vessels become narrowed (i.e., by the buildup of plaque) or obstructed 

(i.e., by a blood clot) then blood, and the oxygen and nutrients it carries, cannot be 

delivered to the vital organs of the body. If blood supply to the brain is impeded, a stroke 

occurs. If blood flow to the heart muscle is impeded, a heart attack occurs. The terms 

coronary heart disease (CHD) and coronary artery disease (CAD) describe specific 

forms of CVD in which the blood vessels supplying the heart muscle are blocked. 

When there is an obstruction in a coronary vessel, the tissue below the blockage 

does not get adequate oxygen. If the lack of oxygen (called ischemia) is too severe, the 

heart tissue dies (called an infarction; a myocardial infarction means death of heart 

muscle tissue). Thus, a person who has suffered a myocardial infarction (also called a 

heart attack) has had a portion of the heart tissue destroyed. If the area supplied by the 

blood vessel is very small, the person may recover from the heart attack or may not even 

know that he or she has suffered a heart attack. However, if the area below the occlusion 

is too great, the heart cannot continue to function as an effective pump and death results. 

CAUSES OF OCCLUSION

When a coronary blood vessel (or any blood vessel) becomes blocked, tissue will 

be deprived of oxygen and die. The two primary causes of blockage are: atherosclerosis

(buildup of plaque) and a thrombus (blood clot). In reality, it appears that these causes 

interact; the buildup of plaque in an artery makes it more likely that a blood clot will 

develop. The initial buildup of plaque, which may begin in the late teens or early 20s, 

causes the arterial wall to become enlarged. Plaque buildup progressively decreases the 

size of the arterial opening until little or no blood can pass through the artery. 

Furthermore, the rupture of a plaque is likely to initiate the formation of a blood clot. 

Atherosclerosis--Atherosclerosis refers to the disease condition in which plaque 

builds up in the arterial wall, which narrows the vessel opening. To fully understand how 

atherosclerosis develops, it is first necessary to understand the structure of an artery. Far 

from being a simple vessel through which blood flows, an artery is a complicated 

structure that plays an important role in blood clotting (or preventing blood clotting) and 

that constantly changes size to meet the demands of the tissue it supplies. 

62 NVFC Health and Wellness Guide 
Appendix B: Relationship Between Cardiovascular Risk Factors and Physical Fitness 

Figure 5 is a schematic of a healthy artery. The vessel has three distinct layers. 

The innermost layer is composed primarily of a single layer of cells called the 

endothelium, and under normal conditions the endothelium plays a critical role in 

preventing blood clots. 

FIGURE 5: STRUCTURE OF A NORMAL ARTERY AND COMPONENTS IN THE BLOOD

Vessel wall

Vessel wall

Innermost layer (endothelium)

Intermediate layer (composed largely of muscle cells) 

Outermost layer (composed largely of elastic tissue) 

Red blood cell

White blood cell

Platelet

Plasma

Lumen (vessel opening) 

Blood lipid (LDL cholesterol) 

The intermediate layer (tunica media) contains smooth muscle that permits the artery to 

change diameter to meet the needs of a tissue. For instance, when a firefighter is involved 

in strenuous fire suppression activities, smooth muscles around the arteries in muscles 

relax so that the vessel becomes larger and allows more blood to be supplied to the 

muscles. The outermost layer (adventia) contains connective tissue and nerves. Within 

the artery is the plasma (fluid portion of blood) that contains nutrients, oxygen, and blood 

lipids (including low-density lipoproteins). The blood vessel also contains red blood cells 

(RBCs), white blood cells (WBCs), and platelets. 

Development of Atherosclerotic Plaque--The initiation of atherosclerotic plaque 

buildup may begin quite early in life; there is strong evidence that it begins in the early 

20s for many people in Western, developed countries. Therefore, it is important to think 

of CVD as a long-term disease that begins early in life, although symptoms are often 

delayed until middle or older age. Also, it must be stressed that CVD may become very 

advanced without symptoms. In many individuals, the first sign of CVD is a fatal heart 

attack, thus reinforcing the need for young firefighters to take steps to avoid or delay 

atherosclerosis. It also suggests that firefighters in their 40s and 50s should begin to 

seriously address the health issues of CVD even if they are symptom free. The plaque

contains a lipid-rich core, composed largely of fat, and is covered by a fibrous cap. The 

NVFC Health and Wellness Guide 63 
Appendix B: Relationship Between Cardiovascular Risk Factors and Physical Fitness 

events in the development of atherosclortic plaque are very complex and are described 

only briefly below. 

The first step in the initiation of atherosclerosis is damage to the endothelium, the 

smooth layer of cells that line the blood vessel and is in contact with the blood. Damage 

may occur due to high blood pressure, chemicals from inhaled cigarette smoke, or 

infection. Damage to the endothelium causes or allows cholesterol, specifically lowdensity lipoproteins (LDLs) to move into the wall of the blood vessel. The presence of 

LDLs in the arterial wall leads WBCs, especially macrophages, to move into the arterial 

wall. The macrophages ingest the LDSs and become known as foam cells. Foam cells 

release chemicals that stimulate smooth muscle to grow and divide in the arterial wall. 

The additional smooth muscle in the arterial wall causes other material to accumulate in 

the vessel wall, thus causing the atherosclerotic plaque to grow. In later stages, the plaque 

may become calcified. The end result is a fatty lesion that contains a core that is rich in

lipids (LDL) and dead or dying cells and a fibrous cap. 

Plaque Rupture and Clot Formation--The body has a highly complicated 

mechanism that balances the need to keep blood in the liquid state under normal 

conditions with the need to produce blood clots quickly when faced with a damaged 

blood vessel. It appears that most cases of acute heart attack are “triggered” when an 

atherosclerotic plaque is disrupted, causing the development of a clot (thrombus). As 

depicted in Figure 6 the clot occurs because the disruption of the plaque exposes platelet 

FIGURE 6: RUPTURE OF ATHEROSCLEROTIC PLAQUE AND CLOT FORMATION

Innermost layer (endothelium)

Intermediate layer (composed largely of muscle cells)

Outermost layer (composed largely of elastic tissue)

Vessel wall

Vessel wall

Red blood cell (RBC) 

White blood cell (WBC) 

Plasma

Lumen (vessel opening)

Clot

and blood coagulatory factors to underlying tissue, such as the smooth muscle and 

connective tissue in the vessel walls that do not possess the anticlotting factors that intact 

endothelium does. Exposure of the blood to underlying tissue causes the platelets to 

64 NVFC Health and Wellness Guide 
Appendix B: Relationship Between Cardiovascular Risk Factors and Physical Fitness 

adhere to one another and form a platelet plug. The platelet plug is then reinforced by

strands of thrombin to form a clot. A clot may be small enough that it does not occlude an 

artery, in which case the person may or may not exhibit symptoms. Conversely, the clot 

may be large enough to block an artery, causing a heart attack. When a plaque ruptures, it 

may also release a “fatty embolism,” meaning a traveling fat clot that occludes an artery. 

Risk Factors for Developing CVD 

Although it is useful to understand how CVD develops, it is more important still 

to understand what predisposes an individual to developing CVD and what measures can 

be taken to reduce the risk of developing CVD. A risk factor is a characteristic that is 

present early in life and is associated with an increased risk of developing future disease. 

A modifiable risk factor is a risk factor that can be minimized by diet, exercise, or

personal habits. Table 6 presents several risk factors for CVD, both nonmodifiable and 

modifiable risks. Men are more likely to suffer CVD at a younger age than females; thus, 

being over 45 years is considered a risk factor for males and being over 55 years is a risk 

factor for females. Family history is defined as the premature death (before 55 years for 

males or before 65 years for females) of a parent or sibling from CVD. 

TABLE 6: RISK FACTORS FOR DEVELOPING CARDIOVASCULAR DISEASE

Risk Factors 

That Cannot be 

Modified 

Risk Factors That Can be 

Modified 

Age 

Heredity 

Race 

Gender

• Cholesterol-lipid fractions 

• Cigarette smoking 

• Diabetes mellitus 

• Hypertension

• Obesity 

• Physical inactivity 

Modifiable risk factors deserve a great deal of attention because it is through 

altering these risk factors that a person can influence his or her likelihood of developing 

CVD. There are six major modifiable risk factors: smoking, hypertension (high blood 

pressure), hypercholesterolemia (high cholesterol levels), diabetes or impaired glucose 

tolerance, obesity, and physical activity. The more risk factors than an individual has, the 

greater the likelihood that he or she will suffer from CVD. The good news is that armed 

with information and supported by coworkers and family, most firefighters can reduce 

their risk for CVD by following reasonable guidelines for healthy living. 

RISK ASSOCIATED WITH SMOKING

Approximately 25 percent of the adult population in the United States smokes, 

and approximately one million young people begin smoking each year.

71 Cigarette 

NVFC Health and Wellness Guide 65 
Appendix B: Relationship Between Cardiovascular Risk Factors and Physical Fitness 

smoking accounts for an estimated 430,000 deaths per year in the United States, more 

than 40 percent of them due to cardiovascular disease.72 In fact, as early as 1983, the 

Surgeon General had established smoking as the leading avoidable cause of 

cardiovascular disease. Thus, the cessation of cigarette smoking is one of the single most 

important interventions that can be undertaken to decrease the risk of premature death 

due to CVD. Smoking increases the risk for sudden cardiac death, aortic aneurysm, 

peripheral vascular disease, and stroke. Smoking one pack of cigarettes per day doubles 

the risk of CVD compared to not smoking, and smoking more than one pack triples the 

risk.73,74 Chemicals in cigarettes stimulate the sympathetic nervous system, causing an 

increase in heart rate and blood pressure. Carbon monoxide binds to hemoglobin, thus 

reducing hemoglobin’s ability to carry oxygen. 

As seen in Figure 7, as the number of cigarettes smoked increases, so does the 

risk of coronary artery disease and stroke. “CAD Mortality,” as depicted on the Y-axis in 

the figure, represents Coronary Artery Disease (or coronary heart disease) mortality. A

CAD mortality of 1.0 implies the same death rate as a non-smoker. 

FIGURE 7: CORONARY ARTERY DISEASE AND STROKE VERSUS CIGARETTE SMOKING IN

CURRENT AND PAST SMOKERS75

0.0

0.5

1.0

1.5

2.0

<10 20-40 20-40 >40

Number of cigarettes smoked daily

Past Smoker

Current Smoker

Source: “The Health Benefits of Smoking Cessation: A Report from the Surgeon General,” 1990. 

Smoking accelerates the process of plaque development by damaging the 

endothelium, enhancing lipid accumulation in the arterial wall, increasing inflammation 

in the arterial wall, and enhancing the movement of white blood cells (especially 

macrophages) into the arterial wall. Simultaneously, smoking increases the likelihood of 

developing a blood clot by increasing platelet activation and making them more likely to 

adhere to each other and form a clot.

Benefits of Smoking Cessation--The good news is that much of the damage done 

by smoking is reversible. Smoking cessation is the single most important intervention for 

preventing cardiovascular death. Encouragingly, smoking cessation reduces the risk of

the first heart attack by 65 percent.76

66 NVFC Health and Wellness Guide 
Appendix B: Relationship Between Cardiovascular Risk Factors and Physical Fitness 

Strategies for Smoking Cessation--The strategies to reduce the risk of CVD 

associated with smoking are straightforward: 

• Quit smoking, and encourage fellow firefighters to quit smoking. 

Individuals wanting to quit smoking should consider attending a smoking 

cessation program, nicotine replacement therapy (nicotine chewing gum), 

or discuss medication options with their physician. There are over-thecounter and prescription medications available to help overcome the 

smoking addiction. 

• Fire departments should aggressively promote smoking cessation 

programs available through local hospitals and other health agencies and 

consider sponsoring programs for their employees. 

• Fire departments should consider policies that ban smoking among 

firefighters. 

• Fire departments should have regulations that protect firefighters from

second-hand smoke. 

RISK ASSOCIATED WITH HYPERTENSION

Hypertension refers to a chronic, persistent elevation of blood pressure. 

Hypertension is actually defined as the level of blood pressure that is associated with a 

twofold increase in long-term risk of mortality.77 Table 7 presents various blood pressure 

categories. Epidemiological data show that the risk of death doubles with a systolic blood 

pressure greater than or equal to 140 mmHg and a diastolic blood pressure of greater than 

or equal to 90; and a blood pressure above 140/90 is defined as hypertension. However, 

as seen in Figure 8, the risk of developing CVD increases directly with increasing levels 

of both systolic and diastolic blood pressure. 

TABLE 7: CLASSIFICATION OF BLOOD PRESSURE – ADULTS (NOT ON BLOOD PRESSURE 

MEDICATIONS) 

Blood Pressure (mmHg) Category 

Systolic Diastolic 

Optimal <120 and <80

Normal <130 and <85

High-normal 130-139 or 85-89

Hypertension

Stage 1 140-159 or 90-99 

Stage 2 160-179 or 100-109

Stage 3 ≥180 or ≥110

NVFC Health and Wellness Guide 67 
Appendix B: Relationship Between Cardiovascular Risk Factors and Physical Fitness 

FIGURE 8: RELATIVE RISK OF CARDIOVASCULAR DISEASE VERSUS BLOOD PRESSURE78

0

1

2

3

4

<70 70-74 75-79 80-84 85-89 90-94 95-99 100+

DBP

0

1

2

3

4

5

<110 110-119 120-129 130-139 140-149 150-159 160+

SBP (mmHg)

Source: National High Blood Pressure Education Program Working Group. Arch. Intern Med., 1993.

Role of Hypertension in Cardiovascular Disease--Hypertension accelerates the 

atherosclerotic progress by damaging the lining of the blood vessels (endothelium). If 

untreated, approximately 50 percent of patients with hypertension die from coronary 

heart disease or congestive heart failure, another 33 percent die from stroke, and 10 to 

15 percent die due to renal failure. 

Reducing blood pressure levels decreases the risk of CVD. In fact, a 5 to 6-mmHg 

reduction in diastolic blood pressure or a 10-mmHg reduction in systolic blood pressure 

decreases the risk of cardiovascular disease by as much as 40 percent.79 

Hypertension could be slowed, and possibly prevented, by preventing obesity, 

moderate reduction in salt intake, higher levels of physical activity, and avoidance of 

excessive alcohol consumption.80

Strategies for Controlling Hypertension--The strategies to reduce the risk of 

CVD associated with hypertension are varied and often overlapping. Furthermore, the 

degree of risk and the appropriate interventions depend upon the degree of hypertension 

and the presence of additional risk factors. If you have elevated blood pressure, even 

high-normal blood pressure, you should consult with your physician. Make sure he or she 

knows the types of job stresses you encounter as you discuss controlling your blood 

68 NVFC Health and Wellness Guide 
Appendix B: Relationship Between Cardiovascular Risk Factors and Physical Fitness 

pressure. Table 8 presents recommendations for treatment based on the level of blood 

pressure and the presence of additional risk factors. This table should serve as a basis for 

discussions with your physician regarding how to best control your blood pressure given 

your overall medical condition. Although your physician may recommend drug therapy

to treat hypertension, lifestyle modifications should be used in conjunction with 

medication. Furthermore, lifestyle modifications may be sufficient to avoid medication or 

to prevent the need for medication. If, however, your physician has prescribed a 

medication, you should take it faithfully. 

TABLE 8: GENERAL GUIDELINES FOR STRATEGIES TO REDUCE OR TREAT BLOOD PRESSURE

BASED ON BLOOD PRESSURE READINGS AND PRESENCE OF ADDITIONAL RISK FACTORS

Blood 

Pressure 

Category 

No Other Risk 

Factor 

At Least One Other 

Risk Factor (Not 

Including Diabetes) 

Diabetes And 

Clinical Evidence 

of Heart Disease 

High-normal Lifestyle modification Lifestyle modification Drug therapy

Stage 1 Lifestyle modification Lifestyle modification Drug therapy

Stages 2 and 3 Drug therapy Drug therapy Drug therapy

Lifestyle Modifications--The primary lifestyle modifications to help reduce 

hypertension include smoking cessation, diet and exercise, with the overall goals of 

losing weight, increasing physical activity levels, and decreasing salt intake. Lifestyle 

modifications may also be appropriate for those who are currently in the normal range 

because blood pressure tends to increase with age. Therefore, it is prudent to take steps to 

control blood pressure before it becomes a problem. The benefits of lifestyle 

modifications are readily apparent when one realizes that even modest reductions in 

blood pressure translate into significant reductions in the risk of cardiovascular disease. 

Diet--A decrease in total caloric intake is important in weight reduction. A loss of 

excess body fat is associated with decreased blood pressure. A two-pound reduction in 

body weight is associated with a 1.6 mmHg reduction in systolic blood pressure and a 

1.3 mmHg reduction in diastolic blood pressure.

81

A reduction in salt intake is beneficial for individuals with elevated blood 

pressure. Sodium restriction is associated with a decrease in blood pressure in most 

people.82 Salt restriction can be achieved by avoidance of salty foods (i.e., potato chips, 

olives, etc.), by not using additional salt while cooking or seasoning foods, and by 

avoiding processed food. 

Other recommended dietary changes include a decrease in alcohol and caffeine 

consumption, and an increase in fruits, vegetables and fish in the diet. 

NVFC Health and Wellness Guide 69 
Appendix B: Relationship Between Cardiovascular Risk Factors and Physical Fitness 

Types of Lipids 

Blood lipids are comprised primarily of triglycerides and cholesterol. 

Triglycerides are composed primarily of fatty acids and are the type of fat ingested in 

food. Cholesterol is also ingested in food but in much smaller amounts than triglycerides. 

Cholesterol is important for cell membranes and hormone synthesis, but when present in 

excessive amounts, it can have negative health outcomes. Cholesterol and triglycerides 

are carried in the blood by a lipoprotein molecule. Low-density lipoproteins (LDLs), also 

known as “bad cholesterol,” and high-density lipoproteins (HDLs), also known as “good 

cholesterol,” vary in their densities and in the way they transport cholesterol. An analysis 

of blood lipids that includes LDLs and HDLs provides important information (in addition 

to total cholesterol) regarding an individual’s risk for cardiovascular disease. As seen in

Table 9, elevated levels of triglycerides, cholesterol, and LDL-cholesterol are associated 

with increased risk of CVD. On the other hand, increased levels of HDL-cholesterol are 

associated with a decreased risk of cardiovascular disease. Therefore, elevated levels of

HDL are desirable. In fact, high HDL levels represent a positive risk factor for 

cardiovascular disease. 

TABLE 9: DESCRIPTION OF VARIOUS LIPIDS AND THEIR RELATIONSHIP TO CVD 

Type of Lipid Description Relationship to CVD 

Triglyceride Simple fat, found in food. Positive relationship. As LDL 

levels increase, so does the risk 

of CVD. 

Cholesterol A derived fat that is essential for cell 

function and hormone production but is

detrimental in excessive amounts.

Positive relationship. As LDL 

levels increase, so does the risk 

of CVD. 

Low-density lipoprotein 

(LDL cholesterol) 

“Bad cholesterol.” These lipoproteins 

transport concentrated amounts of

cholesterol to the arterial wall where it 

contributes to plaque buildup. These 

lipoproteins contain a large portion of

cholesterol. 

Positive relationship. As LDL 

levels increase, so does the risk 

of CVD. 

High-density lipoprotein 

(HDL cholesterol) 

“Good cholesterol.” These lipoproteins

pick up cholesterol in the bloodstream and 

transport it from the arteries to the liver, 

where it is metabolized. These 

lipoproteins contain a small portion of

cholesterol. 

Negative relationship. As HDL

levels increase, the risk of CVD 

decreases, making high HDLs a 

negative risk factor. 

Because high levels of some lipids (triglycerides, total cholesterol, LDLcholesterol) are undesirable and low levels of other lipids (HDL-cholesterol) are 

undesirable, the term hyperlipidemia (high lipid levels) is not always appropriate. Instead, 

medical professionals prefer the term dyslipidemia (altered or dysfunctional levels of

lipids in the blood) to describe lipid disorders that may include values that are too high 

(for triglycerides, total cholesterol or LDL-cholesterol) or too low (for HDL-cholesterol). 

70 NVFC Health and Wellness Guide 
Appendix B: Relationship Between Cardiovascular Risk Factors and Physical Fitness 

CHOLESTEROL

High cholesterol levels (hypercholesterolemia) increase the risk of cardiovascular 

disease. Elevated levels of cholesterol in young adults greatly increase their risk of 

coronary heart disease later in life. In fact, young men who are in the upper quartile 

(highest 25 percent for cholesterol levels) have a ninefold increase in risk of heart attack 

compared to men in the lowest quartile (lowest 25 percent).83 

As seen in Table 10, desirable levels of cholesterol are less than 200 mg/dL, 

whereas high cholesterol is defined as total cholesterol above 240 mg/dL of blood. There 

is a twofold increase in risk of cardiovascular mortality when cholesterol levels are 

elevated to 240 mg/dL vs. 200 mg/dL. Unfortunately, approximately half of American 

adults have cholesterol values greater than 200 mg/dL, and about 20 percent have values 

above 240 mg/dL.84 The increase in risk of cardiovascular disease increases progressively 

with increasing levels of cholesterol; there is a 20 to 30 percent increase in risk for 

coronary heart disease for every 10 mg/dL increase in cholesterol.85 Although values 

above 240 mg/dL are defined as high, it is important to note that the risk of coronary 

heart disease increases in a curvilinear fashion with increasing levels of total cholesterol. 

The 10-year risk of coronary heart disease increases as the total cholesterol level 

increases.86 The risk of coronary heart disease associated with increasing total cholesterol 

levels is affected by the presence of other risk factors. 

LOW--DENSITY LIPOPROTEINS

LDLs are considered the bad form of cholesterol because elevated levels of LDL 

are associated with greater risk of cardiovascular disease. LDLs transport highly 

concentrated amounts of cholesterol to the arterial wall where the cholesterol participates 

in plaque formation. Because LDLs are the primary plaque-causing lipoprotein, they are 

the focus of cholesterol/lipid-lowering efforts. 

TABLE 10: CLASSIFICATION OF LIPID LEVELS87

Lipid 

(classification) 

Value 

(mg/dL) 

Total cholesterol 

Desirable <200

Borderline 200-239

High >240

LDL-cholesterol 

Optimal <100

Near optimal 100-129

Borderline high 130-159

High 160-189

NVFC Health and Wellness Guide 71 
Appendix B: Relationship Between Cardiovascular Risk Factors and Physical Fitness 

Lipid 

(classification) 

Value 

(mg/dL) 

Very high >190

HDL-cholesterol 

Low <40

High >60

Triglyceride level 

Normal <150

Borderline high 150-199

High 200-499

HIGH--DENSITY LIPOPROTEINS

HDL-cholesterol is an independent predictor of coronary heart disease. As the 

level of HDL increases, the incidence of cardiovascular disease decreases and visa versa. 

For every 1-mg/dL decrease in HDL, there is a 3 to 4 percent increase in coronary artery 

disease.88 

As HDL-cholesterol decreases (from 60 to 41 to 37), the risk for coronary heart 

disease increases at all levels of total cholesterol. Additionally, the presence of diabetes 

or smoking greatly affects the risk associated with a given level of total cholesterol. 

Hence, a nondiabetic smoker with elevated blood pressure (134/86); an HDL of 41, and a 

total cholesterol level of 240-279 mg/dL has an approximate 20 percent risk of coronary 

heart disease within 10 years. On the other hand, a diabetic smoker with the same total 

cholesterol level (240-279 mg/dL) but with higher blood pressure (146/94) and a lower 

HDL-cholesterol has an approximate 45 percent risk of coronary heart disease in the 

same time period.89 

Benefits of Improved Lipid Profiles--The risk of cardiovascular disease decreases 

when cholesterol levels are reduced. A lowering of total cholesterol by 10 percent 

reduces the risk of coronary heart disease by 15 percent, and a lowering of LDLcholesterol by 10 percent reduces the risk of coronary heart disease by approximately 20 

percent.90 Furthermore, treatment that is continued for more than 5 years results in a 25 

percent reduction in coronary heart disease events. 

Thus, it is critically important that individuals with high cholesterol aggressively 

pursue treatment (including lifestyle modifications and prescription medications) and that 

they continue with the treatment plan. It is difficult to overstate the importance of this last 

point, as too many individuals are tempted to discontinue treatment because the benefits 

are not obvious to them in the way they feel. That is to say, they may not feel differently 

when they are on or off medication. Nonetheless, left untreated high cholesterol 

(especially elevated LDL-cholesterol) is associated with significantly greater rates of

death from cardiovascular disease. 

72 NVFC Health and Wellness Guide 
Appendix B: Relationship Between Cardiovascular Risk Factors and Physical Fitness 

Strategies for Improving Lipid Profiles--The lifetime risk of coronary heart 

disease can be reduced by 50 percent or more if blood cholesterol levels are reduced 

before age 40, and 30 percent if reduction in blood cholesterol occurs before 50.91 The 

strategies to reduce the risk of CVD associated with dyslipidemia are varied and often

overlapping. Furthermore, the degree of risk, and the appropriate interventions, depends 

on the specific lipid abnormality and the magnitude of the abnormality. In general, the 

strategies for managing lipid/cholesterol levels fall into two categories--life-style 

modification and drug therapy. If you have elevated cholesterol, LDLs or triglycerides, or 

if you have low HDL levels you should consult a physician to see which combination of 

strategies is right for you. 

Life Style Modifications--The primary lifestyle modifications to treat 

dyslipidemia involve diet and exercise: 

1. Diet: An appropriate diet is an important factor in the prevention and 

management of dyslipidemia. In general, there are three primary 

objectives of diet modification for attaining healthy lipid profiles. They 

are: 

• Attaining ideal body weight 

• Obtaining a well-balanced diet high in fruits and vegetables 

• Restricting saturated fats and simple, refined carbohydrates 

(sugars).92 

Less than 30 percent of calories should be from fats (with < 10 percent of 

calories coming from saturated fats). Cholesterol intake should be less 

than 300 mg/day. Additionally, there is growing evidence that omega 3 

fatty acids protect against cardiovascular disease, and for that reason it is 

now commonly recommended that individuals try to eat fish one or two 

times per week. 

2. Exercise: Exercise is an important component of any weight loss program 

and weight loss is associated with positive changes in lipid profiles. 

Furthermore, regular aerobic exercise is associated with decreased 

triglyceride levels and increased HDL levels. 

3. Drug therapy: Drug therapy may be necessary for individuals who are at 

high risk for cardiovascular disease (LDLs > 160 mg/dL and other risk 

factors). In all cases, drug therapy should occur in conjunction with 

dietary therapy and increased physical activity. Prescription drugs are 

available to treat different lipid disorders (elevated cholesterol, elevated 

LDLs, low HDLs). In many instances, drug treatment for cholesterol/lipid 

levels is a long-term treatment strategy, and it is imperative that 

individuals continue to take their medication. Very often individuals will 

not “feel better” when they are taking the medication, but the 

NVFC Health and Wellness Guide 73 
Appendix B: Relationship Between Cardiovascular Risk Factors and Physical Fitness 

cardiovascular system is “working better.” If you have high 

cholesterol/lipid levels you should follow the diet and exercise guidelines 

detailed above, take your medicine religiously, and consult with your 

physician regularly. 

RISK ASSOCIATED WITH OBESITY

Despite what seems to be an obsession with thinness and dieting, approximately 

20 percent of the adult population in the United States is obese and another 25 to 30 

percent of the population is overweight.93,94 The trend in both the adult and the child 

population toward obesity is increasing. Obesity is associated with a number of diseases, 

including cardiovascular disease (high blood pressure, dyslipidemia), diabetes, 

gallbladder disease, and cancer. Obesity is associated with several other risk factors, but 

it also exerts an independent influence on the risk of cardiovascular disease. 

As excess body weight (Body Mass Index (BMI)) increases, so does the risk of 

cardiovascular disease (Figure 9). 

FIGURE 9: RELATIONSHIP BETWEEN BMI AND RELATIVE RISK OF CVD95

0

1

2

3

4

<21 21-22.9 23-24.9 25-28.9 >29

BMI

Source: Manson et Al: A prospective study of obesity and risk of coronary heart disease in women. New

England Journal of Medicine. 322:882-889, 1990. 

This relationship is sometimes referred to as a J-shaped curve because as there is 

little or no change in mortality at the lower end of the BMI range, but as BMI increases 

above 25, risk begins to increase and does so in a nonlinear fashion. Thus, each 

incremental pound gained is associated with additional risk for the person who is 

overweight. 

Not only is excess body weight an important risk factor for cardiovascular 

disease, but where the weight is carried (fat distribution) is also predictive of heart 

disease. Abdominal fat increases one’s risk of heart disease. This risk can be assessed 

74 NVFC Health and Wellness Guide 
Appendix B: Relationship Between Cardiovascular Risk Factors and Physical Fitness 

• BMI = Wt(kg)/Ht(m)

2

• Assume: Wt = 220 lb, Ht = 5’10’’

• Steps

1. Convert wt to kg by dividing by 2.2 (1 kg = 2.2 lb) 

220/2.2 = 100 kg 

2. Convert height to meters by: 

a. Convert inches to centimeters by multiplying by 2.54 

(1” = 2.54 cm) 

70 x 2.54 = 177 cm

b. Convert cm to m by dividing by 100 (1 m = 100 cm) 

177 cm = 1.77 m

Plug numbers into formula BMI = 100/1.772 = 100/3.13 = 31.9 

easily by measuring waist circumference: values greater than 40 inches for males and 

greater than 35 inches for females indicate an increased risk of heart disease. 

Obesity is associated with an increased amount of lipids and cholesterol in the 

blood. Thus, the LDLs are more likely to invade the arterial wall and initiate plaque 

development. Obesity is also associated with an inability to utilize carbohydrates causing 

blood sugar levels to increase. The increased blood glucose levels (and accompanying 

high levels of insulin) interfere with the ability of the artery to change size (vasodilate) 

when the heart needs additional blood flow. 

The extent of body fatness can be measured in several ways; the most precise 

laboratory methods involve sophisticated equipment such as underwater weighing tanks 

or whole body scanning. More commonly, percent body fat is estimated by measuring 

skinfold thickness at various sites and calculating percent body fat based on the known 

relationship between skinfold thickness and total body fat. The easiest way, however, to 

gain a sense of body fatness is through the calculation of Body Mass Index (Figure 10). 

FIGURE 10 CALCULATION OF BODY MASS INDEX (BMI) 

This method requires only that height and weight (in meters and kilograms, 

respectively) be known. Because of its simplicity, the Body Mass Index is often used in 

large-scale studies where hundreds or thousands of people are studied. This simple 

calculation, however, may overestimate the fatness of some individuals, especially those 

who are very muscular. Those individuals with a high BMI who do not believe they are 

overweight or obese, might consult a fitness expert to have percent body fat measured 

more accurately. 

Even modest weight loss can have an important impact on several health 

parameters, including improvements in blood pressure, lipid profiles, and glucose 

tolerance. 

NVFC Health and Wellness Guide 75 
Appendix B: Relationship Between Cardiovascular Risk Factors and Physical Fitness 

Strategies for Weight Loss--The strategies to reduce the risk of CVD associated 

with obesity may seem straightforward: you need to increase the number of calories 

expended by physical activity (exercise program) and/or you need to decrease the number 

of calories consumed. Despite what may seem like simple logic, millions of people fail at

weight loss attempts each year. In general it is healthful and most likely to be successful 

if your weight loss program includes a moderate increase in activity and a moderate 

decrease in caloric intake. Furthermore, you should recognize that your excess weight 

was not gained in a few weeks or months, and hence you should not try to lose the excess 

fat in a few weeks or months. Rather, commit yourself to a lifestyle change that you can 

sustain. 

Diet--An appropriate diet is essential to appropriate weight loss. There is 

considerable controversy over what type of diet is best. In general, it is best to avoid fad 

diets and stick to proven and healthy diets (i.e., the American Heart Association diet). 

Your goals should be to: 

• Attain a healthy body weight 

• Eat a well-balanced diet high in fruits and vegetables 

• Restrict saturated fats and simple, refined carbohydrates (sugars) 

• Eat approximately 250 to 500 calories fewer than you expend each day. 

Most experts agree that you should limit your fat intake to less than 30 percent of 

total calories (with < 10 percent of calories coming from saturated fats). Cholesterol 

intake should be less than 300 mg/day. Additionally, there is growing evidence that

omega 3 fatty acids are protective against cardiovascular disease, and for that reason, it is 

now commonly recommended that you try to eat fish one or two times per week. 

Exercise--Exercise is an important component of any weight loss program. 

Studies have consistently shown that exercise is particularly effective in maintaining 

weight loss. Additionally, exercise is the best way to loss fat and maintain muscle mass. 

When a person losses weight through exercise alone they lose fat and muscle. It is the fat 

that is detrimental to health. In fact, for a firefighter the loss of muscle mass may be

negatively affect performance because of the high strength demands of the job. 

RISK ASSOCIATED WITH TYPE II DIABETES

Diabetes is a metabolic disorder characterized by the inability to use sugar 

(glucose) effectively. In nondiabetic individuals, blood glucose levels increase following 

the ingestion of carbohydrates (complex sugars) or simple sugar. Increased levels of 

glucose cause the body to release insulin (a pancreatic hormone), which helps transport 

glucose from the blood stream into the cells of the body where the glucose is used to 

make energy or is stored as fuel for later use. Individuals with Type II diabetes tend to 

have high insulin levels because their cells are resistant to the effects of insulin (a 

condition known as insulin resistance). Thus the pancreas continues to produce insulin in 

76 NVFC Health and Wellness Guide 
Appendix B: Relationship Between Cardiovascular Risk Factors and Physical Fitness 

an attempt to move glucose into the cell. Since insulin is not effective, however, diabetics 

cannot effectively transport glucose from the blood stream into the cells of the body. 

Thus, diabetics have high glucose levels in the blood (hyperglycemia). 

People with diabetes have a 300 to 500 percent increased risk of cardiac events. 

Furthermore, 75 percent of all deaths among diabetic patients are from CVD. As seen in 

Figure 11, the degree of cardiovascular risk (and risk of death from all cause mortality) is 

directly related to fasting blood glucose levels.96 Additionally, individuals that have 

diabetes along with other risk factors are at a much higher risk than nondiabetic 

individuals with the same number of risk factors. 

FIGURE 11: FASTING BLOOD GLUCOSE LEVELS AND 

CARDIOVASCULAR MORTALITY IN TYPE II DIABETES PATIENTS

5

15

25

35

45

4.7-<6.7 6.7-<7.8 7.8-<8.8 8.8-<9.9 >10.0

Fasting Blood Glucose (mmol/L)

cardiovascular

mortality (%)

All cause

mortality (%)

Adapted from: Nesto & Libby. In: Braunwald, Zipes, & Libby. Heart Disease: A Textbook of

Cardiovascular Medicine. 6th Ed. Volume 2. Page 2138. 

High blood glucose levels (hyperglycemia) are associated with damage to the 

smallest blood vessels (such as those in the retina of the eye) and enhanced 

atherosclerosis. High insulin levels are also associated with enhanced blood clotting.97 

Strategies for Decreasing Blood Glucose Levels--Diabetes often coexists with 

other risk factors for cardiovascular disease. In fact, the cluster of risk factors has been 

termed metabolic syndrome X, and includes abdominal obesity, hypertension, 

dyslipidemia, and an inability to effectively use glucose (diabetes). Therefore, it is 

important that a person with diabetes very aggressively control other risk f actors. A

diabetic should loss excess body weight, exercise regularly and eat a diet low in simple 

sugars and carbohydrates. Because of the complexity of the disease, its relationship to

heart disease, and the difficulty controlling blood glucose levels, a diabetic person should 

consult regularly with their physician about their diet and exercise program and the need 

for medication. 

NVFC Health and Wellness Guide 77 
Appendix B: Relationship Between Cardiovascular Risk Factors and Physical Fitness 

RISK ASSOCIATED WITH PHYSICAL INACTIVITY

Physical inactivity is related to several of the risk factors discussed previously. A

lack of exercise increases an individual’s risk of obesity, hypertension, dyslipidemia, and 

diabetes. However, physical inactivity is also an independent risk factor for 

cardiovascular disease. The risk of CVD in inactive people is about twice that of 

physically active individuals—approximately the same as for hypertension and 

dyslipidemia.98 In fact, physical inactivity is responsible for approximately 200,000 

deaths per year in the United States.99 As seen in Figure 12, several studies have shown 

that CVD mortality is inversely related to level of physical activity or fitness.100 

Increased physical activity improves work capacity, increases strength, decreases 

injury rates, and improves heat tolerance. Exercise training also has a positive impact on 

several other CV risk factors; it decreases blood pressure, increases HDL, improves 

glucose tolerance, and causes loss of fat weight. In addition to these substantial benefits, 

exercise also strengthens the heart muscle, enhances the blood dissolving capacity of the 

blood (making unwanted clots less likely), and stabilizes the electrical activity of the 

heart. 

FIGURE 12: RELATIONSHIP BETWEEN PHYSICAL ACTIVITY AND CARDIOVASCULAR 

MORTALITY101

0

20

40

60

80

100

1 2 3 4 5 6 7 8

Levels of Physical Activity

Blair

Ekelund

Sandvick

Adapted from: Haskell, et al. Medicine and Science in Sports and Exercise. 26(6), 649-660. 

Decreasing CVD Risk Factors 

Cardiovascular disease is a major threat to the health and safety of firefighters. In 

order to stay healthy, and address the risk factors for developing CVD, a firefighter 

should adopt a few healthy lifestyle habits. In short, to reduce the risk of suffering a heart 

attack or stroke, it is imperative that firefighters: 

78 NVFC Health and Wellness Guide 
Appendix B: Relationship Between Cardiovascular Risk Factors and Physical Fitness 

• Do not smoke/stop smoking 

• Follow a regimen of moderate aerobic exercise 

• Eat a balanced diet, avoiding excess saturated fats, excess simple sugars, and 

maintaining normal body weight. 

Table 11 summarizes these recommendations and indicates the risk factors that 

are influenced by each recommendation. Of particular note is the benefit of physical 

activity in eliminating or favorably impacting five of the six modifiable risk factors. 

TABLE 11: RECOMMENDATIONS FOR DECREASING CV RISK FACTORS

Recommendations Risk Factor Influenced 

Exercise Moderately 

• Decreased Blood Pressure 

• Improved Lipid (Chol) Profile 

• Decreased Body Fat 

• Improved Glucose Tolerance 

• Eliminates Physical Inactivity 

Eat a Balanced Diet 

• Improved Lipid (Chol) Profile 

• Decreased Body Weight

• Improved Glucose Tolerance 

• May Decrease Blood Pressure

Do not Smoke • Smoking 

NVFC Health and Wellness Guide 79 
80 NVFC Health and Wellness Guide
Endnotes 

ENDNOTES 

1

 Karter, Michael J. U.S. Fire Department Profile Through 2001. National Fire Protection Association.

December 2002. 

2

 United States Fire Administration. Firefighting Fatalities in the United States 2001. 

3 Leblanc, Paul and Rita Fahy. Firefighter Fatalities in the United States 2002. National Fire Protection

Association, 2003. 

4

 United States Fire Administration Fallen Firefighters Memorial Database Online. Accessed August 15, 

2003. http://www.usfa.fema.gov/applications/ffmem/ffmem_search.jsp

5 Karter, Michael and Molis Joseph, NFPA Journal, “2001 Firefighter Injuries”. January/February 2003. 

6

 Hall, John et. Al. Needs Assessment of the US Fire Service, NFPA/FEMA/USFA, December 2002. 

7

 United States Fire Administration. Firefighting Fatalities in the United States 2001. 

8 Leblanc, Paul and Fahy, Rita. Firefighter Fatalities in the United States 2002. National Fire Protection 

Association, 2003. 

9 Reuters Health, July 17, 2001. 

10 Karter, Michael and Molis, Joseph. NFPA Journal, “2001 Firefighter Injuries”. January/February 2003. 

11 Karter, Michael. Patterns of Firefighter Fireground Injuries, National Fire Protection Association, 2003. 

12 United States Fire Administration. Fire and Emergency Medical Services Ergonomics—A Guide for 

Understanding and Implementing An Ergonomics Program in Your Department.March 1996. 

13 Stewart, Gord. “Fire Fitness – Coping with life on the job.” Accessed August 15, 2003. 

http://www.cfpsa.com/en/psp/fitness/fire_fitness/coping.asp. 

14 Wright, Brad. “Surgeon General to cops: Put down the donuts.” March 2, 2003. Accessed July 25, 2003. 

http://www.cnn.com/2003/HEALTH/02/28/obesity.police/. 

15 Page, James. “Fire service professionals ignore big problems.” Accessed August 15, 2003. 

http://www.jems.com/firerescue/e0301a.html. 

16 Kay, Bridget, et. Al. “Assessment of Firefighter’s Cardiovascular Disease-Related Knowledge and 

Behaviors,” Journal of American Dietetic Association. July 2001, Volume 101, Number 7.

17 Stefano, Michael (adapted from). “Top reasons fitness programs do not work.” March 2002. Accessed

July 9, 2003. http://www.firefightersworkout.com. 

NVFC Health and Wellness Guide 81 
Endnotes 

18 Reprinted with permission from NFPA 1583-2000, Health Related Fitness Programs for Fire Fighters, 

2-2. Copyright © 2000, National Fire Protection, Quincy, MA. This reprinted material is not the complete 

and official position of the NFPA on the referenced subject, which is represented only by the standard in its 

entirety. 

19 Reprinted with permission from NFPA 1583-2000, Health Related Fitness Programs for Fire Fighters, 

2-2. Copyright © 2000, National Fire Protection, Quincy, MA. This reprinted material is not the complete 

and official position of the NFPA on the referenced subject, which is represented only by the standard in its 

entirety. 

20 U.S. Department of the Air Force. “Air Force Instruction 40-501,” 1996. 

21 Ridker, P.M., J. Genest, J, and P. Libby. “Risk Factors for Atherosclerotic Disease.” In: Braumwald, E., 

Zipes, D.P., and P. Libby, (eds). Heart Disease: A Textbook of Cardiovascular Medicine. 6th Edition. W.B. 

Saunders. Philadelphia. 2001.

22 Hahn, R. A., G. et. Al. “Cardiovascular Disease Risk Factors and preventive practices among adultsUnited States, 1994: A behavioral risk factor atlas.” Morbidity and Mortality Weekly Report. 47 (SS-5): 

35-69 (1998).

23 United States Fire Administration. 5-Year Operational Objectives. October 2000. 

24 Ridker, P.M., J. Genest, J, and P. Libby. “Risk Factors for Atherosclerotic Disease”. In: Braumwald, E., 

Zipes, D.P., and Libby, P. (eds). Heart Disease: A Textbook of Cardiovascular Medicine. 6th Edition. W.B. 

Saunders. Philadelphia. 2001.

25 Gaziano, J.M., J.E. Mason, and P.M. Ridker. “Primary and Secondary Prevention of Coronary Heart

Disease”. In: Braumwald, E., D.P. Zipes, and P. Libby, (eds). Heart Disease: A Textbook of 

Cardiovascular Medicine. 6th Edition. W.B. Saunders. Philadelphia. 2001.

26 Ridker, P.M., J. Genest, J, and P. Libby. “Risk Factors for Atherosclerotic Disease.” In: Braumwald, E., 

Zipes, D.P., and Libby, P. (eds). Heart Disease: A Textbook of Cardiovascular Medicine. 6th Edition. W.B. 

Saunders. Philadelphia. 2001.

27 Plowman, S.A. and Smith, Denise. Exercise Physiology: for Health, Fitness, and Performance. Benjamin

Cummings. San Francisco. 2003.

28 Plowman, S.A. and Smith, Denise. Exercise Physiology: for Health, Fitness, and Performance. Benjamin

Cummings. San Francisco. 2003.

29 Oberman, A. Role of Lipids in the Prevention of Cardiovascular Disease. Clinical Reviews, 10-15 Spring

2000. 

30 Gaziano, J.M., J.E. Mason, and P.M. Ridker. “Primary and Secondary Prevention of Coronary Heart

Disease.” In: Braumwald, E., D.P. Zipes, and P. Libby, (eds). Heart Disease: A Textbook of 

Cardiovascular Medicine. 6th Edition. W.B. Saunders. Philadelphia. 2001.

31 Karter, M.J. and S. G. Badger. 1999 United States Firefighter Injuries. National Fire Protection Journal.

November/December 2000. 

32 United States Fire Administration. 5-Year Operational Objectives. October 2000. 

82 NVFC Health and Wellness Guide 
Endnotes 

33 Manson, et. Al. “A prospective study of obesity and risk of coronary heart disease in women.” New 

England Journal of Medicine. 322:882-889. 1990. 

34 Nesto, R.W. and L. Libby. In: Braunwald, Zipes, and Libby. Heart Disease: A Textbook of 

Cardiovascular Medicine. 6th Ed. W.B. Saunders. Philadelphia. 2001.

35 Plowman, S.A. and Smith, Denise. Exercise Physiology: for Health, Fitness, and Performance. 

Benjamin Cummings. San Francisco. 2003. 

36 Ridker, P.M., J. Genest, J, and P. Libby. “Risk Factors for Atherosclerotic Disease.” In: Braumwald, E., 

D.P. Zipes, and P. Libby, (eds). Heart Disease: A Textbook of Cardiovascular Medicine. 6th Edition. W.B. 

Saunders. Philadelphia. 2001.

37 Haskell, W.S.L.: “Health consequences of physical activity: Understanding and challenges regarding

dose response.” Medicine and Science in Sports and Exercise. 26(6):649-660, 1994. 

38 American College of Sports Medicine. Resource Manual for Guidelines for Exercise Testing and 

Prescription, 4th Baltimore, MD. Lippincott. Williams & Wilkins. 2001.

39 National Strength and Conditioning Association. “Essentials of Strenth Training and Conditioning,” 2nd

Edition. Champaign, IL. Human Kinetics, 2000.

40 American College of Sports Medicine. Resource Manual for Guidelines for Exercise Testing and 

Prescription, 4th Edition. Baltimore, MD. Lippincott. Williams & Wilkins. 2001.

41 American College of Sports Medicine. Resource Manual for Guidelines for Exercise Testing and 

Prescription, 6th Baltimore, MD. Lippincott. Williams & Wilkins, 2000.

42 National Strength and Conditioning Association. ”Essentials of Strength Training and Conditioning,” 2nd

Edition. Champaign, IL. Human Kinetics, 2000.

43 American College of Sports Medicine. Resource Manual for Guidelines for Exercise Testing and 

Prescription, 4th Edition. Baltimore, MD. Lippincott. Williams & Wilkins, 2000.

44 American College of Sports Medicine. Resource Manual for Guidelines for Exercise Testing and 

Prescription, 6th Edition. Baltimore, MD. Lippincott. Williams & Wilkins. 2001.

45 United States Department of Health and Human Services “Physical Activity and Health: A Report of the 

Surgeon General. Atlanta.” Centers for Disease Control and Prevention, National Center for Chronic 

Disease Prevention and Health Promotion, 1996.

46 American College of Sports Medicine. Resource Manual for Guidelines for Exercise Tresting and 

Prescription, 4th Edition. Baltimore, MD. Lippincott. Williams & Wilkins. 2001.

47 Fleck S. J. et. Al. “

Designing Resistance Training Programs.” Champaign, IL. Human Kinetics, 1987.

48 United States Fire Administration. Fire and Emergency Medical Services Ergonomics—A Guide for 

Understanding and Implementing An Ergonomics Program in Your Department. March 1996.

NVFC Health and Wellness Guide 83 
Endnotes 

49 Reprinted with permission from NFPA 1582, Medical Requirements for Firefighters and Information for 

Fire Department Physicians Copyright ©2000, National Fire Protection Association, Quincy, MA 02269. 

This reprinted material is not the complete and official position of the National Fire Protection Association,

on the referenced subject, which is represented only by the standard in its entirety.

50 Centers for Disease Control. 2000. 

51 Institute for Research and Education. 1996. 

52 Bentkowski, Frank. “NYC’s Firefighters Strive for Fitness.” Fire Chief. June 2003. pg. 70. 

53 Bentkowski, Frank. “NYC’s Firefighters Strive for Fitness.” Fire Chief. June 2003. pg. 70. 

54 Ridker, P.M., J. Genest, J, and P. Libby. “Risk Factors for Atherosclerotic Disease.” In: Braumwald, E., 

D.P. Zipes, and P.Libby, (eds). Heart Disease: A Textbook of Cardiovascular Medicine. 6th Edition. W.B. 

Saunders. Philadelphia. 2001.

55 Ridker, P.M., J. Genest, J, and P. Libby. “Risk Factors for Atherosclerotic Disease.” In: Braumwald, E., 

D.P. Zipes, and P. Libby, (eds). Heart Disease: A Textbook of Cardiovascular Medicine. 6th Edition. W.B.

Saunders. Philadelphia. 2001.

56 Kaplan, N.M. “Systemic Hypertension: Mechanisms and Diagnosis”. In: Braumwald, E., D.P. Zipes, and 

P. Libby, (eds). Heart Disease: A Textbook of Cardiovascular Medicine. 6th Edition. W.B. Saunders. 

Philadelphia. 2001. 

57 Kaplan, N.M. “Systemic Hypertension: Mechanisms and Diagnosis”. In: Braumwald, E., D.P. Zipes, and 

P. Libby, (eds). Heart Disease: A Textbook of Cardiovascular Medicine. 6th Edition. W.B. Saunders. 

Philadelphia. 2001. 

58 Reprinted with permission from NFPA 1583-2000, Health Related Fitness Programs for Firefighters, 

3.1.1-3.2.2. Copyright © 2000, National Fire Protection, Quincy, MA. This reprinted material is not the 

complete and official position of the NFPA on the referenced subject, which is represented only by the 

standard in its entirety. 

59 United States Fire Administration. 2003 Program Guidance for the Assistance to Firefighter Grant 

Program. March 11, 2003. 

60 Wellness Council of America. Healthy Balance Program. On going program involving 50,000

employees from Caterpillar Inc. Annual review, 2000. 

61Phillips, Jack, et. Al. The Human Resources Scorecard. 2000. 

62 Ridker, P.M., J. Genest, J, and P. Libby. “Risk Factors for Atherosclerotic Disease”. In: Braumwald, E., 

Zipes, D.P., and Libby, P. (eds). Heart Disease: A Textbook of Cardiovascular Medicine. 6th Edition. W.B.

Saunders. Philadelphia. 2001.

63 Hahn, R. A., G.W. Heath, and M.H. Change. “Cardiovascular Disease Risk Factors and preventive

practices among adults-United States, 1994: A behavioral risk factor atlas.” Morbidity and Mortality 

Weekly Report. 47 (SS-5): 35-69 (1998).

84 NVFC Health and Wellness Guide 
Endnotes 

64 United States Fire Administration. Firefighter Fatality Retrospective Study. April 2002. 

65 United States Fire Administration. Firefighter Fatality Retrospective Study. April 2002. 

66 Karter, M.J. and S. G. Badger. “1999 United States Firefighter Injuries.” National Fire Protection 

Journal. November/December 2000. 

67 United States Fire Administration. Firefighter Fatality Retrospective Study. April 2002. 

68 Fahy, Rita and Paul Leblanc. “Firefighter Fatalities 2001.” NFPA Journal. July/August 2002. 

69 Fahy, Rita and Paul Leblanc. “Firefighter Fatalities 2002.” NFPA Journal. July/August 2003. 

70 United States Fire Administration. 5-Year Operational Objectives. October 2000. 

71 Ridker, P.M., J. Genest, J, and P. Libby. “Risk Factors for Atherosclerotic Disease.” In: Braumwald, E., 

D.P. Zipes, and P. Libby, (eds). Heart Disease: A Textbook of Cardiovascular Medicine. 6th Edition. W.B. 

Saunders. Philadelphia. 2001.

72 Gaziano, J.M., J.E. Mason, and P.M. Ridker, “Primary and Secondary Prevention of Coronary Heart

Disease.” In: Braumwald, E., D.P. Zipes, and P. Libby, (eds). Heart Disease: A Textbook of 

Cardiovascular Medicine. 6th Edition. W.B. Saunders. Philadelphia. 2001.

73 Ridker, P.M., J. Genest, J, and P. Libby. “Risk Factors for Atherosclerotic Disease.” In: Braumwald, E., 

D.P. Zipes, and P. Libby, (eds). Heart Disease: A Textbook of Cardiovascular Medicine. 6th Edition. W.B. 

Saunders. Philadelphia. 2001.

74 Plowman, S.A. and Smith, Denise. Exercise Physiology: for Health, Fitness, and Performance. Benjamin

Cummings. San Francisco. 2003.

75 The Health Benefits of Smoking Cessation. A Report from the Surgeon General. 1990. 

76 Ridker, P.M., J. Genest, J., and P. Libby. “Risk Factors for Atherosclerotic Disease.” in Braumwald, E., 

D.P. Zipes, and P. Libby, (eds.). Heart Disease: A Textbook of Cardiovascular Medicine. 6th Edition. 

W.B. Saunders. Philadelphia. 2001. 

77 Kaplan, N.M. “Systemic Hypertension: Mechanisms and Diagnosis.” In: Braumwald, E., D.P. Zipes, and 

P. Libby, (eds). Heart Disease: A Textbook of Cardiovascular Medicine. 6th Edition. W.B. Saunders. 

Philadelphia. 2001. 

78 National High Blood Pressure Education Program Working Group. Arch. Intern Med. 1993

79 Ridker, P.M., J. Genest, J, and P. Libby. “Risk Factors for Atherosclerotic Disease.” In: Braumwald, E., 

D.P. Zipes, and P. Libby, (eds). Heart Disease: A Textbook of Cardiovascular Medicine. 6th Edition. W.B. 

Saunders. Philadelphia. 2001.

80 Kaplan, N.M. “Systemic Hypertension: Mechanisms and Diagnosis.” In: Braumwald, E., D.P. Zipes, and 

P. Libby, (eds). Heart Disease: A Textbook of Cardiovascular Medicine. 6th Edition. W.B. Saunders. 

Philadelphia. 2001. 

NVFC Health and Wellness Guide 85 
Endnotes 

81 Kaplan, N.M. “Systemic Hypertension: Mechanisms and Diagnosis.” In: Braumwald, E., D.P. Zipes, and 

P. Libby, (eds). Heart Disease: A Textbook of Cardiovascular Medicine. 6th Edition. W.B. Saunders. 

Philadelphia. 2001. 

82 Kaplan, N.M. “Systemic Hypertension: Mechanisms and Diagnosis.” In: Braumwald, E., D.P. Zipes, and 

P. Libby, (eds). Heart Disease: A Textbook of Cardiovascular Medicine. 6th Edition. W.B. Saunders. 

Philadelphia. 2001. 

83 Oberman, A. “Role of Lipids in the Prevention of Cardiovascular Disease.” Clinical Reviews, 10-15

Spring 2000. 

84 Gaziano, J.M., J.E. Mason, and P.M. Ridker. “Primary and Secondary Prevention of Coronary Heart

Disease.” In: Braumwald, E., D.P. Zipes, and P. Libby, (eds). Heart Disease: A Textbook of 

Cardiovascular Medicine. 6th Edition. W.B. Saunders. Philadelphia. 2001.

85 Gaziano, J.M., J.E. Mason, and P.M. Ridker. “Primary and Secondary Prevention of Coronary Heart

Disease.” In: Braumwald, E., D.P. Zipes, and P. Libby, (eds). Heart Disease: A Textbook of 

Cardiovascular Medicine. 6th Edition. W.B. Saunders. Philadelphia. 2001.

86 Oberman, A. Role of Lipids in the Prevention of Cardiovascular Disease. Clinical Reviews. Spring: 10-

15, 2000. 

87 Summary of the Third Report of the National Cholesterol Education Program. 2001. 

88 Gaziano, J.M., J.E. Mason, and P.M. Ridker. “Primary and Secondary Prevention of Coronary Heart

Disease.” In: Braumwald, E., D.P. Zipes, and P. Libby, (eds). Heart Disease: A Textbook of 

Cardiovascular Medicine. 6th Edition. W.B. Saunders. Philadelphia. 2001.

89 Oberman, A. Role of Lipids in the Prevention of Cardiovascular Disease. Clinical Reviews. Spring: 10-

15, 2000. 

90 Oberman, A. Role of Lipids in the Prevention of Cardiovascular Disease. Clinical Reviews. Spring: 10-

15, 2000. 

91 Oberman, A. Role of Lipids in the Prevention of Cardiovascular Disease. Clinical Reviews. 10-15 

Spring 2000. 

92 Ridker, P.M., J. Genest, J, and P. Libby. “Risk Factors for Atherosclerotic Disease”. In: Braumwald, E., 

D.P. Zipes, and P. Libby, (eds). Heart Disease: A Textbook of Cardiovascular Medicine. 6th Edition. W.B. 

Saunders. Philadelphia. 2001.

93 Karter, M.J. and S. G. Badger. “1999 United States Firefighter Injuries.” National Fire Protection 

Journal. November/December 2000. 

94 United States Fire Administration. 5-Year Operational Objectives. October 2000. 

95 Manson et al: “A prospective study of obesity and risk of coronary heart disease in women.” New 

England Journal of Medicine. 322:882-889. 1990. 

86 NVFC Health and Wellness Guide 
Endnotes 

96 Nesto, R.W. and L. Libby. In: Braunwald, Zipes, and Libby. Heart Disease: A Textbook of 

Cardiovascular Medicine. 6th Ed. W.B. Saunders. Philadelphia. 2001.

97 Ridker, P.M., J. Genest, J, and P. Libby. “Risk Factors for Atherosclerotic Disease”. In: Braumwald, E., 

D.P. Zipes, and P. Libby, (eds). Heart Disease: A Textbook of Cardiovascular Medicine. 6th Edition. W.B. 

Saunders. Philadelphia. 2001.

98 Plowman, S.A. and Smith, Denise. Exercise Physiology: for Health, Fitness, and Performance. Benjamin

Cummings. San Francisco. 2003.

99 Ridker, P.M., J. Genest, J, and P. Libby. “Risk Factors for Atherosclerotic Disease.” In: Braumwald, E., 

D.P. Zipes, and P. Libby, (eds). Heart Disease: A Textbook of Cardiovascular Medicine. 6th Edition. W.B. 

Saunders. Philadelphia. 2001.

100 Haskell, W.S.L. “Health consequences of physical activity: Understanding and challenges regarding

dose response.” Medicine and Science in Sports and Exercise. 26(6): 649-660. 1994. 

101 Haskell, et al. Medicine and Science in Sports and Exercise. 26(6), 649-660. 

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